Introduction

Obesity is a major health problem all over the world. The prevalence of obesity among children and adolescents by gender is 23.8% in males and 22.6% in females in developed countries, whereas it is 12.9% and 13.4%, respectively, in developing countries [1]. Childhood obesity rates in Turkey are similar to regional and global trends, and the prevalence of overweight and obesity in children has grown in the past few decades. According to the World Health Organization, European Childhood Obesity Surveillance Initiative (COSI, 2013), 14.2% of children were overweight and 8.3% obese. It is now estimated that the prevalence of obesity had grown to around 10% [2].

Excess body fat in obesity negatively influences both physical and mental health. Cardiovascular, endocrine and musculoskeletal complications are well known medical complications in obese adolescents [3]. In addition to physical health concerns, a growing literature has linked obesity to negative psychosocial consequences during adolescence including poor emotional adjustment and stigmatization. Adolescents are more susceptible to body weight and shape-related concerns than younger children because identity development is a primary task in adolescence, and both body image and self-esteem are involved with identity formation [4]. Issues related to body perception, feeling of dislike by peers and adults, social withdrawal and aggression are commonly reported psychosocial symptoms of adolescents with obesity [5]. Also, depression, anxiety, low self-esteem, somatoform disorders, and eating disorders should be considered in the psychiatric evaluation [6].

A recent study stated that the family had a protective effect, but friends and media had a negative effect on the weight-control behaviors of teens [7]. Peers are among the most influential groups in shaping the psychosocial maturation process during adolescence, sometimes causing psychological problems as well as psychiatric symptoms in obese adolescents. It has been reported that adult males with negative emotional experiences created by their peers at an early age had negative body image and experienced more shame about their appearance [8]. Depression and anxiety symptoms, feeling of loneliness or destructive behaviors in obese adolescents are associated with exposure to bullying and victimization of their peers [9, 10]. Parents’ attitudes and beliefs towards obesity may also be influential in the development of psychosocial problems in adolescents with obesity. To the best of our knowledge, there are few studies concerning the attitudes and beliefs of parents towards obesity and the influence of those attitudes and beliefs on the psychiatric symptoms of obese adolescents.

The aim of this study was to determine the psychiatric symptoms of obese or overweight adolescents and effects of the attitudes and beliefs of their parents towards obesity as well as their peers on their psychiatric symptoms.

Methods

This study was conducted at Hacettepe University, Department of Pediatrics, Division of Adolescent Medicine between August 2015 and August 2016 and was approved by the Ethics Committee of Hacettepe University. Written informed consent was obtained from all participants and their parents.

The study group included a total of 110 obese (n = 85, 77.2%) and overweight (n = 25, 22.8%) adolescents (52 male and 58 female) who were evaluated and followed-up in the Adolescent Medicine Outpatient Clinic. Body mass index (BMI) (kg/m2) was used to define healthy weight (5th–85th percentile), overweight (85th–95th percentile) and obesity (equal to or greater than the 95th percentile) categories according to age and gender-specific growth reference data [11]. Adolescents with chronic disease and psychiatric disorders were not included in the study. The control group consisted of 55 adolescents of healthy weight who were enrolled at well-child care visits, with no known chronic disease. All participants were between the ages of 12–18 years.

Measurements of weight (in kilograms) were obtained using electronic scales (Scale-Seca 220, Hamburg, Germany), and measurements of height (in centimeters) were obtained using the Harpenden stadiometer.

Height and body weight of all the participants’ parents were obtained verbally. BMI (kg/m2) of parents was calculated. According to the BMI outcomes, parents were classified as underweight (BMI < 18.5), normal (18.5 ≤ BMI > 25), overweight (25 ≤ BMI < 30) and obese (30 > BMI). All adolescents completed the Brief Symptom Inventory (BSI) and Traditional Bullying Scale (TBS). Either mother or father of the participant completed the Attitudes towards Obese Persons (ATOP) Scale and Beliefs about Obese Persons (BAOP) Scale.

Brief symptom inventory

BSI scale was translated to Turkish and standardized by Şahin and Durak [12] for adolescents in Turkey. Participants were asked “how much the symptoms and complaints indicated in the scale bothered them within the last week” and then were asked to circle any one of the five items accordingly. The items on BSI were scaled between 0 and 4, from “none” to “too much”. The scale includes anxiety, depression, negative self, somatization, and hostility sub-categories. For pathologic psychiatric symptom analysis, Global Severity Index (GSI) was calculated by adding all the points and dividing by 53 which is the total number of the questions in the scale and results above 1.0 indicated psychopathology. If GSI is less than 1.0, this indicates that the symptoms are not at psychopathological level. Sub-categories are scored by dividing the sum of relevant scores into the number of relevant questions in that category. The cutoff point for a sub-category-related psychopathology is accepted as 1.0 [12, 13].

Traditional bullying scale

It comprises two parallel forms (bully and victim) to identify the adolescents’ frequency of being subject to peer bullying and being involved in bullying behaviors themselves at school environment within the last 6 months. The scale is of self-rating type and contains 32 Likert-type items (1 = never, 2 = once, 3 = two–three times, 4 = more than three times). In each item, option “a” measures the adolescent’s experience as the victim, and “b” measures the adolescent’s experience as the bully. Those with a peer bullying score of one standard deviation above the mean are included in the “bully” group; those with an exposure to peer bullying score of one standard deviation above the mean are included in the “victim” group; those with both the peer bullying and the exposure to peer bullying scores of one standard deviation above the mean are included in the “bully/victim” group; those who are not involved in bullying are included in the “not involved” group. In the adaptation studies of the scale to Turkish, the victim form was based on the study by Gültekin and Sayıl [14], and the bully form was based on the study by Pekel-Uludağlı and Uçanok [15]. The psychometric properties of the scale which was adapted for adolescents aged 12–18 years were re-evaluated and developed by Burnukara [16]. Overall internal consistency coefficient of the victim form is 0.90, and the bully form is 0.91.

The attitudes and beliefs toward obese persons scale

Both scales; the “Attitudes toward Obese Persons (ATOP) Scale” and “Beliefs About Obese Persons (BAOP) Scale”, were initially developed by Alison et al. [17]. The ATOP scale includes 20 items in Likert question type. Each item is scored between − 3 (strongly disagree) and + 3 (strongly agree). Scores obtained from the scale can be between 0 and 120. While high scores indicate a positive attitude towards obese people, low scores indicate a negative attitude. In the BAOP scale, there are 8 items in Likert question type and the answers are again scored between − 3 (strongly disagree) and + 3 (strongly agree). Scores obtained from the scale can be between 0 and 48. High scores indicate that the person filling in the questionnaire believes obesity is not under the control of the person with obesity. Low scores indicate that he/she believes obesity is under the control of the obese person. Translation, adaptation, and validity/reliability study of ATOP and BAOP scales were done by Tüzün et al. [18]. Internal reliability coefficient is 0.79 for ATOP, and 0.54 for BAOP. The correlation coefficient between ATOP and BAOP is 0.24 (p < 0.01).

Statistics

IBM SPSS for Windows Version 22.0 was used for statistical analysis. Numerical variables were summarized with mean ± standard deviation. Quantitative variables were shown by number and percentage. All numerical variables have met the parametric test assumptions, and thus, student t test was used for independent groups to find out whether there was any difference in numerical variables among the groups. Chi-Square test or Fisher’s exact test was used to examine whether there was a difference between the groups in terms of quality variables. The significance level was determined as p ≤ 0.05.

Results

A total of 110 adolescents with a mean age 14.0 ± 1.5 years and BMI 29.83 ± 4.56 kg/m2 were included in the study group and 55 adolescents with a mean age 14.9 ± 1.6 years and BMI 20.43 ± 2.23 kg/m2 were included in the control group. Of the adolescents in the study group 52.7% (n = 58) were female and 47.3% (n = 52) were male, in the control group 58.2% (n = 32) were female and 41.8% (n = 23) were male.

There was a significant difference between the study and the control groups in terms of whether their fathers (p = 0.029) or mothers (p = 0.002) were overweight or obese. For fathers, 86.4% of the study group and 70.9% of the control group were overweight or obese, while for mothers 85.5% of the study and 61.8% of the control group were overweight or obese.

The ratio of the adolescents having BSI-depression scores at psychopathological levels in the study group was significantly higher than that of the control group (p = 0.026). There were no significant differences between the study and control groups in regards to the ratio of adolescents having anxiety, negative self, somatization, hostility, and GSI scores at psychopathological levels (p > 0.05) (Fig. 1).

Fig. 1
figure 1

BSI scores at psychopathological levels in adolescents in the control and study groups. *p = 0.026

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The study and control groups were also compared according to gender. The ratio of male adolescents having BSI-anxiety scores at psychopathological levels in the study group was significantly higher than that of the control group, but no other significant differences were found in other categories of BSI (p = 0.014) (Fig. 2).

Fig. 2
figure 2

BSI scores at psychopathological levels in male adolescents in the control and study groups *p = 0.014

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Females in the study and control groups did not demonstrate any statistically significant difference between their BSI scores at psychopathological levels. But the female adolescents in the study group had more depression (p = 0.068), anxiety (p = 0.459), negative self (p = 0.293), somatization (0.586) and hostility (p = 0.330) symptoms than the control group.

Within the study group, BSI scores at psychopathological levels were evaluated depending on the gender. The ratio of female adolescents having anxiety, depression, somatization and GSI scores at psychopathological levels was significantly higher than the males in the study group (p < 0.05) (Fig. 3).

Fig. 3
figure 3

BSI scores at psychopathological levels in female and male adolescents in the study group *p = 0.028, **p = 0.003, ***p < 0.001, ****p = 0.014

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There was no significant difference between the ATOP (56.5 ± 12.8, 59.9 ± 14.5) and BAOP (24.0 ± 31, 23.7 ± 3.6) scores of the parents in the study and control groups, respectively. However, a linear correlation was observed between the ATOP and BAOP scores in the study group (correlation coefficient 0.416, p < 0.001) whereas no correlation was detected between the ATOP and BAOP scores in the control group (correlation coefficient 0.158, p = 0.248).

None of the psychiatric symptoms in the sub-categories of BSI and GSI of the adolescents were correlated with the ATOP and BAOP scores of their parents in both groups (p > 0.05). The ATOP and BAOP scores of the parents according to the cutoff points of the psychiatric symptom scales of BSI in the study group are seen in Table 1.

Table 1 Correlation of the psychiatric symptoms of the study group and ATOP and BAOP scores of their parents
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The percentage of adolescents involved in any type of bullying was higher in the study group (n = 28, 25.5%) when compared with the control group (n = 6, 10.9%); however, the difference between the groups was not statistically significant (p > 0.05) (Table 2).

Table 2 Adolescents involved in any kind of bullying in the control and study groups
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In the study group, psychiatric symptoms in every sub-category of BSI and GSI of adolescents who were involved in any kind of bullying were significantly higher than the adolescents who are not involved in bullying (p < 0.001) (Table 3).

Table 3 Psychiatric symptoms in the study group according to the involvement of bullying
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Discussion

This study aimed to evaluate the psychiatric symptoms of obese or overweight adolescents, the effects of beliefs and attitudes of their parents towards obesity and the effect of peer bullying on these symptoms. This study had two main results: primarily, we determined that the psychiatric symptoms of obese or overweight adolescents who were involved in any peer bullying were significantly increased. Secondly, as a novel finding, the parents of obese or overweight adolescents were not accusatory, judgmental or stigmatizing and did not affect the development of psychiatric symptoms.

In line with the current literature, our study showed, depressive symptoms of obese or overweight adolescents to be significantly higher than that of adolescents with healthy body weight. Studies show increased body weight in adolescents was found to be frequently associated with depressive symptoms followed by symptoms of anxiety [19,20,21,22]. However, a few other studies stated that there might not be a causal relationship between increased body weight and depression and a meta-analysis confirmed a reciprocal link between depression and obesity [23, 24]. In the literature, more psychopathologies are reported in adolescents with obesity in clinical samples than the community-based samples [25, 26]. During adolescence, physical appearance has a strong influence on self-esteem which is highly associated with emotional disorders. In our study, the increase in depressive symptoms in obese or overweight adolescents was attributed to the developmental importance of body perception satisfaction in all adolescents and the fact that increased body weight in these adolescents may negatively affect body perception and therefore self-esteem and low self-esteem may, in turn, lead to depressive mood. However, since the main purpose of this study was to investigate the effects of the beliefs and attitudes of the parents towards obesity and the effects of peer bullying on the psychiatric symptoms of obese or overweight adolescents who applied to the clinic; the body perceptions and self-esteem of these adolescents were not evaluated in the study.

When the female adolescents were evaluated separately, no statistically significant difference was found between the psychiatric symptoms of obese or overweight adolescents and the control group. However, psychiatric symptoms of obese or overweight females were found to be more common, as shown in studies [27,28,29]. The lack of difference could be attributed to the small sample size or to the fact that there may also be dissatisfaction with body perception in female adolescents with healthy body weight. The gender difference is a distinctive feature of adolescents’ perceptions of their own bodies. Generally, female adolescents are less satisfied with their bodies than male adolescents, and body images are more negative [30]. In a study with children and adolescents aged between 9 and 18 years, it was found that body dissatisfaction began when BMI was over the 50th percentile in females and 75th percentile in males [31]. In addition, it has been reported that female adolescents may be more vulnerable to depressive symptoms due to sociocultural, familial and hormonal reasons [32, 33]. In our study, when obese or overweight adolescents were evaluated in two groups depending on gender; depression, anxiety and somatization symptoms were found to be significantly higher in females than in males similar to the literature [27, 34].

Obese or overweight male adolescents had significantly higher anxiety symptoms than male adolescents with healthy body weight. Factors such as being in the clinic and the need for diet planning with the requirement of restrictions may contribute to the increased anxiety symptoms in male adolescents. Previous studies also have concluded that the need for restrictions in the diet might be related to psychopathology in obese or overweight adolescents in both sexes [35, 36]. However, in our study, it was determined that 66.6% of obese or overweight male adolescents were exposed to peer bullying as a victim and/or bully suggesting that peer bullying could be an important cause of increased anxiety in this group. In our study, although the difference between the groups was not statistically significant, the percentage of adolescents involved in any type of bullying was higher more than two folds in obese or overweight adolescents (25.5%) when compared with adolescents of healthy body weight (10.9%) which is similar to the literature [37,38,39]. It is stated that obese adolescents have less ability to cope with peer bullying and have difficulty defending themselves often becoming victims [37]. In a recent study, hopeless feeling and suicidal ideation were significantly associated with being bullied in obese male adolescents [37]. On the other hand, obese teens may also become bullies since they are physically more well-built and sometimes may be both bullies and victims [39]. Previous studies have shown psychiatric symptoms to be observed in those individuals who have been excluded, stigmatized, discriminated and bullied by their peers. In these studies, it is stated that the adolescents who are bullying have aggression, attention deficit, and hyperactivity disorder while victims often have depression, anxiety, psychosomatic problems and eating disorders [40, 41]. Another study reported that adolescents encountering negative verbal or physical peer attitudes in addition to body dissatisfaction due to their weight might cause serious psychopathologies [42].

We also found that symptoms of depression, anxiety, somatization, hostility, and negative self were significantly higher in obese or overweight adolescents who were involved in peer bullying as a victim and/or bully than those who were not. In another study conducted in a weight loss activity, it was found that those who were teased related to their weight by their friends experienced more frequent negative emotions [43]. Also, the global severity index of these adolescents which shows total psychiatric symptom loads were significantly higher. These results support the initial hypothesis of this study suggesting that the peer norms are very important especially in the middle adolescence period as they feel the need to be accepted and approved by their peers.

Our other hypothesis was that the beliefs and attitudes of parents towards obesity would be effective in the development of psychiatric symptoms in obese adolescents. However, we found that there was no significant difference between the scores of beliefs and attitudes of parents towards obesity in the two groups. According to Weiner’s attribution theory [44], causal attributions play crucially important roles in the development of reactions to stigmatized people. Causal attributions of obesity to internal controllable factors have previously been found to be one of the strongest predictors of attitudes towards obesity in observational studies [45, 46]. Thus, considering the fact that obesity can ‘be controlled by the individual’ may cause stigmatization, discrimination, and prejudice against people with obesity. On the contrary, the belief that obesity is not controlled by the person and is caused by other health factors has been associated with a positive attitude towards obesity. In our study, the fact that the attitudes and beliefs of the parents of obese or overweight adolescents did not have an association with the psychiatric symptoms of adolescents, suggested that these adolescents were not treated with any negative attitudes towards obesity by their parents. In addition, the correlation between the beliefs and attitudes of the parents of these adolescents towards obesity shows not only the consistency of our results but also that these parents were not accusatory, judgmental or stigmatizing against their children. In a recent study, it was stated that good relations with the family had a positive effect on the psychology of these children [47]. On the other hand, other studies have concluded that parents can show stigmatization towards adolescents in relation to body weight [48] and that adolescents were teased by their parents because of their weight and there was a relationship between this misbehavior and body dissatisfaction, depression and eating disorders [49, 50].

In our study, the positive beliefs and attitudes of the parents towards obesity in the study group may be related to the fact that most of the parents themselves were also obese or overweight. Additionally, more than half of the parents of the control group were also obese or overweight which might have caused a non-significant difference between the groups. This could be argued as a limitation of the study.

An additional limitation to the study was the relatively small sample size of the obese or overweight adolescents involved in bullying, which meant that the statistical analysis of psychiatric symptoms could not be performed according to gender.

In Turkey, the prevalence of overweight/obesity has increased significantly in the last 2 decades in both adults and children, the results of this study suggest that the clinical treatment of obesity is not just a matter of diet and exercise but also dealing with other issues such as depression and anxiety. Physicians working with obese adolescents should approach this issue with an integrative assessment. A very satisfactory result, in this context, was that the parents of obese or overweight adolescents in Turkey did not show an increased bias due to weight. The positive beliefs and attitudes of the parents towards obesity indicate that they will comply with the treatment and the follow-up much more easily. This study has also shown the association between negative social and psychological ramifications such as peer aggression as the members of the study group were more likely to be the victims and perpetrators of bullying behaviors than their normal-weight peers. These findings emphasize the importance of psychosocial assessment and the necessity of peer-related interventions for adolescents with obesity.