Psychological well-being in adolescents with

excess weight
MAUNO MÄKINEN, NINA LINDBERG, ERKKI KOMULAINEN,
LEENA-RIITTA PUUKKO-VIERTOMIES, VEIKKO AALBERG, MAURI MARTTUNEN

Mäkinen M, Lindberg N, Komulainen E, Puukko-Viertomies L-R, Aalberg V, Marttunen M.

Psychological well-being in adolescents with excess weight. Nord J Psychiatry 2015;
69:354–363.

Background: Self-esteem, perceived health, weight satisfaction, eating habits, physical activity,
friendships, intimate relationships, smoking and substance use habits can be regarded as
important correlates of psychological well-being in adolescence. Aim: The present study aimed
to determine whether problems in the above-mentioned elements of psychological well-being
were more prevalent among mid-adolescent pupils with excess weight than among their healthy-
weight peers. Methods: The study participants comprised 178 adolescents with excess weight
and 1087 healthy-weight peers with a mean age of 14.7 years attending the 8th grade at
secondary school. The Rosenberg Self-Esteem Scale, the Eating Disorder Inventory and a
questionnaire assessing health- and food-related attitudes and habits were used. Results: The
adolescents with excess weight more often reported weight dissatisfaction, abnormal eating
habits and signs of eating disorder pathology than those with healthy weight. No significant
difference in self-esteem was observed between weight groups. The proportion of adolescents
who were non-smokers, did not use alcohol and had one or more close friends did not differ
between those with excess and healthy weight. However, a lower proportion of excess-weight
adolescents had dating experience. Inadequate physical activity was highly prevalent among
adolescents in both weight groups. Conclusions: Despite the high prevalence of eating pathology
and weight dissatisfaction, most mid-adolescent pupils with excess weight expressed good
psychological health. Targeted psychological interventions should be offered to some adolescents
with overweight problems.
• Adolescents, Dating, Disordered eating, Excess weight, Psychological well-being, Self-esteem.

Mauno Mäkinen, M.D., Department of Psychiatry, Division of Adolescent Psychiatry, Helsinki

University Central Hospital, PO Box 640, 00029 HUS, University of Helsinki, Helsinki,
Finland, E-mail: mauno.makinen@helsinki.fi; Accepted 3 November 2014.

Excess weight has become a global epidemic, affecting
youngsters of all ethnic and socio-economic backgrounds.
While the physical and financial consequences of this
development are well documented, less research has been
conducted on the emotional correlates of excess weight
in adolescents, even though they represent the most prev-
alent co-morbidities associated with obesity (1). Among
adults, there is some evidence that subjective well-being
variables influence success in weight loss (2), and a
greater focus on these variables should be considered in
both obesity prevention and weight management pro-
grammes (3).
According to Ryff (4), psychological well-being can
be regarded as positive psychological health, which
includes positive evaluations of oneself and one’s past
life, a sense of continued growth and development as
a person, the belief that one’s life is purposeful and
meaningful, the possession of quality relations with oth-
ers, the capacity effectively to manage one’s life and
surrounding world, and a sense of self-determination.
Because this model is highly theoretical, most clinical
studies have focused on various correlates and risk fac-
tors of psychological well-being. This is also the case
among adolescents with excess weight.
Overweight is linked to dietary restraint and body dis-
satisfaction, leading to low self-esteem, described as an
unfavourable attitude towards oneself (5, 6). Obese ado-
lescents with low levels of self-esteem show high levels
of sadness and anxiety and are more susceptible to
engaging in risky behaviours (7). Moreover, excess
weight in adolescence is associated with physical inac-
tivity (8) and a poor quality of life (9). Overweight
adolescents are socially marginalized, and such isolation
is suggested to aggravate the social and emotional

© 2014 Informa Healthcare DOI: 10.3109/08039488.2014.986194


consequences of overweight in this age group (10). Ado-
lescents with excess weight are at greater risk of mis-
treatment by peers, and they have fewer friends as well
as opportunities to develop intimate romantic relation-
ships (10, 11). Disordered eating is prevalent among
overweight adolescents, and a high level of eating disor-
der pathology has been acknowledged as a predictor for
a poor prognosis and increasing weight gain (12). Over-
weight youths perceive their health as only fair or poor
and express weight-specific concerns, as well as engag-
ing in behaviours such as chronic dieting and binge eat-
ing more frequently than non-overweight youths (13).
Impairment of quality of life among persons with excess
weight is increased by the presence of an eating disorder
(14). Adolescents initiate smoking for diverse reasons,
but smoking for weight control is prevalent (15). In par-
ticular, adolescent smokers who perceive themselves as
overweight often report smoking as a weight control
method (16). The caloric value of alcohol is high, and a
positive association between alcohol intake and body
weight has been reported (17).
On the other hand, research on adolescent commu-
nity samples has suggested that despite moderate levels
of body dissatisfaction, few adolescents with excess
weight show low self-esteem and report poor emotional
or social functioning (18). According to a recent study
by Dingemans and van Furth (19), the severity of eat-
ing psychopathology did not appear to be related to
the body mass index (BMI). Furthermore, findings
from a large community survey demonstrated no asso-
ciation of high BMI with eating disorders (20). Neu-
mark-Sztainer et al. (13) noted that substance abuse
behaviours were equally or less prevalent among the
adolescents with overweight than among those with
healthy weight. In particular, girls with overweight
reported using alcohol less often than those with nor-
mal weight. In summary, previous studies performed
among adolescents with excess weight have reported
highly contradictory results, most probably reflecting
both methodological differences and the heterogeneity
of the study populations.
Among adults, there is some evidence that subjective
well-being variables influence success in weight loss (2)
and a greater focus on these variables in both obesity
prevention and weight management programmes has
been demanded (3). Moreover, among adolescents, emo-
tional correlates of excess weight are important to assess
in order to identify individually appropriate interventions
that could enhance adolescent well-being (21). The
results might also shed light on the important question
of what types of psychological interventions should be
included in weight management programmes directed to
adolescents. Previous studies suggest that problems might
exist in the areas of self-esteem, eating habits, physical
activity, friendships, intimate relationships and substance
NORD J PSYCHIATRY·VOL 69 NO 5·2015
PSYCHOLOGICAL WELL-BEING IN EXCESS-WEIGHT ADOLESCENTS
use habits. However, earlier research focusing on the
psychological well-being of overweight and obese ado-
lescents has been characterized by highly contradictory
results, and further research is needed.
Aim
The principal aim of the present study was to determine
whether problems in the above-mentioned elements of
psychological well-being were more prevalent among
mid-adolescent pupils with excess weight than among
their healthy-weight peers. Furthermore, as gender-spe-
cific differences are known to exist in these variables
(22–24), we aimed to analyse the data separately for girls
and boys.
Patients and methods
Participants
The participants of this cross-sectional study were ado-
lescent girls and boys attending the 8th grade at 24 sec-
ondary schools in the city of Helsinki, Finland, in 2003
and 2004 (25). Although the general population is rela-
tively homogeneous in Helsinki, the schools were
selected in order to cover all the representative socio-
economic groups across the city districts. All participants
attended ordinary education programmes and spoke
Finnish as their mother tongue. Of the 2286 pupils, 1370
agreed to participate in the study, the overall participa-
tion rate being 61.5% for girls and 58.6% for boys. The
mean age (⫾ standard deviation) of the participants was
14.5 ⫾ 0.3 years.
Weights and heights
School nurses measured the body weight and height of
the participants. The pupils also reported their subjec-
tive body weights and heights. This information was
used in analyses in cases where measurements by school
nurses were lacking (n ⫽ 50, 4.0%). BMI was used to
reflect the degree of excess body weight. The respective
cut-off points of 25 and 30 kg/m2 for overweight and
obesity commonly used for adults were substituted with
the international lower cut-off points of BMI percentiles
for adolescents (26). For girls, the cut-off points were
23.66 kg/m2 for overweight and 28.87 kg/m2 for obe-
sity, and for boys the respective cut-offs were 22.96 and
27.98 kg/m2. In addition, the ⬍ 5th percentile of the ref-
erences curves for Finnish children was used as a cut-
off point for being underweight in the study (27). After
excluding adolescents with underweight (n ⫽ 56) and
those with missing values (n ⫽ 49), the sample com-
prised 33 obese, 145 overweight and 1087 healthy
weight adolescents. Obese and overweight adolescents
were combined to form a group of adolescents with
excess weight (n ⫽ 178).
355
M MÄKINEN ET AL.
Self-assessments
Self-esteem
Self-esteem was measured using the Rosenberg Self-
Esteem Scale (RSES) (28). The scale comprises 10
self-appraisal statements. Each statement has four sepa-
rate response options, with higher scores reflecting a
greater level of self-esteem. A sum score below 21 indi-
cates low self-esteem (29). The RSES has been widely
used in measuring self-esteem among adolescents, and
its reliability and validity are well documented (30). In
the present study, the internal consistency was accept-
able for both sexes (Cronbach’s alpha 0.86 for girls and
0.79 for boys).
EATING DISORDER SYMPTOMS
The Eating Disorder Inventory (EDI) was used to mea-
sure subjective eating disorder pathology (31). The EDI
has 64 items scored on a 6-point Likert scale, with
response options ranging from “always” to “never”.
Responses for each item are coded from zero to three,
with scores of 3 and 0 respectively assigned to the three
responses farthest in the “symptomatic” and “non-symp-
tomatic” directions. Above the recognized cut-off sum
score of 42, respondents are regarded as being suscepti-
ble to a clinical disorder (32). In the present study,
the internal consistency was acceptable for both sexes
(Cronbach’s alpha 0.81 for girls and 0.74 for boys).
HEALTH- AND FOOD-RELATED ATTITUDES AND HABITS
Questions related to the participants’ health- and food-
related attitudes and habits were adopted from the
Finnish School Health Promotion Study, a nationwide
school survey carried out biannually in Finnish com-
prehensive schools (33, 34), and from a large Finnish
twin study (35).
Eating habits were assessed with the question: “Which
of the following options best describes you?” The
response options were: “It’s easy for me to eat approxi-
mately the amount I need”; “I quite often eat more than
I actually need”; “I often try to restrict my eating”; and
“Occasionally, I’m on a strict diet or I overeat”.
Attending school lunch was assessed with response
options: “I eat school lunch”; “I eat, but only bread,
milk and/or salad”; and “I eat no school lunch”. In the
further analysis, the first two options were categorized as
attending school lunch.
Attending an evening meal was assessed with the
response options: “I eat an evening meal with my fam-
ily”; “I eat an evening meal without my family”; and “I
eat no evening meal”. In the further analysis, the first
two options were categorized as attending evening meal.
Physical activity was assessed with the question:
“How often do you perform physical activity during your
leisure time?” The options were: “at least once a day”;
“2–6 times a week”; and “once a week or more rarely”.
356
Perceived health was rated with the response options:
“My health is excellent/good/average/poor/very poor”. In
the further analysis, the first two options were interpreted
that the subjective feeling of one’s health was good and
the two last options that the subjective feeling of one’s
health was poor.
Weight satisfaction was assessed with the question
“What do you think about your body weight?” The
response options were: “I have considerable excess
weight”; “I have excess weight”; “I am of a desirable
weight”; “I am underweight”; and “I am considerably
underweight”. In the further analysis, the first two
options were categorized as a feeling of having excess
weight and the last two options as a feeling of being
underweight.
Close friends was assessed with the question: “How
many close friends do you have?” The options were: “I
have no close friends”; “I have one close friend”; “I
have two or more close friends”; and “I have several
close friends”. In the further analysis, the last three
options were categorized as having one or more close
friends.
Dating was assessed with the question: “Have you
ever dated?” The response options were: yes/no.
Smoking was assessed with the question: “Do you
smoke?” The options were: I do not smoke”; “I smoke
occasionally”; and “I smoke regularly”. In the further
analysis, the two last options were interpreted as smoking.
Alcohol use was assessed with the following question:
“How often do you drink alcohol?” The options were: “I
do not use alcohol”; “I use alcohol once or twice a
year”; “I use alcohol monthly”; and “I use alcohol
weekly”. In the further analysis, the three last options
were categorized as using alcohol.
Statistical methods
Single missing values were imputed using the expectation
maximization method. The proportions of imputed values
for the RSES, EDI and BMI were 4.1‰, 8.1‰ and 3.2‰,
respectively. An overall chi-squared was calculated, and
when significant, partition chi-squared values were deter-
mined and their effect sizes reported. Fisher’s exact test
was carried out when the expected values were too small
for a chi-squared test. The differences in the continuous
RSES and EDI scales were calculated using the t-test for
independent groups. The findings were considered signifi-
cant when P ⬍ 0.05. The phi coefficient in 2 ⫻ 2 tables
and Cramer’s V in larger tables was used as an effect size
measure for the chi-squared test and Fisher’s exact test,
and eta-squared for the independent samples t-test. The
magnitudes of the phi coefficient and Cramer’s V coeffi-
cient were interpreted as follows: 0.00 to ⬍ 0.10, negligi-
ble association; 0.10 to ⬍ 0.20, weak association; 0.20 to
⬍ 0.40, moderate association; 0.40 to ⬍ 0.60, relatively
strong association; 0.60 to ⬍ 0.80, strong association; and
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 PSYCHOLOGICAL WELL-BEING IN EXCESS-WEIGHT ADOLESCENTS

0.80 to 1.00, very strong association (36). Respectively,
the magnitude of eta-squared was interpreted as follows:
0.00–0.05, small effect; 0.06–0.13, moderate effect; and
0.14–1.00, large effect (37). Multiple binary logistic
regression analysis was performed to examine the extent
to which dichotomized covariates had a partial explana-
tory effect together with BMI (when other regressors were
held constant), and to reveal possible confounding effects.
The role of gender as a moderator was examined by lin-
ear probability model analysis. Moderation occurs when
the relationship between two variables depends on a third
variable, which is referred to as the moderator variable or
simply the moderator (38). The data were analysed using
SPSS for Windows, version 22.0 (39).
Ethical aspects
The Ethics Committee of the Hospital for Children
and Adolescents at Helsinki University Central Hospital,
Helsinki, Finland approved the study.
Results
Self-esteem
The mean RSES total score (⫾ standard deviation) did
not differ significantly between the adolescents with
excess weight (mean ⫽ 29.06 ⫾ 6.03, range 11–40) and
those with healthy weight (mean ⫽ 29.70 ⫾ 5.55, range
11–40) (t ⫽ 1.41, P ⫽ NS). The proportion of participants
scoring below 21 points did not significantly differ
between the groups (Table 1).
Eating disorder pathology
The mean EDI total score differed significantly between
the adolescents with excess weight (mean ⫽ 30.96 ⫾
20.95, range 2–110) and those with healthy weight
(mean ⫽ 22.86 ⫾ 18.24, range 0–139) (t ⫽ ⫺ 4.87, P ⬍
0.001, eta-squared ⫽ 0.02). The proportion of partici-
pants scoring ⬎ 42 points was significantly higher
among adolescents with excess weight than those with
healthy weight (Table 1).
Health- and food-related attitudes and habits
The prevalence of overeating, restrictive eating and alter-
nating restrictive eating/overeating was significantly
higher among excess-weight than healthy-weight adoles-
cents (Table 1). More than 70% of the adolescents
attended school lunch, and almost 90% ate an evening
meal, with no significant difference between the weight
groups in either of these variables. The excess-weight
adolescents more often expressed feelings of being

Table 1. Self-esteem, eating disorder pathology and health- and food-related attitudes and habits in 14–15-year-old girls and boys with
excess and healthy weight attending the 8th grade at secondary school.
Excess weight, Healthy weight,
n ⫽ 178 n ⫽ 1087 Statistics P Effect size

Rosenberg Self-Esteem Scale (RSES) total score ⬍ 21 19/178 (10.7%) 88/1087 (8.1%) 1.31 NS
Eating Disorder Inventory (EDI) total score ⬎ 42 51/178 (28.7%) 138/1087 (12.7%) 30.64 ⬍ 0.001 0.16
Eating habits 49.29 ⬍ 0.001 0.20
Normal eating 86/178 (48.3%) 805/1087 (74.1%) 48.67 ⬍ 0.001 0.20
Overeating 52/178 (29.2%) 154/1087 (14.2%) 25.40 ⬍ 0.001 0.14
Restrictive eating 29/178 (16.3%) 98/1087 (9.0%) 8.97 0.003 0.08
Alternating restrictive eating/overeating 11/178 (6.2%) 30/1087 (2.8%) 5.70 0.017 0.07
Attending school lunch 132/178 (74.2%) 809/1087 (74.4%) 0.01 NS
Attending evening meal 157/178 (88.2%) 950/1087 (87.4%) 0.09 NS
Weight satisfaction 238.54 ⬍ 0.001 0.43
Feeling of having excess weight 128/178 (71.9%) 195/1087 (17.9%) 234.32 ⬍ 0.001 0.43
Feeling of having a desirable weight 49/178 (27.5%) 711/1087 (65.4%) 91.51 ⬍ 0.001 0.27
Feeling of being underweight 1/178 (0.6%) 181/1087 (16.7%) # ⬍ 0.001 0.16
Perceived health 47.98 ⬍ 0.001 0.20
Well 126/178 (70.8%) 974/1087 (89.6%) 47.75 ⬍ 0.001 0.19
Average 46/178 (25.7%) 102/1087 (9.4%) 40.11 ⬍ 0.001 0.18
Poor 6/178 (3.4%) 11/1087 (1.0%) 6.42 0.012 0.07
Physical activity 12.00 0.002 0.10
At least once a day 33/178 (18.5%) 339/1087 (31.2%) 11.79 0.001 0.10
Two–six times a week 115/178 (64.6%) 605/1087 (55.7%) 5.00 0.025 0.06
Once a week or more rarely 30/178 (16.9%) 143/1087 (13.2%) 1.77 NS
One or more close friends 156/178 (87.6%) 957/1087 (88.0%) 0.02 NS
Experience of dating 62/178 (34.8%) 551/1087 (50.7%) 15.40 ⬍ 0.001 0.11
No smoking 153/178 (86.0%) 907/1087 (83.4%) 0.71 NS
No alcohol use 114/178 (64.0%) 652/1087 (60.0%) 1.16 NS

The overall chi-squared test and Fisher’s exact test (#) were used to compare the groups. Partitioning chi-squared was calculated only in tables with
overall significance. The phi coefficient and Cramer’s V were used as the effect size measures. NS, non-significant, P ⬎ 0.05.

NORD J PSYCHIATRY·VOL 69 NO 5·2015 357

M MÄKINEN ET AL.
overweight than those with healthy weight. There was a
significant difference between the groups in perceived
health: the proportion of adolescents perceiving their
health as good was significantly higher among those with
normal weight. Moreover, the prevalence of daily physi-
cal activity was significantly higher among normal-weight
adolescents. Most of the adolescents had one or more
close friends, and no significant differences were recorded
between the weight groups. Experience of dating was
significantly less prevalent among excess-weight than
normal-weight adolescents. Most of the adolescents did
not smoke or use alcohol, and no significant differences
were detected between the weight groups in the frequen-
cies of smoking or drinking alcohol.
Results according to gender
No significant difference was observed between the weight
groups in the mean RSES total score among either girls
(excess weight: mean ⫽ 26.93 ⫾ 6.73, range 11–39; normal
weight: mean ⫽ 28.00 ⫾ 5.81, range 11–40; t ⫽ 1.45, P ⫽ NS)
or boys (excess weight: mean ⫽ 30.53 ⫾ 5.03, range17–40;
normal weight: mean ⫽ 31.38 ⫾ 4.72, range 12–40; t ⫽ 1.67,
P ⫽ NS). Among both girls and boys, the proportion scor-
ing below 21 points did not significantly differ between
excess- and normal-weight groups (Table 2).
The mean EDI total score differed significantly
between weight groups among both girls (excess
weight: mean ⫽ 38.96 ⫾ 23.99, range 2–110; normal
weight: mean ⫽ 27.93 ⫾ 21.69, range 1–139; t ⫽ ⫺ 4.03,
P ⬍ 0.001, eta-squared ⫽ 0.03) and boys (excess weight:
mean ⫽ 25.40 ⫾ 16.50, range 4–80; normal weight:
mean ⫽ 17.84 ⫾ 12.09, range 0–99; t ⫽ ⫺ 4.47, P ⬍ 0.001,
eta-squared ⫽ 0.03). The proportion of participants scor-
ing ⬎ 42 points was significantly higher among both the
girls and boys with excess weight than among those
with healthy weight (Table 2).
The prevalence of restrictive eating and alternating
restrictive/overeating was higher among girls with excess
weight than among their female peers with healthy
weight. Among the excess-weight boys, the prevalence
of overeating and restrictive eating was higher than
among their healthy peers. In both genders, the propor-
tion with feelings of having a desirable weight was lower
among excess- than normal-weight individuals. Both girls
and boys with excess weight perceived their health as
good more seldom than their healthy-weight peers. In the
boys, the prevalence of poor perceived health was sig-
nificantly higher among those with excess weight than
those with healthy weight. The proportion reporting
physical activity only once a week or rarely was signifi-
cantly higher among excess-weight than normal-weight
boys. However, this difference was not observed among
girls, since the prevalence of minimal exercise was high
in both weight groups. Among both genders, the propor-
tion of adolescents with one or more friends did not
358
differ between the weight groups, but experience of dat-
ing was less prevalent among those with excess weight
than among their healthy-weight peers. The prevalence
of smoking and alcohol use did not differ between the
weight groups among girls or boys (Table 2).
Three logistic models (Table 3) were constructed to
examine how well the six individually significant vari-
ables (Tables 1 and 2) together explained the variance in
the data. The results indicated that there was some mul-
ticollinearity, which inflated the predictor effects. The
EDI lost its significance, because it correlates with
weight satisfaction, which has a stronger correlation with
BMI than the EDI has. Respectively, physical activity
lost its significance, because it correlates with perceived
health, which has a stronger correlation with BMI than
physical activity has. Among girls, weight dissatisfaction,
poor perceived health and a lack of dating experience
together significantly explained the variance in BMI.
Among boys, respectively, abnormal eating habits, weight
dissatisfaction, poor perceived health and a lack of dat-
ing experience together explained the variance in BMI.
Overall, however, the results in Tables 1 and 2 were rea-
sonably consistent in this binary logistic regression anal-
ysis. Taken together, the differences were genuine and
did not display too much multicollinearity, which would
have caused greater uncertainty in the results. No signs
of confounding effects were detected. The model
explained 11.5% (all), 10.6% (girls) and 15.7% (boys) of
the variance in the dichotomous BMI (Cox & Snell
pseudo R-square).
In the linear probability model, five significant
(P ⱕ 0.008) moderator effects emerged: EDI, eating hab-
its, weight satisfaction, perceived health and physical
activity. These five variables had a different association
with the BMI group depending upon gender. All these
associations were stronger in boys than girls.
Discussion
Overall, adolescence is a period of physical growth and
development in which the salience of body shape and
physical appearance is perhaps greater than in any other
developmental stage in life (40). Here, we review our
most important findings among Finnish 8th grade stu-
dents and link them to previous research.
Self-esteem
The present study revealed that most participants showed
good self-esteem, with no significant differences observed
between excess-weight and healthy-weight adolescents.
This result is consistent with earlier findings in commu-
nity-based samples, which have rarely demonstrated
strong associations between excess weight and self-es-
teem in either boys or girls (18). A review by French
et al. (41) concluded that there are age-related differences
NORD J PSYCHIATRY·VOL 69 NO 5·2015
 Table 2. Self-esteem, eating disorder pathology and health- and food-related attitudes and habits in 14–15-year-old girls and boys with excess and healthy weight attending the 8th
grade at secondary school.
Girls with Girls with Boys with Boys with

NORD J PSYCHIATRY·VOL 69 NO 5·2015

excess weight, healthy weight, Effect excess weight, healthy weight, Effect
n ⫽ 73 n ⫽ 541 Statistics P size n ⫽ 106 n ⫽ 545 Statistics P size

Rosenberg Self-Esteem Scale (RSES) total score ⬍ 21 14/73 (19.2%) 75/541 (13.9%) 1.47 NS 5/105 (4.8%) 13/546 (2.4%) 1.86 NS
Eating Disorder Inventory (EDI) total score ⬎ 42 32/73 (43.8%) 108/541 (20.0%) 20.83 ⬍ 0.001 0.18 19/105 (18.1%) 30/546 (5.5%) 20.09 ⬍ 0.001 0.18
Eating habits 15.82 0.001 0.16 47.97 ⬍ 0.001 0.27
Normal eating 31/73 (42.5%) 354/541 (65.4%) 14.51 ⬍ 0.001 0.15 55/105 (52.4%) 451/546 (82.6%) 46.45 ⬍ 0.001 0.27
Overeating 19/73 (26.0%) 98/541 (18.1%) 2.61 NS 33/105 (31.4%) 56/546 (10.3%) 33.45 ⬍ 0.001 0.23
Restrictive eating 16/73 (21.9%) 66/541 (12.2%) 5.25 0.022 0.09 13/105 (12.4%) 33/546 (5.9%) 5.82 0.016 0.10
Alternating restrictive eating/overeating 7/73 (9.6%) 23/541 (4.3%) 3.94 0.047 0.08 4/105 (3.8%) 7/546 (1.3%) # NS
Attending school lunch 48/73 (65.8%) 387/541 (71.5%) 1.04 NS 84/105 (80.0%) 421/546 (77.3%) 0.37 NS
Attending evening meal 62/73 (84.9%) 466/541 (86.1%) 0.08 NS 95/105 (90.5%) 484/546 (88.6%) 0.30 NS
Weight satisfaction 77.62 ⬍ 0.001 0.36 210.84 ⬍ 0.001 0.57
Feeling of having excess weight 58/73 (79.5%) 150/541 (27.7%) 76.83 ⬍ 0.001 0.35 70/105 (66.7%) 45/546 (8.2%) 206.68 ⬍ 0.001 0.56
Feeling of having a desirable weight 15/73 (20.5%) 338/541 (62.5%) 46.27 ⬍ 0.001 0.28 34/105 (32.4%) 373/546 (68.3%) 48.53 ⬍ 0.001 0.27
Feeling of being underweight 0/73 (0.0%) 53/541 (9.8%) # 0.001 0.11 1/105 (1.0%) 128/546 (23.4%) # ⬍ 0.001 0.21
Perceived health 17.03 ⬍ 0.001 0.17 43.03 ⬍ 0.001 0.26
Well 50/73 (68.5%) 469/541 (86.7%) 16.29 ⬍ 0.001 0.16 76/105 (72.4%) 505/546 (92.5%) 37.11 ⬍ 0.001 0.24
Average 21/73 (28.8%) 62/541 (11.5%) 16.48 ⬍ 0.001 0.16 25/105 (23.8%) 40/546 (7.3%) 26.62 ⬍ 0.001 0.20
Poor 2/73 (2.7%) 10/541 (1.8%) # NS 4/105 (3.8%) 1/546 (0.2%) # 0.003 0.15
Physical activity 1.94 NS 15.78 ⬍ 0.001 0.16
At least once a day 14/73 (19.2%) 140/541 (25.9%) 19/105 (18.1%) 199/546 (36.4%) 13.32 ⬍ 0.001 0.14
Two-six times a week 48/73 (65.8%) 312/541 (57.7%) 67/105 (63.8%) 293/546 (53.7%) 3.67 NS
Once a week or more rarely 11/73 (15.1%) 89/541 (16.5%) 19/105 (18.1%) 54/546 (9.9%) 5.96 0.015 0.10
One or more close friends 68/73 (93.2%) 508/541 (93.9%) 0.06 NS 88/105 (83.8%) 449/546 (82.2%) 0.15 NS
Experience of dating 23/73 (31.5%) 258/541 (47.7%) 6.79 0.009 0.11 39/105 (37.1%) 293/546 (53.7%) 9.62 0.002 0.12
No smoking 57/73 (78.1%) 440/541 (81.3%) 0.44 NS 96/105 (91.4%) 467/546 (85.5%) 2.62 NS
No alcohol use 42/73 (57.5%) 307/541 (56.7%) 0.02 NS 72/105 (68.6%) 345/546 (63.2%) 1.11 NS
PSYCHOLOGICAL WELL-BEING IN

The overall chi-squared test and Fisher’s exact test (#) were used to compare the groups. Partitioning chi-squared was calculated only in tables with overall significance. The phi coefficient and Cramer’s
V were used as the effect size measures. NS, non-significant, P ⬎ 0.05.

359
EXCESS-WEIGHT ADOLESCENTS
M MÄKINEN ET AL.

Table 3. Logistic regression analysis coefficients with the dichotomous body mass index (BMI) as the
dependent variable among 1265 adolescent girls and boys (178 adolescents with excess weight vs.
1087 adolescents with healthy weight) attending the 8th grade at secondary school.
All (n ⫽ 1265) Girls (n ⫽ 614) Boys (n ⫽ 651)

Variable OR (95% CI) P OR (95% CI) P OR (95% CI) P

Eating disorder problems 0.97 (0.62–1.53) NS 1.17 (0.62–2.21) NS 1.63 (0.76–3.50) NS

Abnormal eating habits 2.10 (1.43–3.08) ⬍ 0.001 1.47 (0.81–2.70) NS 3.24 (1.94–5.41) ⬍ 0.001
Weight dissatisfaction 4.12 (2.77–6.10) ⬍ 0.001 5.62 (2.80–11.24) ⬍ 0.001 3.61 (2.20–5.95) ⬍ 0.001
Poor perceived health 2.68 (1.70–4.22) ⬍ 0.001 2.16 (1.11–4.21) 0.023 3.57 (1.86–6.85) ⬍ 0.001
Low physical activity 1.24 (0.75–2.06) NS 1.38 (0.64–2.97) NS 1.10 (0.53–2.27) NS
No experience of dating 2.03 (1.41–2.93) ⬍ 0.001 2.23 (1.25–4.00) 0.007 2.05 (1.25–3.37) 0.005
Omnibus test ⬍ 0.001 ⬍ 0.001 ⬍ 0.001
Cox & Snell R-square 0.114 0.106 0.157
Nagelkerke R-square 0.202 0.204 0.261

The pseudo R-squared statistics (Cox & Snell R-square and Nagelkerke R-square) are presented. CI, confidence
interval; OR, odds ratio.

in the strength of the self-esteem/obesity relationship,
with body weight and self-esteem relationships being
stronger in older than in younger adolescents. The par-
ticipants in the present study were youngsters in mid-
adolescence, and in this developmental stage excess
weight does not yet appear to be related to self-esteem.
(46), and regular family meals during early adolescence
have been found to contribute to the formation of healthy
eating habits 5 years later (47). In the present study, most
of the adolescents attended school lunch and evening
dinner, with no significant difference in attendance
between the weight groups.

Eating pathology Physical activity

Eating disorder pathology has been reported to be preva-
lent among under-aged persons with excess weight (12),
and eating disorders and obesity share some biological
and environmental risk factors and behaviours, as well as
intermediate neurocognitive phenotypes (42). However,
the prevalence of eating disorder pathology has varied
considerably depending on the assessment methods and
samples (43). In the present study, approximately 27% of
adolescents with excess weight scored ⬎ 42 points in the
EDI, hinting at a clinical disorder. In a previous study by
Unikel et al. (44), 10% of 13–15-year-old Mexican girls
with overweight and 15% of those with obesity reported
two or more disturbed eating behaviours compared with
6.7% of girls with healthy weight. Among the excess-
weight boys, the proportion of admitting overeating was
significantly higher than among their healthy peers. Inter-
estingly, this difference was not observed among the
girls. However, girls with healthy weight might have
exaggerated their eating habits, since almost 20% of them
reported overeating. On the other hand, among the girls
with excess weight, the proportion reporting alternation
between restrictive eating and overeating was high.
According to a recent study by Stephen et al. (45), girls
are consistently more likely than boys to report unhealthy
weight control behaviours.
Attending meals
An inverse association between meal frequency and the
prevalence of obesity in adolescence has been reported
The strongest health benefit of physical activity for young
people is improved psychological health (48). According
to a review by Haennel & Lemire (49), moderate activ-
ity, such as brisk walking for 30–60 min a day most days
of the week, is recommended in order to reduce the inci-
dence of and mortality associated with cardiovascular
diseases. In a study by Janssen et al. (8), physical activ-
ity levels were lower and television viewing higher in
overweight than in healthy-weight adolescents. This find-
ing is consistent with the results of the present study in
relation to boys. Interestingly, among girls, the preva-
lence of minimal physical activity was high in both
weight groups. It is well known that girls generally
exhibit less physical activity than boys (50), but our
results emphasize that a lack of physical activity associ-
ates with overweight problems more clearly in males
than in females. Overall, the finding that approximately
14% of our whole sample reported minimal exercise sup-
ports the urgent need to develop a national strategy for
physical activities for secondary school students in order
to prevent obesity. According to a previous 4-year ran-
domized trial performed in France, enhancing physical
activity with a multilevel school-based programme can
prevent excessive weight gain in adolescence (51).
Perceived health
Excess weight in adults is known to be strongly associ-
ated with poorer health and quality of life, as well as
the more frequent use of medical services (52). In the

360 NORD J PSYCHIATRY·VOL 69 NO 5·2015


present study, most adolescents, including those with
excess weight, perceived their health as good. The most
probable reason for this is the young age of the partici-
pants: excess weight had not yet resulted in somatic
complications. The finding also implies that the preva-
lence of severe mental health problems among the ado-
lescents was low in both weight groups.
Friendships
One of the key developmental tasks of adolescence is
emotional separation from the parents, which usually
happens when adolescents transfer from early to mid-ad-
olescence (40). During this development, peers become
increasingly important for adolescents. Strauss & Pollack
(10) investigated the social networks of overweight and
normal-weight adolescents, observing that overweight
adolescents received significantly fewer friendship nomi-
nations from others than their healthy-weight peers. In a
recent study by Puhl et al. (53), 64% of adolescents
reported weight-based victimization or bullying at school,
and its risk increased as a function of body weight. In
the present study, almost 90% of the adolescents reported
having one or more close friends, and no significant dif-
ference was observed between the weight groups.
Intimate relationships
Intimate and romantic relationships start to occur and the
sexual identity begins to develop when an adolescent
reaches mid-adolescence (40). In the present study, almost
half of the adolescents with healthy weight had started to
date, while dating was significantly less frequent among
those with excess weight. This finding is in line with that
of Pearce et al. (11), who reported that obese girls were
less likely to date than their peers, and that both obese
girls and boys reported being more dissatisfied with their
dating status than their average-weight peers. The authors
suggested that obese adolescents may have fewer oppor-
tunities to develop intimate romantic relationships,
because psychological and health difficulties frequently
associated with obesity. Further studies are clearly needed
to explore this interesting and important topic.
Smoking and alcohol use
According to a 2004 Finnish nationwide survey among
8th and 9th grade pupils in comprehensive schools (33),
the prevalence of daily smoking was approximately 23%
in boys and 17% in girls. In the present study, over 80%
of the participants reported not smoking at all, and the
prevalence of non-smokers did not differ between the
weight groups. French et al. (54) reported that trying to
lose weight, symptoms of eating disorder, fear of weight
gain and the desire to be thin were all related to current
smoking among American students in the 7th to 9th
grades, especially among females. In the light of the
NORD J PSYCHIATRY·VOL 69 NO 5·2015
PSYCHOLOGICAL WELL-BEING IN EXCESS-WEIGHT ADOLESCENTS
present study, smoking as a means of weight loss or con-
trol appears not to be prevalent among Finnish adoles-
cents. The reasons for this difference might be cultural,
such as the strict tobacco law in Finland, which denies
the selling of any tobacco products to under-aged per-
sons, as well as wide-ranging health education against
smoking.
Substance use is also generally initiated in adoles-
cence (55). In Finland, in a nationwide school survey,
approximately 22% of boys and 18% of girls reported
becoming “really drunk” at least once a month (33). In
the present study, approximately 60% of the adolescents
reported not using alcohol at all, and no difference was
observed between the weight groups. Thus, in mid-ado-
lescence, alcohol use does not appear to associate with
weight problems.
In summary, despite a high prevalence of eating
pathology and weight dissatisfaction, most adolescents
with excess weight expressed good psychological health.
In this perspective, our study lends further support to
earlier findings that the risk of psychological problems in
overweight and obese adolescents in hospital-referred
samples does not reflect what is seen in the general pop-
ulation. On the other hand, targeted psychological inter-
ventions should clearly be offered to some adolescents
with overweight and obesity problems. According to our
results, a marked focus on eating behaviour pathology,
health concerns, physical inactivity and problems in cre-
ating intimate relationships might be indicated in obesity
prevention and weight-management programmes designed
for adolescent populations.
One of the strengths of the present study is the rela-
tively good representativeness of the study sample, cov-
ering 24 secondary schools in the city of Helsinki. The
overall participation rate was approximately 60%, which
can be considered acceptable. A nationwide school sur-
vey carried out biannually in Finnish comprehensive
schools (grades 8 and 9) with the same data collection
method has repeatedly reported a participation rate of
approximately 80% (33). The authors had no ethical per-
mission to contact the dropouts, and no data for drop-out
analyses were consequently available. The prevalence of
overweight and obesity in adolescence has been reported
to vary between 10% and 20% in most European coun-
tries (56, 57), and consistently with this it was approxi-
mately 13% in the present study.
However, an obvious weakness is the limited number
of obese participants. Consequently, participants with
obesity and overweight were combined in statistical anal-
yses. Furthermore, in 50 cases, subjective weight and
height figures provided by the participants were used to
calculate the BMI due to the lack of nurse measure-
ments. Nevertheless, subjective estimates were highly
correlated with measurements by school nurses in our
study (r ⫽ 0.91, P ⬍ 0.001). Notably, adolescents with the
361
M MÄKINEN ET AL.
most marked weight problems might have refused to
participate in the study because of the methodology. One
must also bear in mind that most assessments were based
on self-reports. Consequently, such data do not necessar-
ily reflect actual behaviours, but subjective ideas or
memories of these habits, and adolescents may tend to
give normative answers. It is well known that obese peo-
ple tend to report low intakes of food and to describe
themselves as normal eaters (58). Another obvious limi-
tation is that weight satisfaction as well as health behav-
iours were assessed using single-item questions.
Moreover, the observed effect sizes were only weak or
moderate.
Conclusion
Despite a high prevalence of eating pathology and weight
dissatisfaction, most mid-adolescent pupils expressed
good psychological health. Targeted psychological inter-
ventions should be offered to some adolescents with
overweight problems.
Acknowledgements—This study was supported by the Foundation
for Pediatric Research, the Gyllenberg Foundation, the Children’s Castle
Foundation, the Finnish Association of Adolescent Psychiatry, the
Finnish Psychiatric Association and Helsinki University Central
Hospital.
Disclosure of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content
and writing of the paper.
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Mauno Mäkinen, M.D., Department of Psychiatry, Division of
Adolescent Psychiatry, Helsinki University Central Hospital, PO Box
640, 00029 HUS, University of Helsinki, Helsinki, Finland.
Nina Lindberg, Professor, Department of Forensic Psychiatry, Kellokoski
Hospital, Vanha Valtatie 198, 04500 Kellokoski, and University of
Helsinki, PO Box 3, 00014 University of Helsinki, Finland.
Erkki Komulainen, Professor (emeritus), Department of Behavioural
Sciences, PO Box 9, University of Helsinki, Helsinki, Finland.
Leena-Riitta Puukko-Viertomies, M.D., Ph.D., Department of
Psychiatry, Division of Adolescent Psychiatry, Helsinki University
Central Hospital, PO Box 640, 00029 HUS, University of Helsinki,
Helsinki, Finland.
Veikko Aalberg, Adjunct Professor, Department of Gynecology and
Pediatrics, Helsinki University Central Hospital, PO Box 281, 00029
HUS, University of Helsinki, Helsinki, Finland.
Mauri Marttunen, Professor, Department of Psychiatry, Division of
Adolescent Psychiatry, Helsinki University Central Hospital, PO Box
640, 00029 HUS, University of Helsinki, Helsinki; University of
Helsinki, PO Box 3, 00014 University of Helsinki; and National
Institute for Health and Welfare, PO Box 30, 00271 Helsinki, Finland.
363
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