Keywords

12.1 Introduction

Obesity has been linked to poor body image [1]. Body image is important because it can help in managing the body weight [2, 3]. National Eating Disorders Association [4] defines body image as “How you feel about your body, including your height, shape and weight.” The concept of body image depends on the epistemological postulations about the nature of the mind, the body, the individual, and society [5] and is a multidimensional construct [6]. In recent times, the ideal thin body image for adolescents is widely spread and is overemphasized by western culture, making it likely that adolescents are always anxious about their body image [4] especially those with whopping body weight. Being thin is good for health and much associated with aesthetic reasons, whereas being fat is considered an unwanted condition [7]. Obesity among adolescents is also often associated with body image dissatisfaction [8, 9] and adolescents may feel ashamed of their physical appearance. Interestingly, body image dissatisfaction is not only a phenomenon in western countries but is also becoming increasingly prevalent in non-western countries [10]. Body image, as a social construct might be perceived differently by one another. However, adolescents’ construction of body image is largely dependent on perceptions that develop through social interactions. The understanding of body image is shaped by media, parents, peers, culture, and society [10–12]. Various studies have identified negative social and emotional consequences of excessive body weight. For example, obese teens perceive themselves as less attractive, less accepted by peers, have less communication with parents, and receive a lower academic assessment at school [11]. Research on obesity has also documented the weight-related stigma experienced by overweight and obese people. Weight-related stigma includes verbal teasing, physical bullying, and relational victimization [13]. This weight-related stigma may lead to difficulty in making friends [8] and peer rejection. This weight-related stigma, teasing, and peer rejection may cause impairment in health, emotional well-being, and psychosocial functioning.

The obesity-related health problems are also prominent. Overweight and obese adolescents are at increased risk of the onset of adult chronic diseases such as diabetes, heart disease, hypertension, stroke, and some types of cancers [2]. Thus, these populations often perceive themselves as unhealthy [8, 14] and susceptible to disease. Furthermore, research suggests that the overweight adolescent has difficulties to fit into fashionable clothing. Adolescents prefer smaller body size because it allows them to wear fashionable clothing [14]. It seems that there are many factors that can affect the social construction of body image and most of the factors are related to various interactions. However, very few studies have examined the body image, as a social construct, in Malaysian context and the process by which such construction is understood, experienced, and reacted to, through social interactions. It is equally important to understand the social construct of body image and its effects on adolescents, besides the attention to decrease the obesity rates. Therefore, the aim of this study was to use qualitative methods to explore how the body image is perceived by overweight and obese adolescents in the context of their daily lives and how social interactions constructed their perception towards their body image.

12.2 Methods

A qualitative study was employed to study the social construction of body image among overweight and obese adolescents. Specifically, a phenomenological approach was adopted. In this study, the phenomenological approach attempts to describe the meaning of body image within their own contexts, to understand the experiences of being overweight and obese, and also allows further exploration of such experiences in daily encounters. The approval to conduct the study has been obtained from the Research Ethics Committee of the Faculty of Health Sciences, Universiti Teknologi MARA, The Ministry of Education Malaysia, the state education department and the participating school. In addition, consent was obtained from the parents and the participants.

12.2.1 Recruitment of Participants

The participants were drawn from a school in Klang Valley. Klang Valley is classified as an urban area with evidence that adolescents living in this area are more likely to be overweight and obese. A school was contacted and a list of participants’ weight and height was obtained from the physical education teacher. Eligible participants were derived in accordance to the overweight or obese class based on the WHO categorizations [15].

12.2.2 Data Collection and Procedures

Interviews were conducted after the participants had returned the completed and signed parental inform consent form. Data were collected through in-depth interviews with overweight and obese adolescents. The interview was conducted in the Malay language and was recorded. It was conducted by the researcher after school hours at the school of study and each interview took approximately 1 h. An interview guide was used to address three main topics; perception, experience, and reaction. Participants were asked to (1) describe their perception of body image, (2) express their experiences of being overweight and obese and (3) elaborate their reaction on such experiences in daily encounters. Each question was followed with probes used to gain a complete understanding of the issues raised by participant.

12.2.3 Data Analysis

The data were analyzed using thematic content analysis guided by the guidelines provided by Braun and Clarke [16]. First, the data were transcribed verbatim in the Malay language. Then, they were translated to English by a language expert to ensure that the data were equivalent in meaning. The textual data were carefully read, line-by-line to identify emerging themes related to body image. Finally, the emerging themes were reviewed.

12.3 Results

Seven adolescents aged 13–17 years old, including four girls and three boys participated in the study. Overall, four main themes emerged in the data. The first two themes are related with the perception of body image. The first theme is dissatisfaction with body image, the second theme is that being fat is not beautiful and makes one susceptible to diseases, the third theme is the participants’ view on how the social interaction constructed the body image, and the fourth theme deals with a desire to improve one’s body image.

12.3.1 Own Dissatisfaction of Body Image

Adolescents’ body image can be understood by seeking their perception of body image. Most of the participants expressed their feeling of dissatisfaction with their current body image. For example,

Interviewer::

How do you feel about your body image?

Girl::

Oh, I’m not satisfied with my body image (14 years old).

Girl::

I dislike my body. When I look at myself in the mirror...Eiii...it’s ugly! I can see my ‘fat’ self in the mirror. Then, I imagined myself looking skinny in the mirror (13 years old).

Despite the frequent dissatisfaction of body sizes, a boy expressed a preference to be taller. He said,

Boy::

I want to be taller

Interviewer::

How about your body size?

Boy::

It’s just fine (16 years old).

12.3.2 Being Fat Is Not Beautiful and Makes One Susceptible to Diseases

A participant attributed her physical conditions as fat and not beautiful when asked to describe her body image. Example is as follows:

Interviewer::

How do you describe your body image?

Girl::

I’m quite fat because I’ve a large body frame. I think I got the fat genes from my father while my elder sister has always been thin because she inherited my mom’s body size. Being fat is not beautiful because I don’t look good in my clothes. Yeah, it is difficult. I am fat and the clothes are small. My friends told me the same thing. They said that being thin is beautiful as you can fit into any clothes well (14 years old).

Although most comments focused on the association of overweight and physical appearance, few participants also discussed the obesity-related health problems, as supported by the statement below:

Interviewer::

What is your opinion on obesity and health?

Girl::

Being overweight is susceptible to diseases including diabetes and heart attack. In addition, it is hard for you to walk because you have to carry your heavy body. However, it doesn’t mean that being fat is unhealthy and being thin is healthy (15 years old).

Boy::

Fat is unhealthy. My grandmother told me that fat people is at risk of getting diabetes and heart attack (16 years old).

12.3.3 Body Image Is Constructed by Social Interaction

The third theme that emerged from the interviews was related to how participants’ social interactions with family members, peers, and social environment constructed their understanding of and perception towards their body image.

  1. 1.

    Feedback from peers and family members

The interviews revealed that participants constructed their body image from the feedback of others. For example,

Boy::

I think I’m fat

Interviewer::

What makes you think so?

Boy::

Because people around me such as my family members and friends said so

Interviewer::

What did they say?

Boy::

For example when I eat, they will say, “Can you watch what you are eating and have control of it? Don’t you know that you’re fat?”(14 years old)

  1. 2.

    Body image role modeling

Participants also acknowledged that they view their peers and siblings as role models for having the ideal body image. A girl reported that she would like to look like her friend. She said,

Girl::

I want to look like my friend, Nadirah.

Interviewer::

Why?

Girl::

She’s tall and thin so she can fit into any apparel nicely. I’d like to be slimmer and taller because I want to wear fashionable clothes and to avoid being scolded by mom. My mom said it is difficult for her to find nice clothes for me because of my big size (13 years old).

Additionally, there was also a girl, who adores the body image of her sibling. As described by this girl,

Girl::

I want to be thin and tall like my sister...thinner than her if possible (14 years old).

Unlike girls, boys do not have role models for ideal body image, as shown in the following statements:

Interviewer::

Do you have somebody as your body image role modeling?

Boy::

No. I don’t think so.

Interviewer::

For example like an actor?

Boy::

No

Interviewer::

Or your grandfather?

Boy::

No (17 years old).

  1. 3.

    Social environment

The interaction with social environment such as school was also found to influence participants’ construction of body image. They faced weight-related stigma and teasing, and social exclusion in their daily encounters. Several participants’ explanations about how their social environment influences their construction of body image were captured in the following interviews:

Boy::

I’m embarrassed with my friends because of my big body size. They have asked me to finish their left over meals. So, I really get embarrassed (17 years old).

Girl::

There are a few naughty boys in my class who often tease me. They used to tease me with names like “Bobby” and “Bob”. I will usually ignore them but sometimes...I get mad and would scold them back when I’ve had enough. I’m embarrassed (13 years old).

Boy::

I’m not involved in football because it is like my friends always ignore me. I believe I can play football but when they look at my physical appearance, I assume they probably think “Oh, he can’t play because he is fat” (14 years old).

Despite the common assumption that the social environment could bring negative messages of being overweight and might cause emotional disturbance, several boys expressed a feeling of acceptance of being overweight, as evidenced in the following statements:

Interviewer::

If you’re teased by your friend because of your overweight look, do you feel embarrassed, sad, or mad?

Boy::

I’m not embarrassed because it is me, myself. I can’t be embarrassed of myself. I’m furious at those who tease me, but that’s it (14 years old).

Boy::

No, I’m not. I’m used to being teased about my body weight because I’m fat and have been this way since I was a toddler (16 years old).

12.3.4 Desire to Improve Body Image

Most of the participants do take action to improve their body image. They were involved in weight management to reduce weight. As explained by these two participants:

Girl::

When I got invitation to take part in this study, I feel embarrassed with myself. I want to do something to be thin. But, both my parents are always busy with their work. So, it’s like I can’t do more. I hope that my parents will bring me out for jogging (13 years).

Boy::

I was upset with the weight-teasing. So, I want to be thin. And that is the reason why now I eat least. Previously, I always ate three times a day but now I skipped my breakfast. I just take my lunch and dinner. Yeah, I feel hungry sometimes, but I can bear with it because I really want to be thin! (14 years).

12.4 Discussion

The purpose of the present study was to explore how the body image is perceived by overweight and obese adolescents in the context of their daily lives and how social interaction constructed their perception towards their body image. Most of the participants expressed dissatisfaction with their current body image and would like to improve it. This is also interesting as some of the boys also indicated dissatisfaction towards their body image especially in relation to height. Such findings concur with other studies [8, 9]. Their physical condition leads to an undesirable body shape [7]. It was suggested that body dissatisfaction among adolescents may be prevented by encouraging healthy relationship with peers [17] and the dissatisfaction may be reduced if adolescents have cognitive view of seeing themselves as “big” rather than “fat” [1]. It is actually a good sign for overweight and obese adolescents to have a feeling of body image dissatisfaction. For example, body image dissatisfaction caused by obesity may motivate people to reduce weight [1]. This argument, however, is challenged by research which suggests that overweight adolescents with body dissatisfaction are at risk for engaging in unhealthy weight control behaviors [18] and involving in disordered eating [2, 19].

Adolescents in the present study talked about “fatness” often when being asked to describe their body image. Wills et al. [20] also found that overweight young people always referred themselves as fat and big. Aesthetic appearance is more likely to be acknowledged by female adolescents to describe their body because they always see body as an object to be viewed and evaluated [21]. Besides, thinness in women is frequently represented in the media [22] and the association of thinness with beauty, success, and attractiveness is pervasive. Consistent with the findings in the study of Katz et al. [14], results from the present study reveal that obesity health-related consequences were also raised as considerations by adolescents. They admitted that an obese individual is susceptible to diseases and that fat is unhealthy. However, Diedrichs et al. [22] argued that the assumption about being unhealthy related to overweight is inaccurate. Evidence supporting this assumption is shown in the study of Wildman et al. [23], which found that some of the overweight people are metabolically healthy.

The results also indicated that there are several social interaction domains that influence the construct of body image among adolescents, including feedback from peers and family members, body image role modeling, and social environment. The results of the present study complement those of Mellor et al. [10], which suggest that feedback from peers and parents accounts for body image dissatisfaction and body change behavior. For example, parents’ opinions on body weight and shape have resulted in body dissatisfaction [24] and peers’ feedback on body image may lead an adolescent to lose weight [12]. Unlike participants in the study of Diedrichs et al. [22], adolescents in the present study were more likely to compare their appearance to people they see in real life such as siblings and peers, rather than people in the media. Several reasons were proposed for why media’s influence on overweight and obese adolescents may not be as strong, as it is for adolescents with average body weight. However, this body image role modeling only involved girls and was not applicable to the boys. This finding supports the idea that men are often valued for other traits such as humor or capabilities [22], rather than their appearance. This study adds to our knowledge of the body image role modeling by demonstrating that female adolescents are more likely to view somebody to get the idea of an ideal body image as compared to male adolescents.

In concurrence with past research, present findings also revealed that the social environment may affect adolescents’ perception and understanding of body image, suggesting that obesity may cause adolescents to encounter the negative social and emotional consequences. As part of a socially stigmatized group [11], overweight and obese people are thought to be responsible for their body size [1] and weight-related teasing is a message communicated to them that their body shape and weight are not acceptable in the society. Negative messages about being overweight and obese reflect a strong anti-fat attitude among general population. This is evident in the peer interaction [11], media, schools, and in daily encounters [1]. For example, overweight adolescents experienced peer rejection in school [25]. Internalization of such messages may lead to emotional disturbance [25] and can greatly influence overweight adolescents’ perception of their body image. This might also be one explanation of why overweight and obese adolescents were discontent with their bodies. These findings highlight the importance of creating healthy social environment by improving society’s attitudes towards overweight and obese individuals.

Moreover, adolescents in the present study are motivated to improve their body image. It was suggested that the body image dissatisfaction and the negative outcome from social interaction may be indicative of the emergence of weight management. This finding aligns with the finding by Fonseca and de Matos [8]. This is positive, as it suggests overweight and obese adolescents have a good intention to reduce weight to conform to a prescribed ideal. For example, it was found that overweight adolescents may attempt to reduce weight by engaging in physical activities and involving in dieting regime. It was found that overweight adolescents have greater weight loss strategies [12]. However, this is of concern as they may involve in eating disorders [2, 19] such as anorexia nervosa and bulimia nervosa [3, 4] as these adolescents have greater concern about their appearance and body image. In some of their weight loss strategies, the adolescents mentioned the need to have a companion to be with them. This is most noticeable if the strategy involves physical activities. Therefore, support from parents and friends are greatly needed to encourage adolescents’ participation in physical activities.

12.5 Conclusion

This study provides preliminary evidence which suggests that social interaction constructed the perception about the experiences and the responses to adolescents’ body image. Therefore, it is essential to consider these formative influences and the social interaction processes of body image construction among overweight and obese adolescents, in developing obesity intervention programs. The obesity intervention program may be helpful in managing adolescents’ weight and initiate motivation for weight reduction. Overweight and obese adolescents must be thoroughly taught and effectively informed about the significance of healthy weight and a good body image. However, as has been noted throughout, the present findings are preliminary and should ideally be used to encourage additional research on this important topic. A further in-depth qualitative study is needed to give fuller and richer results. Future research should interview parents to gain their perspective. Parents’ perspective would contribute to our understanding of the topic.