October 2019 Issue
CPE Monthly: Implications of Body Figure Awareness
By Cassie Vanderwall, PhD, RD, CD, CDE, CPT
Today’s Dietitian
Vol. 21, No. 10, P. 42
Suggested CDR Learning Codes: 3090, 4010, 5370, 6010
Suggested CDR Performance Indicators: 2.2.4, 9.1.3, 9.6.1, 10.1.1
CPE Level 2
Take this course and earn 2 CEUs on our Continuing Education Learning Library
The World Health Organization defines health as “a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity.” Health can be achieved through dietary lifestyle, regular physical activity, solid sleep, and attention to mental health care.1,2 Our clients and patients may define health differently, but to most it’s the springboard that permits them to live life as they choose, and for some it’s an aspiration they feel they can never achieve. Awareness is a part of overall health and indirectly influences individuals’ perceptions of their health and their motivation to pursue and maintain health.1 This has become more apparent in recent years as researchers, clinicians, and patients alike attempt to learn more about the origins of the obesity epidemic in hopes of curtailing the upward trends and preventing both increasing prevalence and chronic weight-related morbidities. Even with the preventive measures they take and having well-known facets of health in place, Americans still struggle with the pursuit and maintenance of weight-related change. The literature supports that a decreased sensitivity to obesity could be an underlying hindrance to weight management efforts.3,4
This continuing education course examines the health implications of body figure awareness and compares and contrasts this self-concept among adults, adolescents, children, and racial/ethnic groups as it relates to weight management. It also provides recommendations and strategies for applying this information in a variety of care settings that will enable RDs to be more confident in exploring these self-concepts with their patients, using motivational interviewing techniques to shift the conversation away from weight to these powerful psychometrics.
What Is Oblivobesity?
Knowledge of terms used by the media and embraced by the public and health care providers is important because these are terms to which patients are exposed. Oblivobesity, for example, is a term used in the media to reference body figure awareness. Coined by David Katz, MD, MPH, FACPM, FACP, FACLM, founding director of the Yale-Griffin Prevention Research Center, the term describes the tendency to overlook obesity, usually a parent’s lack of awareness of their child’s weight status.5 Oblivobesity may stem from the fact that individuals tend to recognize harm or crisis from an encounter that deviates from the norm. Now that nearly 40% of adults and 18.5% of children and adolescents in the United States are obese, bodily perceptions may be skewed.4 Oblivobesity doesn’t convey neglect or negative parental care but may be a byproduct of the prevalence of obesity today.
Unawareness isn’t the same as misperception. Unawareness recognizes no harm, whereas misperception denies harm. It’s more likely that individuals today are at greater risk of misperceiving their body habitus and weight but are aware of their weight status.4 This deviation may be compounded in communities of color; the prevalence of obesity is greatest among Hispanic individuals (47%), followed by non-Hispanic blacks (NHB) at 46.8%. While the prevalence of obesity remains high in non-Hispanic white (NHW) and Asian individuals, rates are lower (37.9% and 12.7%, respectively).6
However, recognition of overweight and obesity may wane and accurate perceptions may become skewed as obesity becomes more prevalent.3 A parent’s or individual’s awareness and perception also may be influenced by culture and the family’s body habitus.3,4
Health and Economic Implications of Obesity
It’s well established that the leading causes of mortality in the United States—cancer, heart disease, diabetes, and diseases of the kidneys, lungs, gastrointestinal system, and joints—are attributed in part to excess adiposity.7 The correlation between obesity and mental illnesses such as anxiety and depression also has been confirmed.8,9
The economic implications of obesity include $147 billion in direct medical care costs and $3.4 billion in indirect costs due to obesity-related absenteeism from work.10,11 The implications of obesity are observed among all sex, age, and racial/ethnic groups despite differences in prevalence.3,10,11
Variations in Body Composition
While the consequences of obesity are comparable across racial/ethnic groups, how people carry this excess weight differs. There are differences in body composition and body figures across sex, age, and race/ethnicity.12,13 It’s now well accepted that NHB individuals have higher muscle mass than do NHW persons, resulting in a higher density of fat-free mass. In addition, there are many studies showing that NHB individuals have less visceral fat than their NHW counterparts matched for age, BMI, and girth.12,14 In general, NHW persons tend to have higher waist circumferences and maintain greater degrees of adiposity than do NHB and Hispanic individuals despite having the same BMI.12
Asians share many of the same phenotypic physiological features as Hispanic individuals, which include shorter stature, higher total body fat percentages, and greater abdominal adiposity and waist circumference relative to NHW individuals, while controlling for age and BMI.15 However, the findings of studies involving Asian adults and children are convoluted due to the diversity of individuals from Asia. For example, the literature suggests that persons from China have greater adiposity than individuals from Polynesia. Overall, Asian individuals maintain more body fat than do NHW persons.14
These findings from adult populations can be applied to pediatric populations. NHW boys and girls have greater waist circumference and skinfold thickness—both surrogates for adiposity—than do NHB boys and girls.14,16 Hispanic individuals have been found to have more body fat, as measured by dual-energy X-ray absorptiometry, than do NHW children of the same sex and age group.14 However, when controlling for BMI-for-age percentiles, the overall differences in adiposity between Hispanic and NHW children resolve.
The literature suggests genetic, metabolic, and hormonal explanations for these variations.17 These differences in body composition and ethno-types may influence cultural acceptability of certain body figures and self-perceptions.13-18
Variants of Body Image
Body image is defined by the National Eating Disorders Collaboration as a person’s perception of their physical self and the thoughts and feelings, positive, negative or both, that result from that perception.19 Body image includes the following:
• perceptual body image (how individuals see their bodies);
• affective body image (how individuals feel about their bodies);
• cognitive body image (how individuals think about their bodies); and
• behavioral body image (how individuals react as a result of their body image).
Perceptual body image is most related to an individual’s weight or body figure perception, also referred to as weight perception accuracy or body figure awareness. Affective and cognitive body images are how people respond to their perceptions in regard to feelings and thoughts, while behavioral body image refers to how individuals physically react to their perceptions, thoughts, and feelings. Behavioral body image reactions may include weight management pursuits that are healthful or destructive.19
The manifestation of body image has nutrition-related consequences that are observable by practicing dietitians. Therefore, it’s vital for RDs to be aware of how weight perception and body figure awareness are measured and the differences in awareness among sex, age, and racial/ethnic groups. That knowledge will ensure more productive conversations that lead to better health outcomes.
Weight perception, or the view of one’s body weight can be assessed by asking, “How do you perceive your weight?”20 Responses include: “very underweight,” “slightly underweight,” “about the right weight,” “slightly overweight,” or “very overweight.” This self-concept is most commonly examined in the research setting via incorporation into a survey. However, it also can be used in the clinical setting using the same methods, or this sensitive question could be asked verbally once rapport has been established between patient and provider.
Likewise, body figure awareness most often is assessed in the research setting, but its utility in the clinical setting makes it an attractive tool. Body figure awareness differs from weight perception in that it directs attention to the individual’s perception of their figure vs their weight or weight classification. Body figure awareness is measured using a body figure scale (BFS), which also can be referred to as a figure rating scale.
A BFS can be used to measure aspects of body image disturbance, or body size dissatisfaction, but it’s now more commonly used to assess baseline body figure awareness. Researchers often examine individuals’ actual self-perceptions, their ideal self-perceptions (ie, the body figure or weight that they feel is ideal for themselves), their ideal perceptions for another child or adult of the same and opposite sex, and their ideal perceptions for an adult if they are children, or a child if they are adults of the same or opposite sex. The results provide context for individuals’ perceptual body images.18,21
Gardner and Brown note several advantages to BFS over using words alone to assess perceptual body image, including ease and flexibility in administration; however, it’s vital to select the most appropriate scale for the situation and population.22 These scales have been validated in several niche samples as well as in larger populations for adults and adolescents. When used with children, these scales are quick and simple to administer, require no equipment, and, unlike a questionnaire, the visual images can be understood with minimal verbal comprehension skills.23 Body figure scales that are age-appropriate with omission of body and facial features make BFS more generalizable across sex, race, and ethnic groups.24 These scales have been validated for use in populations from preschool-aged children to older adults and permit investigation of developing attitudes associated with body size and satisfaction in younger individuals vulnerable to obesity.25 Acknowledged limitations of a BFS include potential conceptual biases, gendered body images, confusion of weight and muscularity, and inability to measure perceptive satisfaction or discontent.26
Investigation of Weight Perception Accuracy
Adolescents
The primary aims for examining weight perception accuracy are focused on identifying groups that are at greatest risk of misperception and exploring the implications of this lack of awareness. For example, Yost and colleagues examined the association of BMI and weight perception accuracy with engagement in weight management strategies in a representative sample of female adolescents in the United States using data from Wave II of the National Longitudinal Study of Adolescent Health (n=2,216). Yost used Cash’s weight perception assessment strategy and found that age, NHB race, BMI, and weight perception accuracy were predictive of a teen’s attempt to achieve a healthier weight. Age, BMI, and weight perception accuracy were positively associated with each other (p<0.05). They also found that nearly 80% of the sample accurately identified as either slightly or very overweight (p<0.05). The remaining 20% of the female adolescents with overweight and obesity underestimated their weight. The accuracy of these self-perceptions varied significantly by race/ethnicity. The NHB adolescents were more likely to underestimate their weight than were NHW (p<0.01) and Asian (p<0.01) individuals or those of other racial/ethnic groups (p<0.05). American Indian/Native American adolescents with overweight and obesity were more likely than Asian participants to underestimate their weight (p<0.05).27
Yost and colleagues concluded that weight perception has a stronger association than BMI with the act of trying to lose weight, and this may raise concerns because the association between weight perception and trying to lose weight often is related to disordered eating patterns, eating disorders, or other destructive weight management strategies.27 Yost and colleagues’ results have been replicated, with the finding that about 70% of female adolescents who perceive themselves as overweight are using weight management strategies. This percentage is greater in NHW female adolescents as compared with NHB and Hispanic adolescents.27,28 There also may be differences in awareness by sex, with boys underestimating their weight and size with greater frequency than do girls in any weight category.29-31
Empirical findings support differences in perceived ideal selves between boys and girls. Girls are most satisfied with thinner body figures, and dissatisfaction increases with body figure size and weight. Boys have a stronger desire to increase weight and develop lean mass.30 Whether these observations apply to all racial/ethnic groups remains to be determined.
Epperson and colleagues aimed to examine the relationship between weight management attempts and body figure awareness among a racially diverse group of fifth graders (n=3,953) using the Self-Perception Profile.32 They found that about 15% of students overestimated their ideal body size and 33% underestimated their ideal body size. Hispanic adolescents reported the greatest number of weight loss attempts, whereas NHW reported the least. There was no concern that this methodology would induce body image issues. The number of weight loss attempts increased with body size, degree of adiposity, and inaccurate body perceptions. Therefore, those with overweight and obesity and those who perceived that they were overweight and obese when they weren’t attempted weight loss more often than did those who misperceived their weight status and underestimated their body figure size. They concluded that motivation to achieve a more healthful weight differs by race/ethnicity; NHW adolescents appear to have the strongest association between weight loss attempts and weight perception.30
Female adolescents who perceive themselves as overweight, whether accurately or inaccurately, are more likely to attempt to lose weight. In an examination of weight perception and weight loss strategies among college students in the United States (n=38,204), using data from the National College Health Assessment, 12% of respondents inaccurately perceived their body size. Those with inaccurate perceptions are at a greater risk of using risky weight management methods than are those with accurate self-perceptions.33 These behavioral perceptions have been less studied in males.
Children
These patterns also have been observed in younger adolescents and children, and researchers have found that identification of childhood overweight/obesity is associated with weight loss attempts and weight perception accuracy.34 However, misperception and inaccuracies remain.
Chen and colleagues examined body size perceptions among US adolescents aged 8 to 15 and their parents to evaluate the relationship between accuracy of body perception and attempted weight loss using data from the National Health and Nutrition Examination Surveys 2007–2008 and 2009–2010. Among children and adolescents, 27.3% underestimated their body size and 2.8% overestimated their size. Comparably, 25.2% of parents underestimated their child’s weight status and 1.1% overestimated their child’s size.35 Researchers found that children and adolescents who were of a healthy weight and/or who underestimated their body figure were 9.5 times more likely to engage in weight loss strategies as compared with those who accurately perceived their size. Body figure awareness was highest in those of a healthy weight, whereas only about 25% of overweight children and adolescents were able to accurately perceive their weight status. Parental misperception of their child’s weight wasn’t significantly associated with weight loss behaviors. Overall, obese children and adolescents are more successful in their attempts to manage weight when they have a desire to achieve a more healthful weight and have a correct perception of their body size.35 In the absence of these self-concepts, adolescents are at a greater risk of engaging in disordered eating behaviors as a result of their negative body image.36
Body figure perception discrepancies exist among younger children (<9 years), which may be due to lack of cognitive capacity for these self-concepts, cultural or parental influences, or other factors. However, these noteworthy perceptual discrepancies appear to decrease between first and second grade. Therefore, body image and body dissatisfaction may appear in as early as second grade.37 Younger individuals may require additional questioning by health care professionals to determine whether bias for thinness exists and to explore the rationale for this desirability.21
Individuals’ BMIs and BMIs-for-age may be significantly associated with their weight perceptions. While BMI does have recognized limitations, especially in developing youth, it’s a helpful tool in population research; the author has been published on this subject.38 Individuals with overweight and obesity more commonly misperceive their weight and adiposity as compared with normal-weight individuals.37 This tendency to underestimate has been associated with increasing BMI later in life. Thus, body figure perception plays an important role in the risk of overweight and obesity during adolescence.37,39,40
These self-concepts may be relatively stable over time. O’Connor and colleagues found that the majority of pediatric subjects who underestimated their body size didn’t significantly change over three years; their self-perceptions remained stable. However, body satisfaction improved with no significant differences between ages or sexes. Therefore, adolescents may grow comfortable with their body habitus over time and maintain misperceptions that could lead to weight-related morbidities later in life.41
Most At Risk
Individuals and caregivers from overweight and obese families as well as from communities of color appear to be the most at risk of weight and body figure misperceptions. Paul and colleagues explored weight perception accuracy and body figure awareness among a racially diverse group of mother-child dyads (n=506) in a cross-sectional study using data from a questionnaire adapted from the Behavioral Risk Factor Surveillance System. More than 70% of the obese adult subjects and 35% of overweight adults underestimated their figure size. Most adults (80%) with an overweight child and about 23% of adults with an obese child underestimated their child’s weight and perceived them as normal. Similarly, 86.3% of overweight children and 62% of obese children underestimated their own body figure size. Likewise, children with overweight and obesity misclassified their mothers who were overweight or obese as being of normal weight.42 These outcomes support the observation that caregivers influence the perceptions and behaviors of their children and families, including weight perception.
Overall, women and girls often perceive their current body figures as heavier, resulting in dissatisfaction, and do so with greater frequency than men and boys. Men also tend to underestimate their body figures with less frequency. However, underestimation of body figure size and weight perception remain common across both sexes and all racial/ethnic groups, with NHB adolescents being the most at-risk group for underestimation as compared with NHW and Hispanic adolescents.29,30,35,43
Self-Awareness and Readiness to Change
Body figure awareness and weight perception, facets of perceptual body image, have been found to influence participation in weight management efforts.19,32,33 Measuring perceptual body image is highly recommended to assess both motivation and readiness to change in all individuals who are pursuing behavior changes related to weight management. These psychosocial assessments can facilitate prompt identification of obstacles and resistance to promote a more effective weight management intervention. Assessment is critical because weight management is two-pronged and includes efforts to achieve and maintain a healthier weight.44
The transtheoretical model offers comprehensive, theoretical scaffolding for determining readiness to change and promoting individualized weight management interventions.45,46 This model’s stages of change are precontemplation, contemplation, preparation, action, and maintenance. Individuals move forward and backward throughout the stages based on their readiness to change a specific behavior.45
Motivation to change behaviors isn’t synonymous with motivation to engage in a health intervention. Adherence difficulties often are encountered in individuals who engage in weight management behaviors with little or no awareness of the problem that needs to be changed, including body figure awareness.47 In other words, individuals often partake in interventions without acknowledging the rationale or need for behavior change. These groups may include those who chronically underestimate their body figure size or misperceive their weight. Individuals who don’t adhere to weight management programming often show ambivalence about whether the problematic behavior really needs to be changed, since the perceived cost may not yet outweigh the benefits.48
Maximova and colleagues investigated the association between body size underestimation and self-efficacy and self-esteem in 5,075 fifth-grade students within the Children’s Lifestyle and School-performance Study II. Fifty-three percent of the total sample underestimated their body size.49 More than 90% of overweight boys and obese boys and girls underestimated their body size, while 83% of overweight girls underestimated their body figure. Self-efficacy and self-esteem declined as weight increased and was lower in groups who underestimated their body size—namely overweight and obese children. This was the first study to associate body figure misconceptions with poor psychosocial measures in children.49
The ability to achieve and maintain health behavior changes, such as healthful eating habits, may be compromised by poor psychosocial health, particularly lower self-efficacy.50 A health care environment that supports an individual’s autonomy, competence, and self-efficacy can reliably facilitate change and foster greater internalization and integration of self-concepts, such as body image.51 Evidence exists showing that psychosocial barriers were more common reasons for not engaging in weight-related changes.4,50,51 Motivation for taking action varies from individual to individual and family to family; the literature supports the need for health care providers to explore these psychosocial constructs and values to identify their personal and health-related priorities, which is consistent with facets of motivational interviewing.4,52-55 Therefore, RDs have the opportunity to incorporate psychosocial metrics into their practice to promote a change environment that’s conducive to body figure awareness.
Incorporating Psychosocial Metrics Into Practice
Individualizing recommendations in a patient- or client-centered discussion focused on body shape may be more appropriate to facilitate education than relying on BMI or weight alone. The use of visual cues, such as a BFS may support the assessment and intervention steps of the nutrition care process and facilitate positive dialog between clinicians and patients.55
Some RDs may consider using psychosocial metrics in their practices to better assess self-concepts such as body figure awareness, weight perception, self-efficacy, and readiness to change. A variety of tools including BFS for all ages, valid weight perception questions,20 and Readiness Rulers are available for public use.56 Use of these tools likely will result in the identification of beliefs, attitudes, or behaviors regarding body figure and weight earlier in the nutrition care process, increasing the opportunity for dialog around these variables.57 This will enable earlier identification and use of strategies to overcome potential barriers to weight management efforts. These tools also can help facilitate discussions about influences on perceptions of both present health and change, which may limit a person’s readiness to engage in healthful behaviors.4 These discussions may permit RDs to explore the full range of consequences of change and lack of change, including weight-related morbidities and detriments to both mental and physical well-being.
It’s important for RDs to use a motivational interviewing skill set alongside these additional psychosocial metrics vs tailoring education and counseling toward a specific body habitus or health status. RDs who use motivational interviewing are tour guides for clients and patients who can unbiasedly help them focus on their health parameters as well as on their readiness to change, internal motivation, and competing demands that may pose hurdles to engagement and change. Change will originate within the client.
Further Research
Further research is needed in the area of weight perception and body figure awareness as they relate to chronic disease and behavior change. Research that engages a diverse audience and explores the origins of four aspects of body image will continue to provide ammunition in the fight against obesity. Research that explores the views of families with obesity within communities of color also will clarify cultural influences on body figure perceptions and acceptance of excess adiposity. Further research also is warranted to assess parental and societal influences on body weight perception as well as longitudinal studies to explore how perceptions and preferences change over time.22
Summary
Based on the literature, some individuals may be unaware of their obese habitus, as well as the potential health risks associated with excess adiposity. This oblivobesity may pose risks to individuals’ personal health but also to that of family members, such as children, and the well-being of the nation as health care costs associated with obesity continue to rise.4,5,7,10,11 Individuals who misperceive their weight maintain a low degree of body figure awareness. These trends are more apparent when examined by sex and race/ethnicity. Individuals from obese and overweight families and communities of color are at the greatest risk of these misperceptions.21,30,31,34-37,39 These understandings lay the groundwork for incorporation of the assessment of psychosocial variables including body image concepts, body figure awareness, and weight perception into clinical practice to identify misperceptions earlier and prevent subsequent risk that may result from unawareness. This has potential to greatly influence nutrition-related care by providing a framework for more constructive conversations about weight in the primary care and specialty care settings and in the community. It’s also vital to understand that while it’s important for parents and caregivers to have accurate perceptions of their children’s body habitus and weight, correct observations may not translate into action. Interventions are most effective when they’re individualized using facets of motivational interviewing.4,50-54,57 Therefore, RDs have the potential to be key figures in the change process by facilitating an environment conducive to self-assessment, self-discovery, and self-efficacy, which could make weight management efforts and initiatives more effective and sustainable.
Click here for handout "Tools to Facilitate Self-Awareness and Behavior Change Within the Nutrition Care Process."
— Cassie Vanderwall, PhD, RD, CD, CDE, CPT, is a Madison, Wisconsin–based freelance food and nutrition writer, director of the University of Wisconsin (UW) health dietetic internship program, and ambulatory dietitian at UW Health’s Pediatric Fitness Clinic and American Family Children’s Hospital Diabetes Clinics.
Learning Objectives
After completing this continuing education course, nutrition professionals should be better able to:
1. Describe body figure awareness relative to body image.
2. Distinguish the health implications of misperceptions of body figure and weight perception.
3. Compare and contrast body figure awareness by sex and race/ethnicity.
4. Evaluate the RD’s role in examining an individual’s self-awareness as it relates to body figure and weight.
CPE Monthly Examination
1. What is “oblivobesity”?
a. Ignoring one’s present state of health
b. Being unaware of one’s own or another’s obese habitus
c. Lacking concern for another’s health
d. State of oblivion due to being overweight
2. How do unawareness and misperception differ?
a. Unawareness recognizes no harm. Misperception denies harm.
b. Unawareness is the absence of perception. Misperception is inaccurate recognition.
c. Unawareness results in no action. Misperception leads to risky action.
d. Unawareness can be due to neglect. Misperception has no negative connotations.
3. Which of the following facets of body image is most closely related to the self-concept of body figure awareness?
a. Perceptual body image
b. Cognitive body image
c. Affective body image
d. Behavioral body image
4. Which of the following facets of body image is inclusive of individuals’ feelings regarding their weight perception?
a. Perceptual body image
b. Cognitive body image
c. Affective body image
d. Behavioral body image
5. Which of the following facets of body image would be most closely related to oblivobesity?
a. Weight perception accuracy
b. Cognitive body image
c. Body figure awareness
d. Readiness to change
6. Which of the following facets of body image would explain an individual’s destructive weight management practices?
a. Perceptual body image
b. Cognitive body image
c. Affective body image
d. Behavioral body image
7. Which of the following are likely to have the lowest degree of body figure awareness?
a. Prepubertal non-Hispanic white children
b. Obese Hispanic adolescents
c. College-aged females
d. Non-Hispanic black males with overweight families
8. What is the preferred tool for measuring body figure awareness?
a. Readiness Ruler
b. Body figure scale
c. Dual-energy X-ray absorptiometry
d. Electronic scale
9. Are RDs qualified to distribute psychometric self-assessments to patients?
a. Yes, as long as the tools are validated.
b. Yes, RDs can distribute all self-assessments.
c. Yes, if they’re trained in motivational interviewing.
d. No, this is out of RDs’ scope of practice.
10. In which steps of the nutrition care process can RDs incorporate psychometric tools?
a. Assessment and diagnosis
b. Intervention and monitoring
c. Assessment and intervention
d. Monitoring and evaluation
References
1. World Health Organization. Constitution of the World Health Organization. https://www.who.int/governance/eb/who_constitution_en.pdf. Updated October 2006.
2. Nordqvist C. Health: what does good health really mean? MedicalNewsToday website. https://www.medicalnewstoday.com/articles/150999.php. Updated July 31, 2017.
3. Duncan DT, Hansen AR, Wang W, Yan F, Zhang J. Change in misperception of child’s body weight among parents of American preschool children. Child Obes. 2015;11(4):384-393.
4. Perez A, Ball GD. Beyond oblivobesity: seven myths about parental misperception of children’s weight. Child Obes. 2015;11(6):735-737.
5. Katz DL. Overcoming the overweight we keep overlooking. Huffington Post website. https://www.huffingtonpost.com/david-katz-md/overcoming-the-overweight-we-keep-overlooking_b_7595854.html. Updated June 16, 2016. Accessed September 2018.
6. Hales CM, Carroll MD, Fryar CD, Ogden CL; Centers for Disease Control and Prevention, National Center for Health Statistics. Prevalence of obesity among adults and youth: United States, 2015–2016. https://www.cdc.gov/nchs/data/databriefs/db288.pdf. Published October 2017.
7. National Institutes of Health, National Heart, Lung, and Blood Institute. Managing overweight and obesity in adults: systematic evidence review from the Obesity Expert Panel, 2013. https://www.nhlbi.nih.gov/sites/default/files/media/docs/obesity-evidence-review.pdf
8. Luppino FS, de Wit LM, Bouw PF, et al. Overweight, obesity, and depression: a systematic review and meta-analysis of longitudinal studies. Arch Gen Psychiatry. 2010;67(3):220-229.
9. Kasen S, Cohen P, Chen H, Must A. Obesity and psychopathology in women: a three decade prospective study. Int J Obes (Lond). 2008;32(3):558-566.
10. Finkelstein EA, Trogdon JG, Cohen JW, Dietz W. Annual medical spending attributable to obesity: payer- and service-specific estimates. Health Aff (Millwood). 2009;28(5):w822-w831.
11. Trogdon JG, Finkelstein EA, Hylands T, Dellea PS, Kamal-Bahl SJ. Indirect costs of obesity. Obes Rev. 2008;9(5):489-500.
12. Deurenberg P, Deurenberg-Yap M. Validity of body composition methods across ethnic population groups. Acta Diabetol. 2003;40(Suppl 1):S246-S249.
13. Deurenberg P, Deurenberg-Yap M. Differences in body-composition assumptions across ethnic groups: practical consequences. Curr Opin Clin Nutr Metab Care. 2001;4(5):377-383.
14. Freedman DS, Wang J, Thornton JC, et al. Racial/ethnic differences in body fatness among children and adolescents. Obesity (Silver Spring). 2008;16(5):1105-1111.
15. Heymsfield SB, Peterson CM, Thomas DM, Heo M, Schuna JM Jr. Why are there race/ethnic differences in adult body mass index-adiposity relationships? A quantitative critical review. Obes Rev. 2016;17(3):262-275.
16. Sisson SB, Katzmarzyk PT, Srinivasan SR, et al. Ethnic differences in subcutaneous adiposity and waist girth in children and adolescents. Obesity (Silver Spring). 2009;17(11):2075-2081.
17. Wagner DR, Heyward VH. Measures of body composition in blacks and whites: a comparative review. Am J Clin Nutr. 2000;71(6):1392-1402.
18. Townsend C, Takishima-Lacasa JY, Latner JD, Grandinetti A, Keawe’aimoku Kaholokula J. Ethnic and gender differences in ideal body size and related attitudes among Asians, Native Hawaiians, and whites. Hawaii J Med Public Health. 2014;73(8):236-243.
19. National Eating Disorders Collaboration. NEDC fact sheet — body image. https://www.nedc.com.au/assets/Fact-Sheets/NEDC-Fact-Sheet-Body-Image.pdf. Accessed September 2018.
20. Cash TF, Pruzinsky T, eds. Body Images: Development, Deviance, and Change. New York, NY: Guilford Press; 1990.
21. Collins ME. Body figure perceptions and preferences among preadolescent children. Int J Eat Disord. 1991;10(2):199-208.
22. Gardner RM, Brown DL. Body image assessment: a review of figural drawing scales. Pers Individ Dif. 2010;48(2):107-111.
23. Truby H, Paxton SJ. Development of the children’s body image scale. Br J Clin Psychol. 2002;41(Pt 2):185-203.
24. Thompson JK. Assessment of body image. In: Allison DB, ed. Handbook of Assessment Methods for Eating Behaviors and Weight-Related Problems: Measures, Theory, and Research. 1st ed. Thousand Oaks, CA: Sage Publications; 1995:119-144.
25. Hill AJ. Measurement of body image in childhood. In: Cash TF. Encyclopedia of Body Image and Human Appearance. Waltham, MA: Elsevier; 2012:521-525.
26. Lawler M, Nixon E. Theoretical and methodological considerations in assessing body image among children and adolescents. Greene SB, ed. Body Image: Perceptions, Interpretations and Attitudes. London, UK: Nova Science Publishers; 2011:227-244.
27. Yost J, Krainovich-Miller B, Budin W, Norman R. Assessing weight perception accuracy to promote weight loss among U.S. female adolescents: a secondary analysis. BMC Public Health. 2010;10:465.
28. Kilpatrick M, Ohannessian C, Bartholomew JB. Adolescent weight management and perception: an analysis of the National Longitudinal Study of Adolescent Health. J Sch Health. 1999;69(4):148-152.
29. Paxton RJ, Valois RF, Drane JW. Correlates of body mass index, weight goals, and weight-management practices among adolescents. J Sch Health. 2004;74(4):136-143.
30. Chung AE, Perrin EM, Skinner AC. Accuracy of child and adolescent weight perceptions and their relationships to dieting and exercise behaviors: a NHANES study. Acad Pediatr. 2013;13(4):371-378.
31. McCabe MP, Fuller-Tyszkiewicz M, Mellor D, Ricciardelli L, Skouteris H, Mussap A. Body satisfaction among adolescents in eight different countries. J Health Psychol. 2012;17(5):693-701.
32. Epperson AE, Song AV, Wallander JL, et al. Associations among body size, body image perceptions, and weight loss attempts among African American, Latino, and white youth: a test of a mediational model. J Pediatr Psychol. 2014;39(4):394-404.
33. Wharton CM, Adams T, Hampl JS. Weight loss practices and body weight perceptions among US college students. J Am Coll Health. 2008;56(5):579-584.
34. Delavan EL, Crook T, Phelps J, Hakkak R. Associations between weight-related variables, gender, and age in overweight and obese preadolescents and adolescents. FASEB J. 2016;30(1 Suppl).
35. Chen HY, Lemon SC, Pagoto SL, Barton BA, Lapane KL, Goldberg RJ. Personal and parental weight misperception and self-reported attempted weight loss in US children and adolescents, National Health and Nutrition Examination Survey, 2007-2008 and 2009-2010. Prev Chronic Dis. 2014;11:E132.
36. Littleton HL, Ollendick T. Negative body image and disordered eating behavior in children and adolescents: what places youth at risk and how can these problems be prevented? Clin Child Fam Psychol Rev. 2003;6(1):51-66.
37. Heron KE, Smyth JM, Akano E, Wonderlich SA. Assessing body image in young children: a preliminary study of racial and developmental differences. SAGE Open. 2013;3(1):1-7.
38. Vanderwall CM, Randall Clark R, Eickhoff J, Carrel AL. BMI is a poor predictor of adiposity in young overweight and obese children. BMC Pediatr. 2017;17(1):135.
39. Montoya C, Boursaw B, Tigges B, Lobo ML. Mirror, mirror on the wall: children’s preferences and self-perceptions of weight in a rural Hispanic community. J Pediatr Health Care. 2016;30(6):528-534.
40. Liechty JM, Lee MJ. Body size estimation and other psychosocial risk factors for obesity onset among US adolescents: findings from a longitudinal population level study. Int J Obes (Lond). 2015;39(4):601-607.
41. O’Connor JN, Golley RK, Perry RA, Magarey AM, Truby H. A longitudinal investigation of overweight children’s body perception and satisfaction during a weight management program. Appetite. 2015;85:48-51.
42. Paul TK, Sciacca RR, Bier M, Rodriguez J, Song S, Giardina EG. Size misperception among overweight and obese families. J Gen Intern Med. 2015;30(1):43-50.
43. Martin MA, May AL, Frisco ML. Equal weights but different weight perceptions among US adolescents. J Health Psychol. 2010;15(4):493-504.
44. Ceccarini M, Borrello M, Pietrabissa G, Manzoni GM, Castelnuovo G. Assessing motivation and readiness to change for weight management and control: an in-depth evaluation of three sets of instruments. Front Psychol. 2015;6:511.
45. Prochaska JO, Norcross JC, Fowler JL, Follick MJ, Abrams DB. Attendance and outcome in a work site weight control program: processes and stages of change as process and predictor variables. Addict Behav. 1992;17(1):35-45.
46. Substance Abuse and Mental Health Services Administration, Center for Substance Abuse Treatment; Department of Health and Human Services. Enhancing motivation for change in substance abuse treatment. https://www.ncbi.nlm.nih.gov/books/NBK64967/pdf/Bookshelf_NBK64967.pdf. Updated 2012.
47. Pietrabissa G, Manzoni GM, Corti S, Vegliante N, Molinari E, Castelnuovo G. Addressing motivation in global obesity treatment: a new challenge for clinical psychology. Front Psychol. 2012;3:317.
48. McEvoy PM, Nathan P. Perceived costs and benefits of behavioral change: reconsidering the value of ambivalence for psychotherapy outcomes. J Clin Psychol. 2007;63(12):1217-1229.
49. Maximova K, Khan MK, Austin SB, Kirk SF, Veugelers PJ. The role of underestimating body size for self-esteem and self-efficacy among grade five children in Canada. Ann Epidemiol. 2015;25(10):753-759.
50. Gillespie J, Midmore C, Hoeflich J, Ness C, Ballard P, Stewart L. Parents as the start of the solution: a social marketing approach to understanding triggers and barriers to entering a childhood weight management service. J Hum Nutr Diet. 2015;28(Suppl 1):83-92.
51. Stewart L, Chapple J, Hughes AR, Poustie V, Reilly JJ. Parents’ journey through treatment for their child’s obesity: a qualitative study. Arch Dis Child. 2008;93(1):35-39.
52. Dawson AM, Brown DA, Cox A, et al. Using motivational interviewing for weight feedback to parents of young children. J Paediatr Child Health. 2014;50(6):461-470.
53. Schwarzer R. Social-cognitive factors in changing health-related behaviors. Curr Dir Psychol Sci. 2001;10(2):47-51.
54. Ryan RM, Deci EL. Self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. Am Psychol. 2000;55(1):68-78.
55. Capers PL, Kinsey AW, Miskell EL, Affuso O. Visual representation of body shape in African-American and European American women: clinical considerations. Clin Med Insights Womens Health. 2016;9(Suppl 1):63-70.
56. Readiness Ruler. Case Western Reserve University, Center for Evidence-Based Practices website. https://www.centerforebp.case.edu/resources/tools/readiness-ruler
57. Rees R, Oliver K, Woodman J, Thomas J; University of London, EPPI-Centre. Children’s views about obesity, body size, shape and weight: a systematic review. http://eppi.ioe.ac.uk/cms/Portals/0/Obesity%20Views%20Children%20R2009Rees.pdf?ver=2010-12-22-121209-040. Published December 2009.