Effect of a school based Intervention on self esteem, body image, eating attitudes and behavior of adolescents with obesity in selected schools of Kerala - A Pilot Study

 

Cebi Paul¹*, Dr. Usha V K²

¹Asst. Professor, Dept. of Mental Health Nursing, MOSC College of Nursing, Kolenchery, Kerala.

²Principal, Govt. Nursing College, Kottayam, Kerala.

 

ABSTRACT:

Adolescence, by its very nature, is associated with weight gain, and many adolescents experience dissatisfaction with their changing bodies. This in turn leads to low self esteem and adoption of unhealthy and erroneous eating behaviors. Methodology: The study was conducted among 34 (17 each in intervention and control group) obese adolescents with age between 12 to 18 years, studying in two selected schools of Ernakulam district using a quazi experimental pre test post test control group design. Pretest was conducted among selected students by using Objectified body consciousness scale, Eating attitude test (EAT-26), ACRON Eating Disorders Inventory and Rosenberg’s self esteem scale. After the pretest, the obese adolescents in the intervention group was given the structured school based intervention program. The post test was conducted immediately after the last session of the intervention and 4 weeks following the intervention using the same tools. Result: The study result showed that there is a significant statistical difference between eating attitude scores of intervention and control group (p = 0.02). Similarly there was significant statistical difference in the eating behaviour, body image and self esteem scores too. Conclusion: According to the findings of the present study, the school based intervention was effective in improving the eating attitude, eating behaviour and body image among adolescents with obesity. Hence the study concluded that school based interventions will serve as preventive interventions for eating disorder among adolescents with obesity.

 

 

INTRODUCTION:

Adolescents, as defined by the World Health Organization and United Nations, are those individuals aged 10-19 years. There are currently 1.2 billion adolescents in the world, making up 18% of the world’s population. Around 1 in 6 persons in the world is an adolescent¹. Eighty-eight percent of adolescents live in the developing world, and more than half of the world’s adolescents live in South Asia or East Asia and Pacific region.²

 

Childhood obesity affects both developed and developing countries of all socio-economic groups, irrespective of age, sex or ethnicity. It has been estimated that worldwide over 22 million children under the age of 5 are obese, and one in 10 children is overweight.³ Also, obesity is one among those chronic diseases that pose threat to health of adolescents globally.⁴

 

Adolescence is one of the most rapid phases of human development. Biological maturity precedes psychosocial maturity. Children experience dramatic physical, psycho-social and cognitive changes during adolescents, which is actually perplexing for them. Puberty, by its very nature, is associated with weight gain, and many adolescents experience dissatisfaction with their changing bodies. Obesity in children and adolescents has been associated with several important chronic diseases such as diabetes, asthma, sleep apnea, and gallbladder disease.⁵ In a culture that glorifies being thin, some adolescents; mostly girls become overly preoccupied with their physical appearance. Majority of them experience weight teasing⁸ which adds on to this and results in adoption of erroneous eating behaviours ⁹ and development of poor self esteem.¹⁰ The current study assessed the effect of school based intervention on body image, self esteem, eating attitude and eating behaviour of adolescents with obesity.

 

METHODS:

Study design and procedure:

The study was conducted among obese adolescents with age between 12 to 18 years, studying in two selected schools of Ernakulam district. The research design adopted for the study was quazi experimental pre test post test control group design. The schools were selected conveniently and the students studying in grades 7 to 12 were screened using calibrated weight scale and standing stadiometer. Adolescent with BMI greater than 90^th percentile for girls and 95^th percentile for boys according to revised Indian Academy of Pediatric growth chart were included in the study. Samples were selected using purposive sampling technique. ^6,7A total of 34 adolescents with 17 each in intervention and control group were included in the study.

 

Administrative permission was obtained from the Director of General education, District Educational Officer and the principals of selected schools. Approval was also obtained from scientific review committee and institutional ethics committee. A total of 603 (367 and 236 from each school) adolescents from two schools were screened for obesity. Among them 102 (70 and 32 from each school) adolescents were found to have obesity. From these adolescents 17 from each school are selected to participate in the study. After providing adequate information regarding the study, assent was taken from the subjects and consent was taken from their parents. After obtaining the consent and assent, pretest was conducted among selected students by using Objectified body consciousness scale, Eating attitude test (EAT-26), ACRON Eating Disorders Inventory and Rosenberg’s self esteem scale. After the pretest, the obese adolescents in the intervention group was given the structured intervention program over three weeks. The post test was conducted immediately after the last session of the intervention and 4 weeks following the intervention using the same tools. For the control group, the post test was done at the end of three weeks and then after 4 weeks without giving the intervention (Figure 1).

 

Figure 1: Schematic representation of research design

 

Measures:

Adolescents were initially screened using calibrated weight scale and standing stadiometer. After initial screening, adolescents who met the inclusion criteria and willing to participate in the study were selected randomly. The data were collected from them using a structured socio-personal performa, Objectified body consciousness scale, Eating attitude test, ACRON Eating Disorders Inventory and Rosenberg’s self esteem scale.

 

1.     Calibrated weight scale and standing stadiometer:

The weight and height of the subjects were assessed using calibrated weight scale and standing stadiometer respectively. BMI was calculated based on the obtained height and weight.

 

2.     Socio personal performa:

It included 22 items such as age, gender, religion, type of family, area of residence, education of father, education of mother, occupation of mother, occupation of father, number of meals per day, number of snacks per day, frequency of consumption of fast foods, frequency of consumption of junk foods, regularity of exercise, weight teasing by family and friends, presence of disorders related to thyroid and menstruation and family history of obesity.

 

3.     Objectified Body Consciousness Scale:

Body image of adolescents is measured using Objectified body consciousness scale. It is a 24 item scale with three sub scales viz: body surveillance, body shame and appearance control beliefs. The body surveillance subscale is a measure of defining the body consciousness by how it looks as opposed to how it feels. The body shame subscale measure whether someone believes that they are a bad person because they do not meet the cultural standards for what a body should look like. The appearance control belief subscale measures whether or not a person believes they can control their own appearance, or if it is controlled by other things. The reliability of the tool is established as 0.75. The total score ranges from 24 to 168, with a higher score indicating a higher body consciousness.

 

4.     Eating Attitude Test (EAT- 26):

The eating attitude of young adolescents with obesity is measured Eating attitude test (EAT-26). It is a 26 item standardized self report measure of symptoms and concerns characteristics of eating disorders. The EAT has been a particularly useful screening tool to assess eating disorder risk in high school, college and other special risk ample such as athletes. This tool has three subscales viz: dieting, bulimia and food pre occupation and oral control subscales. A higher score of 20 or higher indicate concerns regarding body weight, body shape and eating.

 

5.     ACRON Eating Disorder Inventory:

Eating behavior of young adolescents is measured using ACRON Eating Disorders Inventory. This tool is a 30 item questionnaire with three subscales viz: anorexia, bulimia, binge eating and food addiction subscales. Each subscale has ten items. The reliability of this tool is established to be 0.94. If the respondent is marking 5 to 10 in any category, it indicates an advanced eating disorder.

6.     Rosenberg Self esteem Scale:

Self esteem will be measured using Rosenberg”s self esteem scale. It is a tool for assessing global self esteem which is developed by Morris Roesnberg. It is a vital part of self esteem measure in social science research and is mainly used in adolescents. Ten items are included in the self report measure that pertains to self worth and self acceptance. The reliability of this tool is established as 0.77.

 

Description of intervention:

The school based intervention program was a program consisting of three sessions viz: Enhancing body image, Building self-esteem and improving eating attitude and behavior given over three weeks. It was an activity based intervention which included group discussions, group activities, and take home work books.

 

After completion of the first session on enhancing body image, the students were given a body image workbook. The activities of the work book included daily self evaluation of body image, a positive statement about your body image today, positive self affirmations, goal for achieving positive body image and activities undertaken to achieve it, managing negative body thoughts. The students were made to complete it immediately following the intervention under the supervision of the researcher. They were then made to complete it on a daily basis for the next four days of the week under the supervision of the researcher.

 

The second session was focusing on building self esteem and the students were given a self esteem workbook following the session. The activities of the work book included positive qualities record and positive activities journal. The students were made to complete it immediately following the intervention under the supervision of the researcher. They are then made to complete it on a daily basis for the next four days of the week under the supervision of the researcher.

 

The third session was focusing on improving the eating attitude and behaviour of adolescents with obesity. This included an interactive session on healthy eating along with some group activities.

 

An exercise program was also given along with the intention with an intention to inculcate a regular exercise habit among the participants.

 

Data analysis:

Data were analyzed using R software using appropriate descriptive and inferential statistics. Socio personal variables were reported using frequency and percentage. Effectiveness of school based intervention program was identified using repeated measures ANOVA. The association of socio personal variables with body image, eating attitude, eating behviour and self esteem was assessed using Mann Whitney U test and Kruskal Wallis test based on the number of categories of each socio demographic variable.

 

RESULTS:

Description of socio - personal variables:

Majority (70.59%) of the subjects were males and most of them (64.71%) belonged to Hindu religion. All the subjects were residing in urban area and majority (55.88%) had family history of obesity. Most of them (5.67%) had no regular exercise and majority (55.88%) used to consume 4 meals per day. 67. 65% of the subjects rarely consumed fast foods. Most of them (32.35%) used to consume junk foods either rarely or once in a week. 61.76% subjects reported weight teasing by peers.

 

Description of eating attitude and eating behaviour among adolescents with obesity:

The median eating attitude score among adolescents with obesity is 14 with q1 (Maximum score 78) and q2 of 8 and 20 respectively. The mean eating behaviour score among adolescents with obesity is 7.35 (Maximum score 30) with a standard deviation of 3.23.

 

Description of body image and self esteem among adolescents with obesity:

The mean body image score among adolescents with obesity is 101.41 (Maximum score 168) with a standard deviation of 10.8. This higher mean score indicates poor body image perception among adolescents with obesity. The mean self esteem score among adolescents with obesity is 16.97 (Maximum score 30) with a standard deviation of 4.12.

 

Effect of school based intervention on eating attitude, eating behaviour, body image perception and self esteem of adolescents with obesity:

Repeated measures ANOVA was performed to check whether there is a significant difference in the average eating attitude, eating behaviour, body image perception and self esteem scores before and after intervention and also between intervention and control group. It is observed that there is a significant statistical difference in the average eating attitude scores before intervention and after first post test (p = 0.00) and also after second post test (p = 0.00). A significant statistical difference was also identified between eating attitude scores of intervention and control group (p = 0.02). Considering the eating behaviour, it is observed that there is a significant statistical difference in the average eating behaviour scores before intervention and after first post test (p = 0.00) and also after second post test (p = 0.00). A significant statistical difference was also identified between eating behaviour scores of intervention and control group (p = 0.045) (Table 1).

 

Table 1: Effect of school based intervention on eating attitude, eating behaviour, body image perception and self esteem of adolescents with obesity n = 34

Variable		Group	Median	q1, q2	F value	p value
EATING ATTITUDE	Pre test	Intervention group	16.00	12,22	1.57	0.02*
		Control group	12.00	5,17
	Post test 1	Intervention group	08.00	4,12
		Control group	09.00	3,12
	Post test 2	Intervention group	07.00	4,11
		Control group	09.00	3,12
EATING BEHAVIOUR	Pre test	Intervention group	8.47	2.98	4.32	0.045*
		Control group	6.23	3.17
	Post test 1	Intervention group	4.88	2.45
		Control group	3.53	2.55
	Post test 2	Intervention group	4.94	2.36
		Control group	3.17	2.24
BODY IMAGE PERCEPTION	Pre test	Intervention group	102.94	6.49	4.73	0.00*
		Control group	99.88	12.75
	Post test 1	Intervention group	87.24	7.86
		Control group	99.71	12.56
	Post test 2	Intervention group	85.94	7.01
		Control group	98.53	12.40
SELF ESTEEM	Pre test	Intervention group	17.71	4.06	1.54	0.92
		Control group	16.24	4.18
	Post test 1	Intervention group	21.76	3.33
		Control group	20.47	3.47
	Post test 2	Intervention group	21.88	3.28
		Control group	20.53	3.45

* Significant at p < 0.05

 

Also, there is a significant statistical difference in the average body image scores before intervention and after first post test (p = 0.00) and also after second post test (p = 0.00). A significant statistical difference was also identified between body image scores of intervention and control group (p = 0.00). In case of self esteem, even though a significant statistical difference was observed in the average self esteem scores before intervention and after first post test (p = 0.00) and also after second post test (p = 0.00), no significant statistical difference was identified between self esteem scores of intervention and control group (p = 0.92) (Table 1).

 

Relationship of body image with eating attitude and eating behaviour of adolescents with obesity.

Relationship between body image and eating attitude was calculated using Spearman's rank correlation and the relationship between body image and eating behaviour was calculated using Karl Pearson’s correlation. A moderate positive correlation of body image was identified with eating attitude (r=0.51, p=0.002) and eating behaviour of adolescents with obesity (r=0.35, p=0.043).

 

DISCUSSION:

The findings of the present study is supported by another study which examined the effect of an interactive, school‐based, self‐esteem education program on the body image, eating attitudes and behaviors of young male and female adolescents following the program and after 12 months. The study identified that the program significantly improved the aspects of their self‐esteem. Social acceptance, physical appearance, and athletic ability became less important for the intervention students and more important for control students. The students had significantly decreased importance of physical appearance to their self‐esteem at 12 months.¹¹ Another study showed that there is a significant reduction in Weight Concerns Scale scores which was used for assessing eating attitude and eating behaviour after attending an Internet-based psychosocial intervention program. In addition, there was a significant reduction in scores on the EDI bulimia subscale from baseline to post intervention.¹²

 

CONCLUSION:

According to the findings of the present study, the school based intervention was effective in improving the eating attitude, eating behaviour and body image among adolescents with obesity. Hence these kinds of interventions can be adopted as preventive interventions at school level so that children will not develop poor eating attitude and body image perception and also they will not slip into abnormal eating behaviours.

 

LIMITATIONS:

The study has not evaluated the long term effect of school based intervention.

 

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Received on 31.08.2020          Modified on 14.10.2020

Accepted on 17.11.2020        © AandV Publications all right reserved