Abstract
OBJECTIVES
In this study we examined the relation between mental health problems and weight in a population-based study of youth aged 12 to 17 years and whether the association between mental health problems and weight is moderated by race and ethnicity.
METHODS
We used 2003 National Survey on Children’s Health data. Logistic regression was used to arrive at adjusted odds ratios showing the relation between BMI and mental health problems.
RESULTS
Compared with their nonoverweight counterparts, both white and Hispanic youth who were overweight were significantly more likely to report depression or anxiety, feelings of worthlessness or inferiority, behavior problems, and bullying of others. Odds ratios relating mental health problems and BMI in black subjects were not statistically significant except for physician diagnosis of depression.
CONCLUSIONS
Our results suggest that, when addressing youth overweight status, mental health problems also need to be addressed. Given that the relationship between mental health problems and youth overweight differs according to race/ethnic group, public health programs that target overweight youth should be cognizant of potential comorbid mental health problems and that race/ethnicity may play a role in the relationship between mental health and overweight status.
Keywords: adolescent health, black, Latino health, mental health, obesity
Adolescent obesity is a growing epidemic in the United States that is known to present a risk for a number of adverse physical outcomes, including type 2 diabetes mellitus, hypertension, musculoskeletal problems, and, more recently, mental health problems.1,2 The relationship between obesity and mental health has been documented nationally and internationally in adults and children.3–6 Obese children are more likely to suffer from psychiatric disorders,7 depression,8 behavior problems,9 and social marginalization,10 and obese children are often victims of bullying.11 Findings from a study by Kolody and Sallis12 provided evidence for a concomitant increase in negative psychological outcomes and BMI over a 1-year period in preadolescent children.
Concern about body weight has been shown to mediate the relationship between BMI and mental health outcomes.13 Youth, especially girls, who are concerned about their weight are more likely to experience depressive symptoms than children who are overweight or obese but who are not concerned about their weight.14 The current literature shows that black youth, both boys and girls, are more likely to be overweight or obese compared with white girls15; however, they are also more likely to perceive themselves as being of normal weight and have less desire to be thin compared with white boys and girls.16,17 In addition, obese black youth report lower levels of impairments in body esteem associated with perceived body image compared with non-Hispanic, white youth.18 Therefore, we hypothesized that the relation between the presence of mental health problems and weight status is stronger in white youth compared with black youth.
This study examined the relation between comorbid mental health problems and youth weight status in a population-based study of youth aged 12 to 17 years and examined whether the association between mental health problems and weight status was moderated by race and ethnicity.
METHODS
Sample
We used the National Survey of Children’s Health (NSCH; conducted by the National Center for Health Statistics, Centers for Disease Control and Prevention [CDC]) survey data. This survey is a module of the State and Local Area Integrated Telephone Survey Program. The survey includes data on physical, emotional, and behavioral health indicators for children in the United States. The response rate for the survey was 55.3%. A stratified sampling frame was used; data were sampled within each state. Respondents were parents reporting on behalf of their children. We restricted the sample to youth between the ages of 12 and 17 years whose parents reported that their child was white, black, or Hispanic. The survey was conducted in Spanish for respondents who preferred this language.
Measures
We examined 3 dimensions of mental health and well-being, including (1) anxiety, depression, and stress coping, (2) self-worth, and (3) behavior problems.
Anxiety, Depression, and Stress Coping
The following questions were included in the survey:
Has a health professional ever told you that your child has a problem with depression or anxiety?
Are you currently concerned, a lot, a little or not at all about how she/he copes with stressful things?
Self-worth
The following points were included in the survey:
He/she feels worthless or inferior (never, sometimes, usually, always).
Are you currently concerned a lot, a little, or not at all about your child’s self-esteem?
Behavior Problems
The following points were included in the survey:
Has a health professional ever told you that your child has a behavior problem?
Your child is withdrawn and does not get along with others (never, sometimes, usually, or always).
Your child bullies or is cruel or mean to others (never, sometimes, usually, or always).
Several measures of anxiety and depression were available in the National Center for Health Statistics data and were all highly correlated (were significant in χ2 tests at a P value of ≤.05). We selected the most objective measure of depression and anxiety (report of physician diagnosis).
Because few parents indicated that their child was in the “usually” or “always” category, mental health items with response categories (never, sometimes, usually, or always) were collapsed into a dichotomous variable with 2 categories: never and sometimes/usually/always. Mental health items with response categories (a lot, a little, or never) were collapsed into a dichotomous variable with 2 categories: never and a little/a lot.
Main Effect
Parent respondents were asked the height and weight of their children. BMI was calculated using the CDC age-and gender-specific percentiles based on the CDC 2000 reference criteria. Youth were classified as underweight, normal, overweight, or obese. We further collapsed BMI into 2 categories: overweight (BMI ≥ 95th percentile) and not overweight (BMI < 95th percentile). Children who were underweight (BMI < 5th percentile) were excluded from the analysis.
Control Variables
All of the analyses accounted for sociodemographic confounding variables known to be related to youth overweight and mental health problems. We controlled for gender, child age in years, indicators of family socioeconomic status (poverty level and highest level of education for any adult family member), and family composition (biological or adoptive parents, 2-parent step-family, single mother, or other) in all of the models.
Analysis
Descriptive statistics were used to examine the distribution of mental health indicators and BMI among the sample of children. Frequencies and percentages presented in this study have been adjusted for the survey weights and the stratified sampling design. Logistic regression was used to arrive at adjusted odds ratios (ORs) showing the relation between BMI and each mental health status indicator.
To assess the role of race/ethnicity as a moderator (the differential effect of race on the relation between BMI classification and mental health outcomes), we conducted logistic regression analyses stratified according to race/ethnic group. Adjusted ORs representing the relation between BMI and each mental health indicator were then calculated within each racial/ethnic group. Because gender is known to be related to perceptions of body weight and potentially to mental health outcomes, all of the ORs expressing the relation between BMI classification and mental health outcomes were adjusted according to gender. Sociodemographic variables were also controlled for in each model by including them in the logistic regression model. All of the analyses were conducted by using Stata (Stata Corp, College Station, TX) survey commands to obtain the correct SEs. The Stata subgroup command was used to specify the use of race/ethnicity subgroups while preserving the complete design matrix to obtain robust standard errors.
What’s Known on This Subject
Obese children are more likely to suffer from depression, behavior problems, and social marginalization and are often victims of bullying. The current literature also indicates a concomitant increase in negative psychological outcomes and BMI over a 1-year period in children.
What This Study Adds
With this study we explored the relation between mental health and overweight and how race/ethnicity moderates this relationship. Understanding the role of race/ethnicity as a moderator of the association between mental health and overweight may help to inform the treatment of overweight adolescents.
RESULTS
Sample Descriptives
A total of 35 184 youth who met the age and ethnicity criteria were included in the sample. Seventy-six percent were white, 17.9% were black, and 5.7% were Hispanic. Fifty percent were boys, more than half (54.8%) lived in a 2-parent home (13.3% lived in a 2-parent step-family), and 26.0% lived in a single parent home. Almost all of the parents reported that their child was in good, very good, or excellent health (96.8%). Two thirds of the families had ≥1 adult who completed high school or greater (67.2%). Almost 15% (14.7%) of the youth surveyed lived in families declaring themselves below the poverty level.
More than one quarter of the youth in our sample were either obese (13.2%) or overweight (15.5%). A larger percentage of boys were obese (16.6%) or overweight (16.4%) compared with girls (9.8% and 14.0%, respectively; for the χ2 test: P < .0001). Black youth were more likely to be classified as obese (21.2%) or overweight (18.4%) compared with white (10.8% and 14.1%) and Hispanic (15.4% and 18.8%) youth (for the χ2 tests: P < .0001 and P < .0001, respectively).
Relation Between Mental Health and BMI
Table 1 displays the percentage of youth in each BMI category, for each mental health condition. Reports of mental health problems increased with increasing BMI; overweight youth had a higher reported occurrence of mental health problems than youth who were classified as normal weight. This relation was true for all of the mental health problems examined in this study. Table 1 also displays adjusted ORs explaining the relation between BMI and mental health indicators. Youth who were overweight were more likely to have been told by a health professional that they suffer from depression (OR: 1.6; P < .001), to have problems coping with stress (OR: 1.3; P < .001), or to have been told by a health professional that they have a behavior problem (OR: 1.7; P = .0001) compared with normal-weight children. Caregivers of youth who were overweight were also ~1.4 times more likely to have concerns about their child’s self-worth, self-esteem, or participation in bullying (P < .0001).
TABLE 1.
Adjusted ORs Representing the Relation Between BMI and Mental Health Problems
| Mental Health Problem | % | OR (95% Confidence Interval) |
|---|---|---|
| Anxiety and depression | ||
| Has a health professional ever told you that your child has a problem with depression or anxiety (yes)? | ||
| Not overweight | 6.7 | Ref |
| Overweight | 11.1 | 1.6 (1.2–2.0)a |
| Are you currently concerned a lot about how he/she copes with stressful things? | 7.1 | Ref |
| Not overweight | 28.3 | Ref |
| Overweight | 37.0 | 1.3 (1.2–1.5)a |
| Self-worth | ||
| He/she feels worthless or inferior (sometimes, usually, or always) | ||
| Not overweight | 29.8 | Ref |
| Overweight | 35.0 | 1.4 (1.2–1.6)b |
| Are you currently concerned a lot about your child’s self-esteem | ||
| Not overweight | 27.4 | Ref |
| Overweight | 36.2 | 1.4 (1.3–1.6)b |
| Behavior problems | ||
| Has a doctor told you that your child has a behavior problem? | ||
| Not overweight | 5.6 | Ref |
| Overweight | 11.5 | 1.7 (1.4–2.2)b |
| Your child (sometimes, usually, or always) is withdrawn and does not get along with others | ||
| Not overweight | 19.1 | Ref |
| Overweight | 24.9 | 1.3 (1.1–1.6)a |
| Your child bullies or is cruel or mean to others (sometimes, usually, or always) | ||
| Not overweight | 22.2 | Ref |
| Overweight | 29.7 | 1.4 (1.2–1.6)b |
For BMI not overweight, n = 30 805. For BMI overweight, n = 4379. Data show the level of significance for ORs indicating the relation between BMI and mental health problems. Ref indicates reference data.
P < .01.
P < .0001.
Effects of Race/Ethnicity on the Relation Between Mental Health and BMI
Table 2 displays the relation between BMI classification and mental health problems according to race/ethnic group. Both white and Hispanic youth who were classified as overweight were significantly more likely to be reported as suffering from depression or anxiety, feeling worthless or inferior, having a behavior problem, and bullying others than their nonoverweight counterparts. Compared with caregivers of nonoverweight youth, caregivers of overweight white and Hispanic youth were more likely to report concern for their child’s ability to cope with stress and their child’s depression or anxiety. Caregivers of overweight, Hispanic youth were 1.9 times as likely to report concern for their overweight child’s self-esteem compared with caregivers of normal-weight Hispanic youth. In general, black youth had a higher occurrence of certain reported mental health problems (eg, coping with stress and anxiety, self-esteem, behavior problems, OR being more likely to bully) compared with white and Hispanic youth, but the occurrence of these problems was unrelated to BMI classification. ORs relating mental health problems and BMI classification in black subjects were not statistically significant.
TABLE 2.
Adjusted ORs Representing the Relation Between BMI and Mental Health Problem According to Race/Ethnicity
| Mental Health Problem | White (N = 30 316) | Black (N = 3259) | Hispanic (N = 1609) | |||
|---|---|---|---|---|---|---|
| % | OR (95% CI) | % | OR (95% CI) | % | OR (95% CI) | |
| Anxiety, depression, stress, and coping | ||||||
| Has a health professional ever told you that your child has a problem with depression or anxiety (yes)? | ||||||
| Not overweight | 7.3 | Ref | 5.3 | Ref | 5.7 | Ref |
| Overweight | 11.7 | 1.6 (1.3–2.0)a | 8.8 | (NS) | 18.5 | 2.7 (1.2–6.5)b |
| Are you currently concerned a lot about how he/she copes with stressful things? | ||||||
| Not overweight | 24.8 | Ref | 40.6 | Ref | 33.4 | Ref |
| Overweight | 31.9 | 1.4 (1.2–1.6)c | 46.9 | (NS) | 52.3 | 2.3 (1.3–4.0)a |
| Self-worth | ||||||
| He/she feels worthless or inferior (sometimes, usually, or always). | ||||||
| Not overweight | 32.7 | Refc | 21.2 | Ref | 24.2 | Refb |
| Overweight | 41.3 | 1.4 (1.3–1.7)c | 24.2 | (NS) | 39.1 | 1.8 (1.2–3.7)b |
| Are you currently concerned a lot about your child’s self-esteem? | ||||||
| Not overweight | 23.2 | Ref | 43.6 | Ref | 31.8 | Ref |
| Overweight | 29.3 | (NS) | 48.4 | (NS) | 47.3 | 1.9 (1.1–3.4)a |
| Behavior problems | ||||||
| Has a doctor told you that your child has a behavior problem (yes)? | ||||||
| Not overweight | 5.1 | Ref | 8.8 | Ref | 3.3 | Ref |
| Overweight | 11.6 | 1.9 (1.5–2.5)c | 12.4 | (NS) | 16.9 | 5.3 (1.9–14.5)a |
| Your child (sometimes, usually, or always) is withdrawn and does not get along with others. | ||||||
| Not overweight | 17.4 | Ref | 21.2 | Ref | 21.7 | Ref |
| Overweight | 22.6 | 1.3 (1.2–1.6)c | 26.5 | (NS) | 38.2 | 1.6 (1.2–2.6)a |
| Your child (sometimes, usually, or always) bullies or is cruel or mean to others. | ||||||
| Not overweight | 20.9 | Ref | 28.3 | Ref | 17.9 | Ref |
| Overweight | 29.1 | 1.3 (1.1–1.6)a | 33.4 | (NS) | 39.1 | 2.9 (1.6–5.6)a |
Reference category was BMI not overweight. Data show the level of significance for ORs, indicating the relation between BMI and mental health problem according to race/ethnicity. NS indicates not significant; Ref, reference data.
P < .01.
P < .05.
P < .0001.
DISCUSSION
We examined the relation between weight status and reported mental health problems in a population-based sample of adolescents. Our findings showed that reported mental health problems increased with BMI class (normal to overweight). However, the relation between obesity and mental health problems was moderated by race. These findings highlight the need to address psychological health among overweight children.
Despite the higher incidence of mental health comorbidities in black youth, it was unclear why there was no association between mental health problems and BMI classification in the black youth in our sample. Young-Hyman et al19 found that depression in black children was not associated with their reports of body image dissatisfaction or weight-related teasing, despite the fact that black children in the study reported higher levels of body dissatisfaction. Perhaps there is a constellation of social and demographic factors that place black youth at risk for developing mental health problems, such that little is left to be explained by BMI. In addition, several study findings show that, regardless of weight status, black youth and adults tend to be more satisfied with larger body sizes than other racial groups.20,21 Hence, it is possible that overweight black youth are mentally unscathed by their weight status, which highlights the need to understand other factors that influence mental health problems in black youth. A recent qualitative study found that, among black adolescents ages 12 to 18 years, body size preferences were determined by their immediate peer group and that the adolescents in the study were not bothered by negative weight-related comments from peers.22 Other studies have also shown that black youth are less likely to be exposed to messages about thinness from their peers and family and that black boys and girls are more likely to desire a larger body size compared with white youth.23 Furthermore, black youth are less likely to be bothered by being overweight compared with white youth.24
For most mental health problems examined in this study, overweight Hispanic youth were more than twice as likely to be reported as being diagnosed with or experiencing the problem compared with their normal-weight counterparts. These findings show that Hispanic youth seem to be at particularly high risk of comorbid mental health problems in the presence of overweight.
Body image may play a role in the relationship between mental health problems and overweight status in Hispanic youth. Higher weight status has been shown to be associated with body image dissatisfaction in Mexican-American female youth and with a stronger affiliation with Mexican culture.25 Robinson et al26 found that Hispanic girls in middle school reported higher body dissatisfaction than white girls.
White youth in this sample were more likely to be reported as experiencing problems with self-worth compared with black and Hispanic youth; however, they were less likely to be reported as experiencing other mental health problems compared with black and Hispanic children. Nevertheless, overweight white youth were moderately more likely to be reported as having mental health problems compared with normal-weight white youth.
Caregivers in this study consistently reported concern for their overweight children’s mental health and problem behavior. A recent study by Hacker et al27 showed that parental concern for children’s mental health increased the effectiveness of mental health screening services for children. Similar findings have been reported for mental health and behavioral problems in children, showing that parental concerns for their child’s behavior resulted in accurate identification of children with mental health problems in the clinical range.28 Thus, parents’ concerns seem to be warranted. In a study based on data from a larger age range of children from the same population-based sample used in the present study, caregivers who reported that their child had chronic emotional, behavioral, or developmental problems reported greater caregiver strain (ie, problems with employment and child care arrangements). In addition, children with chronic emotional, behavioral, or developmental problems were significantly more likely to miss school, which may explain the increased reports of caregiver strain.29 These findings suggest that child mental health and behavioral problems may also have consequences for caregivers and families, which may heighten caregiver concern for children’s mental health and behavior. Furthermore, the dual burden of overweight status and mental health problems may further exacerbate caregiver strain.
Eaton et al30 found that BMI was significantly associated with suicide ideation in adolescents, and, furthermore, perceived weight status was associated with suicide attempts in black, white, and Hispanic adolescents. Collectively, these and the present study findings highlight the association between BMI and mental health problems as a serious public health concern. These findings underscore the need for mental health prevention and intervention programs targeted at overweight youth and youth at considerable risk for developing overweight and obesity status.
Our study is limited by the nature of the data used in this study, which were based on self-report and may be subject to bias. It is possible that parent respondents did not know the actual heights and weights of their children. In addition, parents may have been unaware of depression or stress and anxiety experienced by their child.
Furthermore, single-survey items typically used in a nationally representative survey may not fully represent the constructs of anxiety and depression, self-worth, and behavior problems. It is known that that the national prevalence of depression and anxiety in youth in the United States are ~8.5%31 and 13.0%,32 respectively, which indicates that parent underreporting may be an issue in the NSCH study. Although a random sampling design was used when collecting the NSCH survey, Hispanic youth are still underrepresented, and whites are overrepresented.33–35
Smaller sample sizes for the Hispanic population relative to the white and black populations are reflected in the larger SEs (wider confidence intervals); however, the relationship between BMI classification and mental health outcomes in Hispanic youth is evident. The small sample size also limited us from including other racial and ethnic minorities, such as Asian/Pacific Islanders and Native American youth. Because the NSCH was administered over the telephone, families who do not have telephones were also excluded.
Lastly, given the cross-sectional nature of these data, we were not able to infer causality. We could not infer whether mental health conditions caused obesogenic behavior and, subsequently, overweight or whether overweight youth were more inclined to develop mental health conditions or social problems. More research is needed to establish the causal relation between child overweight and mental health problems and the role that race/ethnicity and other factors may play in this relationship. Furthermore, the current literature indicates a relation between gender and mental health problems. Psychological disorders in male adolescents seem to be unrelated to weight status, whereas psychological disorders are more likely to be related to weight status for women.36 The goal of the current study was to highlight the effect of race/ethnicity on the relation between mental health problems and overweight status in youth, so to achieve that goal we adjusted for gender in our models. However, additional studies are needed to disentangle the effects of race/ethnicity, gender, and mental health problems.
Additional studies are also needed to disentangle the relation between confounders of the relationship between mental health problems and youth overweight. Exposure to violence in the home, school, and neighborhood environments may be related to anxiety, depression, and other mental health problems and should be considered in future research.37,38
CONCLUSIONS
Our results suggest that, when addressing youth overweight status, mental health problems also need to be addressed; the comorbidity of these conditions (mental health problems and overweight/obesity) may hinder any efforts at achieving a healthy weight status. Given that the relationship between mental health problems and youth overweight differs according to race/ethnic group, public health programs that target overweight youth should be cognizant of potential comorbid mental health problems and that race/ethnicity may play a role in the relationship between mental health and overweight status.
Abbreviations
- NSCH
National Survey of Children’s Health
- CDC
Centers for Disease Control and Prevention
- OR
odds ratio
Footnotes
The authors have indicated they have no financial relationships relevant to this article to disclose.
REFERENCES
- 1.Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. JAMA. 1999;282(16):1523–1529. doi: 10.1001/jama.282.16.1523. [DOI] [PubMed] [Google Scholar]
- 2.Daniels SR. The consequences of childhood overweight and obesity. Future Child. 2006;16(1):47–67. doi: 10.1353/foc.2006.0004. [DOI] [PubMed] [Google Scholar]
- 3.Onyike CU, Crum RM, Lee HB, Lyketsos CG, Eaton WW. Is obesity associated with major depression? Results from the Third National Health and Nutrition Examination Survey. Am J Epidemiol. 2003;158(12):1139–1147. doi: 10.1093/aje/kwg275. [DOI] [PubMed] [Google Scholar]
- 4.Scott KM, Bruffaerts R, Simon GE, et al. Obesity and mental disorders in the general population: results from the world mental health surveys. Int J Obes (Lond) 2008;32(1):192–200. doi: 10.1038/sj.ijo.0803701. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Carpenter KM, Hasin DS, Allison DB, Faith MS. Relationships between obesity and DSM-IV major depressive disorder, suicide ideation, and suicide attempts: results from a general population study. Am J Public Health. 2000;90(2):251–257. doi: 10.2105/ajph.90.2.251. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Wyatt SB, Winters KP, Dubbert PM. Overweight and obesity: prevalence, consequences, and causes of a growing public health problem. Am J Med Sci. 2006;331(4):166–174. doi: 10.1097/00000441-200604000-00002. [DOI] [PubMed] [Google Scholar]
- 7.Mustillo S, Worthman C, Erkanli A, Keeler G, Angold A, Costello EJ. Obesity and psychiatric disorder: developmental trajectories. Pediatrics. 2003;111(4):851–859. doi: 10.1542/peds.111.4.851. [DOI] [PubMed] [Google Scholar]
- 8.Goodman E, Whitaker RC. A prospective study of the role of depression in the development and persistence of adolescent obesity. Pediatrics. 2002;110(3):497–504. doi: 10.1542/peds.110.3.497. [DOI] [PubMed] [Google Scholar]
- 9.Datar A, Sturm R. Childhood overweight and parent- and teacher-reported behavior problems: evidence from a prospective study of kindergartners. Arch Pediatr Adolesc Med. 2004;158(8):804–810. doi: 10.1001/archpedi.158.8.804. [DOI] [PubMed] [Google Scholar]
- 10.Strauss RS, Pollack HA. Social marginalization of overweight children. Arch Pediatr Adolesc Med. 2003;157(8):746–752. doi: 10.1001/archpedi.157.8.746. [DOI] [PubMed] [Google Scholar]
- 11.Janssen I, Craig WM, Boyce WF, Pickett W. Associations between overweight and obesity with bullying behaviors in school-aged children. Pediatrics. 2004;113(5):1187–1194. doi: 10.1542/peds.113.5.1187. [DOI] [PubMed] [Google Scholar]
- 12.Kolody B, Sallis JF. A prospective study of ponderosity, body image, self-concept, and psychological variables in children. J Dev Behav Pediatr. 1995;16(1):1–5. [PubMed] [Google Scholar]
- 13.Allen KL, Byrne SM, Blair EM, Davis EA. Why do some overweight children experience psychological problems? The role of weight and shape concern. Int J Pediatr Obes. 2006;1(4):239–247. doi: 10.1080/17477160600913552. [DOI] [PubMed] [Google Scholar]
- 14.Erickson SJ, Robinson TN, Haydel KF, Killen JD. Are overweight children unhappy? Body mass index, depressive symptoms, and overweight concerns in elementary school children. Arch Pediatr Adolesc Med. 2000;154(9):931–935. doi: 10.1001/archpedi.154.9.931. [DOI] [PubMed] [Google Scholar]
- 15.Ogden CL, Carroll MD, Curtin LR, McDowell MA, Tabak CJ, Flegal KM. Prevalence of overweight and obesity in the United States, 1999–2004. JAMA. 2006;295(13):1549–1555. doi: 10.1001/jama.295.13.1549. [DOI] [PubMed] [Google Scholar]
- 16.Ard JD, Rosati R, Oddone EZ. Culturally-sensitive weight loss program produces significant reduction in weight, blood pressure, and cholesterol in eight weeks. J Natl Med Assoc. 2000;92(11):515–523. [PMC free article] [PubMed] [Google Scholar]
- 17.Paeratakul S, Lovejoy JC, Ryan DH, Bray GA. The relation of gender, race and socioeconomic status to obesity and obesity comorbidities in a sample of US adults. Int J Obes Relat Metab Disord. 2002;26(9):1205–1210. doi: 10.1038/sj.ijo.0802026. [DOI] [PubMed] [Google Scholar]
- 18.Kolotkin RL, Zeller M, Modi AC, et al. Assessing weight-related quality of life in adolescents. Obesity (Silver Spring) 2006;14(3):448–457. doi: 10.1038/oby.2006.59. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19.Young-Hyman D, Tanofsky-Kraff M, Yanovski SZ, et al. Psychological status and weight-related distress in overweight or at-risk-for-overweight children. Obesity (Silver Spring) 2006;14(12):2249–2258. doi: 10.1038/oby.2006.264. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20.Thompson SH, Corwin SJ, Sargent RG. Ideal body size beliefs and weight concerns of fourth-grade children. Int J Eat Disord. 1997;21(3):279–284. doi: 10.1002/(sici)1098-108x(199704)21:3<279::aid-eat8>3.0.co;2-h. [DOI] [PubMed] [Google Scholar]
- 21.Fitzgibbon ML, Blackman LR, Avellone ME. The relationship between body image discrepancy and body mass index across ethnic groups. Obes Res. 2000;8(8):582–589. doi: 10.1038/oby.2000.75. [DOI] [PubMed] [Google Scholar]
- 22.Boyington JEA, Carter-Edwards L, Piehl M, Hutson J, Langdon D, McManus S. Cultural attitudes toward weight, diet, and physical activity among overweight African American girls. [Accessed May 24, 2008];Prev Chronic Dis. 2008 5(2) Available at: www.cdc.gov/pcd/issues/2008/apr/07_0056.htm. [PMC free article] [PubMed] [Google Scholar]
- 23.Ricciardelli LA, McCabe MP. Children’s body image concerns and eating disturbance: a review of the literature. Clin Psychol Rev. 2001;21(3):325–344. doi: 10.1016/s0272-7358(99)00051-3. [DOI] [PubMed] [Google Scholar]
- 24.Schreiber GB, Robins M, Striegel-Moore R, Obarzanek E, Morrison JA, Wright DJ. Weight modification efforts reported by black and white preadolescent girls: National Heart, Lung, and Blood Institute Growth and Health Study. Pediatrics. 1996;98(1):63–70. [PubMed] [Google Scholar]
- 25.Ayala G, Mickens L, Galindo P, Elder J. Acculturation and body image perception among Latino youth. Ethn Health. 2007;12(1):21–41. doi: 10.1080/13557850600824294. [DOI] [PubMed] [Google Scholar]
- 26.Robinson TN, Killen JD, Litt IF, et al. Ethnicity and body dissatisfaction: are Hispanic and Asian girls at increased risk for eating disorders? J Adolesc Health. 1996;19(6):384–393. doi: 10.1016/s1054-139x(96)00087-0. [DOI] [PubMed] [Google Scholar]
- 27.Hacker KA, Myagmarjav E, Harris V, Suglia SF, Weidner D, Link D. Mental health screening in pediatric practice: factors related to positive screens and the contribution of parental/personal concern. Pediatrics. 2006;118(5):1896–1906. doi: 10.1542/peds.2006-0026. [DOI] [PubMed] [Google Scholar]
- 28.Glascoe FP. Parents’ evaluation of developmental status: how well do parents’ concerns identify children with behavioral and emotional problems? Clin Pediatr (Phila) 2003;42(2):133–138. doi: 10.1177/000992280304200206. [DOI] [PubMed] [Google Scholar]
- 29.Blanchard LT, Gurka MJ, Blackman JA. Emotional, developmental, and behavioral health of American children and their families: a report from the 2003 National Survey of Children’s Health. Pediatrics. 2006;117(6) doi: 10.1542/peds.2005-2606. Available at: www.pediatrics.org/cgi/content/full/117/6/e1202. [DOI] [PubMed] [Google Scholar]
- 30.Eaton DK, Lowry R, Brener ND, Galuska DA, Crosby AE. Associations of body mass index and perceived weight with suicide ideation and suicide attempts among US high school students. Arch Pediatr Adolesc Med. 2005;159(6):513–519. doi: 10.1001/archpedi.159.6.513. [published correction appears in Pediatr Adolesc Med. 2005;159(8): 773] [DOI] [PubMed] [Google Scholar]
- 31.Substance Abuse and Mental Health Services Administration. National survey on drug use and health report. [Accessed May 26, 2008];2008 May; Available at: www.oas.samhsa.gov/2k8/youthDepress/youthDepress.pdf. [PubMed]
- 32.Surgeon General. Mental health: a report of the Surgeon General. [Accessed May 26, 2008]; Available at: www.surgeongeneral.gov/library/mentalhealth/chapter3/sec6.html.
- 33.Staub L, Morgenstern L. Stroke in Hispanic Americans. Neurol Clin. 2000;18(2):291–307. doi: 10.1016/s0733-8619(05)70193-6. [DOI] [PubMed] [Google Scholar]
- 34.Rochon PA, Mashari A, Cohen A, et al. The inclusion of minoriy groups in clinical trials: problems of under representation and under reporting of data. Account Res. 2004;11(3–4):215–223. doi: 10.1080/08989620490891412. [DOI] [PubMed] [Google Scholar]
- 35.US Census Bureau. Hispanic population of the United States. [Accessed May 26, 2008]; Available at: www.census.gov/population/www/socdemo/hispanic/hispanic.html.
- 36.Anderson SE, Cohen P, Naumova EN, Jacques PF, Must A. Adolescent obesity and risk for subsequent major depressive disorder and anxiety disorder: prospective evidence. Psychosom Med. 2007;69(8):740–747. doi: 10.1097/PSY.0b013e31815580b4. [DOI] [PubMed] [Google Scholar]
- 37.McFarlane JM, Groff JY, O’Brien JA, Watson K. Behaviors of children who are exposed and not exposed to intimate partner violence: an analysis of 330 black, white, and Hispanic children. Pediatrics. 2003;112(3) doi: 10.1542/peds.112.3.e202. Available at: www.pediatrics.org/cgi/content/full/112/3/e202. [DOI] [PubMed] [Google Scholar]
- 38.Aisenberg E, Herrenkohl J. Community violence in context: risk and resilience in children and families. J Interpers Violence. 2008;23(3):296–315. doi: 10.1177/0886260507312287. [DOI] [PubMed] [Google Scholar]