body image research articles

• Search Menu
• Sign in through your institution
• Advance Articles
• Editor's Choice
• Author Guidelines
• Submission Site
• Open Access
• About Health Education Research
• Editorial Board
• Advertising and Corporate Services
• Journals Career Network
• Self-Archiving Policy
• Dispatch Dates
• Journals on Oxford Academic
• Books on Oxford Academic

Article Contents

Introduction, conflict of interest statement.

• < Previous

Body image and perceived health in adolescence

• Article contents
• Figures & tables
• Supplementary Data

Eivind Meland, Siren Haugland, Hans-Johan Breidablik, Body image and perceived health in adolescence, Health Education Research , Volume 22, Issue 3, June 2007, Pages 342–350, https://doi.org/10.1093/her/cyl085

• Permissions Icon Permissions

Perceived health is an important health predictor, and self-assessed health during adolescence is of great interest. This study examined the relationship between perceived negative health and body image in early and mid-adolescence, focusing on age and gender differences. Analyses were based on Norwegian data from a World Health Organization cross-national survey (Health Behaviour in School-Aged Children) among 5026 pupils aged 11, 13 and 15 years. The response rate was 76%. Stratified analyses with presentations of frequency and relative risk were performed, as well as logistic regression analyses. Girls are more likely to report negative health than boys are, and the probability of such reports increases with age. Girls and older age groups report dieting and dissatisfaction with weight and appearance more often than boys and younger age groups. Body dissatisfaction is associated with an increased risk of perceived negative health, also when controlling for the possible confounding effects of age and gender. The present ‘ideals’ of weight and appearance might contribute to an unfavourable perception of health in this age group.

Young people typically have low rates of serious physical morbidity. However, a large and increasing number of adolescents report on subjective health complaints and health worries [ 1 ]. Such complaints increase during a few critical years of adolescence and are strongly associated with a deterioration of self-evaluated health. Self-rated health is therefore an important health measure in adolescence. Prospective studies in adult populations have demonstrated that perceived health may predict morbidity, mortality, the use of health services and disability pensioning [ 2–5 ].

The individual's evaluation of biological changes, health and illness is shaped by sociocultural and social–psychological factors [ 6 ]. Social factors also constitute an important frame of reference for perceived health, e.g. social roles [ 3 ]. Health is conceptualized during childhood and adolescence [ 7, 8 ]. Based on qualitative studies among adults, self-rated health is a weighted sum of different aspects, including health status, life situation and lifestyle [ 9 ]. Adolescents seem to include functional ability, psychological well-being, social factors and lifestyle in their evaluation of health [ 10, 11 ], as well as absence of disease [ 11 ].

Previous studies suggest that physical appearance and body image may influence perceived health. Adolescence is a period of increased awareness of bodily cues and self-reflection, including evaluation of body and appearance. In Western cultures, adolescents who depart from socially determined norms of attractiveness or individual ideals are vulnerable to body dissatisfaction. Body dissatisfaction may be defined as the discrepancy between an individual's perceived current body size and perceived ideal body size [ 12 ]. Body dissatisfaction, negative body image, concern with body size and shape represent attitudinal aspects of body image. The concept of body image has been defined in different terms, according to scientific discipline. Body image is also often discussed without a definition, or used interchangeably with other constructs [ 12 ]. For the purpose of this paper, body image is defined as the individual, subjective sense of satisfaction or dissatisfaction with one's body or physical appearance [ 13 ].

Previous studies suggest that adolescents who are dissatisfied with their bodies are more likely to perceive their health as fair or poor and more likely to show depression, low self-esteem and low social functioning [ 14 ]. Adolescents who are overweight are more likely to express weight-specific concerns and engage in dieting and binge eating compared with non-overweight adolescents [ 15 , 16 ]. However, causality or direction of effect is not established.

Previous research suggests that there may be age and gender differences in body dissatisfaction. The dual process of sociocultural and peer pressure may contribute to such gender differences [ 17 , 18 ], as well as markers of identity. Social comparison is linked to the important but vulnerable process of social identity making [ 19 ]. Among females, even normal-weight individuals are often concerned about body shape, and the vast majority wants to be thinner [ 12 ].

In a longitudinal study, gender differences in body dissatisfaction emerged between 13 and 15 years of age, and were maintained at 18 years. Throughout this period, girls increased and boys decreased body dissatisfaction [ 20 ]. However, recent research suggests that a growing number of adolescent boys tend to exercise, diet or take steroids to adhere to the social and individual ideals of a more muscular body [ 21 ].

The objectives of the present study were to explore the relationships between body dissatisfaction and self-rated health. In particular, we wanted to discern gender and age differences, testing the hypothesis that body dissatisfaction is more likely to be associated with perceived negative health among girls and older age groups. Finally, we aimed at translating our findings into a sustainable strategy for dealing with these issues in the school health services and interdisciplinary work.

The analyses were based on Norwegian data from a World Health Organization (WHO) cross-national survey, Health Behaviour in School-Aged Children (HBSC). The overall goal of the survey was to increase the understanding of lifestyle and health behaviour, and their context in the lives of young people [ 22 ]. The HBSC study has been carried out every fourth year, from 1983–84 onwards. The present study was based on the Norwegian data from the 1997–98 study. In Norway, these studies were conducted by the Research Centre for Health Promotion, University of Bergen.

Sample and design

The sample was selected by systematic cluster sampling. The primary sampling unit was the school class, that is, cluster sampling. Because children in the same class tend to be similar in many ways, standard errors may be higher than would be the case if the same sample size was acquired through simple random sampling. A design factor model was therefore used to predict standard errors. Nearly all the design factors were found to lie within the range of 1.0–1.5. The sample was therefore based on a design factor of 1.5, resulting in a sample size that was 1.5 times larger than it would have been if individual students had been selected randomly [ 22 ]. Allowing for this factor, the sample can be treated as representative. The sample was drawn from three age groups with mean ages of 11.5, 13.5 and 15.5 years, respectively. Boys and girls were equally represented.

The response rate was 76%. After internal cleaning procedures that excluded 3.5% of the sample, 5026 pupils (2547 boys and 2479 girls) were included in the present study. The cleaning procedure is based on strict criteria developed for the international study, e.g. excluding pupils who were older or younger than the sample or >25% of the responses were missing from a questionnaire [ 23 ]. Missing responses were mainly due to non-cooperation of classes or schools or pupils being absent when the questionnaire was administered. There was no substitute sampling. Pupils who were non-responders on single variables were included in the analyses on variables with valid response.

Data collection

Data were collected in December 1997, via anonymous, self-completion questionnaires, which were pre-coded. Each school administered the survey during 1 day, thus, excluding pupils who were absent on that day. Teachers administered the surveys in the classroom, and the pupils returned the questionnaires in sealed envelopes.

‘Perceived health’ was measured by the following question: ‘How healthy do you think you are?’ with three response categories ‘very healthy’, ‘quite healthy’ and ‘not very healthy’. To measure ‘body image’, the pupils were asked four questions to obtain information about general satisfaction/dissatisfaction about body and physical appearance (response options in parentheses). ‘Do you think your body is’ (‘much too thin’, ‘a bit too thin’, ‘about the right size’, ‘a bit too fat’, ‘much too fat’, ‘I don't think about it’). These categories were reduced to four in the analyses by combining ‘much too thin/a bit too thin’ and ‘much too fat/a bit too fat’. Similarly, they were asked to consider physical appearance by choosing one out of six categories: ‘Do you think you are’ (‘very good looking’, ‘quite good looking’, ‘about average’, ‘not very good looking’, ‘not at all good looking’, ‘I don't think about my looks’). The numbers of categories were reduced by combining ‘very good looking/quite good looking’ and ‘not at all good looking/not very good looking’. In addition, the following items were included: ‘Are you on a diet to lose weight? (‘no, because my weight is fine’, ‘no, but I need to loose weight’, ‘yes’) and ‘Is there anything about your body you would like to change?’ (‘yes’, ‘no’). Reduction of analytic categories was based on frequency distribution and preliminary bivariate analyses.

Reliability and validity

Although a measure of perceived health including three response categories is a crude measure of a complex construct, predictive and construct validity have been documented for similar items in adult populations [ 2 ]. Previous studies show that 11- to 15-year olds can evaluate and respond to survey measures [ 24, 25 ]. A study among Norwegian 16-year olds showed that a similar one-item measure is correlated to subjective health complaints and depressed mood (although including five response categories). The results of this longitudinal study also showed stability in reporting over time [ 26 ]. The variables concerning body dissatisfaction are similar but not identical to variables of proven validity in the literature on body image disturbances [ 27 ]. Dieting is commonly looked upon as a construct of its own in this literature. However, the concept of body image pertains to an individual's perception, attitudes about the perception, as well as associated behaviours. Dieting also has a strong correlation with body dissatisfaction, and is associated with some types of body image disturbances.

Perceived negative health (not very healthy) was treated as the dependent variable. Together with the background variables gender and age (grade), the four items on body image constituted independent variables in the present study. All independent variables were treated as categorical. Measures of relative risks and odds ratios are presented with 95% confidence intervals (CIs) for both genders and the three age groups (11, 13 and 15 years). The program Confidence Interval Analysis release 1.0 was used to calculate relative risks with CIs. Effect modification was tested by performing stratified analyses, and was also examined by logistic regression. Binary logistic regression analysis was conducted to adjust for possible confounders, by means of SPSS-PC 11.0. Interaction effect was controlled for when significant. Statistical significance was accepted at the 5% level.

Table I shows perceived health and body image according to age and gender. The results show that reports of perceived negative health increase with age, and that girls report negative health more often than boys do. A great majority, however, reports their health to be very or quite healthy, although reports of ‘very healthy’ were most common among boys and 11-year olds. Compared with boys, the number of girls who reported the most favourable category was significantly lower for all age groups, and this effect of gender increased with age.

Perceived health and body image variables according to gender and age (number and per cent)

Sum of the categories: ‘A bit too fat’ and ‘much too fat’.

Sum of the categories: ‘A bit too thin’ and ‘much too thin’.

Sum of the categories: ‘Not at all good’ and ‘not very good’.

Sum of the categories: ‘Very good’ and ‘quite good’.

Table I also illustrates that body dissatisfaction is prevalent in the studied age groups. Girls are more likely to report body dissatisfaction. Among boys, the need for body change was reported most frequently. A substantial increase in body dissatisfaction is observed across age groups among girls. Reports of dieting and concern about body shape and physical appearance increase with increasing age for girls. A majority of 15-year-old girls wants to change their body; 51% of girls in this age group consider themselves too fat and 36% view themselves as not good looking. A total of 28% of 15-year-old girls are already dieting, and another 28% report that they are not on a diet but need to loose weight.

Table II summarizes the probability of reporting ‘not very healthy’ as relative risk according to age and gender. Favourable categories concerning body image are used as references. The risk of reporting not very healthy increases significantly if dieting or dissatisfied with weight, with the perceived need for changing body, the evaluation of being too fat and the perception of not being good looking. The relative risk of reporting negative health in relation to body dissatisfaction decreases with increasing age. The stratified analyses in Table II show significant interaction between gender and age for dieting. This interaction effect was confirmed in logistic analysis. Even though the relative risk of reporting ‘not very healthy’ was greatest among young girls on a diet, the increasing prevalence of dieting with increasing age add to the absolute impact of this risk. No significant gender difference was observed for perceived negative health in relation to body dissatisfaction. However, the higher prevalence of body dissatisfaction among girls increases the effect of this risk.

The probability of reporting ‘not very healthy’ according to body image variables

Probabilities are expressed as relative risks according to age and gender (95% CI). The first two categories are used as reference group concerning the variables: ‘Think about body’ and ‘Think about looks’.

Table III shows the results of logistic regression analyses for each of the body image variables in relation to perceived negative health (unadjusted) and adjusted for age and gender. Reports of ‘not very healthy’ are associated with female gender and increasing age. Dissatisfaction with body is associated with reports of negative health. This is also evident after controlling for the possible confounding effects of age and gender in the multivariate models. Due to significant interaction, the interaction term between age and gender was entered in the model in the second column in Table III . The results show that gender differences in perceived health are mediated by dieting. Such a mediation effect was not found for dissatisfaction with appearance.

The univariate and multivariate logistic regression analysis with OR and 95% CI for variables influencing perceived health

Gender and age are entered in the model together with each of the body image variables. The first two categories are used as reference group concerning the variables: ‘Think about body’ and ‘Think about looks’. The response ‘Not very healthy’ is compared with the others.

The interaction term between gender and age was entered in this model due to significant interaction.

The results of this large Norwegian national survey show that perceived negative health is prevalent in adolescence, and that these prevalence rates are highest among girls and older age groups. Prevalence rates of body dissatisfaction are also high. Furthermore, this study shows that perceived negative health is associated with body dissatisfaction in early and mid-adolescence. This association is significant across age and gender. Body dissatisfaction is most frequently reported and most strongly associated with perceived negative health among girls. Gender differences in the relationship between body dissatisfaction and perceived health seem to be mediated by dieting. The relative impact of body dissatisfaction on perceived health decreases with increasing age among girls, but this decrease is outweighted by the substantial increase in prevalence of body dissatisfaction in the studied age group.

The results are based on a cross-sectional survey. Thus, causal relationships or direction of effect cannot be established, but the findings highlight associations that can be examined further in longitudinal studies. Pupils who were absent on the day of the survey were not included in this study. Pupils who reported poor health, and adolescents who experience body dissatisfaction, are likely to be overrepresented among absentees. The expected pattern of missing may have decreased the prevalence of these categories and weakened the association between body dissatisfaction and perceived negative health.

The included measure of perceived health is a rather crude one-item measure with three response categories, which may have contributed to misclassification and self-reporting bias. However, similar measures have demonstrated construct and predictive validity in other studies [ 2 ]. Results from 29 countries revealed differences between countries in reports of ‘not very healthy’, but the patterns according to age and gender were consistent with the present findings [ 23 ].

In the present findings, gender differences in perceived health may, in part, be attributed to gender variance in concern about physical appearance, as demonstrated for dieting. In addition, girls may be more willing to report on negative health than boys are [ 28 ]. Gender differences may also be explained by differences in pubertal timing. In the studied age groups, more girls than boys have experienced pubertal changes. Maturing girls tend to increase in weight and proportion of fat, which may increase the discrepancy between body shape and ideal. In contrast, maturing boys gain muscle mass, approaching current ideals.

A previous Scottish study found that pubertal timing influences body image and self-esteem. The results showed that among 11-year-old girls, ‘early’ maturation and dissatisfaction with body size and appearance were associated with low self-esteem. For this age group, there was evidence that body image mediated the relation of pubertal timing on self-esteem. Among 13-year-old girls, concerns about body size and appearance and ‘late’ maturation were predictive of low ratings of self-esteem, without evidence of mediation [ 29 ].

The present findings suggest that body image is an important target of intervention to improve subjective health in adolescence. The results show that a large number of adolescents give reports of body dissatisfaction, and girls report more concern about appearance and weight than boys do. These findings are consistent with a survey among English adolescents in 1994. Half of the girls and every third boy reported to be concerned about their body, and twice as many girls as boys wanted to lose weight. Douvan and Adelson [ 30 ] showed that >60% of high school girls wished to change their physical appearance compared with 27% of the boys. The noted gender differences in weight concerns among 15-year olds correspond to findings in other European countries.

In the present study, 79% of the boys and 44% of the girls were satisfied with their weight, showing higher figures than in previous studies. In a European Union-based population aged 15 years and older, McElhone et al . [ 31 ] showed that only 46% of males and 31% of females were satisfied with their weight. The present study showed an increase in body dissatisfaction with increasing age for girls, but no significant change was observed for boys. A similar study revealed an increase in reports of body dissatisfaction among girls and a decrease among boys [ 21 ].

Our study shows that body dissatisfaction is associated with perceived negative health among Norwegian 11- to 15-year olds. These findings correspond with studies among young adults in Sweden (18–34 years), showing that both obesity and underweight were associated with perceived negative health, also when health problems were controlled for [ 32 ]. This relationship between body image and perceived health may be explained by adolescents' views of health. A global definition of health suggests that several domains related to self-esteem may influence the responses, including body image. Adolescents may also have learned (from health personnel) that factors such as obesity and a sedentary lifestyle are unhealthy. Consequently, adolescents may rate their health as ‘not very healthy’ based on lifestyle factors. Perceived negative health may also have lead to body dissatisfaction. However, a 5-year longitudinal study among Norwegian 13-, 15- and 18-year olds showed that body image predicted changes in depressed mood both for boys and girls, but showed no support for a causal effect of depressed mood upon body image [ 33 ].

Ego identity and definition of self are important in preparing for the adult role, and physical appearance seems to be important in the social negotiations of identity [ 19 ]. Adolescents may experience increased vulnerability during such processes.

Previous studies suggest that both school and school health services may influence perceived health and body image in adolescence [ 34, 35 ]. School staff and health personnel are also important in the fight against obesity and physical inactivity. Risk communication with a strong emphasis on perfect health and absence of bodily symptoms may, however, contribute to health worries and the undermining of subjective health. Social identity theory emphasizes that adults, in spite of good intentions, may actually strengthen dysfunctional identities and add to adolescent worries [ 19 ].

As part of a health-promotive strategy, building of self-esteem and self-confidence is recognized as important task. Recent research shows that it is possible to unite preventive efforts against obesity with efforts against body dissatisfaction and eating disorders [ 34 , 36 , 37 ]. There is also evidence that intervention may be more effective if it is not explicitly presented as an eating disorder prevention programme. Integrated approaches may enhance the effects of intervention and reduce the possibility of potential harmful effects of programmes that address only one end of the spectrum [ 36 ]. In schools, it is possible to implement a conjunction of environmental and educational changes, both as universal programmes and aimed at high-risk individuals.

An ecological perspective on health promotion suggests that pupils, school staff and parents need to determine how self-confidence and humanistic values can be promoted at a system level in schools. Increased physical activity and healthy eating may be promoted through curricular and structural changes, e.g. daily physical activity and healthy school meals [ 37 , 38 ]. School health services have a unique position, as a potential partner in planning, implementing and evaluating health-promotive strategies within the school system.

None declared.

We thank Bente Wold and Oddrun Samdal at the Research Centre for Health Promotion, University of Bergen, Norway, for providing HBSC data to the present study. The WHO, Regional office for Europe, has adopted the HBSC project as a WHO collaborative study. International coordinator of the 1997–98 study was Dr Candace Currie, Scotland.

Google Scholar

Google Preview

• world health organization
• health behavior
• school-age child
• gender differences
• dissatisfaction

Email alerts

Citing articles via.

• Recommend to your Library

Affiliations

• Online ISSN 1465-3648
• Print ISSN 0268-1153
• Copyright © 2024 Oxford University Press
• About Oxford Academic
• Publish journals with us
• University press partners
• What we publish
• New features  
• Open access
• Institutional account management
• Rights and permissions
• Get help with access
• Accessibility
• Advertising
• Media enquiries
• Oxford University Press
• Oxford Languages
• University of Oxford

Oxford University Press is a department of the University of Oxford. It furthers the University's objective of excellence in research, scholarship, and education by publishing worldwide

• Copyright © 2024 Oxford University Press
• Cookie settings
• Cookie policy
• Privacy policy
• Legal notice

This Feature Is Available To Subscribers Only

Sign In or Create an Account

This PDF is available to Subscribers Only

For full access to this pdf, sign in to an existing account, or purchase an annual subscription.

Thank you for visiting nature.com. You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

• View all journals
• Explore content
• About the journal
• Publish with us
• Sign up for alerts
• NEWS Q&A
• 27 July 2023
• Correction 28 July 2023

Barbie and body image: a scholar’s take on the research — and the blockbuster film

• Emma Marris 0

Emma Marris is an environmental writer who lives in Oregon.

You can also search for this author in PubMed   Google Scholar

Barbie the movie is a pretty pink phenomenon, raking in US$337 million around the world on its opening weekend this month — a record for a film helmed by a woman. Director Greta Gerwig’s film explores the legacy of the iconic doll, which has been put forward as a feminist icon but has also been criticized for being a passive sex object.

Access options

Access Nature and 54 other Nature Portfolio journals

Get Nature+, our best-value online-access subscription

24,99 € / 30 days

cancel any time

Subscribe to this journal

Receive 51 print issues and online access

185,98 € per year

only 3,65 € per issue

Rent or buy this article

Prices vary by article type

Prices may be subject to local taxes which are calculated during checkout

Nature 620 , 254-255 (2023)

doi: https://doi.org/10.1038/d41586-023-02433-8

This interview has been edited for length and clarity.

Updates & Corrections

Correction 28 July 2023 : An earlier version of this story misstated the results of research on young girls’ attitudes towards fuller-figured dolls.

Webb, J. B., Ford, N. M. & Padro, M. P. Body Image 45 , 201–209 (2023).

Article   PubMed   Google Scholar  

Download references

Related Articles

It’s time for your performance review

Futures 29 MAY 24

Time’s restless ocean

Futures 22 MAY 24

The origin of the cockroach: how a notorious pest conquered the world

News 20 MAY 24

Defying the stereotype of Black resilience

Career Q&A 30 MAY 24

Nature’s message to South Africa’s next government: talk to your researchers

Editorial 29 MAY 24

Anglo-American bias could make generative AI an invisible intellectual cage

Correspondence 28 MAY 24

Why role-playing games can spur climate action

World View 22 MAY 24

How does ChatGPT ‘think’? Psychology and neuroscience crack open AI large language models

News Feature 14 MAY 24

Is the Internet bad for you? Huge study reveals surprise effect on well-being

News 12 MAY 24

Multi-Disciplinary Studies of Biomolecular Condensates

Dallas, Texas (US)

The University of Texas Southwestern Medical Center (UT Southwestern Medical Center)

Research assistant (Postdoc) (m/f/d) - Department of Biology, Chemistry, Pharmacy - Institute of Bio

Department of Biology, Chemistry, Pharmacy - Institute of Biology Plant Physiology Research assistant (Postdoc) (m/f/d) full-time-job limited for u...

14195, Berlin Dahlem (DE)

Freie Universität Berlin

Global Faculty Recruitment of School of Life Sciences, Tsinghua University

The School of Life Sciences at Tsinghua University invites applications for tenure-track or tenured faculty positions at all ranks (Assistant/Ass...

Beijing, China

Tsinghua University (The School of Life Sciences)

Dr. Rolf M. Schwiete Professor (W2) of Translational Pediatric Oncology

The Faculty of Medicine of the Goethe University Frankfurt am Main and the University Hospital Frankfurt, in the Department of Pediatrics (Chairman...

Frankfurt am Main, Hessen (DE)

Johann Wolfgang Goethe-Universität Frankfurt

Nanjing Forestry University is globally seeking Metasequoia Scholars and Metasequoia Talents

Located next to Purple Mountain and Xuanwu Lake, Nanjing Forestry University (NJFU) is a key provincial university jointly built by Jiangsu Province

Nanjing, Jiangsu, China

Nanjing Forestry University (NFU)

Sign up for the Nature Briefing newsletter — what matters in science, free to your inbox daily.

Quick links

• Explore articles by subject
• Guide to authors
• Editorial policies

Click through the PLOS taxonomy to find articles in your field.

For more information about PLOS Subject Areas, click here .

Loading metrics

Open Access

Peer-reviewed

Research Article

Does Body Image Affect Quality of Life?: A Population Based Study

Affiliation Administrative Department, Mersin Public Health Directorate, Mersin, Turkey

Affiliation Department of Public Health, Süleyman Demirel University Faculty of Medicine, Isparta, Turkey

* E-mail: [email protected]

Affiliation Department of Communicable Diseases, Ceyhan Community Health Center, Adana, Turkey

• Tufan Nayir, 
• Ersin Uskun, 
• Mustafa Volkan Yürekli, 
• Hacer Devran, 
• Ayşe Çelik, 
• Ramazan Azim Okyay

• Published: September 20, 2016
• https://doi.org/10.1371/journal.pone.0163290
• Reader Comments

Body image (BI) can be described as the assessment of both positive and negative emotion for one’s own body parts and their characteristics by himself or herself. Current research has concentrated mostly on the status of negative BI as a risk factor for mental health problems rather than as a public health problem, thereby little is known about the effects of BI on quality of life. Thus, the purpose of this study was to assess the BI and Quality of Life (QoL) of individuals and to investigate the relationship between the two. Individuals over 15 living in Isparta city center constitute the universe of this cross-sectional analytical study, carried out in 2014. The BI of individuals was measured by the Body Image Scale and The QoL of individuals was measured using the World Health Organization (WHO) Quality of Life Scale Short Form. The mean age of the participants was 31.9 ± 13.0 and 56.0% were female, 36.8% were married and 81.7% had education above high school. 25.7% had at least one chronic disease and 17.7% received medication regularly. Having good-very good health perception, having higher income than expenses, making regular exercises were predictors in enhancing the quality of life in certain aspects, however having a good body image came out as a predictor enhancing the quality of life in all sub-domains. BI was found closely related with QoL in all sub-domains. Our findings suggest that greater attention should be to be given to BI as a strong predictor of QoL.

Citation: Nayir T, Uskun E, Yürekli MV, Devran H, Çelik A, Okyay RA (2016) Does Body Image Affect Quality of Life?: A Population Based Study. PLoS ONE 11(9): e0163290. https://doi.org/10.1371/journal.pone.0163290

Editor: Massimo Ciccozzi, National Institute of Health, ITALY

Received: July 4, 2016; Accepted: September 5, 2016; Published: September 20, 2016

Copyright: © 2016 Nayir et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: Data are available from Süleyman Demirel University Faculty of Medicine, Public Health Department, for researchers who meet the criteria for access to confidential data.

Funding: The authors received no specific funding for this work.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Body image (BI) can be described as the assessment of both positive and negative emotion for one’s own body parts and their characteristics by himself or herself [ 1 ]. BI is a complicated construct that is composed of several components such as mental and emotional components, perceptual components and behavioral components [ 2 ].

It is well documented that a negative BI is associated with a range of adverse health outcomes, including low self-esteem, depressive mood and eating disorder symptoms [ 3 , 4 ].

However attention has concentrated mostly on the status of negative BI as a risk factor for mental health problems rather than as a public health problem in its own right, thereby little is known about the effects of BI on quality of life (QoL) [ 5 ].

The World Health Organization (WHO) defines QoL as the individual’s assessment of their position in life in the scope of culture and values, considering their goals, expectations, standards and concerns [ 6 ].

The concept of life quality closely related to health status, is one of the topics that is paid much attention by a large group of researchers engaged in the field of medicine and found worthy to investigate. The concept of life quality related to health, alternative explanations exist though, means “the perception of health and illness experience from the individuals’s point of view” [ 6 , 7 ].

As mentioned above not much attention was given to BI in terms of QoL. To the best of our knowledge, in Turkey, there is no previously conducted study investigating the association between BI and QoL. Therefore, the goal of this study is to assess the BI and QoL of individuals over 15 living in a city center and to investigate the relationship between the two.

Materials and Methods

Study design.

Individuals over 15 living in Isparta city center constitute the universe of this study which is a cross-sectional analytical study, carried out in 2014 (n:175.409). The sample size was calculated as 638 with an obesity prevalence of 30% with a 5% margin of error in OpenEpi Program (Open Source Epidemiologic Statistics for Public Health, Version 3.01, 2013). Using the cluster sampling method we reached a total of 650 people in 26 clusters and 25 people in each cluster.

The inclusion criterias for enrollment are to volunteer to participate in the study and to be over 15 years old. The exclusion criteria is to have mental retardation.

Data collection instruments

Socio-demographic characteristics (age, gender, education level, economical perception, having a chronic disease, smoking, drinking alcohol, doing sport, weight, height) and other characteristics (the thoughts and requests about the weight of himself/herself, family, friends and spouse/partner, the status of using any method to lose weight at the time of survey and in the past year, the status of skipping meals and snacking between meals etc.) were collected with a questionnaire prepared by authors and included 28 items.

The BI of individuals was measured by the Body Image Scale developed by Secord and Jourard [ 8 ] and adapted to Turkish by Hovardaoglu [ 9 ]. Body Image Scale consists of 40 articles aiming to measure the level of satisfaction of various body functions and various parts of the body of individuals. This scale is a quinary Likert-type scale evaluated from the total score obtained from the scale and can get a score ranging from 40 to 200. Higher scores got by an individual indicates a higher level of satisfaction of individual’s own body. The QoL of individuals was measured using the Turkish version (TR) of WHO Quality of Life Scale Short Form (WHOQOL-BREF) [ 10 ]. WHOQOL-BREF (TR), a type of scale having the reliability and validity study [ 11 , 12 ], consists of 26 quinary Likert-type questions, two of which are general questions and the rest of which are questions about four different fields (physical, psychological, social and environment). Culture Standardized (CS) Environmental Area, which is obtained considering the answers to the 27th question added as a national question during the study for adaptation to Turkish, is an additional field used in national studies. The scale not having a total score, each area is evaluated independently and can have a value between 4–20 points. The increasing points for each area indicates the increasing QoL for this field. In this study, scores of the QoL were calculated for all fields of WHOQOL-BREF (TR) scale.

Data was gathered by making surveys prepared by researchers using face to face interview method.

Statistical analysis

The dependent variables of the study were the scores of QoL and BI. Age, gender, education level, economical perception, having a chronic disease, smoking, drinking alcohol, doing sport, body mass index (BMI), the thoughts and requests about the weight of himself/herself, family, friends and spouse/partner, the status of using any method to lose weight at the time of survey and in the past year, the status of skipping meals and snacking between meals were independant variables. Data was evaluated using descriptive statistics, t-test, Pearson and Spearman correlation and linear regression analysis in computer. Statistical Package for the Social Sciences soft-ware (SPSS, Version 9.0, Inc. California, 1999) was used for all the statistical calculations.

Ethical considerations

This study was conducted in accordance with the ethical standards of the Declaration of Helsinki, which promotes respect for all human beings and protects their health and rights. The Ethics Committee of Süleyman Demirel University Faculty of Medicine approved this study.

After informing the participants about the purpose of the trial (investigation, research, study), and where and how the obtained data would be used, written consents were obtained. The written consent was a separate standard document prepared according to the ethics committee suggestion. The participants of this study were over 15 years old. For over 18, written informed consent was provided by the participant ownself and for between 16–18 the written informed consent to participate was provided by his/her legal representative.

The mean age of the study group was 31.9 ± 13.0 and 56.0% were female, 36.8% were married and 81.7% had education of high school or above. 70.5% perceived their income as middle income ( Table 1 ).

• PPT PowerPoint slide
• PNG larger image
• TIFF original image

https://doi.org/10.1371/journal.pone.0163290.t001

31.1% were smoking, 28.8% were drinking alcohol and 22.0% were making regular exercise. The average BMI of the study group was 24.0±4.4 and 36.0% were fat or overwight (BMI ≥25kg/m2). 25.7% had at least one chronic disease and 17.7% received medication regularly. 71.5% were skipping at least one meal during the day ( Table 2 ). The most skipped meal was lunch (49.0%). 84.2% of the group were snacking between meals and the most preferred snack was fruit with 49.7%.

https://doi.org/10.1371/journal.pone.0163290.t002

Specific Results on BI

The average of BI Score of the research group was 152.1±24.0. ( Table 3 ). The average of BI Scores of women, those with a chronic disease, those using medication, those skipping meals, those having the opinion that they are not normal by their family, friends, spouse and himself/herself, those having the consideration that they need to make changes in their weight by their family, friends, spouse and himself/herself and those having the history of dieting in the past year were lower than others.(p<0.001, p<0.001, p<0.001, p<0.05, p<0.001, p<0.001, p<0.001, p<0.001, p<0.001, p<0.001, p<0.001 and p<0.001 respectively) (Tables 2 and 4 ).

https://doi.org/10.1371/journal.pone.0163290.t003

https://doi.org/10.1371/journal.pone.0163290.t004

Being a woman decreased the BI score of 3.7 units, the individual’s own desire to make changes in body weight decreased the BI score of 7.7 units (p<0.05 and p<0.01 respectively). Working increased the BI score of 4.5 units, having good-very good economical sense increased the BI score of 6.8 units, having good-very good health perception increased the BI score of 9.3 units, smoking increased the BI score of 5.7 units and making regular exercise increased the BI score of 6.5 units. (p<0.05, p<0.05, p<0.001, p<0.01 and p<0.01 respectively) ( Table 5 ).

https://doi.org/10.1371/journal.pone.0163290.t005

Specific Results on QoL

The mean scores of WHOQOL-BREF (TR) regarding physical, psychological, social, environment and CS environmental areas were 15.4±2.8, 14.5±2.7, 14.8±3, 14.5±2.5 and 13.8±4.2 respectively. ( Table 3 ).

Physical domain scores were significantly lower for women, the married, the fat/overweight according to BMI, patients with chronic diseases, those using drugs, those having the opinion that they are not normal by their family, friends, spouse and himself/herself, those having the consideration that they need to make changes in their weight by their family, friends, spouse and himself/herself (p<0.01, p<0.01, p<0.01, p<0.001, p<0.001, p<0.001, p<0.01, p<0.01, p<0.001, p<0.001, p<0.001, p<0.001, p<0.001 and p<0.001 respectively) (Tables 2 and 4 ). Physical domain scores were higher for those having higher education than high school, those having good-very good economical sense, those having good-very good health perception, those drinking alcohol and those making regular exercises (p<0.05, p<0.001, p<0.001, p<0.001, p<0.01 and p<0.001 respectively) (Tables 1 and 2 ).

Psychological domain scores were significantly lower for women, patients with chronic diseases, those using drugs, those having the opinion that they are not normal by their family, friends, spouse and himself/herself, those having the consideration that they need to make changes in their weight by their family, friends, spouse and himself/herself (p<0.001, p<0.001, p<0.001, p<0.01, p<0.01, p<0.001, p<0.001, p<0.001, p<0.001, p<0.001 and p<0.001 respectively) (Tables 2 and 4 ). Psychological domain scores were higher for those having higher education than high school, those working, those having good-very good economical sense, those having good-very good health perception, those drinking alcohol and those making regular exercises (p<0.01, p<0.01, p<0.001, p<0.001, p<0.05, p<0.01 and p<0.001) (Tables 1 and 2 ).

Social domain scores were significantly lower for women, those having the opinion that they are not normal by their family, friends, wife and himself/herself, those having the consideration that they need to make changes in their weight by their family, friends, spouse and himself/herself (p<0.01, p<0.001, p<0.01, p<0.001 and p<0.01 respectively) (Tables 2 and 4 ). Social domain scores were higher for those having good-very good economical sense, those drinking alcohol, smoking and those making regular exercises (p<0.01, p<0.001, p<0.05, p<0.001 and p<0.001 respectively) (Tables 1 and 2 ).

Environmental domain scores were significantly lower for women, the married, those using drugs, those skipping meals, those having the opinion that they are not normal by their family, friends, spouse and himself/herself, those having the consideration that they need to make changes in their weight by their family, friends, spouse and himself/herself (p<0.001, p<0.05, p<0.01, p<0.05, p<0.01, p<0.001, p<0.001, p<0.001, p<0.01, p<0.01 and p<0.01 respectively) (Tables 2 and 4 ). Environmental domain scores were higher for those having higher education than high school, those having good-very good economical sense, those having good-very good health perception, those having more income than expenses, those drinking alcohol and those making regular exercises (p<0.01, p<0.001, p<0.001, p<0.001, p<0.01 and p<0.001 respectively) (Tables 1 and 2 ).

CS environmental domain scores were significantly lower for patients with chronic diseases and those using drugs, those skipping meals, those having the opinion that they are not normal by their family, friends, spouse and himself/herself, those having the consideration that they need to make changes in their weight by their family, friends, spouse and himself/herself (p<0.01, p<0.05, p<0.05, p<0.01, p<0.01, p<0.05, p<0.01, p<0.001, p<0.001, p<0.01, p<0.01 and p<0.01 respectively) (Tables 2 and 4 ).

As age and number of applications for health organizations increased, physical, psychological and environmental domain scores reduced (for age; p<0.001, p<0.05 and p<0.05 respectively, for applications for health organizations; p<0.001, p<0.001 and p<0.01 respectively). Furthermore, as age increased, social domain scores decreased (p<0.05). As BI score increased, QoL scores in five sub-areas also increased (for all p<0.001) ( Table 3 ).

Regression analysis results

As a result of regression analysis of variables associated with the univariate analysis with sub parameters of WHOQOL-BREF (TR) ( Table 5 );

Having good-very good health perception increased physical domain score by 1.1 units, making regular exercises increased physical domain score by 0.7 units (p<0.001 and p<0.01 respectively). A unit increase in applications for health organizations reduced physical domain score by 0.1 units (p<0.05).

Having higher income than expenses increased psychological domain score by 0.6 units, having good-very good health perception increased psychological domain score by 0.6 units (p<0.05 and p<0.01 respectively). Skipping meals during the day reduced psychological domain score by 0.4 units (p<0.05).

Drinking alcohol increased social domain score by 1.0 units (p<0.001).

Being married reduced environmental domain score by 0.4 units (p<0.05). Having good-very good economical perception increased environmental domain score by 0.8 units, having higher income than expenses increased environmental domain score by 0.8 units and having good-very good health perception increased environmental domain score by 0.5 units (p<0.01, p<0.001 and p<0.01 respectively).

A unit increase in BI score results in 0.1 unit increased for every five domains (for all p<0.001).

This study revaled that BI significantly affects the QoL in every sub-domain. It is very important to create a positive BI perception to improve the QoL of individuals. When risk groups and risk factors associated with negative BI is known, particular attention may be given to these groups. Similarly, knowing the factors which positively affect BI may give hints for possible interventions. The findings of this study provide us important evidence on this aspect. Being a woman affects BI negatively, making women a risk group. In this respect steps should be taken to ensure a positive BI in females. Individuals who have a desire to change in terms of BI, are also a risk group. BI is positive in the individuals with a good or very good health perception. Also, making regular exercises was found to improve BI. Thus, regular exercise programs that positively affect health perception should be encouraged.

In this study we assessed the factors that are independently associated with BI perception and QoL among individuals over 15 living in Isparta city center, while controlling for all other factors. Below, only the factors that displayed significant associations in the regression analysis were discussed.

Anticipated relation between gender and BI perception is verified by the results of this study: females tended to have a more negative BI perception compared to males. This is supported by other studies showing that women were more likely to perceive themselves as being overweight than men [ 13 , 14 ]. At this point it should be noted that in women, many unhealthy attitudes such as bulimia and anorexia are the results of dissatisfaction with self image, especially dissatisfaction with aspects associated to body weight [ 15 ].

We found that working and making regular exercises increased the BI score. Positive effects of exercise on BI have been firmly established in the literature [ 16 – 19 ]. There is also evidence that exercise improves BI, even though body weight and shape do not change [ 20 ]. However, exercising compulsively and excessively is a prevalent purging strategy used to make up for caloric intake or to alter one’s body weight, size, or shape, resulting in eating disorders related to body dissatisfaction, thus this fact should be considered while appraising exercise in regards to BI [ 21 ].

Having good-very good economical sense was found to increase the BI score in this study. Likewise, in a study conducted in Brazil in 2011 people with lower economic status were reported to be more dissatisfied with their current body silhouette [ 22 ]. However this result is controversial in the literature since some say BI dissatisfaction was most evident among people of higher socioeconomic classes [ 23 ]. The diversities in these studies are thought to be due to the differences in the methodologies.

In this study, it is found that having good-very good health perception increased the BI score. There are studies in line with our study, reporting body dissatisfaction was associated with the increased likelihood of impairment for certain aspects of health [ 24 , 25 ]. It is thought that personality characteristics related to body dissatisfaction, such as low self-esteem, depressive mood and perfectionism, may promote negative evaluation of physical health [ 26 ].

Interestingly we found that smoking increased the BI score. Although some local studies are in accordance with our results [ 27 , 28 ], it is widely accepted that smoking is associated with poor BI [ 29 – 32 ]. We believe that smoking may improve BI as a coping skill, however further research on this subject should be carried out.

In our study having good-very good health perception was a predictor in enhancing the QoL in physical, psychological and environmental domains. In the literature, it is well documented that several health problems, especially the chronic conditions are associated with a decreased QoL [ 33 – 35 ]. It is stated that subjective health parameters could be more significant factors of life satisfaction than objective ones [ 36 ]. Thus, it is not surprising that having a better health sense improves QoL.

We found that having higher income than expenses was a predictor in enhancing the QoL in psychological and environmental domains and having good-very good economical sense was a predictor in enhancing the QoL in environmental domain. Although there are studies in line with our study [ 37 , 38 ], the issue is inconclusive in the literature. For example, research by Kenny [ 39 ] and Stewart [ 40 ] reported that in middle-income countries and across several European countries, there was little proof of relationship between economic development and gross domestic product per capita and subjective well-being. The relation described in the present research is considered to be the result of richer individuals’ having more access to social activities/services enhancing their social attendance and hence their QoL.

Our results demonstrated making regular exercises was a predictor in enhancing QoL only in the physical domain. Making exercises and physical activity have been shown to maintain good QoL in several studies [ 41 , 42 ]. There is a positive association between physical activity and perception of QoL, which varies according to the domains of QoL assessed [ 43 ]. Further studies should be encouraged to investigate the association between physical activity and exercise and the different domains of QoL.

We found that skipping meals during the day was reducing the QoL in psychological domain. Although there are numerous studies investigating the association between nutrition and QoL [ 44 – 46 ], we did not come across much evidence particularly regarding skipping meals. In a study from Mexico, however, low QoL was reported to be associated with skipping meals, which is in line with our results [ 47 ]. Since there is not sufficient evidence to discuss the association found in this study, we suggest further studies to be conducted.

In our study drinking alcohol was a predictor in enhancing QoL in the social domain. Some researches indicated a linear or inverse J-shaped relationship between QoL and alcohol use, in such a manner that at the greater levels of use of alcohol, which includes individuals diagnosed with alcohol use disorders, QoL is lower as compared to standard or low risk users and abstainers [ 48 , 49 ]. The association identified in the present study is thought to be due to the fact that alcohol consumption at a moderate level of may be positive in terms of stress relief and psychological health [ 50 ].

Another interesting result found in this study is that being married was reducing the QoL in environmental domain. In the literature considerable evidence points to the enjoyment of better health and QoL among married older adults relative to their non-married peers [ 51 – 53 ]. However, being in line with our study, there are studies reporting younger married people did not have better QoL than their non-married peers [ 54 , 55 ]. We believe that the negative impact of marriage on QoL is likely to be due to the younger sample in this study.

As a final result, this study demonstrated that having a good BI came out as a predictor enhancing the QoL in all sub-domains. In accordance with our study, Mond et al. reported higher levels of body dissatisfaction were associated with poorer QoL [ 5 ]. This finding is notable because interest in BI has principally focused on for more adverse outcomes, such as low self-esteem, depressive mood and eating disorders [ 56 , 57 ].

Conclusions

In conclusion, as distinct from all of the other parameters used to assess QoL, BI was found closely related with QoL in all sub-domains. Our findings suggest that greater attention should be to be given to BI as a strong predictor of QoL. We expect that the data collected in this study will serve as a base for other researchers to investigate BI from a different point of view.

Supporting Information

S1 file. dataset..

https://doi.org/10.1371/journal.pone.0163290.s001

S2 File. Questionnaire.

https://doi.org/10.1371/journal.pone.0163290.s002

Author Contributions

• Conceptualization: TN EU.
• Data curation: MVY HD AÇ RAO.
• Formal analysis: TN EU MVY HD AÇ.
• Funding acquisition: TN EU MVY HD AÇ RAO.
• Investigation: TN EU MVY HD AÇ RAO.
• Methodology: TN EU.
• Project administration: TN EU.
• Resources: TN EU MVY HD AÇ RAO.
• Software: TN EU MVY HD AÇ.
• Supervision: TN EU.
• Validation: TN EU MVY HD AÇ.
• Visualization: MVY HD AÇ RAO.
• Writing – original draft: TN EU RAO.
• Writing – review & editing: TN EU RAO.
• View Article
• Google Scholar
• PubMed/NCBI
• 6. World Health Organization (WHO). 1996. WHOQOL-BREF introduction, administiration scoring and generic version of the assessment, Field Trial Version. Geneva: WHO, Programme on Mental Health. Available: http://www.who.int/mental_health/media/en/76.pdf . Accessed 2014 Sep 6.
• 7. World Health Organization (WHO). WHOQOL User Manual. Geneva: WHO, Programme on Mental Health; 1998.

The mediating role of positive body image between friendship qualities, well-being strategies and identity development among adolescents

• Open access
• Published: 24 May 2024

Cite this article

You have full access to this open access article

• Ali Eryılmaz   ORCID: orcid.org/0000-0001-9301-5946 1 ,
• Ahmet Kara   ORCID: orcid.org/0000-0002-1155-619X 2 &
• Abdullah Ensar Uzun   ORCID: orcid.org/0000-0001-7809-4789 3  

278 Accesses

Explore all metrics

This study aimed to explore the mediating role of body image in the association between The utilization of strategies aimed at enhancing subjective well-being, friendship qualities, and identity development. The participants consisted of 270 early adolescents, comprising 157 girls (58.15%) and 113 boys (41.85%). Data were collected using several scales, including the “Body Appreciation Scale,” “Subjective Well-Being Increasing Strategies Scale for Adolescents,” “Friendship Qualities Scale,” and “The Dimensions of Identity Development Scale.” Two-stage structural equation modeling was employed to analyze the gathered data. The findings indicated a positive model of identity development in adolescents, highlighting that subjective well-being increasing strategies contribute positively to identity development, and this relationship is mediated by positive body image. Furthermore, the study found that positive body image also mediates the association between adolescents’ identity development and the establishment of quality friendships.

Similar content being viewed by others

Appearance Esteem Trajectory According to Three Different Sources of Support Among Adolescents Over a School Year

Identity Formation, Body Image, and Body-Related Symptoms: Developmental Trajectories and Associations Throughout Adolescence

The Mediating Roles of Subjective Well-being Increasing Strategies and Emotional Autonomy Between Adolescents’ Body Image and Subjective Well-being

Avoid common mistakes on your manuscript.

Introduction

Adolescence represents a critical developmental period in human life, marked by substantial changes. It is acknowledged as a transitional phase, during which individuals undergo a multitude of transformations (Erikson, 1968 ; Steinberg, 2016 ). A pivotal aspect of psychosocial development during adolescence is the formation of one’s identity (Erikson, 1968 ; Steinberg, 2016 ). The process of acquiring an identity in this stage has been extensively explored in numerous studies on identity. Furthermore, psycho-social development theory posits that successful identity formation in adolescents fosters a robust sense of self and purpose, thereby facilitating their transition into more independent and confident adults (Erikson, 1968 ). Establishing a strong identity enhances the likelihood of experiencing positive outcomes in both personal and social spheres (Branje, 2022 ). Self-categorization theory suggests that achieving a positive identity promotes a profound sense of belonging and positive self-view. Beyond theoretical perspectives, an adolescent’s well-developed identity, shielded from psychopathologies like anxiety and depression, augments motivation for academic pursuits, enriches relationships with peers, parents, and adults, encourages engagement in healthy behaviors (Albarello et al., 2018 ; Schwartz et al., 2005 ), fosters openness to career aspirations and informed career choices. Conversely, struggles in identity development are linked to psychological distress (Schwartz et al., 2005 ), substance abuse (Trujillo & Reitz, 2018 ), academic challenges, interpersonal difficulties, social isolation, risky behaviors, and delinquency (Erikson, 1968 ), along with career development hurdles (Steinberg, 2016 ).

Throughout adolescence, a myriad of psychological and social factors plays a critical role in nurturing a robust and flourishing identity (Branje, 2022 ). Factors such as familial support, constructive peer interactions, educational practices, along with individual traits like self-efficacy, self-esteem, and motivation, and cultural dimensions including norms and values, significantly contribute to the development of a healthy identity among adolescents (Koepke & Denissen, 2012 ; Steinberg, 2016 ). Therefore, devising a model that examines the mediating role of positive body image in linking the formation of identity in adolescents with the quality of their friendships and strategies to enhance personal well-being could empower teenagers to cultivate a healthy identity and sustain positive development.

Relationships between friendship qualities and identity development

The exploration of identity development encompasses a blend of theoretical insights from leading figures in identity research. Central to this discourse is the quest to answer “Who am I?“, a question pivotal to understanding personal identity (Erikson, 1994 ; Motyl, 2010 ). Waterman ( 1999 ) suggests that identity formation is a journey of self-discovery and goal setting, where individuals realize their potential through activities linked to their developing identity. Berzonsky ( 2005 ) presents a social-cognitive approach to identity, highlighting cognitive processes such as information gathering and self-evaluation as essential to developing one’s identity. He categorizes identity styles into informational, normative, and avoidant, each offering a unique pathway through the identity formation landscape. Erikson ( 1994 ) views identity as an evolving principle that grants individuals a sense of continuity and uniqueness, crucial for independent functioning. His theory emphasizes the balance between identity synthesis and confusion, with synthesis leading to a cohesive self-concept and confusion resulting in a lack of functional self-definition. This is particularly significant during adolescence, a vital period for identity formation.

The dual-cycle model further refines our understanding of identity development, outlining a process of exploration and commitment through which adolescents solidify their sense of self (Branje, 2022 ; Crocetti, 2017 ). Initially, adolescents explore various self-concepts before committing to those that resonate, gradually enhancing their identity through continuous exploration and reaffirmation of commitments. This model underscores the dynamic nature of identity development, emphasizing continuity and uniqueness as adolescents forge their identities.

Adolescents’ friendship qualities are crucial for their identity development, underpinned by theories such as Tajfel and Turner’s ( 1979 ) social identity theory, which suggests that joining social groups enhances self-esteem and belonging, supported by friends’ acceptance, positively impacting identity. Attachment theory (Bowlby, 1969 ), highlights the importance of stable interactions and supportive contact, with friendship quality enhancing secure attachments, fostering positive identity development (Steinberg, 2016 ). Additionally, social-cognitive theory (Bandura, 1986 ), points out that observing and imitating others, along with understanding societal norms, shapes identity, with friendship qualities playing a key role in this process. These theories collectively emphasize the significant role of friendship qualities in adolescents’ identity formation.

Adolescents’ relationships with their peers are significant for identity acquisition. During the identity acquisition process, the alignment of adolescents with people like family members and friends in terms of sameness and continuity is an important factor (Branje, 2022 ). The impact of peer relationships on adolescents’ identity development can be both positive and negative. Supportive and responsive friendships help adolescents confidently explore their identity options (Koepke & Denissen, 2012 ). The positive quality of friendships means that adolescents are supported by their peers in terms of relational and educational aspects of identity (de Moor et al., 2019 ). Similarly, when adolescents identify with their classmates, their explorations and commitments towards their interpersonal identities are strengthened (Albarello et al., 2018 ).

In conclusion, personal identity and sense of self develop and shape in conjunction with close relationships with family members and peers (Branje et al., 2021 ). Adolescents’ identification with their classmates and friend groups over time is associated with stronger interpersonal identity commitment and exploration, as well as lower reassessment (Albarello et al., 2018 ). Quality peer relationships among adolescents aid in forming norms by modeling their peers (Verhoeven et al., 2019 ). Friendship qualities, in particular, are highly likely to positively influence this process. Therefore, this study hypothesized that with each unit increase in adolescents’ friendship qualities, their identity development would also positively increase.

Subjective increasing strategies and identity

In the literature, the relationships between identity and well-being have been examined. Achieving a successful identity or exploring identity enhances individuals’ well-being (Eryılmaz & Aypay, 2011 ; Hofer et al., 2011 ). However, there are no direct studies explaining the relationship between well-being strategies and identity. Yet, theoretical explanations and empirical studies with related variables indicate the direction of the relationship between the two variables. Accordingly, strategies to enhance subjective well-being and exploring identity or achieving a successful identity are related psychological patterns. One of the theories explaining well-being is the activity theory. According to this theory, individuals engage in various activities by achieving their goals and satisfying their needs (Newman et al., 2014 ). Such activities are considered strategies to enhance well-being. Generally, strategies to enhance well-being include responding positively to the environment and receiving positive feedback, fulfilling religious beliefs, satisfying desires, practicing mental control, and engaging in activities that directly increase well-being (Buss, 2000 ; Eryılmaz, 2010 ; Fordyce, 1983 ; Tkach & Lyubomirsky, 2006 ). As Maslow ( 1968 ) indicated, such need and goal-oriented activities mean moving towards self-improvement. One dimension of individuals’ self-actualization is owning an identity. In the identity formation process, there are two important dimensions: experimenting and decision-making. Strategies of subjective well-being enhancement, such as receiving and giving positive feedback from/to the environment, satisfying desires, and fulfilling religious beliefs, represent the areas in which individuals experiment. Especially, according to Marcia ( 1980 ), experimenting in the areas of ideology and relationships is fundamental in identity structuring. At this point, using strategies like receiving and giving positive feedback and fulfilling religious beliefs can be seen as trial areas for individuals to explore their identities. Experiencing positive outcomes in such areas strengthens identity exploration. Additionally, according to him, identity is the internal, self-created, dynamic organization of instincts, abilities, beliefs, and personal history. In this regard, using strategies to enhance well-being can be said to express the positive aspect of this dynamic organization.

Strategies to enhance subjective well-being, like positive environmental responses and feedback, are crucial within social contexts that shape adolescent thoughts and experiences (Buss, 2000 ; Fordyce, 1983 ). These strategies, reflecting continuity and consistency in developmental contexts (Côté & Levine, 1988 ), support identity development by offering positive environments. Adherence to religious beliefs and practices (Eryılmaz, 2010 ) serves as a strategy enhancing well-being and identity development, especially in the ideological context where adolescents explore and decide on their beliefs. This intentional engagement with religious practices aids in creating supportive settings for identity formation. Drawing from these theories and research, the study hypothesizes that increasing subjective well-being strategies positively affects adolescent identity development. Building upon the aforementioned theories and empirical research, the study put forth a hypothesis suggesting that an incremental increase of one unit in strategies aimed at increasing subjective well-being would contribute positively to the development of identity among adolescents.

Body image and identity

Substantial and significant connections exist between body image and personal identity, with numerous scholars positing that body image constitutes a fundamental aspect of an individual’s sense of self (Dittmar, 2008 ; Halliwell & Dittmar, 2006 ). This stems from the understanding that an individual’s perception of their physical self is intricately linked to their identity, serving as a vital means of self-expression. Furthermore, the tripartite influence model elucidates that body image formation is influenced by three pivotal social contexts: peers, family, and media (Cash & Pruzinsky, 2002 ), mirroring the process of identity development where relational contexts provide essential norms.

Adolescents, in particular, navigate their social, sexual, and professional realms within these contexts, establishing patterns of body image that become intertwined with their evolving identities (Dittmar, 2009 ). The interplay between body image and identity is underscored by the notion that “Identity formation occurs through bodily experience” (Pelican et al., 2005 , p.61), highlighting the importance of bodily experiences in shaping one’s self-concept. These experiences encompass both the physical and physiological upkeep of the body and the expression of psychological wellness through a positive body image (Tylka & Wood-Barcalow, 2015 ), thereby facilitating identity formation.

Moreover, from a cognitive psychology perspective, the relationship between body image and identity is anchored in the personal perceptions that individuals hold towards themselves, suggesting a symbiotic relationship between a positive body image and a coherent identity (Carlson & Kiemele, 2016 ). The concept of perceptual integrity suggests that for an individual to maintain a cohesive sense of self, these perceptions must be congruent, as enduring contradictions in self-perception is unsustainable. This synthesis underscores the necessity of a supportive interrelation between body image and identity, highlighting their mutual importance in the formation and maintenance of a healthy self-concept.

In conclusion, theoretical and empirical research underscores the significant link between positive body image and identity formation. Erikson’s ( 1968 ) concept of identity formation as a unified self-concept aligns with the notion that positive body image, self-esteem, and self-acceptance are crucial for identity development (Tylka & Wood-Barcalow, 2015 ). The theory of social comparison (Festinger, 1954 ) highlights how individuals evaluate themselves against peers, suggesting that adolescents with a positive body image are likely to develop a positive identity through favorable comparisons. Empirical studies, including those by Tiggemann and Slater ( 2013 ), provide strong evidence of the relationship between positive body image and enhanced self-esteem, self-efficacy, resilience, and identity achievement, while noting its inverse relation to identity confusion in adolescents. Akhtar and Samuel ( 1996 ) also emphasize the role of an authentic body image in forming a coherent identity. This synthesis of theories and studies forms the basis for the hypothesis that improving positive body image will positively affect adolescent identity development.

Mediator role of body image

Research underscores the profound impact of peer groups and friendship quality on adolescents’ body image development. The triple effect model by Clark and Tiggemann ( 2007 ) identifies peers as crucial influencers, capable of affecting body image positively through supportive friendships or negatively. Consistent with this, empirical evidence, such as studies by LaFontana and Cillessen ( 2010 ), highlights that positive friendships play a key role in fostering a positive body image. The quality of adolescent friendships is crucial, with supportive relationships often leading to a healthier body image, as demonstrated by research from Shroff and Thompson ( 2006 ) and McCabe and Ricciardelli ( 2005 ), which found that peer acceptance and social support significantly contribute to positive body image perceptions among teenagers.

Peer groups significantly impact adolescent identity development, with friendship quality—covering conflict, support, and amity—being essential for companionship and closeness (Bukowski et al., 1994 ). Body acceptance is vital for healthy identity growth. Cash ( 2004 ) views body image as encompassing attitudes, thoughts, and feelings towards one’s appearance. Tylka and Wood-Barcalow ( 2015 ) describe body image in two dimensions: positive, with aspects like appreciation, and negative.

Subjective well-being improvement strategies, such as mental control, positive feedback, religious engagement, and adaptive responses, can boost happiness and potentially influence body image positively (Tkach & Lyubomirsky, 2006 ; Fordyce, 1983 ). Research shows a connection between these well-being strategies and positive body image development, with practices like smiling and avoiding negative feedback playing key roles (Holmqvist & Frisén, 2012 ; Cash, 2004 ). A higher power’s perception and proactive body appreciation are also linked to improved well-being and body image (Eryılmaz, 2010 ; Tkach & Lyubomirsky, 2006 ). Despite the broad application of these strategies across various life aspects (Buss, 2000 ; Eryılmaz, 2010 ), their specific impact on body image necessitates further study. Current literature, including recent findings (Eryılmaz et al., 2023 ), suggests that employing positive psychology practices can foster a better body image among adolescents, highlighting the need for more research in this area (Tylka & Wood-Barcalow, 2015 ).

In the scholarly examination of body image literature, it becomes evident that cultural variances significantly influence the anchoring of identity, either in familial, communal, and interpersonal dynamics or within the corporeal and personal self-concept (Becker, 2004 ). According to the socio-theoretical perspectives on identity formation, identity is fundamentally constructed through interactions with others (Pelican et al., 2005 ). These theoretical insights underscore the imperative inclusion of social mechanisms, notably friendships, in the exploration and construction of identity. Within the framework of this discourse, the model addressed herein posits that the engagement in friendship relations and the implementation of strategies aimed at augmenting subjective well-being serve as both individual and societal antecedents to identity formation. Body image is posited to occupy a mediatory role between associated variables and identity, encapsulating the concept that identity is intrinsically linked to the physical self and personal identity. The intermediary function of body image is predicated on its capacity to facilitate and enable the influence of antecedent variables pertinent to identity on the construct of identity itself, thereby underpinning the processes of experimentation and decision-making integral to identity development (Branje, 2022 ; Crocetti, 2017 ).

Furthermore, friend support and strategies for enhancing subjective well-being are positive psychological attributes. The literature indicates that positive psychological attributes lead to a positive body image (Tylka & Wood-Barcalow, 2015 ). Positive body image, in turn, offers positive contributions to individuals’ identities within the context of body perception. In this aspect, it is considered that body image has a reinforcing effect on individuals’ identities. Alongside this, empirical studies in the literature also suggest that body image could mediate the relationship between strategies for enhancing subjective well-being and friendship quality and identity. For example, Pelican and colleagues ( 2005 ) highlight this relationship by stating: “Other people can profoundly influence individuals’ feelings about their own body and physical abilities—important dimensions of personal identity” (p.57).

Consequently, according to the assumptions of social support (Cobb, 1976 ), social identity theory (Tajfel & Turner, 1979 ), and empirical research results in the literature (McCabe & Ricciardelli, 2005 ; Shroff & Thompson, 2006 ), adolescents’ friendship qualities positively affect their body images. Especially, based on the triple effect model (Clark & Tiggemann, 2007 ), negative messages from peers adversely affect body image. On the flip side of the coin, positive messages from peers also affirmatively affect adolescents’ body images. In addition to all these, the positive quality of friendship relations causes adolescents to accept and approve of themselves as they are. In Tylka and Wood-Barcalow ( 2015 ) assert that increasing approval and acceptance contributes significantly to individuals’ ability to accept their bodies, consequently leading to an elevation in self-esteem. Positive acceptance and approval of one’s own body lead individuals to successfully develop identity (Akhtar & Samuel, 1996 ; Tiggemann & Slater, 2013 ). Building upon the theoretical underpinnings and empirical investigations, the hypothesis proposed that positive body image would mediate the relationship between friendship qualities and the developmental processes of identity in adolescents.

Adolescents use a number of strategies to increase their well-being (Buss, 2000 ; Eryılmaz, 2010 ; Tkach & Lyubomirsky, 2006 ). In the literature, it is evident that the strategies utilized to foster a positive body image align harmoniously with the strategies employed to promote subjective well-being, as supported by Holmqvist and Frisén’s ( 2012 ) findings. It is worth highlighting that the strategy of fostering a positive body image, including actions like smiling and hugging, aligns harmoniously with the strategies of positively engaging with the environment and seeking positive responses, which are recognized approaches for increasing subjective well-being (Tkach & Lyubomirsky, 2006 ). Moreover, it is apparent that keeping a distance from negative reactions and criticisms from the media, peers, and family (Cash, 2004 ) to create a positive body image is compatible with the mental control strategy (Eryılmaz, 2010 ). It can be inferred from these associations that the utilization of strategies to enhance subjective well-being contributes positively to the formation of a positive body image (Eryılmaz et al., 2023 ). Empirical studies show that the positive body image of adolescents positively affects their identity development (Akhtar & Samuel, 1996 ; Tiggemann & Slater, 2013 ). Building upon the theoretical underpinnings and empirical investigations, the hypothesis proposed that that a one-unit increase in positive body image could positively affect the identity development of adolescents. The hypothesis posited by the study, derived from the theoretical frameworks and empirical investigations, suggests that positive body image may play a mediating role between the utilization of strategies aimed at enhancing subjective well-being and the development of identity. The study aims to examine whether body image acts as a mediator between the utilization of strategies aimed at enhancing subjective well-being, friendship qualities, and identity development (Fig. 1 ).

Hypothesis 1 = Friendship qualities is in a meaningful predicts positive body image.

Hypothesis 2 = Friendship qualities is in a meaningful predicts identity development.

Hypothesis 3 = The utilization of strategies aimed at enhancing subjective well-being is in a meaningful predicts positive body image.

Hypothesis 4 = The utilization of strategies aimed at enhancing subjective well-being is in a meaningful predicts identity development.

Hypothesis 5 = Positive body image is in a meaningful predicts identity development.

Hypothesis 6 = The mediating effect of positive body Image is significant between friendship qualities and identity development.

Hypothesis 7 = The mediating effect of positive body image is significant between the utilization of strategies aimed at enhancing subjective well-being and identity development.

Hypothetical structural model. Note. BII = Body Image Investment, GBA = General Body Appreciation, CL = Closeness, SE = Security, HE = Help, CO = Companionship, RPRFE = Receiving Positive Reaction from an Environment; PRA = Participating in Religious Activities, RPTE = Reacting Positively to an Environment, SD = Satisfaction of Desires, MC = Mental Control, CM = Commitment Making, IWC = Identification with Commitment, EB = Exploration in Breadth, ED = Exploration in Depth. SWBIS = Subjective Well-Being Increasing Strategies

Participants and procedure

The research procedures were carried out as follows: First, for the collection of the data, permission was obtained from the relevant researchers for the measurements to be used in the study and ethics committee approval was obtained from the [Omitted] University Social and Human Sciences Ethics Committee (Meeting No: 20,230,301,997). The study commenced by preparing a consent form, which was presented to the children for their voluntary acceptance. Informed consent was then obtained from the families of the children for their participation. Data collection tools were then administered individually to early adolescents face-to-face in a school setting, following approval from their families. The participants, who were early adolescents, were duly notified about their entitlement to terminate their involvement in the study whenever they desired. Additionally, eight individuals who failed to complete all the scales and nine participants who expressed unwillingness were omitted from the study, yielding a final analysis sample of 270 early adolescents. 270 early adolescents (157 girls (58.15%), 113 boys (41.85%)) selected by criterion sampling method participated in the present study. The study enlisted participants based on predetermined criteria, which entailed not having any psychiatric diagnosis, being an adolescent of Turkish descent, and demonstrating willingness to volunteer. It is noted that the age distribution of the participants is [Agerange = 13–15, AgeMean = 14.12, AgeSd = 1.04].

Body Appreciation Scale (BAS)

In the Turkish adaptation of the Body Appreciation Scale (BAS) by Avalos et al. ( 2005 ), Bakalım and Taşdelen-Karçkay ( 2016 ) conducted reliability and validity analyses. Confirmatory factor analysis was employed to evaluate the construct validity of the scale. The findings revealed satisfactory goodness of fit indices: GFI = 0.92, CFI = 0.93, and RMSEA = 0.11 for women, and GFI = 0.91, CFI = 0.93, and RMSEA = 0.11 for men. Internal consistency reliability coefficients were found to be reliable, with a coefficient of 0.92 for the entire BAS in men, and ranging from 0.70 to 0.91 for the sub-dimensions. For women, the internal consistency reliability coefficient was 0.87 for the entire BAS, with sub-dimension values ranging from 0.62 to 0.80.

The Friendship Qualities Scale

Atik et al. ( 2014 ) conducted validity and reliability studies on the Turkish adaptation of the Friendship Qualities Scale (FQS) developed by Bukowski et al. ( 1994 ). The FQS encompasses five dimensions: companionship, help, security, closeness, and conflict (with conflict excluded from the analysis due to its negative connotation). To establish construct validity, Atik et al. ( 2014 ) employed confirmatory factor analysis, which yielded acceptable goodness of fit values: GFI = 0.88, NNFI = 0.96, CFI = 0.97, and RMSEA = 0.063. Internal consistency reliability coefficients were reported to range from 0.66 to 0.86, according to Atik et al. ( 2014 ).

The Subjective Well-Being Increasing Strategies Scale for Adolescents (SWBIS)

Eryılmaz ( 2010 ) developed the SWBIS for Adolescents (SWBIS) and subsequently conducted validity and reliability assessments. The scale encompasses five dimensions: mental control, receiving positive reactions from the environment, satisfaction of desires, participation in religious activities, and reacting positively to the environment. Eryılmaz ( 2010 ) employed exploratory factor analysis to evaluate the construct validity of the scale, finding that it accounted for 59.86% of the total variance. Additionally, internal consistency reliability analysis indicated a reliability coefficient of 0.89 for the entire scale, with the sub-dimensions ranging from 0.68 to 0.92, as reported by Eryılmaz ( 2010 ).

The Dimensions of Identity Development Scale (DIDS)

Morsünbül and Çok ( 2014 ) conducted validity and reliability analyses on the Turkish version of the DIDS developed by Luyckx et al. ( 2008 ). The DIDS comprises five dimensions: Commitment making, exploration in depth, identification with commitment, exploration in breadth, and ruminative exploration (which was not considered in this study, focusing on positive variables). Both exploratory and confirmatory factor analyses were employed to assess the construct validity of the DIDS. The exploratory factor analysis accounted for 57.43% of the explained variance, while the confirmatory factor analysis yielded good fit indices: GFI = 0.95, NFI = 0.98, CFI = 0.92, and RMSEA = 0.062. Moreover, Morsünbül and Çok ( 2014 ) reported internal consistency reliability coefficients ranging from 0.78 to 0.88 for the sub-dimensions of the DIDS.

Data analysis

The initial phase of data analysis in this study involved conducting preliminary assessments of skewness, kurtosis, multicollinearity, and correlations, following the procedures outlined by Kline ( 2015 ). Subsequently, a two-stage structural equation modeling approach was employed to evaluate the data. Maximum likelihood estimation was chosen as the preferred probability method, as suggested by Kline ( 2015 ). The fit of the model to the data was evaluated using various goodness-of-fit indices, such as χ2/df, GFI, AGFI, NFI, RMSEA, and CFI. Furthermore, the AIC and ECVI model comparison indices were utilized to determine the most appropriate model, following the guidelines put forth by Schermelleh-Engel et al. ( 2003 ). Bootstrapping analysis was conducted to examine the significance of indirect effects, involving 1000 resamples and the creation of upper and lower confidence intervals. Effects were considered significant if the confidence intervals did not include zero, as recommended by Shrout and Bolger ( 2002 ).

Preliminary analysis

Based on the preliminary analysis, the researchers evaluated the normality assumption and the assumption of multicollinearity in their study. The skewness and kurtosis values were used to assess normality. The skewness value ranged from − 1.44 to 0.08, and the kurtosis value ranged from − 1.13 to 1.85. These values fall within the acceptable range of normality, as suggested by Kline ( 2015 ), which is between − 2 and + 2. Therefore, the data can be considered to meet the normality assumption. The researchers used VIF (Variance Inflation Factor) and tolerance values to investigate multicollinearity. The VIF value ranged from 1.18 to 1.26, and the tolerance value ranged from 0.79 to 0.83. These results indicate that there is no multicollinearity problem in the present study. Since the VIF value is less than 5 and the tolerance value is greater than 0.10, the assumption of no multicollinearity is met (Kline, 2015 ). In summary, the preliminary analysis suggests that the data in the study meet the assumptions of normality and no multicollinearity. This provides a solid foundation for further statistical analyses and interpretations of the study’s findings (Table 1 ).

Testing structural equation modeling

Stage 1: measurement model.

In this study, there are four latent variables and 15 observed variables. After conducting an analysis of the measurement model, the researchers examined various goodness-of-fit indices, including χ2/df (167.433/84) = 1.99, GFI = 0.93, AGFI = 0.89, NFI = 0.92, CFI = 0.96, and RMSEA = 0.06 (with a 90% confidence interval for RMSEA as [0.04, 0.07]). The results indicated that the measurement model achieved an acceptable level of goodness-of-fit, signifying its validity. Additionally, the standardized factor loadings, ranging from 0.53 to 1.00, were all significant with respective t-values, providing further support for the soundness of the measurement model (refer to Fig. 2 ). In summary, the measurement model was thoroughly evaluated, and the attained goodness-of-fit indices and significant factor loadings demonstrate the validity of the model in this study.

Standardized Factor Loadings of the Measurement Model. Note. ** p  <.001, BII = Body Image Investment, GBA = General Body Appreciation, CL = Closeness, SE = Security, HE = Help, CO = Companionship, RPRFE = Receiving Positive Reaction from an Environment; PRA = Participating in Religious Activities, RPTE = Reacting Positively to an Environment, SD = Satisfaction of Desires, MC = Mental Control, CM = Commitment Making, IWC = Identification with Commitment, EB = Exploration in Breadth, ED = Exploration in Depth, SWBIS = Subjective Well-Being Increasing Strategies

Stage 2: Structural model

After verifying the measurement model, the researchers tested the structural model to investigate the mediation effect of positive body image on the relationship between friendship qualities, the utilization of strategies aimed at enhancing subjective well-being, and identity development. They removed specific paths between friendship qualities and the utilization of strategies aimed at enhancing subjective well-being, as well as between friendship qualities and identity development, to examine potential mediation. The impact of these path removals on the model’s fit was assessed to gain insights into the mediating role of positive body image. First, when the path from friendship qualities to identity development was removed from the model and the model was retested, goodness of fit indices (χ2/df (181.140/85) = 2.13; GFI = 0.92; AGFI = 0.88; NFI = 0.91; CFI = 0.95; RMSEA = 0.06 (90% CI for RMSEA = [0.05, 0.07]) was found to be at an acceptable level. However according to the chi-square difference test finding, removing the path from friendship qualities to identity development caused a significant deterioration in the model (Δχ2 = 13.70, df = 1: p  <.001). It was understood that this path should not be removed from the model because there is a significant deterioration.

Secondly, the path from the utilization of strategies aimed at enhancing subjective well-being to identity development was excluded from the model. When the model was retested, the goodness of fit indices (χ2/df (203.874/86) = 2.37; GFI = 0.91; AGFI = 0.87; NFI = 0.90; CFI = 0.94; RMSEA = 0.07 (90% CI for RMSEA = [0.05, 0.08]) was found to be at an acceptable level. However according to the chi-square difference test findings, it was determined that removing the path to identity development from the utilization of strategies aimed at enhancing subjective well-being caused a significant deterioration in the model (Δχ2 = 22.73, df = 2: p  <.001). Since a significant deterioration was detected, it was decided to include this path in the model.

As a result of chi-square difference tests, it was determined that positive body image partially mediated the relationship between friendship qualities, the utilization of strategies aimed at enhancing subjective well-being and identity development. In addition, it is seen that model comparison goodness of fit indices of the Partial Mediation Structural Model (AIC = 239.433; ECVI = 0.890) are smaller than the model comparison goodness of fit indices of the Full Mediation Structural Model (AIC = 271.874; ECVI = 1.011). In line with all these results, it was decided that the model in which positive body image partially mediated between friendship qualities, the utilization of strategies aimed at enhancing subjective well-being and identity development was the best model (Table 2 ).

In Fig. 3 analysis, it was evident that an increase of one unit in friendship qualities showed significant associations with a 0.28 (t = 3.436; p  <.001) unit increase in positive body image and a 0.26 (t = 3.494; p  <.001) unit increase in identity development. Likewise, a one-unit increase in the utilization of strategies aimed at enhancing subjective well-being had a significant relationship with a 0.18 (t = 2.491; p  <.05) unit increase in positive body image and a 0.22 (t = 3.093; p  <.01) unit increase in identity development. Lastly, a one-unit increase in positive body image was significantly associated with a 0.28 (t = 4.390; p  <.001) unit increase in identity development (Table 3 ).

Standardized regression weights for partial mediation structural model. Note. *** p  <.001, ** p  <.01; * p  <.05, BII = Body Image Investment, GBA = General Body Appreciation, CL = Closeness, SE = Security, HE = Help, CO = Companionship, RPRFE = Receiving Positive Reaction from an Environment; PRA = Participating in Religious Activities, RPTE = Reacting Positively to an Environment, SD = Satisfaction of Desires, MC = Mental Control, CM = Commitment Making, IWC = Identification with Commitment, EB = Exploration in Breadth, ED = Exploration in Depth, SWBIS = Subjective Well-Being Increasing Strategies

Bootstrapping analysis (significance of indirect effects)

In the current study, bootstrapping analysis was employed to assess the significance of two indirect effects. The first indirect effect pertained to the relationship between friendship qualities and identity development, with positive body image acting as a partial mediator. The second indirect effect focused on the link between the utilization of strategies aimed at enhancing subjective well-being and identity development, with positive body image also acting as a partial mediator.

According to Table 4 , the partial mediation effect of positive body image between friendship qualities and identity development is significant (β = 0.07, SE = 0.03 [95% CI = 0.024, 0.147, p  <.05]. In addition, the partial mediating role of positive body image was found to be significant between the utilization of strategies aimed at enhancing subjective well-being and identity development (β = 0.05, SE = 0.02 [95% CI = 0.010, 0.105, p  <.05]. In line with all these results, it has been proven that early adolescents’ positive body images have a partial mediating role between friendship qualities, the utilization of strategies aimed at enhancing subjective well-being and identity development.

Alternative model

The study developed an alternative model to validate the main partial structural model. In this alternative model, positive body image was an exogenous variable, while friendship qualities and the utilization of strategies aimed at enhancing subjective well-being acted as mediator variables, and identity development remained the internal variable. The goodness-of-fit indices for the alternative model (χ2/df (194.153/85) = 2.28; GFI = 0.92; AGFI = 0.88; NFI = 0.91; CFI = 0.95; RMSEA = 0.07 with a 90% CI = [0.06, 0.08]) were acceptable, indicating a reasonable fit. Figure 4 illustrates the path diagram of the alternative model. This alternative model further supports the relationships among positive body image, friendship qualities, the utilization of strategies aimed at enhancing subjective well-being, and identity development.

Standardized regression weights for alternative model. Note. ** p  <.001, * p  <.01, BII = Body Image Investment, GBA = General Body Appreciation, CL = Closeness, SE = Security, HE = Help, CO = Companionship, RPRFE = Receiving Positive Reaction from an Environment; PRA = Participating in Religious Activities, RPTE = Reacting Positively to an Environment, SD = Satisfaction of Desires, MC = Mental Control, CM = Commitment Making, IWC = Identification with Commitment, EB = Exploration in Breadth, ED = Exploration in Depth, SWBIS = Subjective Well-Being Increasing Strategies

After analyzing Fig. 4 , the study revealed the following associations: An increase of one unit in positive body image was significantly related to a 0.38 unit increase (t = 5.012; p  <.001) in friendship qualities. An increase of one unit in friendship qualities was significantly associated with a 0.27 unit increase (t = 3.768; p  <.001) in identity development. Moreover, an increase of one unit in positive body image was significantly linked to a 0.33 unit increase (t = 4.676; p  <.001) in the utilization of strategies aimed at enhancing subjective well-being. An increase of one unit the utilization of strategies aimed at enhancing subjective well-being was significantly related to a 0.22 unit increase (t = 3.282; p  <.01) in identity development. Finally, an increase of one unit in positive body image was significantly associated with a 0.29 unit increase (t = 4.048; p  <.001) in identity development.

In this study, a positive identity development model was reached for adolescents. In this direction, while adolescents develop their identities in a positive way by using subjective well-being-increasing strategies, positive body image also mediates this process. Similarly, it was concluded that while adolescents develop their identities by friendships quality, positive body image also mediates this process.

In this study, the hypothesis that the quality of the friendship relationship would positively affect identity development has been confirmed. Thus, the findings of this study confirmed the assumptions of social identity theory (Tajfel & Turner, 1979 ), attachment theory (Bowlby, 1969 ), and social-cognitive theory (Bandura, 1986 ). Moreover, the findings of this study can be considered in terms of cognitive development theory (Piaget, 1968 ). Cognitive development theory, which explains adolescent development, shows that the quality of friendship relationships is of utmost importance for identity development. Studies conducted in this direction demonstrate that the quality of peer relations supports adolescents’ identities by helping them discover options in terms of identity (Steinberg, 2016 ).

In this study, the hypothesis that the utilization of strategies aimed at enhancing subjective well-being would positively affect identity development has been confirmed. By means of this study that is based on the fact that there are positive relationships between subjective well-being and identity development (Van Hoof & Raaijmakers, 2002 ), it has been concluded that the utilization of strategies aimed at enhancing subjective well-being have a positive effect on identity development. The findings of this study confirm the assumptions of goal theory explaining subjective well-being. Because, according to the goal theory, individuals realize themselves by setting goals and satisfying their needs (Diener, 1984 ). Identity development is also a dimension of self-actualization. Furthermore, studies conducted on the basis of self-determination theory show that adolescents will reach a healthy self and identity structure if they satisfy their needs (Deci & Ryan, 2000 ). It is plausible to argue that individuals discover their own identities by satisfying their aforementioned needs (Eryılmaz, 2012 ), particularly through strategies to increase subjective well-being.

According to this study, the hypothesis that positive body image can positively affect identity development has been confirmed. The results of this study provide support for Erikson’s ( 1968 ) psychosocial development theory, as well as Festinger’s ( 1954 ) social comparison theory. Additionally, the findings align with the principles of self-determination theory proposed by Deci and Ryan ( 2000 ). According to self-determination theory, individuals have intrinsic psychological needs, including autonomy, competence, and relatedness, which were also confirmed in this study as posited by Deci and Ryan ( 2000 ). Adolescents who exhibit positive body image in this study may have experienced a feeling of autonomy and competence regarding their physical selves, which, in turn, might have played a role in their comprehensive well-being and identity development.

The findings of this study support bio-psycho-social models for human development in general, especially considering the mediation relations in the study (Miller, 2011 ). The positive body image variable employed in this research encompasses elements of somatic development, peer relationship quality, and strategies to promote subjective well-being, incorporating both physical (gratifying desires and mental regulation) and social (positive environmental responses and receiving positive feedback) aspects. It can be speculated that identity development represents other dimensions besides the psychological dimension. Herein, we may assert that this study has presented a comprehensive identity development model (Table 5 ).

The research findings can be interpreted as follows. Subjective well-being enhancement strategies can be considered in relation to the connections between identity exploration or achieving a successful identity and well-being as a whole (Table 5). During the identity development process, individuals utilize subjective well-being enhancement strategies. As a result of this process, they encounter a developmental outcome. This developmental outcome can be interpreted as either identity exploration or achieving a successful identity. As individuals explore their identities, their levels of well-being increase.

The findings related to the significance of body image in the study can be interpreted as follows. Human beings are bio-psycho-social entities. The psychological and social reality of humans cannot be realized without their bodily reality. The use of friendship relations and subjective well-being enhancement strategies by adolescents can be considered psycho-social variables that affect their identities. For these variables to impact individuals’ identities, it is necessary for individuals to possess a bodily reality and a positive body image. At this point, bodily reality is a very important mediator for both psychological and social factors to become active (Fig. 5 ). The perception of one’s body is also influenced by this mediating relationship in the process. This is because studies in the literature have shown that body image is a very important condition for both physical and mental health (Cash & Pruzinsky, 2002 ; Grogan, 2008 ; Thompson, 2004 ). A positive body image leads individuals to achieve a successful identity and to explore their identities (Carlson & Kiemele, 2016 ; Harter, 1999 ; Levine-Rasky, 2011 ; Pelican et al., 2005 ).

Mediator role of body and body image

Besides all these, the findings of the study also support the positive youth development theory. According to this theory, adolescents’ positive development is linked to their ability to develop positive relationships, engage in meaningful activities, and achieve a sense of purpose. This model considers well-being as a positive youth development product (Lerner et al., 2009 ). Studies in the literature demonstrate that positive youth development models are constantly renewed and developed. This study, on the other hand, took the assumptions of this theory one step further and discussed identity development by bringing together the factors that provide positive youth development (the utilization of strategies aimed at enhancing subjective well-being, friendship quality, and positive body image) in a relational structure. Herein, it is revealed that identity development can be an important element of positive development.

An alternative model is also presented in this study. As seen in the findings of the study, it was concluded that the current model had a higher level of explained variance than the alternative model. The theoretical explanations and empirical studies discussed above explain the underlying reason for addressing this result.

A summary of the theoretical contributions of the current study

This study has made several significant theoretical contributions to understanding identity development. First, by confirming Tajfel and Turner’s ( 1979 ) social identity theory, Bowlby’s ( 1969 ) attachment theory, and Bandura’s ( 1986 ) social-cognitive theory, it shows that high-quality friendships are crucial for adolescent identity development. It also aligns with Piaget’s ( 1968 ) theory of cognitive development by showing that these relationships provide vital support for adolescents to explore identity options, as indicated in Steinberg’s ( 2016 ) recent research. Furthermore, this study supports goal theory’s (Diener, 1984 ) idea that using strategies to enhance subjective well-being positively affects identity development, which is intertwined with self-actualization. This is also supported by self-determination theory (Deci & Ryan, 2000 ), which suggests that meeting autonomy needs leads to a healthy identity structure. Finally, the study supports Erikson’s psychosocial development theory ( 1968 ) and Festinger’s social comparison theory ( 1954 ), showing that adolescents positively develop their identities by using strategies that enhance subjective well-being; positive body image mediates this process.

A summary of the current study’s practical contributions and implications

This study underscores friendship qualities, subjective well-being strategies, and positive body image development in supporting adolescents’ identity development. Evidence suggests that improving the quality of friendships can lead to significant gains in adolescents’ body image and self-identity. School psychologists and counselors should consider developing peer support programs promoting positive student interactions and relationships. Furthermore, the positive impact of subjective well-being strategies on body image and identity development highlights the need for well-being programs that teach students effective coping mechanisms and goal-setting techniques. Workshops or regular classes could be integrated into school curricula to increase subjective well-being strategies. Finally, given the strong relationship between positive body image and identity development, school psychologists and counselors should implement positive body image programs to help students develop a healthy and accepting attitude toward their physical selves. By focusing on these strategic areas, school professionals can create a supportive environment that contributes significantly to the holistic development of adolescents.

Suggestions for educators and policymakers regarding the development of support programs

The study reveals the positive effects of friendship qualities, subjective well-being strategies, and positive body image on identity development. Educators and policymakers should focus on these areas to design and implement support programs in educational settings. Schools and universities can implement peer mentoring programs that encourage the development of high-quality friendships and thus directly enhance students’ body image and identity formation. Furthermore, including educational sessions that teach students strategies to improve their subjective well-being can further support their psychological and emotional development. Promoting positive body image through campaigns and workshops that address body positivity and media literacy is also essential and helps students develop a healthier relationship with their physical selves. These combined efforts can create a supportive educational environment that meets students’ immediate needs and fosters long-term well-being and personal growth.

Generalizability of the findings from this study beyond the current sample to the population

The sample consisted only of early adolescents of Turkish origin without any psychiatric diagnosis, which may limit the broader applicability of the results to other demographic or cultural groups. Age range and cultural context are particularly critical; developmental stages differ, and cultural factors profoundly influence social relationships and self-perception. Therefore, while this study provides valuable insights into the dynamics of identity development among Turkish adolescents, the results must be validated in other cultural and age contexts to confirm their universality. Further research involving diverse demographic groups would help determine whether these findings hold in different societies or whether modifications are necessary to accommodate other cultural or developmental nuances. Such research could provide a more comprehensive understanding of the factors of global identity development.

Limitations and future research

One of the critical limitations of this study is that it was conducted on adolescents without a psychiatric diagnosis. In addition, the study is a cross-sectional study. Performing longitudinal studies with similar variables can contribute to the literature. Based on the findings of this study, specific recommendations can be developed. Primarily, this study has presented a model for positive identity development. Based on this model, programs can be prepared to support adolescents’ identity development. Furthermore, the model in this study can be used as a protective factor against identity disruption. The identity disruption model suggests that adverse experiences in early life can heighten the likelihood of developing body dissatisfaction and disordered eating habits. This model asserts that adverse experiences can interrupt normal identity development and make individuals more vulnerable to sociocultural risk factors such as internalizing social beauty standards and comparing oneself based on appearance. The dimensions discussed in the study can each be seen as protective factors against these risks.

Based on the findings of this study, it is clear that friendship qualities, subjective well-being strategies, and positive body image significantly influence early adolescents’ identity development. Significant increases in identity development and positive body image were associated with enhanced friendship qualities and well-being strategies, highlighting the profound influence of interpersonal connections and personal satisfaction on adolescents’ psychological development.

This emphasizes developing positive relationships among young people and promoting mental health and self-care practices. The results of this study provide strong empirical support for existing theories. The association between increased friendship qualities and improvements in body image and identity suggests that social interactions are beneficial and necessary for developing a healthy sense of self during adolescence. This may be because peer acceptance and belongingness in adolescents’ lives influence their identity, body image, and well-being. Equipped with strategies to manage their emotions and maintain a positive outlook, adolescents may be better positioned to navigate the challenges of this critical developmental stage, leading to more robust identity formation. Overall, this study enriches our understanding of how friendship qualities, subjective well-being, and body image contribute to adolescents’ identity development. It calls for continued research in different populations to further explore these dynamics and develop targeted interventions to enhance these adolescent life aspects.

Data availability

The data set is available upon request.

Akhtar, S., & Samuel, S. (1996). The concept of identity: Developmental origins, phenomenology, clinical relevance, and measurement. Harvard Review of Psychiatry, 3 (5), 254–267. https://doi.org/10.3109/10673229609017193

Article   PubMed   Google Scholar  

Albarello, F., Crocetti, E., & Rubini, M. (2018). I and us: A longitudinal study on the interplay of personal and social identity in adolescence. Journal of Youth and Adolescence, 47 , 689–702. https://doi.org/10.1007/s10964-017-0791-4

Atik, Z. E., Çoban, A. E., Çok, F., Doğan, T., & Karaman, N. G. (2014). Adaptation of thepeer relationship scale to Turkish: Validity and reliability study. Educational Sciences in Theory and Practice, 14 (2), 433–446.  https://doi.org/10.12738/estp.2014.2.1778

Avalos, L., Tylka, T. L., & Wood-Barcalow, N. (2005). The body appreciation scale: Development and psychometric evaluation. Body Image, 2 , 285–297. https://doi.org/10.1016/j.bodyim.2005.06.002

Bakalım, O., & Taşdelen-Karçkay, A. (2016).Body appreciation scale: Evaluation of the factor structure and psychometric properties among male and female Turkish university students. Mersin University Journal of the Faculty of Education, 12 (1), 410–422. https://doi.org/10.17860/efd.38032

Bandura, A. (1986). Fearful expectations and avoidant actions as coeffects of perceived self-inefficacy. American Psychologist, 41 (12), 1389–1391. https://doi.org/10.1037/0003-066X.41.12.1389

Article   Google Scholar  

Becker, A. E. (2004). Television, disordered eating, and young women in Fiji: Negotiating body image and identity during rapid social change. Culture Medicine and Psychiatry, 28 , 533–559. https://doi.org/10.1007/s11013-004-1067-5

Berzonsky, M. D. (2005). Ego identity: A personal standpoint in a postmodern world. Identity: An International Journal of Theory and Research, 5 (2), 125–136. https://doi.org/10.1207/s1532706xid0502_3

Bowlby, J. (1969). Attachment and loss (Vol. 1). Random House.

Google Scholar  

Branje, S. (2022). Adolescent identity development in context. Current Opinion in Psychology, 45 , 101286. https://doi.org/10.1016/j.copsyc.2021.11.006

Branje, S., De Moor, E. L., Spitzer, J., & Becht, A. I. (2021). Dynamics of identity development in adolescence: A decade in review. Journal of Research on Adolescence, 31 (4), 908–927. https://doi.org/10.1111/jora.12678

Article   PubMed   PubMed Central   Google Scholar  

Bukowski, W. M., Hoza, B., & Boivin, M. (1994). Measuring friendship quality during pre-and early adolescence: The development and psychometric properties of the Friendship qualities Scale. Journal of Social and Personal Relationships, 11 (3), 471–484. https://doi.org/10.1177/0265407594113011

Buss, D. M. (2000). The evolution of happiness. American Psychologist, 55 , 15–23. https://doi.org/10.1037/0003-066X.55.1.15

Carlson, M., & Kiemele, R. (2016). In the looking glass: An examination of body image and Identity Development through Research and Poetry. The Vermont Connection, 37 (1), 26–37.

Cash, T. F. (2004). Body image: Past, present, and future. Body Image, 1 (1), 1–5. https://doi.org/10.1016/S1740-1445(03)00011-1

Cash, T. F., & Pruzinsky, T. (Eds.). (2002). Body image: A handbook of theory, research, and clinical practice . Guilford.

Clark, L., & Tiggemann, M. (2007). Sociocultural influences and body image in 9 to 12-year-old girls: The role of appearance schemas. Journal of Clinical Child and Adolescent Psychology, 36 (1), 76–86. https://doi.org/10.1080/15374410709336570

Cobb, S. (1976). Social support as a moderator of life stress. Psychosomatic Medicine, 38 (5), 300–314.  https://journals.lww.com/psychosomaticmedicine/Abstract/1976/09000/Social_Support_as_a_Moderator_of_Life_Stress.3.aspx

Côté, J. E., & Levine, C. (1988). The relationship between ego identity status and Erikson’s notions of institutionalized moratoria, value orientation stage, and ego dominance. Journal of Youth and Adolescence, 17 (1), 81–99. https://doi.org/10.1007/BF01538725

Crocetti, E. (2017). Identity formation in adolescence: The dynamic of forming and consolidating identity commitments. Child Development Perspectives, 11 (2), 145–150. https://doi.org/10.1111/cdep.12226

De Moor, E. L., Van der Graaff, J., Van Dijk, M. P., Meeus, W., & Branje, S. (2019). Stressful life events and identity development in early and mid-adolescence. Journal of Adolescence, 76 , 75–87. https://doi.org/10.1016/j.adolescence.2019.08.006

Deci, E. L., & Ryan, R. M. (2000). The what and why of goal pursuits: Human needs and the self-determination of behavior. Psychological Inquiry, 11 (4), 227–268. https://doi.org/10.1207/S15327965PLI1104_01

Diener, E. (1984). Subjective well-being. Psychological Bulletin, 95 (3), 542–575. https://doi.org/10.1037/0033-2909.95.3.542

Dittmar, H. (2008). Consumer culture, identity, and well-being: The search for the good life and body perfect. European Monographs in Social Psychology (Series editor: Rupert Brown). Psychology Press.

Dittmar, H. (2009). How do ‘“body perfect”’ ideals in the media have a negative impact on body image and behaviours? Factors and processes related to self and identity. Journal of Social and Clinical Psychology, 28 , 1–8. https://doi.org/10.1521/jscp.2009.28.1.1

Erikson, E. H. (1968). Identity: Youth and crisis . W. W. Norton & Company.

Erikson, E. H. (1994). Identity and the life cycle. WW Norton & Company.

Eryılmaz, A. (2010). Developing a scale about subjective well-being increases strategies for adolescents. Turkish Psychological Counseling & Guidance Journal, 4 (33), 81–88. https://doi.org/10.17066/pdrd.47701

Eryılmaz, A. (2012). A model of subjective well-being for adolescents in high school. Journal of Happiness Studies, 13 (2), 275–289. https://doi.org/10.1007/s10902-011-9263-9

Eryılmaz, A., & Aypay, A. (2011). Ergen öznel iyi oluşu ile kimlik statüsü ilişkisinin incelenmesi. Dicle Üniversitesi Ziya Gökalp Eğitim Fakültesi Dergisi, 16 , 167–179.

Eryılmaz, A., Kara, A., & Huebner, E. S. (2023). The mediating roles of subjective well-being?ncreasing strategies and emotional autonomy between adolescents? body?mage and subjective well-being. Applied Research in Quality of Life, 1–27. https://doi.org/10.1007/s11482-023-10156-1

Festinger, L. (1954). A theory of social comparison processes. Human Relations, 7 (2), 117–140. https://doi.org/10.1177/001872675400700202

Fordyce, M. W. (1983). A program to increase happiness: Further studies. Journal of Counseling Psychology, 30 , 483–498. https://doi.org/10.1037/0022-0167.30.4.483

Grogan, S. (2008). Body image: Understanding body dissatisfaction in men, women and children . 2nd Edition. Routledge.

Halliwell, E., & Dittmar, H. (2006). Associations between appearance-related self-discrepancies and young women’s and men’s affect, body satisfaction, and emotional eating: A comparison of fixed-item and participant-generated self-discrepancies. Personality and Social Psychology Bulletin, 32 (4), 447–458. https://doi.org/10.1177/0146167205284005

Harter, S. (1999). Symbolic interactionism revisited: Potential liabilities for the self constructed in the crucible of interpersonal relationships. Merrill-Palmer Quarterly,45 (4), 677–703. https://www.jstor.org/stable/23093377

Hofer, J., Busch, H., & Kärtner, J. (2011). Self–regulation and well–being: The influence of identity and motives. European Journal of Personality, 25 (3), 211–224. https://doi.org/10.1002/per

Holmqvist, K., & Frisén, A. (2012). I bet they aren’t that perfect in reality: Appearance ideals viewed from the perspective of adolescents with a positive body image. Body Image, 9 (3), 388–395. https://doi.org/10.1016/j.bodyim.2012.03.007

Kline, R. B. (2015). Principles and practice of structural equation modeling.  Guilford.

Koepke, S., & Denissen, J. J. (2012). Dynamics of identity development and separation–individuation in parent–child relationships during adolescence and emerging adulthood–A conceptual integration. Developmental Review, 32 (1), 67–88. https://doi.org/10.1016/j.dr.2012.01.001

LaFontana, K. M., & Cillessen, A. H. (2010). Developmental changes in the priority of perceived status in childhood and adolescence. Social Development, 19 (1), 130–147. https://doi.org/10.1111/j.1467-9507.2008.00522.x

Lerner, J. V., Phelps, E., Forman, Y., & Bowers, E. P. (2009). Positive youth development . Wiley.

Levine-Rasky, C. (2011). Intersectionality theory applied to whiteness and middleclassness. Social Identities, 17 , 239–253. https://doi.org/10.1080/13504630.2011.558377

Luyckx, K., Goossens, L., Soenens, B., Beyers, W., & Vansteenkiste, M. (2008). Identity statuses based on 4 rather than 2 identity dimensions: Extending and refining Marcia’s paradigm. Journal of Youth and Adolescence, 37 (6), 695–716. https://doi.org/10.1007/s10964-005-8949-x

Marcia, J. E. (1980). Identity in adolescence. In J. Adelson (Ed.), Handbook of adolescent psychology (pp. 159–187). Wiley.

Maslow, A. (1968). Some educational implications of the humanistic psychologies. Harvard Educational Review, 38 (4), 685–696. https://doi.org/10.17763/haer.38.4.j07288786v86w660

McCabe, M. P., & Ricciardelli, L. A. (2005). A prospective study of pressures from parents, peers, and the media on extreme weight change behaviors among adolescent boys and girls. Behaviour Research and Therapy, 43 (5), 653–668. https://doi.org/10.1016/j.brat.2004.05.004

Miller, P. H. (2011). Theories of developmental psychology (5th ed.). Worth.

Morsünbül, Ü., ve, & Çok, F. (2014). The adaptation of the dimension of identity development scale into Turkish. Düşünen Adam the Journal of Psychiatry and Neurological Sciences, 27 , 6–14. https://doi.org/10.5350/DAJPN2014270101 .

Motyl, A. J. (2010). The social construction of social construction: Implications for theories of nationalism and identity formation. Nationalities Papers, 38 (1), 59–71. https://doi.org/10.1080/00905990903394508

Newman, D. B., Tay, L., & Diener, E. (2014). Leisure and subjective well-being: A model of psychological mechanisms as mediating factors. Journal of Happiness Studies, 15 , 555–578. https://doi.org/10.1007/s10902-013-9435-x

Pelican, S., Heede, F. V., Holmes, B., Melcher, L. M., Wardlaw, M. K., Raidl, M.,… Moore, S. A. (2005). The power of others to shape our identity: Body image, physical abilities, and body weight. Family and Consumer Sciences Research Journal, 34 (1), 57–80. https://doi.org/10.1177/1077727X05277738

Piaget, J. (1968). Quantification, conservation, and nativism: Quantitative evaluations of children aged two to three years are examined. Science, 162 (3857), 976–979. https://doi.org/10.1126/science.162.3857.976

Schermelleh-Engel, K., Moosbrugger, H., & Müller, H. (2003). Evaluating the fit of structural equation models: Tests of significance and descriptive goodness-of fit measures. Methods of Psychological Research Online, 8 (2), 23–74.  http://www.mpr-online.de

Schwartz, S. J., Pantin, H., Prado, G., Sullivan, S., & Szapocznik, J. (2005). Family functioning, identity, and problem behavior in hispanic immigrant early adolescents. The Journal of Early Adolescence, 25 (4), 392–420. https://doi.org/10.1177/0272431605279843

Shroff, H., & Thompson, J. K. (2006). The tripartite influence model of body image and eating disturbance: A replication with adolescent girls. Body Image, 3 (1), 17–23. https://doi.org/10.1016/j.bodyim.2005.10.004

Shrout, P. E., & Bolger, N. (2002). Mediation in experimental and nonexperimental studies: New procedures and recommendations. Psychological Methods, 7 (4), 422–445. https://doi.org/10.1037//1082-989x.7.4.422

Steinberg, L. (2016). Adolescence . McGraw-Hill.

Tajfel, H., & Turner, J. C. (1979). An integrative theory of intergroup conflict. In W. G. Austin & S. Worchel (Eds.), The social psychology of intergroup relations (pp. 33–47). Brooks/Cole.

Thompson, J. (2004). Handbook of eating disorders and obesity . John Wiley & Sons, Inc.

Tiggemann, M., & Slater, A. (2013). NetGirls: The internet, Facebook, and body image concern in adolescent girls. International Journal of Eating Disorders, 46 (6), 630–633. https://doi.org/10.1002/eat.22141

Tkach, C., & Lyubomirsky, S. (2006). How do people pursue happiness? Relating personality, happiness increasing strategies, and well-being. Journal of Happiness Studies, 7 , 183–225. https://doi.org/10.1007/s10902-005-4754-1

Trujillo, N., & Reitz, A. K. (2018). Examining the relationship between identity and substance use among adolescents: A systematic literature review. Current Addiction Reports, 5 (3), 303–312.

Tylka, T. L., & Wood-Barcalow, N. L. (2015). What is and what is not positive body image? Conceptual foundations and construct definition. Body Image, 14 , 118–129. https://doi.org/10.1016/j.bodyim.2015.04.001

Van Hoof, A., & Raaijmakers, Q. A. (2002). The spatial integration of adolescent identity: Its relation to age, education, and subjective well–being. Scandinavian Journal of Psychology, 43 (3), 201–212. https://doi.org/10.1111/1467-9450.00288

Verhoeven, M., Poorthuis, A. M., & Volman, M. (2019). The role of school in adolescents’ identity development. A literature review. Educational Psychology Review, 31 , 35–63. https://doi.org/10.1007/s10648-018-9457-3

Waterman, A. S. (1999). Identity, the identity statuses, and identity status development: A contemporary statement. Developmental Review, 19 (4), 591–621. http://www.idealibrary.com/

Download references

Open access funding provided by the Scientific and Technological Research Council of Türkiye (TÜBİTAK).

Author information

Authors and affiliations.

Yıldız Technical University, Istanbul, Türkiye

Ali Eryılmaz

Kastamonu University, Kastamonu, Türkiye

Republic of Turkey, Ministry of National Education, Ankara, Türkiye

Abdullah Ensar Uzun

You can also search for this author in PubMed   Google Scholar

Corresponding author

Correspondence to Ahmet Kara .

Ethics declarations

Ethics approval.

To collect the data, permissions were obtained from the relevant researchers for the measures to be used in the study and ethical committee approval was also obtained from [Omitted] University Social and Human Sciences Ethical Committee (Meeting No: 20230301997). All stages of the study were conducted according to Helsinki Declaration.

Consent to participate and for publication

All participants provided informed consent for the data to be published and to participate in the present study.

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ .

Reprints and permissions

About this article

Eryılmaz, A., Kara, A. & Uzun, A.E. The mediating role of positive body image between friendship qualities, well-being strategies and identity development among adolescents. Curr Psychol (2024). https://doi.org/10.1007/s12144-024-06092-4

Download citation

Accepted : 30 April 2024

Published : 24 May 2024

DOI : https://doi.org/10.1007/s12144-024-06092-4

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Positive body image
• Friendship qualities
• Identity development
• Subjective well-being increasing strategies
• Find a journal
• Publish with us
• Track your research

ORIGINAL RESEARCH article

The role of body image in internalizing mental health problems in spanish adolescents: an analysis according to sex, age, and socioeconomic status.

• 1 Department of Developmental and Educational Psychology, Faculty of Psychology, University of Seville, Seville, Spain
• 2 Department of Experimental Psychology, Faculty of Psychology, University of Seville, Seville, Spain

During adolescence there is a relatively high prevalence of weight problems and eating disorders. Furthermore, body image plays an important role in weight control and eating behaviors as well as in mental health. This study analyses the influence of body mass index, perception of being overweight, and body image satisfaction (BIS) on internalizing symptoms related to mental health in adolescents. In addition, sex, age, socioeconomic status (SES), dieting, and physical activity are taken into consideration. This research is based on the international study Health Behaviour in School-aged Children (HBSC). The sample consists of 4531 Spanish adolescents from 13 to 18 years old. Participants were selected through random multi-stage sampling stratified by conglomerates. Two instruments were employed: the HBSC questionnaire and the Youth Self-Report (Achenbach System of Empirically Based Assessment, ASEBA). Results demonstrated that BIS –the emotional component related to body image– was the main predictor of adolescent internalizing symptoms. In addition, results show double-inequalities according to the interaction effects of sex, age, and SES. Likewise, interesting results are shown regarding how dieting behaviors to lose or gain weight/volume and physical activity relate to body image perception and satisfaction, as well as with internalizing symptoms. This study highlights important body image aspects relevant to intervention and prevention of internalized mental health problems in adolescence.

Introduction

Adolescence is a period characterized by physiological, emotional, cognitive, and social changes that lead to a greater concern for physical appearance. The physical changes that accompany the onset of puberty demand a constant restructuring of the adolescent’s perception of their body, provoking an increased preoccupation for this image that in many cases leads to a decrease in self-esteem ( Harter, 2006 ; Mills et al., 2011 ). The propensity of adolescents to be unhappy with their body image has been addressed in many studies, arguing that this problem with body image can threaten their health and wellbeing ( Shagar et al., 2017 ).

Body image refers to the multifaceted psychological experience of embodiment that encompasses one’s body-related self-perceptions and self-attitudes, including thoughts, beliefs, feelings, and behaviors. Body image has often been defined as the self-perception of the physical self and the feelings and thoughts that result from that perception ( Cash, 2004 ; Grogan, 2006 ). Disturbance in any of these domains is referred to as body image concerns or negative body image.

Previous findings have shown a relationship between body image concerns and the development of psychopathology in adolescence, especially with internalizing symptoms (IS) – i.e., anxiety, depression, or social withdrawal ( Thompson et al., 1995 ; McClintock, 2001 ; Siegel, 2002 ; Ter Bogt et al., 2006 ; Patalay and Hardman, 2019 )–, which in turn is a risk factor for the development of eating disorders ( Graber and Sontag, 2009 ; Puccio et al., 2016 ). For example, a previous study of more than 7000 Dutch adolescents showed an association between deviance from normal weight and IS, however not with externalizing problems ( Ter Bogt et al., 2006 ). According to the authors, “lower body mass index [BMI] scores relate to greater problems, more specifically to anxiety/depression and social problems, higher BMI is associated with withdrawnness. However, body weight perception is a more substantial predictor of adolescent distress (…). Perception of being too heavy is the most substantial predictor of a wide range of problems and both the overweight and the young people with normal BMI are affected” (p. 32).

Appraisals of physical development or body image are areas of self-evaluation that are particularly salient to adolescents and their risk for internalizing problems ( Graber and Sontag, 2009 ). Children with higher BMI may feel discriminated against due to their image, which would lead them to present internalizing symptoms in the long-term. This is related to an increased awareness and internalization of social attitudes around weight throughout childhood, which is manifested in more psychological problems in adolescents with worse body image ( Puhl and Latner, 2007 ). Specifically, body image concerns can often be attributed to social and cultural pressures ( Bessenoff and Snow, 2006 ). According to the systematic review conducted by Sobrino-Bazaga and Rabito-Alcoón (2018) , sociocultural factors had the most influence on body image dissatisfaction. In addition, having a body image close to the socially accepted ideal of beauty is conceptually associated with possessing other positive characteristics such as being a successful or healthy person ( Tiggemann et al., 2000 ; Neziroglu et al., 2008 ; Mischner et al., 2013 ).

In explaining human development, and in this case adolescent development, certain theoretical models highlighting the importance of an individual’s actions in guiding their own evolutionary development are currently gaining more importance. In this respect, the recently proposed Relational Developmental Systems (RDS; Overton, 2015 ) metatheory collects those theories defending that change throughout the life cycle occurs through mutually influential relationships between individuals and their contexts. Thus, this perspective states that biological and environmental entities influence human development through a process of coaction. Specifically, Overton (2014) propose this metatheory based on the process-relational paradigm according to which any part of the developmental system is inextricably embodied by all other parts of the system. “Embodiment refers to the way individuals behave, experience, and live in the world by their being active agents with particular kinds of bodies; the body is integratively understood as form (a biological referent), as lived experience (a psychological referent), and as an entity in active engagement with the world (a sociocultural referent)” ( Lerner, 2018 , p. 25).

Therefore, attending to the importance of an individual’s actions in the relationship between body image and internalizing symptoms, it is imperative to understand the role that behaviors related to weight control and body image play when analyzing the different components of body image in adolescence. In this regard, BMI represents the physiological aspect of body changes during adolescence, body image perception (BIP) represents the cognitive component, and body image satisfaction (BIS) corresponds to the emotional component of body image. Moreover, these domains are also related to a behavioral component –dieting or exercising– that contributes to control weight and body image ( Banfield and McCabe, 2002 ; Ramos et al., 2012 ).

Furthermore, some studies warn that these components –physiological, cognitive, emotional, and behavioral– interrelate differently depending on the adolescent’s sociodemographic factors [i.e., sex, age, and socioeconomic status (SES)]. Firstly, concern for body image differs according to sex; whereas boys tend to be more concerned with having a muscular body image, girls are more likely to have beauty ideals that are inseparable from thinness, in most cases below a healthy size ( Neumark-Sztainer et al., 1999 ; Cafri and Thompson, 2004 ). In addition, although a higher proportion of girls tend to have a normal BMI compared to boys, they also show a greater prevalence of suffering misperceptions about their body image leading to a greater number of weight-control behaviors ( Barker and Galambos, 2003 ; Larson et al., 2009 ; Ramos et al., 2013 ). Systematic literature reviews about sex inequalities in body dissatisfaction, such as those conducted by McCabe and Ricciardelli (2004) and Sobrino-Bazaga and Rabito-Alcoón (2018) , support this perspective. However, there is less research regarding sex differences in the relationship between body image problems and IS in adolescence. Current studies such as that published by Bacopoulou et al. (2018) point out that girls showing higher anxiety on the internalizing subscale of the Youth Self-Report (YSR) have a higher risk of developing eating disorders than girls without anxiety, whereas this does not occur in their male peers.

Secondly, with regards to age researchers agree that both boys and girls are less satisfied with their body image throughout the period stretching from adolescence to adulthood ( Sobrino-Bazaga and Rabito-Alcoón, 2018 ). However, during adolescence it appears that only girls decrease their body satisfaction with age (e.g., Bully and Elosua, 2011 ). This same tendency has been found in other variables such as BIP and weight control ( Neumark-Sztainer et al., 1999 ; Barker and Galambos, 2003 ; McArthur et al., 2005 ). These results indicate that during adolescence girls’ association of ideal beauty with being thin, in most cases below a healthy size, is strengthened. However, there are no results that directly address how the relationship varies between body image and IS according to the age of the adolescents, and therefore remains an important unanswered question.

Thirdly, adolescents from families with a low SES tend to present higher rates of overweightness and obesity ( O’Dea and Caputi, 2001 ; Cheung et al., 2011 ; Pereira et al., 2011 ). In addition, pertaining to families with a low SES also contributes to the persistence of meal-related health problems during this life stage (e.g., Wadsworth and Achenbach, 2005 ). Nevertheless, there is little research exploring the impact of SES on IS, or how SES moderates the association between body image and IS, and results are inconsistent. For example, in the study conducted by Ter Bogt et al. (2006) both boys and girls across all SES showed to experience elevated levels of IS when perceiving their body as too thin or (more frequently) too heavy. Another study ( Zeller et al., 2004 ) conducted with 121 obese children and adolescents and their mothers found that in mothers with distress, low SES related to higher IS in their obese children. However, this study did not find a relationship between SES and IS self-reported by the children themselves.

In Spain, 17.2% of 11–18 year old adolescents show signs of being overweight or obese, with this percentage being clearly higher in boys and adolescents with a lower SES ( Moreno et al., 2016 ). This study also shows that despite girls having a lower index of being overweight or obese, they are less satisfied with their body image and diet more frequently to lose weight, a behavior that also increases with age. Regarding internalizing symptoms, Oliva et al. (2015) underscores the higher proportion of internalizing symptoms in girls. In addition, unlike their male peers, in girls the internalizing symptoms increased with age and with a lower SES.

Therefore, in the context of the current research, it is important to further study the roles of sex, age, and socioeconomic level in the relationship between body image problems and IS in adolescence. With this objective we first propose to understand how the physiological (BMI), cognitive (BIP), and emotional (BIS) components of body image interrelate when predicting the adolescents’ internalizing symptoms. In addition, we will attempt to analyze the specific role that the variables sex, age, and socioeconomic level play in the aforementioned relationship. Along these lines, we assume that the exposure to double/triple/multiple factors of inequalities is more harmful than the exposure to a single one. Therefore, following an interesting approach from social sciences of exploring multiple inequalities and its intersectionality, mostly initiated from a gender perspective ( Acker, 2006 ; Walby, 2011 ), this present study examined interactions between sex, age, and SES as sources of inequalities.

Secondly, this study proposes to further research those adolescents with worse scores in the specific component (physiological, cognitive, or emotional) that in the previous objective was the most important for IS. In this case, this study proposes to analyze in detail the profile of these adolescents, not only based on the physiological, cognitive, or emotional components, but also according to how the configuration of these variables relates with the behavioral component, measured through dieting and the frequency of physical activity.

Materials and Methods

Data comes from the Health Behaviour in School-aged Children (HBSC) cross-sectional survey. The HBSC study is an international network supported by the World Health Organization that collects data in almost 50 countries in Europe and North America. The survey is conducted every 4 years with the aim of increasing knowledge about health-related behaviors, lifestyles, wellbeing, and developmental contexts of youth. Specifically, the data used in this paper is obtained from the 2018 edition of the HBSC study in Spain.

Participants

This study is based on a nationally representative sample composed of 4531 adolescents aged 13–18 years who participated in the 2018 edition of the HBSC study in Spain. They were selected using random multi-stage sampling stratified by conglomerates according to age, type of school (public or private), and region ( Moreno et al., 2018 ).

The sample was divided equally between boys and girls. The percentage of adolescents according to each age group was 16.7% who were 13–14, 51.3% were 15–16, and 32% were 17–18 years old. Likewise, the global sample was distributed between 63.3% that attended public schools, 31.7% that attended charter schools, and 5% that attended private schools. Regarding SES, 18.9% reported a low level, 48.8% a medium level, and 32.3% a high level.

Lastly, the sample was distributed between the different regions of Spain in the following percentages: 6.7% Andalucia, 4.1% Aragon, 4.6% Principado de Asturias, 7.2% Illes Balears, 5.5% Canarias, 3.7% Cantabria, 3.3% Castilla y León, 6.9% Castilla-La Mancha, 10.2% Cataluña, 6.6% Comunitat Valenciana, 5.7% Extremadura, 3.5% Galicia, 8.5% Comunidad de Madrid, 4.4% Región de Murcia, 6.4% Comunidad Foral de Navarra, 7.2% País Vasco, 3.6% La Rioja, and 1.9% Ceuta y Melilla.

Instruments

The HBSC questionnaire is a broad survey that measures adolescents’ healthy habits, wellbeing, and their developmental contexts from a multidisciplinary perspective. The questionnaire uses a variety of validated scales and items. Spanish-language versions of the scales were used, that were translated/back-translated between English and Spanish following the guidelines and cooperation of the international coordination of the HBSC study ( Roberts et al., 2009 ). The specific variables employed in this study –selected according to their scientific basis and study objectives– are detailed below.

Demographic variables were sex (students had to self-identify as a boy or girl) and SES evaluated using the Family Affluence Scale (FAS III, Schnohr et al., 2013 ). The FAS score was calculated as the sum of the responses from the six items included in the latest version of the instrument: “Does your family own a car, van or truck?” (0 = no ; 1 = yes, one; 2 = yes, two or more ); “Do you have your own bedroom for yourself?” (0 = no ; 1 = yes ); “How many computers do your family own (including laptops and tablets, not including game consoles and smartphones)?” (0 = none , 1 = one , 2 = two, 3 = more than two ); “How many bathrooms (room with a bath/shower or both) are in your home?” (0 = none , 1 = one , 2 = two , 3 = more than two ); “Does your family have a dishwasher at home?” (0 = no; 1 = yes); “How many times did you and your family travel out of Spain for a holiday/vacation last year?” (0 = not at all , 1 = once , 2 = twice , 3 = more than twice ). The terciles (low, medium, and high), with cut-off points of 6 and 9 (in a range of 0–13) were used as a categorical variable.

This paper analyses different body-related variables:

– Body Mass Index is the ratio between self-reported weight and height (kg/m 2 ). To use it as a categorical variable BMI was recoded according to the cut-off points proposed by Cole et al. (2000 , 2007) , with the options thin, normal, and overweight/obese.

– Body Image Perception was assessed with an item created for the HBSC study. Specifically, students were asked “Do you think your body is?” and their response options on a 5-point Likert scale ranged from 1 much too thin , to 5 much too fat . Responses were recoded into 3 categories: thin (1 too thin , and 2 a bit thin ), normal (3 I have the correct size ) and overweight (4 a bit fat , and 5 too fat ).

– Body Image Satisfaction was assessed through the feelings and attitudes toward the body subscale of the Body Investment Scale ( Orbach and Mikulincer, 1998 ). This subscale consists of 6 items (“I am frustrated with my physical appearance,” “I am satisfied with my appearance,” “I hate my body,” “I feel comfortable with my body,” “I feel anger toward my body,” and “I like my appearance in spite of its imperfections”). It is answered on a 5-point Likert scale from 1 totally agree , to 5 totally disagree . The Cronbach’s alpha in the analyzed sample was 0.89. In order to use it as a categorical variable, the sample was divided into terciles (low, medium, and high) with the cut-off points 3.6 and 4.5 (in a range of 1 to 5). When it is used as a continuous variable, high scores reflect high body satisfaction.

Two variables were included regarding the behavioral component: (1) a measure that was created by the international HBSC protocol to explore the behavior of dieting, asking adolescents whether they were currently dieting to lose or gain weight/volume; and (2) adolescents were asked about their level of Moderate to Vigorous Physical Activity (MVPA), as indicated by the number of days in which they felt physically active during a total of at least 60 min a day over the last 7 days. The response options ranged from 0 to 7 days ( Prochaska et al., 2001 ). In addition, their level of Vigorous Physical Activity (VFA) was assessed as the frequency with which they engaged in some type of physical activity that made them sweat or out of breath in their free time outside of school hours. The response options on a Likert scale ranged from 1 never , to 7 every day .

Lastly, the variables related to internalizing mental health problems were assessed using the licensed version of the Spanish version of the YSR ( Achenbach and Rescorla, 2001 ). The three internalizing syndrome scales employed were: anxious/depressed (13 items, with a 0 to 13 response range), withdrawn/depressed (8 items, with a 0 to 8 response range), and somatic complaints (10 items, with a 0 to 10 response range). All the items are Likert-type response format comprising three categories (0 = not true , 1 = somewhat true or sometimes true , 2 = very true or often true ) and refer to symptoms and experiences from the past 6 months. The application guidelines marked by Achenbach (2013) were followed in the application of this instrument within the HBSC study in Spain. The Cronbach’s alpha in the present study was 0.79 for anxious/depressed, 0.75 for withdrawn/depressed, 0.76 for somatic complaints, and 0.87 for the global scale of IS. In order to use IS as categorical (for the second objective of the study) low (12–24), medium (24.50–32) and high (32.50–80) terciles were used. When it is used as a continuous variable, high scores reflect high internalizing symptoms.

The international coordination of the HBSC study stipulates three basic conditions that must be complied with during data collection: the questionnaires must be answered by the students themselves; the anonymity of the answers must be strictly guaranteed; and the questionnaires must be administered within the school context ( Inchley et al., 2016 ). Thus, the data was always collected in the school setting under the supervision of teachers. In all the schools, instructions were given to the teachers who would be supervising the classroom when the adolescents responded to the questionnaires.

New information and communication technologies (ICT) based on a CAWI (Computer-Assisted Web Interviewing) model were used in data collection. The guided computerized procedure has the advantage of immediately receiving and incorporating the students’ responses in the database, thus reducing possible errors from the data entry process, as well as helping to maintain the anonymity of the responses. In addition, instructions for the students were included at the beginning of the questionnaire to guarantee homogeneity amongst all the participants.

In all the participating education centers, permission was requested from the committee board of each school and they handled the request of permission of the adolescents and their families according to each centers’ protocols. This study was approved by the Ethical Research Committee of the regional government of Andalusia, Spain (Junta de Andalucía).

Sample selection was carried out between February and June 2018. Once data were collected, they were cleaned and controlled according to the international HBSC protocols offered by the Norwegian Centre for Research Data ( Currie et al., 2014 ). In this procedure, from the initial sample composed of 5356 adolescents, subjects who showed a response rate below 40% of the total questionnaire (9.5% of the initial sample), who did not give basic sociodemographic information (0.9% of the initial sample), who showed an overly elevated pattern in their answers (4.3% of the initial sample), or who had not responded to all the analyzed variables (3.5% of the initial sample) were eliminated. Due to the large remaining sample (4531 adolescents), the decision made was to not impute the missing values and instead analyze only those subjects with valid values in the analyzed variables.

Statistical Analysis

Bivariate analyses including chi-square, t -test and ANOVA were used, requiring a significance level of 0.01. The corresponding effect size was reported in every case. Thus, phi , Crammer’s V and Tau-b were calculated to determine the effect size in the comparison of proportions, with the following cut-off points: 0–0.09 = negligible, 0.10–0.29 = small, 0.30–0.49 = medium, 0.50 and above = high. Cohen’s d was calculated in the comparison of two groups’ means, with the following cut-off points: 0–0.19 = negligible, 0.20–0.49 = small, 0.50–0.79 = medium, 0.80 and above = high. Eta-squared was calculated in the comparison of more than two groups’ means, with the following cut-off points: 0–0.009 = negligible, 0.010–0.059 = small, 0.060–0.139 = medium, 0.140 and above = high. Pearson’s correlation was calculated in the relationship between two quantitative variables, with cut-off points 0–0.090 = negligible, 0.10–0.239 = small, 0.24–0.369 = medium, 0.37 and above = high ( Cohen, 1988 ).

Linear regression analysis was used to examine the relationship between sociodemographic variables (sex, age, and FAS) and the indicators of body image on the total scale of IS and each one of the subscales (anxious/depressed, withdrawn/depressed, and somatic complaints). The principal effects were analyzed first, and afterward the previous models were replicated adding the interaction effects. Pearson’s correlations were analyzed to determine the significant interaction effects, segmented according to the variables implicated in said interaction. Differences in correlations were compared using the Fisher’s Z -test, establishing the cut-off point in values above 2.33 (in absolute values), corresponding to a 99% unilateral confidence interval.

To analyze the characteristics that define the two groups established for the second objective of the present study, a logistical regression model was created which incorporated the value of the odds ratio with its corresponding confidence interval.

Statistical analyses were conducted using the IBM SPSS Statistics 25.0 software.

Analysis of the Bivariate Relationship Between Variables

Firstly, the distribution of the sample in the three components of body image (BMI, BIP, and BIS) is shown in Table 1 . These variables presented a high correlation between them. Specifically, a higher BMI was positively related with overweight BIP ( r = 0.514, p < 0.001) and negatively associated with BIS ( r = −0.268, p < 0.001). Psychological components (BIP and BIS) were also negatively correlated, indicating that overweight BIP is associated with a lower BIS ( r = −0.410, p < 0.001).

Table 1. Sample description in the three variables related to body image, dieting, and physical activity.

These three components of body image varied according to the adolescents’ sex, age, and socioeconomic level. As shown in Table 2 , BMI was higher in 15–16 year old adolescents compared to the 13–14 year olds, as well as being higher in adolescents with a low FAS score. Regarding overweight BIP, this was higher in girls and in adolescents with low FAS. Lastly, BIS was lower in girls, 17–18 year old adolescents, and those with low FAS.

Table 2. Means (standard deviations), significance test and effect sizes of sex, age, family affluence, dieting, and physical activity with the three variables related with body image.

Differences were also found in these three components of body image in their relationship with indicators of IS, as shown in Table 3 . Specifically, the adolescents with higher BMI showed higher scores in withdrawn/depressed and in the global scale of IS. However, a relationship was found between all the indicators of IS and BIS and BIP: those adolescents with overweight BIP and low BIS were more anxious/depressed, withdrawn/depressed, had more somatic complaints, and had a higher global IS score.

Table 3. Means (standard deviations), significance test and effect sizes of the three variables related with body image, sex, age, family affluence, dieting, and physical activity with anxious/depressed, withdrawn/depressed, somatic complaints, and total of internalizing symptoms.

Analysis of IS distribution according to sociodemographic variables (shown in Table 3 ) also revealed inequalities according to sex (girls had higher scores in all indicators analyzed), age (differences were lower than in sex, however older adolescents had higher scores in the withdrawn/depressed subscale and in the global IS score), and FAS (adolescents with lower family affluence scored higher in the three subscales, but the global score did not show relevant differences).

Examining behaviors related to weight control and body image, Table 1 shows the distribution of the sample in these variables. Table 3 shows no relationship with the behavior of gaining weight/volume but does with the weight-loss diets. Specifically, adolescents that dieted to lose weight/volume had higher scores in all the subscales and in the global scale of IS. This same relationship was found with the two indicators of physical activity, meaning that those adolescents who did less physical activity (either MVPA or VPA) showed higher scores in all the internalizing indicators.

Returning to the body image variables, Table 2 also shows the bivariate relationship between the three components of body image and the weight control and body image behaviors. In general, adolescents with higher BMI more frequently dieted to lose weight/volume and did MVPA. Adolescents with an overweight BIP showed a higher frequency of dieting to lose weight/volume, and a lower tendency to practice either type of physical activity, as well as a lower frequency of dieting to gain weight/volume. Those adolescents with lower BIS dieted more to lose weight/volume and were more inclined to not practice either of the two types of physical activity (MVPA or VPA).

Regarding the relationship between these weight and body image behaviors, differences were found according to sex, age, and FAS score, as shown in Table 4 . Specifically, dieting to lose weight/volume was more frequent in girls. On the contrary, dieting to gain weight/volume was more frequent in boys, those higher in age, and with high FAS. On the other hand, both MVPA and VPA were more frequent in boys, of a lower age, and with high FAS.

Table 4. Percentage, significance test and effect sizes of sex, age, and family affluence with dieting and physical activity.

The Predictive Capacity of Body Image Variables (BMI, BIP, and BIS) on IS, Considering the Influence of Sociodemographic Variables (Sex, Age, and Family Affluence)

Table 5 shows the results of the linear regression analyses conducted for each of the four measures of IS (anxious/depressed, withdrawn/depressed, and somatic complaints) and for the global scale of IS. Two types of linear regression analyses were conducted for each internalizing indicator: one simple and another global. Whereas the simple analysis only measured the direct influence of the independent variables, the global analysis controlled possible interaction effects of the sociodemographic variables in the relationship between body image and the internalizing indicators.

Table 5. Linear regression analysis of the simple model, only with main effects, and the global model, with interaction effects, on anxious/depressed, withdrawn/depressed, somatic complaints, and total of internalizing symptoms.

Regarding the individual predictive capacity (without interaction) of the sociodemographic and body image variables on the four internalizing indicators, results showed BIS as the variable with the most weight. Therefore, BIS showed to be the most important predictor of IS, whether in the global score ( η P 2 = 0.140 ) or in the three subscales: anxious/depressed ( η P 2 = 0.166 ), withdrawn/depressed ( η P 2 = 0.127 ), and somatic complaints ( η P 2 = 0.068 ). The adolescents’ sex was the second most important dependent variable, both in the global scale and in the anxious/depressed and withdrawn/depressed scales. Age was the second highest predictive variable of withdrawn/depressed and the third in the global scale.

Following this initial linear regression analysis, interaction of the sociodemographic variables was included both independently –as shown in Table 6 – as well as simultaneously combining two of these demographic variables –as shown in Table 7 . This exhaustive control of demographic variables increased the percentages of explained variance of the four regression analyses. Thus, the global scale showed a 23.5% predictive capacity, 25.3% for anxious/depressed, 17.4% for withdrawn/depressed, and 16.3% for somatic complaints. In addition, congruent with the aforementioned, the main effects of these global linear regression models once again demonstrated the importance of BIS. Specifically, BIS is the only dependent variable amongst the first three positions in the prediction of all the dependent variables, that is to say, both in the global scale and the three subscales.

Table 6. Pearson’s correlation and Fisher’s Z between variables of first-order interaction effects of the linear regression analysis shown in Table 5 .

Table 7. Pearson’s correlation and Fisher’s Z between variables of second-order interaction effects of the linear regression analysis shown in Table 5 .

Closely analyzing the first-order interaction effects (see Table 6 ), BMI was found to predict somatic complaints only in girls ( r = 0.138), but not in their male peers ( r = 0.041). However, delving deeper and considering the second-order interaction effects, upon combining the influence of sex and age, BMI showed a double inequality with respect to its influence on somatic complaints. Specifically, the positive relationship between BMI and somatic complaints occurred both in boys and girls at 13–14 years old, without differences between them, with a Pearson’s correlation of 0.165 and 0.161, respectively. However, from 15 years old onward a relationship between BMI and somatic complaints was only found in the case of girls (see Table 7 ).

Regarding the predictive capacity of BMI on anxious/depressed, the first-order interaction effects showed this relationship in 13–14 year-old adolescents ( r = 0.207) but not in the other age groups (see Table 6 ). The relationship between BMI and the global scale of IS was found to be stronger in 13–14 year-olds ( r = 0.274) than at later ages, although in this case the relationship continued to be significant for 15–16 year-olds ( r = 0.147) and for 17–18 years old ( r = 0.164). Lastly, in the case of affluence level, it was found that BMI had a predictive capacity on anxious/depressed only in the case of the adolescents with a low FAS score ( r = 0.164), but not in those with a medium or high score.

The results regarding the first- and second-order interaction effects of overweight BIP on the internalizing indicators will be described next. Table 6 shows that the positive relationship between overweight BIP and all IS indicators were higher in girls. In fact, regarding somatic complaints and in the total of IS, this relationship with overweight BIP only occurred in girls. However, analysis of second-order interaction effects revealed that sex differences in the relationship between BIP and internalizing indicators varied according to FAS score. Specifically, Table 7 shows no sex differences in the relationship between overweight BIP and internalizing indicators in low FAS. In fact, in this affluence level it is boys rather than girls who show a relationship between body perception and IS. By contrast, in medium and high affluence only the girls demonstrated a relationship between overweight BIP and internalizing indicators. This relationship was stronger in high FAS, where the correlation reached 0.207 for anxious/depressed, 0.199 for withdrawn/depressed, and 0.246 for the global scale.

Lastly, the interaction effects also provided relevant information regarding the predictive capacity of BIS on internalizing indicators. Table 6 shows that, although age and FAS do not influence the aforementioned relationship, the adolescents’ sex does affect the negative relationship between BIS and withdrawn/depressed showing to be stronger in girls ( r = −0.411) than in boys ( r = −0.350). In addition, when sex differences in the relationship between BIS and internalizing indicators were analyzed –keeping in mind differences in FAS– differences were found in all internalizing indicators revealing new, previously undetected relationships, not only in withdrawn/depressed. Specifically, Table 7 shows a relationship between higher BIS and fewer internalizing indicators both in boys and girls when the adolescents had lower FAS. However, sex differences emerged as the family affluence increased. Thus, in adolescents with a high affluence, although the negative relationship between BIS and internalizing indicators kept occurring both in boys and in girls, this relationship was significantly higher in girls than in boys. For example, whereas the relationship between body image and the global scale of IS was −0.269 in boys, this relationship increased to −0.484 in the case of girls.

The Role of BMI, Overweight BIP, Dieting, Physical Activity, and Sociodemographic Variables on the IS of Adolescents With Low BIS

Regarding the second research objective, this third section of the results focused on those adolescents with lower scores in the more significant body image component for IS. Specifically, BIS was the most important component in this relationship for the following two reasons: (a) on the bivariate level, satisfaction was the body image component that related most with the internalizing symptoms, as shown in Table 3 ; and (b) satisfaction with body image had a higher predictive capacity on IS in the linear regression, as shown in Table 5 .

Therefore, we will next elaborate on the analyses of those adolescents with lower BIS, who represent 36.7% of the sample. For this objective, the sample was first divided into terciles according to body satisfaction (as shown in the rows of Table 8 ) and these adolescents were subsequently divided into three groups according to their level in the global scale of IS (as shown in the columns of Table 8 ).

Table 8. Sample subgroups (N and percentage) according to their tercile position in the internalizing scale of YSR and the BIS.

Through this process, by selecting the extreme groups we were able to identify two groups of adolescents who, while in both cases showing low BIS, were differentiated amongst themselves by the low or high effect on IS. Specifically, Group 1 has low BIS and a low IS level (representing 8% of the sample), whereas Group 2 has low BIS and high levels of IS (19.6% of the sample).

Table 9 shows the differences between Groups 1 and 2 in the other research variables: sociodemographic variables, BMI, overweight BIP, dieting behaviors, and physical activity. In general terms, differences were found between the two groups in sex, age, overweight BIP, and physical activity. Specifically, there was a higher propensity to fall into Group 2, that is to say, the group of adolescents unsatisfied with their body image and who also had IS: girls (71.2% of adolescents in group 2); older (31.8% were 17–18 years old); those that perceived themselves as overweight (67.71%); and those that did not do any physical exercise or did so with low frequency, both in the case of moderate-vigorous (88.3%) and vigorous (79.1%) physical activity.

Table 9. Percentages (N), significance test, effect sizes, and logistic regression models on sample subgroups with low BIS comparing low (group 1) and high (group 2) presence of IS.

Lastly, the last column of Table 9 shows the odds ratio (OR) analysis obtained from the logistical regression model highlighting the difference in the probability that the adolescents would pertain to Group 2, according to the aforementioned variables. This analysis showed a high predictive capacity, specifically 15.7%. Selecting only those OR in which the value 1 falls out of the confidence interval, a risk and protection profile was obtained based on the analyzed variables. Thus, in order of importance, the identified risk factors for pertaining to Group 2 were: be a girl (OR = 2.83), be aged 17–18 compared to 13–14 (OR = 2.58), and be 15–16 compared to 13–14 (OR = 1.71). By contrast, protective factors included a high level of moderate-VFA compared to none (OR = 0.28), the low level of this physical activity compared to none (OR = 0.48), have a BMI corresponding to thinness compared to overweight/obese (OR = 0.49), and perceiving oneself as a normal size compared to perceiving oneself as overweight (OR = 0.60).

Problems With Body Image and Adolescence

Adolescence is an important stage for developing problems related to physical appearance, which can seriously affect the health of this population ( Shagar et al., 2017 ). This present study –based on more than 4500 adolescents– shows body image to be a key aspect of their mental health. Specifically, considering the research objective of determining the predictive capacity of sociodemographic and body image variables on IS, in the second section of the results it was demonstrated that the 23.5% variability of IS in this sample was explained by the physiological (BMI), cognitive (BIP), and emotional (BIS) components of body image, as well as through the influence of sex, age, and FAS. More specifically, the anxious/depressed component was the dimension better explained by the aforementioned variables (25.3%), from amongst the four specific internalizing indicators examined and the global scale of IS.

Regarding the second research objective, explained in the third section of the Results, analyses focused on those adolescents with lower scores in the more significant body image component for IS. These results demonstrate that beyond BMI, the cognitive-emotional factors of body image –BIP and BIS– had a higher predictive capacity on mental health during adolescence. In fact, BIS was the body image dimension most strongly related to IS.

The results related to the central role that BIS has in adolescent health are congruent with findings from other research ( Stice et al., 2003 ; Neumark-Sztainer et al., 2006 ; Ramos et al., 2012 ). For example, Rotenberg et al. (2004) noticed the difficulty of modifying aspects related to the subjective state of mind, despite achieving changes in the cognitive area with regards to body image. In addition, these results are congruent with studies that identify the self-imposition of having a body that is attractive to others as the root of body image related health problems, which is indicative of the need of people to be socially accepted ( Sobrino-Bazaga and Rabito-Alcoón, 2018 ).

Therefore, in applying these results to intervention, it would appear critical to address factors related to self-acceptance and self-esteem. In fact, despite the importance of adequate cognitive restructuring in those adolescents who tend to perceive themselves as more overweight than they really are, the emotional component showed to have the highest predictive capacity in explaining internalizing symptomology. Therefore, based on our results it would be advised to prioritize this emotional component in intervention and prevention of body image disorders.

Problems With Body Image in Adolescence, the Moderation of Sex and the Double Inequality Sex-Age

In recent years, various systematic reviews have highlighted the selection bias that exists in much of the research in this field ( Larsen et al., 2015 ; Sobrino-Bazaga and Rabito-Alcoón, 2018 ), criticizing the higher level of attention on the feminine sex in studies on problems related to body image. On account of this, the results of the systematic reviews should be interpreted with caution due to the over-representation of females in the samples analyzed. In the present study, conducted with an equal representation of both sexes (2265 boys and 2266 girls), clear sex differences were found in problems related to body image, IS, and the combination of the two. To begin with, and coinciding with other studies ( Barker and Galambos, 2003 ; McCabe and Ricciardelli, 2004 ; Larson et al., 2009 ; Kanaan and Afifi, 2010 ; Ramos et al., 2012 , 2013 ), the bivariate results presented in the first section of the Results showed that girls present a higher frequency than boys to see themselves as fat, be dissatisfied with their body image, and diet to lose weight/volume.

Sex inequalities were also found regarding psychopathological problems related to IS, as was also found in the first section of the Results dedicated to determining the bivariate relationships between the studied variables. Congruent with other studies ( Hayward and Sanborn, 2002 ; Rutter et al., 2003 ; Chaplin and Aldao, 2013 ; Oliva et al., 2015 ), adolescent girls had higher scores in all the subscales and in the global scale of IS. Likewise, regarding the last objective of this study, focused on the adolescents with lower scores in the more significant body image component for IS, the results showed that sex was also the most important factor in the presence of IS amongst adolescents with low BIS.

It is precisely in this specific area –the differences between adolescent boys and girls in the relationship of body image problems to IS– where fewer studies exist. Therefore, this research offers interesting information upon finding that the variable sex moderates the relationship between body image and mental health. Specifically, it is in the cognitive component (BIP) – amongst all the aspects of body image– where more differences exist between boys and girls in the relationship with IS. Thus, findings showed a stronger relationship in girls between overweight BIP and having IS. In this sense, Harter (2006) explained that many girls worship an ideal of thinness, overestimate the preferences of boys for slender female bodies, see themselves as fatter than other girls and negatively compare themselves with the models of women on display in the media. In addition, the results of this present study are not surprising in light of other research that shows how girls are more vulnerable to certain negative thought patterns found in depression, such as self-blame, a negative social comparison, hyper-vigilance to potential stress and brooding (that is to say, an obsession about the future consequences of their hypothetical decisions) ( Hyde et al., 2008 ; Andrews and Thompson, 2009 ).

Regarding age, the bivariate results presented in the first section of the Results demonstrated that younger adolescents –between 13 and 14 years old– showed higher BIS and a lower IS. However, based on data from the last section of the Results, focused on analyzing the profile of those adolescents with low BIS, this age group also show a higher probability of suffering IS when they have low BIS. The reason for younger adolescents’ higher vulnerability could be due to the increased accumulation or simultaneousness of different developmental transitions at this time, such as puberty, changes in peer groups, parental relationships, or an increase in school demands. According to Brooks-Gunn (1991) the amount of stressful events increases during the beginning and middle of adolescence, and later decreases. Most adolescents transition positively through this period, however for some the coping skills could be overwhelmed by multiple life changes very close together, which would increase IS. In fact, the most vulnerable group in our study (low BIS and IS) represents only 19.6% of the sample. However, it would be opportune for future research to contrast these results with longitudinal data, which would permit one to analyze if in fact body dissatisfaction is a predecessor to IS in this developmental moment. In this sense, differential sensitivity models ( Graber and Brooks-Gunn, 1996 ) or diathesis-stress models ( Ingram and Luxton, 2005 ) could be compared, which refer to how individuals with specific preexisting characteristics are potentially more sensitive to developing problems in periods of transition and change.

Moreover, this study analyzed double inequality effects combining sex and age based on the analysis of second-order interaction effects shown in the second section of the Results. These results showed that whereas BMI predicted psychosomatic complaints in both boys and girls at 13–14 years old, the association among adolescents older than 15 years old was significant only among girls. There could be a biological explanation behind these sex inequalities, since the relationship is only found in the physiological component of body image (BMI), and not in the cognitive (BIP) or emotional components (BIS). In fact, among adolescents 15 years old and up, girls are more likely to receive medical attention in comparison with boys ( Ozer and Irwin, 2009 ), something assistance services should keep in mind in. In this regard, AbouZahr (2014 , p. 3) states: “paying due attention to the health of girls and women today is an investment not just for the present but also for the future and for future generations.”

Problems With Body Image in Adolescence, the Moderation of FAS, and the Double Inequality Sex-Socioeconomic Level

Despite the importance of socioeconomic factors in the health of children and adults having been widely demonstrated (e.g., Marmot and Bell, 2012 ), there is little evidence on the impact of socioeconomic inequalities on adolescent health ( Viner et al., 2012 ). However, inequalities in overweightness and obesity during adolescence have been stated ( O’Dea and Caputi, 2001 ; Cheung et al., 2011 ; Pereira et al., 2011 ). In close relationship to the findings of these prior studies, the bivariate results of this present research shown in the first section of the Results, reveal a higher BMI in adolescents with low FAS compared to their peers with high FAS.

In explanation of these results, significant associations have been found between FAS and eating breakfast, fruit, vegetables, and candy ( Fismen et al., 2012 ; Vereecken et al., 2015 ; Lazzeri et al., 2016 ; Yannakoulia et al., 2016 ; Moreno-Maldonado et al., 2018 ). Food access seems to be central in the relationship between family socioeconomic level and the type of food consumed. Turrell et al. (2003) points out that economically disadvantaged parents are less likely to buy healthy foods. Ward et al. (2013) found that families with lower incomes would have to spend approximately 30% of their family income to heating healthily, whereas families with higher income would spend around 10%.

Results from previous research examining socioeconomic inequalities in the cognitive-emotional component of body image are less consistent. For example, whereas a study conducted by Cok (1990) found no association between BIS and SES, Pereira et al. (2009) found a relationship between lower BIS due to being overweight and adolescents with low SES, and in a study conducted by Wang et al. (2005) results showed an opposite relationship: adolescents with a higher SES showed lower BIS. The incongruences found in the previous studies might be due to differences in the place of origin of the samples used. Studies conducted in developed countries tend to show that adolescents with a higher SES and better access to social media –where thinness is shown as a beauty ideal– are less satisfied with their body image than their peers from a lower SES ( Wang et al., 2005 ; Pereira et al., 2011 ; Feng and Wilson, 2016 ). However, the results of our current study showed, in the first section of the Results focused on the bivariate analyses, that adolescents with a low FAS score more frequently demonstrated an overweight BIP and have low BIS. This discrepancy could be explained by the high correlation found between the variables BMI, overweight BIP, and low BIS. However, other interesting explanations could be found in the double inequality effect that happens between socioeconomic level and the adolescents’ sex in how their body image affects their mental health.

In this regard, our research showed in the second section of the Results, and more specifically in the second-order interaction effects, that the relationship between overweight BIP and IS was only significant among boys with low FAS. In contrast, the association was found in all socioeconomic levels in the case of girls, being even stronger for girls pertaining to families with a medium/higher SES. Likewise, the association between low BIS and IS did not show differences among boys and girls pertaining to families with low FAS. However, sex differences were found in high FAS, with adolescent girls demonstrating a stronger association than boys between low BIS and IS.

Although little research has taken into account the double inequality perspective, a previous study conducted by Story et al. (1995) showed that girls with lower socioeconomic levels have a lower probability of perceiving themselves as fat. Likewise, O’Dea and Caputi (2001) , based on research with 1131 Australian children and adolescents between 6 and 19 years old, pointed out that the youth with lower socioeconomic level, especially males, could be particularly resistant to sociocultural influences of thinness as an ideal of beauty. However, considering the presence of indigenous people in Australia one should be cautious when generalizing these results. It would be opportune for future to control aspects related to the ethnicity of the studied population.

The Role of Weight and Body Image Behaviors in the Presence of Internalizing Symptoms

As was discussed in the Introduction section, and in consonance with the RDS metatheory, this research focused not only on the biological, psychological, and emotional components of body image, but also on its behavioral dimensions in considering dieting behavior and physical activity.

Regarding dieting behaviors, the first section of the Results showed the bivariate relationship of this type of variable and the rest of the studied variables. This research found that boys, older adolescents, and those pertaining to families with higher FAS more frequently diet to gain weight/volume. However, sex inequalities were less pronounced with respect to dieting to lose weight/volume nor were there age or socioeconomic differences. Therefore, an interesting finding from this research, within these bivariate analyses, was that whereas boys were clearly more likely than girls to diet to gain weight, the differences between them were less pronounced in dieting to lose weight. These results are congruent with a recent study ( Chu et al., 2019 ) that showed a greater pressure in general on boys to lose weight as well as to gain weight. Although it seems paradoxical, it appears that boys feel pressure to gain weight and muscles, as well as pressure to lose weight for leanness.

Attending to the higher frequency of dieting to gain weight/volume as age increases, these results are found in the first section of the Results dedicated to bivariate analysis. These results are congruent with other studies that report an increased pressure to be muscular throughout this developmental stage, which is especially noticeable in the case of boys. For example, in a study conducted by McCabe and Ricciardelli (2004) with 800 Australian adolescents, boys were almost equally divided between wanting to lose weight and wanting to gain muscle size. In addition, a prospective study conducted over the course of 1 year by Shomaker and Furman (2010) demonstrated that adolescent boys had higher scores on driving for muscularity and preoccupation with muscularity. This pressure might be stronger for adolescents from a higher SES, which would explain our bivariate results indicating that adolescents with high FAS were more likely to diet to gain weight/volume than adolescents with low FAS. For example, a comprehensive research previously exploring differences in dieting behaviors in almost 10000 adolescents from different socioeconomic backgrounds conducted by Neumark-Sztainer et al. (1999) found that, besides weight preoccupation being prevalent among all groups, adolescents from more affluent families dieted and exercised more to gain weight, which supports our findings. However, the same study also showed that adolescents pertaining to less affluent families presented more disordered eating and behaviors such as taking food supplements to gain weight or muscle.

Adolescence marks a time of increased independence about food choices and consumption. Among those adolescents who are dissatisfied with their body image, some will undertake weight control methods. In fact, in the last section of the Results, the relationship between low BIS and dieting to lose weight/volume –which was significant for both adolescents with IS (23.6% of the adolescents) as well as those without these symptoms (23.5% of the adolescents)– but not with dieting to gain weight/volume. These findings are important, given that medical monitoring is generally absent during dieting ( Eisenberg et al., 2005 ; Larson et al., 2009 ) and the weight-reduction behaviors that adolescents undertake are not always appropriate ( Timlin et al., 2008 ; Ramos et al., 2013 ) and often results in a weight gain and poorer overall health ( Neumark-Sztainer et al., 2006 ).

With respect to physical activity, its relationship with weight has been extensively studied, and the global reduction in physical activity has been identified as a possible cause of the increase in obesity among western societies ( Janssen et al., 2005 ). Short-term intervention trials also indicate that physical activity is the most effective weight control strategy ( McGuire et al., 1999 ).

The bivariate results outlined in the first section of the Results showed that girls, older adolescents, and those with low FAS scores present less psychical activity in both measures examined (MVPA and VPA). It is commonly known that boys associate sports with masculinity and believe they earn prestige through competition, whereas girls are less likely to relate a sports activity with femininity and may avoid participating in those activities that could threaten their femininity ( Coakley and White, 1992 ). Likewise, as Inchley and Currie (2004) explain, historically males have always had fewer restrictions on their activities compared to females, for example in many contexts boys get permission to be out of the house unsupervised with more frequency than girls.

In addition, just like in the aforementioned research by Neumark-Sztainer et al. (1999) , other studies ( Borraccino et al., 2009 ; Stalsberg and Pedersen, 2010 ) have demonstrated socioeconomic inequalities in doing physical activity. Thus, it is important to emphasize the importance of implementing and carrying out public policies that make sports more affordable, as well as facilitate resources and infrastructure, so that they can become a daily practice in all layers of society.

In the first part of this study, dedicated to the bivariate results, an association was also found between a higher frequency of physical activity and higher BIS, and with a lower presence of IS. Along these lines Hausenblas and Fallon (2006) and Holmqvist and Frisen (2019) found that regular physical activity is a protective factor against the development of body image problems. In fact, the results of our study found that even a low frequency of physical activity is beneficial in comparison to its complete absence. Likewise, in the logistical regression shown in the last part of the Results, it was found that MVPA, even on a low level, is a protective factor amongst adolescents with low BIS, who more frequently show IS.

These results are especially relevant for intervention given the health promotion recommendations to increase healthy food consumption and the frequency of physical activity for long-term body weight control and to maintain a healthy weight ( Centers for Disease Control and Prevention, 1997 ; European Commission for Health, and Consumer Protection, 2003 ). However, according to the displacement hypothesis ( Andersen et al., 1998 ), it is increasingly difficult for adolescents to dedicate time to physical activity given the increase in sedentary activities in this developmental stage, such as in time dedicated to school work or recreation related to small screens like watching videos or playing videogames. Therefore, these sedentary activities would compete for the adolescents’ available time for physical activity. However, the fact that our study has demonstrated that a low frequency of physical activity (compared to none) had a higher predictive capacity on internalizing symptoms of the adolescents with low BIS, gives hope that this behavior could really be carried out during this developmental stage on a beneficial level. In this sense, health programs trying to promote physical activity in adolescents –as part of a healthy lifestyle– should take into consideration this question related to the effectiveness of physical activity also on a low level.

Limitations and Strengths of This Study

This study has some limitations that should be taken into consideration when interpreting its results. Firstly, the cross-sectional design means that the results must be interpreted on an associative level, and it is not possible to draw conclusions about the directionality of the relationships found. Secondly, some methodological limitations should be mentioned. Several variables were assessed by frequency, not quantity. For example, VPA was measured with a seven-point Likert scales but recoded into a three-level categorical variable to facilitated data analysis. This reduced information diversity. Thirdly, it would be appropriate to include different contextual factors in the analysis. Further research should explore how family, peers, and school environment influence adolescent body image and the relationship with internalizing symptoms. Fourthly, self-reported BMI was used as an anthropometric measure, which may lead one to question its validity. However, previous studies have shown an elevated coincidence between BMI information provided by adolescents and the real measures taken on their weight and size. For example, Strauss (1999) reported more than a 94% coincidence between the information provided by 12–16 year old youth regarding their BMI and the scores obtained through precise and objective measures. Nonetheless, all the variables in this study were self-reported, which could imply a mono-method bias. Therefore, it could be convenient for future research to replicate these analysis based on measures obtained from other informants, not only in aspects such as BMI, but also in other questions such as, for example, the SES of the family.

Despite the aforementioned limitations, this study also has important strengths. This research offers information about a large and representative sample. Specifically, the sample selection was conducted under strict methodological guidelines, obtaining a representative sample of school-aged adolescents by age, type of school (public or private), and region of Spain. This size and representativeness support our recommendations for practical implications derived from the thoroughly discussed results.

In addition, the instruments used add to the strength of this research. On one hand, as has been explained in the Method, evaluation measures from classic and internationally acclaimed adolescent research, like the HBSC, have been used. On the other, this study is innovative in its addition of the YSR, a very exhaustive instrument currently recognized in psychopathological evaluation. This evaluation instrument uses a dimensional approach when assuming that the adolescents’ behaviors, as part of a continuum, could vary in their degree as well as be condensed in groups of symptoms or problems ( Achenbach and Rescorla, 2001 ). Thus, by using this instrument this study has avoided adopting a purely taxonomic approach of mental health disorders, which has shown a higher identification of false positives ( Helzer et al., 2008 ).

Finally, this research not only considered representative variables of all body image dimensions and used a validated instrument to evaluate internalizing symptoms, but in addition their associations were analyzed to observe the effects of sex, age, and socioeconomic inequalities on their relationship allowing double social inequalities to be detected.

Based on a sample and quality evaluation instruments, this paper has identified the roles of sex, age, and FAS in the relationship between body image problems and IS in a representative sample of adolescents. On one hand, of the three dimensions in the scale of IS (anxious/depressed, withdrawn/depressed, and somatic complaints), it is anxious/depressed that is best explained by the combination of BMI, overweight BIP, BIS, sex, age, and FAS. On the other hand, between the different components of body image, BIS showed a higher predictive capacity both on the three subscales and on the global scale of IS.

In addition, the large sample size used in this study allowed our analyses to detect possible double inequality effects. For example, this study found that whereas boys are more vulnerable in the high relationship between body image problems and IS when they have low FAS, in the case of girls they are most vulnerable in high FAS. These results require prevention programs and interventions to adapt to the specific combination of sociodemographic characteristics of the people with whom they work.

On the other hand, this study has found interesting results regarding the role that body image behaviors have, such as dieting to lose or gain weight/volume, and physical activity, when analyzing in detail those adolescents with worse scores in BIS. In this sense, a strong relationship is found between low BIS and dieting to lose weight/volume that occurs independently from whether the adolescents show IS or not. Keeping in mind the low nutritional quality of diets that adolescents usually do (as has been discussed above), it is indispensable to prevent them from adopting these weight control behaviors as well as promote eating habits that achieve weight control in a healthier way. Likewise, this study finds that even a low frequency of physical activity, compared to none, is beneficial and protects adolescents against IS. This finding also supports interventions focused on this area, which may be able to set less demanding and more achievable goal since adolescents generally have to juggle many activities simultaneously.

Data Availability

The datasets for this study will not be made publicly available because the data belong to the HBSC study network. The Spanish Ministry of Health, Social Services and Equality has a link to request the dataset in http://www.mscbs.gob.es/ , within the following links: Sanidad – Profesionales – Salud pública – Prevención y Promoción – Promoción de la salud – Salud de los Jóvenes. Requests to access the datasets should be directed to CM: [email protected].

Ethics Statement

The protocol was approved by the “Comité de Ética de la Investigación en Andalucía (Sistema Sanitario Público Andaluz).” Informed consent was obtained in accordance with the Declaration of Helsinki.

Author Contributions

All authors conceived of the study, participated in its design and helped to draft the manuscript. Likewise, all authors made suggestions and critical reviews to the initial draft and contributed to its improvement until reaching the final manuscript, which was read and approved by all authors.

This work was supported in Spain by the Spanish Ministry of Health, Social Services and Equality (PRJ201703153).

Conflict of Interest Statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

We thank the participating adolescents and schools, the research assistants from the Spanish HBSC team who took part in this study and Ian Scionti for providing language help.

AbouZahr, C. (2014). Progress and challenges in women’s health: an analysis of levels and patterns of mortality and morbidity. Contraception 90, 3–13. doi: 10.1016/j.contraception.2014.03.007

PubMed Abstract | CrossRef Full Text | Google Scholar

Achenbach, T. M. (2013). DSM Guide for the ASEBA. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families.

Google Scholar

Achenbach, T. M., and Rescorla, L. A. (2001). Manual for the ASEBA School-Age Forms & Profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families.

Acker, J. (2006). Class Questions: Feminist Answers. Lanham, MD: Rowman & Littlefield Publishers Inc.

Andersen, R. E., Crespo, C. J., Bartlett, S. J., Cheskin, L. J., and Pratt, M. (1998). Relationship of physical activity and television watching with body weight and level of fatness among children: results from the third national health and nutrition examination survey. J. Am. Med. Assoc. 279, 938–942. doi: 10.1001/jama.279.12.938

Andrews, P. W., and Thompson, J. A. (2009). The bright side of being blue: depression as an adaptation for analyzing complex problems. Psychol. Rev. 116, 620–654. doi: 10.1037/a0016242

Bacopoulou, F., Foskolos, E., Stefanaki, C., Tsitsami, E., and Vousoura, E. (2018). Disordered eating attitudes and emotional/behavioral adjustment in Greek adolescents. Eat. Weight Disord. 23, 621–628. doi: 10.1007/s40519-017-0466-x

Banfield, S. S., and McCabe, M. P. (2002). An evaluation of the construct of body image. Adolescence 37, 373–393.

Barker, E., and Galambos, N. (2003). Body dissatisfaction of adolescent girls and boys: risk and resource factors. J. Early Adolescence 23, 141–165. doi: 10.1177/0272431603023002002

CrossRef Full Text | Google Scholar

Bessenoff, G., and Snow, D. (2006). Absorbing society’s influence: body image self- discrepancy and internalized shame. Sex Roles 54, 727–731. doi: 10.1007/s11199-006-9038-7

Borraccino, A., Lemma, P., Iannotti, R., Zambon, A., Dalmasso, P., Lazzeri, G., et al. (2009). Socioeconomic effects on meeting physical activity guidelines: comparisons among 32 countries. Med. Sci. Sport Exerc. 41, 749–756. doi: 10.1249/MSS.0b013e3181917722

Brooks-Gunn, J. (1991). “How stressful is the transition to adolescence for girls?,” in Adolescent Stress: Causes and Consequences , eds M. E. Colten, and S. Gore, (New York, NY: Aldine de Gruyter), 131–149.

Bully, P., and Elosua, P. (2011). Changes in body dissatisfaction relative to gender and age: the modulating character of BMI. Span. J. Psychol. 14, 313–322. doi: 10.5209/rev_SJOP.2011.v14.n1.28

Cafri, G., and Thompson, J. K. (2004). Measuring male body image: a review of the current methodology. Psychol. Men Masc. 5, 18–29. doi: 10.1037/1524-9220.5

Cash, T. F. (2004). Body image: past, present, and future. Body Image 1, 1–5. doi: 10.1016/S1740-1445(03)00011-1

Centers for Disease Control and Prevention, (1997). Guidelines for school health programs to promote lifelong healthy eating. J. Sch. Health 67, 9–26. doi: 10.1111/j.1746-1561.1997.tb06289.x

Chaplin, T. M., and Aldao, A. (2013). Gender differences in emotion expression in children: a meta-analytic review. Psychol. Bull. 139, 735–765. doi: 10.1037/a0030737

Cheung, Y. T., Lee, A. M., Ho, S. Y., Li, E. T., Lam, T. H., Fan, S. Y., et al. (2011). Who wants a slimmer body? The relationship between body weight status, education level and body shape dissatisfaction among young adults in Hong Kong. BMC Public Health 11:835. doi: 10.1186/1471-2458-11-835

Chu, T. L., Martin, S. B., Petrie, T. A., and Greenleaf, C. (2019). Relations between sociocultural pressures and weight control behavior among early adolescent boys. Psychol. Sch. 56, 163–175. doi: 10.1002/pits.22212

Coakley, J., and White, A. (1992). Making decisions: gender and sport participation among British adolescents. Sociol. Sport J. 9, 20–35. doi: 10.1123/ssj.9.1.20

Cohen, J. (1988). Statistical Power Analysis for the Behavioral Science , 2nd Edn. Hillsdale, NJ: Lawrence Erlbaum Associates.

Cok, F. (1990). Body image satisfaction in Turkish adolescents. Adolescence 25, 409–413.

PubMed Abstract | Google Scholar

Cole, T. J., Bellizzi, M. C., Flegal, K. M., and Dietz, W. H. (2000). Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 320, 1240–1243. doi: 10.1136/bmj.320.7244.1240

Cole, T. J., Flegal, K. M., Nicholls, D., and Jackson, A. A. (2007). Body mass index cut offs to define thinness in children and adolescents: international survey. BMJ 335:194. doi: 10.1136/bmj.39238.399444.55

Currie, C., Inchley, J., Molcho, M., Lenzi, M., Veselska, Z., and Wild, F. (2014). Health Behaviour in School-Aged Children (HBSC) Study Protocol: Background, Methodology and Mandatory items for the 2013/14 Survey. St. Andrews: CAHRU.

Eisenberg, M. E., Neumark-Sztainer, D., Story, M., and Perry, C. (2005). The role of social norms and friends’ influences on unhealthy weight- control behaviors among adolescent girls. Soc. Sci. Med. 60, 1165–1173. doi: 10.1016/j.socscimed.2004.06.055

European Commission for Health, and Consumer Protection, (2003). Status Report on the European Commission’s Work in the Field of Nutrition in Europe. Luxembourg: Office for Official Publications of the European Communities.

Feng, X., and Wilson, A. (2016). Neighborhood socioeconomic disadvantage modifies the relationship between weight status and weight-related satisfaction. Int. J. Obes. 40, 1922–1926. doi: 10.1038/ijo.2016.120

Fismen, A.-S., Samdal, O., and Torsheim, T. (2012). Family affluence and cultural capital as indicators of social inequalities in adolescent’s eating behaviours: a population-based survey. BMC Public Health 12:1036. doi: 10.1186/1471-2458-12-1036

Graber, J. A., and Brooks-Gunn, J. (1996). Transitions and turning points: navigating the passage from childhood through adolescence. Dev. Psychol. 32, 768–776. doi: 10.1037/0012-1649.32.4.768

Graber, J. A., and Sontag, L. M. (2009). “Internalizing problems during adolescence,” in Handbook of Adolescent Psychology , eds R. M. Lerner, and L. Steinberg, (New York, NY: John Wiley and Sons Inc.), 642–682.

Grogan, S. (2006). Body image and health contemporary perspectives. J. Health Psychol. 11, 523–530. doi: 10.1177/1359105306065013

Harter, S. (2006). “The self,” in Handbook of Child Psychology: Social, Emotional, and Personality Development , Vol. 3, eds W. Damon and R. M. Lerner, (Hoboken, NJ: John Wiley & Sons), 505–570.

Hausenblas, H. A., and Fallon, E. A. (2006). Exercise and body image: a meta-analysis. Psychol. Health 21, 33–47. doi: 10.1080/14768320500105270

Hayward, C., and Sanborn, K. (2002). Puberty and the emergence of gender differences in psychopathology. J. Adolescent Health 30, 49–58. doi: 10.1016/S1054-139X(02)00336-1

Helzer, J. E., Kraemer, H. C., Krueger, R. F., Wittchen, H. U., Sirovatka, P. J., and Regier, D. A. (2008). Dimensional Approaches in Diagnostic Classification: Refining the Research Agenda for DSM-V. Washington, DC: American Psychiatric Association.

Holmqvist, K., and Frisen, A. (2019). From negative to positive body image: men’s and women’s journeys from early adolescence to emerging adulthood. Body Image 28, 53–65. doi: 10.1016/j.bodyim.2018.12.002

Hyde, J. S., Mezulis, A. H., and Abramson, L. Y. (2008). The ABCs of depression: integrating affective, biological, and cognitive models to explain the emergence of the gender difference in depression. Psychol. Rev. 115, 291–313. doi: 10.1037/0033-295X.115.2.291

Inchley, J., and Currie, C. (2004). Summary of Key Findings From the 2003/04 Pupil Survey. Findings from the Physical Activity in Scottish Schoolchildren (PASS) Survey. Available at: https://risweb.st-andrews.ac.uk/portal/en/researchoutput/report-of-findings-from-the-pass-200304-pupil-survey(a4228636-8b81-49a8-83b2-8aca4bc2958d).html

Inchley, J., Currie, D., Young, T., Samdal, O., Torsheim, T., Augustson, L., et al. (2016). Growing up Unequal: Gender and Socioeconomic Differences in Young People’s Health and Well-being: Health Behaviour in School-Aged Children (HBSC) Study: International Report from the 2013/2014 Survey. (Health Policy for Children and Adolescents, No. 7). Copenhagen: WHO Regional Office for Europe.

Ingram, R. E., and Luxton, D. D. (2005). “Vulnerability-stress models,” in Development of Psychopathology: A Vulnerability-Stress Perspective , eds B. L. Hankin, and J. R. Z. Abela, (Thousand Oaks, CA: Sage Publications Inc.), 32–46. doi: 10.4135/9781452231655.n2

Janssen, I., Katzmarzyk, P. T., Boyce, W. F., Vereecken, C., Mulvihill, C., Roberts, C., et al. (2005). Comparison of overweight and obesity prevalence in school-aged youth from 34 countries and their relationships with physical and dietary patterns. Obes. Rev. 6, 123–132. doi: 10.1111/j.1467-789x.2005.00176.x

Kanaan, M. N., and Afifi, R. A. (2010). Gender differences in determinants of weight-control behaviours among adolescents in Beirut. Public Health Nutr. 13, 71–81. doi: 10.1017/S136898000900500X

Larsen, P. S., Strandberg-Larsen, K., Micali, N., and Nybo Andersen, A.-M. (2015). Parental and child characteristics related to early-onset disordered eating: a systematic review. Harv. Rev. Psychiatry 23, 395–412. doi: 10.1097/HRP.0000000000000073

Larson, N. I., Neumark-Sztainer, D., and Story, M. (2009). Weight control behaviors and dietary intake among adolescents and young adults: longitudinal findings from project EAT. J. Am. Diet Assoc. 109, 1869–1877. doi: 10.1016/j.jada.2009.08.016

Lazzeri, G., Ahluwalia, N., Niclasen, B., Pammolli, A., Vereecken, C., Rasmussen, M., et al. (2016). Trends from 2002 to 2010 in daily breakfast consumption and its socio-demographic correlates in adolescents across 31 countries participating in the HBSC study. PLoS One 11:e0151052. doi: 10.1371/journal.pone.0151052

Lerner, R. M. (2018). Concepts and Theories of Human Development. New York, NY: Routledge.

Marmot, M., and Bell, R. (2012). Fair society, healthy lives. Public Health 126, S4–S10. doi: 10.1016/j.puhe.2012.05.014

McArthur, L., Holbert, D., and Peña, M. (2005). An exploration of the attitudinal and perceptual dimensions of body image among male and female adolescents from six latin american cities. Adolescence 40, 801–816.

McCabe, M. P., and Ricciardelli, L. A. (2004). Body image dissatisfaction among males across the lifespan: a review of past literature. J. Psychosom. Res. 56, 675–685. doi: 10.1016/S0022-3999(03)00129-6

McClintock, J. M. (2001). The underlying psychopathology of eating disorders and social phobia: a structural equation analysis. Eat. Behav. 2, 247–261. doi: 10.1016/S1471-0153(01)00032-0

McGuire, M. T., Wing, R. R., Klem, M. L., and Hill, J. O. (1999). The behavioral characteristics of individuals who lose weight unintentionally. Obes. Res. 7, 485–490. doi: 10.1002/j.1550-8528.1999.tb00437.x

Mills, J. S., Roosen, K., and Vella-Zarb, R. (2011). “The psychology of body image: Understanding body image instability and distortion,” in Body Image: Perceptions, Interpretations, and Attitudes , ed. S. B. Greene, (New York, NY: Nova Science Publishers), 59–80.

Mischner, I., van Schie, H., and Engels, R. (2013). Breaking the circle: challenging western sociocultural norms for appearance influences young women’s attention to appearance-related media. Body Image 10, 316–325. doi: 10.1016/j.bodyim.2013.02.005

Moreno, C., Ramos, P., Rivera, F., Jiménez-Iglesias, A., García-Moya, I., Sánchez-Queija, I., et al. (2016). Los adolescentes españoles: estilos de vida, salud, ajuste psicológico y relaciones en sus contextos de desarrollo. Resultados del Estudio HBSC-2014 en España. Madrid: Ministerio de Sanidad, Servicios Sociales e Igualdad.

Moreno, C., Ramos, P., Sánchez-Queija, I., Rivera, F., Jiménez-Iglesias, A., García-Moya, I., et al. (2018). Informe técnico de la recogida de datos (cuestionario empleado y muestreo seguido) en el Estudio HBSC (Health Behaviour in School-Aged Children) - 2018. Madrid: Ministerio de Sanidad y Política Social.

Moreno-Maldonado, C., Ramos, P., Moreno, C., and Rivera, F. (2018). How family socioeconomic status, peer behaviors, and school-based intervention on healthy habits influence adolescent eating behaviors. Sch. Psychol. Int. 39, 92–118. doi: 10.1177/0143034317749888

Neumark-Sztainer, D., Paxton, S. J., Hannan, P. J., Haines, J., and Story, M. (2006). Does body satisfaction matter? Five-year longitudinal associations between body satisfaction and health behaviors in adolescent females and males. J. Adolescent Health 39, 244–251. doi: 10.1016/j.jadohealth.2005.12.001

Neumark-Sztainer, D., Story, M., Falkner, N., Beuhring, T., and Resnick, M. (1999). Sociodemographic and personal characteristics of adolescents engaged in weight loss and weight/muscle gain behaviors: who is doing what? Prev. Med. 28, 40–50. doi: 10.1006/pmed.1998.0373

Neziroglu, F., Khemlani-Patel, S., and Veale, D. (2008). Social learning theory and cognitive behavioral models of body dysmorphic disorder. Body Image 5, 28–38. doi: 10.1016/j.bodyim.2008.01.002

O’Dea, J. A., and Caputi, P. (2001). Association between socioeconomic status, weight, age and gender, and the body image and weight control practices of 6- to 19-year-old children and adolescents. Health Educ. Res. 16, 521–532. doi: 10.1093/her/16.5.521

Oliva, A., Parra, A., and Reina, M. C. (2015). Personal and contextual factors related to internalizing problems during adolescence. Child Youth Care For. 43, 505–520. doi: 10.1007/s10566-014-9250-5

Orbach, I., and Mikulincer, M. (1998). Body investment scale: construction and validation of a body experience scale. Psychol. Assess. 10, 415–425. doi: 10.1037/1040-3590.10.4.415

Overton, W. F. (2014). The process-relational paradigm and relational-developmental-systems metamodel as context. Res. Hum. Dev. 11, 323–331. doi: 10.1080/15427609.2014.971549

Overton, W. F. (2015). “Process and relational developmental systems,” in Handbook of Child Psychology and Developmental Science: Theory and Method , eds W. F. Overton, and P. C. M. Molenaar, (Hoboken, NJ: Wiley), 9–62.

Ozer, E. M., and Irwin, C. E. (2009). “Adolescent and Young adult health: from basic health status to clinical interventions,” in Handbook of Adolescent Psychology: Individual Bases of Adolescent Development , eds R. Lerner, and L. Steinberg, (Hoboken, NJ: Wiley), 618–641.

Patalay, P., and Hardman, C. (2019). Comorbidity, codevelopment, and temporal associations between body mass index and internalizing symptoms from early childhood to adolescence. JAMA Psychiatry 76, 721–729. doi: 10.1001/jamapsychiatry.2019.0169

Pereira, E. F., Graup, S., Lopes, A. S., Borgatto, A. F., and Daronco, L. S. (2009). Percepção da imagem corporal de crianças e adolescentes com diferentes níveis socio- econômicos na cidade de Florianópolis, Santa Catarina, Brasil. Rev. Bras. Saude Matern. Infant 9, 253–262. doi: 10.1590/S1519-38292009000300004

Pereira, E. F., Teixeira, C. S., Gattiboni, B. D., Bevilacqua, L. A., Confortin, S. C., and Rodriguez de Silva, T. (2011). Adolescent body image perceptions and socioeconomic status: a systematic review. Rev. Paul. Pediatr. 29, 423–429. doi: 10.1590/S0103-05822011000300018

Prochaska, J. J., Sallis, J. F., and Long, B. (2001). A physical activity screening measure for use with adolescents in primary care. Arch. Pediatr. Adolesc. Med. 155, 554–559. doi: 10.1001/archpedi.155.5.554

Puccio, F., Fuller-Tyszkiewicz, M., Ong, D., and Krug, L. (2016). A systematic review and meta-analysis on the longitudinal relationship between eating pathology and depression. Int. J. Eat. Disord. 49, 439–454. doi: 10.1002/eat.22506

Puhl, R. M., and Latner, J. D. (2007). Stigma, obesity, and the health of the nation’s children. Psychol. Bull. 133, 557–580. doi: 10.1037/0033-2909.133.4.557

Ramos, P., Brooks, F., García-Moya, I., Rivera, F., and Moreno, C. (2013). Eating habits and physical activity in dieter and non-dieter youth: a gender analysis of English and Spanish adolescents. Soc. Sci. J. 50, 575–582. doi: 10.1016/j.soscij.2013.09.017

Ramos, P., Rivera, F., and Moreno, C. (2012). “Key variables in the development of eating disorders during the adolescence: implications for sex differences,” in Relevant Topics in Eating Disorders , ed. I. Jauregui, (Rijeka: InTech), 31–44.

Roberts, C., Freeman, J., Samdal, O., Schnohr, C., de Looze, M. E., NicGabhainn, S., et al. (2009). The Health Behaviour in School-aged Children (HBSC) study: methodological developments and current tensions. Int. J. Public Health 54, 140–150. doi: 10.1007/s00038-009-5405-9

Rotenberg, K. J., Taylor, D., and Davis, R. (2004). Selective mood- induced body image disparagement and enhancement effects: are they due to cognitive priming or subjective mood? Int. J. Eat. Disord. 35, 317–332. doi: 10.1002/eat.10263

Rutter, M., Caspi, A., and Moffitt, T. E. (2003). Using sex differences in psychopathology to study causal mechanisms: unifying issues and research strategies. J. Child Psychol. Psychiatry 44, 1092–1115. doi: 10.1111/1469-7610.00194

Schnohr, C. W., Makransky, G., Kreiner, S., Torsheim, T., Hofmann, F., De Clercq, B., et al. (2013). Item response drift in the family affluence scale: a study on three consecutive surveys of the Health Behaviour in School-aged Children (HBSC) survey. Measurement 46, 3119–3126. doi: 10.1016/j.measurement.2013.06.016

Shagar, P. S., Harris, N., Boddy, J., and Donovan, C. L. (2017). The relationship between body image concerns and weight-related behaviours of adolescents and emerging adults: a systematic review. Behav. Change 34, 208–252. doi: 10.1017/bec.2018.3

Shomaker, L. B., and Furman, W. (2010). A prospective investigation of interpersonal influences on the pursuit of muscularity in late adolescent boys and girls. J. Health Psychol. 15, 391–404. doi: 10.1177/1359105309350514

Siegel, J. M. (2002). Body image change and adolescent depressive symptoms. J. Adolescent Res. 17, 27–41. doi: 10.1177/0743558402171002

Sobrino-Bazaga, A., and Rabito-Alcoón, M. F. (2018). Gender differences existing in the general population in relation to body dissatisfaction associated with the ideal of beauty: a systematic review. Stud. Psychol. 39, 548–587. doi: 10.1080/02109395.2018.1517860

Stalsberg, R., and Pedersen, A. V. (2010). Effects of socioeconomic status on the physical activity in adolescents: a systematic review of the evidence. Scand. J. Med. Sci. Sports 20, 368–383. doi: 10.1111/j.1600-0838.2009.01047.x

Stice, E., Trost, A., and Chase, A. (2003). Healthy weight control and dissonance-based eating disorder prevention programs: results from a controlled trial. Int. J. Eat. Disord. 33, 10–21. doi: 10.1002/eat.10109

Story, M., French, S. A., Resnick, M. D., and Blum, R. W. (1995). Ethnic/racial and socioeconomic differences in dieting behaviors and body image perceptions in adolescents. Int. J. Eat. Disord. 18, 173–179. doi: 10.1002/1098-108x(199509)18:2<173::aid-eat2260180210>3.0.co;2-q

Strauss, R. S. (1999). Comparison of measured and self-reported weight and height in a cross-sectional sample of young adolescents. Int. J. Obes. 23, 904–908. doi: 10.1038/sj.ijo.0800971

Ter Bogt, T., van Dorsselaer, S., Monshouwer, K., Verdurmen, J., Engels, R., and Vollebergh, W. (2006). Body mass index and body weight perception as risk factors for internalizing and externalizing problem behavior among adolescents. J. Adolescent Health 39, 27–34. doi: 10.1016/j.jadohealth.2005.09.007

Thompson, J. K., Coovert, M. D., Richards, D. J., Johnson, S., and Cattarin, J. (1995). Development of body image, eating disturbance, and general psychological functioning in female adolescents: covariance structure modelling and longitudinal investigations. Int. J. Eat. Disord. 18, 221–236. doi: 10.1002/1098-108x(199511)18:3<221::aid-eat2260180304>3.0.co;2-d

Tiggemann, M., Gardiner, M., and Slater, A. (2000). “I would rather be size 10 than have straight A’s”: a focus group study of adolescent girls’ wish to be thinner. J. Adolesc. 23, 645–659. doi: 10.1006/jado.2000.0350

Timlin, M. T., Pereira, M. A., Story, M., and Neumark-Sztainer, D. (2008). Breakfast eating and weight change in a 5-year prospective analysis of adolescents: project EAT (eating among teens). Pediatrics 121, 638–645. doi: 10.1542/peds.2007-1035

Turrell, G., Hewitt, B., Patterson, C., and Oldenburg, B. (2003). Measuring socio-economic position in dietary research: is choice of socio-economic indicator important? Public Health Nutrit. 6, 191–200. doi: 10.1079/PHN2002416

Vereecken, C., Pedersen, T. P., Ojala, K., Krølner, R., Dzielska, A., Ahluwalia, N., et al. (2015). Fruit and vegetable consumption trends among adolescents from 2002 to 2010 in 33 countries. Eur. J. Public Health 25, 16–19. doi: 10.1093/eurpub/ckv012

Viner, R. M., Ozer, E. M., Denny, S., Marmot, M., Resnick, M., Fatusi, A., et al. (2012). Adolescence and the social determinants of health. Lancet 379, 1641–1652. doi: 10.1016/s0140-6736(12)60149-4

Wadsworth, M. E., and Achenbach, T. M. (2005). Explaining the link between low socioeconomic status and psychopathology: testing two mechanisms of the social causation hypothesis. J. Consult. Clin. Psychol. 73, 1146–1153. doi: 10.1037/0022-006X.73.6.1146

Walby, S. (2011). “Globalization and multiple inequalities,” in Analyzing Gender, Intersectionality, and Multiple Inequalities: Global, Transnational and Local Contexts: Advances in Gender Research , Vol. 15, eds E. Ngan-Ling Chow and M. Texler Segal, (Bingley: Emerald Group Publishing Limited), 17–33. doi: 10.1108/s1529-2126(2011)0000015006

Wang, Z., Byrne, N. M., Kenardy, J. A., and Hills, A. P. (2005). Influences of ethnicity and socioeconomic status on the body dissatisfaction and eating behaviour of Australian children and adolescents. Eat. Behav. 6, 23–33. doi: 10.1016/j.eatbeh.2004.05.001

Ward, P. R., Verity, F., Carter, P., Tsourtos, G., Coveney, J., and Wong, K. C. (2013). Food stress in adelaide: the relationship between low income and the affordability of healthy food. J. Environ. Public Health 10:968078. doi: 10.1155/2013/968078

Yannakoulia, M., Lykou, A., Kastorini, C. M., Papasaranti, E. S., Petralias, A., Veloudaki, A., et al. (2016). Socio-economic and lifestyle parameters associated with diet quality of children and adolescents using classification and regression tree analysis: the DIATROFI study. Public Health Nutr. 19, 339–347. doi: 10.1017/S136898001500110X

Zeller, M. H., Saelens, B. E., Roehrig, H., Kirk, S., and Daniels, S. (2004). Psychological adjustment of obese youth presenting for weight management treatment. Obes. Res. 12, 1576–1586. doi: 10.1038/oby.2004.197

Keywords : body image, body mass index, dieting, physical activity, internalizing symptoms, sex, age, socioeconomic status

Citation: Ramos P, Moreno-Maldonado C, Moreno C and Rivera F (2019) The Role of Body Image in Internalizing Mental Health Problems in Spanish Adolescents: An Analysis According to Sex, Age, and Socioeconomic Status. Front. Psychol. 10:1952. doi: 10.3389/fpsyg.2019.01952

Received: 19 April 2019; Accepted: 08 August 2019; Published: 22 August 2019.

Reviewed by:

Copyright © 2019 Ramos, Moreno-Maldonado, Moreno and Rivera. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Pilar Ramos, [email protected]

Disclaimer: All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.

Improving Body Image Among People With a Visible Difference

New research shows that asking "what can my body do" may be helpful..

Posted May 30, 2024 | Reviewed by Gary Drevitch

• What Is Body Image?
• Find counselling to improve body image
• People with a visible difference may experience appearance concerns.
• Expand Your Horizon (EYH) can help individuals focus on what their body can do and why that is important.
• Among people with a visible difference EYH led to higher functionality appreciation in a 3-month follow-up.
• No group differences were found for overall body appreciation, anxiety, and depression.

Visible differences refer to any appearance-altering condition that a person is born with (e.g., cleft lip and/or palate) or acquires later in life (e.g., due to burns, injuries, or medical treatments).

Although many people adjust well to their visible difference, for others, visible differences can contribute to aspects of ill-being such as appearance dissatisfaction, social anxiety , and depression . A large reason for this is the depiction of visible differences in the media—where such individuals are often depicted as villains or victims—and experiences of stigma and discrimination in daily life, such as staring, unwanted questions, and teasing.

While system-wide changes are needed to address these issues, individual-level techniques that can boost and protect individuals’ well-being are also important. To this end, in a recent study led by my colleague at the Centre for Appearance Research, Ella Guest, we investigated an online programme to improve positive body image as one aspect of well-being.

The programme is Expand Your Horizon , which was developed by me and my colleagues back in 2015 . Expand Your Horizon is made up of three writing exercises that help individuals to focus on the functionality of their body. Body functionality refers to everything that the body can do , including functions related to physical capacities (e.g., walking), internal processes (e.g., digesting food), creative endeavours (e.g., painting), bodily senses (e.g., hearing), communication with others (e.g., via body language ), and self-care activities (e.g., bathing). In the writing exercises, users are asked to reflect on the various functions of their body and why those functions are important to them.

The idea behind Expand Your Horizon is that it helps to shift the focus from an overemphasis on physical appearance (which has been shown to contribute to negative body image and ill-being) to an appreciative and holistic focus on all of the valuable things the body can do, which are often taken for granted in daily life. To date, Expand Your Horizon has been tested among different populations , but Guest’s study is the first in which it was tested among people with a visible difference.

In the study, 68 adults with a visible difference were randomized to either Expand Your Horizon or a waitlist group. Participants in the Expand Your Horizon group completed questionnaires at pretest, then completed the Expand Your Horizon programme over the course of one week. They completed the same questionnaires again immediately after finishing Expand Your Horizon, and three months later. Participants in the waitlist group completed the questionnaires at the same time points, and received Expand Your Horizon after finishing the follow-up measurement.

We used the questionnaire data to test whether there were any changes in positive body image, anxiety , and depression across time. We expected that, compared to the waitlist group, participants in the Expand Your Horizon group would report higher positive body image, and lower anxiety and depression, across time.

The Results

The data showed that, as expected, participants in the Expand Your Horizon group reported higher functionality appreciation at posttest and at the three-month follow-up compared to the waitlist group. Functionality appreciation is a core component of positive body image and refers to appreciating and respecting the body for what it is able to do . Based on content analyses of participants’ writing exercises, we also found that participants were able to describe their body functionality holistically, and appreciated how their body is positively connected to the Self and helps them to lead their daily lives. For example, one participant described, “My body and brain allow me to work and be good at my job.”

Unexpectedly, we did not find any group differences for overall body appreciation, anxiety, or depression. Nevertheless, based on intervention feedback questions, the participants in Expand Your Horizon evaluated the programme positively. For example, they scored the programme as being enjoyable and impactful, and thought that the number and length of the writing exercises was acceptable.

The Take-Home Message

On the one hand, the findings are promising because they suggest that Expand Your Horizon led to higher functionality appreciation among people with a visible difference, with these improvements even persisting three months later. Functionality appreciation is a core aspect of positive body image, and extensive research has shown that it is positively related to many other aspects of well-being. Further, Expand Your Horizon is an individual-level technique that is easily accessible given its online format, and it is self-led, so it can easily be distributed to larger numbers of people. It is also promising to see that Expand Your Horizon , which has substantial support among other participant populations, can lead to positive changes for people with a visible difference too. The participants themselves also gave Expand Your Horizon positive scores in their intervention feedback. Therefore, overall, Expand Your Horizon could be a useful tool for adults with a visible difference who are looking for ways to improve their body image.

On the other hand, it is important to underscore that we did not find any group differences for the other outcome measures: overall body appreciation, anxiety, and depression. As described above, a major contributor to ill-being for many people with a visible difference is poor treatment by other people, and unfair depictions of visible differences in mass media. Luckily, there are other individual-level techniques that may address these experiences, such as those that focus on coping strategies . Therefore, as described by Guest in the research article, “having a toolbox of different interventions may provide the best approach for supporting this population.” We also underscore that system-wide changes are crucial to tackle how visible differences are portrayed in media and how people with a visible difference are treated by others.

To access a PDF version of the Expand Your Horizon exercises for adults with a visible difference, click here.

Jessica Alleva, Ph.D ., is an assistant professor of psychology at Maastricht University in the Netherlands, and a Visiting Fellow at the Centre for Appearance Research in the U.K.

• Find a Therapist
• Find a Treatment Center
• Find a Psychiatrist
• Find a Support Group
• Find Online Therapy
• International
• New Zealand
• South Africa
• Switzerland
• Asperger's
• Bipolar Disorder
• Chronic Pain
• Eating Disorders
• Passive Aggression
• Personality
• Goal Setting
• Positive Psychology
• Stopping Smoking
• Low Sexual Desire
• Relationships
• Child Development
• Self Tests NEW
• Therapy Center
• Diagnosis Dictionary
• Types of Therapy

At any moment, someone’s aggravating behavior or our own bad luck can set us off on an emotional spiral that threatens to derail our entire day. Here’s how we can face our triggers with less reactivity so that we can get on with our lives.

• Emotional Intelligence
• Gaslighting
• Affective Forecasting
• Neuroscience

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings

Preview improvements coming to the PMC website in October 2024. Learn More or Try it out now .

• Advanced Search
• Journal List
• v.13(2); 2021 Feb

Body Image and its Role in Physical Activity: A Systematic Review

Cassidy m foley davelaar.

1 Orthopedics, Nemours Children's Health System, Orlando, USA

Despite the benefits of youth sports, most children drop out by the age of 13 years. A better understanding of the etiology of sports dropout in children will serve to improve interventions to keep children active. The objective of this review was to investigate the associations between body image and perceived physical competence and sports attrition in children. A systematic literature review was conducted using PubMed and MEDLINE database searches in compliance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Included studies were full-text English articles that addressed body image or perceived competence and attrition or dropout with subjects 21 years and younger. The results were organized by age to demonstrate the changing relationship body image has on physical activity. Evidence revealed that children younger than 7 years have an inflated self-perception and are eager to participate in activities regardless of competence. Between 7 to 10 years of age, children begin to more accurately perceive their skills and draw comparisons with their peers. Elevated body mass index (BMI) becomes a deterrent between 6 to 11 years. After 12 years, teasing and gender identification issues become causes of attrition. In adolescence, body image becomes a significant determinant of continuation of physical activity, more than actual skill. Perceived physical competency and body image do not appear to affect sports attrition in children younger than 7 years. As children get older, BMI/body image and physical competency become greater factors in sports attrition, with body image playing a significant role in adolescents.

Introduction and background

The benefits of youth sports participation are numerous and uncontested. Motor competence in children is positively associated with cardiorespiratory fitness, muscular strength, muscular endurance, and a healthy weight status [ 1 ]. Research has proven that children who play sports are more likely to incorporate health and fitness into their adolescent lives [ 2 , 3 ]. In addition to their physical benefits, sports should be fun, and the exercises involved in participation should assist in the development of movement skills. Fundamental movement skills are movements that are the building blocks for more complex physical activities like sports. Examples of these skills include object control skills (throwing, kicking, striking, catching, underhand rolling, and dribbling) and locomotor skills (running, hopping, jumping, sliding, leaping, and galloping). The acquisition and gradual mastery of these skills lead to the development of physical literacy. Somewhat similar to academic literacy, physical literacy is important to the motor development and the physical, cognitive, and social growth of children [ 4 ].

Despite the benefits of developing motor competence at a young age, 70% of children will drop out of sports by age 13 years. By age 14 years, girls drop out of sports at a rate two times greater than that of boys [ 5 ]. “Not fun” followed by “not good enough” are often cited as top reasons for sports attrition [ 6 - 8 ]. However, diving deeper into the literature, “fun” and “not good enough” are very subjective and are packed with deeper meaning. Children will drop out of sports because of their perception of competence, even when competency is not measured [ 8 ]. The deeper meaning to sports attrition, children’s perceptions, and self-assessment fueled this research into the role body image plays in sports attrition. Negative body image and poor self-esteem affect physical activity in a similar way as poor perception of skills [ 7 - 10 ]. By looking at the data in a new way, organized by children’s ages, new information regarding causes and timing of sports attrition will be gained as well as new knowledge as to how to improve children’s and adolescents’ physical activity levels. With that, we set out to answer the following questions: 1) what are the specific factors that affect sports attrition in children and adolescents, and 2) does body image and self-perception of physical competency vary by age with regard to sports attrition in children and adolescents?

A systematic review of the literature following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines was conducted by a medical librarian. A PubMed (MEDLINE) search was initially performed to collect applicable literature using the terms “body image” AND “young athletes.” This process was repeated every six months from February 2017 to April 2020 to include new references. The reference section for each full-text article was reviewed for additional inclusions. Articles were included if their demographics were of a pediatric population (average 21 years and younger) and if they were in English. Synonyms “drop out” and “perceived competence” were included to obtain best-fit articles. “Perceived competence” is the term used in the youngest ages of our results. We interpreted “perceived competence” to be similar to the definition of body image: an individual’s psychological experience of the function of his or her own body [ 11 ]. Articles were excluded if there was only an abstract available, the paper was a review, or the paper did not address physical activity and sports attrition or drop out. There were many articles supporting overweight children with excessive weight being a factor in their continuation or involvement in physical activity. In this case, only articles that reported novel results were included to avoid redundancy.

Three hundred eighty-three articles met the initial criteria. Of those, two were excluded because they were not in English, 11 were excluded because they were only abstracts, seven were excluded because they were related to eating disorders, 37 were outside the age range, 90 did not address body image or perceived competence, and 192 did not address attrition or dropout from sports. From the remaining 44 most accurately fitting articles, 19 were excluded because they were related to increased weight being a deterrent of physical activity and they did not add new data to the time continuum, and, lastly, three were excluded because they were reviews (Figure ​ (Figure1 1 ).

The age-related continuum of data, viewed across the years of childhood, portrays a greater picture and provides more specific information regarding the temporal nature of interventions than each article alone. A summary of the results is detailed in Table ​ Table1. 1 . Mean age was included if the age range of participants was not provided.

*year of publication

Youngest athletes (data on ages - birth to 5 years and 7 months)

A positive relationship between motor skill performance and physical activity is not as apparent in the youngest athletes [ 12 ]. There was no correlation between gross motor skill acquisition as babies and toddlers and sports participation later in life [ 12 ].

Children under the age of 7 years demonstrate an inflated self-perception of their motor skill competence. Younger children are eager to participate in activities whether or not they are competent in those activities [ 3 ]. High perceptions of competence contribute to increased physical activity and act as a valuable driving force to the acquisition of motor skills [ 3 ]. At a young age, participation in physical activity is not yet influenced by perceptions [ 28 ]. At a mean age of 5 years and 7 months, children’s activity participation did not seem to be affected by their perceptions, but, as they crept closer to 6 years (mean age, 5 years and 9 months), perception of their skills began [ 14 , 28 ]. 

Despite performing slightly lower on a gross motor development test, kindergarten-aged children still perceived their abilities as high [ 14 ]. When assessing perceptions of skills using locomotor skills, kindergarten girls had higher perceived physical competence than boys; this was a unique finding, as perception of skills is typically lower in girls [ 14 ]. Results point to early kindergarten as a window of opportunity to improve children’s fundamental movement skills, especially for girls, as this may lead to greater involvement in activity later in life [ 14 ].

In the young population (19 months-5 years), higher levels of exposure to physical activity correlate with increased sports participation [ 13 ]. Results of more than three years of longitudinal data found that higher levels of moderate-to-vigorous physical activity (accelerometry) at 3.5 years were associated with actual locomotor skill and perceived total skill at 5 years [ 13 ]. As children age, modest relationships between perceptions of competence and motor skill develop [ 14 , 15 ]. There is convincing data that physical activity and actual motor skill competence are associated in children aged 4 years and older [ 6 , 13 ]. 

Later childhood ages (data on ages - 5 years and 9 months to 11 years of age)

As children age (4-8 years), actual object control results in greater physical activity [ 6 ]. It has been hypothesized that children with better motor competence participate in higher levels of physical activity and that this in turn helps to further develop higher actual and perceived motor competence [ 13 ]. As early as 6 to 10 years of age, children start to make self-judgements of their abilities compared with peers [ 14 ]. Around 7 to 10 years of age, children begin to more accurately compare their skills with those of their peers, and their perception of their abilities, whether or not they are being measured, can result in attrition [ 16 , 28 ]. Actual rather than perceived skill was more indicative of physical activity in the Slykerman et al. cohort [ 16 ], therefore indicating that the relationship is only just emerging at this age. Between 9 and 11 years, children develop a more accurate perception of their skills in comparison with others. 

Body mass index (BMI) becomes a major determinant in body image and continuation of physical activity between 6 and 11 years of age [ 18 ]. Children who were overweight or obese struggled with fundamental movement skills, bilateral motor coordination, body strength, balance, speed, and agility [ 18 ]. Overweight children have lower perceptions of themselves regarding physical abilities and are less likely to continue participation in sports and other active leisure-time pursuits [ 18 ]. This is an extremely vulnerable time for children. Poulsen et al. [ 18 ] reported on a group of young children 6 to 11 years of age (mean age 8.75 years) who already developed poor physical abilities and self-concept. Equally disheartening was the cohort of 5th and 6th graders (mean age 10.8 years) who reported experiencing high levels of body dissatisfaction [ 10 ]. Low body image correlated positively with physical activity, but, when the girls with low body image were criticized for their weight, their participation decreased [ 10 ].

Adolescent athletes (ages 12 and older)

During the adolescent years, the ability to perform object control skills (catching, throwing, kicking) relates to athletes’ perceptions of their athletic competence [ 24 ]. Actual competence is needed for perceived competence, which is the factor affecting participation in physical activity [ 24 ]. The previous common understanding of sports attrition is the positive relationship between motor competence and physical activity across childhood [ 4 ]. But results have shown, especially in adolescents, perception of skills may be lower than actual skills [ 11 , 20 ]. In a cohort of 12- to 16-year-old male soccer players (mean = 14.5), low perceived competence directly affected dropout from soccer, whether or not the adolescents felt that soccer was important [ 21 ].

In adolescence, body image, teasing, and gender identification issues become significant determinants of continuation of physical activity, more so than actual skill [ 2 , 20 ]. Motor competence is both a precursor and a consequence of weight status and demonstrates an inverse relationship across childhood and adolescence with BMI [ 4 ]. Fitness levels and BMI often display a negative inverse association [ 4 , 11 ]. Subjects also report body dissatisfaction and poor body image as major determinants in enjoyment and fitness levels [ 2 , 9 , 18 , 20 , 28 ]. Hausenblas et al. [ 20 ] discovered body dissatisfaction was a greater deterrent of physical activity than BMI. Children also had poor body image concerns with a healthy BMI, but a higher BMI did relate to lower body image [ 20 ].

Adolescents are teased about their weight and coordination [ 2 ]. They are also becoming aware of societal pressure to measure up to magazine pictures or elite athletes in their sport [ 9 ]. During this time, self-perceptions appear to deviate from skill. Even the most unsuspecting athletes, like the premenstrual female figure skaters who still maintain an ideal body type, become inappropriately sensitive and negative toward themselves [ 23 ]. The more frequently girls observed images in fashion magazines, the more dissatisfied they were with their own body [ 9 ]. In the case of magazines, girls were more inclined to lose weight, go on a diet, exercise to lose weight, improve their body shape, or exercise because of an article [ 9 ]. Gym attendance appears to negatively affect their perception of themselves as does gaining weight [ 2 , 18 ]. Their perceptions are lower than their skills, and this results in them opting out of physical activity because they perceive they are not as competent as their peers [ 11 , 20 ]. If we are able to keep this population in sports until they are slightly older children and adolescents, then physical activity and weight positively correlate again [ 11 ]. Evidence reveals that educational fitness programs, where children learn about the effects of physical activity, can improve perceived and actual fitness levels in young people [ 6 ].

Gender identification

At a very early age, sports participation differs between boys and girls depending on previous injury. Previously injured boys are more likely to continue participation compared with previously injured girls who are more likely to drop out [ 12 ]. This may be connected to boys being viewed as tougher and can “take a hit,” whereas parents are more protective of injured girls [ 12 ].

Pubertal development is linked with adolescents’ perceived physical self-concept, and boys and girls experience a different degree of physical self-concept depending on the type of sport in which they participate [ 19 ]. Girls more frequently felt that people were staring at them during physical activity. Girls are more likely to report being made fun of or laughed at because of how they looked [ 2 ]. They are concerned that a sport may make them less feminine or too feminine [ 2 ]. Girls also experienced more teasing for being uncoordinated and being called names because of their weight than boys [ 2 ]. Especially during adolescence, girls experience body dissatisfaction and express a desire to be thinner [ 2 ]. This body dissatisfaction affects the propensity to participate in sports and other physical activities [ 2 , 11 ].

Interestingly enough, there was a link between social stereotypes of gender and sports participation. Both boys and girls who participated in more cross-gendered sports (boys in ballet and girls in football), in addition to gender-typed sports, have an improved body image and self-concept than those who only participate in gender-typed sports [ 19 ]. Particularly in girls, those who participated in skateboarding and rollerblading had an improved sense of self [ 19 ].

The literature supports the hypothesis that body image and perceived competence act as mediators for physical activity in older children and adolescents. The results of this study suggest participants’ positive perception of their physical competence and image positively correlates with participation in physical activity. Perceiving they are not good enough, or not as good as they hoped, or lacking skill improvement was strongly linked to their discontinuation of physical activity [ 8 ]. The model conceived by Harter [ 26 ] in 1978 is supported: children who perceive competence and have high self-esteem are more likely to participate. Most remarkable was that the participants’ perceptions of competence predicted the extent to which they valued the activity, despite actual competence not being measured [ 8 ]. Strategies to enhance physical self-perceptions in children and adolescents may assist in efforts to promote physical activity [ 6 ]. Sports attrition appears to be moderately associated with fitness and at higher physical activity levels was associated with higher levels of general physical self-concept [ 6 ]. The astonishing phenomenon identified by this research was the age at onset of negative body image [ 18 ].

Children start to perceive competence as early as 6 years of age. Age 5 years may be the window of opportunity to improve acquisition of fundamental movement skills: object control particularly and locomotor skills [ 13 , 14 ]. Evidence has shown that interventions to increase physical activity early in school years are effective in the development of motor skills even at a young age [ 29 ]. Five years of age or starting in preschool is the prime time for improving children’s skill competence because children at this age view themselves as more competent than they are capable [ 14 ]. They are not able to accurately view their competence, and their skill levels are relatively equal between males and females. Greater exposure to activities in youth has been shown to lead to greater sports participation in children [ 6 , 24 ]. The key to improving youth sports participation may be capitalization on this time frame in children’s lives when they have an inflated self-perception. By exposing children to a wide variety of fundamental movement skills and by spending a longer duration of time on the development of physical literacy, children may perceive their abilities as higher later in life. Also, previous physical activity appears to have more influence on children’s perceptions than current physical activity [ 13 ]. Therefore, if the initiation of physical activity begins when children are less self-conscious, their success rate might be higher later in life. Understanding the effects of age on participation in physical activity can have profound effects later in these children’s lives. 

Fundamental movement skill ability in older children and adolescents is positively associated with engagement in physical activity [ 24 ]. A positive relationship exists between competence, physical activity, weight, strength, and endurance [ 4 ]. In older children, the relationship between object control skill and physical activity becomes more important. Movement skill interventions are effective, and it is likely that their benefits can be sustained. There is opportunity to improve children’s fitness by improving their perceptions of sports competence, especially targeting object control skills [ 24 ]. Interventions at a young age appear to have a “flow-on effect” on physical activity later in childhood. Children who are more proficient in object control are more likely to become active adolescents [ 30 ]. There is evidence that intervention at a young age can produce significant and meaningful improvements in motor skill acquisition and positively influence perceptions of competence and self-esteem [ 14 ].

Perceived competence plays an even greater role in motivation for physical activity, possibly more so than actual competence, as children age into adolescence [ 21 ]. Interventions that stressed motor skill activity appear to be the best for improving perceived competence and enjoyment in physical activity [ 31 ]. There is opportunity for the reintegration of adolescents into physical activity. Educational programs and strength-based weight training have been effective at promoting a healthier body image and increasing physical activity in adolescents [ 27 ]. Exercise programs based on fundamental movement skills and motor coordination skills are the most effective in improving desire to participate in physical activity in the overweight and obese youth population [ 31 ]. Coaches play an important role in young players’ participation by fostering an individual mastery climate among their teams [ 5 , 21 ]. Better understanding of the needs of these adolescents may not only provide them better care and programs but may improve the success of those programs available.

Limitations in identifying all references because of synonyms used for the searchable items were challenged by including those synonyms in searches. Bias toward articles that provided novel information may have minimized the appearance of how many articles support the effect of BMI on participation in physical activity. Further research is needed on what forms of physical activity, object control versus locomotor skills, for example, are recommended during the “window of opportunity” to improve development of physical literacy. 

Conclusions

Literature reveals that body image is significantly associated with physical activity in youth. The very young demonstrate an inflated perception of motor skill competence, which may be a valuable window into the acquisition of fundamental movement skills and the eventual development of physical literacy. Actual skill, particularly object control, does correlate with physical activity as children age, but there may be an opportunity to influence perceived competence by promoting physical activity in the very young. There does appear to be success in programs that place emphasis on education and improving body image, decreasing teasing and comparison with others, where children are able to succeed and personally improve. These programs may assist in the reintegration of adolescents into physical activity.

The content published in Cureus is the result of clinical experience and/or research by independent individuals or organizations. Cureus is not responsible for the scientific accuracy or reliability of data or conclusions published herein. All content published within Cureus is intended only for educational, research and reference purposes. Additionally, articles published within Cureus should not be deemed a suitable substitute for the advice of a qualified health care professional. Do not disregard or avoid professional medical advice due to content published within Cureus.

The authors have declared that no competing interests exist.