Elsevier

Social Science & Medicine

Volume 60, Issue 6, March 2005, Pages 1165-1173
Social Science & Medicine

The role of social norms and friends’ influences on unhealthy weight-control behaviors among adolescent girls

https://doi.org/10.1016/j.socscimed.2004.06.055Get rights and content

Abstract

Dieting is common among adolescent girls and may place them at risk of using unhealthy weight-control behaviors (UWCBs), such as self-induced vomiting, laxatives, diet pills, or fasting. Research has suggested that social factors, including friends and broader cultural norms, may be associated with UWCBs. The present study examines the relationship between the school-wide prevalence of current weight loss efforts among adolescent girls, friends’ dieting behavior, and UWCBs, and investigates differences in these associations across weight categories. Survey data were collected in 31 middle and high schools in ethnically and socio-economically diverse communities in Minnesota, USA. The response rate was 81.5%. Rates of UWCBs were compared across the spectrum of prevalence of trying to lose weight and friends’ involvement with dieting, using χ2 analysis and multivariate logistic regression, controlling for demographic factors and clustering by school. Girls with higher body mass index (BMI) were more likely to engage in UWCBs than those of lower BMI. Multivariate models indicated that friends’ dieting behavior was significantly associated with UWCBs for average weight girls (OR=1.57, CI=1.40–1.77) and moderately overweight girls (OR=1.47, CI=1.19–1.82). The school-wide prevalence of trying to lose weight was significantly, albeit modestly, related to UWCBs for average weight girls (15th–85th percentile; OR=1.17, CI=1.01–1.36), and marginally associated for modestly overweight girls (85th–95th percentile; OR=1.21, CI=.97–1.50), even after controlling for friends’ dieting behaviors. The social influences examined here were not associated with UWCBs among underweight (<15th percentile) or overweight (>95th percentile) girls. Findings suggest that social norms, particularly from within one's peer group, but also at the larger school level may influence UWCBs, particularly for average weight girls. Implications for school-based interventions to reduce UWCBs are discussed.

Introduction

Dieting is a common occurrence among adolescent girls (Huon, 1994). According to the Youth Risk Behavior Surveillance System of the Centers for Disease Control (CDC) in the USA, almost two-thirds (59.4%) of adolescent girls report trying to lose weight in the past 30 days (CDC, 2000). While many use healthy strategies, such as exercising (67.4%) or eating fewer calories or foods lower in fat (56.1%), unhealthy strategies, such as fasting (18.8%), using diet pills/powders/liquids (10.9%), and vomiting or taking laxatives (7.5%) were also common (CDC, 2000). Research has shown that adolescent dieters, particularly those practicing unhealthy weight-control behaviors (UWCBs), may be less likely to consume fruits and vegetables and adequate amounts of calcium rich foods, compared to non-dieters (Neumark-Sztainer, Story, Dixon, Resnick, & Blum, 1997). Further, adolescent dieters may actually experience excess weight gain or the onset of obesity (Stice, Cameron, Killen, Hayward, & Taylor, 1999). Dieting also increases girls’ risk for developing UWCBs, disordered eating (Drewnowski, Yee, Kurth, & Krahn, 1994; French & Jeffery, 1994; Patton, Johnson-Sabine, Wood, Mann, & Wakeling, 1990; Huon, 1994; Patton, Selzer, Coffey, Carlin, & Wolfe, 1999), and depression (Stice, Hayward, Cameron, Killen, & Taylor, 2000). One study found that dieters were eight times more likely to develop an eating disorder than non-dieters (Patton et al., 1990). More extreme weight-control methods such as induced vomiting, laxative abuse, and binge-purge cycling have also been associated with tooth decay, damage to the esophagus, digestive problems, amenorrhea, and cardiomyopathy (Herzog & Copeland, 1985; Ho, Dweik, & Cohen, 1998; Johnson & Whitaker, 1992).

Given the multiple risks associated with UWCBs, the purpose of the current study is to examine elements of girls’ social environment and determine the extent to which they may be associated with such practices. Identifying modifiable social factors may suggest appropriate avenues for intervention and prevention of UWCBs.

Researchers have already begun to uncover certain social factors that may act on adolescent eating and weight-related behaviors, including direct persuasion (e.g. from parents), social norms and need to fit in with peers, and food availability at home, school, and away from home (Conner & Armitage, 2002; Stice, 1994; Story, Neumark-Sztainer, & French, 2002). Research has suggested that socio-cultural factors, such as a value on thinness, may be related to unhealthy weight-control and disordered eating behaviors (Levine, Smolak, & Hayden, 1994; Stice, 1994). In particular, exposure to media images of thin women have also been shown to contribute to poor body image and unhealthy weight-control practices (Field, Camargo, Taylor, Berkey, & Colditz, 1999; Field et al., 2001, Field et al., 1999; Turner, Hamilton, Jacobs, Angood, & Dwyer, 1997).

One of the most extensive segments of the literature on the social influences on adolescents’ weight-related behaviors addresses the role of peers and friends. Several researchers have demonstrated the important influence of friends, suggesting that the weight-related attitudes and behaviors among friendship groups may predict body image, dieting onset, chronic dieting, UWCBs, and eating disorder symptoms, even after controlling for various family, friend, and individual factors (Gibbs, 1986; Huon, Lim, & Gunewardene, 2000; Huon & Walton, 2000; Paxton, Schutz, Wertheim, & Muir, 1999; Pike, 1995). Several mechanisms have been proposed to explain these similarities, such as friends’ sharing information on weight-control strategies (Desmond, Prince, Gray, & O’Connell, 1986), friends participating in “fat-talk” (Nichter, 2000), modeling disordered eating behavior (e.g. teaching how to induce vomiting; Stice, 1994), or self-comparison to others in the clique (Wertheim, Paxton, Schutz, & Muir, 1997).

Peer influence may also operate more broadly, in a larger social unit such as the school environment. Pressure to diet may come through direct contact in the form of weight-teasing, which is widespread—particularly among overweight individuals—and has been linked to UWCBs (Neumark-Sztainer et al., 2001). Wertheim et al. (1997) suggest a more indirect mechanism, such as the idealization of “popular” girls as thin and pretty, which may manifest itself in a desire to diet in order to emulate or fit in with this crowd, even in the absence of any overt persuasion from the popular girls.

Social norms are another mechanism through which peer influence may operate without any direct contact. A high prevalence of a behavior among young people in a setting may send a subtle message that such behavior is accepted and indeed, expected, which may encourage adoption of that behavior throughout that social setting. Social norms of binge drinking (Lo & Globetti, 1995; Wechsler, Kuh, & Davenport, 1996) and binge eating (Crandall, 1988) have been tied to these behaviors among individuals in the relatively cohesive settings of college fraternities and sororities. Austin (2001) has also illustrated this relationship in middle schools, where the school-wide prevalence of dieting (without high-risk methods) was associated with the school-level prevalence of disordered eating behaviors.

Social influences related to dieting may function differently across the weight spectrum. For example, overweight girls may be socially marginalized (Strauss & Pollack, 2003), may be frequent victims of weight-based teasing (Neumark-Sztainer et al., 2001), or may be motivated due to health concerns, all of which may impact their dieting behavior. The dieting behavior of underweight or average weight girls, by contrast, may be more directly influenced by the attitudes and behaviors of family or friends. However, the moderating effect of body weight in the relationship between socio-cultural influences and weight-related behaviors has not been well examined in the scientific literature (Stice, 1994).

Although the existing literature documents the importance of social influences on girls’ dieting and UWCBs, to our knowledge no study has simultaneously examined the influences of friends and social norms. Such an investigation would allow us to parse out the contribution of proximal influences of friends and the more distal influences of the school environment. Distinguishing these influences may provide insight into strategies for reducing the use of unhealthy weight-control practices among girls. Thus, the purpose of the present study is to examine the relationship between two social factors: (a) the school-wide prevalence of girls’ trying to lose weight (a proxy for normative dieting behavior in the school environment) and (b) perceptions of friends’ dieting behavior (as modeling of dieting behavior), and associations with UWCBs in a large, community-based sample of adolescent girls. This study further addresses the question of whether these social factors operate consistently across weight categories of adolescent girls. We hypothesize that girls attending schools that have a high prevalence of girls trying to lose weight and who have many friends who diet will be more likely to engage in UWCBs than girls without these characteristics. Furthermore, we expect these social influences to be more salient for average weight and underweight girls than overweight girls.

Section snippets

Methods

Data for this study come from Project EAT (Eating Among Teens), a comprehensive study of eating patterns and weight concerns among adolescents. Thirty-one public middle and senior high schools in ethnically and socio-economically diverse communities in the urban and suburban school districts of the Minneapolis/St. Paul metropolitan area participated in the study. A 221-item survey assessing a range of socio-economic, personal, and behavioral factors relevant to dietary intake and weight status

Characteristics of the sample

Characteristics of the student sample are shown in Table 1. Approximately two-thirds of the girls were in high school, and almost half (45.7%) were white. Girls were fairly evenly distributed across the five SES categories. The majority (62.8%) of girls were of normal weight, 19.9% were moderately overweight and an additional 12.5% were overweight. Many girls (44.9%) reported engaging in UWCBs. Likewise, many reported their friends were either somewhat (26.4%) or very much (15.8) involved in

Discussion

Results from this study show that social influences—perceptions of friends’ dieting and, to a lesser extent, the prevalence of trying to lose weight throughout a school—are associated with UWCBs for a large group of adolescent girls. The relationship of the school-wide prevalence of trying to lose weight and UWCBs was maintained for average weight girls and moderately overweight girls (at a marginally significant level) after friends’ dieting was included in multivariate models. This suggests

Acknowledgements

This study was supported by grant #MCJ-270834 (D. Neumark-Sztainer, principal investigator) from the Maternal and Child Health Bureau (Title V, Social Security Act), Health Resources and Service Administration, US Department of Health and Human Services

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