ABSTRACT:

Introduction:

This study aimed to analyze the association between nutritional status, body image perception, and extreme weight control behaviors among adolescents.

Methods:

This is an analytical cross-sectional study conducted in Brazil based on the National Adolescent Student Health Survey (Pesquisa Nacional de Saúde do Escolar - PeNSE) of 2015, with adolescents aged 13 to 17 years. Nutritional status and body image perception were the independent variables. The two dependent variables were vomiting or laxative use and use of medicines and other formulas for weight control in the 30 days prior to data collection. We used Poisson regression models for association, with demographic variables for control.

Results:

7.4% of adolescents (95%CI 6.7 - 8.2) reported vomiting or using laxatives, with no difference between genders. The prevalence of use of medicines and formulas was higher among boys (7.8%; 95%CI 6.6 - 8.9). The association between nutritional status and extreme behaviors was not significant. However, the prevalence of vomiting or laxative use for adolescents who considered themselves very fat was 2.3 (95%CI 1.1 - 4.7) times higher for boys and 5.3 (95%CI 3.3 - 8.6) times higher for girls, while the use of medicines and formulas was 4.0 (95%CI 2.3 - 7.1) times higher for girls who considered themselves very fat.

Conclusion:

Body image perception seems to have a greater influence on extreme behaviors than nutritional status. Strategies involving health services and schools have great potential to impact the self-esteem and health of students positively.

Keywords:
Body image; Nutritional status; Adolescent; Vomiting; Weight perception; Weight loss

INTRODUCTION

Body image can be defined as the perception individuals have of their own body, that is, the way they see themselves¹1. Slade PD. What is body image? Behav Res Ther [Internet]. 1994 [citado 25 ago. 2017]; 32(5): 497-502. Disponível em: Disponível em: https://www.ncbi.nlm.nih.gov/pubmed/8042960
https://www.ncbi.nlm.nih.gov/pubmed/8042... . This image is built during all stages of life and is strongly influenced by cultural and social issues, such as media, family, and friends²2. Alves D, Pinto M, Alves S, Mota A, Leirós V. Cultura e imagem corporal. Motri [Internet]. 2009 [citado 25 ago. 2017]; 5(1): 1-20. Disponível em Disponível em http://www.scielo.mec.pt/scielo.php?pid=S1646-107X2009000100002&script=sci_arttext&tlng=pt
http://www.scielo.mec.pt/scielo.php?pid=... ^,33. Damasceno VO, Vianna V, Vianna J, Lacio M, Lima J, Novaes J. Imagem corporal e corpo ideal. Rev Bras Ciênc Mov [Internet]. 2006 [25 ago. 2017]; 14(2): 87-96. Disponível em Disponível em https://portalrevistas.ucb.br/index.php/RBCM/article/view/691/696
https://portalrevistas.ucb.br/index.php/... .

Adolescence is a period of identity construction and biological, cognitive, and emotional transformations, which stimulate adolescents to feel insecure about their body, constituting a critical phase for body image building⁴4. Fonseca H. Obesidade na adolescência: um contributo para a melhor compreensão dos factores psicossociais associados à obesidade e excesso de peso nos adolescentes portugueses [tese] [Internet]. Lisboa: Faculdade de Medicina da Universidade de Lisboa; 2009 [citado 25 ago. 2017]. Disponível em: Disponível em: http://repositorio.ul.pt/handle/10451/1153
http://repositorio.ul.pt/handle/10451/11... ^,55. Fabrin TK, Fin G, Baretta M, Baretta E. Percepção da imagem corporal e percentual de gordura em adolescentes do gênero feminino. Unoesc Ciênc [Internet]. 2013 [citado 25 ago. 2017]; 4(2): 195-202. Disponível em: Disponível em: https://editora.unoesc.edu.br/index.php/acbs/article/viewFile/3615/pdf_17
https://editora.unoesc.edu.br/index.php/... ^,66. Pereira AM. Preocupação com o peso e prática de dietas por adolescentes. Acta Port Nutr [Internet]. 2016 [citado 24 ago. 2017]; (6): 14-18. Disponível em: Disponível em: http://www.scielo.mec.pt/scielo.php?script=sci_arttext&pid=S2183-59852016000300003&lang=pt http://dx.doi.org/10.21011/apn.2016.0603
http://www.scielo.mec.pt/scielo.php?scri... .

The use of laxatives and medicines, as well as induced vomiting, are strategies that adolescents have been using for weight control, as they strive to have a socially acceptable body standard⁷7. Leal GVS, Philippi ST, Polacow VO, Cordás TA, Alvarenga MS. O que é comportamento de risco para transtornos alimentares em adolescentes? J Bras de Psiquiatr [Internet]. 2013 [citado 20 set. 2017]; 62(1): 62-75. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0047-20852013000100009 http://dx.doi.org/10.1590/S0047-20852013000100009
http://www.scielo.br/scielo.php?script=s... . The factors related to this kind of conduct need to be better elucidated, since such practices are considered risk behaviors for the development of eating disorders, such as anorexia and bulimia.

Body image perception seems to be one of the determining factors for the emergence of abnormal eating behaviors and inadequate weight control practices⁸8. Nunes MA, Olinto MT, Barros FC, Camey S. Influência da percepção do peso e do índice de massa corporal nos comportamentos alimentares anormais. Rev Bras Psiquiatr [Internet]. 2001 [citado 22 ago. 2017]; 23(1): 21-7. Disponível em: Disponível em: http://www.scielo.br/pdf/rbp/v23n1/a06v23n1.pdf http://dx.doi.org/10.1590/S1516-44462001000100006
http://www.scielo.br/pdf/rbp/v23n1/a06v2... . Previous studies conducted with 9th-grade adolescents in Brazilian state capitals⁹9. Kubota LC. Discriminação contra os estudantes obesos e os muito magros nas escolas brasileiras [Internet]. 2014 [citado 22 set. 2017]. Disponível em: Disponível em: http://repositorio.ipea.gov.br/handle/11058/2643
http://repositorio.ipea.gov.br/handle/11... ^,1010. Castro IRR, Levy RB, Cardoso LO, Passos MD, Sardinha LMV, Tavares LF, et al. Imagem corporal, estado nutricional e comportamento com relação ao peso entre adolescentes brasileiros. Ciênc Saúde Coletiva [Internet]. 2010 [citado 20 set. 2017]; 15(Supl. 2): 3099-4108. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232010000800014 http://dx.doi.org/10.1590/S1413-81232010000800014
http://www.scielo.br/scielo.php?script=s... revealed a relationship between extreme weight control behaviors and body image perception. However, we still do not know the strength of this association in a representative Brazilian sample, with an expanded age group, and measured anthropometric data that allow the assessment of nutritional status.

Considering this context and the need to deepen the knowledge about the topic in the country, this study aimed to analyze the association between nutritional status, body image perception, and extreme weight control behaviors in a representative Brazilian sample of adolescent students aged 13 to 17 years, who participated in the National Adolescent Student Health Survey (Pesquisa Nacional de Saúde do Escolar - PeNSE) in 2015.

METHODS

This is an analytical cross-sectional study carried out with PeNSE 2015 data. PeNSE is a health survey aimed at the adolescent population and conducted triennially since 2009, through a partnership between the Ministry of Health and the National Institute of Geography and Statistics (Instituto Nacional de Geografia e Estatística - IBGE), with the support of the Ministry of Education¹¹11. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar: 2015 [Internet]. Rio de Janeiro: IBGE; 2016 [citado 13 jun. 2017]. Disponível em: Disponível em: http://biblioteca.ibge.gov.br/visualizacao/livros/liv97870.pdf
http://biblioteca.ibge.gov.br/visualizac... .

In 2015, PeNSE data collection was based on two distinct sampling plans: Sample 1, which included 9th-grade students from elementary school, representing state capitals, Brazil, regions, and federative units; and Sample 2, which consisted of adolescents aged 13 to 17 years, representing Brazil and its regions¹¹11. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar: 2015 [Internet]. Rio de Janeiro: IBGE; 2016 [citado 13 jun. 2017]. Disponível em: Disponível em: http://biblioteca.ibge.gov.br/visualizacao/livros/liv97870.pdf
http://biblioteca.ibge.gov.br/visualizac... . This study used Sample 2 of PeNSE 2015, as it contains anthropometric measurements (weight and height) that allowed the assessment of the nutritional status of these students.

The population comprises students who, in 2015, attended from 6th to 9th grade of elementary school and 1st to 3rd grade of high school, both public and private, in the national territory. Further details regarding PeNSE design and sampling can be found in specific publication¹¹11. Instituto Brasileiro de Geografia e Estatística. Pesquisa Nacional de Saúde do Escolar: 2015 [Internet]. Rio de Janeiro: IBGE; 2016 [citado 13 jun. 2017]. Disponível em: Disponível em: http://biblioteca.ibge.gov.br/visualizacao/livros/liv97870.pdf
http://biblioteca.ibge.gov.br/visualizac... . In summary, Sample 2 comprised 653 selected classes of the mentioned population, distributed in 380 schools in 179 cities. Schools were selected from the School Census 2013, considering only those who had at least 15 students enrolled in the set of classes chosen.

In these schools, all students from the classes selected who were present on the day of the questionnaire application were invited to participate in the survey. However, we only kept students aged 13 to 17 years in the sample.

Students recorded their answers directly on an electronic questionnaire accessed on smartphones, without interference from the interviewer.

After filling out the questionnaire, the students went to an environment different from the classroom, so a trained interviewer could measure their anthropometric data (weight and height). Students with impairments that could hamper the anthropometric measurements or who refused to participate in the procedure were excluded from this stage of the study. A portable electronic scale measured the weight, and a portable stadiometer fixed on a smooth wall, with the help of adhesive tape, measured the height. The technicians were instructed to measure weight and height twice and repeat it a third time if the previous results were different. However, only one information for each variable was recorded on the student’s smartphone.

Among the information available on PeNSE 2015, the ones of particular interest for the present study are nutritional status, body image perception, and extreme weight control behaviors of adolescents.

Nutritional status was assessed through body mass index (BMI), calculated from the ratio between weight (kg) and height squared (m²). We adopted the BMI classification for age in z-scores, with cut-offs proposed by the World Health Organization (WHO)¹²12. World Health Organization. Growth reference 5-19 years [Internet]. Genebra: WHO; 2007 [citado jun. 2017]. Disponível em: Disponível em: http://www.who.int/growthref/who2007_bmi_for_age/en/
http://www.who.int/growthref/who2007_bmi... : z-score < -2: thinness; z-score > -2 and < +1: normal weight; z-score > +1: overweight; and z-score > +2: obesity. The indicator of body image perception was based on the question “Regarding your body, do you consider yourself”: with answers categorized into “thin/very thin, normal, fat, or very fat.”

Two indicators represented extreme weight control behaviors:

Some control variables identified in the literature complemented the analyses:

We estimated the frequencies (and confidence interval of 95% - 95%CI) of the studied variables, stratified by gender, and the indicators of extreme weight control behaviors, categorized by gender, region, age, and school administrative dependence. The estimate of prevalence ratios (PRs) and the association between dependent and independent variables were calculated by Poisson regression models, stratified by gender. We used a model for the association between nutritional status and extreme weight control behaviors, adjusted for body image perception, region, age, and administrative dependence; and another to estimate the association between body image perception and extreme behaviors, adjusted for nutritional status, and the same demographic variables of the previous model. We used the Stata S/E 14.2 software to analyze the data, considering the complex design of the PeNSE 2015 sample, and adopting a significance level of 5%.

The National Committee for Ethics in Research of the National Health Council approved this research. Participation in the survey was voluntary and with minimal risk to the adolescents. Students consented to participate in the study digitally using the data collection instrument. Parents or guardians were not required to sign the informed consent form due to the autonomy of adolescents, guaranteed by the Child and Adolescent Statute¹³13. Brasil. Lei nº 8.069, de 13 de julho de 1990. Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências [Internet]. Brasília: 1990 [citado 20 set. 2017]. Disponível em: Disponível em: http://www.planalto.gov.br/ccivil_03/leis/L8069.htm
http://www.planalto.gov.br/ccivil_03/lei... .

RESULTS

Sample 2 of PeNSE 2015 consists of data collected from 16,608 adolescents from elementary and high school. After excluding adolescents out of the age group selected and questionnaires without gender and age variables, 10,926 students remained in the sample and were analyzed in the present study. Among them, 50.3% were male, 61.9% were 13- to 15-year-olds, and 87.1% attended public schools (Table 1).

Assessment of nutritional status showed that 73.2% of the students had normal weight. Thinness prevalence was higher among male adolescents (3.8%), and there were no differences between genders regarding overweight and obesity. In relation to body image, 52.5% of adolescents reported considering themselves normal, with lower prevalence among boys. We underline that 27.6% of adolescents saw themselves as thin or very thin, and the prevalence of those who considered themselves fat or very fat was higher among girls (21.5 and 3.2%, respectively) (Table 1).

Out of the total number of adolescents, 7.4% reported vomiting or using laxatives for weight control in the 30 days prior to data collection, with no differences between genders. The prevalence of use of medicines, formulas, or other products with the same purpose was greater among male adolescents (7.8%) (Table 1).

For them, the prevalence of both extreme weight control behaviors decreased with age, with vomiting and laxative use having a more pronounced reduction. The prevalence of both extreme behaviors was higher for boys attending public schools. These phenomena did not happen with girls (Table 2).

The analysis by region showed no differences in the prevalence of extreme behaviors, except for the Northeast region, where male adolescents had a higher prevalence of vomiting or using laxatives, compared with the North and Midwest regions (Table 2).

The descriptive analysis also emphasizes that, among girls and the total number of adolescents, the prevalence of extreme behaviors tends to increase with the rise in BMI. It is noteworthy, however, the significant prevalence of vomiting or laxative use (8.2%; 95%CI 4.3 - 15.2) and use of medicines, formulas, or other products (10.3%; 95%CI 6.1 - 16.8) among thin boys (Table 2).

Similarly to nutritional status, the prevalence of extreme behaviors was higher among boys who considered themselves thin/very thin (9.8%; 95%CI 7.6 - 12.5 for vomiting or laxative use and 9.6%; 95%CI% 7.3 - 12.7 for use of medicines, formulas, or other products). For both genders, the prevalence of extreme behaviors increased significantly in adolescents who saw themselves as fat or very fat, when compared to those who considered themselves normal (Table 2).

The results of the multiple model showed that, except for overweight girls, the effect of nutritional status on the prevalence of extreme behaviors was not significant.

For male adolescents, the prevalence of vomiting or laxative use was 2.32 (95%CI 1.15 - 4.69) times higher among those who saw themselves as very fat, in relation to those who considered themselves normal (Table 3). The prevalence of both behaviors was significantly higher for boys who considered themselves thin/very thin (Tables 3 and 4).

Vomiting or laxative use was 5.32 (95%CI 3.30 - 8.57) times higher for girls who thought of themselves as very fat when compared to those who saw themselves as normal (Table 3). The prevalence of use of medicines, formulas, or other products, in turn, was 4.0 (95%CI 2.26 - 7.07) times higher among girls who saw themselves as very fat, in comparison with those who considered themselves normal (Table 4).

DISCUSSION

In 2015, the prevalence of vomiting and laxative use for weight control did not differ between genders. However, the use of medicines, formulas, or other products was higher among male students. These results were similar to those found in a 2009 study with 9th-grade students from elementary school in Brazilian state capitals and the Federal District¹⁰10. Castro IRR, Levy RB, Cardoso LO, Passos MD, Sardinha LMV, Tavares LF, et al. Imagem corporal, estado nutricional e comportamento com relação ao peso entre adolescentes brasileiros. Ciênc Saúde Coletiva [Internet]. 2010 [citado 20 set. 2017]; 15(Supl. 2): 3099-4108. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232010000800014 http://dx.doi.org/10.1590/S1413-81232010000800014
http://www.scielo.br/scielo.php?script=s... . Also in Brazil, a school-based study conducted in a city of Santa Catarina revealed that the use of medicines and formulas presented similar prevalence between genders. On the other hand, the practice of inducing vomiting or using laxatives was higher among girls¹⁴14. Frank R, Claumann GS, Felden EPG, Silva DAS, Pelegrini A. Body weight perception and body weight control behaviors in adolescents. J Pediatr. 2018. https://doi.org/10.1016/j.jped.2017.03.008
https://doi.org/10.1016/j.jped.2017.03.0... . We also found divergent results, in which the estimated prevalence for these behaviors was higher among female adolescents¹⁵15. Gonsalves D, Hawk H, Goodenow C. Unhealthy Weight Control Behaviors and Related Risk Factors in Massachusetts Middle and High School Students. Matern Child Health J. 2014; 18(8): 1803-13. https://doi.org/10.1007/s10995-013-1424-5
https://doi.org/10.1007/s10995-013-1424-... ^,1616. Stephen EM, Rose JS, Kenney L, Rosselli-Navarra F, Weissman RS. Prevalence and correlates of unhealthy weight control behaviors: findings from the national longitudinal study of adolescent health. J Eat Disord. 2014; 2: 1-9. https://doi.org/10.1186/2050-2974-2-16
https://doi.org/10.1186/2050-2974-2-16... .

The high prevalence of extreme behaviors among thin boys or those who saw themselves as thin or very thin should receive special attention. It is unclear whether adolescents who are or see themselves as thin displayed an extreme behavior motivated by weight control or to stay thin. We emphasize, however, that such conduct had already been observed in a similar 2009 study carried out with 9th-grade students from elementary school in Brazilian state capitals and the Federal District¹⁰10. Castro IRR, Levy RB, Cardoso LO, Passos MD, Sardinha LMV, Tavares LF, et al. Imagem corporal, estado nutricional e comportamento com relação ao peso entre adolescentes brasileiros. Ciênc Saúde Coletiva [Internet]. 2010 [citado 20 set. 2017]; 15(Supl. 2): 3099-4108. Disponível em: Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232010000800014 http://dx.doi.org/10.1590/S1413-81232010000800014
http://www.scielo.br/scielo.php?script=s... . The prevalence of extreme behaviors among boys who considered themselves thin or very thin, compared to those who saw themselves as normal, was also higher in studies conducted in the state of Massachusetts, United States¹⁵15. Gonsalves D, Hawk H, Goodenow C. Unhealthy Weight Control Behaviors and Related Risk Factors in Massachusetts Middle and High School Students. Matern Child Health J. 2014; 18(8): 1803-13. https://doi.org/10.1007/s10995-013-1424-5
https://doi.org/10.1007/s10995-013-1424-... , and Palestine¹⁷17. Al Sabbah H, Vereecken C, Abdeen Z, Kelly C, Ojala K, Németh A, et al. Weight control behaviors among overweight, normal weight and underweight adolescents in Palestine: findings from the national study of Palestinian schoolchildren (HBSC-WBG2004). Int J Eat Disord. 2010; 43(4): 326-36. https://doi.org/10.1002/eat.20698
https://doi.org/10.1002/eat.20698... , a characteristic not observed among girls. Another highlight is that boys underestimate their body image, seeing themselves as thin/very thin and adopting practices to gain muscle mass¹⁸18. Alves C, Lima RVB. Uso de suplementos alimentares por adolescentes. J Pediatr [Internet]. 2009 [citado 29 set. 2017]; 85(4): 287-94. Disponível em: Disponível em: http://www.redalyc.org/pdf/3997/399738171004.pdf http://dx.doi.org/10.1590/S0021-75572009000400004
http://www.redalyc.org/pdf/3997/39973817... .

The prevalence of vomiting and laxative use, as well as the use of medicines, formulas, or other products decreased with age for boys and the total population. A study carried out in Palestine found similar results. In it, adolescents of both genders in their final years of study showed a lower chance of displaying extreme weight control behaviors¹⁷17. Al Sabbah H, Vereecken C, Abdeen Z, Kelly C, Ojala K, Németh A, et al. Weight control behaviors among overweight, normal weight and underweight adolescents in Palestine: findings from the national study of Palestinian schoolchildren (HBSC-WBG2004). Int J Eat Disord. 2010; 43(4): 326-36. https://doi.org/10.1002/eat.20698
https://doi.org/10.1002/eat.20698... . In the United States, an investigation revealed this same behavior, but only among female adolescents¹⁵15. Gonsalves D, Hawk H, Goodenow C. Unhealthy Weight Control Behaviors and Related Risk Factors in Massachusetts Middle and High School Students. Matern Child Health J. 2014; 18(8): 1803-13. https://doi.org/10.1007/s10995-013-1424-5
https://doi.org/10.1007/s10995-013-1424-... .

Among boys, the prevalence of both extreme behaviors was higher for those attending public schools, and the prevalence of vomiting and laxative use was higher in the Northeast region. Such findings could be related to the socioeconomic conditions of these students, similar to results found in a North American study in which male adolescents from schools located in poor areas had a greater chance of displaying extreme weight control behaviors¹⁹19. Austin SB, Richmond TK, Spanado-Gasbarro J, Greaney ML, Blood EA, Walls C, et al. The Contribution of School Environmental Factors to Individual and School Variation in Disordered Weight Control Behaviors in a Statewide Sample of Middle Schools. Eat Disord. 2013; 21(2): 91-108. https://doi.org/10.1080/10640266.2013.761080
https://doi.org/10.1080/10640266.2013.76... . Despite the evidence of a possible relationship between extreme behaviors and socioeconomic conditions, further studies, including qualitative ones, are necessary to understand the peculiarities of this phenomenon among boys. A hypothesis to be tested is whether boys from lower social classes are more vulnerable to pressures to fit their body image into a socially established standard.

There was an association between body image perception and extreme weight control behaviors - stronger for girls who thought of themselves as very fat -, a relationship not found between extreme behaviors and nutritional status. These results allow us to infer that body image perception might have a greater influence on the adoption of extreme behaviors than nutritional status.

The literature has evidence of the direct association between nutritional status and extreme weight control behaviors¹⁵15. Gonsalves D, Hawk H, Goodenow C. Unhealthy Weight Control Behaviors and Related Risk Factors in Massachusetts Middle and High School Students. Matern Child Health J. 2014; 18(8): 1803-13. https://doi.org/10.1007/s10995-013-1424-5
https://doi.org/10.1007/s10995-013-1424-... ^,2020. Santana MLP, Assis AMO, Silva RDCR, Raich RM, Machado MEPDC, Pinto EDJ, et al. Risk Factors for Adopting Extreme Weight-Control Behaviors among Public School Adolescents in Salvador, Brazil: A Case-Control Study. J Am Coll Nutr. 2016; 35(2): 113-7.. However, the hypothesis that body image perception could have a more significant impact on extreme behaviors is reinforced when considering the relationship between body image distortion and such practices. For example, normal weight adolescents who overestimate or underestimate their nutritional status have higher chances of fasting, vomiting, or using laxatives and medicines without a medical prescription, when compared to those who consider their weight adequate²¹21. Lee J, Lee Y. The association of body image distortion with weight control behaviors, diet behaviors, physical activity, sadness, and suicidal ideation among Korean high school students: a cross-sectional study. BMC Public Health. 2016; 16(1): 1-10. https://doi.org/10.1080/07315724.2014.951903
https://doi.org/10.1080/07315724.2014.95... ^,2222. Ursoniu S, Putnoky S, Vlaicu B. Body weight perception among high school students and its influence on weight management behaviors in normal weight students: a cross-sectional study. Wien Klin Wochenschr. 2011; 123(11-12): 327-33. https://doi.org/10.1007/s00508-011-1578-3
https://doi.org/10.1007/s00508-011-1578-... .

It is important to emphasize that unhealthy weight control behaviors are associated with body image perception in adolescents. Pressure from the media to conform to aesthetic standards of thinness can influence such habits, especially among girls²³23. Chang FC, Lee CM, Chen PH, Chiu CH, Pan YC, Huang TF. Association of thin-ideal media exposure, body dissatisfaction and disordered eating behaviors among adolescents in Taiwan. Eat Behav. 2013; 14(3): 382-5. https://doi.org/10.1016/j.eatbeh.2013.05.002
https://doi.org/10.1016/j.eatbeh.2013.05... . The media disseminates standards of perfect bodies for men and women, which can affect the adolescent’s self-image, and result in suffering and discrimination for those who do not feel they fit this ideal²⁴24. Silva ML, Taquette SR, Coutinho ES. Sentidos da imagem corporal de adolescentes no ensino fundamental. Rev Saúde Pública [Internet]. 2014 [citado 24 ago. 2017]; 48(3): 438-44. Disponível em: Disponível em: http://www.scielo.br/pdf/rsp/v48n3/pt_0034-8910-rsp-48-3-0438.pdf https://doi.org/10.1590/S0034-8910.2014048005083
http://www.scielo.br/pdf/rsp/v48n3/pt_00... .

To circumvent this problem, schools, together with health services, become important spaces for discussion and construction of healthy and real frames of reference for adolescents, decreasing the negative influence of the media on behaviors related to nutrition and health²⁵25. Florêncio RS, Moreira TMM, Silva MRF, Almeida ILS. Overweight in young adult students: the vulnerability of a distorted self-perception of body image. Rev Bras Enferm. 2016; 69(2): 258-65. http://dx.doi.org/10.1590/0034-7167.2016690208i
http://dx.doi.org/10.1590/0034-7167.2016... . In this scenario, the Health at School Program, an intersectoral initiative, represents a strategy to implement actions that positively impact the self-esteem, body image perception, and health of students, with interventions ranging from the promotion of healthy eating habits to the encouragement of body practices, and physical and leisure activities in schools²⁶26. Brasil. Ministério da Saúde. Portaria Interministerial nº 1.055, de 25 de abril de 2017. Redefine as regras e os critérios para adesão ao Programa Saúde na Escola - PSE por estados, Distrito Federal e municípios e dispõe sobre o respectivo incentivo financeiro para custeio de ações [Internet]. Brasília: 2017 [citado 22 set. 2017]. Disponível em: Disponível em: http://189.28.128.100/dab/docs/portaldab/documentos/academia/prt_pse_1055_25_04_2017.pdf
http://189.28.128.100/dab/docs/portaldab... .

As a limitation of the present study, we underline that since PeNSE is a cross-sectional survey, reverse causality bias can occur, as it is not possible to determine if body image perception among adolescents stimulates extreme weight control behaviors or if these practices cause a body image perception that justifies these actions. Furthermore, the results cannot be generalized to adolescents who do not attend schools. Also, the study did not include variables of mental health, which can be correlated with the outcome.

We suggest dividing the question about vomiting or laxative use for weight control in the 30 days prior to data collection into two to allow the identification of behaviors specifically attributed to bulimia due to the proliferation of sites and social media groups that encourage the adoption of bulimic behaviors during adolescence.

CONCLUSION

The results of this study allow us to infer that body image perception seems to have a more significant influence on the practice of extreme behaviors than nutritional status, especially among female adolescents.

To deal with this problem, intersectoral strategies involving health services and schools have great potential in developing actions that result in a positive body image perception and improve the self-esteem and health of students.

References

Publication Dates

History