This study demonstrated a lack of adverse effects on self-esteem and body satisfaction among all study participants regardless of study group assignment. Among adolescent girls assigned to the PACE intervention who maintained or lost weight over the intervention period, we demonstrated improvements in body image over time. This is reassuring given that the PACE+ study is the largest randomized controlled trial to date to evaluate a primary care-based behavioral intervention to improve physical activity, sedentary and diet behaviors among adolescents [14
In our study cohort, there were differences in body image and self-esteem among adolescents at the baseline evaluation. In particular, girls and overweight adolescents reported lower body image and self-esteem compared to boys and normal weight adolescents across all measurement visits. We also demonstrated significant correlations between body image and self-esteem measures among both boys and girls. These findings concur with several previous studies. In a recent review of body image studies among community samples of overweight children, all evaluated studies documented greater body dissatisfaction among heavier children and adolescents [19
]. Prior work indicates that children with poorer body image report lower global self-worth and poorer self-esteem [20
Adolescents participating in the PACE+ study demonstrated no differences in body image or self-esteem measures over the intervention period as compared to the control group. Among males, modest improvements in self-esteem independent of study group assignment or weight change status over the 12-month intervention period were observed. These findings are encouraging and suggest that adolescent-directed health promotion programs focused on improved physical activity and dietary habits are not likely to have negative psychological consequences. Although the PACE+ intervention did not specifically target weight loss as an outcome, PACE+ did focus on increasing healthy behaviors such as reducing fat intake and sedentary behavior and increasing fruit and vegetable intake and physical activity, which have been associated with successful weight maintenance and loss [24
We previously demonstrated that a behavioral intervention (GRAD: Graduate Ready for Activity Daily) among university seniors targeting physical activity behaviors can induce adverse psychological effects (increased drive for thinness) among female intervention participants [15
]. In contrast, our PACE intervention did not adversely affect either body image or self-esteem among both boys and girls. The PACE intervention targeted adolescent youth, while the GRAD intervention was performed among college students. Therefore, one potential factor that may explain the differences in secondary effects of these behavioral programs is the targeted age of intervention. The lack of adverse psychological effect demonstrated in our PACE cohort may support early interventions targeting adolescent youth instead of young adults.
Among adolescent girls assigned to the PACE condition who were able to maintain or reduce weight over the intervention period, we found improvements in body image over the intervention period compared to adolescent girls whose body weight increased. This is an encouraging, albeit secondary outcome from the intervention. However, the same positive effect on body image was not found for PACE-assigned boys who maintained or reduced their weight. This disparity between boys and girls may be explained by gender differences in weight identity [27
] where weight status is more closely tied to judgments of relationship desirability among women versus men [28
It is interesting that adolescents randomized to the PACE intervention who lost or maintained their weight over the 12-month study period demonstrated lower baseline body image and self-esteem scores than those who went on to gain weight. These findings suggest that personal efforts to manage weight may be initially prompted by body dissatisfaction. Our finding in girls of an association between improvement in body image and weight management has been shown in previous studies [30
], which highlights the importance of psychological change in effective weight management treatment. Taken together, our results suggest that cognitive behavioral therapy programs that encourage patients to change the way they think about themselves and their bodies in a more positive, realistic manner [33
] may achieve the crucial lifestyle changes needed for long-term weight maintenance.
The findings of this study are subject to a number of limitations. First, generalizability of this study is limited to generally healthy adolescents seen in primary care settings. These findings might not apply to overweight adolescents who seek medical advice for weight control and who may be at increased risk for psychological morbidity [34
]. In addition, our notable attrition rate in participation among heavier and older adolescents may have resulted in a selection bias favoring thinner and younger children with fewer body image and self-esteem issues. Potential response bias in regards to demonstrated improvement in self-esteem measures over time among boys must be considered in this study given the reliance on self-report measures. The observed increases in self-esteem scores may reflect a methodological artifact of repeated assessment with participants becoming more comfortable with the assessment procedures and more inclined to provide socially desirable responses with repeated testing [35
]. Alternatively, this pattern may reflect age-related differences in children’s cognitive development and response biases [38
] although such findings have mainly been found in children younger than the current study cohort.
In conclusion, we demonstrated a lack of adverse effects on body satisfaction and self-esteem among adolescents undergoing a behavioral intervention study targeting healthy dietary and physical activity behaviors. Given the increasing prevalence of childhood obesity, similar interventions that are sensitive to body concept and self-esteem issues must be promoted among at-risk for overweight and overweight youth in order to reduce the prevalence of obesity-associated morbidities. While weight management programs must be vigilant regarding the potential development of eating disorders, our results from a large intervention program among adolescent youth suggest that behavioral interventions focused on health outcomes rather than actual weight loss and promoting healthy behaviors as part of a weight management program may be safely undertaken in otherwise healthy at risk for overweight and overweight adolescents without adverse psychological consequences.