Overall, this study demonstrated that obese youth perceive varying levels of social support based on source. Specifically, obese youth not only derived the greatest level of social support from parents and close friends but also placed the most value on these sources. In contrast, obese youth seemed to perceive the least amount of social support from classmates and schools. The latter finding is interesting given that classmate support seemed to have the strongest influence on obesity-specific health-related quality of life (HRQOL).
Close friends, closely followed by parents, play a significant role in providing support to obese youth. These findings are consistent with prior research, suggesting that parents and friends are primary sources of social support for children and adolescents.22
These individuals are significant sources of empathy and love (i.e., emotional support), assistance with daily tasks (i.e., instrumental support), and evaluative feedback (i.e., appraisal support). Although generic, not obesity-specific social support, was examined, close friends and parents may be key agents of change for obesity intervention and prevention efforts, by supporting treatment-seeking obese youth in their weight loss attempts, making healthier food choices, engaging in physical activity, and maintaining healthy self-esteem. Preliminary research with children who are overweight suggests that including peers23
in treatment is promising. For example, Janicke et al24
found that children assigned to a parent-only intervention, as well as a family-based group intervention (parent and child), demonstrated greater decreases in body mass index (BMI). Including close friends and parents in clinical interventions may be an important area for future research, given that enlisting friend support has shown positive effects for self-care in other pediatric conditions, such as Type 1 diabetes.25
As hypothesized, teachers were identified as an important source of support, particularly informational support. In terms of giving advice and problem solving, obese youth identified teachers as providing the highest level of support. Receiving such support was also deemed more important from teachers than classmates and school. Although overall teacher support is likely not specific to weight management, given their perceived importance, teachers and other adult figures in the school (e.g., coaches, school nurses, health counselors) may be in a unique position to first, receive education and training on the psychosocial and nutritional aspects of childhood obesity and second, provide developmentally-appropriate education on nutrition and healthy lifestyle behaviors in the classroom. School-based obesity interventions have mostly been provided by external sources (e.g., volunteers and students) and demonstrate some improvements on BMI and healthy lifestyle practices.26–27
Receiving intervention from a teacher who is familiar and whom obese youth value may be a promising avenue. In contrast, obese youth rated classmates and schools as providing the least social support and also placing little importance on support from these sources. This may be due to factors identified in the literature, which document that (a) obese youth self-report greater victimization/bullying by school peers,28
and (b) school peers perceive them as less socially competent29
relative to youth who are not overweight.
The concordance between frequency and importance ratings should also be considered. Adult research suggests that individuals do not necessarily receive the type of support they value or seek out, which can lead to dissatisfaction and distress.30
However, in our sample, obese youth reported receiving the type of support they value most from the people they seek it from. Although youth may have greater difficulty discerning the differences between these 2 constructs (i.e., frequency and importance), it is also possible that the support needs of obese youth are being met.
Results regarding relations between sociodemo-graphic variables, anthropometric characteristics, and importance/frequency ratings of social support partially supported our hypotheses. Contrary to the developmental literature, no gender differences were noted on social support. The presence of a chronic condition (e.g., obesity) may play a more salient role than gender, with boys and girls reporting similar levels of support. Minority youth also reported greater support from parents, compared with nonminority youth. This extends prior research showing that African-American youth, which made up more than half of our sample (e.g., 60.8%), often derive large amounts of support from family networks relative to outside sources.31
Cultural differences regarding weight and body size beliefs may contribute to these findings. For example, research shows that African-Americans prefer a significantly heavier body size compared with whites,32
with obesity being more acceptable in African-American families.33
Finally, higher BMI z-score (zBMI) in this exclusively obese sample was associated with less perceived teacher support. Previous work has demonstrated that treatment-seeking youth with extreme obesity (BMI > 40 kg/m2
) reported greater impairments in school functioning than nontreatment-seeking obese youth.34
It is possible that youth in the present sample with higher BMIs were experiencing such difficulties and perceived their teachers as less supportive.
Our hypothesis on the relation between social support and obesity-specific HRQOL was partially supported. Close friends did not significantly predict the HRQOL of children with obesity, but support from classmates was the main predictor of most dimensions of QOL. As perceptions of support from classmates increased, obese youth endorsed better emotional and physical functioning, greater comfort in and less avoidance of social situations, less marginalization/teasing, and greater overall QOL. This is consistent with research on generic HRQOL, linking greater classmate support to higher HRQOL.2
This finding is ironic, given that obese youth reported receiving little support from classmates and placing little importance on their support. However, perceptions of social support from classmates may indirectly reflect the degree to which obese youth are teased or bullied by classmates; that is, low classmate support may reflect greater teasing by classmates, which is related to lower HRQOL. The higher frequency of peer bullying documented among children who are obese and overweight35
suggests that negative or minimal peer interactions may lead to perceptions of not being supported and lead to less value placed on classmate support. Yet, classmates appear highly salient to how obese children feel about themselves and how comfortable they feel in their surroundings. This may be due to the large amount of time children spend with classmates during the school day or the role classmates play in creating peer norms and/or social status that children who are obese may not “fit” into.
Our findings must be interpreted within the context of study limitations. Future research that compares the support networks of obese youth across various support providers with those of healthy children may provide a better representation of whether obese youth differ significantly from nonobese counterparts in the amount of support they receive and the type of support they value. Second, the Child and Adolescent Social Support Scale (CASSS) assesses general social support, not support specific to the demands of a chronic condition like pediatric obesity. Although an obesity-specific social support measure does not currently exist, an important future direction would be to assess supportive behaviors related to engagement in healthy eating, physical activity, and dieting behaviors. Prior research in obese young adults illustrates the importance of examining support for specific weight-related behaviors (e.g., physical activity) because lack of support has been linked to greater BMI.36
Third, this study focused on treatment-seeking youth with obesity; the possibility that obese children and adolescents who are not involved in weight management treatment may perceive social support networks differently must be considered. For example, obese youth whose families do not seek treatment may perceive receiving greater social support from all networks and consequently might not pursue treatment. Alternately, an obese child or adolescent whose QOL is impaired by their excess weight may perceive lower social support from adults and age-mates if their family is unable to pursue care or minimizes its impact. Future research should explore the role of perceived social support in the process of a child or adolescent's consideration of intervention and the family's pursuit of care. Fourth, this study was descriptive and did not assess the causal link between obese youth's perceptions of social support and other salient outcome variables (e.g., healthy lifestyle behaviors). Future research evaluating the relations between perceptions of support from different sources and lifestyle behaviors may prove particularly beneficial. For example, if close friends are influential in supporting or sabotaging healthy eating behaviors, weight management interventions can focus on enlisting the help of these individuals and/or problem solving with obese youth about the social pressures of eating with friends. Fifth, these data characterize a clinically referred sample of obese youth. Obese children who present to multidisciplinary weight management programs may differ from obese youth in the broader community who lack access to care. Finally, suppressor variables, which we identified, may reflect interrelations or redundancy among items or subscales on the CASSS; for example, classmates may be interpreted by our sample as being subsumed under the larger school support variable. This is possible because the CASSS provides no instructions, definition, or specifications to the respondent regarding which individuals are subsumed into the school subscale; rather, respondents are asked to answer items based on “people in my school.” Suppressor variables can consequently be useful for altering research instruments.37
Future research is needed to first replicate these suppressor effects to determine whether these are instrument specific, and next, make any modifications to this instrument to reduce potential redundancy or interrelatedness between subscales and better distinguish between school and classmate support.
This study represents an initial step in describing the social support networks of obese youth and examining its association to obesity-specific HRQOL. Overall, findings suggest that obese youth perceive themselves as being well supported by close friends, parents, and teachers, and valuing support from these sources. In contrast, although obese youth did not perceive classmates as providing high levels of support nor being a highly valued source of support, classmate support seems to be the only significant predictor of HRQOL. Findings may inform weight management interventions by identifying which individuals to include in treatment surrounding healthy eating behaviors, physical activity, and obesity-specific HRQOL.