Peer, Parent, and Media Influences on the Development of Weight Concerns and

Frequent Dieting Among Preadolescent and Adolescent Girls and Boys

Alison E. Field, Carlos A. Camargo Jr, C. Barr Taylor, Catherine S. Berkey, Susan B.
Roberts and Graham A. Colditz
Pediatrics 2001;107;54-60
DOI: 10.1542/peds.107.1.54

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://www.pediatrics.org/cgi/content/full/107/1/54

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2001 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

Downloaded from www.pediatrics.org by on September 1, 2008

 Peer, Parent, and Media Influences on the Development of Weight
Concerns and Frequent Dieting Among Preadolescent and Adolescent
Girls and Boys
Alison E. Field, ScD*; Carlos A. Camargo, Jr, MD, DrPH*‡; C. Barr Taylor, MD§;
Catherine S. Berkey, ScD, MA*储; Susan B. Roberts, PhD¶; and Graham A. Colditz, MD, DrPH*#
ABSTRACT. Objective. To assess prospectively the
influence of peers, parents, and the media on the devel-
opment of weight concerns and frequent dieting.
Design. Prospective cohort study.
Setting. Questionnaires mailed annually to partici-
pants throughout the United States.
Participants. One-year follow-up of 6770 girls and
5287 boys who completed questionnaires in 1996 and
1997 and were between 9 and 14 years of age in 1996.
Main Outcome Measure. Onset of high levels of con-
cern with weight and dieting frequently to control
weight.
Results. During 1 year of follow-up, 6% of girls and
2% of boys became highly concerned with weight and 2%
of girls and 1% of boys became constant dieters. Peer
influence was negligible. Independent of age and body
mass index, both girls (odds ratio [OR]): 1.9; 95% confi-
dence interval [CI]: 1.1–3.1) and boys (OR: 2.7; 95% CI:
1.1– 6.4) who were making a lot of effort to look like
same-sex figures in the media were more likely than their
peers to become very concerned with their weight. More-
over, both girls (OR: 2.3; 95% CI: 1.1–5.0) and boys (OR:
2.6; 95% CI: 1.1– 6.0) who reported that their thinness/lack
of fat was important to their father were more likely than
their peers to become constant dieters.
Conclusions. Our results suggest that parents and the
media influence the development of weight concerns and
weight control practices among preadolescents and ado-
lescents. However, there are gender differences in the
relative importance of these influences. Pediatrics 2001;
107:54 – 60; dieting, adolescents, parents, peers, media.
ABBREVIATIONS. GUTS, Growing Up Today Study; NHS II,
Nurses’ Health Study II; BMI, body mass index; MRFS, McKnight
Risk Factor Survey; OR, odds ratio; CI, confidence interval.
From the *Channing Laboratory, Department of Medicine, Brigham and
Women’s Hospital and Harvard Medical School, Boston, Massachusetts;
‡Department of Emergency Medicine, Massachusetts General Hospital and
Harvard Medical School, Boston, Massachusetts; §Department of Psychiatry
and Behavioral Science, Stanford Medical School, Stanford, California; 储De-
partment of Health Policy and Management, Harvard School of Public
Health, Boston, Massachusetts; ¶Energy Metabolism Laboratory, Jean
Mayer US Department of Agriculture Human Nutrition Research Center on
Aging, Tufts University, Boston, Massachusetts; and the #Department of
Epidemiology, Harvard School of Public Health, Boston, Massachusetts.
Received for publication Nov 4, 1999; accepted May 23, 2000.
Reprint requests to (A.E.F.) Channing Laboratory, 181 Longwood Ave,
Boston, MA 02115. E-mail: alison.field@channing.harvard.edu
PEDIATRICS (ISSN 0031 4005). Copyright © 2001 by the American Acad-
emy of Pediatrics.
54 PEDIATRICS Vol. 107 No. 1 January 2001
Downloaded from www.pediatrics.org by on September 1, 2008
T
he association between body weight of chil-
dren and their parents is known to be influ-
enced by both genetic and cultural factors.
However, little is known about the relationship be-
tween the weight concerns and weight control prac-
tices of parents and their children. Concerns with
weight and body shape and dieting to lose weight
are common among preadolescent and adolescent
girls1– 6 and have been suggested as risk factors for
eating disorders of at least subsyndromal severity.7
Although weight concerns are less common among
males, recent data suggest that these concerns are
becoming more prevalent8; however, little is known
about how weight-related concerns arise in either
gender.
The development of eating disorders is believed to
be related to personal factors, family and peer influ-
ences and pressures, and sociocultural pressures.
Stice et al9 have postulated that “internalization of
the thin-ideal body image” for women in Western
culture results in dissatisfaction with weight and
shape, because the ideal body shape and weight are
unattainable for most women. Moreover, family,
peer, and media pressures to be thin also increase or
sustain body dissatisfaction by repeatedly reminding
women how far away they are from the ideal shape
and weight.
The mass media are believed to encourage girls to
form unrealistically thin body ideals,10 –15 which are
unattainable for most females, but their impact on
boys has not been investigated. Several cross-sec-
tional studies have observed a positive association
between exposure to beauty and fashion magazines
and higher levels of weight concerns or eating dis-
order symptoms in girls.16 The most likely mecha-
nisms through which frequency of exposure to the
mass media increases the likelihood that a girl be-
comes concerned with her weight or develops eating
disorder symptoms are via encouraging girls to com-
pare their bodies with those depicted in the media19
and inspiring them to try to look like the unrealistic
and unhealthy models and actresses in the media.
According to the theory of Stice et al,9 one should
expect overweight females to be more dissatisfied
with their weight because they are far away from the
ideal weight and shape glorified by popular western
culture. Thus, it is not surprising that several popu-
lation-based studies have reported a positive associ-
ation between weight and engaging in bulimic be-
haviors.20 –24 Obesity is a large public health problem
among both children and adults in the United
States,25 thus, a relatively large proportion of youth
may be at risk for developing weight concerns, diet-
ing, and bulimic behaviors.
The media is not the only source of pressure to be
thin. Levine et al26 suggested that weight control
behaviors among young girls are modeled partially
on their mothers’ behavior. Although there is a pau-
city of data, several studies have observed that girls
whose mothers diet and are concerned with their
weight and shape are more likely than their peers to
developing unhealthy weight control practices.27–28
Data are lacking on boys, but Smolak et al29 observed
the comments by mothers had a larger impact than
those by fathers and that daughters were more ef-
fected than were sons by the comments.
In addition to being affected by the comments and
behaviors of their parents, preadolescents and ado-
lescents are influenced by their peers. To gain accep-
tance by their peers, adolescents may resort to adopt-
ing the perceived beliefs and behaviors practiced by
members of their peer group.30 –33 Levine et al26 as-
sessed the relationship of weight control practices of
middle school girls and their peers. They observed
that the weight control practices of the girls were
significantly related to those of their peers. More-
over, peer pressure10 has been found to be a risk
factor for developing bulimic behaviors and disor-
dered eating but has not been assessed prospectively
as a risk factor for becoming highly concerned with
weight among girls and boys.
To prevent the development of unhealthy weights
and weight control practices, it is important to know
the factors associated with the development of high
levels of concern with weight and the initiation of
frequent dieting, a known risk factor for disordered
eating.10,34 To determine the relative contribution of
peer, parental, and media influences on the develop-
ment of weight concerns and dieting practices
among girls and boys, we analyzed data from
⬃12 000 preadolescents and adolescents in a pro-
spective cohort study.
METHODS
The Growing Up Today Study (GUTS) was established in 1996
by recruiting children, who were 9 to 14 years of age, of women
participating in the Nurses’ Health Study II (NHS II).35 Using the
NHS II data, we identified mothers who had children 9 to 14 years
of age. In total, we identified over 53 000 children in the eligible
age range. We wrote a detailed letter to the mothers, explaining
that the purpose of GUTS was to study the predictors of weight
change during adolescence and sought parental consent to enroll
their children. The mothers who responded to the invitational
letter provided us with the names, age, and gender of 25 000
children in the eligible age range. In October 1996, we mailed
letters and baseline questionnaires to the 13 261 girls and 13 504
boys whose mothers had granted us consent to invite them to
participate in GUTS. The invitation letter to the child explained the
study and asked them to complete the questionnaire if they
wished to participate. The letter assured the children that no
information they provided would be made available to anyone,
including their parents. Approximately 68% of the girls (n ⫽ 9039)
and 58% of the boys (n ⫽ 7843) returned completed question-
naires, thereby assenting to participate in the cohort. Because
ongoing participation is crucial to the validity of cohort studies,
we did not make efforts to increase baseline participation from the
unwilling children (ie, the nonrespondents).
Downloaded from www.pediatrics.org by on September 1, 2008
Mothers who gave us permission to contact their children were
slightly less likely to smoke (8% vs 10%) and were slightly leaner
(25.3 vs 25.7 kg/m2) and younger (37.7 vs 37.8 years) than were the
women who did not grant us permission; however, the differences
were quite minimal. In addition, among those given permission to
participate, children who decided to participate had slightly
leaner (25.2 vs 25.5 kg/m2) mothers than did children who did not
return the baseline questionnaire. However, there was no differ-
ence in terms of age between ages of mothers of children who
decided to join the study and those who declined to participate.
After 2 mailings of follow-up questionnaires and a reminder
e-mail, ⬃81% of girls (n ⫽ 7299) and 72% of boys (n ⫽ 5653)
returned the 1997 questionnaire. Girls and boys who returned
only the baseline questionnaire were similar to children who
completed both questionnaires in terms of the prevalence of binge
eating (girls: 2.2% vs 1.9%; boys: 1.1% vs .7%), constant dieting
(girls: 3% vs 2.4%; boys: 1.3% vs. 1.1%), and overweight (girls:
17.9% vs 18.7%; boys: 25.0% vs 25.7%). However, girls who re-
turned only the baseline questionnaire were more likely than were
girls who completed both questionnaires to have been trying to
lose weight in 1996 (36% vs 30%).
Measures
Information From Mothers (NHS II Participants)
Women participating in NHS II have been sent questionnaires
biennially since 1989. Body mass index (BMI [kg/m2]) was calcu-
lated from self-reported weight and height information collected
in 1995. Women were classified as weight cyclers if they had
intentionally lost 10 or more pounds 3 or more times between 1989
and 1993. In 1995 women were asked whether they were likely to
buy low-calorie foods and whether the following statements were
true: “I eat anything I want, whenever I want,” “I pay a great deal
of attention to changes in my figure.” From these 3 questions, a
summary score from 0 (inattentive to diet, weight, and shape) to 3
(attentive to diet, weight, and shape) was created. The distribution
was as follows 0 (3.3% girls, 3.5% boys), 1 (55.5% girls, 56.8%
boys), 2 (31.4% girls, 31.3% boys), and 3 (9.8% girls, 8.4% boys).
Information From Girls and Boys
Questions adapted from the junior high school version of the
McKnight Risk Factor Survey (MRFS)36 were used to measure
weight concerns, attitudes, and behaviors. The MRFS for junior
high school and high school students uses 5 response categories:
never/not at all, a little, sometimes/pretty much, a lot, and al-
ways/totally. The 7 MRFS-based domains included on the ques-
tionnaire are concern with weight (4 questions), importance of
thinness to peers (3 questions), importance of thinness to adults (3
questions), teasing and comments about weight by peers (8 ques-
tions), teasing and comments about weight by adults (3 questions),
social eating (2 questions), and influence of the media (1 question).
Among females, thinness and low body fat are associated with
one another, and both are considered to be positive attributes.
Among males, however, the 2 are not necessarily related to one
another, and they are not both considered to be positive attributes.
As with females, low body fat is desirable, but thinness may be
associated with weakness or femininity and, therefore, is not
considered a desirable characteristic by young males. Therefore, to
make the MRFS appropriate for boys, the questions on thinness
were replaced with questions inquiring about the importance of
not being fat or desiring not to be fat and the question assessing
concern about gaining 2 lbs was deleted. One question on how
often the mother had tried to lose weight during the past year and
2 others assessing the importance to each of the parents that the
child be thin (or not fat for boys) were adapted from the MRFS.
The MRFS-based domain of concern with weight was modeled
as the mean response on a scale of 1 to 5; other MRFS-based
questions and domains were dichotomized. The concern with
weight subscale was comprised of the following questions: “In the
past year, how often have you felt fat?”, “In the past year, how
often have you thought about wanting to be thinner”, “In the past
year, how often have you worried about having fat on your
body?”, and (for the girls), “In the past year, how much have you
worried about gaining 2 pounds?” Thinness/lack of fatness was
considered very important (to parent or peer) if the child indicated
the degree of importance as “a lot” or “totally.” Because so few
boys reported that lack of fat was very important, the cutoff was
ARTICLES 55
lowered to include boys who reported it was “pretty much”
important. Girls and boys were considered to be making a lot of
effort to look like females/males in the media if they responded “a
lot” or “totally” to the question, “In the past year, how much effort
have you made to look like the girls or women (boys or men) you
see on television, in movies, or in magazines?” Mothers were
classified as frequent dieters if their child reported that during the
last year the mother was trying to lose weight “a lot” or “always.”
The parent influence questions included on the girls question-
naire were: “During the past year how important has it been to
your father that you be thin?” (“Father means the adult man in
your life who acts most like a father to you”), and “During the past
year how important has it been to your mother that you be thin?”
Boys were asked, “During the past year how important has it been
to your father that you not be fat?” (“Father means the adult man
in your life who acts most like a father to you”), and “During the
past year how important has it been to your mother that you not
be fat?” The questions were assessed individually as well as
combined into a measure of importance to both parents.
Dieting was assessed with a question adapted from the Youth
Risk Behavior Surveillance System questionnaire.37 The questions
asks, “During the past year, how often did you diet to lose weight
or to keep from gaining weight?” The response categories for the
frequency of dieting to control weight during the past year were:
“never,” “less than once a month,” “1 to 3 times a month,” “once
a week,” “2 to 6 times per week,” or “every day.”
We calculated BMI using self-reported weight and height in-
formation collected in 1996 and computed quintiles of gender- and
age-specific z score of BMI for use in analyses.
Reliability and Validity of Self-Report Measures:
Weight Concerns and Influences, Height, and Weight
The test–retest correlations and Cronbach’s ␣s of the 7 MRFS-
based domains included on the questionnaire have been evaluated
among girls in junior high school. Both were found to be moderate
to high for the subscales relevant to our study: concern with
weight (test–retest ⫽ .84; Cronbach’s ␣ ⫽ .86), influence of the
media (test–retest ⫽ .66; only 1 question so no Cronbach’s ␣),
teasing or comments about weight by peers (test–retest ⫽ .76;
Cronbach’s ␣ ⫽ .85), teasing or comments about weight by adults
(test–retest ⫽ .63; Cronbach’s ␣ ⫽ .67), importance of thinness to
peers (test–retest ⫽ .62; Cronbach’s ␣ ⫽ .54), importance of thin-
ness to parents (test–retest ⫽ .59; Cronbach’s ␣ ⫽ .75), and change
in eating patterns around peers (test–retest ⫽ .77; Cronbach’s ␣ ⫽
.63).36
The validity of self-reported weight and height among pread-
olescents and adolescents has been investigated by several groups
of researchers. Shannon et al,38 in a sample of 806 sixth graders,
report moderately high correlations for weight and height for both
boys (r ⫽ .90; r ⫽ .74) and girls (r ⫽ .84; r ⫽ .62). More children
tended to underreport than to overreport their weight, with the
taller and heavier children and girls showing the greatest ten-
dency to do so. We did not find a systematic bias in reported
heights. Among 1657 adolescents 12 to 16 years of age in the
National Health and Nutrition Examination Survey III study,
Strauss39 observed high correlations between self-reported weight
and actual weight (r ⫽ .87 and .94, depending on gender or race)
and self-reported height and actual height (ranged from r ⫽
.82–.91). Moreover, the use of self-reported weight and height
resulted in the correct classification of weight status in 94% of
children. In addition, in a nationally representative sample of
youth from the National Longitudinal Study of Adolescent
Health, Goodman et al40 observed that the correlation between
BMI calculated form self-report versus measured height and
weight was .92 and only 3.8% of the youth were misclassified as
obese using self-reported BMI. Thus, the results suggest that pre-
adolescents and adolescents provide information on weight and
height that is as valid as the information provided by adults.
Outcome
The 2 outcomes were the incidence of high level of weight
concerns and the incidence of constant dieting. Both outcomes
were defined with data provided by the girls and boys.
Constant dieting to lose weight was defined as reporting to
always (ie, every day) be on a diet to lose weight. High level of
concern with weight was defined as a mean score on the MRFS
56 DEVELOPMENT OF WEIGHT CONCERNS AND FREQUENT DIETING AMONG ADOLESCENTS
Downloaded from www.pediatrics.org by on September 1, 2008
weight concern subscale of at least 4, corresponding to “a lot” or
“totally.”
Sample
Participants included 7299 girls and 5653 boys who completed
questionnaires in 1996 and 1997, excluding those whose mothers
did not complete NHS II questionnaires in 1989, 1993, or 1995 (245
girls and 179 boys), and participants who did not complete the
questions on weight concerns or dieting in 1996 (26 girls and 24
boys) or 1997 (14 girls and 19 boys), were younger than 9 or older
than 14 years old in 1996 (138 girls and 70 boys) or provided no or
implausible information on height or weight for height (106 girls
and 83 boys), thus leaving 6770 girls and 5287 boys for analysis.
Children who did not report the importance of thinness to their
friends (26 girls), how much effort they make to look like same sex
figures in the media (33 girls and 73 boys), how important their
thinness (or lack of fatness) is to their father (16 girls and 27 boys)
or mother (41 girls and 18 boys), or how often their mother diets
(65 girls and 38 boys) were also excluded from multivariate anal-
yses. Children whose mother did not provide information on
weight cycling (1534 girls and 1258 boys) or did not complete the
3 questions on concern with weight and shape (823 girls and 593
boys) were excluded from specific analyses.
Analysis
All analyses were stratified by gender and conducted with SAS
software.41 To account for the correlation between siblings, gen-
eralized estimating equations, using the logit link, were used for
all multivariate analyses (SAS Proc Genmod, Cary, NC). Children
who were cases at baseline (ie, who were highly concerned with
weight or constant dieters in 1996) were excluded from the rele-
vant analyses. All statistical models adjusted for age and age-
specific z score of BMI. In addition, all models predicting weight
concerns in 1997 adjusted for level of concern with weight in 1996
(1, 2, or 3— children with values of 4 and 5 were excluded as
prevalent cases). Likewise, all models predicting becoming a con-
stant dieter adjusted for frequency of dieting in 1996 (“never,”
“less than once a month,” “1–3 times a month,” “once a week,” or
“2– 6 times per week,” children reporting “every day” were ex-
cluded as prevalent cases). All P values are 2-sided, with P ⬍ .05
considered statistically significant.
RESULTS
In 1996, ⬃9% of girls and 4% of boys were highly
concerned with their weight and 2% of girls and 1%
of boys reported always being on a diet to lose or
maintain weight. Over 1 year of follow-up, 6% of
girls and 2% of boys became highly concerned with
weight and 2% of girls and 1% of boys became con-
stant dieters.
Cumulative incidence of becoming highly con-
cerned with weight (Fig 1) and starting to diet con-
stantly (Fig 2) increased across the quintiles of BMI in
1996. Associations with BMI were stronger among
boys (odds ratio [OR]: 2.2–2.6; P ⬍ .001) than among
girls (OR: 1.2–1.4; P ⬍ .01) because outcomes were
very rare among boys in lower quintiles of BMI in
1996.
The children’s BMI was associated with the moth-
er’s BMI (Spearman r ⫽ .29 for girls; r ⫽ .30 for boys).
After control for the child’s BMI, the mother’s BMI
was not significantly associated with either outcome
(data not shown). Among girls, but not boys, age was
modestly associated with the development of con-
stant dieting (OR: 1.2 per year of age; 95% confidence
interval [CI]: 1.0 –1.4).
Girls who reported that it was important to either
parent that they were thin were twice as likely as
their peers to become highly concerned with weight
(OR: 2.1; 95% CI: 1.1– 4.0; Table 1), whereas among
Fig 1. Cumulative incidence of becoming highly con-
cerned with weight by quintile of BMI in 1996. The
dark colored bar represents girls; the lighter bar, boys.

Fig 2. Cumulative incidence of becoming a constant

dieter by quintile of BMI in 1996. The dark colored bar
represents girls; the lighter bar, boys.

TABLE 1. Multivariate ORs and 95% CIs for Predictors of Becoming Highly Concerned With Weight Between 1996 and 1997㛳 Among
the Girls in GUTS
Cases# ORs
Adjusted for Adjusted for Age and Multivariate*
Age Level of Concern
With Weight in 1996
OR OR OR 95% CI
BMI‡ 106 1.7 1.2 1.2 1.1–1.3
Thinness is very important to peers§ 3 4.1 1.7 1.5 .3–7.3
Thinness is very important to 23 4.6 2.5 2.1 1.1–4.0
mother or father§
Mother frequently trying to lose 78 1.4 1.1 1.0 .8–1.3
weight§
Mom’s weight cycling¶ 71 1.8 1.4 1.3 .9–1.8
Making efforts to look like females 40 6.0 1.9 1.9 1.1–3.1
in the media§
* Adjusted for age, concern with weight in 1996, and the correlation between siblings, as well as the other covariates listed in the table.
† Two hundred eighty-five cases developed over the year among the 4966 girls with complete information on all covariates.
‡ Per increase in quintile of age-specific z score of BMI.
§ Information provided by the girl in 1996 about herself, her mother, and her father.
㛳 Per 1-category increase on a scale ranging from 1 to 5, corresponding to never, a little, sometimes, a lot, and always.
¶ Women who intentionally lost ⱖ10 lb at least 3 times between 1989 and 1993.
# Cases in the highest category of the exposure variable.

the boys the development of concern with weight
was unrelated to the perceived importance to the
mother or the father that the boy not be fat. Peer
influences were not predictive in either gender of
becoming highly concerned with weight. Girls (OR:
1.9; 95% CI: 1.1–3.1; Table 2) and boys (OR: 2.7; 95%
CI: 1.1– 6.4; Table 3) who reported making a lot of
effort to look like same-sex figures in the media were
more likely to become weight concerned.
Girls (OR: 2.3; 95% CI: 1.1–5.0; Table 2) and boys
(OR: 2.6; 95% CI: 1.1– 6.0; Table 4) who reported that
it was important to their father that they be thin

ARTICLES 57
Downloaded from www.pediatrics.org by on September 1, 2008
TABLE 2. Multivariate ORs and 95% CIs for Predictors of Becoming a Constant Dieter Between 1996 and 1997† Among the Girls in
GUTS
Cases# ORs
Age-Adjusted Adjusted for Age Multivariate*
and Frequency of
Dieting in 1996
OR OR OR 95% CI
BMI‡ 53 1.7 1.4 1.3 1.1–1.5
Thinness is very important to peers§ 2 2.2 1.0 .6 .1–3.3
Thinness is very important to father§ 11 5.3 3.3 2.3 1.1–5.0
Mother frequently trying to lose weight§ 47 2.0 1.6 1.3 .9–2.0
Mother’s attention to her diet, weight, 11 .8 .8 .8 .6–1.0
and shape㛳
Concern with weight¶ 8 2.3 1.9 1.5 1.2–1.9
Making efforts to look like females in 37 5.2 2.5 1.6 .9–2.7
the media§
* Adjusted for age, frequency of dieting in 1996, and the correlation between siblings, as well as the other covariates listed in the table.
† One hundred twenty-seven cases developed over the year among 5555 girls with complete information on all covariates.
‡ Per increase in quintile of age-specific z score of BMI.
§ Information provided by the girl in 1996 about herself, her mother, and her father.
㛳 Attention to diet, weight, and shape between 1994 and 1995 as reported by the mother. The OR is per 1-unit increase on a scale ranging
from 0 to 3.
¶ Per 1-category increase on a scale ranging from 1 to 5, corresponding to never, a little, sometimes, a lot, and always.
# Cases in the highest category of the exposure variable.

TABLE 3. Multivariate ORs and 95% CIs for Predictors of Becoming Highly Concerned With Weight Between 1996 and 1997㛳 Among
the Boys in GUTS
Cases# ORs
Age-Adjusted Adjusted for Age Multivariate*
and Frequency of
Dieting in 1996
OR OR OR 95% CI
BMI‡ 62 3.4 2.2 2.3 1.7–3.0
Not being fat is important to peers§ 4 3.1 1.1 1.2 .4–3.8
Not being fat is very important to mother 7 1.4 .7 .6 .2–1.5
or father§
Mother frequently trying to lose weight§ 34 2.7 2.0 1.9 1.2–3.2
Mom’s weight cycling¶ 18 1.3 1.0 .7 .4–1.3
Making efforts to look like males in the 9 5.7 2.2 2.7 1.1–6.4
media§
* Adjusted for age, concern with weight in 1996, and the correlation between siblings, as well as the other covariates listed in the table.
† Ninety-two cases developed over the year among 3662 boys with complete data on all covariates.
‡ Per increase in quintile of age-specific z score of BMI.
§ Information provided by the boy in 1996 about himself, his mother, and his father.
㛳 Per 1-category increase on a scale ranging from 1 to 5, corresponding to never, a little, sometimes, a lot, and always.
¶ Women who intentionally lost ⱖ10 lb at least 3 times between 1989 and 1993.
# Cases in the highest category of the exposure variable.

(girls)/not fat (boys) were more likely than their
peers to become constant dieters. The child’s percep-
tion that it was important to the mother that the child
be thin/not fat was unrelated to development of
dieting (data not shown). There was a suggestion
that girls whose mothers reported being attentive to
their diet, weight, and shape were less likely to be-
come constant dieters (OR: .8; 95% CI: .6 –1.0); how-
ever, the difference was not significant (P ⫽ .07).
DISCUSSION
Weight concerns, which developed among girls
across the weight spectrum, were less common, but
more strongly related to BMI, among boys. BMI was
similarly associated with the development of con-
stant dieting. The associations were stronger among
the boys because both outcomes were very rare
among boys, but not girls, in the lower quintiles of
BMI in 1996. Thus, boys, but not girls, who became
highly concerned with their weight or began to diet
constantly may have been partially justified in their
concerns and actions because of their excessive
weight. Among both girls and boys, constant dieting
was relatively rare, but approximately twice as many
girls became constant dieters over the 1-year follow-up.
To our knowledge, this is the first study to assess
the relative importance of peer, parental, and media
influences on the development of weight concerns
and frequent dieting among both girls and boys.
Independent of age and BMI, parental influences
were predictive of becoming highly concerned with
weight and becoming a constant dieter. Among both
girls and boys, making considerable effort to look
like same-sex figures in the media was predictive of
developing weight concerns and becoming a con-
stant dieter.

58 DEVELOPMENT OF WEIGHT CONCERNS AND FREQUENT DIETING AMONG ADOLESCENTS

Downloaded from www.pediatrics.org by on September 1, 2008
TABLE 4. Multivariate ORs and 95% CIs for Predictors of Becoming a Constant Dieter Between 1996 and 1997† Among the Boys in
GUTS
Cases# ORs
Age-Adjusted Adjusted for Age Multivariate*
and Frequency of
Dieting in 1996
OR OR OR 95% CI
BMI‡ 44 3.5 2.6 2.2 1.5–3.3
Not being fat is important to peers§ 7 6.4 3.2 1.7 .7–4.2
Not being fat is very important to father§ 8 5.5 4.2 2.6 1.1–6.0
Mother frequently trying to lose weight§ 17 1.8 1.3 1.0 .5–1.8
Mom’s attention to her diet, weight, and 5 1.1 1.0 1.0 .7–1.4
shape㛳
Concern with weight¶ 5 2.9 2.1 1.4 1.1–1.8
Making efforst to look like males in the 10 7.8 4.2 1.9 .8–4.1
media§
* Adjusted for age, frequency of dieting in 1996, and the correlation between siblings, as well as the other covariates listed in the table.
† Sixty cases developed over the year among 4328 boys with complete information on all covariates.
‡ Per increase in quintile of age-specific z score of BMI.
§ Information provided by the boy in 1996 about him, his mother, and his father.
㛳 Attention to diet, weight, and shape between 1994 and 1995 as reported by the mother. The OR is per 1-unit increase on a scale rantging
from 0 to 3.
¶ Per 1-category increase on a scale ranging from 1 to 5, corresponding to never, a little, sometimes, a lot, and always.
# Cases in the highest category of the exposure variable.

The results suggest that children who perceive that
their mother is frequently trying to lose weight were
more likely to become highly concerned with weight
(boys) or constant dieters (girls), thus offering sup-
port for the role mothers play in the transmission of
cultural values about desirable body weight and
shape.27–29 An unexpected finding was that the
child’s perception of the importance of thinness/lack
of fatness to the father was more important than their
perception of its importance to the mother. It is un-
clear whether the child’s perceptions are accurate
reflections of the parents’ beliefs; however, regard-
less of their accuracy, further study is needed to
understand the role of fathers in the development of
weight concerns and weight control behaviors.
Our results are not in complete agreement with
those of Stice42 who assessed the influence of peers,
family, and the media on the development of bulimic
behaviors among 218 adolescent girls. Similar to our
findings, he did observe a significant effect of family
influences; however, in contrast to our findings, he
observed that peers but not the media were predic-
tive of developing bulimic behaviors. There are sev-
eral possible explanations for the discrepancies be-
tween his findings and those that we observed. First,
his sample was older and it is possible that peer
influences are more important among adolescents
than preadolescents. Second, our sample was com-
prised of children throughout the United States,
whereas his sample was comprised of girls who were
seniors in 2 high schools in an urban southwestern
location. It is possible that the prevalence of weight
concerns and bulimic behaviors vary by region and
that the determinants of these outcomes show geo-
graphic variation. Future research is needed to ad-
dress these issues. Another possible explanation for
the discrepancy in results is that our sample was
much larger; thus, we had more statistical power to
pick up differences in media influence.
The media have been criticized for promoting ex-
cessively thin body images and playing a role in the
development of weight concerns and disordered eat-
ing among females.10 The impact of the media on
weight and shape concerns and weight control be-
haviors of boys has not been studied in detail. If the
barrage of images of females with perfect bodies has
a deleterious effect on young girls, it seems plausible
that the recent increase in the number of media im-
ages of males baring their carefully sculpted chests
or chests devoid of any body fat may have a similar
negative impact on boys. More research is needed to
better understand media influences.
A strength of the study is that both self-reported
weight38 – 40 and the questions on weight concerns
and influences36 have been validated among pread-
olescents and adolescents. Moreover, a prospective
design and relatively high follow-up rate guard
against the effect of biased sampling on the outcome,
which can result in incorrect inference. However,
there are several limitations to the present study. The
information on the importance to parents that their
daughter is thin or that their son is not fat was
collected from the participants. Thus, it is possible
that the child’s perceptions are inaccurate reflections
of the parents’ beliefs. Another limitation is that we
did not measure hours per week exposed to various
media sources. Thus, our measure should be inter-
preted as influence of the media, not exposure to the
media.
Overall, our data suggest that weight-related is-
sues of parents are transmitted to their children.
Given the substantial health risks associated with
overweight, the weight concerns of some of the par-
ents may be justifiable. However, to maintain a
healthy weight and to ensure that their children do
not become either overweight or overly concerned
with weight, it is advisable that parents remind
themselves that they serve as role models and, there-
fore, should attempt to adopt the diet and activity
patterns that they would like their children to emu-

ARTICLES 59
Downloaded from www.pediatrics.org by on September 1, 2008
late. Because, like obesity, excessive weight concerns
are hard to treat, efforts should be made to prevent
these conditions. Our results suggest that to prevent
children and adolescents from developing extreme
concern with weight and unhealthy weight control
behaviors, peers, parents, and the media must be
targeted for intervention.
ACKNOWLEDGMENTS
Drs Field and Colditz were partially supported by Grant DK
46200 from the Boston Obesity Nutrition Research Center. Addi-
tional funding was provided by Research Grant DK-46834 from
the National Institutes of Health, and First Independent Research
Support and Training Award (R29) Grant HL57871-01 from the
National Institutes of Health, and the Kellogg Company.
We thank Susan Bryson for her helpful comments and sugges-
tions on the statistical analysis and interpretation.
REFERENCES
1. Field AE, Wolf AM, Herzog DB, Cheung L, Colditz GA. The relation-
ship of caloric intake to frequency of dieting among preadolescent and
adolescent girls. J Am Acad Child Adolesc Psychiatry. 1993;32:1246 –1252
2. Casper RC, Offer D. Weight and dieting concerns in adolescents, fash-
ion or symptom? Pediatrics. 1990;86:384 –390
3. Chandarana P, Helmes E, Benson N. Eating attitudes as related to
demographic and personality characteristics: a high school survey. Can
J Psychiatry. 1988;33:834 – 837
4. Crowther JH, Post G, Zaynor L. The prevalence of bulimia and binge
eating in adolescent girls. Int J Eat Disord. 1985;4:29 – 42
5. Desmond SM, Price JH, Gray N, O’Connell JK. The etiology of adoles-
cents’ perceptions of their weight. J Youth Adolesc. 1986;15:461– 473
6. Moses N, Banilivy MM, Lifshitz F. Fear of obesity among adolescent
girls. Pediatrics. 1989;83:393–398
7. Taylor CB, Altman T, Shisslak CM, et al. Factors associated with weight
concerns in adolescents. Int J Eat Disord. 1998;24:31– 42
8. Braun DL, Sunday SR, Huang A, Halmi KA. More males seek treatment
for eating disorders. Int J Eat Disord. 1999;25:415– 424
9. Stice E, Nemeroff C, Shaw H. A test of the dual pathway model of
bulimia nervosa: evidence for restrained-eating and affect-regulation
mechanisms. J Soc Clin Psychol. 1996;15:340 –363
10. Field AE, Camargo CA Jr, Taylor CB, Bekey CB, Colditz GA. Relation of
peers and media influences to the development of purging behaviors
among preadolescent and adolescent girls. Arch Pediatr Adolesc Med.
1999;153:1184 –1189
11. Tiggemann M, Pickering AS. Role of television in adolescent women’s
body dissatisfaction and drive for thinness. Int J Eat Disord. 1996;20:
199 –203
12. Wiseman CV, Gray JJ, Mosimann JE, Ahrens AH. Cultural expectations
of thinness in women: an update. Int J Eat Disord. 1992;11:85– 89
13. Silverstein B, Perdue L, Peterson B, Bogel L, Fantini DA. Possible causes
of the thin standard of bodily attractiveness for women. Int J Eat Disord.
1986;5:907–916
14. Silverstein B, Perdue L, Peterson B, Kelley E. The role of the mass media
in promoting a thin standard of bodily attractiveness for women. Sex
Roles. 1986;14:519 –533
15. Garner DM, Garfinkle PE. Socio-cultural factors in the development of
anorexia nervosa. Psychol Med. 1980;10:647– 656
16. Stice EM, Schipak-Neuberg E, Shaw HE, Stein RI. Relation of media
exposure to eating disorder symptomatolgy: an examination of medi-
ating mechanisms. J Abnorm Psychol. 1994;103:836 – 844
17. Field AE, Cheung L, Wolf AM, Herzog DB, Gortmaker SL, Colditz GA.
Exposure to the mass media and weight concerns among girls. Pediatrics
1999;103(3). URL: http://www.pediatrics.org/cgi/content/full/103/
3/e36
18. Harrison K, Cantor J. The relationship between media consumption and
eating disorders. J Comm. 1997;47:40 – 67
60 DEVELOPMENT OF WEIGHT CONCERNS AND FREQUENT DIETING AMONG ADOLESCENTS
Downloaded from www.pediatrics.org by on September 1, 2008
19. Festinger L. A theory of social comparison processes. Hum Relations.
1954;7:117–140
20. Shisslak CM, Crago M, McKnight KM, Estes LS, Gray N, Parnaby OG.
Potential risk factors associated with weight control behaviors among
elementary and middle school girls. J Psychosom Res. 1998;44:301–313
21. Wertheim EH, Paxton SJ, Maude D, Szmukler GI, Gibbons K, Hiller L.
Psychosocial predictors of weight loss behaviors and binge eating in
adolescent girls and boys. Int J Eat Disord. 1992;12:151–169
22. Field AE, Camargo CA, Taylor CB, et al. Overweight, weight concerns,
and bulimic behaviors among girls and boys. J Am Acad Child Adolesc
Psychiatry. 1999;38:754 –760
23. Neumark-Sztainer D, Story M, French SA, Hannan PJ, Resnick MD,
Blum RW. Psychosocial concerns and health-compromising behaviors
among overweight and nonoverweight adolescents. Obes Res. 1997;5:
237–249
24. Striegel-Moore RH, Schreiber GB, Lo A, Crawford P, Obarzanek E,
Rodin J. Eating disorder symptoms in a cohort of 11- to 16-year-old
black and white girls: the NHLBI growth and health study. Int J Eat
Disord. 2000;27:49 – 66
25. Troiano RP, Flegal KM, Kuzmarski RJ, Campbell SM, Johnson CL.
Overweight prevalence and trends for children and adolescents. Arch
Pediatr Adolesc Med. 1995;149:1085–1091
26. Levine MP, Smolak L, Moodey MD, Hessen LD. Normative develop-
mental challenges and dieting and eating disturbances in middle school
girls. Int J Eat Disord. 1994;15:11–20
27. Hill AJ, Franklin JA. Mothers, daughter, and dieting: investigating the
transmission of weight control. Br J Clin Psychol. 1998;37:3–13
28. Pike KM, Rodin J. Mothers, daughters, and disordered eating. J Abnorm
Psychol. 1991;100:198 –204
29. Smolak L, Levine MP, Schermer F. Parental input and weight concerns
among elementary school children. Int J Eat Disord. 1999;25:263–271
30. Sieving RE, Perry CL, Williams CL. Do friendships change behaviors, or
do behaviors change friendships? Examining paths of influence in
young adolescents’ alcohol use. J Adolesc Health. 2000;26:27–35
31. West P, Sweeting H, Ecob R. Family and friends’ influences on the
uptake of regular smoking from mid-adolescence to early adulthood.
Addiction. 1999;94:1397–1411
32. Epstein JA, Botvin GJ, Diaz T. Etiology of alcohol use among Hispanic
adolescents: sex-specific effects of social influences to drink and prob-
lem behaviors. Arch Pediatr Adolesc Med. 1999;153:1077–1084
33. Paxton SJ, Schutz HK, Wertheim EH, Muir SL. Friendship clique and
peer influences on body image concerns, dietary restraint, extreme
weight-loss behaviors, and binge eating in adolescent girls. J Abnorm
Psychol. 1999;108:255–266
34. Patton GC, Selzer R, Coffey C, Carlin JB, Wolfe R. Onset of adolescent
eating disorders: population based cohort over 3 years. Br Med J. 1999;
318:765–768
35. Solomon CG, Willett WC, Carey VC, et al. A prospective study of the
pregravid determinants of diabetes mellitus. JAMA. 1997;278:1078 –1083
36. Shisslak CM, Renger R, Sharpe T, et al. Development and evaluation of
the McKnight Risk Factor Survey for assessing potential risk and pro-
tective factors for disordered eating in preadolescent and adolescent
girls. Int J Eat Disord. 1999;25:195–214
37. Kann L, Warren CW, Harris WA, et al. Youth risk behavior surveil-
lance—United States, 1995. MMWR Morb Mortal Wkly Rep. 1996;45:1– 84
38. Shannon B, Smiciklas-Wright H, Wang MQ. Inaccuracies in self-
reported weights and heights of a sample of sixth-grade children. J Am
Diet Assoc. 1991;91:675– 678
39. Strauss RS. Comparison of measured and self-reported weight and
height in a cross-sectional sample of young adolescents. Int J Obes Relat
Metab Disord. 1999;23:904 –908
40. Goodman E, Hinden B, Khandelwal S. Accuracy of teen and parental
reports of obesity and body mass index. Pediatrics. 2000;106:52–58
41. SAS Institute Inc. SAS User’s Guide: Statistics. 4th ed. Cary, NC: SAS
Institute; 1990
42. Stice E. Modeling of eating pathology and social reinforcement of the
thin-ideal predict onset of bulimic symptoms. Behav Res Ther. 1998;36:
931–944
Peer, Parent, and Media Influences on the Development of Weight Concerns and
Frequent Dieting Among Preadolescent and Adolescent Girls and Boys
Alison E. Field, Carlos A. Camargo Jr, C. Barr Taylor, Catherine S. Berkey, Susan B.
Roberts and Graham A. Colditz
Pediatrics 2001;107;54-60
DOI: 10.1542/peds.107.1.54
Updated Information including high-resolution figures, can be found at:
& Services http://www.pediatrics.org/cgi/content/full/107/1/54
References This article cites 35 articles, 8 of which you can access for free
at:
http://www.pediatrics.org/cgi/content/full/107/1/54#BIBL
Citations This article has been cited by 24 HighWire-hosted articles:
http://www.pediatrics.org/cgi/content/full/107/1/54#otherarticles
Subspecialty Collections This article, along with others on similar topics, appears in the
following collection(s):
Adolescent Medicine
http://www.pediatrics.org/cgi/collection/adolescent_medicine
Permissions & Licensing Information about reproducing this article in parts (figures,
tables) or in its entirety can be found online at:
http://www.pediatrics.org/misc/Permissions.shtml
Reprints Information about ordering reprints can be found online:
http://www.pediatrics.org/misc/reprints.shtml

Downloaded from www.pediatrics.org by on September 1, 2008