Overweight, body image and bullying--an epidemiological study of 11- to 15-years olds.

Abstract

The purpose of this study was to examine the association between weight status and exposure to bullying among 11-, 13- and 15-year-old Danish school children. Furthermore, the purpose was to investigate the potentially mediating effect of body image.
Data from the Danish contribution to the international cross-sectional research project Health Behaviour in School-aged Children (HBSC) 2002 was used. Data were assessed from questionnaires and 4781 students aged 11-, 13- and 15-years old were included in the analyses. Logistic regression was used for the analyses.
The regression analyses showed that overweight and obese students were more exposed to bullying than their normal weight peers. Among boys, odds ratios (ORs) for exposure to bullying were 1.75 (1.18-2.61) in overweight and 1.98 (0.79-4.95) in obese boys compared with normal weight. Among girls, the corresponding ORs were 1.89 (1.25-2.85) in overweight and 2.74 (0.96-7.82) in obese girls. The mediation analyses showed that body image fully mediated the associations between weight status and exposure to bullying in both boys and girls.
This study shows that overweight and obese boys and girls are of higher odds of being exposed to bullying than their normal weight peers. Moreover, this study finds that body image may statistically explain this association between overweight and exposure to bullying. However, the study is cross-sectional, and hypotheses of possibilities for opposite causality are possible.

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Overweight, body image and bullying—an epidemiological
study of 11- to 15-years olds
Carina S. Brixval, Signe L. B. Rayce, Mette Rasmussen, Bjørn E. Holstein, Pernille Due
National Institute of Public Health, University of Southern Denmark, Copenhagen, Denmark
Correspondence: Pernille Due, National Institute of Public Health, Øster Farrigmagsgade 5, 1353 København K, Denmark,
tel: +45 39 20 77 77, fax: +45 39 20 80 10 e-mail: pdu@si-folkesundhed.dk
Received 26 April 2010, accepted 3 February 2011
Background: The purpose of this study was to examine the association between weight status and exposure to bullying among
11-, 13- and 15-year-old Danish school children. Furthermore, the purpose was to investigate the potentially mediating effect of
body image. Methods: Data from the Danish contribution to the international cross-sectional research project Health Behaviour
in School-aged Children (HBSC) 2002 was used. Data were assessed from questionnaires and 4781 students aged 11-, 13- and
15-years old were included in the analyses. Logistic regression was used for the analyses. Results: The regression analyses showed
that overweight and obese students were more exposed to bullying than their normal weight peers. Among boys, odds ratios
(ORs) for exposure to bullying were 1.75 (1.18–2.61) in overweight and 1.98 (0.79–4.95) in obese boys compared with normal
weight. Among girls, the corresponding ORs were 1.89 (1.25–2.85) in overweight and 2.74 (0.96–7.82) in obese girls. The
mediation analyses showed that body image fully mediated the associations between weight status and exposure to bullying
in both boys and girls. Conclusions: This study shows that overweight and obese boys and girls are of higher odds of being
exposed to bullying than their normal weight peers. Moreover, this study finds that body image may statistically explain this
association between overweight and exposure to bullying. However, the study is cross-sectional, and hypotheses of possibilities
for opposite causality are possible.
Keywords: overweight, body image, bullying, adolescents
......................................................................................................................
Introduction
O
world and have several physical and psychological health con-
sequences in children, adolescents and adults.1Exposure to
bullying has been linked to overweight in children.2–7Children
who are exposed to bullying have higher risks of health problems
and poor well-being, e.g. head- and stomach ache, disturbed sleep,
anxiety and depression.8–10These health problems even tend
to track into adulthood.11Bullying is defined as a deliberate,
repeated or long-term exposure to negative acts performed by a
person or group of persons regarded as having a higher status than
the victim.12Bullying can be expressed both as physical, verbal and
relational harassment.
Many adolescents are both burdened by overweight and expos-
ure to bullying and are therefore in great risk of the mentioned
health outcomes, but little is known about the mechanisms behind
the association between overweight and exposure to bullying.
Earlier studies of the association between overweight and a range
of psychological outcomes, for instance depression, suicide
attempts and low self-esteem, indicate that body image and
weight dissatisfaction may be mediating factors.13–18Body image
is a person’s own impression of his or her body. Body image
reflects actual body composition,
lifelong social response to body appearance and sociocultural
body values and ideals.13In the Western culture, the male body
is ideally muscular and the female body is thin and young people
who fail—or feel that they fail—to reach these ideals may suffer
from lower self-esteem.
Six previous papers have examined the association between
overweight and exposure to bullying in general among children
and adolescents.2–7Cross-sectional studies of children between
the ages of 6–17 years from the US,2Canada,3Wales,4Australia6
verweight and obesity are increasing problems around the
body-related experiences,
and England7have all found an association between weight status
and exposure to bullying. Griffiths et al. studied the association in
a prospective design of 7.5- to 8.5-year-old English children, and
found that weight status predicted exposure to bullying a year
later.5Only one of the six studies investigated possible explanatory
factors for the association between overweight and exposure to
bullying. The results of this study of 376 11- to 14-year-old
English school students indicated that both global self-worth,
self-esteem for physical appearance and body dissatisfaction each
fully mediated the relation between weight status and being
exposed to bullying.7Because of the few studies in this area, it is
important to increase knowledge about these associations and
mechanisms in other settings and other populations. Therefore,
the purpose of the present study was to examine the association
between overweight and exposure to bullying in a cross-sectional
study of 11-, 13- and 15-year-old Danish students. Moreover, the
purpose was to examine the potentially mediating effect of body
image. We focus on adolescence as a period of changes and
challenges where the person also becomes more dependent
on peer relationships and peer acceptance.9During puberty, the
body changes dramatically and while boys experience positive
feelings towards body changes in muscularity, girls become more
dissatisfied withtheirbody
accumulation.19
duetoincreasedbody fat
Methods
Population
Data used in this study comes from the Danish contribution to
the Health Behaviour in School-aged Children study (HBSC)
2002, which is a standardized international WHO collaborative
European Journal of Public Health, 1–5
? The Author 2011. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
doi:10.1093/eurpub/ckr010

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survey with repeated cross-sectional data collections among 11-,
13- and 15-year-old students in representative samples of schools
in the participating countries.20In Denmark, 79 schools were
randomly selected and 68 of these agreed to participate with
a total of 5400 students in the relevant grades. Of these, 4824
(89.3%) returned a complete questionnaire that was included
in the data file. For the purpose of this study, 43 students who
did not answer the question on exposure to bullying were omitted.
Hence, this study comprised 4781 students in the relevant age
groups.
There is no formal agency for ethical approval of school surveys
in Denmark. Therefore, we asked the school leader, the board of
students and the board of parents in each of the participating
schools for assessment and approval of the study. Participation
was anonymous and voluntary.
Variables
Weight and height status were measured by the items: ‘How
much do you weigh without clothes?’ and ‘How tall are you
without shoes?’ BMI (Body Mass Index) was computed as
weight/height2(kg/m2). Overweight and obesity were deter-
mined using the internationally standardized age- and sex-specific
metric proposed by Cole et al.21This metric provides cut-off
points for BMI in childhood and adolescence linked to adult
BMIs of 25 and 30kg/m2. About 12% of the students did
not answer one or both of these items, and missing data were
coded as a special category in the weight status variable. We did
so to maintain power in the analyses and to investigate if this
special group differed from the students, who answered the
questions.
Exposure to bullying was measured by the item: ‘How often
have you been bullied at school in the last couple of months?’.22
The responses were dichotomized into having been bullied 2–3
times a month or more vs. bullied less than 2–3 times a month.
This dichotomization is in accordance with the recommendations
from Olweus who developed the measurement.22
Body image was measured by the item: ‘Do you think your body
is...?’ and with following response categories: much too thin, a bit
too thin, about the right size, a bit too fat, much too fat.
Weincludedsocio-demographic
confounders in the analyses. Socio-economic position was mea-
sured by mother and father’s occupational status, based on the
student’s response to items about their parent’s occupation.
Mother and father’s occupational status were coded into social
Classes I–V in accordance with the standards of the Danish
National Institute of Social Research. We classified the students
by the highest ranking parent. Social Class VI was added repre-
senting economically inactive parents including people on transfer
income, sickness benefits and disability pension. Another category
(non-categorizable) was added: parents who are known to be in the
labour market but where information was inadequate to categorize
them into social classes. Family social class was recoded into
the levels high (I–II), middle (III–IV), low (V–VI) and non-
categorizable.
Ethnic background was measured by four items and dichoto-
mized into the categories shown in parentheses: ‘Are you born in
Denmark (yes/no)?’, ‘In which country was your father/mother
born? (in Denmark/outside Denmark)’ and ‘What language do
you most often speak at home? (Danish/other than Danish)’.
The four items were summed to a new variable indicating the
level of Danish background from 0 to 4 indicators of Danish
background. This means that students categorized as four are
born in Denmark by parents who are both born in Denmark
and primarily speak Danish at home.
Type of family was categorized into four groups: traditional
family (living with both parents), one-parent family (living with
variables aspotential
one parent), reconstructed family (living with one parent and his/
hers new partner) and other.
Statistical analyses
All analyses were carried out by SAS version 9.1. First, we
examined the covariates association with determinant and
outcome by ?2-test and bivariate logistic regression analysis,
respectively.
Second, we used multivariate logistic regression with stepwise
backwards selection to examine the associations between weight
status and being bullied (Model I). As a starting point weight status,
grade, family social class, type of family and ethnic background
were included as potential confounders.
The mediation effect23of body image was examined by adding
body image to the final regression model (Model II) considering
the change in association between weight status and exposure to
bullying. All regression analyses were run by PROC GLIMMIX to
account for the design effect caused by the cluster sampling
approach by which school was the sampling unit.
Finally, we examined by ?2-tests how the students not answering
height and/or weight differed from those who did answer the ques-
tions. Moreover, we used ?2-tests to investigate whether those
students not included in the analyses because of missing answers
in one or more variables differed from those included with respect
to relevant variables.
Results
In this study, 11.2 % had been exposed to bullying 2–3 times a
month or more during the past couple of months. Moreover, 8.6%
were classified as overweight and 1.1 % as obese (table 1). Bivariate
logistic regression analyses showed that among students exposed
to bullying, there was a statistically significant accumulation of
overweight students (P<0.000), of students in the lower grades
(P<0.000), of students, who do not consider their bodies to
have the right size (P<0.000) and of students with lower family
social class (P<0.000). This tendency was also present when
stratified for sex. Moreover, there was a statistical significant ac-
cumulation of girls in non-traditional family types among girls
exposed to bullying (P=0.001). The logistic regression analysis
of the association between body image and exposure to bullying
showed a significant association (P<0.000) with a U-shaped
pattern. Students who are dissatisfied with their body image,
both feeling too thin and too fat, have greater odds for being
bullied (table 1).
The covariates of ethnicity and type of family were excluded
from the final multivariate regression model, since they showed
no association with either exposure to bullying or weight status.
Model I thus included weight status, grade and family social class.
Table 2 shows that for both boys and girls the crude analyses
show a significant and graded relationship between weight status
and exposure to bullying with ORs for being bullied increasing by
weight status. Among boys, the OR for exposure to bullying is 1.74
(1.18–2.57) in overweight boys. Further, there was a high although
not significant accumulation of bullying [OR=2.05 (0.83–5.08)] in
obese compared with normal weight boys. Among girls, the OR for
exposure to bullying is 1.88 (1.25–2.83) in overweight and 3.60
(1.37–9.47) in obese girls. In Model I, the ORs attenuate slightly
for obese boys and girls after adjustment for grade and family
social class.
ORs for bullying according to weight status attenuate dramat-
ically from Models I to II and for both boys and girls the associ-
ation becomes insignificant (Pboys=0.441 and Pgirls=0.972). The
mediating effect of body image is more pronounced among girls
than among boys. Among obese boys, ORs for exposure to bullying
are reduced from 1.98 (0.79–4.95) to 1.14 (0.41–3.17). Among
obese girls, the corresponding ORs are reduced from 2.74
(0.96–7.82) to 0.87 (0.28–2.65).
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Table 1 Characteristics of study population, in total and stratified for exposure to bullying ?2–3 times a month
Distribution in percent (n) Percent who are bullied ?2–3 times a month
Total
n=4781
Boys
n=2322
Girls
n=2459
Total
n=542 (11.2%)
Boys
n=269 (11.6%)
Girls
n=273 (11.1%)
Exposure to bullying the last couple of months
Have not
Only one or two times
2–3 times a month
About once a week
Several times a week
Weight status
Normal weight
Overweight
Obese
Missing
P-value
Grade
5th
7th
9th
P-value
Body image
Much too thin
A bit too thin
About the right size
A bit too fat
Much too fat
Missing
P-value
Family social class
High
Middle
Low
Non-catagorizable
Missing
P-value
Type of family
Traditional family
One-parent family
Reconstructed family
Other
Missing
P-value
Numbers of indicators of Danish ethnicity
0
1
2
3
4
P-value
68.3 (3265)
20.4 (974)
4.3 (205)
2.9 (137)
4.2 (200)
68.6 (1594)
19.8 (459)
4.7 (110)
2.8 (65)
4.0 (94)
68.0 (1671)
20.9 (515)
3.9 (95)
2.9 (72)
4.3 (106)
78.4 (3746)
8.6 (409)
1.1 (53)
12.0 (573)
76.9 (1786)
9.2 (213)
1.3 (31)
12.6 (292)
79.7 (1960)
8.0 (196)
0.9 (22)
11.4 (281)
10.2
16.9
22.6
13.8
<0.000
10.5
16.9
19.4
13.7
0.012
9.9
16.8
27.3
13.9
0.001
36.3 (1736)
33.7 (1612)
30.0 (1433)
35.6 (827)
34.6 (803)
29.8 (692)
37.0 (909)
32.9 (809)
30.1 (741)
14.1
12.2
7.1
<0.000
14.5
12.5
7.1
<0.000
13.6
11.9
7.2
<0.000
1.6 (77)
11.4 (546)
52.8 (2524)
29.1 (1391)
4.2 (199)
0.9 (44)
1.4 (32)
12.7 (296)
60.4 (1402)
22.3 (517)
2.2 (52)
1.0 (23)
1.8 (45)
10.2 (250)
45.6 (1122)
35.5 (874)
6.6 (147)
0.9 (21)
26.0
12.1
8.4
12.6
32.7
6.8
<0.000
40.6
12.5
9.2
14.1
30.8
4.3
<0.000
15.6
11.6
7.5
11.7
33.3
9.5
<0.000
22.2 (1059)
48.6 (2323)
18.7 (896)
9.6 (458)
0.9 (45)
23.1 (536)
47.1 (1093)
18.3 (424)
10.4 (242)
1.2 (27)
21.3 (523)
50.0 (1230)
19.2 (472)
8.8 (216)
0.7 (18)
7.9
11.0
14.1
15.3
15.6
<0.000
8.8
10.9
15.3
14.9
7.4
0.005
7.1
11.1
12.9
15.7
27.8
0.002
59.9 (2862)
15.2 (727)
11.9 (567)
1.9 (90)
11.2 (535)
61.2 (1420)
15.5 (359)
11.2 (260)
1.7 (39)
10.5 (244)
58.6 (1442)
15.0 (368)
12.5 (307)
2.1 (51)
11.8 (291)
10.6
12.5
13.9
15.6
10.3
0.050
11.7
11.4
11.9
10.3
11.1
0.990
9.5
13.6
15.6
19.6
9.6
0.001
4.0 (190)
3.1 (148)
2.7 (131)
9.0 (431)
81.2 (3881)
4.0 (94)
3.1 (71)
3.1 (72)
9.3 (215)
80.5 (1870)
3.9 (96)
3.1 (77)
2.4 (59)
8.8 (216)
81.8 (2011)
11.0
12.8
16.0
11.1
11.1
0.506
14.9
8.5
15.3
9.8
11.6
0.508
7.3
16.9
16.9
12.5
10.7
0.158
P-values represent test for association in logistic regression analysis.
Table 2 Crude, adjusted (Model I) and mediation (Model II) analysis for exposure to bullying ?2–3 times a month in the last couple of
months by weight status and body image, respectively, and stratified by sex [OR (95% CI)]
Boys Girls
Crude Model Ia
Model IIa
Crude Model Ia
Model IIa
Weight status
Normal weight
Overweight
Obese
Missing
P-value
Body image
Much too thin
A bit too thin
About the right size
A bit too fat
Much too fat
P-value
N=2322
1
1.74 (1.18–2.57)
2.05 (0.83–5.08)
1.36 (0.94–1.97)
0.012
N=2299
6.84 (3.29–14.23)
1.40 (0.95–2.07)
1
1.62 (1.19–2.20)
4.40 (2.37–8.18)
<0.0001
N=2295
1
1.75 (1.18–2.61)
1.98 (0.79–4.95)
1.21 (0.83–1.76)
0.023
N=2273
1
1.43 (0.92–2.23)
1.14 (0.41–3.17)
1.16 (0.78–1.71)
0.441
N=2459
1
1.88 (1.25–2.83)
3.60 (1.37–9.47)
1.46 (1.00–2.13)
0.001
N=2438
2.15 (0.92–4.99)
1.60 (1.02–2.51)
1
1.63 (1.21–2.22)
6.04 (3.99–9.16)
<0.000
N=2441
1
1.89 (1.25–2.85)
2.74 (0.96–7.82)
1.30 (0.88–1.90)
0.001
N=2420
1
1.09 (0.69–1.72)
0.87 (0.28–2.65)
1.02 (0.68–1.53)
0.972
7.13 (3.38–15.02)
1.56 (1.05–2.34)
1
1.52 (1.10–2.12)
3.39 (1.67–6.87)
<0.0001
2.00 (0.85–4.68)
1.59 (1.00–2.52)
1
1.73 (1.25–2.39)
6.36 (3.97–10.19)
<0.0001
a: Adjusted for grade and family social class.
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The ORs for exposure to bullying increase by degree of dissat-
isfaction with one’s body image with both feeling too thin and too
fat, respectively. Among boys, the highest OR is seen when they
think their body is much too thin [OR=7.13 (3.38–15.02)] while
the highest OR among girls is observed when they think their body
is much too fat OR=6.36 (3.97–10.19).
Non-respondents were analysed by ?2-tests. Students, who did
not answer questions on weight and/or height, differed from
the rest in a range of variables. There were larger proportions of
missing answers among students in the lower grades (P<0.000),
among those bullied ?2–3 times a month (P=0.049), among
students who thought their body was too fat (P=0.002), among
those with lower family social class (P<0.000) and with few
indicatorsof Danish ethnicity
non-respondents on family social class, type of family and body
image (n=88) showed that in this group significantly more
students did not report their height and/or weight (P<0.000).
(P<0.000).Analysesof
Discussion
The present study has two key findings; first: in both boys and
girls, the risk of being bullied is higher among overweight and
obese 11-, 13- and 15 year-old students compared with their
normal weight classmates. Second, this association between
weight status and exposure to bullying seems to be mediated by
body image.
The results of this study are in accordance with results of
previous studies examining the association between weight status
and exposure to bullying.2–7All these studies support the finding
that the risk of exposure to bullying is greater among overweight
and obese students than among normal weight students.
Only one previous study7has focused on examining mediating
factors, explaining the association between overweight and
exposure to bullying. Their results indicated that both global
self-worth, self-esteem for physical appearance and body dissatis-
faction each fully mediated the relation between weight status
and exposure to bullying. The study comprised 201 boys and
girls but only 54% of the original sample provided useful data of
height and weight. While children who are bullied often have char-
acteristics that make them stand out from their classmates, the
characteristics are not necessarily the reason, why they are being
bullied. Some scholars in bullying behaviour point to low self-
esteem as a reason why some children are bullied and others
are not.12,24Previous research has shown that overweight and
obese children are more likely to report greater dissatisfaction
with their body and lower self-esteem compared with normal
weight children.15,25,26Hence, it may be that the lower self-
esteem in the overweight and obese students in some way are
communicated to their classmates which make them easy targets
for bullying.
The pattern of associations between weight status and exposure
to bullying was more or less the same among boys and girls.
In both boys and girls, we found an U-shaped relation between
body image and exposure to bullying, indicating that the further
away from ‘the right size’ the students think of their body, the
greater risk of exposure to bullying. However, while boys were
in much higher risk of exposure to bullying, when they thought
their body was much too thin, the girls reported more bullying
when they thought their body was much too fat. Although Fox and
Farrow (2009) investigated mediating factors, they did not specif-
ically look for gender differences, but concluded, that no signifi-
cant differences were seen between boys and girls.7Among boys,
it is high status to be physically strong while being skinny is an
indication of weakness.12Among girls, there is no advantage
of being physically superior—on the contrary there is a large
pressure on young girls to live up to the extremely slim ideal of
female body composition.15Therefore, it seems plausible that low
self-esteem may result in feeling too fat among girls and too thin
among boys.
The present study has some limitations; the results indicate that
overweight and obese students are more exposed to bullying than
normal weight students, and that the mechanism behind this may
be negative body image. However, this study is based on
cross-sectional data and therefore it is not possible to make con-
clusions about causality. It might be that negative body image is
rather a consequence of being bullied than a precursor. It is also
possible that some children would start over-eating as a way of
coping with being bullied and/or having a negative body image.
Longitudinal research is needed to establish the correct causal
pathways. Even though this study has a high participation rate,
selection bias may be present. Research shows that both bullied27
and overweight28students are more absent from school. This
possible bias mayhave resulted
However, this study has a high response rate that reduces the
risk of bias consequences. Another source of selection bias may
occur if the students who were excluded from the analyses due to
missing answers in one or more variables are different from the
included students. Comparison between participants and non-
participants in the study, however, did not reveal such problems.
An additional source of bias may be information bias. It is
well-known that BMI calculations based on self-reported height
and weight are underestimated.29–32However, due to economic
and ethical considerations self-reported data may be the best way
to measure weight status in large surveys. The potential
underreporting of BMI in this study may have resulted in
underestimated associations between weight status and exposure
to bullying.
This study suggests that negative body image may explain why
overweight and obese students are bullied more than their normal
weight peers. Regardless of the processes which connect overweight
and bullying, the most radical and effective way to deal with the
problem may be to intervene against bullying. First, bullying seems
to be related to the social context33rather than to individual char-
acteristics of the victims.12Second, there is now a bulk of inter-
vention research which suggests that it is possible to reduce
bullying considerably by pedagogical and structural interventions
at the school level.34These studies also demonstrate that individual
level interventions directed at the victims of bullying cannot stand
alone. Interventions at the school level including multiple tools
and levels are the most efficient to reduce bullying exposure
among school students.34
Another potential strand of interventions relate to the presenta-
tion of the perfect body in media and advertisements. Policies to
encourage a more relaxed attitude to body shape in media and
adds may be difficult to implement but it is important to
support research which explores whether such efforts could have
beneficial public health effects.35
in underestimatedORs.
Acknowledgements
HBSC is an international study in collaboration with the World
Health Organization. The international coordinator is Candace
Currie from the University of Edinburgh and the international
data bank manager is Oddrun Samdal from the University of
Bergen. The authors thank the Nordea-Foundation for financial
support of the study.
Funding
The Danish part of the HBSC survey is funded by the
Nordea-Foundation from 2008 to 2012.
Conflicts of interest: None declared.
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Key points:
? This study confirms what has already been shown earlier,
that overweight children and adolescents are more exposed
to bullying than their normal weight peers.
? This study adds to the previous studies by demonstrating
that body image mediates the association between
overweight and exposure to bullying.
? While boys seem to have a greater risk of being bullied,
when they think their body is too thin, girls have higher
risks, when they think their body is too fat.
? Regardless of the processes, which connect overweight and
bullying, it is important to intervene against bullying
because of its multiple harmful consequences.
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