Where Perception Meets Reality: Self-Perception of Weight in Overweight Adolescents

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1 Where Perception Meets Reality: Self-Perception of Weight in Overweight Adolescents WHAT S KNOWN ON THIS SUBJECT: The prevalence of overweight and obesity in adolescents has risen in recent years. Previous measures of weight misperception have ranged from 20% to 40% in overweight patients. Some studies have revealed positive and negative effects of overweight perception. WHAT THIS STUDY ADDS: We provide recent, nationally representative information on the prevalence of weight misperception in overweight adolescents in the United States and its relationship to demographic characteristics and weightrelated behaviors, assisting clinicians in their individualized counseling efforts with overweight and obese patients. abstract OBJECTIVE: The goal of this study was to examine weight misperception among overweight adolescents in recent years and compare the demographic characteristics and weight-related behaviors of overweight adolescents who accurately and inaccurately perceive their weight status. METHODS: We used data from the nationally representative Youth Risk Behavior Surveillance System, collected every 2 years from 1999 through On the basis of self-reported height and weight, BMI percentile for age and sex was calculated. Overweight and obese respondents (BMI 85th percentile) were classified into 2 groups: (1) misperceivers (weight perception about right or underweight ) or (2) accurate perceivers (weight perception overweight ). We examined the proportion of misperceivers at each time point. Using the 2007 data, we compared demographic characteristics and weight-related behaviors of accurate perceivers and misperceivers with bivariate and multivariate analyses. RESULTS: Among overweight adolescents, the overall proportion of misperceivers ranged between 29% and 33% from 1999 through In 2007, 23% of overweight girls and 40% of overweight boys were misperceivers (P.001). Both male and female accurate perceivers were significantly more likely than misperceivers to report trying to maintain or lose weight, exercising for weight control, and eating less for weight control. Adjusting for age, race/ethnicity, and BMI percentile, no significant differences in unhealthy weight-related behaviors were found between accurate perceivers and misperceivers in boys or girls. Male accurate perceivers were significantly less likely to report achieving recommended levels of fruit and vegetable intake and physical activity. CONCLUSIONS: Nearly 3 in 10 overweight adolescents do not consider themselves overweight. Those with an accurate weight perception reported some healthy weight-related behaviors but not higher levels of unhealthy weight-related behaviors. With the substantial prevalence of weight misperception, clinicians should consider their patients perceived weight status when pursuing patient-centered counseling of overweight adolescents. Pediatrics 2010;125:e452 e458 AUTHORS: Nicholas Murphy Edwards, MD, a Sandra Pettingell, PhD, b and Iris Wagman Borowsky, MD, PhD a a Division of General Pediatrics, Department of Pediatrics, and b Center for Adolescent Nursing, School of Nursing, University of Minnesota, Minneapolis, Minnesota KEY WORDS adolescent, BMI, obesity, perception, self-assessment ABBREVIATIONS CDC Centers for Disease Control and Prevention YRBS Youth Risk Behavior Survey FV fruit and vegetable PA physical activity OR odds ratio CI confidence interval The views in this article are those of the authors and do not necessarily represent the views of the Centers for Disease Control and Prevention. doi: /peds Accepted for publication Sep 2, 2009 Address correspondence to Nicholas Murphy Edwards, MD, University of Minnesota, Department of Pediatrics, Division of General Pediatrics, 717 Delaware St SE, 3rd Floor West, Minneapolis, MN edwar387@umn.edu PEDIATRICS (ISSN Numbers: Print, ; Online, ). Copyright 2010 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose. e452 EDWARDS et al

2 ARTICLES The prevalence of overweight among children and adolescents has risen in recent years and has become a focus of public health efforts nationally. 1 Thirty years ago, the prevalence of overweight and obesity (BMI 85th percentile) in the pediatric population was 15%; in it was more than 30%. 2 Recent studies indicate the upward trend may be stabilizing over the previous few years. 3 There are many acute and chronic comorbidities associated with overweight and obesity; for instance, higher BMI during childhood is significantly associated with higher coronary heart disease risk in adulthood. 4 Despite the increase in overweight prevalence and the increased attention by government organizations and the media on the public health problem of obesity, studies have revealed that many overweight adolescents do not recognize their own overweight status. For example, Goodman et al 5 examined data from 1994 to 1995 and found that for nearly 40% of obese adolescents, neither the adolescent nor their parent recognized the adolescent s obesity. Brener et al 6 found that 20% of overweight participants in a convenience sample of adolescents reported they were underweight; more recently, Standley et al 7 found that 26% of overweight adolescents in a sample in London did not accurately perceive their weight status. In addition, sex and racial/ethnic disparities exist in adolescents around the issue of weight perception. 6,8 Assessing recognition of the problem is a key component of patient-centered counseling. These counseling methods, such as motivational interviewing, have been efficacious 9 and have been recommended when addressing overweight in the clinical setting. 10,11 Although overweight among adolescents has increased over the previous decade, the recognition of overweight status among adolescents in the United States during this time period is unclear. It is unclear how weight misperception relates to weight-related behaviors in overweight adolescents; most research thus far has focused on behaviors in all overweight adolescents 12 and all adolescents who perceive themselves as overweight. 13 Shi et al 13 found nearly twice as many adolescents who perceive themselves as overweight reported dieting in the previous year compared with those who perceived themselves as normal. Information about weight-related behaviors in overweight misperceivers may be useful for clinicians in their counseling efforts; for example, if an overweight adolescent reports he or she is normal or underweight, the clinician may consider assessing weightrelated behaviors and matching counseling efforts to patients self-efficacy. The purpose of this study was to examine within overweight adolescents the (1) proportion of misperceivers (those who do not assess themselves as overweight) over time and (2) demographic characteristics and weightrelated behaviors of accurate perceivers compared with misperceivers. We examined weight self-perception in overweight adolescents by using nationally representative data collected every 2 years from 1999 to The weight-related behaviors compared among accurate perceivers and misperceivers in 2007 included both healthy and unhealthy practices. METHODS Study Population and Design The Centers for Disease Control and Prevention (CDC) national Youth Risk Behavior Survey (YRBS) is a biennial nationally representative survey of students in 9th through 12th grade. 14 Self-report of height and weight was added in For this study, data from the 1999 through 2007 surveys were used to describe perception accuracy over a range of years. Analysis of demographic characteristics and weight-related behaviors was conducted on data from the 2007 survey. Survey administration was approved by the CDC s institutional review board and secondary analysis was approved by the University of Minnesota s institutional review board. A 3-stage cluster sample design produced a nationally representative sample of students in grades 9 to 12 who attend public and private schools. Oversampling of black and Hispanic students was performed to enable separate analysis. 14 The surveys were completed voluntarily with the permission of schools and parents. Surveys were selfadministered with the guidance of trained data collectors during 1 class period, and no identifying information was recorded. The numbers of participants were in 1999, in 2001, in 2003, in 2005, and in The overall response rates (school response rate multiplied by the participant response rate) were 66% in 1999, 63% in 2001, 67% in 2003, 67% in 2005, and 68% in Measures Survey questions pertaining to height, weight, age, sex, race/ethnicity, weight perception, and weight-related behaviors were used. BMI was calculated by converting the self-report of height in feet and inches and weight in pounds to metric units and by using the standard formula (weight in kg/m 2 ). We used a program available from the CDC to estimate BMI percentiles, which accounts for age and sex. 20 Age in months was used to obtain the BMI percentiles, estimated by taking the age in years recorded on the survey, multiplying by 12, and adding 6. Implausible BMI val- PEDIATRICS Volume 125, Number 3, March 2010 e453

3 ues were excluded by using the CDC s criteria. 20 BMI percentile categories were assigned according to the 2000 growth charts as follows: 95th percentile, obese; 85th to 95th percentile, overweight; 5th to 85th percentile, normal; and 5th percentile, underweight. 21 The present study included only respondents who were classified as overweight or obese (BMI 85th percentile), collectively referred to in this article as overweight. Self-perception of weight was measured by asking the question, How do you describe your weight? Response options included very overweight, slightly overweight, about the right weight, slightly underweight, and very underweight. To aid in analysis, response options were collapsed into 2 categories: (1) overweight (includes very and slightly ) and (2) about right or underweight (includes very and slightly ). Using these 2 weight perception categories, overweight respondents who described themselves as overweight were classified as accurate perceivers; overweight respondents who described themselves as about right or underweight were classified as misperceivers. Grade level was described by 4 categories (grades 9 12). Sex was classified as male or female by asking What is your sex? Race/ethnicity was ascertained by asking 2 questions: (1) Are you Hispanic or Latino? (yes or no) ; and (2) What is your race? Possible classifications were American Indian or Alaska Native, Asian, black or African American (non-hispanic), Hispanic or Latino, Native Hawaiian or other Pacific Islander, white (non-hispanic), multiple-hispanic, or multiple non- Hispanic. To maintain sufficient numbers of participants in each category, categories were collapsed into the following: black or African American (non-hispanic), Hispanic or Latino, white (non-hispanic), and other. Weight control behaviors were assessed with several questions. Participants were asked, which of the following are you trying to do about your weight? Possible responses were, lose weight, gain weight, stay the same weight, or I am not trying to do anything about my weight. Questions about behaviors used in the previous 30 days to lose weight or to keep from gaining weight were, did you exercise, eat less food, fewer calories, or foods low in fat, go without eating for 24 hours or more (also called fasting), take any diet pills, powders, or liquids without a doctor s advice, or vomit or take laxatives? Possible responses were yes or no. Other weight-related activities analyzed were fruit and vegetable (FV) intake (percentage of students who ate FVs 5 times per day during the previous 7 days), mild physical activity (PA) (percentage of students who participated in PA that did not make them sweat or breathe hard for 30 minutes or more on 5 days of the previous 7 days), and moderate-to-vigorous PA (percentage of students who exercised or participated in PA that made them sweat and breathe hard for 20 minutes on 3 of the previous 7 days). These thresholds are consistent with goals and recommendations published by the US government Analysis Statistical analyses were performed by using Stata 9.2 (StataCorp, College Station, TX). An level of.05 was used to indicate statistical significance and all tests were 2-sided. All analyses were performed on weighted data to reflect a nationally representative sample and controlled for the cluster sampling design. We examined the proportions of overweight participants with weight misperception at each of the 5 waves of data. To compare demographic and weight-related characteristics and behaviors of accurate perceivers and misperceivers, cross tabulations were examined by using 2 tests for categorical variables and t tests for continuous variables. Weight-related behaviors of accurate perceivers were compared with misperceivers by using multivariate logistic regression, adjusting for age, race/ ethnicity, and BMI percentile, and stratifying by sex. On the basis of previous evidence of sex differences in weight perception, stratification by sex was performed. 5,6 RESULTS The number of participants available for analysis in 1999, 2001, 2003, 2005, and 2007 were , , , , and , respectively. The proportion of participants at 85th percentile in each of the years studied were 25% in 1999, 24% in 2001, 27% in 2003, 29% in 2005, and 29% in Weight Misperception in From 1999 through 2007, the proportion of overweight adolescents who misperceived their weight ranged from 29% to 33%. In 1999, 30.6% of overweight adolescents were misperceivers. Subsequently, the proportion of misperceivers was 30.7% in 2001, 31.2% in 2003, 29.3% in 2005, and 32.8% in Specifically in 2007, 0.8% of overweight respondents described themselves as very underweight, 1.7% as slightly underweight, 30% as about the right weight, 56% as slightly overweight, and 12% as very overweight. Demographic Characteristics in 2007 The mean age of misperceivers was years (SE: 0.05) compared with years (SE: 0.03) for overweight youth who accurately perceived their e454 EDWARDS et al

4 ARTICLES weight status (P.12). Among male respondents, 40.2% were misperceivers, whereas 22.6% of female respondents inaccurately perceived their weight status (P.001; Table 1). Over 4 in 10 African American respondents (45.2%) were misperceivers, whereas 28.2% of white respondents were misperceivers (P.001). Significantly more Hispanic respondents were misperceivers (34.7%) compared with white respondents (P.02). Significantly more African American respondents were misperceivers compared with Hispanic respondents (P.009) and respondents of other races/ethnicities (32%; P.001). The proportion of respondents of other races/ethnicities who were misperceivers did not differ significantly from white respondents or Hispanic respondents. Weight-Related Characteristics and Behaviors in 2007 The mean BMI percentile of the accurate perceivers was 95% (SE: 0.13), which was significantly higher compared with the misperceivers, who had a BMI percentile of 92% (SE: 0.12) (P.001). In bivariate analyses, the proportion of accurate perceivers reporting engaging in most of the weight-related behaviors assessed was significantly higher than the proportion of misperceivers engaging in these activities (Table 2). Significantly fewer accurate perceivers reported achieving recommended levels of FV intake and PA compared with misperceivers. Table 3 contains measures from the adjusted model of weight-related behaviors among overweight adolescents who accurately perceive and misperceive their weight status. When compared with misperceivers, accurate perceivers of both sexes had significantly higher odds of engaging in several weight-related behaviors, adjusting for age, race/ethnicity, and BMI percentile. Among female participants, Misperceivers P TABLE 1 Demographic Characteristics: Accurate Perceivers Versus Misperceivers, 2007 Characteristic Accurate Perceivers (N 2479), n (%) a (N 1208), n (%) a Sex.001 Female 1206 (77.4) 352 (22.6) Male 1274 (59.8) 856 (40.2) Race/ethnicity African American 382 (54.8) 314 (45.2).001 Hispanic 238 (65.3) 126 (34.7).02 Other 420 (67.8) 200 (32.2).10 White 1402 (71.8) 550 (28.2) Referent a All counts and percentages are weighted. TABLE 2 Weight-Related Behaviors: Misperceivers Versus Accurate Perceivers, 2007 Behavior Accurate Perceivers Misperceivers P (N 2478), % (N 1204), % Weight-related behaviors, % in each group reporting behavior Weight control or loss, trying to lose or stay same Exercise a Eat less food, fewer calories, or food low in fat a Fasting a Use of diet supplements a Vomiting or laxative use a In the previous week Ate 5 servings FV per day Had 60 min PA on 5 d Had 20 min of moderate-to-vigorous PA 3 d Proportions reported are unadjusted. a Used in previous 30 days to lose weight or prevent weight gain. TABLE 3 Weight-Related Behaviors: ORs of Accurate Perceivers Versus Misperceivers, 2007 Question OR a 95% CI P Female Participants Weight control or loss, trying to lose or stay same Specific weight control behaviors (in previous 30d) Exercise Eat less food, fewer calories, or food low in fat Fasting Use of diet supplements Vomiting or laxative use In previous week Ate 5 servings of FV per day Had 60 min PA on 5 d Had 20 min of moderate-to-vigorous PA 3 d Male Participants Weight control or loss, trying to lose or stay same Specific weight control behaviors (in previous 30 d) Exercise Eat less food, fewer calories, or food low in fat Fasting Use of diet supplements Vomiting or laxative use In previous week Ate 5 servings of FV per day Had 60 min PA on 5 d Had 20 min of moderate-to-vigorous PA 3 d ORs reported are from a logistic regression model, adjusting for age, race/ethnicity, and BMI percentile. a Values represent odds of accurate perceivers responding affirmatively relative to odds of misperceivers responding affirmatively. accurate perceivers had nearly 3 times the odds of trying to lose weight or stay the same weight when compared with misperceivers (odds ratio [OR]: 2.7 [95% confidence interval (CI): ]). Among male respondents PEDIATRICS Volume 125, Number 3, March 2010 e455

5 who were boys, accurate perceivers had over 4 times the odds of reporting attempting weight maintenance or weight loss compared with misperceivers (OR: 4.2 [95% CI: ]). Both male and female accurate perceivers had significantly higher odds of exercising and eating less to lose or maintain weight compared with misperceivers. Weight perception accuracy was not significantly associated with fasting, using diet supplements, vomiting, or using laxatives for weight control among overweight adolescents. Male accurate perceivers had significantly lower odds of reporting recommended levels of FV intake and PA in the week before the survey administration. Among female accurate perceivers compared with female misperceivers, there was no significant difference in the odds of reporting recommended levels of FV intake and PA. DISCUSSION In this nationally representative sample of overweight adolescents, we found that the proportion of overweight adolescents who were misperceivers (reported they are about right or underweight ) was substantial, ranging from 29% to 33% from 1999 through Significantly more male respondents were misperceivers compared with female respondents. In addition, both female and male accurate perceivers had significantly higher odds of reporting some healthy weight-related behaviors compared with misperceivers, after adjusting for age, race/ethnicity, and BMI percentile. Our finding that nearly 1 in 3 overweight adolescents misperceives their weight coincides with previous findings. In previous studies of adolescents, the proportion of misperceivers ranged from 20% to 40%, 5 7,13 and recent adult data shows that the rate of weight misperception increased from 32% in the years to 38% in the years There may be opposing influences on weight perception in children. Some factors could decrease misperception: childhood overweight and obesity is perceived as a serious problem, 27 and exposure to weight-related media is positively associated with weight-related behaviors in adolescent girls. 28 However, in some populations overweight perception is associated with psychological distress 29 ; this may provide a disincentive for developing an overweight perception. There is also evidence that despite increasing weight in the general population, recent improvements have been reported in body image in adolescents. 30 We found that overweight male adolescents were more likely to be misperceivers compared with overweight female adolescents. The authors of previous studies investigating weight misperception in adolescents have also found higher rates of misperception among overweight boys compared with overweight girls. 5,6 Wardle et al 31 reported gender differences in weight perception in a study of university students from several countries, such as a pattern of underestimation of weight in men. Investigators have explored various possible explanations for these differences. Field et al 32 found gender differences in influences on weight-related concerns (eg, parental opinion about a child s weight affects weight concerns more in girls than in boys), and comparing one s own body with images found in the media (media body comparison) has been demonstrated to mediate effects on body dissatisfaction among adolescent girls but not adolescent boys. 33 In our study, African American and Hispanic respondents were significantly more likely to be misperceivers compared with white respondents. This finding coincides with other research finding race/ethnicity differences in weight perception. 7,34 Neumark-Sztainer et al 8 found that adolescent girls who were African American reported fewer weightrelated concerns compared with adolescent girls who were white. Significant differences in BMI for age exist across races/ethnicities, with higher rates of obesity found in some groups of Mexican American and black youth compared with white children and adolescents. 3 If health disparities are to be eliminated, we need to better understand how these differences in perception may disturb progress toward reducing overweight and obesity. After adjusting for age, race/ethnicity, and BMI percentile, we found that overweight accurate perceivers of both sexes had significantly higher odds of reporting several healthy weightrelated behaviors, whereas the odds of reporting some unhealthy weightrelated behaviors were not significantly higher among accurate perceivers. The authors of other studies of adolescents have linked unhealthy weight-related behaviors with overweight 12 and overweight perception, 13 but these studies did not focus on overweight misperceivers. Accurate perception of overweight status was not without its downsides. Accurate perceivers were less likely to report recommended levels of PA and FV intake. This is consistent with studies in adults, 35 but Shi et al 13 did not find that FV intake differed by weight perception. One potential explanation for the difference in FV intake is that accurate perceivers may be eating less overall, although these differences need to be replicated before any major conclusions can be reached. One limitation of this study was the use of self-report to calculate BMI. Objective measures of height and weight are e456 EDWARDS et al

6 ARTICLES REFERENCES 1. Centers for Disease Control and Prevention. DATA2010: The healthy people 2010 database. Available at: cdc.gov/data2010. Accessed August 29, Ogden CL, Yanovski SZ, Carroll MD, Flegal KM. The epidemiology of obesity. Gastroenterology. 2007;132(6): Ogden CL, Carroll MD, Flegal KM. High body mass index for age among US children and adolescents, JAMA. 2008; 299(20): Baker JL, Olsen LW, Sorensen TIA. Childhood body mass index and the risk of coronary heart disease in adulthood. N Engl J Med. 2007;357(23): Goodman E, Hinden BR, Khandelwal S. Accuracy of teen and parental reports of obesity more accurate than self-report and are preferred, although self-reported data are valuable when no directly measured source is available. 36 Many studies have revealed that bias occurs in self-report compared with direct measures of height and weight, mostly overestimation of height and underestimation of weight. 36,37 The authors of a study measuring the reliability of the height and weight self-report in YRBS found the questions to be highly reliable, with high correlation between self-reported values and measured values, although with overestimation of height by an average of 2.7 in, and underestimation of weight by an average of 3.5 lb. 38 If the potential misclassification is nondifferential, this bias could result in underestimation of weight misperception in our sample because the misperceivers had a lower mean BMI percentile compared with those with accurate weight perception. Additional studies on the topic of weight perception disparity in adolescents should explore these relationships by using objective measurements of height and weight when possible. Another study limitation is the unavailability of a socioeconomic status marker in the YRBS. Thus, socioeconomic status remains a potential confounder. In addition, because height and weight questions were not introduced until 1999, the data used to calculate the proportion of overweight adolescents who are misperceivers is limited to 1999 through Thus, the present study does not assess misperception before 1999, when the rise in prevalence of overweight in children began. 39 The findings in this study have important implications for clinical practice. Our findings that a substantial proportion of overweight adolescents do not recognize they are overweight is a reminder to clinicians that a variety of counseling strategies, such as patientcentered counseling and motivational interviewing, will be needed to combat overweight and obesity. 11 Misperceivers may need counseling directed at recognition of the problem; the findings that accurate perceivers did not have significantly higher levels of unhealthy weight-related behaviors after adjustment for age, race/ethnicity, and BMI percentile provide some support that increased recognition may not be harmful. In addition, the findings of higher levels of some healthy weightrelated behaviors in accurate perceivers provide support to the hypothesis that recognition of one s own overweight status may carry some benefit. However, on the basis of the findings that some accurate perceivers were less likely to achieve recommended levels of FV intake and PA, clinicians need to remain focused on educating their overweight and obese patients on healthy lifestyle choices. CONCLUSIONS The data presented in this study highlight the substantial weight misperception that exists in overweight adolescents. Accurate weight perception is associated with several healthy weight-related behaviors. Clinicians should individualize their approach to their overweight patients, depending on the patients recognition of the problem. ACKNOWLEDGMENTS The authors were supported in part by the Adolescent Health Protection Program (School of Nursing, University of Minnesota) grant number T01-DP (Principal Investigator: Bearinger) from the CDC. We thank the fellows, faculty, and staff in the Department of Pediatrics and School of Nursing, University of Minnesota for their assistance. and body mass index. 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7 Ottesen G. Perceptions of weight and associated factors of adolescents in Jiangsu province, china. Public Health Nutr. 2007; 10(3): Brener ND, Kann L, Kinchen SA, et al. Methodology of the youth risk behavior surveillance system. MMWR Recomm Rep. 2004; 53(RR-12): Kann L, Kinchen SA, Williams BI, et al. Youth risk behavior surveillance: United States, MMWR CDC Surveill Summ. 2000; 49(5): Grunbaum JA, Kann L, Kinchen S, et al. Youth risk behavior surveillance: United States, MMWR Surveill Summ. 2004; 53(2): Grunbaum JA, Kann L, Kinchen SA, et al. Youth risk behavior surveillance: United States, MMWR Surveill Summ. 2002; 51(4): Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance: United States, MMWR Surveill Summ. 2006;55(5): Eaton DK, Kann L, Kinchen S, et al. Youth risk behavior surveillance: United States, MMWR Surveill Summ. 2008;57(4): Centers for Disease Control and Prevention. A SAS program for the CDC growth charts. Available at: growthcharts/resources/sas.htm. Accessed August 29, Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, et al. CDC growth charts: United States. Adv Data. 2000;8(314): US Department of Health and Human Services Physical Activity Guidelines for Americans. Hyattsville, MD: US Department of Health and Human Services; Available at: Accessed August 29, US Department of Health and Human Services. Dietary Guidelines for Americans. Washington, DC: US Department of Health and Human Services; Available at: Accessed August 29, US Department of Health and Human Services. Objective 22. In: Healthy People Washington, DC: US Department of Health and Human Services; Available at: Volume2/22Physical.htm. Accessed August 29, US Department of Health and Human Services. Objective 19. In: Healthy People Washington, DC: US Department of Health and Human Services; Available at: Volume2/19Nutrition.htm. Accessed August 29, Johnson-Taylor WL, Fisher RA, Hubbard VS, Starke-Reed P, Eggers PS. The change in weight perception of weight status among the overweight: comparison of NHANES III ( ) and NHANES. Int J Behav Nutr Phys Act. 2008;5:9 27. Evans WD, Finkelstein EA, Kamerow DB, Renaud JM. Public perceptions of childhood obesity. Am J Prev Med. 2005;28(1): Field AE, Cheung L, Wolf AM, Herzog DB, Gortmaker SL, Colditz GA. Exposure to the mass media and weight concerns among girls. Pediatrics. 1999;103(3). Available at: e Atlantis E, Ball K. Association between weight perception and psychological distress. Int J Obes (Lond). 2008;32(4): Cash TF, Morrow JA, Hrabosky JI, Perry AA. How has body image changed? A crosssectional investigation of college women and men from 1983 to J Consult Clin Psychol. 2004;72(6): Wardle J, Haase AM, Steptoe A. Body image and weight control in young adults: international comparisons in university students from 22 countries. Int J Obes (Lond). 2006; 30(4): Field AE, Camargo CA, Jr, Taylor CB, Berkey CS, Roberts SB, Colditz GA. Peer, parent, and media influences on the development of weight concerns and frequent dieting among preadolescent and adolescent girls and boys. Pediatrics. 2001;107(1): van den Berg P, Paxton SJ, Keery H, Wall M, Guo J, Neumark-Sztainer D. Body dissatisfaction and body comparison with media images in males and females. Body Image. 2007;4(3): Strauss RS. Self-reported weight status and dieting in a cross-sectional sample of young adolescents: national health and nutrition examination survey III. Arch Pediatr Adolesc Med. 1999;153(7): Atlantis E, Barnes EH, Ball K. Weight status and perception barriers to healthy physical activity and diet behavior. Int J Obes (Lond). 2008;32(2): Sherry B, Jefferds ME, Grummer-Strawn LM. Accuracy of adolescent self-report of height and weight in assessing overweight status: a literature review. Arch Pediatr Adolesc Med. 2007;161(12): Gorber SC, Tremblay M, Moher D, Gorber B. A comparison of direct versus self-report measures for assessing height, weight and body mass index: a systematic review. Obes Rev. 2007;8(4): Brener ND, Mcmanus T, Galuska DA, Lowry R, Wechsler H. Reliability and validity of selfreported height and weight among high school students. J Adolesc Health. 2003; 32(4): Ogden CL, Carroll MD, Flegal KM. Epidemiologic trends in overweight and obesity. Endocrinol Metab Clin North Am. 2003;32(4): , vii e458 EDWARDS et al

8 Where Perception Meets Reality: Self-Perception of Weight in Overweight Adolescents Nicholas Murphy Edwards, Sandra Pettingell and Iris Wagman Borowsky Pediatrics 2010;125;e452; originally published online February 8, 2010; DOI: /peds Updated Information & Services References Citations Subspecialty Collections Permissions & Licensing Reprints including high resolution figures, can be found at: /content/125/3/e452.full.html This article cites 31 articles, 4 of which can be accessed free at: /content/125/3/e452.full.html#ref-list-1 This article has been cited by 3 HighWire-hosted articles: /content/125/3/e452.full.html#related-urls This article, along with others on similar topics, appears in the following collection(s): Endocrinology /cgi/collection/endocrinology_sub Adolescent Health/Medicine /cgi/collection/adolescent_health:medicine_sub Obesity /cgi/collection/obesity_new_sub Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: /site/misc/permissions.xhtml Information about ordering reprints can be found online: /site/misc/reprints.xhtml PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, Copyright 2010 by the American Academy of Pediatrics. All rights reserved. Print ISSN: Online ISSN:

9 Where Perception Meets Reality: Self-Perception of Weight in Overweight Adolescents Nicholas Murphy Edwards, Sandra Pettingell and Iris Wagman Borowsky Pediatrics 2010;125;e452; originally published online February 8, 2010; DOI: /peds The online version of this article, along with updated information and services, is located on the World Wide Web at: /content/125/3/e452.full.html PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, Copyright 2010 by the American Academy of Pediatrics. All rights reserved. Print ISSN: Online ISSN: