The Triple Burden of Malnutrition Among Adolescents in Indonesia

Food and Nutrition Bulletin

2021, Vol. 42(1S) S109-S121
ª The Author(s) 2020
The Association of Body Image Article reuse guidelines:
sagepub.com/journals-permissions
Perception With Dietary and DOI: 10.1177/0379572120977452
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Physical Activity Behaviors

Among Adolescents in Indonesia

Ilyatun Niswah, MSc1, Jee Hyun Rah, PhD2, and

Airin Roshita, PhD2

Abstract
Background: Growing evidence highlights the linkage between body image, eating, and exercise
behaviors among adolescents.
Objective: This study aims to determine the association between body image perception, nutritional
status, and dietary and physical activity behaviors among adolescents in Indonesia.
Methods: A cross-sectional household survey was conducted among a representative sample
(n ¼ 2160) of adolescent girls and boys aged 12 to 18 years in Klaten and Lombok Barat districts. The
association between adolescents’ body image, their diets, and physical activity patterns was deter-
mined using complex samples Cox’s regression analysis. Separate multivariate models were developed
for adolescent girls and boys.
Results: Physical appearance was considered important to nearly all adolescents. Approximately
11% of girls and 14% of boys were overweight or obese, the majority of whom (*70%) correctly
perceived themselves as overweight or obese. More of overweight or obese adolescents felt unhappy
about their perceived weight than their thin counterparts. With respect to the overweight/obese girls,
the adolescents’ perceptions of being overweight or obese was associated with a 63% reduction in the
prevalence of overweight/obese girls consuming fatty snacks, such as deep-fried crackers (adjusted
prevalence ratio (PR): 0.37, 95% confidence interval (CI): 0.19-0.71) and a 40% reduction in the
prevalence of overweight/obese girls engaging in moderate-intensity physical activity (adjusted PR:
0.60, 95% CI: 0.38-0.94), after adjusting for potential confounders. No association between body image
and eating and physical activity behaviors was observed among adolescent boys.
Conclusions: Body image may be one of the most important determinants of dietary and physical
activity behaviors, and thus future efforts to foster healthy eating and physical activity behaviors among
Indonesian adolescents need to address body image concerns.

Keywords
adolescents, nutritional status, body image, dietary behavior, physical activity

1
Division of Human Nutrition and Health, Wageningen University and Research, Wageningen, the Netherlands
2
UNICEF Indonesia, Jakarta, Indonesia

Corresponding Author:
Jee Hyun Rah, UNICEF Indonesia, World Trade Center 6 (10th Floor), Jalan Jenderal Sudirman Kav. 31, Jakarta 12920, Indonesia.
Email: jhrah@unicef.org
S110
Introduction
The double burden of malnutrition, characterized
by the coexistence of undernutrition and over-
weight and obesity, is a global public health con-
cern which affects all countries and age groups.1
Adolescents in low- and middle-income countries
are among the hardest hit, and an important target
group for early interventions. In Indonesia, 11% of
adolescent girls and boys aged 13 to 15 years were
estimated to be thin in 2013, while a further 11% of
adolescents of the same age were overweight or
obese. 2 Changes in dietary intake patterns,
coupled with the decrease in physical activity
associated with industrialization and urbanization,
are known to have contributed to an increased pre-
valence of overweight and obesity and related
noncommunicable disease, whereas the problem
of undernutrition remains undefeated.
Adolescence is a period of rapid growth and
development, accompanied by prominent psy-
chosocial and emotional changes. 1 Various
health-related behaviors, including food intake
and physical activity, are developed during ado-
lescence and carry over into adulthood, with
major implications for health prospects.3 Nota-
bly, body image perceptions formed during the
early life course contribute to nutritional status,
and body size and shape at a later life-stage,
which, in turn, influence a range of physiological
and psychological outcomes.4,5
Body image is a multidimensional construct,
which reflects an individual’s perception,
thoughts, feelings, and behaviors about the size,
shape, and structure of his or her body.6 It is a
dynamic perception, which can change according
to mood, physical experience, and the environ-
ment. 4 Most adolescents develop their body
image perception due to the influence of their
peers, parents, and the media, as well as wider
social perceptions of what constitutes an ideal
body type.7,8 Their personal (physical and phy-
siological changes during puberty), cultural,
and environmental factors may also influence
their perceptions. Body image is also highly
gender-influenced, with girls and boys expressing
different body image perceptions,9,10 such as the
perception that girls should be slim and boys
should be muscular.8
Food and Nutrition Bulletin 42(1S)
Evidence is conflicting on whether accurate
body image perception (perception relative to
anthropometric norms) has adverse or positive
consequences on adolescents’ health-related
behavior. Research has shown that concerns
about being overweight or obese have the poten-
tial to lead to eating disorders, excessive exercise,
depression, and other unhealthy weight manage-
ment.11,12 Conversely, overweight adolescents
who accurately perceive their body weight were
reported to engage in healthy weight-related
behavior compared to their counterparts. 13
Importantly, much of the existing evidence on
adolescents’ perception of their body weight and
shape, and its influence on their dietary intake
and physical activity, has been generated by
high-income countries.14-17 Given the epidemio-
logic transition and emerging burden of obesity
and noncommunicable disease in low- and
middle-income countries, additional evidence
from these contexts is essential for informing
public health interventions.
This study aims to describe body image per-
ceptions among Indonesian adolescent girls and
boys in relation to their actual nutritional status
and to examine associations with diet and physi-
cal activity behaviors. The findings will have
implications for the design, planning, and imple-
mentation of localized gender-responsive inter-
vention strategies.
Methods
Study Design and Participants
A cross-sectional household survey was con-
ducted across all subdistricts in Klaten district
in Central Java province and Lombok Barat dis-
trict in West Nusa Tenggara province between
April and May 2017. The 2 districts were selected
in consultation with the national and subnational
government and having taken into account differ-
ences in cultural context, infrastructure, and ado-
lescent nutritional status. The survey was
administered among a representative sample of
adolescent girls and boys aged 12 to 18 years and
their parents or guardians, as appropriate. The
survey sample (n ¼ 2160) was obtained using a
multistage cluster sampling strategy powered to
Niswah et al
detect a 7.5% difference in key physical activity
and dietary behaviors between boys and girls and
between the 2 districts. A probability proportion-
ate to size sampling strategy was first employed
to select 45 clusters in each district to ensure that
more clusters were selected in subdistricts with
more villages. Subsequently, at least 12 girls and
12 boys aged 12 to 18 years were selected from
each cluster in one or more subvillages using
simple random sampling. If there were more than
12 adolescents of either sex in a cluster, we
selected 12 using simple random sampling. If
there were less than 12 boys and 12 girls, a second
or potentially a third subvillage were randomly
selected to obtain the required sample size. Only
one adolescent from each household was
included in the sample. The methods has been
described elsewhere.18
The study excluded those refusing an inter-
view or anthropometric measurements, those
with any form of mental and/or physical disabil-
ity, and/or those not physically living in the
selected village. Married or pregnant adolescents
were excluded in the analysis. The survey was
approved by the Ethical Committee of Gadjah
Mada University in Yogyakarta, Indonesia. Inter-
views and assessments were only conducted after
written consent was obtained from both the ado-
lescent and the parents/guardian.
Data Collection
Data were collected by 2-person field teams using
standardized digital questionnaires on a mobile
data collection system on Android-based tablets.
All interviews and anthropometric measurements
were conducted in the respondent’s home. Inter-
views were conducted either in Indonesian or the
local language (Javanese/Sasak), separately with
both the parents and adolescents in order to mini-
mize any parental influence on the adolescents’
answers.
Information was collected from adolescents on
their demographic characteristics, education,
morbidity, reproductive health, dietary intake,
physical activity, smoking and alcohol use, and
body image. Specifically, the body image percep-
tion was assessed using a standard questionnaire
developed based on locally adapted validated
S111
tools from other settings, including the Figure
Ranking Scale and Body Shape Questionnaire.
The standard questionnaire inquired about ado-
lescents’ awareness and perception of their body
size and shape, relevant influencing factors, and
efforts being made to improve their body weight.
Dietary intake was determined by using a 7-day
qualitative food frequency questionnaire (FFQ),
for which the list of food items was developed in
line with the food groups used in the Household
Dietary Diversity Score (HDDS). Adolescents
were also questioned about their consumption
frequencies of snacks, fast food, ready-to-eat
meals, sweetened beverages, and fruits. Data on
physical activity were collected using a 7-day
activities frequency table,19 which assessed the
number of days in which each activity was per-
formed, and the average duration of the perfor-
mance of each activity. A wide range of mild,
moderate, and vigorous activities was included
in the questionnaire. In addition, household
sociodemographic characteristics, access to sani-
tation, the source of drinking water, and other
relevant information were collected from the par-
ents and/or guardians of the adolescents.
The adolescent’s height and weight were
assessed following standard procedures. The
height measurement was taken to the nearest
0.1 cm, using a SECA 206 Mechanical Measuring
Tape (Microtoise), and weight was assessed to the
nearest 0.1 kg, using SECA 874 flat digital
weighing scales, which were calibrated regularly.
The height and weight were measured in a dupli-
cate manner. If the differences between the 2 mea-
surements were more than 0.1 cm and 0.2 kg, the
third and fourth measurements were taken.
Hemoglobin concentration was assessed using
HemoCue cuvettes from peripheral blood
obtained from the participants’ fingertip with the
use of a softclix device and lancet. In Klaten,
HemoCue 201þ (HemoCue) was used and in
Lombok Barat, Hemocue 201þ and HemoCue
301þ were used. Efforts were made to obtain the
adolescent’s date of birth from his/her birth
certificate, family/ID card, or other official doc-
uments, to the extent possible. Otherwise, the
adolescent’s self-reported date of birth was used.
The field enumerators were trained according
to the study protocols prior to the survey and were
S112
directly supervised by field coordinators as data
collection proceeded. All data were checked for
measurement bias and underwent stringent qual-
ity control (QC) checks. At least 10% of all
respondents of each enumerator were reinter-
viewed by the QC team on selected indicators.
The QCs were selected from the trained enumera-
tors who scored highest during the training.
Height and weight measurements of 10% partici-
pants were also repeated. The QC team revisited
the respondents within 2 to 7 days of the original
data collection period.
Statistical Analysis
A total of 2144 adolescent girls and boys were
included in the analysis, after the exclusion of
married and pregnant adolescents (n ¼ 16). All
data were double-entered, and appropriate data
cleaning procedures were conducted. Descriptive
analyses were employed to examine the distribu-
tion of the full range of variables. The data were
weighted for probability of selection and adjusted
for the multistage cluster sampling design.
Body mass index (BMI) was defined as the
adolescent’s weight in kilograms divided by
height in meters squared (kg/m2). Z-score of BMI
for age (BMIZ) were estimated using the 2007
World Health Organization (WHO) growth refer-
ence standard. Thinness and overweight or obe-
sity were defined as BMIZ less than 2 and
above 1, respectively.
Appropriate cutoffs were applied to create
dichotomous or categorical variables. Household
wealth quintile was assessed using the principal
component analysis outlined in the Demographic
Health Survey, while household food security
was determined by applying the Household Food
Insecurity Access Scale. Household sanitation
and drinking water sources were dichotomized
into private (private facility with/without a septic
tank) or nonprivate facilities (shared/public
latrine, pit latrine without slab, yard/bush/forest,
river/stream/creek, and others); and improved
(piped water, well with pump, protected well,
protected spring, and rain) or unimproved sources
(unprotected well, unprotected spring, bottled
water, refilled water, river/lake/pond/irrigation/
dam, and others), respectively.
Food and Nutrition Bulletin 42(1S)
The adolescents’ dietary diversity was
assessed following the recommended methodol-
ogy for determining the HDDS. A dichotomous
variable was created to define low and high diet-
ary diversity intake using the following cutoffs:
low (<5 food groups) or high (5 food groups).
Similarly, adolescents were classified into
2 groups, as to whether their daily physical activ-
ity met the recommendations from the WHO or
not (at least 60 minutes of moderate to vigorous
daily physical activity for adolescents aged 12-17
years, and at least 150 minutes of moderate or
75 minutes of vigorous daily physical activity for
18 year-olds).20
Analyses were performed separately for ado-
lescent girls and boys to understand the differ-
ences in their perceptions. First, the adolescent’s
body image perception was compared to their
nutritional status through the use of a w2 test.
No comparison was made for the normal weight
adolescents due to specific interest to understand
the perceptions of thin and overweight or obese
adolescents. Subsequently, among adolescents
who were overweight or obese, the association
between body image perception and their dietary
and physical activity behaviors was determined
using a complex samples w2 test. No analysis on
the above associations were made for the adoles-
cents who were thin due the small numbers of thin
adolescents who misperceived their body weight.
The key binary variables of dietary and physical
activity behaviors were included as the dependent
variable, and body image perception was
included as the independent variable, adjusting
for all potential confounders such as age, educa-
tion, place of residence, and maternal education.
Potential confounders were selected based on
their known association with individual dietary
and physical activity behaviors and were included
in the final regression models if they were signif-
icantly associated with dietary and physical activ-
ity behaviors in the bivariate analyses (P < .05).
Separate regression models were constructed for
each key dietary and physical activity behavior
using complex samples Cox regression with fixed
time effect. All analyses were performed using
the Statistical Package for Social Science Com-
plex Samples module version 24.0 (SPSS Com-
plex Samples, Inc).
Niswah et al
Results
Of the 2144 adolescents included in the analysis,
48% were girls, and about two-thirds (65%) were
living in Klaten district (Table 1). Half the ado-
lescents (51%) lived in food-insecure households.
Most adolescents (94%) were enrolled in school,
and almost all the adolescent girls (89%) had had
their first menstruation at the time of interview.
Approximately 4% and 10% of the adolescent
girls and boys were thin, respectively, whereas
11% and 14% were overweight or obese, respec-
tively. Less than half adolescent girls (46%) and
boys (44%) reported consuming more than 5 food
groups in the past week, and only around
one-third of girls (35%) and boys (37%) met the
daily recommendations for physical activity
(Table 1).
Two-thirds (66%) and slightly more than half
(55%) of adolescent girls and boys, respectively,
knew their current weight (Table 2). About 60%
of adolescent girls and boys perceived themselves
as being thin, whereas 13% considered them-
selves to be overweight or obese. Overall, more
adolescent boys than girls (87% vs 76%, P < .05)
felt either neutral or satisfied with their body
image. Nearly all (96%) adolescents thought
physical appearance was important, and about a
quarter of girls (26%) and boys (27%) reported
feeling under pressure to maintain a certain body
image. More than half of adolescents reported
feeling embarrassed about or lacked confidence
in their body image, whereas only 41% of girls
and 37% of boys reported having made efforts to
change their body weight in the 30 days prior to
data collection (Table 2). Many adolescent girls
(61%) and boys (50%) compared their own body
shape with that of others, including their friends.
Peer groups had the greatest influence on defining
the ideal body shape of adolescents (Table 2).
More overweight and obese girls (57% vs
31%) and boys (34% vs 20%) felt unhappy about
their current body weight than their thin counter-
parts (Table 3). Whereas the majority of thin ado-
lescent girls (92%) and boys (94%) perceived
themselves as being thin, only about two-thirds
of overweight or obese girls (67%) and boys
(70%) perceived themselves as being overweight
or obese. More overweight or obese adolescent
S113
girls (60%) and boys (55%) reported having made
efforts to change their weight than their thin
counterparts (51% and 47%; Table 3).
In a multivariate analysis, overweight or obese
adolescent girls who also perceived themselves as
being overweight or obese were 0.37 times as
likely consuming deep-fried crackers, after adjust-
ing for the mother’s education (prevalence ratio
(PR) ¼ 0.37, 95% CI (Confidence Interval):
0.19-0.71) compared to overweight or obese ado-
lescent girls who perceived themselves as being
normal weight or thin (Table 4). Likewise, over-
weight or obese adolescent girls who also per-
ceived themselves as being overweight or obese
were 0.64 and 0.60 times as likely meeting phys-
ical activity recommendations and engaging in
moderate-intensity physical activity on a daily
basis, respectively, adjusting for district, adoles-
cent’s age, and education compared to overweight
or obese adolescent girls who perceived them-
selves as being normal weight or thin (PR ¼
0.64, 95% CI: 0.21-0.90; PR ¼ 0.60, 95% CI:
0.38-0.94). No association between body image
and eating and physical activity behaviors was
observed among adolescent boys (data not
shown).
Discussion
Few studies have examined the body image per-
ception of adolescent girls and boys in Indonesia
and its association with their nutritional status,
dietary intake, and physical activity. In this
cross-sectional analysis, body image emerged as
an important determinant of dietary and physical
activity behaviors, particularly among adolescent
girls. Specifically, among overweight or obese
adolescent girls, the perception of being over-
weight or obese was associated with a reduction
in the prevalence of overweight or obese adoles-
cent girls consuming certain high-caloric snacks
and reduced the likelihood of meeting daily phys-
ical activity recommendations. Overall, *25% of
adolescent girls and *10% of boys felt unhappy
about their body image, and these proportions
were higher among overweight or obese adoles-
cent girls and boys. Importantly, however, less
than half of Indonesian adolescents reported hav-
ing made efforts to change their body weight.
S114 Food and Nutrition Bulletin 42(1S)

Table 1. Characteristics of Adolescent Girls and Boys Included in the Analysis.a

Background characteristics Girls Boys

N (%) 1067 (48) 1077 (52)

Household characteristics (%)
District
Klaten 65 65
Lombok Barat 35 35
Residence
Urban 49 51
Rural 51 49
Food-insecure householdb 51 51
Parental characteristics (%)
Mother’s educationc
No education 9 9
Primary school 41 42
Junior and/or senior high school 43 41
University or higher 6 7
Mother’s age, year (mean + SD) 42 + 8 43 + 8
Father’s age, year (mean + SD) 46 + 8 47 + 8
Adolescent’s characteristics (%)
Age group
12-14 years 46 45
15-18 years 54 55
Currently enrolled in school 94 94
Educationc
Incomplete primary school 10 10
Primary school 49 53
Junior and/or senior high school 41 37
Has begun menstruation 89 NA
Dietary intake
Dietary diversity (5 food groups)d (%) 46 44
Met Physical Activity recommendationc,e (%) 35 37
Nutritional statusf (%)
Stuntingc 23 19
Thinnessc 4 10
Overweight/obesec 11 14
Anemiac 19 5g
Abbreviations: BMI, body mass index; WHO, World Health Organization; NA, not available.
a
Data are presented as weighted prevalence estimates (%) unless stated otherwise. Different percentages were assessed using
complex sample w2 test.
b
Assessed by Food and Nutrition Technical Assistance (FANTA), 2007 Household Food Insecurity Access Scale (HFIAS) for
Measurement of Food Access: Indicator Guide. Version.
c
Missing values were found for mother’s education (n ¼ 29), adolescent’s education (n ¼ 14) thinness, and overweight (n ¼ 1),
stunting (n ¼ 1), anemia (n ¼ 1), and dietary diversity (n ¼ 1) Recommended physical activity (n ¼ 55).
d
Swindale, Anne, and Paula Bilinsky. 2006. Household Dietary Diversity Score (HDDS) for Measurement of Household Food
Access: Indicator Guide (v.2). Washington, D.C.: FHI 360/FANTA.
e
Physical Activity Recommendation (WHO): 12-17 years: at least 60 minutes of moderate- to vigorous-intensity physical activity
daily; 18 years: is at least 150 minutes of moderate or 75 minutes of vigorous physical activity throughout the week.
f
Indicators of stunting (height-for-age Z-score (HAZ) < 2 SD), thinness (BMI for age z-score < 2), and overweight/obesity
(BMI for age z-score >1) were estimated using the 2007 WHO growth reference. Anemia was defined as hemoglobin level <120
g/L among children 12 to 14 years old, <120 g/L among nonpregnant women (15 years of age), and <110 g/L among men (15
years of age).
g
P < .05.
Niswah et al S115

Table 2. Body Image Perception of Adolescent Girls and Boys Included in the Analysis.a,b

Body image indicators Adolescent girls Adolescent boys

N (%) 1067 (48) 1077 (52)

Know their current weight (%) 66 55c
Feelings about current weight (%)
Unhappy 24 13
Neutral/happy 76 87c
Perception of body image (%)
Thin 60 59
Normal 27 28
Overweight/obese 13 13
Know their height (%) 43 39
Feelings about current height (%)
Unhappy 22 10
Neutral/happy 78 90c
Think appearance is important (%) 96 94
Under pressure to have a certain body shape (%) 26 27
Most influential persond (%)
Adolescents themselves (no influence) 30 27
Friends 42 43
Family 24 24
Others 4 6
Feeling if body shape is not ideal (%)
Don’t care 22 26
Feeling lack of confidence and/or embarrassed 55 50
Motivated to do sports and control diet, live healthily 5 5
Unhappy/sad/disappointed 16 17
Others 2 3
Compare body shape with others (%) 61 50c
Compare with whome (%)
Friends 95 94
Family 3 5
Public figure and others 2 1
Most influence on ideal body image (%)
Friends 61 49
Media and public figure 6 11
Family 12 15
Adolescents themselves (no influence) 19 22
Teachers 2 3c
Make efforts to change body weight (%) 41 37
What efforts (%)
Reduce meal only or with sports 41 22
Sports 18 39
Increase meal only or with sports 32 35
Others 9 5c
a
Missing values were found for all variables (n ¼ 2), for feeling if body shape is not ideal, answers don’t know were considered as
missing values (n ¼ 35).
b
Different percentages were assessed using complex sample w2 test.
c
P < .001.
d
Percentages for the most influential persons were calculated for adolescents who feel under pressure to have a certain body
shape (n ¼ 619).
e
Percentages were calculated within adolescents who compare their body shape (n ¼ 1227).
S116 Food and Nutrition Bulletin 42(1S)

Table 3. Description of Body Image According to the Nutritional Status of Adolescent Girls and Boys in Klaten
and Lombok Barat Districts, Indonesia 2017.a

Nutritional statusb

Adolescent girls Adolescent boys

Overweight/ Normal Overweight/ Normal

Thin obese Stunted height Thin obese Stunted height

Body image indicators n ¼ 54 n ¼ 116 n ¼ 261 n ¼ 806 n ¼ 120 n ¼ 124 n ¼ 227 n ¼ 849

Know their current 58 59 – – 53 68c – –

weight (%)
Feelings about current
weight (%)
Unhappy 31 57 – – 20 34 – –
Neutral/happy 69 43d – – 80 66d – –
Perception of body
image relative to
actual nutritional
status (%)
Thin 92 8 – – 94 6 – –
Normal 7 25 – – 5 24 – –
Overweight/obese 1 67d – – 1 70d – –
Know their current – – 36 45c – – 32 41c
height (%)
Feelings about current
height (%)
Unhappy – – 45 15 – – 25 7
Neutral/happy – – 55 85d – – 75 93d
Make effort to change 51 60d – – 47 55d – –
body weight (%)
Self-reported efforts (%)
Reduce meal only or 11 77 – – 6 42 – –
with sports
Sports 3 15 – – 20 57 – –
Increase meal only or 79 2 – – 60 0 – –
with sports
Others 8 6 – – 17 1 – –
Abbreviation: WHO, World Health Organization.
a
Different percentages were assessed using complex sample w2 test.
b
Indicators of stunting (height-for-age Z-score (HAZ) < 2 SD), thinness (BMI for age z-score < -2), and overweight/obesity
(BMI for age z-score >1) were estimated using the 2007 WHO growth reference.
c
P < .05.
d
P < .001.

In this study, physical appearance was consid-
ered to be important by nearly all adolescent girls
and boys, and 1 in 4 adolescents felt under pres-
sure to have their perceived ideal body image
which described as slim for girls and muscular
for boys.21 More than half of adolescents reported
comparing their body weight and shape with that
of their friends. These findings are supported by
evidence highlighting the perceived importance
of physical appearance among adolescents,22-24
and associations with adverse psychological con-
sequences, including sadness, lack of confidence,
and even depression.25,26 Adolescents’ excessive
concerns about their physical appearance have
 Table 4. Univariate and Multivariate Analysis of the Association Between Sociodemographic Characteristics, Body Image Perception, and Snack Consumption and Physical
Activity Behavior Among Overweight/Obese Adolescent Girls.a
Adolescent girls

n ¼ 116

Deep-fried crackers Met physical activity requirement Moderate physical activity, (60 minutes/day)

Unadjusted Adjusted Unadjusted Adjusted Unadjusted Adjusted

Background characteristics Prevalence Ratio (PR) (95% CI)

Household characteristics
District
Klaten 1.00 1.00 1.00 1.00
Lombok Barat 1.77 (0.88-3.55) 3.18 (1.45-6.97)b 2.86 (1.37-5.94)b 1.12 (0.68-1.84)
Parental characteristics
Mother’s education
No education 1.00 1.00 1.00 1.00
Primary school 0.35 (0.16-0.77)c 0.33 (0.15-0.72)b 0.43 (0.15-1.23) 1.04 (0.41-2.66)
Junior and/or senior high school 0.22 (0.10-0.50)d 0.22 (0.10-0.49)d 0.40 (0.14-1.11)e 1.02 (0.40-2.56)
University or higher 0.48 (0.09-2.61) 0.72 (0.12-4.22) E 0.66 (0.10-4.24)
Adolescent’s characteristics
Age group
12-14 years 1.00 1.00 1.00 1.00 1.00
15-18 years 0.84 (0.40-1.75) 0.16 (0.06-0.41)d 0.17 (0.04-0.64)b 1.79 (1.04-3.08)c 1.78 (1.05-3.00)c
Currently enrolled in school
Yes 1.00 1.00 1.00 1.00
No 1.75 (0.53-5.82) 1.07 (0.21-5.38) 2.05 (1.26-3.34)b 1.41 (0.75-2.66)
Education
Incomplete primary school 1.00 1.00 1.00 1.00
Primary school 1.40 (0.31-6.36) 0.42 (0.12-1.47) 0.56 (0.24-1.32) 0.91 (0.26-3.53)
Junior and/or senior high school 0.85 (0.18-4.07) 0.11 (0.03-0.50)b 0.64 (0.09-4.36) 1.01 (0.29-3.53)
Body image perception
Perceived thin/normal 1.00 1.00 1.00 1.00 1.00 1.00
Perceived overweight/obese 0.40 (0.20-0.82)c 0.37 (0.19-0.71)b 0.33 (0.16-0.69)b 0.44 (0.21-0.90)c 0.61 (0.38-0.97)c 0.60 (0.38-0.94)c
a
Prevalence ratio was obtained from Cox Regression with a fixed time effect, with the level of significance P < .05.
b
.001  P < .01.
c
.01  P < .05.
d
P < .001.
e
.05  P < .10.

S117
S118
also led to various eating disorders and distur-
bances,27-29 which are hazardous to their growth
and development.
Nutritional status is a well-accepted determi-
nant of body image perception.30-32 More over-
weight or obese adolescent girls and boys in this
study were found to be dissatisfied with their
body image than their thin counterparts. Notably,
while most of the thin adolescents correctly
perceived themselves to be thin, only about
two-thirds of overweight or obese girls and boys
perceived themselves to be overweight or obese.
Comparable results were reported from a previ-
ous study conducted in South Korea, in which
64% and 59% of overweight adolescent girls and
boys, respectively, correctly perceived their body
weight.25
Body weight perception has been suggested as
a predictor of food choice.33 In the current study,
overweight or obesity self-perception was associ-
ated with a reduction in the prevalence of over-
weight or obese adolescent girls consuming
certain fatty snacks, such as deep-fried crackers,
indicating that the overweight or obese girls who
perceived themselves accordingly were more
likely to restrict unhealthy food intake. This cor-
roborates previous research, including a study on
Slovak adolescents aged 13 to 15 years, which
reported that adolescent girls who perceived
themselves to be fat were eating less fatty
foods.15,34 However, we did not find an associa-
tion between body weight perception and intake
of fruits and vegetables, indicating that having a
corresponding body weight perception and nutri-
tional status among overweight and obese adoles-
cents may contribute to a reduced intake of
unhealthy foods but may not necessarily promote
healthy eating.
Our results also indicated that perception of
overweight or obesity was associated with a
reduction in the prevalence of overweight or
obese adolescent girls engaging in moderate-
intensity physical activity, especially among
those adolescent girls who were truly overweight
or obese. This is consistent with previous research
suggesting that overweight or obese girls who
perceived themselves as such, had higher social
physique anxiety scores, and were less confident
about performing physical activities in a public
Food and Nutrition Bulletin 42(1S)
setting.34,35 A few studies also revealed that there
were several perceived barriers to performing
physical activity among adolescent girls, such
as feeling lazy, a lack of time, no partner, men-
struation, and concerns about physical appear-
ance.36,37 Thus, overall, our findings correspond
with earlier research, which revealed that, despite
having strong intentions to lose weight, over-
weight adolescents who perceived themselves
accordingly did not improve their eating or phys-
ical activity behaviors. Other research also
showed that these adolescents engaged in unsafe
and health-compromising weight loss behaviors,
such as fasting, meal skipping, taking diet pills,
and vomiting.16,38,39
Importantly, our findings highlighted the
gender differences across various aspects of body
image perception. Overall, more girls than boys
knew their weight and height and were dissatisfied
with their body size and shape. Perceived body
image was only associated with eating and exer-
cise behaviors in overweight or obese girls and not
in boys. This is not surprising, as previous research
has consistently shown that females tend to per-
ceive a negative body image more frequently than
men40-42 and want to have a slim body in order to
conform to the social ideals shaped through the
media and by their peers.43 Earlier qualitative
research conducted in these same districts sug-
gested that girls were generally less motivated to
perform physical activity because they did not
want to get sweaty. There was also a perception
that “sports are not a girl’s thing,” which lessened
the motivation to perform physical activity. These
findings highlight the need to apply a strong gen-
der dimension for interventions aiming to improve
body image perception, nutritional status, diet, and
physical activity.
A few limitations need to be considered. First,
the body image assessment tool was adapted and
pretested in local settings, but future efforts are
needed to validate the findings with a more robust
assessment tool. Second, this was a cross-sectional
analysis, which limits causal inferences. Third, the
use of a qualitative FFQ in the current study lim-
ited our ability to accurately assess the total
amount of food intake. Fourth, the out of school
adolescents may be underrepresented in this study
due to response bias related to their consent to
Niswah et al
participate in the study. Nonetheless, we believe
this study adds significantly to existing knowledge
on adolescents’ body perception, and its associa-
tion with their nutritional status, dietary intake,
and physical activity, a neglected area of research
in Indonesia.
In conclusion, body image perception may be
an important predictor of eating and physical
activity behaviors among adolescents in Indone-
sia, and this association may be influenced by the
gender and nutritional status of adolescents.
However, the extent to which adolescents’ body
image perceptions trigger their intention
to change body size and shape, make healthier
food choices, and increase their physical activity
level deserves further investigation. In an
emerging middle-income country setting such
as Indonesia, obesity prevalence is rapidly
increasing among adolescents, and thus effective
gender-responsive social and behavior change
communication strategies are warranted to pro-
mote a healthy lifestyle. Various efforts, such as
establishing a peer education group and counsel-
ing sessions, may be needed to promote a more
positive body image perception among adoles-
cent girls and boys. Importantly, these interven-
tions need to incorporate the influence of body
image perception.
Acknowledgments
The authors wish to thank Harriet Torlesse for her con-
tributions to the study design, Damayanti Soekarjo,
Julia Suryantan, and Asrinisa Rachmadewi for their
support with data collection, Doddy Izwardy and Dyah
Yuniar Setyawati for their support and leadership in
relation to the adolescent nutrition pilot project, and
Paul Pronyk for his insightful comments on the
manuscript.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest
with respect to the research, authorship, and/or publi-
cation of this article.
Funding
The author(s) disclosed receipt of the following finan-
cial support for the research, authorship, and/or publi-
cation of this article: The study was funded by The
Government of Canada, the Canadian UNICEF Com-
mittee, and the 25th Team for the “Addressing MNCH
S119
gaps to create scalable investments for the future” proj-
ect implemented by the UNICEF Indonesia Country
Office and the Ministry of Health Republic Indonesia.
ORCID iD
Airin Roshita https://orcid.org/0000-0003-0118-
7893
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