Systematic Review and Meta-Analysis
The Impact of Multicomponent Weight
Management Interventions on Self-Esteem
in Overweight and Obese Adolescents
Margaret Murray BNUT(HONS) Aimee L Dordevic PHD and
Maxine P Bonham PHD
Department of Nutrition amp Dietetics Monash University
All correspondence concerning this article should be addressed to Maxine Bonham PHD Department of Nutrition
amp Dietetics Monash University Level 1 264 Ferntree Gully Rd Notting Hill Victoria 3168 Australia E-mail
maxinebonhammonashedu
Received April 24 2016 revisions received November 17 2016 accepted November 30 2016
Abstract
Objective Building self-esteem in overweight adolescents is key to long-term weight manage-
ment yet self-esteem is rarely a key outcome of adolescent weight management interventions
This systematic review investigates the impact of multicomponent weight management interven-
tions on self-esteem in overweight and obese adolescents Method Six databases were searched
in December 2014 Eligible studies met the following criteria (1) randomized controlled trial (2)
overweight or obese participants (3) adolescents (10ndash19 years) (4) multicomponent weight man-
agement intervention (5) reported self-esteem and weight changes Results Thirteen studies with
1157 overweight or obese adolescents aged 10ndash19 years were included Meta-analyses showed
no significant change in self-esteem (027 [004 059]) but body mass index z-score reduced
following intervention (017 [022 011]) Conclusion The lack of change in self-esteem sug-
gests weight loss alone is insufficient to improve self-esteem Multicomponent weight manage-
ment interventions require a specific focus on self-esteem to improve this outcome in overweight
and obese adolescents
Key words adolescent at-risk youth health promotion and prevention meta-analysis obesitysystematic review weight management
Introduction
In the United States gt20 of adolescents (12ndash19years) are classified as obese (Ogden Carroll Kit ampFlegal 2014) and at an increased risk of experiencingthe associated physiological comorbidities Howeverthe psychosocial comorbidities such as reduced self-esteem have a more immediate impact and are oftendrivers for overweight or obese adolescents to seektreatment (Lobstein Baur amp Uauy 2004)Adolescence is a critical period of physical and psy-chological development that occurs between 10 and19 years of age (World Health Organization 2014)
during which young people are at an increased risk ofexperiencing low self-esteem (Mission Australia2012) This risk is further exacerbated if they are
obese (Griffiths Parsons amp Hill 2010 McClureTanksi Kingsbury Gerrard amp Sargent 2010Sanders Han Baker amp Cobley 2015)
Global self-esteem is the sum of onersquos perceivedability or competence in comparison with onersquos aspir-
ations in domains of importance (eg physical ap-pearance cognitive ability) Low self-esteem is causedwhen there is a discrepancy between onersquos perceivedlevel of competence and aspirations in one or more
VC The Author 2017 Published by Oxford University Press on behalf of the Society of Pediatric PsychologyAll rights reserved For permissions please e-mail journalspermissionsoupcom 379
Journal of Pediatric Psychology 42(4) 2017 379ndash394
doi 101093jpepsyjsw101
Advance Access Publication Date 10 March 2017
Systematic Review
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domains that are of importance to the individual(Harter 1993) Self-esteem can fluctuate greatly dur-
ing adolescence and there is an increased risk of self-esteem being low particularly from the age of 13 years
(French Story amp Perry 1995 Strauss 2000)During adolescence self-esteem plays an important
role in metal health and development (McClure et al2010) Low self-esteem in adolescents particularly
overweight adolescents has been linked to disturbedeating and dieting behaviors a preoccupation with
body weight and shape an inactive lifestyle andpoorer performance in education and developmental
tasks (Latzer amp Stein 2013) Low self-esteem hasbeen hypothesized both as a contributing factor and
consequence of obesity (French et al 1995) Increasedself-esteem purportedly leads to better weight out-
comes in the long term (Elfhag amp Rossner 2005French et al 1995 Roberts 2006) Therefore weight-
management interventions for adolescents should aimto improve self-esteem
Multicomponent weight management interventions(MWMI) with behavioral dietary and physical activity
components are best practice for achieving successfulweight loss in overweight and obese adolescents (Kohn
et al 2006 Luttikhuis et al 2009 National Health andMedical Research Council 2013 National Institutes for
Health and Care Excellence 2013) However their im-pact on self-esteem is still not well reported (Luttikhuis
et al 2009) despite this being a recommendation froma previous review of the effect of weight management
programs on pediatric self-esteem (Lowry Sallinen ampJanicke 2007)
This systematic review and meta-analysis ofrandomized controlled trials (RCTs) examines the ef-
fect of MWMIs on self-esteem in overweight andobese adolescents A secondary outcome is the impact
of MWMIs on weight loss and whether this is associ-ated with improvements in self-esteem This review
provides an update of the literature since the reviewby Lowry et al (2007) and focuses specifically on (1)
adolescents an at-risk group for experiencing lowself-esteem and (2) MWMIs the most effective
method for weight management in children and ado-lescents (Luttikhuis et al 2009)
Methods
This review was registered with PROSPERO
International prospective register of systematic re-views (registration number CRD42015016889) and is
reported according to the Preferred Reporting Itemsfor Systematic reviews and Meta-Analysis (PRISMA)
Statement (see Table S1 in the supplement forPRISMA Checklist Moher et al 2015)
Literature SearchA literature search was conducted in December 2014in the Scopus MEDLINE PsychInfo CochraneLibrary Cumulative Index to Nursing and AlliedHealth Literature and Embase databases Searchterms were used to describe the population (eg over-weight youth) intervention (eg lifestyle health edu-cation nutrition physical activity) control (eg usualcare) outcomes (eg esteem body mass index) andstudy design (eg RCT controlled trial) Studies werelimited to English and humans where databases pro-vided that option (see Table S2 in the supplement forfull search strategy) The criteria for inclusion in thisreview were (1) RCT (2) overweight or obese (3)adolescent (10ndash19 years World Health Organization2014) (4) a MWMI (behavioral dietary and physicalactivity components) (5) reported self-esteem andweight changes Body mass index (BMI) z-score wasthe preferential choice for ascertaining weight statusbut if not reported other weight outcomes werecollected
Search results were imported into EndNote X72Version 1702 (Thomson Reuters New York CityUSA) Duplicate articles were manually removed bythe lead author (MM) Throughout the title and ab-stract screening two authors (MM and AD) inde-pendently excluded papers if they did not report theresults of an RCT if the intervention did not includeall three behavioral dietary and physical activitycomponents or if there was no measure of self-esteemIncluded papers were cross-checked and discrepancieswere resolved by the third author (MB) Papers thatincluded healthy weight individuals or individuals out-side the adolescent age range were included at full-paper screening and the authors were contacted to re-trieve results specific to the population of interestThese papers were subsequently excluded if authorsdid not respond within 1 month of initial contact orwere unable to provide the requested data All fullpapers were independently screened by two authors(MM and AD) and were cross-checked with anydisagreements resolved by the third author (MB)
Data ExtractionData extraction was conducted using the NationalHealth and Medical Research Council of Australiadata extraction tool for RCT and cohort studies Datawere independently extracted by two researchers(MM and AD) and included outcome measuresintervention and control conditions study designpopulation characteristics and results The two sets ofextracted data were compared to ensure complete andcorrect interpretation Any disagreements were settledby the MB Data that were missing from the includedstudies such as additional results and detailed meth-odology were obtained from separate publications
380 Murray Dordevic and Bonham
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(Brennan Walkley Fraser Greenway amp Wilks2008 Brennan Walkley Wilks Fraser amp Greenway
2013 Kornman et al 2010 Nguyen McGregoret al 2012 Shrewsbury et al 2011 Shrewsbury
et al 2009) or requested from authors
Risk of BiasThe American Dietetic Association Quality CriteriaChecklist was used to assess the quality of the papers
(Academy of Nutrition and Dietetics 2012) Criteriawere independently tested by two researchers (MM
and AD) to determine study quality including ran-domization research question participant selection
and comparability blinding outcome measures stat-istical analysis and potential for bias from funding
Studies were designated a positive neutral or negativerating Publication bias was assessed through visual in-
terpretation of funnel plots created using RevMan 53(Cochrane Informatics amp Knowledge Management
Department 2014 see Figure S1)
Statistical AnalysisCohenrsquos d effect sizes were calculated for weight andself-esteem outcomes to allow for comparison of re-
sults across studies Positive effect sizes indicated theoutcome had improved that is increased self-esteem
or decreased weight (02frac14 small effect05frac14me-dium effect08frac14 large effect) Where an effect size
could not be calculated the reported significance ofresults was assessed Following tests for normality ef-
fect sizes for self-esteem and weight changes were as-sessed for correlation using the Pearson Correlation
test and the coefficient of determination (R2)Meta-analyses were performed to compare the
change in the intervention and control groups forboth self-esteem and BMI z-score using Stata
Statistical Software (Release 13 2013 Texas USA)Only studies that reported the mean (SD) change in
self-esteem or BMI z-score and compared the inter-vention with a no-treatment control group were
included in the meta-analyses If data were not origin-ally reported in this format results were requested
from the authors for inclusion in this review To ac-count for the different tools used to measure self-
esteem outcomes a standard mean difference (SMD)was calculated from the Cohenrsquos d effect size for each
study Studies that reported a weight outcome otherthan BMI z-score were excluded from the meta-
analysis Weighted mean difference was calculated forBMI z-score for the meta-analysis All meta-analyses
were carried out using random effects analysisSensitivity analyses were not performed as only a
small number of studies were included and they wereall of neutral or positive quality
Results
Database searches identified 4707 original papersFollowing title and abstract screening 115 full-textarticles were retrieved and assessed for eligibilityThirteen papers met the review criteria including 2studies that were reviewed by Lowry et al (2007) and11 studies published since Seven studies wereincluded in the meta-analyses (Figure 1)
Description of Included StudiesThe included studies involved between 32 and 208male andor female participants aged 10ndash19 yearswho were overweight or obese (BMI 85th percent-ile) Owing to the limited number of studies that ex-clusively examined the overweight adolescentpopulation studies with mixed populations wereincluded (Croker et al 2012 Danielsen NordhusJulıusson Maelighle amp Pallesen 2013 Lochrie et al2013 Lubans et al 2012 Morgan Saunders ampLubans 2012 Neumark-Sztainer et al 2010 Sacheret al 2010) However only data relating to the popu-lation of interest are reported
Interventions ranged from seven weeks up to a yearin length Only results taken immediately postinterven-tion were assessed in this review For studies thatincluded an intense treatment phase followed by a main-tenance phase the results taken immediately after the in-tense treatment phase have been used as theldquopostinterventionrdquo results (Brennan Wilks WalkleyFraser amp Greenway 2012 Daley Copeland WrightRoalfe amp Wales 2006 Neumark-Sztainer et al 2010)One exception to this was the study by NguyenShrewsbury et al (2012) that had an additional outcomemeasurement at 12 months half way through the main-tenance phase For this study the 12-month measureshave been used as the ldquopostinterventionrdquo results as thiswas the first time point that reported separate results forthe intervention and control groups
All interventions included dietary physical activityand behavioral strategies (Table I) For the purpose ofthis review all groups that received a treatment that metthe review criteria for a MWMI were considered ldquointer-vention groupsrdquo hence there are a greater number ofintervention than control groups In all studies theintervention and control groups were considered com-parable at baseline for the outcomes of interest
Risk of BiasIncluded studies were assessed against 10 criteria andstudy quality was generally high (Table I) Four criteriahad to be met for a study to receive a positive quality rat-ing The remaining six criteria contributed to the overallrating but were not compulsory for a positive rating tobe assigned All 14 studies in this review met the criteriafor a clearly stated research question clearly definedvalid and reliable outcome measures and low risk of bias
The Impact of Weight Management on Self-Esteem 381
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owing to funding or sponsorship Four studies weredowngraded to a neutral quality rating for not meetingthe criteria (1) selection of participants free from bias(Danielsen et al 2013 Morgan et al 2012) (2) studygroups comparable at baseline (Neumark-Sztainer et al2010) or (3) intervention and comparison conditionsdescribed in detail (Mellin Slinkard amp Irwin 1987Morgan et al 2012) Other criteria that were not met byall studies but did not result in the assignment of any neu-tral quality ratings included appropriate statistical
analysis handling of withdrawals described and use
blinding to prevent bias Funnel plot analysis (Figure S1)did not suggest publication bias however should be inter-
preted with caution owing to the small number of studies
The Impact of Multicomponent WeightManagement Interventions on AdolescentSelf-EsteemSelf-esteem effect sizes were able to be calculated foreight studies (Table II) A positive effect on adolescent
Figure 1 PRISMA flow diagram of included and excluded studies
382 Murray Dordevic and Bonham
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Tab
leI
Stu
dy
Qu
ality
P
art
icip
an
tsIn
terv
en
tio
ns
Du
rati
on
a
nd
Ou
tco
me
Me
asu
res
Stu
dy
(auth
or
yea
rlo
cati
on)
Quali
tyra
ting
Part
icip
ants
Inte
rven
tions
Focu
son
self
-est
eem
Dura
tion
Outc
om
em
easu
res
Bre
nnan
etal
2012A
ust
ralia
25
Posi
tive
29
(46
)m
ale
sand
34
(54
)fe
-m
ale
s11ndash19
yea
rsover
wei
ght
or
obes
e
IIn
terv
enti
on
base
don
cognit
ive
be-
havio
ralpri
nci
ple
sw
ith
afo
cus
on
makin
gsm
all
sust
ain
able
changes
indie
tary
inta
ke
physi
calact
ivit
yand
beh
avio
ralst
rate
gie
sPare
nts
involv
edfo
rfirs
thalf
of
trea
tmen
tphase
C
W
ait
list
No
spec
ific
men
-ti
on
of
self
-es-
teem
but
one
sess
ion
on
de-
vel
opin
ghel
pfu
lth
oughts
and
emoti
ons
Tre
atm
ent
phase
mdashtw
elve
60-m
inse
ssio
ns
and
one
tele
phone
call
sess
ion
over
16
wee
ks
Main
tenance
phase
mdashtw
o60-m
incl
inic
sess
ions
and
seven
15-m
inte
le-
phone
sess
ions
over
6m
onth
s
Rose
nber
gSel
f-E
stee
mSca
leB
MI
z-sc
ore
Cro
ker
etal2012
Unit
edK
ingdom
26
Posi
tive
13
(32
)m
ale
sand
28
(68
)fe
-m
ale
s10ndash12
yea
rsover
wei
ght
or
obes
e
IFam
ily-b
ase
din
terv
enti
on
del
iver
edin
gro
ups
wit
ha
focu
son
makin
gw
hole
-fam
ily
life
style
changes
thro
ugh
beh
avio
r-ch
ange
stra
tegie
sand
nutr
itio
nand
physi
calact
ivit
ygoals
Pare
nt
and
child
sess
ions
de-
liver
edse
para
tely
C
W
ait
list
No
spec
ific
men
-ti
on
of
self
-es-
teem
but
one
sess
ion
on
soci
al
support
and
how
tom
anage
bullyin
g
Fif
teen
15
-hr
sess
ions
over
6m
onth
sFollow
up
12
month
sfr
om
base
line
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
(sel
f-es
teem
)B
MI
SD
S
Dale
yet
al2006
Unit
edK
ingdom
32
Posi
tive
36
(44
)m
ale
sand
45
(56
)fe
-m
ale
s11ndash16
yea
rsB
MI
gt98th
per
centi
le
IPart
icip
ants
com
ple
ted
ara
nge
of
aer
obic
act
ivit
ies
and
min
igam
esand
wer
epro
vid
edw
ith
exer
cise
counse
l-in
gfo
rbeh
avio
rch
ange
ina
one-
on-
one
sett
ingH
ealt
hy
eati
ng
habit
sw
ere
enco
ura
ged
and
wri
tten
info
r-m
ati
on
was
pro
vid
edPart
icip
ants
wer
egiv
enan
indiv
idualize
dex
erci
sepro
gra
mto
conti
nue
aft
erth
etr
eat-
men
tpro
gra
m
CN
otr
eatm
ent
contr
ol
No
spec
ific
men
-ti
on
of
self
-es-
teem
but
beh
avio
ralin
ter-
ven
tions
incl
uded
findin
gso
cial
support
Tre
atm
ent
phase
mdashT
wen
ty-f
our
1hr
ses-
sions
wer
ehel
dover
8w
eeks
Main
tenance
phase
mdashhom
eex
erci
sepro
gra
mfo
r6
wee
ks
no
re-
searc
her
conta
ctFollow
up
at
28
wee
ks
from
base
line
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
for
Adole
scen
ts(s
elf-
este
em)
BM
Iz-
score
Danie
lsen
etal
2013N
orw
ay
27
Neu
tral
17
(53
)m
ale
sand
15
(47
)fe
-m
ale
s10ndash13
yea
rsobes
e
IPart
icip
ants
and
thei
rpare
nts
at-
tended
indiv
idualfa
mily
mee
tings
wit
ha
clin
icalpsy
cholo
gis
tT
he
inte
rven
tion
focu
sed
on
incr
easi
ng
physi
calact
ivit
yand
reduci
ng
seden
-ta
rybeh
avio
res
tablish
ing
abala
nce
ddie
tdev
elopin
gin
div
idualand
fam
ily
copin
gsk
ills
and
pro
moti
ng
aposi
-ti
ve
self
-per
cepti
on
CW
ait
list
No
spec
ific
men
-ti
on
of
self
-es-
teem
st
andard
beh
avio
ralte
ch-
niq
ues
use
d
Tw
elve
wee
kly
45-m
inse
ssio
ns
wit
ha
boost
erse
ssio
n6
month
saft
ertr
eatm
ent
Follow
up
15
month
sfr
om
base
line
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
for
Childre
n(s
elf-
este
em)
BM
ISD
S
The Impact of Weight Management on Self-Esteem 383
Dow
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arolina at wilm
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Tab
leI
(co
nti
nu
ed
)
Stu
dy
(auth
or
yea
rlo
cati
on)
Quali
tyra
ting
Part
icip
ants
Inte
rven
tions
Focu
son
self
-est
eem
Dura
tion
Outc
om
em
easu
res
DeB
ar
etal2012
Unit
edSta
tes3
3Posi
tive
208
(100
)fe
-m
ale
s12ndash17
yea
rsB
MI
90th
per
centi
le
IIn
terv
enti
on
focu
sed
on
changin
gdie
tary
inta
ke
and
eati
ng
patt
erns
incr
easi
ng
physi
calact
ivit
yta
ckling
com
mon
psy
choso
cialis
sues
of
obes
-it
yand
teach
ing
beh
avio
raland
cog-
nit
ive
tools
for
wei
ght
managem
ent
Pare
nt
support
mee
tings
wer
ein
cluded
C
W
ait
list
No
spec
ific
focu
son
self
-est
eem
but
issu
essu
chas
dep
ress
ion
and
poor
body
image
wer
eaddre
ssed
and
cognit
ive
rest
ruct
uri
ng
tech
niq
ues
tore
-duce
neg
ati
ve
self
-talk
wer
euse
d
Six
teen
90-m
ingro
up
mee
tings
over
5m
onth
sFollow
up
12
month
sfr
om
base
line
Rose
nber
gSel
f-E
stee
mSca
leB
MI
z-sc
ore
Loch
rie
etal
2013U
nit
edSta
tes2
8
Posi
tive
29
(43
)m
ale
sand
39
(57
)fe
-m
ale
s10ndash11
yea
rsB
MI
85th
per
centi
le
IPart
icip
ants
and
thei
rpare
nts
at-
tended
gro
up
sess
ions
led
by
apsy
ch-
olo
gis
tand
regis
tere
ddie
titi
an
that
cover
ednutr
itio
nbeh
avio
rm
odifi
ca-
tionex
erci
seto
pic
spsy
choso
cial
inte
rven
tions
and
med
icalis
sues
ass
oci
ate
dw
ith
obes
ity
CO
ne
gro
up
sess
ion
for
fam
ilie
sle
dby
are
gis
tere
ddie
titi
an
pro
vid
ing
in-
form
ati
on
on
nutr
itio
nand
physi
cal
act
ivit
y
Psy
choso
cialas-
pec
tsof
inte
rven
tionmdash
stre
ssm
anage-
men
tre
laxati
on
managin
gpee
rpre
ssure
and
teasi
ng
Fourt
een
sess
ions
last
ing
60ndash90
min
over
6m
onth
sN
ofo
llow
up
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
for
Childre
n(s
elf-
este
em)
BM
Iz-
score
Lubans
etal
2012A
ust
ralia
34
Posi
tive
152
(100
)fe
-m
ale
s12ndash14
yea
rsB
MI
85th
per
centi
le
ISch
ool-
base
din
terv
enti
on
incl
udin
gen
hance
dsp
ort
sess
ions
inte
ract
ive
sem
inars
lu
nch
-tim
eact
ivit
yse
ssio
ns
ped
om
eter
sfo
rse
lf-m
onit
ori
ngpar-
ent
new
slet
ter
text
mes
sages
for
so-
cialsu
pport
and
nutr
itio
nw
ork
shops
del
iver
edby
Acc
redit
edPra
ctic
ing
Die
titi
ans
CN
otr
eatm
ent
contr
ol
No
spec
ific
men
-ti
on
of
self
-es
teem
Del
iver
edover
the
four
schoolte
rms
inth
eyea
rFollow
up
24
month
sfr
om
base
line
Mars
hrsquos
Glo
bal
Sel
f-es
teem
BM
Iz-
score
Mel
lin
etal1987
Unit
edSta
tes2
9N
eutr
al
14
(21
)m
ale
sand
52
(79
)fe
-m
ale
s12ndash18
yea
rsgt
13
over
wei
ght
IIn
terv
enti
on
use
dco
gnit
ive
beh
av-
iora
laff
ecti
ve
and
inte
ract
ive
tech
-niq
ues
toen
coura
ge
sust
ain
able
modifi
cati
ons
todie
tex
erci
sere
la-
tionsh
ips
life
style
co
mm
unic
ati
ons
and
att
itudes
T
wo-p
are
nt
sess
ions
incl
uded
C
W
ait
list
No
spec
ific
men
-ti
on
of
self
-es-
teem
but
inte
rven
tions
enco
ura
ged
posi
-ti
ve
rela
tionsh
ips
and
att
itudes
Fourt
een
90-m
inse
ssio
ns
over
14
wee
ks
Follow
up
15
month
sfr
om
base
line
Rose
nber
gSel
f-E
stee
mSca
leR
elati
ve
wei
ght
384 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Tab
leI
(co
nti
nu
ed
)
Stu
dy
(auth
or
yea
rlo
cati
on)
Quali
tyra
ting
Part
icip
ants
Inte
rven
tions
Focu
son
self
-est
eem
Dura
tion
Outc
om
em
easu
res
Morg
an
etal
2012A
ust
ralia
30
Neu
tral
40
(100
)m
ale
s13ndash16
yea
rs
BM
I
85th
per
centi
le
ISch
ool-
base
din
terv
enti
on
incl
udin
gen
hance
dsp
ort
sess
ions
physi
calac-
tivit
yand
nutr
itio
nhandbooks
wit
hhom
e-base
dch
allen
ges
and
inte
r-act
ive
sem
inars
on
nutr
itio
nand
physi
calact
ivit
ybeh
avio
rsand
leader
ship
C
W
ait
list
No
spec
ific
men
-ti
on
of
self
-es
teem
3-m
onth
inte
rven
tion
Follow
up
6m
onth
sfr
om
base
line
Physi
calSel
f-Per
cepti
on
Pro
file
Adole
scen
tver
-si
on
(sel
f-es
teem
)B
MI
Neu
mark
-Szt
ain
eret
al2010
USA
(27)
Neu
tral
164
(100
)fe
-m
ale
s13ndash18
yea
rsB
MI
85th
per
centi
le
Iphysi
calact
ivit
yn
utr
itio
ns
oci
alsu
p-
port
sel
f-em
pow
erm
ent
less
ons
at
schoolw
ith
rela
ted
lett
ers
sent
hom
eto
pare
nts
alo
ng
wit
hin
div
idualm
o-
tivati
onalin
terv
iew
ing
sess
ions
toen
-co
ura
ge
goal-
sett
ingFollow
edby
lunch
tim
ese
ssio
ns
duri
ng
the
main
-te
nance
per
iod
and
a1-d
ay
pare
ntndash
daughte
rre
trea
tC
A
llgir
lsphysi
calact
ivit
ycl
ass
wit
hin
norm
alsc
hoolcu
rric
ulu
m
One
of
the
pro
-gra
mobje
ctiv
esw
as
toen
hance
aposi
tive
self
-fo
cus
and
ses-
sions
focu
sed
on
self
-em
pow
erm
ent
Phase
1mdash
daily
less
ons
at
schoolfo
r16
wee
ks
Sev
enin
div
idualse
ssio
ns
ever
y3ndash4
wee
ks
thro
ughout
inte
rven
tion
Phase
2mdash
wee
kly
lunch
tim
ese
ssio
ns
for
rem
ain
-der
of
schoolyea
r(
5m
onth
s)
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
(sel
f-es
teem
)B
MI
Nguyen
etal
2013A
ust
ralia
35
Posi
tive
55
(36
)m
ale
sand
96
(64
)fe
-m
ale
s13ndash16
yea
rsover
wei
ght
tom
oder
ate
lyobes
eB
MI
z-sc
ore
10
ndash25
(BM
I84ndash99th
per
centi
le)
IIn
terv
enti
on
base
don
the
soci
alco
g-
nit
ive
theo
ryto
modif
yse
lf-e
ffica
cy
moti
vati
onper
sever
ance
and
self
-re
gula
tionSes
sions
focu
sed
on
phys-
icalact
ivit
yhea
thy
eati
nggoalse
t-ti
ngst
ress
managem
ent
and
buildin
gse
lf-e
stee
mIn
terv
enti
on
gro
up
rece
ived
Addit
ional
Ther
apeu
tic
Conta
ct(A
TC
)fo
rtnig
htl
yth
rough-
out
the
main
tenance
per
iodPare
nt
sess
ions
incl
uded
C
A
sabove
wit
hout
the
AT
C
Buildin
gposi
tive
self
-est
eem
was
the
focu
sof
ase
ssio
n
Phase
1mdash
seven
wee
kly
75-m
ingro
up
sess
ions
Phase
2mdash
from
2to
24
month
sfive
60-m
ingro
up
sess
ions
hel
dappro
xev
ery
3m
onth
sA
TC
Fort
nig
htl
yte
le-
phone
coach
ing
sess
ions
and
SM
Se
mes
sages
Hart
errsquos
Sel
fPer
cepti
on
Pro
file
for
Adole
scen
ts(s
elf-
este
em)
BM
Iz-
score
Sach
eret
al2010
Unit
edK
ingdom
31
Posi
tive
21
(48
)m
ale
sand
23
(52
)fe
-m
ale
s10ndash12
yea
rsB
MI
gt98th
per
centi
le
IPart
icip
ants
and
thei
rfa
milie
sat-
tended
gro
up
sess
ions
focu
sing
on
be-
havio
rch
ange
nutr
itio
nand
physi
calact
ivit
ySes
sion
conte
nt
focu
sed
on
buildin
gsk
ills
tom
ain
tain
long-t
erm
beh
avio
rch
anges
Follow
ing
trea
tmen
tfa
milie
sw
ere
giv
ena
12-w
eek
free
fam
ily
swim
pass
C
W
ait
-lis
t
No
spec
ific
men
-ti
on
of
self
-es
teem
Eig
hte
en2-h
rse
ssio
ns
over
9w
eeks
Follow
up
12
month
sfr
om
base
line
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
for
Childre
n(s
elf-
este
em)
BM
Iz-
score
The Impact of Weight Management on Self-Esteem 385
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
self-esteem was observed following four MWMIsacross three studies (Croker et al 2012 Danielsenet al 2013 Nguyen Shrewsbury et al 2012) Fivestudies showed no effect on adolescent self-esteem fol-lowing MWMI (Brennan et al 2012 DeBar et al2012 Lochrie et al 2013 Lubans et al 2012Neumark-Sztainer et al 2010) No positive effects onself-esteem were observed in any of the controlgroups One wait-listed control group (Croker et al2012) showed a small negative effect on self-esteem
Mixed results were also observed in the studies forwhich an effect size could not be calculatedImprovements in adolescent self-esteem were observedfollowing MWMIs by Daley et al (2006) Mellin et al(1987) Sacher et al (2010) and Wadden et al(1990) However only Daley et al (2006) reportedthat this change was different to that observed in thecontrol group No changes in self-esteem were de-tected following intervention by Morgan et al (2012)although a significant decline in self-esteem wasobserved in the wait-listed control group who receivedthe normal school curriculum throughout the studyperiod
Multicomponent Weight ManagementInterventions Improve Weight Outcomes inAdolescentsOf the 13 included studies there were 14 groups whoreceived a MWMI and 11 no-treatment controlgroups Of these effect sizes were able to be calculatedfor nine intervention groups and seven control groups(Table III) Seven intervention groups had small to me-dium positive effects indicating successful weight loss(Brennan et al 2012 Croker et al 2012 Danielsenet al 2013 DeBar et al 2012 Lochrie et al 2013Lubans et al 2012 Nguyen Shrewsbury et al2012) and two intervention groups had no effect(Neumark-Sztainer et al 2010 Nguyen Shrewsburyet al 2012) All seven control groups showed no ef-fect on weight
Of the studies for which effect size could not be cal-culated the results were similar Mellin et al (1987)Morgan et al (2012) Sacher et al (2010) andWadden et al (1990) all observed significant weightloss following intervention Morgan et al (2012) andSacher et al (2010) also showed that these changeswere significantly different to changes observed in thecontrol groups No studies observed significant weightchange in the control groups
Correlation Between Self-Esteem Improvementand Weight Loss Effect SizesThere is a strong (rfrac14 641 R2frac140410) positive linearrelationship between effect sizes for self-esteem im-provement and weight loss across all intervention andcontrol groups (pfrac14 008)T
ab
leI
(co
nti
nu
ed
)
Stu
dy
(auth
or
yea
rlo
cati
on)
Quali
tyra
ting
Part
icip
ants
Inte
rven
tions
Focu
son
self
-est
eem
Dura
tion
Outc
om
em
easu
res
Wadden
etal
1990U
nit
edSta
tes3
6
Posi
tive
47
(100
)fe
male
s12ndash16
yea
rsat
least
10-k
gover
wei
ght
IIn
terv
enti
on
cover
eddie
tand
eati
ng
patt
erns
modif
yin
gse
lf-d
efea
ting
thoughts
and
incr
easi
ng
physi
calac-
tivit
yH
om
ework
ass
ignm
ents
and
ince
nti
ves
aw
ard
sw
ere
use
dto
en-
coura
ge
part
icip
ati
onT
her
ew
ere
thre
edif
fere
nt
inte
rven
tion
gro
ups
who
rece
ived
this
trea
tmen
tch
ild
only
ch
ild
and
moth
erto
get
her
ch
ild
and
moth
erse
para
tely
C
N
ocl
ear
contr
olgro
upse
eabove
No
spec
ific
men
-ti
on
of
self
-es
teem
Six
teen
wee
kly
1-h
rle
ssons
No
follow
up
Pie
rs-H
arr
issc
ale
(sel
f-es
teem
)B
MI
Note
B
MIfrac14
body
mass
index
Ifrac14
inte
rven
tionCfrac14
Com
par
ato
rC
om
par
ato
rgro
ups
that
rece
ived
an
inte
rven
tion
wer
etr
eate
das
inte
rven
tion
gro
ups
for
the
purp
ose
of
anal
ysi
sin
this
revie
w
Stu
die
sare
list
edin
alp
habet
icalord
erin
all
table
s
386 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Tab
leIIS
elf
-Est
ee
mO
utc
om
es
of
Mu
ltic
om
po
ne
nt
We
igh
tM
an
ag
em
en
tIn
terv
en
tio
ns
Co
mp
are
dW
ith
Co
ntr
ols
in
Ov
erw
eig
ht
an
dO
be
seA
do
lesc
en
ts
Auth
or
yea
rIn
terv
enti
on
gro
ups
Contr
olgro
ups
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
Bre
nnan
etal2012
20
215
(54
)a206
(63
)a
21
1(4
78)a
01
514
188
(47
)a192
(47
)a06
4(3
91)a
00
9C
roker
etal2012
13
26
9(0
57)b
29
5(0
45)b
03
6(0
39)b
05
110
29
0(0
61)b
26
8(0
52)b
00
2(0
59)b
03
9D
ale
yet
al2006
28
24
2(0
56)b
26
1(0
08
SE)b
NA
NA
30
24
9(0
49)b
25
6(0
10
SE)b
NA
NA
Danie
lsen
etal2013
16
28
8(0
52)b
31
7(0
53)b
02
9(0
53)b
05
516
31
1(0
57)b
30
6(0
59)b
00
5(0
37)b
00
9D
eBar
etal2012
105
23
9(0
26)a
24
0(0
25)a
NA
00
4103
24
1(0
27)a
23
9(0
25)a
NA
00
8L
och
rie
etal2013
29
183
(50
2)b
191
(44
8)b
07
3(4
51)b
01
718
199
(34
6)b
199
(34
3)b
00
0(3
11)b
00
0L
ubans
etal2012
54
40
3(1
12)c
40
6(1
32)c
NA
00
268
40
4(0
99)c
42
3(0
98)c
NA
01
9M
ellin
etal1987
37
NA
NA
08
8(1
50)a
NA
29
NA
NA
05
2(1
34)a
NA
Morg
an
etal2012
19
NA
NA
00
8(0
48)d
NA
21
NA
NA
02
6(0
47)d
NA
Neu
mark
-Szt
ain
eret
al2010
85
152
(34
)b151
(29
)bN
A
00
379
141
(34
)b140
(34
)bN
A
00
3
Nguyen
etal2012
(wit
hA
TC
)57
25
8(0
76)b
27
7(0
63)b
01
9(0
67)b
02
7
Nguyen
etal2012
(wit
hout
AT
C)
50
25
9(0
58)b
29
3(0
61)b
01
9(0
51)b
05
7
Sach
eret
al2010
20
NA
32
5(0
68)b
02
5(0
66)b
NA
24
NA
30
4(0
75)b
01
1(0
74)b
NA
Wadden
etal1990
3gro
ups
com
bin
ed47
576
e599
eN
AN
A
Note
D
ata
pre
sente
das
report
edin
ori
gin
alpaper
sSDfrac14
standard
dev
iati
onN
Afrac14
data
not
pro
vid
edu
nab
leto
be
calc
ula
ted
SEfrac14
Sta
ndard
erro
rnot
Sta
ndard
Dev
iati
onE
ffec
tsi
zefrac14
Cohen
rsquosdB
old
font
indic
ate
sw
her
eef
fect
size
was
small
(02
0)
or
gre
ate
raR
ose
nber
gse
lf-e
stee
msc
ale
(gen
erally
score
dfr
om
0[l
ow
est
self
-est
eem
]to
30
[hig
hes
tse
lf-e
stee
m])
bH
art
errsquos
SPPA
SPPC
(gen
erally
score
d1
[low
est
self
-est
eem
]to
4[h
ighes
tse
lf-e
stee
m])
cM
ars
hrsquos
Physi
calSel
f-D
escr
ipti
on
Ques
tionnair
e
dPhysi
calSel
f-Per
cepti
on
Pro
file
for
Adole
scen
ts
ePie
rs-H
arr
isSel
f-C
once
pt
Sca
le
Sco
ring
range
sunav
ailab
lehig
her
valu
eeq
uals
hig
her
self
-est
eem
The Impact of Weight Management on Self-Esteem 387
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Tab
leIII
We
igh
tO
utc
om
es
of
Mu
ltic
om
po
ne
nt
We
igh
tM
an
ag
em
en
tIn
terv
en
tio
ns
Co
mp
are
dW
ith
Co
ntr
ols
in
Ov
erw
eig
ht
an
dO
be
seA
do
lesc
en
ts
Auth
or
yea
rIn
terv
enti
on
gro
ups
Contr
olgro
ups
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
Bre
nnan
etal2012
20
20
8(0
37)
19
9(0
46)
02
0(0
18)
02
214
20
8(0
40)
20
9(0
39)
00
1(0
12)
00
3C
roker
etal2012
13
29
5(0
52)
26
6(0
63)
01
7(0
21)
05
010
31
4(0
68)
31
4(0
68)
00
6(0
13)
00
0D
ale
yet
al2006
28
31
7(0
33)
32
3(0
02
SE)
NA
NA
30
33
2(0
37)
32
3(0
02
SE)
NA
NA
Danie
lsen
etal2013
16
25
9(0
30)
24
6(0
41)
01
2(0
17)
03
616
24
9(0
27)
25
3(0
29)
00
5(0
15)
01
4D
eBar
etal2012
105
20
0(0
34)
18
8(0
41)
NA
03
2103
20
0(0
33)
19
4(0
38)
NA
01
7L
och
rie
etal2013
29
21
9(0
40)
20
6(0
52)
01
2(0
20)
02
818
20
7(0
40)
20
5(0
43)
00
2(0
11)
00
5L
ubans
etal2012
54
19
3(0
61)
18
0(0
68)
NA
02
068
18
5(0
59)
18
0(0
67)
NA
00
8M
ellin
etal1987
37
1365
aN
A
59
(67
5)a
NA
29
1295
aN
A
03
(66
1)a
NA
Morg
an
etal2012
19
NA
NA
04
2(0
91)b
NA
21
NA
NA
00
3(0
87)b
NA
Neu
mark
-Szt
ain
eret
al2010
85
321
(61
)b322
(62
)bN
A
00
279
310
(53
)b314
(55
)bN
A
00
7
Nguyen
etal2012
(wit
hA
TC
)57
20
3(0
37)
19
7(0
42)
00
8(0
19)
01
5
Nguyen
etal2012
(wit
hout
AT
C)
50
20
2(0
29)
19
4(0
32)
00
9(0
17)
02
6
Sach
eret
al2010
20
NA
23
7(0
52)
02
2(0
27)
NA
24
NA
26
0(0
54)
00
1(0
20)
NA
Wadden
etal1990
3gro
ups
com
bin
ed47
352
b339
bN
AN
A
Note
D
ata
pre
sente
das
report
edin
ori
gin
al
paper
sA
llw
eight
outc
om
esre
port
edas
body
mass
index
(BM
I)z-
score
unle
ssoth
erw
ise
state
d
SDfrac14
standar
ddev
iati
on
NAfrac14
data
not
pro
vid
ed
unab
leto
be
calc
ula
ted
SEfrac14
Sta
ndard
Err
or
report
edra
ther
than
Sta
ndard
Dev
iati
onE
ffec
tsi
zefrac14
Cohen
rsquosdB
old
font
indic
ate
sw
her
eef
fect
size
was
smal
l(0
20)
or
gre
ate
raR
elati
ve
wei
ght
bB
MI
388 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Quantitative Data AnalysisDifferences between intervention and control groupsfor change in self-esteem are presented in Figure 2aThis analysis included seven intervention groups(nfrac14 191) and seven control groups (nfrac14 132) with
interventions or intensive treatment phases rangingfrom 9 weeks to 6 months in duration A moderatelevel of the variation across studies was owing to het-erogeneity (I2frac14464 Higgins Thompson Deeksamp Altman 2003) The overall summary effect showed
Figure 2 Comparison between intervention and control groups for the change in adolescent self-esteem effect size (a) andbody mass index z-score (b) following multicomponent weight management interventions SMD frac14 standard mean differ-ence WMD frac14 weighted mean difference
The Impact of Weight Management on Self-Esteem 389
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no effect on self-esteem as a result of interventionSMD of 027 (95 confidence interval 004 059)zfrac14 169 and pfrac14 092 However all studies exceptone favored the intervention for improvements in self-esteem
The difference between intervention and controlgroups for change in BMI z-score is illustrated inFigure 2b This analysis included five interventiongroups (nfrac14 135) and five control groups (nfrac14 82) withinterventions ranging from 9 weeks to 6 months induration Heterogeneity in this sample was low(I2frac14177 Higgins et al 2003) and the overall sum-mary effect was 017 (022 011) BMI z-scorepoints (zfrac14613 and plt 001) indicating statisticallysignificant weight loss following MWMI
Discussion
The purpose of this review was to examine the effectof MWMIs on self-esteem in overweight and obeseadolescents Increased self-esteem is proposed as a keyfactor for maintaining long-term weight management(Elfhag amp Rossner 2005 French et al 1995Roberts 2006) A secondary outcome of this reviewwas to examine the impact of MWMIs on weight lossand whether this was associated with improvements inself-esteem
The meta-analysis showed no difference in self-esteem between the intervention and control groupsHowever six of the seven studies in the meta-analysisfavored the intervention over control for improve-ments in self-esteem and four of the six studies notincluded in the meta-analysis found significant im-provements in self-esteem following intervention Thelatter of these findings are similar to those of an earlierreview (Lowry et al 2007) that showed improve-ments in self-esteem following weight managementinterventions in a pediatric population particularlywhen certain intervention features were presentSimilarly a number of intervention features that con-tributed to an increased likelihood of improving self-esteem were identified in this review
Improvements in self-esteem regardless of weightloss have been demonstrated in children who tookpart in weight management interventions thatincluded a focus on building self-esteem and it is rec-ommended that this be a focus of all pediatric weightmanagement interventions (Lowry et al 2007) Yetthe majority of studies identified in this review did notinclude building self-esteem as a key aspect of theirintervention Nguyen Shrewsbury et al (2012)described the greatest focus on self-esteem (one75-min group session focused on building self-esteem)and also resulted in the largest treatment effect (057)and a significant improvement in self-esteem (NguyenShrewsbury et al 2012) A focus on similar topics
such as body image social support and managing bul-lying may also contribute to improvements in self-esteem (Croker et al 2012 Pierce amp Wardle 1997Tiggemann 2005) however these findings highlightthe lack of uptake of these recommendations
Among overweight and obese youth reductions inself-esteem are often observed in domains of physicalappearance and physical ability (Franklin DenyerSteinbeck Caterson amp Hill 2006 French et al1995 Latzer amp Stein 2013 Lowry et al 2007)Particularly for adolescent girls body image is a keyconcern (Cave Fildes Luckett amp Wearring 2015)and comprises a large portion of global self-esteem(Lowry et al 2007 Pesa Syre amp Jones 2000)However weight loss and associated changes in phys-ical appearance do not necessarily reflect improve-ments in self-esteem (Lowry et al 2007) Changes inbody-esteem often occur more rapidly than changes inglobal self-esteem as a result of weight management(Lowry et al 2007) This may explain the lack ofchange observed in global self-esteem in this meta-analysis and highlights the need to also include body-esteem (or physical self-esteem) as a focus and out-come of weight management interventions foradolescents
Parental involvement in adolescent weight manage-ment interventions is a critical component for success-ful weight loss and may also be important forimproving self-esteem (Lowry et al 2007) Weight-related teasing from family is shown to be negativelyassociated with self-esteem in overweight adolescentswhereas family connectedness was positively associ-ated with adolescent self-esteem (Fulkerson StraussNeumark-Sztainer Story amp Boutelle 2007) The in-clusion of parents in weight management interventionsfosters a safer and more encouraging home environ-ment for the adolescent (Lowry et al 2007) which isassociated with increased self-esteem in nonover-weight children (Marx amp Neumark-Sztainer 2005)All studies in the present review baring one includedparents in the intervention Parental involvementshould continue to be a key component of weightmanagement interventions to ensure a supportivehome environment for the adolescent to help fosterpositive self-esteem
Weight management interventions that used agroup setting to target self-esteem have shown im-provements in self-esteem without significant weightchange (Lowry et al 2007 Sherman AlexanderGomez Kim amp Marole 1992) The ability of the peergroup setting to provide opportunities for bondingsupport feelings of belonging development of peer-based skills and positive peer exchanges is key toincreasing self-esteem (Lowry et al 2007) The im-portance of this element is being acknowledged in the
390 Murray Dordevic and Bonham
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field with all the studies in this review baring twousing group sessions in their intervention
Measures of self-esteem are self-reported and there-fore subjective Responses to questionnaires are likelyto be influenced by individual (eg age gender) andenvironmental (eg cultural group socioeconomicstatus) factors (Khanlou 2004) Changes followinginterventions may represent genuine long-termchanges in self-esteem or may be due to short-termfluctuations in self-esteem in response to specificevents (eg winning a sporting event or performanceon a test at school) (Kernis 1993) While validatedtools were used to measure self-esteem in all studies itwas difficult to conclude whether outcomes were en-tirely dependent on the intervention without inclusionof a no-treatment control group
The variety of self-esteem assessment tools also addsto the difficulty of interpretation Across the 13 studies inthis review five different tools were used with differentquestions and different scales Even within tools therewere different scales used to report the results (RosenbergSelf-esteem Scale) and different versions of the same ques-tionnaire (Harterrsquos Self-perception Profile for ChildrenHarterrsquos Self-perception Profile for Adolescents) HarterrsquosSelf-Perception Profile (Harterrsquos Self-perception Profilefor Adolescents for adolescents) which measures ninesubscales of self-esteem including physical self-esteem issuggested as the most appropriate measure for adolescentself-esteem (Lowry et al 2007) It was also the mostcommonly used tool among papers included in this re-view While Cohenrsquos d effect sizes were used to stand-ardize results in this review the consistent use of one toolwould provide the ability to compare raw self-esteemscores and create a stronger analysis in the future
Results from this review support evidence thatMWMIs induce weight loss in overweight and obeseadolescents (Hoelscher Kirk Ritchie ampCunningham-Sabo 2013 Kelly amp Melnyk 2008Luttikhuis et al 2009) The change in BMI z-score inthe present meta-analysis (017 [022 011]) wassimilar to the clinically meaningful weight loss re-ported in the 2009 Cochrane Review in children 12years at 6 months follow up from a lifestyle weightmanagement intervention (014 [017 012])(Luttikhuis et al 2009) Jelalian Mehlenbeck Lloyd-Richardson Birmaher and Wing (2006) and WalkerGately Bewick and Hill (2003) have demonstratedassociations between weight loss and increased self-esteem in overweight and obese adolescents after at-tending a weight-management intervention Similarlyin the present review a strong positive relationship be-tween treatment effects for weight loss and improve-ment in self-esteem was identified However itremains unclear whether the improvement in self-esteem was as a result of successful weight loss orwhether it was a contributing factor toward successful
weight loss Nonetheless building self-esteem shouldbe a key focus of MWMIs as improved self-esteem ap-
pears to be linked to enhanced weight lossA key strength of this review was that all included
studies had strong designs and presented level II evi-dence (Coleman et al 2009) However to further elu-
cidate the role of self-esteem in adolescent weightmanagement future research should consider power-
ing studies to detect changes in psychosocial as well asphysiological outcomes Only one study in this reviewwas powered to detect a change in psychosocial out-
comes (Daley et al 2006) which may explain thelack of significant results observed for self-esteem
Additionally a large number of included studies didnot describe their method of handling withdrawals or
use blinding to prevent the introduction of bias Toimprove confidence in the effectiveness of MWMIs
and reduce the risk of bias future studies should bedesigned with concealed allocation and document andreport in detail the flow of participants
Identification of intervention components that im-
prove self-esteem is important for future weight man-agement intervention design Included interventionswere heterogeneous offering different levels of diet-
ary physical activity and behavioral interventionwhich may have collectively or individually influenced
the results Inconsistent reporting of intervention andcomparator conditions make it difficult to elucidate
the components that contributed to improvements inself-esteem Future studies should report intervention
and comparator procedures in adequate detail so thatsuccessful components can be identified and repli-cated These limitations highlight areas for improve-
ment to develop best-practice guidelines forundertaking and evaluating MWMIs in adolescents to
enhance self-esteem
Conclusion
Overweight and obese adolescents experience low
self-esteem largely owing to poor body image yetthis meta-analysis found no improvement in self-esteem even with significant weight loss Although it
was noted that interventions that had larger effects onself-esteem also had larger effects on weight loss The
incorporation of intervention components that wereidentified to contribute to improvements in self-
esteem may assist future weight management interven-tions to improve the self-esteem of overweight and
obese adolescents Furthermore a consistent measureof self-esteem would enable easier interpretation ofself-esteem scores and comparison of results across
studies to improve our understanding of the relation-ship between self-esteem and weight management in
adolescents
The Impact of Weight Management on Self-Esteem 391
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Supplementary Data
Supplementary data can be found at httpwwwjpepsy
oxfordjournalsorg
Acknowledgments
The authors would like to acknowledge Dr Zoe Davidson
for her assistance in performing the meta-analyses
Funding
This work was supported by an Australian GovernmentResearch Training Program Scholarship
Conflicts of interest none declared
References
Academy of Nutrition and Dietetics (2012) Evidence ana-lysis manual Steps in the academy evidence analysis pro-cess Chicago IL ADA Research and Strategic Business
DevelopmentBrennan L Walkley J Fraser S F Greenway K amp
Wilks R (2008) Motivational interviewing and cognitivebehaviour therapy in the treatment of adolescent over-
weight and obesity Study design and methodologyContemporary Clinical Trials 29 359ndash375
Brennan L Walkley J Wilks R Fraser S F amp
Greenway K (2013) Physiological and behavioural out-comes of a randomised controlled trial of a cognitive be-havioural lifestyle intervention for overweight and obese
adolescents Obesity Research and Clinical Practice 7e23ndashe41
Brennan L Wilks R Walkley J Fraser S F amp
Greenway K (2012) Treatment acceptability and psycho-social outcomes of a randomised controlled trial of a cog-nitive behavioural lifestyle intervention for overweight and
obese adolescents Behaviour Change 29 36ndash62Cave L Fildes J Luckett G amp Wearring A (2015)
Mission Australiarsquos 2015 youth survey report MissionAustralia
Coleman K Norris S Weston A Grimmer-Somers KHillier S Merlin T Salisbury J (2009) NHMRCadditional levels of evidence and grades for recommenda-tions for developers of guidelines (Vol Stage 2Consultation) Australia National Health and Medical
Research CouncilCroker H Viner R M Nicholls D Haroun D
Chadwick P Edwards C Wardle J (2012) Family-based behavioural treatment of childhood obesity in a UK
national health service setting Randomized controlledtrial International Journal of Obesity 36 16ndash26 doi
101038ijo2011182Daley A J Copeland R J Wright N P Roalfe A amp
Wales J K H (2006) Exercise therapy as a treatment forpsychopathologic conditions in obese and morbidly obese
adolescents A randomized controlled trial Pediatrics118 2126ndash2134
Danielsen Y S Nordhus I H Julıusson P B Maelighle Mamp Pallesen S (2013) Effect of a family-based cognitive
behavioural intervention on body mass index self-esteem
and symptoms of depression in children with obesity (aged
7mdash13) A randomised waiting list controlled trial ObesityResearch amp Clinical Practice 7 e116ndashe128
DeBar L L Stevens V J Perrin N Wu P Pearson J ampJo B (2012) A primary care-based multicomponent life-
style intervention for overweight adolescent femalesPediatrics 129 e611ndashe620
Elfhag K amp Rossner S (2005) Who succeeds in maintain-ing weight loss A conceptual review of factors associated
with weight loss maintenance and weight regain ObesityReviews 6 67ndash85
Franklin J Denyer G Steinbeck K S Caterson I D ampHill A J (2006) Obesity and risk of low self-esteem Astatewide survey of Australian children Pediatrics 118
2481ndash2487French S A Story M amp Perry C L (1995) Self-esteem
and obesity in children and adolescents A literature re-view Obesity Research 3 479ndash490
Fulkerson J Strauss J Neumark-Sztainer D Story M
amp Boutelle K (2007) Correlates of psychosocial well-being among overweight adolescents The role of the fam-ily Journal of Consulting and Clinical Psychology 75
181ndash186Griffiths L J Parsons T J amp Hill A J (2010) Self-es-
teem and quality of life in obese children and adolescentsA systematic review International Journal of PediatricObesity 5 282ndash304
Harter S (1993) Causes and consequences of low self-
esteem in children and adolescents In R F Baumeister(Ed) Self-esteemmdashThe puzzle of low self-regard (pp87ndash116) USA Springer
Higgins J Thompson S Deeks J amp Altman D (2003)
Measuring inconsistency in meta-analyses BMJ 327557ndash560
Hoelscher D M Kirk S Ritchie L amp Cunningham-Sabo L (2013) Position of the Academy of Nutrition and
Dietetics Interventions for the prevention and treatmentof pediatric overweight and obesity Journal of theAcademy of Nutrition and Dietetics 113 1375ndash1394
Jelalian E Mehlenbeck R Lloyd-Richardson EBirmaher V amp Wing R (2006) lsquoAdventure therapyrsquo
combined with cognitivebehavioral treatment for over-weight adolescents International Journal of Obesity 3031ndash39
Kelly S A amp Melnyk B M (2008) Systematic review of
multicomponent interventions with overweight middleadolescents implications for clinical practice and researchWorldviews on Evidence-Based Nursing 5 113ndash135
Kernis M (1993) The roles of stability and level of self-
esteem in psychological functioning In R Baumeister(Ed) Self-esteem (pp 167ndash182) USA Springer
Khanlou N (2004) Influences on adolescent self-esteem inmulticultural Canadian secondary schools Public HealthNursing 21 404ndash411
Kohn M Rees J M Brill S Fonseca H Jacobson M
Katzman D K Schneider M (2006) Preventing andtreating adolescent obesity A position paper of the Societyfor Adolescent Medicine Journal of Adolescent Health
38 784ndash787Kornman K P Shrewsbury V A Chou A C Ngyuen
B Lee A Orsquoconnor J Baur L A (2010) Electronic
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arolina at wilm
ington user on 14 February 2019
therapeutic contact for adolescent weight management
The Loozit study Telemedicine and E-Health 16
678ndash685Latzer Y amp Stein D (2013) A review of the psychological
and familial perspectives of childhood obesity Journal of
Eating Disorders 1 7Lobstein T Baur L amp Uauy R (2004) Obesity in chil-
dren and young people a crisis in public health Obesity
Reviews 5(Suppl 1) 4ndash104Lochrie A S Wysocki T Hossain J Milkes A Antal
H Buckloh L Lang J (2013) The effects of a family-
based intervention (FBI) for overweightobese children on
health and psychological functioning Clinical Practice in
Pediatric Psychology 1 159ndash170 doi httpdxdoiorg
101037cpp0000020Lowry K W Sallinen B amp Janicke D (2007) The effects
of weight management programs on self-esteem in pediat-
ric overweight populations Journal of Pediatric
Psychology 32 1179ndash1195Lubans D R Morgan P J Okely A D Dewar D
Collins C E Batterham M Plotnikoff R C (2012)
Preventing obesity among adolescent girls One-year out-
comes of the nutrition and enjoyable activity for teen girls
(NEAT Girls) cluster randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
821ndash827Luttikhuis H Baur L Jansen H Shrewsbury V
Orsquomalley C Stolk R amp Summerbell C (2009)
Interventions for treating obesity in children (Review)
Cochrane Database of Systematic Reviews 3 1ndash57Marx R D amp Neumark-Sztainer D (2005) Questions amp
Answers Eating Disorders The Journal of Treatment amp
Prevention 13 491ndash495McClure A C Tanksi S E Kingsbury J Gerrard M amp
Sargent J D (2010) Characteristics associated with low
self-esteem among US adolescents Academic Pediatrics
10 238ndash244Mellin L M Slinkard L A amp Irwin C E (1987)
Adolescent obesity intervention Validation of the
SHAPEDOWN program Journal of the American Dietetic
Association 87 333ndash338Mission Australia (2012) Youth Survey 2012 SydneyMoher D Shamseer L Clarke M Ghersi D Liberati
A Petticrew M PRISMA-P Group (2015) Preferred
reporting items for systematic review and meta-analysis
protocols (PRISMA-P) 2015 statement Systematic
Reviews 4 1Morgan P Saunders K amp Lubans D (2012) Improving
physical self-perception in adolescent boys from disadvan-
taged schools Psychological outcomes from the Physical
Activity Leaders randomized controlled trial Pediatric
Obesity 7 e27ndashe32 doi httpdxdoiorg101111j
2047-6310201200050xNational Health and Medical Reasearch Council (2013)
Clinical practice guidelines for the management of over-
weight and obesity in adults adolescents and children in
Australia Australia NHMRC Australian Government
Department of HealthNational Institutes for Health and Care Excellence (2013)
Managing overweight and obesity among children and
young people lifestyle weight management services NICE
public health guidance United Kingdom 47 NICENeumark-Sztainer D R Friend S E Flattum C F
Hannan P J Story M T Bauer K W Petrich C A
(2010) New moves-preventing weight-related problems in
adolescent girls A group-randomized study American
Journal of Preventive Medicine 39 421ndash432Nguyen B McGregor K A Orsquoconnor J Shrewsbury V
A Lee A Steinbeck K S Baur L A (2012)
Recruitment challenges and recommendations for adoles-
cent obesity trials Journal of Paediatrics and Child
Health 48 38ndash43Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Hill A J Shah S Baur L A (2013) Two-year
outcomes of an adjunctive telephone coaching and elec-
tronic contact intervention for adolescent weight-loss
maintenance the Loozit randomized controlled trial
International Journal of Obesity 37 468ndash472Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2012) Twelve-month
outcomes of the Loozit randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
170ndash177Ogden C L Carroll M D Kit B K amp Flegal K M
(2014) Prevalence of childhood and adult obesity in the
United States 2011-2012 Journal of the American
Medical Association 311 806ndash814Pesa J A Syre T R amp Jones E (2000) Psychosocial dif-
ferences associated with body weight among female ado-
lescents The importance of body image Journal of
Adolescent Health 26 330ndash337Pierce J W amp Wardle J (1997) Cause and effect beliefs
and self-esteem of overweight children Journal of Child
Psychology and Psychiatry 38 645ndash650 doi 101111
j1469-76101997tb01691xRoberts J E (2006) Self-esteem from a clinical perspective
In M H Kernis (Ed) Self-esteem issues and answers A
sourcebook of current perspectives Psychology Press
Taylor amp Francis New York and Hove (pp 298ndash305)
Psychology PressSacher P M Kolotourou M Chadwick P M Cole T J
Lawson M S Lucas A amp Singhal A (2010)
Randomized controlled trial of the MEND program A
family-based community intervention for childhood obes-
ity Obesity 18(Suppl 1) S62ndashS68 doi httpdxdoiorg
101038oby2009433Sanders R H Han A Baker J S amp Cobley S (2015)
Childhood obesity and its physical and psychological co-
morbidities a systematic review of Australian children and
adolescents Eur J Pediatr 174 715ndash746Sherman J B Alexander M A Gomez D Kim M amp
Marole P (1992) Intervention program for obese school chil-
dren Journal of Community Health Nursing 9 183ndash190Shrewsbury V A Nguyen B Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2011) Short-term
outcomes of community-based adolescent weight manage-
ment The LoozitVR
Study BMC Pediatrics 11 13Shrewsbury V A Orsquoconnor J Steinbeck K S Stevenson
K Lee A Hill A J Baur L A (2009) A randomised
controlled trial of a community-based healthy lifestyle
The Impact of Weight Management on Self-Esteem 393
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
program for overweight and obese adolescents TheLoozitV
R
study protocol BMC Public Health 9 119Strauss R S (2000) Childhood obesity and self-esteem
Pediatrics 105 5Tiggemann M (2005) Body dissatisfaction and adolescent
self-esteem Prospective findings Body Image 2 129ndash135doi httpdxdoiorg101016jbodyim200503006
Wadden T A Stunkard A J Rich L Rubin C JSweidel G amp McKinney S (1990) Obesity in black ado-lescent girls A controlled clinical trial of treatment by diet
behaviour modification and parental support Pediatrics85 345ndash352
Walker L Gately P Bewick B amp Hill A (2003)Childrenrsquos weight-loss camps psychological benefit orjeopardy International Journal of Obesity 27 748ndash754
World Health Organization (2014) Maternal newbornchild and adolescent health Adolescent developmentRetrieved from httpwwwwhointmaternal_child_adolescenttopicsadolescencedeven Retrieved 28 May2014
394 Murray Dordevic and Bonham
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icoupcomjpepsyarticle-abstract4243793065789 by U
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arolina at wilm
ington user on 14 February 2019
- jsw101-TF1
- jsw101-TF2
- jsw101-TF3
- jsw101-TF4
- jsw101-TF5
- jsw101-TF6
- jsw101-TF7
- jsw101-TF8
- jsw101-TF9
- jsw101-TF10
- jsw101-TF11
-
domains that are of importance to the individual(Harter 1993) Self-esteem can fluctuate greatly dur-
ing adolescence and there is an increased risk of self-esteem being low particularly from the age of 13 years
(French Story amp Perry 1995 Strauss 2000)During adolescence self-esteem plays an important
role in metal health and development (McClure et al2010) Low self-esteem in adolescents particularly
overweight adolescents has been linked to disturbedeating and dieting behaviors a preoccupation with
body weight and shape an inactive lifestyle andpoorer performance in education and developmental
tasks (Latzer amp Stein 2013) Low self-esteem hasbeen hypothesized both as a contributing factor and
consequence of obesity (French et al 1995) Increasedself-esteem purportedly leads to better weight out-
comes in the long term (Elfhag amp Rossner 2005French et al 1995 Roberts 2006) Therefore weight-
management interventions for adolescents should aimto improve self-esteem
Multicomponent weight management interventions(MWMI) with behavioral dietary and physical activity
components are best practice for achieving successfulweight loss in overweight and obese adolescents (Kohn
et al 2006 Luttikhuis et al 2009 National Health andMedical Research Council 2013 National Institutes for
Health and Care Excellence 2013) However their im-pact on self-esteem is still not well reported (Luttikhuis
et al 2009) despite this being a recommendation froma previous review of the effect of weight management
programs on pediatric self-esteem (Lowry Sallinen ampJanicke 2007)
This systematic review and meta-analysis ofrandomized controlled trials (RCTs) examines the ef-
fect of MWMIs on self-esteem in overweight andobese adolescents A secondary outcome is the impact
of MWMIs on weight loss and whether this is associ-ated with improvements in self-esteem This review
provides an update of the literature since the reviewby Lowry et al (2007) and focuses specifically on (1)
adolescents an at-risk group for experiencing lowself-esteem and (2) MWMIs the most effective
method for weight management in children and ado-lescents (Luttikhuis et al 2009)
Methods
This review was registered with PROSPERO
International prospective register of systematic re-views (registration number CRD42015016889) and is
reported according to the Preferred Reporting Itemsfor Systematic reviews and Meta-Analysis (PRISMA)
Statement (see Table S1 in the supplement forPRISMA Checklist Moher et al 2015)
Literature SearchA literature search was conducted in December 2014in the Scopus MEDLINE PsychInfo CochraneLibrary Cumulative Index to Nursing and AlliedHealth Literature and Embase databases Searchterms were used to describe the population (eg over-weight youth) intervention (eg lifestyle health edu-cation nutrition physical activity) control (eg usualcare) outcomes (eg esteem body mass index) andstudy design (eg RCT controlled trial) Studies werelimited to English and humans where databases pro-vided that option (see Table S2 in the supplement forfull search strategy) The criteria for inclusion in thisreview were (1) RCT (2) overweight or obese (3)adolescent (10ndash19 years World Health Organization2014) (4) a MWMI (behavioral dietary and physicalactivity components) (5) reported self-esteem andweight changes Body mass index (BMI) z-score wasthe preferential choice for ascertaining weight statusbut if not reported other weight outcomes werecollected
Search results were imported into EndNote X72Version 1702 (Thomson Reuters New York CityUSA) Duplicate articles were manually removed bythe lead author (MM) Throughout the title and ab-stract screening two authors (MM and AD) inde-pendently excluded papers if they did not report theresults of an RCT if the intervention did not includeall three behavioral dietary and physical activitycomponents or if there was no measure of self-esteemIncluded papers were cross-checked and discrepancieswere resolved by the third author (MB) Papers thatincluded healthy weight individuals or individuals out-side the adolescent age range were included at full-paper screening and the authors were contacted to re-trieve results specific to the population of interestThese papers were subsequently excluded if authorsdid not respond within 1 month of initial contact orwere unable to provide the requested data All fullpapers were independently screened by two authors(MM and AD) and were cross-checked with anydisagreements resolved by the third author (MB)
Data ExtractionData extraction was conducted using the NationalHealth and Medical Research Council of Australiadata extraction tool for RCT and cohort studies Datawere independently extracted by two researchers(MM and AD) and included outcome measuresintervention and control conditions study designpopulation characteristics and results The two sets ofextracted data were compared to ensure complete andcorrect interpretation Any disagreements were settledby the MB Data that were missing from the includedstudies such as additional results and detailed meth-odology were obtained from separate publications
380 Murray Dordevic and Bonham
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arolina at wilm
ington user on 14 February 2019
(Brennan Walkley Fraser Greenway amp Wilks2008 Brennan Walkley Wilks Fraser amp Greenway
2013 Kornman et al 2010 Nguyen McGregoret al 2012 Shrewsbury et al 2011 Shrewsbury
et al 2009) or requested from authors
Risk of BiasThe American Dietetic Association Quality CriteriaChecklist was used to assess the quality of the papers
(Academy of Nutrition and Dietetics 2012) Criteriawere independently tested by two researchers (MM
and AD) to determine study quality including ran-domization research question participant selection
and comparability blinding outcome measures stat-istical analysis and potential for bias from funding
Studies were designated a positive neutral or negativerating Publication bias was assessed through visual in-
terpretation of funnel plots created using RevMan 53(Cochrane Informatics amp Knowledge Management
Department 2014 see Figure S1)
Statistical AnalysisCohenrsquos d effect sizes were calculated for weight andself-esteem outcomes to allow for comparison of re-
sults across studies Positive effect sizes indicated theoutcome had improved that is increased self-esteem
or decreased weight (02frac14 small effect05frac14me-dium effect08frac14 large effect) Where an effect size
could not be calculated the reported significance ofresults was assessed Following tests for normality ef-
fect sizes for self-esteem and weight changes were as-sessed for correlation using the Pearson Correlation
test and the coefficient of determination (R2)Meta-analyses were performed to compare the
change in the intervention and control groups forboth self-esteem and BMI z-score using Stata
Statistical Software (Release 13 2013 Texas USA)Only studies that reported the mean (SD) change in
self-esteem or BMI z-score and compared the inter-vention with a no-treatment control group were
included in the meta-analyses If data were not origin-ally reported in this format results were requested
from the authors for inclusion in this review To ac-count for the different tools used to measure self-
esteem outcomes a standard mean difference (SMD)was calculated from the Cohenrsquos d effect size for each
study Studies that reported a weight outcome otherthan BMI z-score were excluded from the meta-
analysis Weighted mean difference was calculated forBMI z-score for the meta-analysis All meta-analyses
were carried out using random effects analysisSensitivity analyses were not performed as only a
small number of studies were included and they wereall of neutral or positive quality
Results
Database searches identified 4707 original papersFollowing title and abstract screening 115 full-textarticles were retrieved and assessed for eligibilityThirteen papers met the review criteria including 2studies that were reviewed by Lowry et al (2007) and11 studies published since Seven studies wereincluded in the meta-analyses (Figure 1)
Description of Included StudiesThe included studies involved between 32 and 208male andor female participants aged 10ndash19 yearswho were overweight or obese (BMI 85th percent-ile) Owing to the limited number of studies that ex-clusively examined the overweight adolescentpopulation studies with mixed populations wereincluded (Croker et al 2012 Danielsen NordhusJulıusson Maelighle amp Pallesen 2013 Lochrie et al2013 Lubans et al 2012 Morgan Saunders ampLubans 2012 Neumark-Sztainer et al 2010 Sacheret al 2010) However only data relating to the popu-lation of interest are reported
Interventions ranged from seven weeks up to a yearin length Only results taken immediately postinterven-tion were assessed in this review For studies thatincluded an intense treatment phase followed by a main-tenance phase the results taken immediately after the in-tense treatment phase have been used as theldquopostinterventionrdquo results (Brennan Wilks WalkleyFraser amp Greenway 2012 Daley Copeland WrightRoalfe amp Wales 2006 Neumark-Sztainer et al 2010)One exception to this was the study by NguyenShrewsbury et al (2012) that had an additional outcomemeasurement at 12 months half way through the main-tenance phase For this study the 12-month measureshave been used as the ldquopostinterventionrdquo results as thiswas the first time point that reported separate results forthe intervention and control groups
All interventions included dietary physical activityand behavioral strategies (Table I) For the purpose ofthis review all groups that received a treatment that metthe review criteria for a MWMI were considered ldquointer-vention groupsrdquo hence there are a greater number ofintervention than control groups In all studies theintervention and control groups were considered com-parable at baseline for the outcomes of interest
Risk of BiasIncluded studies were assessed against 10 criteria andstudy quality was generally high (Table I) Four criteriahad to be met for a study to receive a positive quality rat-ing The remaining six criteria contributed to the overallrating but were not compulsory for a positive rating tobe assigned All 14 studies in this review met the criteriafor a clearly stated research question clearly definedvalid and reliable outcome measures and low risk of bias
The Impact of Weight Management on Self-Esteem 381
Dow
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arolina at wilm
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owing to funding or sponsorship Four studies weredowngraded to a neutral quality rating for not meetingthe criteria (1) selection of participants free from bias(Danielsen et al 2013 Morgan et al 2012) (2) studygroups comparable at baseline (Neumark-Sztainer et al2010) or (3) intervention and comparison conditionsdescribed in detail (Mellin Slinkard amp Irwin 1987Morgan et al 2012) Other criteria that were not met byall studies but did not result in the assignment of any neu-tral quality ratings included appropriate statistical
analysis handling of withdrawals described and use
blinding to prevent bias Funnel plot analysis (Figure S1)did not suggest publication bias however should be inter-
preted with caution owing to the small number of studies
The Impact of Multicomponent WeightManagement Interventions on AdolescentSelf-EsteemSelf-esteem effect sizes were able to be calculated foreight studies (Table II) A positive effect on adolescent
Figure 1 PRISMA flow diagram of included and excluded studies
382 Murray Dordevic and Bonham
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arolina at wilm
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Tab
leI
Stu
dy
Qu
ality
P
art
icip
an
tsIn
terv
en
tio
ns
Du
rati
on
a
nd
Ou
tco
me
Me
asu
res
Stu
dy
(auth
or
yea
rlo
cati
on)
Quali
tyra
ting
Part
icip
ants
Inte
rven
tions
Focu
son
self
-est
eem
Dura
tion
Outc
om
em
easu
res
Bre
nnan
etal
2012A
ust
ralia
25
Posi
tive
29
(46
)m
ale
sand
34
(54
)fe
-m
ale
s11ndash19
yea
rsover
wei
ght
or
obes
e
IIn
terv
enti
on
base
don
cognit
ive
be-
havio
ralpri
nci
ple
sw
ith
afo
cus
on
makin
gsm
all
sust
ain
able
changes
indie
tary
inta
ke
physi
calact
ivit
yand
beh
avio
ralst
rate
gie
sPare
nts
involv
edfo
rfirs
thalf
of
trea
tmen
tphase
C
W
ait
list
No
spec
ific
men
-ti
on
of
self
-es-
teem
but
one
sess
ion
on
de-
vel
opin
ghel
pfu
lth
oughts
and
emoti
ons
Tre
atm
ent
phase
mdashtw
elve
60-m
inse
ssio
ns
and
one
tele
phone
call
sess
ion
over
16
wee
ks
Main
tenance
phase
mdashtw
o60-m
incl
inic
sess
ions
and
seven
15-m
inte
le-
phone
sess
ions
over
6m
onth
s
Rose
nber
gSel
f-E
stee
mSca
leB
MI
z-sc
ore
Cro
ker
etal2012
Unit
edK
ingdom
26
Posi
tive
13
(32
)m
ale
sand
28
(68
)fe
-m
ale
s10ndash12
yea
rsover
wei
ght
or
obes
e
IFam
ily-b
ase
din
terv
enti
on
del
iver
edin
gro
ups
wit
ha
focu
son
makin
gw
hole
-fam
ily
life
style
changes
thro
ugh
beh
avio
r-ch
ange
stra
tegie
sand
nutr
itio
nand
physi
calact
ivit
ygoals
Pare
nt
and
child
sess
ions
de-
liver
edse
para
tely
C
W
ait
list
No
spec
ific
men
-ti
on
of
self
-es-
teem
but
one
sess
ion
on
soci
al
support
and
how
tom
anage
bullyin
g
Fif
teen
15
-hr
sess
ions
over
6m
onth
sFollow
up
12
month
sfr
om
base
line
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
(sel
f-es
teem
)B
MI
SD
S
Dale
yet
al2006
Unit
edK
ingdom
32
Posi
tive
36
(44
)m
ale
sand
45
(56
)fe
-m
ale
s11ndash16
yea
rsB
MI
gt98th
per
centi
le
IPart
icip
ants
com
ple
ted
ara
nge
of
aer
obic
act
ivit
ies
and
min
igam
esand
wer
epro
vid
edw
ith
exer
cise
counse
l-in
gfo
rbeh
avio
rch
ange
ina
one-
on-
one
sett
ingH
ealt
hy
eati
ng
habit
sw
ere
enco
ura
ged
and
wri
tten
info
r-m
ati
on
was
pro
vid
edPart
icip
ants
wer
egiv
enan
indiv
idualize
dex
erci
sepro
gra
mto
conti
nue
aft
erth
etr
eat-
men
tpro
gra
m
CN
otr
eatm
ent
contr
ol
No
spec
ific
men
-ti
on
of
self
-es-
teem
but
beh
avio
ralin
ter-
ven
tions
incl
uded
findin
gso
cial
support
Tre
atm
ent
phase
mdashT
wen
ty-f
our
1hr
ses-
sions
wer
ehel
dover
8w
eeks
Main
tenance
phase
mdashhom
eex
erci
sepro
gra
mfo
r6
wee
ks
no
re-
searc
her
conta
ctFollow
up
at
28
wee
ks
from
base
line
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
for
Adole
scen
ts(s
elf-
este
em)
BM
Iz-
score
Danie
lsen
etal
2013N
orw
ay
27
Neu
tral
17
(53
)m
ale
sand
15
(47
)fe
-m
ale
s10ndash13
yea
rsobes
e
IPart
icip
ants
and
thei
rpare
nts
at-
tended
indiv
idualfa
mily
mee
tings
wit
ha
clin
icalpsy
cholo
gis
tT
he
inte
rven
tion
focu
sed
on
incr
easi
ng
physi
calact
ivit
yand
reduci
ng
seden
-ta
rybeh
avio
res
tablish
ing
abala
nce
ddie
tdev
elopin
gin
div
idualand
fam
ily
copin
gsk
ills
and
pro
moti
ng
aposi
-ti
ve
self
-per
cepti
on
CW
ait
list
No
spec
ific
men
-ti
on
of
self
-es-
teem
st
andard
beh
avio
ralte
ch-
niq
ues
use
d
Tw
elve
wee
kly
45-m
inse
ssio
ns
wit
ha
boost
erse
ssio
n6
month
saft
ertr
eatm
ent
Follow
up
15
month
sfr
om
base
line
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
for
Childre
n(s
elf-
este
em)
BM
ISD
S
The Impact of Weight Management on Self-Esteem 383
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Tab
leI
(co
nti
nu
ed
)
Stu
dy
(auth
or
yea
rlo
cati
on)
Quali
tyra
ting
Part
icip
ants
Inte
rven
tions
Focu
son
self
-est
eem
Dura
tion
Outc
om
em
easu
res
DeB
ar
etal2012
Unit
edSta
tes3
3Posi
tive
208
(100
)fe
-m
ale
s12ndash17
yea
rsB
MI
90th
per
centi
le
IIn
terv
enti
on
focu
sed
on
changin
gdie
tary
inta
ke
and
eati
ng
patt
erns
incr
easi
ng
physi
calact
ivit
yta
ckling
com
mon
psy
choso
cialis
sues
of
obes
-it
yand
teach
ing
beh
avio
raland
cog-
nit
ive
tools
for
wei
ght
managem
ent
Pare
nt
support
mee
tings
wer
ein
cluded
C
W
ait
list
No
spec
ific
focu
son
self
-est
eem
but
issu
essu
chas
dep
ress
ion
and
poor
body
image
wer
eaddre
ssed
and
cognit
ive
rest
ruct
uri
ng
tech
niq
ues
tore
-duce
neg
ati
ve
self
-talk
wer
euse
d
Six
teen
90-m
ingro
up
mee
tings
over
5m
onth
sFollow
up
12
month
sfr
om
base
line
Rose
nber
gSel
f-E
stee
mSca
leB
MI
z-sc
ore
Loch
rie
etal
2013U
nit
edSta
tes2
8
Posi
tive
29
(43
)m
ale
sand
39
(57
)fe
-m
ale
s10ndash11
yea
rsB
MI
85th
per
centi
le
IPart
icip
ants
and
thei
rpare
nts
at-
tended
gro
up
sess
ions
led
by
apsy
ch-
olo
gis
tand
regis
tere
ddie
titi
an
that
cover
ednutr
itio
nbeh
avio
rm
odifi
ca-
tionex
erci
seto
pic
spsy
choso
cial
inte
rven
tions
and
med
icalis
sues
ass
oci
ate
dw
ith
obes
ity
CO
ne
gro
up
sess
ion
for
fam
ilie
sle
dby
are
gis
tere
ddie
titi
an
pro
vid
ing
in-
form
ati
on
on
nutr
itio
nand
physi
cal
act
ivit
y
Psy
choso
cialas-
pec
tsof
inte
rven
tionmdash
stre
ssm
anage-
men
tre
laxati
on
managin
gpee
rpre
ssure
and
teasi
ng
Fourt
een
sess
ions
last
ing
60ndash90
min
over
6m
onth
sN
ofo
llow
up
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
for
Childre
n(s
elf-
este
em)
BM
Iz-
score
Lubans
etal
2012A
ust
ralia
34
Posi
tive
152
(100
)fe
-m
ale
s12ndash14
yea
rsB
MI
85th
per
centi
le
ISch
ool-
base
din
terv
enti
on
incl
udin
gen
hance
dsp
ort
sess
ions
inte
ract
ive
sem
inars
lu
nch
-tim
eact
ivit
yse
ssio
ns
ped
om
eter
sfo
rse
lf-m
onit
ori
ngpar-
ent
new
slet
ter
text
mes
sages
for
so-
cialsu
pport
and
nutr
itio
nw
ork
shops
del
iver
edby
Acc
redit
edPra
ctic
ing
Die
titi
ans
CN
otr
eatm
ent
contr
ol
No
spec
ific
men
-ti
on
of
self
-es
teem
Del
iver
edover
the
four
schoolte
rms
inth
eyea
rFollow
up
24
month
sfr
om
base
line
Mars
hrsquos
Glo
bal
Sel
f-es
teem
BM
Iz-
score
Mel
lin
etal1987
Unit
edSta
tes2
9N
eutr
al
14
(21
)m
ale
sand
52
(79
)fe
-m
ale
s12ndash18
yea
rsgt
13
over
wei
ght
IIn
terv
enti
on
use
dco
gnit
ive
beh
av-
iora
laff
ecti
ve
and
inte
ract
ive
tech
-niq
ues
toen
coura
ge
sust
ain
able
modifi
cati
ons
todie
tex
erci
sere
la-
tionsh
ips
life
style
co
mm
unic
ati
ons
and
att
itudes
T
wo-p
are
nt
sess
ions
incl
uded
C
W
ait
list
No
spec
ific
men
-ti
on
of
self
-es-
teem
but
inte
rven
tions
enco
ura
ged
posi
-ti
ve
rela
tionsh
ips
and
att
itudes
Fourt
een
90-m
inse
ssio
ns
over
14
wee
ks
Follow
up
15
month
sfr
om
base
line
Rose
nber
gSel
f-E
stee
mSca
leR
elati
ve
wei
ght
384 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Tab
leI
(co
nti
nu
ed
)
Stu
dy
(auth
or
yea
rlo
cati
on)
Quali
tyra
ting
Part
icip
ants
Inte
rven
tions
Focu
son
self
-est
eem
Dura
tion
Outc
om
em
easu
res
Morg
an
etal
2012A
ust
ralia
30
Neu
tral
40
(100
)m
ale
s13ndash16
yea
rs
BM
I
85th
per
centi
le
ISch
ool-
base
din
terv
enti
on
incl
udin
gen
hance
dsp
ort
sess
ions
physi
calac-
tivit
yand
nutr
itio
nhandbooks
wit
hhom
e-base
dch
allen
ges
and
inte
r-act
ive
sem
inars
on
nutr
itio
nand
physi
calact
ivit
ybeh
avio
rsand
leader
ship
C
W
ait
list
No
spec
ific
men
-ti
on
of
self
-es
teem
3-m
onth
inte
rven
tion
Follow
up
6m
onth
sfr
om
base
line
Physi
calSel
f-Per
cepti
on
Pro
file
Adole
scen
tver
-si
on
(sel
f-es
teem
)B
MI
Neu
mark
-Szt
ain
eret
al2010
USA
(27)
Neu
tral
164
(100
)fe
-m
ale
s13ndash18
yea
rsB
MI
85th
per
centi
le
Iphysi
calact
ivit
yn
utr
itio
ns
oci
alsu
p-
port
sel
f-em
pow
erm
ent
less
ons
at
schoolw
ith
rela
ted
lett
ers
sent
hom
eto
pare
nts
alo
ng
wit
hin
div
idualm
o-
tivati
onalin
terv
iew
ing
sess
ions
toen
-co
ura
ge
goal-
sett
ingFollow
edby
lunch
tim
ese
ssio
ns
duri
ng
the
main
-te
nance
per
iod
and
a1-d
ay
pare
ntndash
daughte
rre
trea
tC
A
llgir
lsphysi
calact
ivit
ycl
ass
wit
hin
norm
alsc
hoolcu
rric
ulu
m
One
of
the
pro
-gra
mobje
ctiv
esw
as
toen
hance
aposi
tive
self
-fo
cus
and
ses-
sions
focu
sed
on
self
-em
pow
erm
ent
Phase
1mdash
daily
less
ons
at
schoolfo
r16
wee
ks
Sev
enin
div
idualse
ssio
ns
ever
y3ndash4
wee
ks
thro
ughout
inte
rven
tion
Phase
2mdash
wee
kly
lunch
tim
ese
ssio
ns
for
rem
ain
-der
of
schoolyea
r(
5m
onth
s)
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
(sel
f-es
teem
)B
MI
Nguyen
etal
2013A
ust
ralia
35
Posi
tive
55
(36
)m
ale
sand
96
(64
)fe
-m
ale
s13ndash16
yea
rsover
wei
ght
tom
oder
ate
lyobes
eB
MI
z-sc
ore
10
ndash25
(BM
I84ndash99th
per
centi
le)
IIn
terv
enti
on
base
don
the
soci
alco
g-
nit
ive
theo
ryto
modif
yse
lf-e
ffica
cy
moti
vati
onper
sever
ance
and
self
-re
gula
tionSes
sions
focu
sed
on
phys-
icalact
ivit
yhea
thy
eati
nggoalse
t-ti
ngst
ress
managem
ent
and
buildin
gse
lf-e
stee
mIn
terv
enti
on
gro
up
rece
ived
Addit
ional
Ther
apeu
tic
Conta
ct(A
TC
)fo
rtnig
htl
yth
rough-
out
the
main
tenance
per
iodPare
nt
sess
ions
incl
uded
C
A
sabove
wit
hout
the
AT
C
Buildin
gposi
tive
self
-est
eem
was
the
focu
sof
ase
ssio
n
Phase
1mdash
seven
wee
kly
75-m
ingro
up
sess
ions
Phase
2mdash
from
2to
24
month
sfive
60-m
ingro
up
sess
ions
hel
dappro
xev
ery
3m
onth
sA
TC
Fort
nig
htl
yte
le-
phone
coach
ing
sess
ions
and
SM
Se
mes
sages
Hart
errsquos
Sel
fPer
cepti
on
Pro
file
for
Adole
scen
ts(s
elf-
este
em)
BM
Iz-
score
Sach
eret
al2010
Unit
edK
ingdom
31
Posi
tive
21
(48
)m
ale
sand
23
(52
)fe
-m
ale
s10ndash12
yea
rsB
MI
gt98th
per
centi
le
IPart
icip
ants
and
thei
rfa
milie
sat-
tended
gro
up
sess
ions
focu
sing
on
be-
havio
rch
ange
nutr
itio
nand
physi
calact
ivit
ySes
sion
conte
nt
focu
sed
on
buildin
gsk
ills
tom
ain
tain
long-t
erm
beh
avio
rch
anges
Follow
ing
trea
tmen
tfa
milie
sw
ere
giv
ena
12-w
eek
free
fam
ily
swim
pass
C
W
ait
-lis
t
No
spec
ific
men
-ti
on
of
self
-es
teem
Eig
hte
en2-h
rse
ssio
ns
over
9w
eeks
Follow
up
12
month
sfr
om
base
line
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
for
Childre
n(s
elf-
este
em)
BM
Iz-
score
The Impact of Weight Management on Self-Esteem 385
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arolina at wilm
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self-esteem was observed following four MWMIsacross three studies (Croker et al 2012 Danielsenet al 2013 Nguyen Shrewsbury et al 2012) Fivestudies showed no effect on adolescent self-esteem fol-lowing MWMI (Brennan et al 2012 DeBar et al2012 Lochrie et al 2013 Lubans et al 2012Neumark-Sztainer et al 2010) No positive effects onself-esteem were observed in any of the controlgroups One wait-listed control group (Croker et al2012) showed a small negative effect on self-esteem
Mixed results were also observed in the studies forwhich an effect size could not be calculatedImprovements in adolescent self-esteem were observedfollowing MWMIs by Daley et al (2006) Mellin et al(1987) Sacher et al (2010) and Wadden et al(1990) However only Daley et al (2006) reportedthat this change was different to that observed in thecontrol group No changes in self-esteem were de-tected following intervention by Morgan et al (2012)although a significant decline in self-esteem wasobserved in the wait-listed control group who receivedthe normal school curriculum throughout the studyperiod
Multicomponent Weight ManagementInterventions Improve Weight Outcomes inAdolescentsOf the 13 included studies there were 14 groups whoreceived a MWMI and 11 no-treatment controlgroups Of these effect sizes were able to be calculatedfor nine intervention groups and seven control groups(Table III) Seven intervention groups had small to me-dium positive effects indicating successful weight loss(Brennan et al 2012 Croker et al 2012 Danielsenet al 2013 DeBar et al 2012 Lochrie et al 2013Lubans et al 2012 Nguyen Shrewsbury et al2012) and two intervention groups had no effect(Neumark-Sztainer et al 2010 Nguyen Shrewsburyet al 2012) All seven control groups showed no ef-fect on weight
Of the studies for which effect size could not be cal-culated the results were similar Mellin et al (1987)Morgan et al (2012) Sacher et al (2010) andWadden et al (1990) all observed significant weightloss following intervention Morgan et al (2012) andSacher et al (2010) also showed that these changeswere significantly different to changes observed in thecontrol groups No studies observed significant weightchange in the control groups
Correlation Between Self-Esteem Improvementand Weight Loss Effect SizesThere is a strong (rfrac14 641 R2frac140410) positive linearrelationship between effect sizes for self-esteem im-provement and weight loss across all intervention andcontrol groups (pfrac14 008)T
ab
leI
(co
nti
nu
ed
)
Stu
dy
(auth
or
yea
rlo
cati
on)
Quali
tyra
ting
Part
icip
ants
Inte
rven
tions
Focu
son
self
-est
eem
Dura
tion
Outc
om
em
easu
res
Wadden
etal
1990U
nit
edSta
tes3
6
Posi
tive
47
(100
)fe
male
s12ndash16
yea
rsat
least
10-k
gover
wei
ght
IIn
terv
enti
on
cover
eddie
tand
eati
ng
patt
erns
modif
yin
gse
lf-d
efea
ting
thoughts
and
incr
easi
ng
physi
calac-
tivit
yH
om
ework
ass
ignm
ents
and
ince
nti
ves
aw
ard
sw
ere
use
dto
en-
coura
ge
part
icip
ati
onT
her
ew
ere
thre
edif
fere
nt
inte
rven
tion
gro
ups
who
rece
ived
this
trea
tmen
tch
ild
only
ch
ild
and
moth
erto
get
her
ch
ild
and
moth
erse
para
tely
C
N
ocl
ear
contr
olgro
upse
eabove
No
spec
ific
men
-ti
on
of
self
-es
teem
Six
teen
wee
kly
1-h
rle
ssons
No
follow
up
Pie
rs-H
arr
issc
ale
(sel
f-es
teem
)B
MI
Note
B
MIfrac14
body
mass
index
Ifrac14
inte
rven
tionCfrac14
Com
par
ato
rC
om
par
ato
rgro
ups
that
rece
ived
an
inte
rven
tion
wer
etr
eate
das
inte
rven
tion
gro
ups
for
the
purp
ose
of
anal
ysi
sin
this
revie
w
Stu
die
sare
list
edin
alp
habet
icalord
erin
all
table
s
386 Murray Dordevic and Bonham
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icoupcomjpepsyarticle-abstract4243793065789 by U
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ington user on 14 February 2019
Tab
leIIS
elf
-Est
ee
mO
utc
om
es
of
Mu
ltic
om
po
ne
nt
We
igh
tM
an
ag
em
en
tIn
terv
en
tio
ns
Co
mp
are
dW
ith
Co
ntr
ols
in
Ov
erw
eig
ht
an
dO
be
seA
do
lesc
en
ts
Auth
or
yea
rIn
terv
enti
on
gro
ups
Contr
olgro
ups
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
Bre
nnan
etal2012
20
215
(54
)a206
(63
)a
21
1(4
78)a
01
514
188
(47
)a192
(47
)a06
4(3
91)a
00
9C
roker
etal2012
13
26
9(0
57)b
29
5(0
45)b
03
6(0
39)b
05
110
29
0(0
61)b
26
8(0
52)b
00
2(0
59)b
03
9D
ale
yet
al2006
28
24
2(0
56)b
26
1(0
08
SE)b
NA
NA
30
24
9(0
49)b
25
6(0
10
SE)b
NA
NA
Danie
lsen
etal2013
16
28
8(0
52)b
31
7(0
53)b
02
9(0
53)b
05
516
31
1(0
57)b
30
6(0
59)b
00
5(0
37)b
00
9D
eBar
etal2012
105
23
9(0
26)a
24
0(0
25)a
NA
00
4103
24
1(0
27)a
23
9(0
25)a
NA
00
8L
och
rie
etal2013
29
183
(50
2)b
191
(44
8)b
07
3(4
51)b
01
718
199
(34
6)b
199
(34
3)b
00
0(3
11)b
00
0L
ubans
etal2012
54
40
3(1
12)c
40
6(1
32)c
NA
00
268
40
4(0
99)c
42
3(0
98)c
NA
01
9M
ellin
etal1987
37
NA
NA
08
8(1
50)a
NA
29
NA
NA
05
2(1
34)a
NA
Morg
an
etal2012
19
NA
NA
00
8(0
48)d
NA
21
NA
NA
02
6(0
47)d
NA
Neu
mark
-Szt
ain
eret
al2010
85
152
(34
)b151
(29
)bN
A
00
379
141
(34
)b140
(34
)bN
A
00
3
Nguyen
etal2012
(wit
hA
TC
)57
25
8(0
76)b
27
7(0
63)b
01
9(0
67)b
02
7
Nguyen
etal2012
(wit
hout
AT
C)
50
25
9(0
58)b
29
3(0
61)b
01
9(0
51)b
05
7
Sach
eret
al2010
20
NA
32
5(0
68)b
02
5(0
66)b
NA
24
NA
30
4(0
75)b
01
1(0
74)b
NA
Wadden
etal1990
3gro
ups
com
bin
ed47
576
e599
eN
AN
A
Note
D
ata
pre
sente
das
report
edin
ori
gin
alpaper
sSDfrac14
standard
dev
iati
onN
Afrac14
data
not
pro
vid
edu
nab
leto
be
calc
ula
ted
SEfrac14
Sta
ndard
erro
rnot
Sta
ndard
Dev
iati
onE
ffec
tsi
zefrac14
Cohen
rsquosdB
old
font
indic
ate
sw
her
eef
fect
size
was
small
(02
0)
or
gre
ate
raR
ose
nber
gse
lf-e
stee
msc
ale
(gen
erally
score
dfr
om
0[l
ow
est
self
-est
eem
]to
30
[hig
hes
tse
lf-e
stee
m])
bH
art
errsquos
SPPA
SPPC
(gen
erally
score
d1
[low
est
self
-est
eem
]to
4[h
ighes
tse
lf-e
stee
m])
cM
ars
hrsquos
Physi
calSel
f-D
escr
ipti
on
Ques
tionnair
e
dPhysi
calSel
f-Per
cepti
on
Pro
file
for
Adole
scen
ts
ePie
rs-H
arr
isSel
f-C
once
pt
Sca
le
Sco
ring
range
sunav
ailab
lehig
her
valu
eeq
uals
hig
her
self
-est
eem
The Impact of Weight Management on Self-Esteem 387
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arolina at wilm
ington user on 14 February 2019
Tab
leIII
We
igh
tO
utc
om
es
of
Mu
ltic
om
po
ne
nt
We
igh
tM
an
ag
em
en
tIn
terv
en
tio
ns
Co
mp
are
dW
ith
Co
ntr
ols
in
Ov
erw
eig
ht
an
dO
be
seA
do
lesc
en
ts
Auth
or
yea
rIn
terv
enti
on
gro
ups
Contr
olgro
ups
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
Bre
nnan
etal2012
20
20
8(0
37)
19
9(0
46)
02
0(0
18)
02
214
20
8(0
40)
20
9(0
39)
00
1(0
12)
00
3C
roker
etal2012
13
29
5(0
52)
26
6(0
63)
01
7(0
21)
05
010
31
4(0
68)
31
4(0
68)
00
6(0
13)
00
0D
ale
yet
al2006
28
31
7(0
33)
32
3(0
02
SE)
NA
NA
30
33
2(0
37)
32
3(0
02
SE)
NA
NA
Danie
lsen
etal2013
16
25
9(0
30)
24
6(0
41)
01
2(0
17)
03
616
24
9(0
27)
25
3(0
29)
00
5(0
15)
01
4D
eBar
etal2012
105
20
0(0
34)
18
8(0
41)
NA
03
2103
20
0(0
33)
19
4(0
38)
NA
01
7L
och
rie
etal2013
29
21
9(0
40)
20
6(0
52)
01
2(0
20)
02
818
20
7(0
40)
20
5(0
43)
00
2(0
11)
00
5L
ubans
etal2012
54
19
3(0
61)
18
0(0
68)
NA
02
068
18
5(0
59)
18
0(0
67)
NA
00
8M
ellin
etal1987
37
1365
aN
A
59
(67
5)a
NA
29
1295
aN
A
03
(66
1)a
NA
Morg
an
etal2012
19
NA
NA
04
2(0
91)b
NA
21
NA
NA
00
3(0
87)b
NA
Neu
mark
-Szt
ain
eret
al2010
85
321
(61
)b322
(62
)bN
A
00
279
310
(53
)b314
(55
)bN
A
00
7
Nguyen
etal2012
(wit
hA
TC
)57
20
3(0
37)
19
7(0
42)
00
8(0
19)
01
5
Nguyen
etal2012
(wit
hout
AT
C)
50
20
2(0
29)
19
4(0
32)
00
9(0
17)
02
6
Sach
eret
al2010
20
NA
23
7(0
52)
02
2(0
27)
NA
24
NA
26
0(0
54)
00
1(0
20)
NA
Wadden
etal1990
3gro
ups
com
bin
ed47
352
b339
bN
AN
A
Note
D
ata
pre
sente
das
report
edin
ori
gin
al
paper
sA
llw
eight
outc
om
esre
port
edas
body
mass
index
(BM
I)z-
score
unle
ssoth
erw
ise
state
d
SDfrac14
standar
ddev
iati
on
NAfrac14
data
not
pro
vid
ed
unab
leto
be
calc
ula
ted
SEfrac14
Sta
ndard
Err
or
report
edra
ther
than
Sta
ndard
Dev
iati
onE
ffec
tsi
zefrac14
Cohen
rsquosdB
old
font
indic
ate
sw
her
eef
fect
size
was
smal
l(0
20)
or
gre
ate
raR
elati
ve
wei
ght
bB
MI
388 Murray Dordevic and Bonham
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Quantitative Data AnalysisDifferences between intervention and control groupsfor change in self-esteem are presented in Figure 2aThis analysis included seven intervention groups(nfrac14 191) and seven control groups (nfrac14 132) with
interventions or intensive treatment phases rangingfrom 9 weeks to 6 months in duration A moderatelevel of the variation across studies was owing to het-erogeneity (I2frac14464 Higgins Thompson Deeksamp Altman 2003) The overall summary effect showed
Figure 2 Comparison between intervention and control groups for the change in adolescent self-esteem effect size (a) andbody mass index z-score (b) following multicomponent weight management interventions SMD frac14 standard mean differ-ence WMD frac14 weighted mean difference
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no effect on self-esteem as a result of interventionSMD of 027 (95 confidence interval 004 059)zfrac14 169 and pfrac14 092 However all studies exceptone favored the intervention for improvements in self-esteem
The difference between intervention and controlgroups for change in BMI z-score is illustrated inFigure 2b This analysis included five interventiongroups (nfrac14 135) and five control groups (nfrac14 82) withinterventions ranging from 9 weeks to 6 months induration Heterogeneity in this sample was low(I2frac14177 Higgins et al 2003) and the overall sum-mary effect was 017 (022 011) BMI z-scorepoints (zfrac14613 and plt 001) indicating statisticallysignificant weight loss following MWMI
Discussion
The purpose of this review was to examine the effectof MWMIs on self-esteem in overweight and obeseadolescents Increased self-esteem is proposed as a keyfactor for maintaining long-term weight management(Elfhag amp Rossner 2005 French et al 1995Roberts 2006) A secondary outcome of this reviewwas to examine the impact of MWMIs on weight lossand whether this was associated with improvements inself-esteem
The meta-analysis showed no difference in self-esteem between the intervention and control groupsHowever six of the seven studies in the meta-analysisfavored the intervention over control for improve-ments in self-esteem and four of the six studies notincluded in the meta-analysis found significant im-provements in self-esteem following intervention Thelatter of these findings are similar to those of an earlierreview (Lowry et al 2007) that showed improve-ments in self-esteem following weight managementinterventions in a pediatric population particularlywhen certain intervention features were presentSimilarly a number of intervention features that con-tributed to an increased likelihood of improving self-esteem were identified in this review
Improvements in self-esteem regardless of weightloss have been demonstrated in children who tookpart in weight management interventions thatincluded a focus on building self-esteem and it is rec-ommended that this be a focus of all pediatric weightmanagement interventions (Lowry et al 2007) Yetthe majority of studies identified in this review did notinclude building self-esteem as a key aspect of theirintervention Nguyen Shrewsbury et al (2012)described the greatest focus on self-esteem (one75-min group session focused on building self-esteem)and also resulted in the largest treatment effect (057)and a significant improvement in self-esteem (NguyenShrewsbury et al 2012) A focus on similar topics
such as body image social support and managing bul-lying may also contribute to improvements in self-esteem (Croker et al 2012 Pierce amp Wardle 1997Tiggemann 2005) however these findings highlightthe lack of uptake of these recommendations
Among overweight and obese youth reductions inself-esteem are often observed in domains of physicalappearance and physical ability (Franklin DenyerSteinbeck Caterson amp Hill 2006 French et al1995 Latzer amp Stein 2013 Lowry et al 2007)Particularly for adolescent girls body image is a keyconcern (Cave Fildes Luckett amp Wearring 2015)and comprises a large portion of global self-esteem(Lowry et al 2007 Pesa Syre amp Jones 2000)However weight loss and associated changes in phys-ical appearance do not necessarily reflect improve-ments in self-esteem (Lowry et al 2007) Changes inbody-esteem often occur more rapidly than changes inglobal self-esteem as a result of weight management(Lowry et al 2007) This may explain the lack ofchange observed in global self-esteem in this meta-analysis and highlights the need to also include body-esteem (or physical self-esteem) as a focus and out-come of weight management interventions foradolescents
Parental involvement in adolescent weight manage-ment interventions is a critical component for success-ful weight loss and may also be important forimproving self-esteem (Lowry et al 2007) Weight-related teasing from family is shown to be negativelyassociated with self-esteem in overweight adolescentswhereas family connectedness was positively associ-ated with adolescent self-esteem (Fulkerson StraussNeumark-Sztainer Story amp Boutelle 2007) The in-clusion of parents in weight management interventionsfosters a safer and more encouraging home environ-ment for the adolescent (Lowry et al 2007) which isassociated with increased self-esteem in nonover-weight children (Marx amp Neumark-Sztainer 2005)All studies in the present review baring one includedparents in the intervention Parental involvementshould continue to be a key component of weightmanagement interventions to ensure a supportivehome environment for the adolescent to help fosterpositive self-esteem
Weight management interventions that used agroup setting to target self-esteem have shown im-provements in self-esteem without significant weightchange (Lowry et al 2007 Sherman AlexanderGomez Kim amp Marole 1992) The ability of the peergroup setting to provide opportunities for bondingsupport feelings of belonging development of peer-based skills and positive peer exchanges is key toincreasing self-esteem (Lowry et al 2007) The im-portance of this element is being acknowledged in the
390 Murray Dordevic and Bonham
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field with all the studies in this review baring twousing group sessions in their intervention
Measures of self-esteem are self-reported and there-fore subjective Responses to questionnaires are likelyto be influenced by individual (eg age gender) andenvironmental (eg cultural group socioeconomicstatus) factors (Khanlou 2004) Changes followinginterventions may represent genuine long-termchanges in self-esteem or may be due to short-termfluctuations in self-esteem in response to specificevents (eg winning a sporting event or performanceon a test at school) (Kernis 1993) While validatedtools were used to measure self-esteem in all studies itwas difficult to conclude whether outcomes were en-tirely dependent on the intervention without inclusionof a no-treatment control group
The variety of self-esteem assessment tools also addsto the difficulty of interpretation Across the 13 studies inthis review five different tools were used with differentquestions and different scales Even within tools therewere different scales used to report the results (RosenbergSelf-esteem Scale) and different versions of the same ques-tionnaire (Harterrsquos Self-perception Profile for ChildrenHarterrsquos Self-perception Profile for Adolescents) HarterrsquosSelf-Perception Profile (Harterrsquos Self-perception Profilefor Adolescents for adolescents) which measures ninesubscales of self-esteem including physical self-esteem issuggested as the most appropriate measure for adolescentself-esteem (Lowry et al 2007) It was also the mostcommonly used tool among papers included in this re-view While Cohenrsquos d effect sizes were used to stand-ardize results in this review the consistent use of one toolwould provide the ability to compare raw self-esteemscores and create a stronger analysis in the future
Results from this review support evidence thatMWMIs induce weight loss in overweight and obeseadolescents (Hoelscher Kirk Ritchie ampCunningham-Sabo 2013 Kelly amp Melnyk 2008Luttikhuis et al 2009) The change in BMI z-score inthe present meta-analysis (017 [022 011]) wassimilar to the clinically meaningful weight loss re-ported in the 2009 Cochrane Review in children 12years at 6 months follow up from a lifestyle weightmanagement intervention (014 [017 012])(Luttikhuis et al 2009) Jelalian Mehlenbeck Lloyd-Richardson Birmaher and Wing (2006) and WalkerGately Bewick and Hill (2003) have demonstratedassociations between weight loss and increased self-esteem in overweight and obese adolescents after at-tending a weight-management intervention Similarlyin the present review a strong positive relationship be-tween treatment effects for weight loss and improve-ment in self-esteem was identified However itremains unclear whether the improvement in self-esteem was as a result of successful weight loss orwhether it was a contributing factor toward successful
weight loss Nonetheless building self-esteem shouldbe a key focus of MWMIs as improved self-esteem ap-
pears to be linked to enhanced weight lossA key strength of this review was that all included
studies had strong designs and presented level II evi-dence (Coleman et al 2009) However to further elu-
cidate the role of self-esteem in adolescent weightmanagement future research should consider power-
ing studies to detect changes in psychosocial as well asphysiological outcomes Only one study in this reviewwas powered to detect a change in psychosocial out-
comes (Daley et al 2006) which may explain thelack of significant results observed for self-esteem
Additionally a large number of included studies didnot describe their method of handling withdrawals or
use blinding to prevent the introduction of bias Toimprove confidence in the effectiveness of MWMIs
and reduce the risk of bias future studies should bedesigned with concealed allocation and document andreport in detail the flow of participants
Identification of intervention components that im-
prove self-esteem is important for future weight man-agement intervention design Included interventionswere heterogeneous offering different levels of diet-
ary physical activity and behavioral interventionwhich may have collectively or individually influenced
the results Inconsistent reporting of intervention andcomparator conditions make it difficult to elucidate
the components that contributed to improvements inself-esteem Future studies should report intervention
and comparator procedures in adequate detail so thatsuccessful components can be identified and repli-cated These limitations highlight areas for improve-
ment to develop best-practice guidelines forundertaking and evaluating MWMIs in adolescents to
enhance self-esteem
Conclusion
Overweight and obese adolescents experience low
self-esteem largely owing to poor body image yetthis meta-analysis found no improvement in self-esteem even with significant weight loss Although it
was noted that interventions that had larger effects onself-esteem also had larger effects on weight loss The
incorporation of intervention components that wereidentified to contribute to improvements in self-
esteem may assist future weight management interven-tions to improve the self-esteem of overweight and
obese adolescents Furthermore a consistent measureof self-esteem would enable easier interpretation ofself-esteem scores and comparison of results across
studies to improve our understanding of the relation-ship between self-esteem and weight management in
adolescents
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Supplementary Data
Supplementary data can be found at httpwwwjpepsy
oxfordjournalsorg
Acknowledgments
The authors would like to acknowledge Dr Zoe Davidson
for her assistance in performing the meta-analyses
Funding
This work was supported by an Australian GovernmentResearch Training Program Scholarship
Conflicts of interest none declared
References
Academy of Nutrition and Dietetics (2012) Evidence ana-lysis manual Steps in the academy evidence analysis pro-cess Chicago IL ADA Research and Strategic Business
DevelopmentBrennan L Walkley J Fraser S F Greenway K amp
Wilks R (2008) Motivational interviewing and cognitivebehaviour therapy in the treatment of adolescent over-
weight and obesity Study design and methodologyContemporary Clinical Trials 29 359ndash375
Brennan L Walkley J Wilks R Fraser S F amp
Greenway K (2013) Physiological and behavioural out-comes of a randomised controlled trial of a cognitive be-havioural lifestyle intervention for overweight and obese
adolescents Obesity Research and Clinical Practice 7e23ndashe41
Brennan L Wilks R Walkley J Fraser S F amp
Greenway K (2012) Treatment acceptability and psycho-social outcomes of a randomised controlled trial of a cog-nitive behavioural lifestyle intervention for overweight and
obese adolescents Behaviour Change 29 36ndash62Cave L Fildes J Luckett G amp Wearring A (2015)
Mission Australiarsquos 2015 youth survey report MissionAustralia
Coleman K Norris S Weston A Grimmer-Somers KHillier S Merlin T Salisbury J (2009) NHMRCadditional levels of evidence and grades for recommenda-tions for developers of guidelines (Vol Stage 2Consultation) Australia National Health and Medical
Research CouncilCroker H Viner R M Nicholls D Haroun D
Chadwick P Edwards C Wardle J (2012) Family-based behavioural treatment of childhood obesity in a UK
national health service setting Randomized controlledtrial International Journal of Obesity 36 16ndash26 doi
101038ijo2011182Daley A J Copeland R J Wright N P Roalfe A amp
Wales J K H (2006) Exercise therapy as a treatment forpsychopathologic conditions in obese and morbidly obese
adolescents A randomized controlled trial Pediatrics118 2126ndash2134
Danielsen Y S Nordhus I H Julıusson P B Maelighle Mamp Pallesen S (2013) Effect of a family-based cognitive
behavioural intervention on body mass index self-esteem
and symptoms of depression in children with obesity (aged
7mdash13) A randomised waiting list controlled trial ObesityResearch amp Clinical Practice 7 e116ndashe128
DeBar L L Stevens V J Perrin N Wu P Pearson J ampJo B (2012) A primary care-based multicomponent life-
style intervention for overweight adolescent femalesPediatrics 129 e611ndashe620
Elfhag K amp Rossner S (2005) Who succeeds in maintain-ing weight loss A conceptual review of factors associated
with weight loss maintenance and weight regain ObesityReviews 6 67ndash85
Franklin J Denyer G Steinbeck K S Caterson I D ampHill A J (2006) Obesity and risk of low self-esteem Astatewide survey of Australian children Pediatrics 118
2481ndash2487French S A Story M amp Perry C L (1995) Self-esteem
and obesity in children and adolescents A literature re-view Obesity Research 3 479ndash490
Fulkerson J Strauss J Neumark-Sztainer D Story M
amp Boutelle K (2007) Correlates of psychosocial well-being among overweight adolescents The role of the fam-ily Journal of Consulting and Clinical Psychology 75
181ndash186Griffiths L J Parsons T J amp Hill A J (2010) Self-es-
teem and quality of life in obese children and adolescentsA systematic review International Journal of PediatricObesity 5 282ndash304
Harter S (1993) Causes and consequences of low self-
esteem in children and adolescents In R F Baumeister(Ed) Self-esteemmdashThe puzzle of low self-regard (pp87ndash116) USA Springer
Higgins J Thompson S Deeks J amp Altman D (2003)
Measuring inconsistency in meta-analyses BMJ 327557ndash560
Hoelscher D M Kirk S Ritchie L amp Cunningham-Sabo L (2013) Position of the Academy of Nutrition and
Dietetics Interventions for the prevention and treatmentof pediatric overweight and obesity Journal of theAcademy of Nutrition and Dietetics 113 1375ndash1394
Jelalian E Mehlenbeck R Lloyd-Richardson EBirmaher V amp Wing R (2006) lsquoAdventure therapyrsquo
combined with cognitivebehavioral treatment for over-weight adolescents International Journal of Obesity 3031ndash39
Kelly S A amp Melnyk B M (2008) Systematic review of
multicomponent interventions with overweight middleadolescents implications for clinical practice and researchWorldviews on Evidence-Based Nursing 5 113ndash135
Kernis M (1993) The roles of stability and level of self-
esteem in psychological functioning In R Baumeister(Ed) Self-esteem (pp 167ndash182) USA Springer
Khanlou N (2004) Influences on adolescent self-esteem inmulticultural Canadian secondary schools Public HealthNursing 21 404ndash411
Kohn M Rees J M Brill S Fonseca H Jacobson M
Katzman D K Schneider M (2006) Preventing andtreating adolescent obesity A position paper of the Societyfor Adolescent Medicine Journal of Adolescent Health
38 784ndash787Kornman K P Shrewsbury V A Chou A C Ngyuen
B Lee A Orsquoconnor J Baur L A (2010) Electronic
392 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
therapeutic contact for adolescent weight management
The Loozit study Telemedicine and E-Health 16
678ndash685Latzer Y amp Stein D (2013) A review of the psychological
and familial perspectives of childhood obesity Journal of
Eating Disorders 1 7Lobstein T Baur L amp Uauy R (2004) Obesity in chil-
dren and young people a crisis in public health Obesity
Reviews 5(Suppl 1) 4ndash104Lochrie A S Wysocki T Hossain J Milkes A Antal
H Buckloh L Lang J (2013) The effects of a family-
based intervention (FBI) for overweightobese children on
health and psychological functioning Clinical Practice in
Pediatric Psychology 1 159ndash170 doi httpdxdoiorg
101037cpp0000020Lowry K W Sallinen B amp Janicke D (2007) The effects
of weight management programs on self-esteem in pediat-
ric overweight populations Journal of Pediatric
Psychology 32 1179ndash1195Lubans D R Morgan P J Okely A D Dewar D
Collins C E Batterham M Plotnikoff R C (2012)
Preventing obesity among adolescent girls One-year out-
comes of the nutrition and enjoyable activity for teen girls
(NEAT Girls) cluster randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
821ndash827Luttikhuis H Baur L Jansen H Shrewsbury V
Orsquomalley C Stolk R amp Summerbell C (2009)
Interventions for treating obesity in children (Review)
Cochrane Database of Systematic Reviews 3 1ndash57Marx R D amp Neumark-Sztainer D (2005) Questions amp
Answers Eating Disorders The Journal of Treatment amp
Prevention 13 491ndash495McClure A C Tanksi S E Kingsbury J Gerrard M amp
Sargent J D (2010) Characteristics associated with low
self-esteem among US adolescents Academic Pediatrics
10 238ndash244Mellin L M Slinkard L A amp Irwin C E (1987)
Adolescent obesity intervention Validation of the
SHAPEDOWN program Journal of the American Dietetic
Association 87 333ndash338Mission Australia (2012) Youth Survey 2012 SydneyMoher D Shamseer L Clarke M Ghersi D Liberati
A Petticrew M PRISMA-P Group (2015) Preferred
reporting items for systematic review and meta-analysis
protocols (PRISMA-P) 2015 statement Systematic
Reviews 4 1Morgan P Saunders K amp Lubans D (2012) Improving
physical self-perception in adolescent boys from disadvan-
taged schools Psychological outcomes from the Physical
Activity Leaders randomized controlled trial Pediatric
Obesity 7 e27ndashe32 doi httpdxdoiorg101111j
2047-6310201200050xNational Health and Medical Reasearch Council (2013)
Clinical practice guidelines for the management of over-
weight and obesity in adults adolescents and children in
Australia Australia NHMRC Australian Government
Department of HealthNational Institutes for Health and Care Excellence (2013)
Managing overweight and obesity among children and
young people lifestyle weight management services NICE
public health guidance United Kingdom 47 NICENeumark-Sztainer D R Friend S E Flattum C F
Hannan P J Story M T Bauer K W Petrich C A
(2010) New moves-preventing weight-related problems in
adolescent girls A group-randomized study American
Journal of Preventive Medicine 39 421ndash432Nguyen B McGregor K A Orsquoconnor J Shrewsbury V
A Lee A Steinbeck K S Baur L A (2012)
Recruitment challenges and recommendations for adoles-
cent obesity trials Journal of Paediatrics and Child
Health 48 38ndash43Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Hill A J Shah S Baur L A (2013) Two-year
outcomes of an adjunctive telephone coaching and elec-
tronic contact intervention for adolescent weight-loss
maintenance the Loozit randomized controlled trial
International Journal of Obesity 37 468ndash472Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2012) Twelve-month
outcomes of the Loozit randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
170ndash177Ogden C L Carroll M D Kit B K amp Flegal K M
(2014) Prevalence of childhood and adult obesity in the
United States 2011-2012 Journal of the American
Medical Association 311 806ndash814Pesa J A Syre T R amp Jones E (2000) Psychosocial dif-
ferences associated with body weight among female ado-
lescents The importance of body image Journal of
Adolescent Health 26 330ndash337Pierce J W amp Wardle J (1997) Cause and effect beliefs
and self-esteem of overweight children Journal of Child
Psychology and Psychiatry 38 645ndash650 doi 101111
j1469-76101997tb01691xRoberts J E (2006) Self-esteem from a clinical perspective
In M H Kernis (Ed) Self-esteem issues and answers A
sourcebook of current perspectives Psychology Press
Taylor amp Francis New York and Hove (pp 298ndash305)
Psychology PressSacher P M Kolotourou M Chadwick P M Cole T J
Lawson M S Lucas A amp Singhal A (2010)
Randomized controlled trial of the MEND program A
family-based community intervention for childhood obes-
ity Obesity 18(Suppl 1) S62ndashS68 doi httpdxdoiorg
101038oby2009433Sanders R H Han A Baker J S amp Cobley S (2015)
Childhood obesity and its physical and psychological co-
morbidities a systematic review of Australian children and
adolescents Eur J Pediatr 174 715ndash746Sherman J B Alexander M A Gomez D Kim M amp
Marole P (1992) Intervention program for obese school chil-
dren Journal of Community Health Nursing 9 183ndash190Shrewsbury V A Nguyen B Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2011) Short-term
outcomes of community-based adolescent weight manage-
ment The LoozitVR
Study BMC Pediatrics 11 13Shrewsbury V A Orsquoconnor J Steinbeck K S Stevenson
K Lee A Hill A J Baur L A (2009) A randomised
controlled trial of a community-based healthy lifestyle
The Impact of Weight Management on Self-Esteem 393
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
program for overweight and obese adolescents TheLoozitV
R
study protocol BMC Public Health 9 119Strauss R S (2000) Childhood obesity and self-esteem
Pediatrics 105 5Tiggemann M (2005) Body dissatisfaction and adolescent
self-esteem Prospective findings Body Image 2 129ndash135doi httpdxdoiorg101016jbodyim200503006
Wadden T A Stunkard A J Rich L Rubin C JSweidel G amp McKinney S (1990) Obesity in black ado-lescent girls A controlled clinical trial of treatment by diet
behaviour modification and parental support Pediatrics85 345ndash352
Walker L Gately P Bewick B amp Hill A (2003)Childrenrsquos weight-loss camps psychological benefit orjeopardy International Journal of Obesity 27 748ndash754
World Health Organization (2014) Maternal newbornchild and adolescent health Adolescent developmentRetrieved from httpwwwwhointmaternal_child_adolescenttopicsadolescencedeven Retrieved 28 May2014
394 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
- jsw101-TF1
- jsw101-TF2
- jsw101-TF3
- jsw101-TF4
- jsw101-TF5
- jsw101-TF6
- jsw101-TF7
- jsw101-TF8
- jsw101-TF9
- jsw101-TF10
- jsw101-TF11
-
(Brennan Walkley Fraser Greenway amp Wilks2008 Brennan Walkley Wilks Fraser amp Greenway
2013 Kornman et al 2010 Nguyen McGregoret al 2012 Shrewsbury et al 2011 Shrewsbury
et al 2009) or requested from authors
Risk of BiasThe American Dietetic Association Quality CriteriaChecklist was used to assess the quality of the papers
(Academy of Nutrition and Dietetics 2012) Criteriawere independently tested by two researchers (MM
and AD) to determine study quality including ran-domization research question participant selection
and comparability blinding outcome measures stat-istical analysis and potential for bias from funding
Studies were designated a positive neutral or negativerating Publication bias was assessed through visual in-
terpretation of funnel plots created using RevMan 53(Cochrane Informatics amp Knowledge Management
Department 2014 see Figure S1)
Statistical AnalysisCohenrsquos d effect sizes were calculated for weight andself-esteem outcomes to allow for comparison of re-
sults across studies Positive effect sizes indicated theoutcome had improved that is increased self-esteem
or decreased weight (02frac14 small effect05frac14me-dium effect08frac14 large effect) Where an effect size
could not be calculated the reported significance ofresults was assessed Following tests for normality ef-
fect sizes for self-esteem and weight changes were as-sessed for correlation using the Pearson Correlation
test and the coefficient of determination (R2)Meta-analyses were performed to compare the
change in the intervention and control groups forboth self-esteem and BMI z-score using Stata
Statistical Software (Release 13 2013 Texas USA)Only studies that reported the mean (SD) change in
self-esteem or BMI z-score and compared the inter-vention with a no-treatment control group were
included in the meta-analyses If data were not origin-ally reported in this format results were requested
from the authors for inclusion in this review To ac-count for the different tools used to measure self-
esteem outcomes a standard mean difference (SMD)was calculated from the Cohenrsquos d effect size for each
study Studies that reported a weight outcome otherthan BMI z-score were excluded from the meta-
analysis Weighted mean difference was calculated forBMI z-score for the meta-analysis All meta-analyses
were carried out using random effects analysisSensitivity analyses were not performed as only a
small number of studies were included and they wereall of neutral or positive quality
Results
Database searches identified 4707 original papersFollowing title and abstract screening 115 full-textarticles were retrieved and assessed for eligibilityThirteen papers met the review criteria including 2studies that were reviewed by Lowry et al (2007) and11 studies published since Seven studies wereincluded in the meta-analyses (Figure 1)
Description of Included StudiesThe included studies involved between 32 and 208male andor female participants aged 10ndash19 yearswho were overweight or obese (BMI 85th percent-ile) Owing to the limited number of studies that ex-clusively examined the overweight adolescentpopulation studies with mixed populations wereincluded (Croker et al 2012 Danielsen NordhusJulıusson Maelighle amp Pallesen 2013 Lochrie et al2013 Lubans et al 2012 Morgan Saunders ampLubans 2012 Neumark-Sztainer et al 2010 Sacheret al 2010) However only data relating to the popu-lation of interest are reported
Interventions ranged from seven weeks up to a yearin length Only results taken immediately postinterven-tion were assessed in this review For studies thatincluded an intense treatment phase followed by a main-tenance phase the results taken immediately after the in-tense treatment phase have been used as theldquopostinterventionrdquo results (Brennan Wilks WalkleyFraser amp Greenway 2012 Daley Copeland WrightRoalfe amp Wales 2006 Neumark-Sztainer et al 2010)One exception to this was the study by NguyenShrewsbury et al (2012) that had an additional outcomemeasurement at 12 months half way through the main-tenance phase For this study the 12-month measureshave been used as the ldquopostinterventionrdquo results as thiswas the first time point that reported separate results forthe intervention and control groups
All interventions included dietary physical activityand behavioral strategies (Table I) For the purpose ofthis review all groups that received a treatment that metthe review criteria for a MWMI were considered ldquointer-vention groupsrdquo hence there are a greater number ofintervention than control groups In all studies theintervention and control groups were considered com-parable at baseline for the outcomes of interest
Risk of BiasIncluded studies were assessed against 10 criteria andstudy quality was generally high (Table I) Four criteriahad to be met for a study to receive a positive quality rat-ing The remaining six criteria contributed to the overallrating but were not compulsory for a positive rating tobe assigned All 14 studies in this review met the criteriafor a clearly stated research question clearly definedvalid and reliable outcome measures and low risk of bias
The Impact of Weight Management on Self-Esteem 381
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
owing to funding or sponsorship Four studies weredowngraded to a neutral quality rating for not meetingthe criteria (1) selection of participants free from bias(Danielsen et al 2013 Morgan et al 2012) (2) studygroups comparable at baseline (Neumark-Sztainer et al2010) or (3) intervention and comparison conditionsdescribed in detail (Mellin Slinkard amp Irwin 1987Morgan et al 2012) Other criteria that were not met byall studies but did not result in the assignment of any neu-tral quality ratings included appropriate statistical
analysis handling of withdrawals described and use
blinding to prevent bias Funnel plot analysis (Figure S1)did not suggest publication bias however should be inter-
preted with caution owing to the small number of studies
The Impact of Multicomponent WeightManagement Interventions on AdolescentSelf-EsteemSelf-esteem effect sizes were able to be calculated foreight studies (Table II) A positive effect on adolescent
Figure 1 PRISMA flow diagram of included and excluded studies
382 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
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Tab
leI
Stu
dy
Qu
ality
P
art
icip
an
tsIn
terv
en
tio
ns
Du
rati
on
a
nd
Ou
tco
me
Me
asu
res
Stu
dy
(auth
or
yea
rlo
cati
on)
Quali
tyra
ting
Part
icip
ants
Inte
rven
tions
Focu
son
self
-est
eem
Dura
tion
Outc
om
em
easu
res
Bre
nnan
etal
2012A
ust
ralia
25
Posi
tive
29
(46
)m
ale
sand
34
(54
)fe
-m
ale
s11ndash19
yea
rsover
wei
ght
or
obes
e
IIn
terv
enti
on
base
don
cognit
ive
be-
havio
ralpri
nci
ple
sw
ith
afo
cus
on
makin
gsm
all
sust
ain
able
changes
indie
tary
inta
ke
physi
calact
ivit
yand
beh
avio
ralst
rate
gie
sPare
nts
involv
edfo
rfirs
thalf
of
trea
tmen
tphase
C
W
ait
list
No
spec
ific
men
-ti
on
of
self
-es-
teem
but
one
sess
ion
on
de-
vel
opin
ghel
pfu
lth
oughts
and
emoti
ons
Tre
atm
ent
phase
mdashtw
elve
60-m
inse
ssio
ns
and
one
tele
phone
call
sess
ion
over
16
wee
ks
Main
tenance
phase
mdashtw
o60-m
incl
inic
sess
ions
and
seven
15-m
inte
le-
phone
sess
ions
over
6m
onth
s
Rose
nber
gSel
f-E
stee
mSca
leB
MI
z-sc
ore
Cro
ker
etal2012
Unit
edK
ingdom
26
Posi
tive
13
(32
)m
ale
sand
28
(68
)fe
-m
ale
s10ndash12
yea
rsover
wei
ght
or
obes
e
IFam
ily-b
ase
din
terv
enti
on
del
iver
edin
gro
ups
wit
ha
focu
son
makin
gw
hole
-fam
ily
life
style
changes
thro
ugh
beh
avio
r-ch
ange
stra
tegie
sand
nutr
itio
nand
physi
calact
ivit
ygoals
Pare
nt
and
child
sess
ions
de-
liver
edse
para
tely
C
W
ait
list
No
spec
ific
men
-ti
on
of
self
-es-
teem
but
one
sess
ion
on
soci
al
support
and
how
tom
anage
bullyin
g
Fif
teen
15
-hr
sess
ions
over
6m
onth
sFollow
up
12
month
sfr
om
base
line
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
(sel
f-es
teem
)B
MI
SD
S
Dale
yet
al2006
Unit
edK
ingdom
32
Posi
tive
36
(44
)m
ale
sand
45
(56
)fe
-m
ale
s11ndash16
yea
rsB
MI
gt98th
per
centi
le
IPart
icip
ants
com
ple
ted
ara
nge
of
aer
obic
act
ivit
ies
and
min
igam
esand
wer
epro
vid
edw
ith
exer
cise
counse
l-in
gfo
rbeh
avio
rch
ange
ina
one-
on-
one
sett
ingH
ealt
hy
eati
ng
habit
sw
ere
enco
ura
ged
and
wri
tten
info
r-m
ati
on
was
pro
vid
edPart
icip
ants
wer
egiv
enan
indiv
idualize
dex
erci
sepro
gra
mto
conti
nue
aft
erth
etr
eat-
men
tpro
gra
m
CN
otr
eatm
ent
contr
ol
No
spec
ific
men
-ti
on
of
self
-es-
teem
but
beh
avio
ralin
ter-
ven
tions
incl
uded
findin
gso
cial
support
Tre
atm
ent
phase
mdashT
wen
ty-f
our
1hr
ses-
sions
wer
ehel
dover
8w
eeks
Main
tenance
phase
mdashhom
eex
erci
sepro
gra
mfo
r6
wee
ks
no
re-
searc
her
conta
ctFollow
up
at
28
wee
ks
from
base
line
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
for
Adole
scen
ts(s
elf-
este
em)
BM
Iz-
score
Danie
lsen
etal
2013N
orw
ay
27
Neu
tral
17
(53
)m
ale
sand
15
(47
)fe
-m
ale
s10ndash13
yea
rsobes
e
IPart
icip
ants
and
thei
rpare
nts
at-
tended
indiv
idualfa
mily
mee
tings
wit
ha
clin
icalpsy
cholo
gis
tT
he
inte
rven
tion
focu
sed
on
incr
easi
ng
physi
calact
ivit
yand
reduci
ng
seden
-ta
rybeh
avio
res
tablish
ing
abala
nce
ddie
tdev
elopin
gin
div
idualand
fam
ily
copin
gsk
ills
and
pro
moti
ng
aposi
-ti
ve
self
-per
cepti
on
CW
ait
list
No
spec
ific
men
-ti
on
of
self
-es-
teem
st
andard
beh
avio
ralte
ch-
niq
ues
use
d
Tw
elve
wee
kly
45-m
inse
ssio
ns
wit
ha
boost
erse
ssio
n6
month
saft
ertr
eatm
ent
Follow
up
15
month
sfr
om
base
line
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
for
Childre
n(s
elf-
este
em)
BM
ISD
S
The Impact of Weight Management on Self-Esteem 383
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Tab
leI
(co
nti
nu
ed
)
Stu
dy
(auth
or
yea
rlo
cati
on)
Quali
tyra
ting
Part
icip
ants
Inte
rven
tions
Focu
son
self
-est
eem
Dura
tion
Outc
om
em
easu
res
DeB
ar
etal2012
Unit
edSta
tes3
3Posi
tive
208
(100
)fe
-m
ale
s12ndash17
yea
rsB
MI
90th
per
centi
le
IIn
terv
enti
on
focu
sed
on
changin
gdie
tary
inta
ke
and
eati
ng
patt
erns
incr
easi
ng
physi
calact
ivit
yta
ckling
com
mon
psy
choso
cialis
sues
of
obes
-it
yand
teach
ing
beh
avio
raland
cog-
nit
ive
tools
for
wei
ght
managem
ent
Pare
nt
support
mee
tings
wer
ein
cluded
C
W
ait
list
No
spec
ific
focu
son
self
-est
eem
but
issu
essu
chas
dep
ress
ion
and
poor
body
image
wer
eaddre
ssed
and
cognit
ive
rest
ruct
uri
ng
tech
niq
ues
tore
-duce
neg
ati
ve
self
-talk
wer
euse
d
Six
teen
90-m
ingro
up
mee
tings
over
5m
onth
sFollow
up
12
month
sfr
om
base
line
Rose
nber
gSel
f-E
stee
mSca
leB
MI
z-sc
ore
Loch
rie
etal
2013U
nit
edSta
tes2
8
Posi
tive
29
(43
)m
ale
sand
39
(57
)fe
-m
ale
s10ndash11
yea
rsB
MI
85th
per
centi
le
IPart
icip
ants
and
thei
rpare
nts
at-
tended
gro
up
sess
ions
led
by
apsy
ch-
olo
gis
tand
regis
tere
ddie
titi
an
that
cover
ednutr
itio
nbeh
avio
rm
odifi
ca-
tionex
erci
seto
pic
spsy
choso
cial
inte
rven
tions
and
med
icalis
sues
ass
oci
ate
dw
ith
obes
ity
CO
ne
gro
up
sess
ion
for
fam
ilie
sle
dby
are
gis
tere
ddie
titi
an
pro
vid
ing
in-
form
ati
on
on
nutr
itio
nand
physi
cal
act
ivit
y
Psy
choso
cialas-
pec
tsof
inte
rven
tionmdash
stre
ssm
anage-
men
tre
laxati
on
managin
gpee
rpre
ssure
and
teasi
ng
Fourt
een
sess
ions
last
ing
60ndash90
min
over
6m
onth
sN
ofo
llow
up
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
for
Childre
n(s
elf-
este
em)
BM
Iz-
score
Lubans
etal
2012A
ust
ralia
34
Posi
tive
152
(100
)fe
-m
ale
s12ndash14
yea
rsB
MI
85th
per
centi
le
ISch
ool-
base
din
terv
enti
on
incl
udin
gen
hance
dsp
ort
sess
ions
inte
ract
ive
sem
inars
lu
nch
-tim
eact
ivit
yse
ssio
ns
ped
om
eter
sfo
rse
lf-m
onit
ori
ngpar-
ent
new
slet
ter
text
mes
sages
for
so-
cialsu
pport
and
nutr
itio
nw
ork
shops
del
iver
edby
Acc
redit
edPra
ctic
ing
Die
titi
ans
CN
otr
eatm
ent
contr
ol
No
spec
ific
men
-ti
on
of
self
-es
teem
Del
iver
edover
the
four
schoolte
rms
inth
eyea
rFollow
up
24
month
sfr
om
base
line
Mars
hrsquos
Glo
bal
Sel
f-es
teem
BM
Iz-
score
Mel
lin
etal1987
Unit
edSta
tes2
9N
eutr
al
14
(21
)m
ale
sand
52
(79
)fe
-m
ale
s12ndash18
yea
rsgt
13
over
wei
ght
IIn
terv
enti
on
use
dco
gnit
ive
beh
av-
iora
laff
ecti
ve
and
inte
ract
ive
tech
-niq
ues
toen
coura
ge
sust
ain
able
modifi
cati
ons
todie
tex
erci
sere
la-
tionsh
ips
life
style
co
mm
unic
ati
ons
and
att
itudes
T
wo-p
are
nt
sess
ions
incl
uded
C
W
ait
list
No
spec
ific
men
-ti
on
of
self
-es-
teem
but
inte
rven
tions
enco
ura
ged
posi
-ti
ve
rela
tionsh
ips
and
att
itudes
Fourt
een
90-m
inse
ssio
ns
over
14
wee
ks
Follow
up
15
month
sfr
om
base
line
Rose
nber
gSel
f-E
stee
mSca
leR
elati
ve
wei
ght
384 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Tab
leI
(co
nti
nu
ed
)
Stu
dy
(auth
or
yea
rlo
cati
on)
Quali
tyra
ting
Part
icip
ants
Inte
rven
tions
Focu
son
self
-est
eem
Dura
tion
Outc
om
em
easu
res
Morg
an
etal
2012A
ust
ralia
30
Neu
tral
40
(100
)m
ale
s13ndash16
yea
rs
BM
I
85th
per
centi
le
ISch
ool-
base
din
terv
enti
on
incl
udin
gen
hance
dsp
ort
sess
ions
physi
calac-
tivit
yand
nutr
itio
nhandbooks
wit
hhom
e-base
dch
allen
ges
and
inte
r-act
ive
sem
inars
on
nutr
itio
nand
physi
calact
ivit
ybeh
avio
rsand
leader
ship
C
W
ait
list
No
spec
ific
men
-ti
on
of
self
-es
teem
3-m
onth
inte
rven
tion
Follow
up
6m
onth
sfr
om
base
line
Physi
calSel
f-Per
cepti
on
Pro
file
Adole
scen
tver
-si
on
(sel
f-es
teem
)B
MI
Neu
mark
-Szt
ain
eret
al2010
USA
(27)
Neu
tral
164
(100
)fe
-m
ale
s13ndash18
yea
rsB
MI
85th
per
centi
le
Iphysi
calact
ivit
yn
utr
itio
ns
oci
alsu
p-
port
sel
f-em
pow
erm
ent
less
ons
at
schoolw
ith
rela
ted
lett
ers
sent
hom
eto
pare
nts
alo
ng
wit
hin
div
idualm
o-
tivati
onalin
terv
iew
ing
sess
ions
toen
-co
ura
ge
goal-
sett
ingFollow
edby
lunch
tim
ese
ssio
ns
duri
ng
the
main
-te
nance
per
iod
and
a1-d
ay
pare
ntndash
daughte
rre
trea
tC
A
llgir
lsphysi
calact
ivit
ycl
ass
wit
hin
norm
alsc
hoolcu
rric
ulu
m
One
of
the
pro
-gra
mobje
ctiv
esw
as
toen
hance
aposi
tive
self
-fo
cus
and
ses-
sions
focu
sed
on
self
-em
pow
erm
ent
Phase
1mdash
daily
less
ons
at
schoolfo
r16
wee
ks
Sev
enin
div
idualse
ssio
ns
ever
y3ndash4
wee
ks
thro
ughout
inte
rven
tion
Phase
2mdash
wee
kly
lunch
tim
ese
ssio
ns
for
rem
ain
-der
of
schoolyea
r(
5m
onth
s)
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
(sel
f-es
teem
)B
MI
Nguyen
etal
2013A
ust
ralia
35
Posi
tive
55
(36
)m
ale
sand
96
(64
)fe
-m
ale
s13ndash16
yea
rsover
wei
ght
tom
oder
ate
lyobes
eB
MI
z-sc
ore
10
ndash25
(BM
I84ndash99th
per
centi
le)
IIn
terv
enti
on
base
don
the
soci
alco
g-
nit
ive
theo
ryto
modif
yse
lf-e
ffica
cy
moti
vati
onper
sever
ance
and
self
-re
gula
tionSes
sions
focu
sed
on
phys-
icalact
ivit
yhea
thy
eati
nggoalse
t-ti
ngst
ress
managem
ent
and
buildin
gse
lf-e
stee
mIn
terv
enti
on
gro
up
rece
ived
Addit
ional
Ther
apeu
tic
Conta
ct(A
TC
)fo
rtnig
htl
yth
rough-
out
the
main
tenance
per
iodPare
nt
sess
ions
incl
uded
C
A
sabove
wit
hout
the
AT
C
Buildin
gposi
tive
self
-est
eem
was
the
focu
sof
ase
ssio
n
Phase
1mdash
seven
wee
kly
75-m
ingro
up
sess
ions
Phase
2mdash
from
2to
24
month
sfive
60-m
ingro
up
sess
ions
hel
dappro
xev
ery
3m
onth
sA
TC
Fort
nig
htl
yte
le-
phone
coach
ing
sess
ions
and
SM
Se
mes
sages
Hart
errsquos
Sel
fPer
cepti
on
Pro
file
for
Adole
scen
ts(s
elf-
este
em)
BM
Iz-
score
Sach
eret
al2010
Unit
edK
ingdom
31
Posi
tive
21
(48
)m
ale
sand
23
(52
)fe
-m
ale
s10ndash12
yea
rsB
MI
gt98th
per
centi
le
IPart
icip
ants
and
thei
rfa
milie
sat-
tended
gro
up
sess
ions
focu
sing
on
be-
havio
rch
ange
nutr
itio
nand
physi
calact
ivit
ySes
sion
conte
nt
focu
sed
on
buildin
gsk
ills
tom
ain
tain
long-t
erm
beh
avio
rch
anges
Follow
ing
trea
tmen
tfa
milie
sw
ere
giv
ena
12-w
eek
free
fam
ily
swim
pass
C
W
ait
-lis
t
No
spec
ific
men
-ti
on
of
self
-es
teem
Eig
hte
en2-h
rse
ssio
ns
over
9w
eeks
Follow
up
12
month
sfr
om
base
line
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
for
Childre
n(s
elf-
este
em)
BM
Iz-
score
The Impact of Weight Management on Self-Esteem 385
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
self-esteem was observed following four MWMIsacross three studies (Croker et al 2012 Danielsenet al 2013 Nguyen Shrewsbury et al 2012) Fivestudies showed no effect on adolescent self-esteem fol-lowing MWMI (Brennan et al 2012 DeBar et al2012 Lochrie et al 2013 Lubans et al 2012Neumark-Sztainer et al 2010) No positive effects onself-esteem were observed in any of the controlgroups One wait-listed control group (Croker et al2012) showed a small negative effect on self-esteem
Mixed results were also observed in the studies forwhich an effect size could not be calculatedImprovements in adolescent self-esteem were observedfollowing MWMIs by Daley et al (2006) Mellin et al(1987) Sacher et al (2010) and Wadden et al(1990) However only Daley et al (2006) reportedthat this change was different to that observed in thecontrol group No changes in self-esteem were de-tected following intervention by Morgan et al (2012)although a significant decline in self-esteem wasobserved in the wait-listed control group who receivedthe normal school curriculum throughout the studyperiod
Multicomponent Weight ManagementInterventions Improve Weight Outcomes inAdolescentsOf the 13 included studies there were 14 groups whoreceived a MWMI and 11 no-treatment controlgroups Of these effect sizes were able to be calculatedfor nine intervention groups and seven control groups(Table III) Seven intervention groups had small to me-dium positive effects indicating successful weight loss(Brennan et al 2012 Croker et al 2012 Danielsenet al 2013 DeBar et al 2012 Lochrie et al 2013Lubans et al 2012 Nguyen Shrewsbury et al2012) and two intervention groups had no effect(Neumark-Sztainer et al 2010 Nguyen Shrewsburyet al 2012) All seven control groups showed no ef-fect on weight
Of the studies for which effect size could not be cal-culated the results were similar Mellin et al (1987)Morgan et al (2012) Sacher et al (2010) andWadden et al (1990) all observed significant weightloss following intervention Morgan et al (2012) andSacher et al (2010) also showed that these changeswere significantly different to changes observed in thecontrol groups No studies observed significant weightchange in the control groups
Correlation Between Self-Esteem Improvementand Weight Loss Effect SizesThere is a strong (rfrac14 641 R2frac140410) positive linearrelationship between effect sizes for self-esteem im-provement and weight loss across all intervention andcontrol groups (pfrac14 008)T
ab
leI
(co
nti
nu
ed
)
Stu
dy
(auth
or
yea
rlo
cati
on)
Quali
tyra
ting
Part
icip
ants
Inte
rven
tions
Focu
son
self
-est
eem
Dura
tion
Outc
om
em
easu
res
Wadden
etal
1990U
nit
edSta
tes3
6
Posi
tive
47
(100
)fe
male
s12ndash16
yea
rsat
least
10-k
gover
wei
ght
IIn
terv
enti
on
cover
eddie
tand
eati
ng
patt
erns
modif
yin
gse
lf-d
efea
ting
thoughts
and
incr
easi
ng
physi
calac-
tivit
yH
om
ework
ass
ignm
ents
and
ince
nti
ves
aw
ard
sw
ere
use
dto
en-
coura
ge
part
icip
ati
onT
her
ew
ere
thre
edif
fere
nt
inte
rven
tion
gro
ups
who
rece
ived
this
trea
tmen
tch
ild
only
ch
ild
and
moth
erto
get
her
ch
ild
and
moth
erse
para
tely
C
N
ocl
ear
contr
olgro
upse
eabove
No
spec
ific
men
-ti
on
of
self
-es
teem
Six
teen
wee
kly
1-h
rle
ssons
No
follow
up
Pie
rs-H
arr
issc
ale
(sel
f-es
teem
)B
MI
Note
B
MIfrac14
body
mass
index
Ifrac14
inte
rven
tionCfrac14
Com
par
ato
rC
om
par
ato
rgro
ups
that
rece
ived
an
inte
rven
tion
wer
etr
eate
das
inte
rven
tion
gro
ups
for
the
purp
ose
of
anal
ysi
sin
this
revie
w
Stu
die
sare
list
edin
alp
habet
icalord
erin
all
table
s
386 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Tab
leIIS
elf
-Est
ee
mO
utc
om
es
of
Mu
ltic
om
po
ne
nt
We
igh
tM
an
ag
em
en
tIn
terv
en
tio
ns
Co
mp
are
dW
ith
Co
ntr
ols
in
Ov
erw
eig
ht
an
dO
be
seA
do
lesc
en
ts
Auth
or
yea
rIn
terv
enti
on
gro
ups
Contr
olgro
ups
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
Bre
nnan
etal2012
20
215
(54
)a206
(63
)a
21
1(4
78)a
01
514
188
(47
)a192
(47
)a06
4(3
91)a
00
9C
roker
etal2012
13
26
9(0
57)b
29
5(0
45)b
03
6(0
39)b
05
110
29
0(0
61)b
26
8(0
52)b
00
2(0
59)b
03
9D
ale
yet
al2006
28
24
2(0
56)b
26
1(0
08
SE)b
NA
NA
30
24
9(0
49)b
25
6(0
10
SE)b
NA
NA
Danie
lsen
etal2013
16
28
8(0
52)b
31
7(0
53)b
02
9(0
53)b
05
516
31
1(0
57)b
30
6(0
59)b
00
5(0
37)b
00
9D
eBar
etal2012
105
23
9(0
26)a
24
0(0
25)a
NA
00
4103
24
1(0
27)a
23
9(0
25)a
NA
00
8L
och
rie
etal2013
29
183
(50
2)b
191
(44
8)b
07
3(4
51)b
01
718
199
(34
6)b
199
(34
3)b
00
0(3
11)b
00
0L
ubans
etal2012
54
40
3(1
12)c
40
6(1
32)c
NA
00
268
40
4(0
99)c
42
3(0
98)c
NA
01
9M
ellin
etal1987
37
NA
NA
08
8(1
50)a
NA
29
NA
NA
05
2(1
34)a
NA
Morg
an
etal2012
19
NA
NA
00
8(0
48)d
NA
21
NA
NA
02
6(0
47)d
NA
Neu
mark
-Szt
ain
eret
al2010
85
152
(34
)b151
(29
)bN
A
00
379
141
(34
)b140
(34
)bN
A
00
3
Nguyen
etal2012
(wit
hA
TC
)57
25
8(0
76)b
27
7(0
63)b
01
9(0
67)b
02
7
Nguyen
etal2012
(wit
hout
AT
C)
50
25
9(0
58)b
29
3(0
61)b
01
9(0
51)b
05
7
Sach
eret
al2010
20
NA
32
5(0
68)b
02
5(0
66)b
NA
24
NA
30
4(0
75)b
01
1(0
74)b
NA
Wadden
etal1990
3gro
ups
com
bin
ed47
576
e599
eN
AN
A
Note
D
ata
pre
sente
das
report
edin
ori
gin
alpaper
sSDfrac14
standard
dev
iati
onN
Afrac14
data
not
pro
vid
edu
nab
leto
be
calc
ula
ted
SEfrac14
Sta
ndard
erro
rnot
Sta
ndard
Dev
iati
onE
ffec
tsi
zefrac14
Cohen
rsquosdB
old
font
indic
ate
sw
her
eef
fect
size
was
small
(02
0)
or
gre
ate
raR
ose
nber
gse
lf-e
stee
msc
ale
(gen
erally
score
dfr
om
0[l
ow
est
self
-est
eem
]to
30
[hig
hes
tse
lf-e
stee
m])
bH
art
errsquos
SPPA
SPPC
(gen
erally
score
d1
[low
est
self
-est
eem
]to
4[h
ighes
tse
lf-e
stee
m])
cM
ars
hrsquos
Physi
calSel
f-D
escr
ipti
on
Ques
tionnair
e
dPhysi
calSel
f-Per
cepti
on
Pro
file
for
Adole
scen
ts
ePie
rs-H
arr
isSel
f-C
once
pt
Sca
le
Sco
ring
range
sunav
ailab
lehig
her
valu
eeq
uals
hig
her
self
-est
eem
The Impact of Weight Management on Self-Esteem 387
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Tab
leIII
We
igh
tO
utc
om
es
of
Mu
ltic
om
po
ne
nt
We
igh
tM
an
ag
em
en
tIn
terv
en
tio
ns
Co
mp
are
dW
ith
Co
ntr
ols
in
Ov
erw
eig
ht
an
dO
be
seA
do
lesc
en
ts
Auth
or
yea
rIn
terv
enti
on
gro
ups
Contr
olgro
ups
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
Bre
nnan
etal2012
20
20
8(0
37)
19
9(0
46)
02
0(0
18)
02
214
20
8(0
40)
20
9(0
39)
00
1(0
12)
00
3C
roker
etal2012
13
29
5(0
52)
26
6(0
63)
01
7(0
21)
05
010
31
4(0
68)
31
4(0
68)
00
6(0
13)
00
0D
ale
yet
al2006
28
31
7(0
33)
32
3(0
02
SE)
NA
NA
30
33
2(0
37)
32
3(0
02
SE)
NA
NA
Danie
lsen
etal2013
16
25
9(0
30)
24
6(0
41)
01
2(0
17)
03
616
24
9(0
27)
25
3(0
29)
00
5(0
15)
01
4D
eBar
etal2012
105
20
0(0
34)
18
8(0
41)
NA
03
2103
20
0(0
33)
19
4(0
38)
NA
01
7L
och
rie
etal2013
29
21
9(0
40)
20
6(0
52)
01
2(0
20)
02
818
20
7(0
40)
20
5(0
43)
00
2(0
11)
00
5L
ubans
etal2012
54
19
3(0
61)
18
0(0
68)
NA
02
068
18
5(0
59)
18
0(0
67)
NA
00
8M
ellin
etal1987
37
1365
aN
A
59
(67
5)a
NA
29
1295
aN
A
03
(66
1)a
NA
Morg
an
etal2012
19
NA
NA
04
2(0
91)b
NA
21
NA
NA
00
3(0
87)b
NA
Neu
mark
-Szt
ain
eret
al2010
85
321
(61
)b322
(62
)bN
A
00
279
310
(53
)b314
(55
)bN
A
00
7
Nguyen
etal2012
(wit
hA
TC
)57
20
3(0
37)
19
7(0
42)
00
8(0
19)
01
5
Nguyen
etal2012
(wit
hout
AT
C)
50
20
2(0
29)
19
4(0
32)
00
9(0
17)
02
6
Sach
eret
al2010
20
NA
23
7(0
52)
02
2(0
27)
NA
24
NA
26
0(0
54)
00
1(0
20)
NA
Wadden
etal1990
3gro
ups
com
bin
ed47
352
b339
bN
AN
A
Note
D
ata
pre
sente
das
report
edin
ori
gin
al
paper
sA
llw
eight
outc
om
esre
port
edas
body
mass
index
(BM
I)z-
score
unle
ssoth
erw
ise
state
d
SDfrac14
standar
ddev
iati
on
NAfrac14
data
not
pro
vid
ed
unab
leto
be
calc
ula
ted
SEfrac14
Sta
ndard
Err
or
report
edra
ther
than
Sta
ndard
Dev
iati
onE
ffec
tsi
zefrac14
Cohen
rsquosdB
old
font
indic
ate
sw
her
eef
fect
size
was
smal
l(0
20)
or
gre
ate
raR
elati
ve
wei
ght
bB
MI
388 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Quantitative Data AnalysisDifferences between intervention and control groupsfor change in self-esteem are presented in Figure 2aThis analysis included seven intervention groups(nfrac14 191) and seven control groups (nfrac14 132) with
interventions or intensive treatment phases rangingfrom 9 weeks to 6 months in duration A moderatelevel of the variation across studies was owing to het-erogeneity (I2frac14464 Higgins Thompson Deeksamp Altman 2003) The overall summary effect showed
Figure 2 Comparison between intervention and control groups for the change in adolescent self-esteem effect size (a) andbody mass index z-score (b) following multicomponent weight management interventions SMD frac14 standard mean differ-ence WMD frac14 weighted mean difference
The Impact of Weight Management on Self-Esteem 389
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no effect on self-esteem as a result of interventionSMD of 027 (95 confidence interval 004 059)zfrac14 169 and pfrac14 092 However all studies exceptone favored the intervention for improvements in self-esteem
The difference between intervention and controlgroups for change in BMI z-score is illustrated inFigure 2b This analysis included five interventiongroups (nfrac14 135) and five control groups (nfrac14 82) withinterventions ranging from 9 weeks to 6 months induration Heterogeneity in this sample was low(I2frac14177 Higgins et al 2003) and the overall sum-mary effect was 017 (022 011) BMI z-scorepoints (zfrac14613 and plt 001) indicating statisticallysignificant weight loss following MWMI
Discussion
The purpose of this review was to examine the effectof MWMIs on self-esteem in overweight and obeseadolescents Increased self-esteem is proposed as a keyfactor for maintaining long-term weight management(Elfhag amp Rossner 2005 French et al 1995Roberts 2006) A secondary outcome of this reviewwas to examine the impact of MWMIs on weight lossand whether this was associated with improvements inself-esteem
The meta-analysis showed no difference in self-esteem between the intervention and control groupsHowever six of the seven studies in the meta-analysisfavored the intervention over control for improve-ments in self-esteem and four of the six studies notincluded in the meta-analysis found significant im-provements in self-esteem following intervention Thelatter of these findings are similar to those of an earlierreview (Lowry et al 2007) that showed improve-ments in self-esteem following weight managementinterventions in a pediatric population particularlywhen certain intervention features were presentSimilarly a number of intervention features that con-tributed to an increased likelihood of improving self-esteem were identified in this review
Improvements in self-esteem regardless of weightloss have been demonstrated in children who tookpart in weight management interventions thatincluded a focus on building self-esteem and it is rec-ommended that this be a focus of all pediatric weightmanagement interventions (Lowry et al 2007) Yetthe majority of studies identified in this review did notinclude building self-esteem as a key aspect of theirintervention Nguyen Shrewsbury et al (2012)described the greatest focus on self-esteem (one75-min group session focused on building self-esteem)and also resulted in the largest treatment effect (057)and a significant improvement in self-esteem (NguyenShrewsbury et al 2012) A focus on similar topics
such as body image social support and managing bul-lying may also contribute to improvements in self-esteem (Croker et al 2012 Pierce amp Wardle 1997Tiggemann 2005) however these findings highlightthe lack of uptake of these recommendations
Among overweight and obese youth reductions inself-esteem are often observed in domains of physicalappearance and physical ability (Franklin DenyerSteinbeck Caterson amp Hill 2006 French et al1995 Latzer amp Stein 2013 Lowry et al 2007)Particularly for adolescent girls body image is a keyconcern (Cave Fildes Luckett amp Wearring 2015)and comprises a large portion of global self-esteem(Lowry et al 2007 Pesa Syre amp Jones 2000)However weight loss and associated changes in phys-ical appearance do not necessarily reflect improve-ments in self-esteem (Lowry et al 2007) Changes inbody-esteem often occur more rapidly than changes inglobal self-esteem as a result of weight management(Lowry et al 2007) This may explain the lack ofchange observed in global self-esteem in this meta-analysis and highlights the need to also include body-esteem (or physical self-esteem) as a focus and out-come of weight management interventions foradolescents
Parental involvement in adolescent weight manage-ment interventions is a critical component for success-ful weight loss and may also be important forimproving self-esteem (Lowry et al 2007) Weight-related teasing from family is shown to be negativelyassociated with self-esteem in overweight adolescentswhereas family connectedness was positively associ-ated with adolescent self-esteem (Fulkerson StraussNeumark-Sztainer Story amp Boutelle 2007) The in-clusion of parents in weight management interventionsfosters a safer and more encouraging home environ-ment for the adolescent (Lowry et al 2007) which isassociated with increased self-esteem in nonover-weight children (Marx amp Neumark-Sztainer 2005)All studies in the present review baring one includedparents in the intervention Parental involvementshould continue to be a key component of weightmanagement interventions to ensure a supportivehome environment for the adolescent to help fosterpositive self-esteem
Weight management interventions that used agroup setting to target self-esteem have shown im-provements in self-esteem without significant weightchange (Lowry et al 2007 Sherman AlexanderGomez Kim amp Marole 1992) The ability of the peergroup setting to provide opportunities for bondingsupport feelings of belonging development of peer-based skills and positive peer exchanges is key toincreasing self-esteem (Lowry et al 2007) The im-portance of this element is being acknowledged in the
390 Murray Dordevic and Bonham
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field with all the studies in this review baring twousing group sessions in their intervention
Measures of self-esteem are self-reported and there-fore subjective Responses to questionnaires are likelyto be influenced by individual (eg age gender) andenvironmental (eg cultural group socioeconomicstatus) factors (Khanlou 2004) Changes followinginterventions may represent genuine long-termchanges in self-esteem or may be due to short-termfluctuations in self-esteem in response to specificevents (eg winning a sporting event or performanceon a test at school) (Kernis 1993) While validatedtools were used to measure self-esteem in all studies itwas difficult to conclude whether outcomes were en-tirely dependent on the intervention without inclusionof a no-treatment control group
The variety of self-esteem assessment tools also addsto the difficulty of interpretation Across the 13 studies inthis review five different tools were used with differentquestions and different scales Even within tools therewere different scales used to report the results (RosenbergSelf-esteem Scale) and different versions of the same ques-tionnaire (Harterrsquos Self-perception Profile for ChildrenHarterrsquos Self-perception Profile for Adolescents) HarterrsquosSelf-Perception Profile (Harterrsquos Self-perception Profilefor Adolescents for adolescents) which measures ninesubscales of self-esteem including physical self-esteem issuggested as the most appropriate measure for adolescentself-esteem (Lowry et al 2007) It was also the mostcommonly used tool among papers included in this re-view While Cohenrsquos d effect sizes were used to stand-ardize results in this review the consistent use of one toolwould provide the ability to compare raw self-esteemscores and create a stronger analysis in the future
Results from this review support evidence thatMWMIs induce weight loss in overweight and obeseadolescents (Hoelscher Kirk Ritchie ampCunningham-Sabo 2013 Kelly amp Melnyk 2008Luttikhuis et al 2009) The change in BMI z-score inthe present meta-analysis (017 [022 011]) wassimilar to the clinically meaningful weight loss re-ported in the 2009 Cochrane Review in children 12years at 6 months follow up from a lifestyle weightmanagement intervention (014 [017 012])(Luttikhuis et al 2009) Jelalian Mehlenbeck Lloyd-Richardson Birmaher and Wing (2006) and WalkerGately Bewick and Hill (2003) have demonstratedassociations between weight loss and increased self-esteem in overweight and obese adolescents after at-tending a weight-management intervention Similarlyin the present review a strong positive relationship be-tween treatment effects for weight loss and improve-ment in self-esteem was identified However itremains unclear whether the improvement in self-esteem was as a result of successful weight loss orwhether it was a contributing factor toward successful
weight loss Nonetheless building self-esteem shouldbe a key focus of MWMIs as improved self-esteem ap-
pears to be linked to enhanced weight lossA key strength of this review was that all included
studies had strong designs and presented level II evi-dence (Coleman et al 2009) However to further elu-
cidate the role of self-esteem in adolescent weightmanagement future research should consider power-
ing studies to detect changes in psychosocial as well asphysiological outcomes Only one study in this reviewwas powered to detect a change in psychosocial out-
comes (Daley et al 2006) which may explain thelack of significant results observed for self-esteem
Additionally a large number of included studies didnot describe their method of handling withdrawals or
use blinding to prevent the introduction of bias Toimprove confidence in the effectiveness of MWMIs
and reduce the risk of bias future studies should bedesigned with concealed allocation and document andreport in detail the flow of participants
Identification of intervention components that im-
prove self-esteem is important for future weight man-agement intervention design Included interventionswere heterogeneous offering different levels of diet-
ary physical activity and behavioral interventionwhich may have collectively or individually influenced
the results Inconsistent reporting of intervention andcomparator conditions make it difficult to elucidate
the components that contributed to improvements inself-esteem Future studies should report intervention
and comparator procedures in adequate detail so thatsuccessful components can be identified and repli-cated These limitations highlight areas for improve-
ment to develop best-practice guidelines forundertaking and evaluating MWMIs in adolescents to
enhance self-esteem
Conclusion
Overweight and obese adolescents experience low
self-esteem largely owing to poor body image yetthis meta-analysis found no improvement in self-esteem even with significant weight loss Although it
was noted that interventions that had larger effects onself-esteem also had larger effects on weight loss The
incorporation of intervention components that wereidentified to contribute to improvements in self-
esteem may assist future weight management interven-tions to improve the self-esteem of overweight and
obese adolescents Furthermore a consistent measureof self-esteem would enable easier interpretation ofself-esteem scores and comparison of results across
studies to improve our understanding of the relation-ship between self-esteem and weight management in
adolescents
The Impact of Weight Management on Self-Esteem 391
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Supplementary Data
Supplementary data can be found at httpwwwjpepsy
oxfordjournalsorg
Acknowledgments
The authors would like to acknowledge Dr Zoe Davidson
for her assistance in performing the meta-analyses
Funding
This work was supported by an Australian GovernmentResearch Training Program Scholarship
Conflicts of interest none declared
References
Academy of Nutrition and Dietetics (2012) Evidence ana-lysis manual Steps in the academy evidence analysis pro-cess Chicago IL ADA Research and Strategic Business
DevelopmentBrennan L Walkley J Fraser S F Greenway K amp
Wilks R (2008) Motivational interviewing and cognitivebehaviour therapy in the treatment of adolescent over-
weight and obesity Study design and methodologyContemporary Clinical Trials 29 359ndash375
Brennan L Walkley J Wilks R Fraser S F amp
Greenway K (2013) Physiological and behavioural out-comes of a randomised controlled trial of a cognitive be-havioural lifestyle intervention for overweight and obese
adolescents Obesity Research and Clinical Practice 7e23ndashe41
Brennan L Wilks R Walkley J Fraser S F amp
Greenway K (2012) Treatment acceptability and psycho-social outcomes of a randomised controlled trial of a cog-nitive behavioural lifestyle intervention for overweight and
obese adolescents Behaviour Change 29 36ndash62Cave L Fildes J Luckett G amp Wearring A (2015)
Mission Australiarsquos 2015 youth survey report MissionAustralia
Coleman K Norris S Weston A Grimmer-Somers KHillier S Merlin T Salisbury J (2009) NHMRCadditional levels of evidence and grades for recommenda-tions for developers of guidelines (Vol Stage 2Consultation) Australia National Health and Medical
Research CouncilCroker H Viner R M Nicholls D Haroun D
Chadwick P Edwards C Wardle J (2012) Family-based behavioural treatment of childhood obesity in a UK
national health service setting Randomized controlledtrial International Journal of Obesity 36 16ndash26 doi
101038ijo2011182Daley A J Copeland R J Wright N P Roalfe A amp
Wales J K H (2006) Exercise therapy as a treatment forpsychopathologic conditions in obese and morbidly obese
adolescents A randomized controlled trial Pediatrics118 2126ndash2134
Danielsen Y S Nordhus I H Julıusson P B Maelighle Mamp Pallesen S (2013) Effect of a family-based cognitive
behavioural intervention on body mass index self-esteem
and symptoms of depression in children with obesity (aged
7mdash13) A randomised waiting list controlled trial ObesityResearch amp Clinical Practice 7 e116ndashe128
DeBar L L Stevens V J Perrin N Wu P Pearson J ampJo B (2012) A primary care-based multicomponent life-
style intervention for overweight adolescent femalesPediatrics 129 e611ndashe620
Elfhag K amp Rossner S (2005) Who succeeds in maintain-ing weight loss A conceptual review of factors associated
with weight loss maintenance and weight regain ObesityReviews 6 67ndash85
Franklin J Denyer G Steinbeck K S Caterson I D ampHill A J (2006) Obesity and risk of low self-esteem Astatewide survey of Australian children Pediatrics 118
2481ndash2487French S A Story M amp Perry C L (1995) Self-esteem
and obesity in children and adolescents A literature re-view Obesity Research 3 479ndash490
Fulkerson J Strauss J Neumark-Sztainer D Story M
amp Boutelle K (2007) Correlates of psychosocial well-being among overweight adolescents The role of the fam-ily Journal of Consulting and Clinical Psychology 75
181ndash186Griffiths L J Parsons T J amp Hill A J (2010) Self-es-
teem and quality of life in obese children and adolescentsA systematic review International Journal of PediatricObesity 5 282ndash304
Harter S (1993) Causes and consequences of low self-
esteem in children and adolescents In R F Baumeister(Ed) Self-esteemmdashThe puzzle of low self-regard (pp87ndash116) USA Springer
Higgins J Thompson S Deeks J amp Altman D (2003)
Measuring inconsistency in meta-analyses BMJ 327557ndash560
Hoelscher D M Kirk S Ritchie L amp Cunningham-Sabo L (2013) Position of the Academy of Nutrition and
Dietetics Interventions for the prevention and treatmentof pediatric overweight and obesity Journal of theAcademy of Nutrition and Dietetics 113 1375ndash1394
Jelalian E Mehlenbeck R Lloyd-Richardson EBirmaher V amp Wing R (2006) lsquoAdventure therapyrsquo
combined with cognitivebehavioral treatment for over-weight adolescents International Journal of Obesity 3031ndash39
Kelly S A amp Melnyk B M (2008) Systematic review of
multicomponent interventions with overweight middleadolescents implications for clinical practice and researchWorldviews on Evidence-Based Nursing 5 113ndash135
Kernis M (1993) The roles of stability and level of self-
esteem in psychological functioning In R Baumeister(Ed) Self-esteem (pp 167ndash182) USA Springer
Khanlou N (2004) Influences on adolescent self-esteem inmulticultural Canadian secondary schools Public HealthNursing 21 404ndash411
Kohn M Rees J M Brill S Fonseca H Jacobson M
Katzman D K Schneider M (2006) Preventing andtreating adolescent obesity A position paper of the Societyfor Adolescent Medicine Journal of Adolescent Health
38 784ndash787Kornman K P Shrewsbury V A Chou A C Ngyuen
B Lee A Orsquoconnor J Baur L A (2010) Electronic
392 Murray Dordevic and Bonham
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icoupcomjpepsyarticle-abstract4243793065789 by U
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arolina at wilm
ington user on 14 February 2019
therapeutic contact for adolescent weight management
The Loozit study Telemedicine and E-Health 16
678ndash685Latzer Y amp Stein D (2013) A review of the psychological
and familial perspectives of childhood obesity Journal of
Eating Disorders 1 7Lobstein T Baur L amp Uauy R (2004) Obesity in chil-
dren and young people a crisis in public health Obesity
Reviews 5(Suppl 1) 4ndash104Lochrie A S Wysocki T Hossain J Milkes A Antal
H Buckloh L Lang J (2013) The effects of a family-
based intervention (FBI) for overweightobese children on
health and psychological functioning Clinical Practice in
Pediatric Psychology 1 159ndash170 doi httpdxdoiorg
101037cpp0000020Lowry K W Sallinen B amp Janicke D (2007) The effects
of weight management programs on self-esteem in pediat-
ric overweight populations Journal of Pediatric
Psychology 32 1179ndash1195Lubans D R Morgan P J Okely A D Dewar D
Collins C E Batterham M Plotnikoff R C (2012)
Preventing obesity among adolescent girls One-year out-
comes of the nutrition and enjoyable activity for teen girls
(NEAT Girls) cluster randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
821ndash827Luttikhuis H Baur L Jansen H Shrewsbury V
Orsquomalley C Stolk R amp Summerbell C (2009)
Interventions for treating obesity in children (Review)
Cochrane Database of Systematic Reviews 3 1ndash57Marx R D amp Neumark-Sztainer D (2005) Questions amp
Answers Eating Disorders The Journal of Treatment amp
Prevention 13 491ndash495McClure A C Tanksi S E Kingsbury J Gerrard M amp
Sargent J D (2010) Characteristics associated with low
self-esteem among US adolescents Academic Pediatrics
10 238ndash244Mellin L M Slinkard L A amp Irwin C E (1987)
Adolescent obesity intervention Validation of the
SHAPEDOWN program Journal of the American Dietetic
Association 87 333ndash338Mission Australia (2012) Youth Survey 2012 SydneyMoher D Shamseer L Clarke M Ghersi D Liberati
A Petticrew M PRISMA-P Group (2015) Preferred
reporting items for systematic review and meta-analysis
protocols (PRISMA-P) 2015 statement Systematic
Reviews 4 1Morgan P Saunders K amp Lubans D (2012) Improving
physical self-perception in adolescent boys from disadvan-
taged schools Psychological outcomes from the Physical
Activity Leaders randomized controlled trial Pediatric
Obesity 7 e27ndashe32 doi httpdxdoiorg101111j
2047-6310201200050xNational Health and Medical Reasearch Council (2013)
Clinical practice guidelines for the management of over-
weight and obesity in adults adolescents and children in
Australia Australia NHMRC Australian Government
Department of HealthNational Institutes for Health and Care Excellence (2013)
Managing overweight and obesity among children and
young people lifestyle weight management services NICE
public health guidance United Kingdom 47 NICENeumark-Sztainer D R Friend S E Flattum C F
Hannan P J Story M T Bauer K W Petrich C A
(2010) New moves-preventing weight-related problems in
adolescent girls A group-randomized study American
Journal of Preventive Medicine 39 421ndash432Nguyen B McGregor K A Orsquoconnor J Shrewsbury V
A Lee A Steinbeck K S Baur L A (2012)
Recruitment challenges and recommendations for adoles-
cent obesity trials Journal of Paediatrics and Child
Health 48 38ndash43Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Hill A J Shah S Baur L A (2013) Two-year
outcomes of an adjunctive telephone coaching and elec-
tronic contact intervention for adolescent weight-loss
maintenance the Loozit randomized controlled trial
International Journal of Obesity 37 468ndash472Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2012) Twelve-month
outcomes of the Loozit randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
170ndash177Ogden C L Carroll M D Kit B K amp Flegal K M
(2014) Prevalence of childhood and adult obesity in the
United States 2011-2012 Journal of the American
Medical Association 311 806ndash814Pesa J A Syre T R amp Jones E (2000) Psychosocial dif-
ferences associated with body weight among female ado-
lescents The importance of body image Journal of
Adolescent Health 26 330ndash337Pierce J W amp Wardle J (1997) Cause and effect beliefs
and self-esteem of overweight children Journal of Child
Psychology and Psychiatry 38 645ndash650 doi 101111
j1469-76101997tb01691xRoberts J E (2006) Self-esteem from a clinical perspective
In M H Kernis (Ed) Self-esteem issues and answers A
sourcebook of current perspectives Psychology Press
Taylor amp Francis New York and Hove (pp 298ndash305)
Psychology PressSacher P M Kolotourou M Chadwick P M Cole T J
Lawson M S Lucas A amp Singhal A (2010)
Randomized controlled trial of the MEND program A
family-based community intervention for childhood obes-
ity Obesity 18(Suppl 1) S62ndashS68 doi httpdxdoiorg
101038oby2009433Sanders R H Han A Baker J S amp Cobley S (2015)
Childhood obesity and its physical and psychological co-
morbidities a systematic review of Australian children and
adolescents Eur J Pediatr 174 715ndash746Sherman J B Alexander M A Gomez D Kim M amp
Marole P (1992) Intervention program for obese school chil-
dren Journal of Community Health Nursing 9 183ndash190Shrewsbury V A Nguyen B Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2011) Short-term
outcomes of community-based adolescent weight manage-
ment The LoozitVR
Study BMC Pediatrics 11 13Shrewsbury V A Orsquoconnor J Steinbeck K S Stevenson
K Lee A Hill A J Baur L A (2009) A randomised
controlled trial of a community-based healthy lifestyle
The Impact of Weight Management on Self-Esteem 393
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
program for overweight and obese adolescents TheLoozitV
R
study protocol BMC Public Health 9 119Strauss R S (2000) Childhood obesity and self-esteem
Pediatrics 105 5Tiggemann M (2005) Body dissatisfaction and adolescent
self-esteem Prospective findings Body Image 2 129ndash135doi httpdxdoiorg101016jbodyim200503006
Wadden T A Stunkard A J Rich L Rubin C JSweidel G amp McKinney S (1990) Obesity in black ado-lescent girls A controlled clinical trial of treatment by diet
behaviour modification and parental support Pediatrics85 345ndash352
Walker L Gately P Bewick B amp Hill A (2003)Childrenrsquos weight-loss camps psychological benefit orjeopardy International Journal of Obesity 27 748ndash754
World Health Organization (2014) Maternal newbornchild and adolescent health Adolescent developmentRetrieved from httpwwwwhointmaternal_child_adolescenttopicsadolescencedeven Retrieved 28 May2014
394 Murray Dordevic and Bonham
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icoupcomjpepsyarticle-abstract4243793065789 by U
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arolina at wilm
ington user on 14 February 2019
- jsw101-TF1
- jsw101-TF2
- jsw101-TF3
- jsw101-TF4
- jsw101-TF5
- jsw101-TF6
- jsw101-TF7
- jsw101-TF8
- jsw101-TF9
- jsw101-TF10
- jsw101-TF11
-
owing to funding or sponsorship Four studies weredowngraded to a neutral quality rating for not meetingthe criteria (1) selection of participants free from bias(Danielsen et al 2013 Morgan et al 2012) (2) studygroups comparable at baseline (Neumark-Sztainer et al2010) or (3) intervention and comparison conditionsdescribed in detail (Mellin Slinkard amp Irwin 1987Morgan et al 2012) Other criteria that were not met byall studies but did not result in the assignment of any neu-tral quality ratings included appropriate statistical
analysis handling of withdrawals described and use
blinding to prevent bias Funnel plot analysis (Figure S1)did not suggest publication bias however should be inter-
preted with caution owing to the small number of studies
The Impact of Multicomponent WeightManagement Interventions on AdolescentSelf-EsteemSelf-esteem effect sizes were able to be calculated foreight studies (Table II) A positive effect on adolescent
Figure 1 PRISMA flow diagram of included and excluded studies
382 Murray Dordevic and Bonham
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Tab
leI
Stu
dy
Qu
ality
P
art
icip
an
tsIn
terv
en
tio
ns
Du
rati
on
a
nd
Ou
tco
me
Me
asu
res
Stu
dy
(auth
or
yea
rlo
cati
on)
Quali
tyra
ting
Part
icip
ants
Inte
rven
tions
Focu
son
self
-est
eem
Dura
tion
Outc
om
em
easu
res
Bre
nnan
etal
2012A
ust
ralia
25
Posi
tive
29
(46
)m
ale
sand
34
(54
)fe
-m
ale
s11ndash19
yea
rsover
wei
ght
or
obes
e
IIn
terv
enti
on
base
don
cognit
ive
be-
havio
ralpri
nci
ple
sw
ith
afo
cus
on
makin
gsm
all
sust
ain
able
changes
indie
tary
inta
ke
physi
calact
ivit
yand
beh
avio
ralst
rate
gie
sPare
nts
involv
edfo
rfirs
thalf
of
trea
tmen
tphase
C
W
ait
list
No
spec
ific
men
-ti
on
of
self
-es-
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The Impact of Weight Management on Self-Esteem 385
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
self-esteem was observed following four MWMIsacross three studies (Croker et al 2012 Danielsenet al 2013 Nguyen Shrewsbury et al 2012) Fivestudies showed no effect on adolescent self-esteem fol-lowing MWMI (Brennan et al 2012 DeBar et al2012 Lochrie et al 2013 Lubans et al 2012Neumark-Sztainer et al 2010) No positive effects onself-esteem were observed in any of the controlgroups One wait-listed control group (Croker et al2012) showed a small negative effect on self-esteem
Mixed results were also observed in the studies forwhich an effect size could not be calculatedImprovements in adolescent self-esteem were observedfollowing MWMIs by Daley et al (2006) Mellin et al(1987) Sacher et al (2010) and Wadden et al(1990) However only Daley et al (2006) reportedthat this change was different to that observed in thecontrol group No changes in self-esteem were de-tected following intervention by Morgan et al (2012)although a significant decline in self-esteem wasobserved in the wait-listed control group who receivedthe normal school curriculum throughout the studyperiod
Multicomponent Weight ManagementInterventions Improve Weight Outcomes inAdolescentsOf the 13 included studies there were 14 groups whoreceived a MWMI and 11 no-treatment controlgroups Of these effect sizes were able to be calculatedfor nine intervention groups and seven control groups(Table III) Seven intervention groups had small to me-dium positive effects indicating successful weight loss(Brennan et al 2012 Croker et al 2012 Danielsenet al 2013 DeBar et al 2012 Lochrie et al 2013Lubans et al 2012 Nguyen Shrewsbury et al2012) and two intervention groups had no effect(Neumark-Sztainer et al 2010 Nguyen Shrewsburyet al 2012) All seven control groups showed no ef-fect on weight
Of the studies for which effect size could not be cal-culated the results were similar Mellin et al (1987)Morgan et al (2012) Sacher et al (2010) andWadden et al (1990) all observed significant weightloss following intervention Morgan et al (2012) andSacher et al (2010) also showed that these changeswere significantly different to changes observed in thecontrol groups No studies observed significant weightchange in the control groups
Correlation Between Self-Esteem Improvementand Weight Loss Effect SizesThere is a strong (rfrac14 641 R2frac140410) positive linearrelationship between effect sizes for self-esteem im-provement and weight loss across all intervention andcontrol groups (pfrac14 008)T
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rgro
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ose
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s
386 Murray Dordevic and Bonham
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nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
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Tab
leIIS
elf
-Est
ee
mO
utc
om
es
of
Mu
ltic
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ne
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We
igh
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an
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terv
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Co
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seA
do
lesc
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Auth
or
yea
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terv
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gro
ups
Contr
olgro
ups
nPre
-mea
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D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
nPre
-mea
n(S
D)
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-mea
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mea
n(S
D)
Eff
ect
size
Bre
nnan
etal2012
20
215
(54
)a206
(63
)a
21
1(4
78)a
01
514
188
(47
)a192
(47
)a06
4(3
91)a
00
9C
roker
etal2012
13
26
9(0
57)b
29
5(0
45)b
03
6(0
39)b
05
110
29
0(0
61)b
26
8(0
52)b
00
2(0
59)b
03
9D
ale
yet
al2006
28
24
2(0
56)b
26
1(0
08
SE)b
NA
NA
30
24
9(0
49)b
25
6(0
10
SE)b
NA
NA
Danie
lsen
etal2013
16
28
8(0
52)b
31
7(0
53)b
02
9(0
53)b
05
516
31
1(0
57)b
30
6(0
59)b
00
5(0
37)b
00
9D
eBar
etal2012
105
23
9(0
26)a
24
0(0
25)a
NA
00
4103
24
1(0
27)a
23
9(0
25)a
NA
00
8L
och
rie
etal2013
29
183
(50
2)b
191
(44
8)b
07
3(4
51)b
01
718
199
(34
6)b
199
(34
3)b
00
0(3
11)b
00
0L
ubans
etal2012
54
40
3(1
12)c
40
6(1
32)c
NA
00
268
40
4(0
99)c
42
3(0
98)c
NA
01
9M
ellin
etal1987
37
NA
NA
08
8(1
50)a
NA
29
NA
NA
05
2(1
34)a
NA
Morg
an
etal2012
19
NA
NA
00
8(0
48)d
NA
21
NA
NA
02
6(0
47)d
NA
Neu
mark
-Szt
ain
eret
al2010
85
152
(34
)b151
(29
)bN
A
00
379
141
(34
)b140
(34
)bN
A
00
3
Nguyen
etal2012
(wit
hA
TC
)57
25
8(0
76)b
27
7(0
63)b
01
9(0
67)b
02
7
Nguyen
etal2012
(wit
hout
AT
C)
50
25
9(0
58)b
29
3(0
61)b
01
9(0
51)b
05
7
Sach
eret
al2010
20
NA
32
5(0
68)b
02
5(0
66)b
NA
24
NA
30
4(0
75)b
01
1(0
74)b
NA
Wadden
etal1990
3gro
ups
com
bin
ed47
576
e599
eN
AN
A
Note
D
ata
pre
sente
das
report
edin
ori
gin
alpaper
sSDfrac14
standard
dev
iati
onN
Afrac14
data
not
pro
vid
edu
nab
leto
be
calc
ula
ted
SEfrac14
Sta
ndard
erro
rnot
Sta
ndard
Dev
iati
onE
ffec
tsi
zefrac14
Cohen
rsquosdB
old
font
indic
ate
sw
her
eef
fect
size
was
small
(02
0)
or
gre
ate
raR
ose
nber
gse
lf-e
stee
msc
ale
(gen
erally
score
dfr
om
0[l
ow
est
self
-est
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]to
30
[hig
hes
tse
lf-e
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bH
art
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(gen
erally
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[low
est
self
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ighes
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ars
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Physi
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e
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Pro
file
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ts
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le
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ring
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lehig
her
valu
eeq
uals
hig
her
self
-est
eem
The Impact of Weight Management on Self-Esteem 387
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Tab
leIII
We
igh
tO
utc
om
es
of
Mu
ltic
om
po
ne
nt
We
igh
tM
an
ag
em
en
tIn
terv
en
tio
ns
Co
mp
are
dW
ith
Co
ntr
ols
in
Ov
erw
eig
ht
an
dO
be
seA
do
lesc
en
ts
Auth
or
yea
rIn
terv
enti
on
gro
ups
Contr
olgro
ups
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
Bre
nnan
etal2012
20
20
8(0
37)
19
9(0
46)
02
0(0
18)
02
214
20
8(0
40)
20
9(0
39)
00
1(0
12)
00
3C
roker
etal2012
13
29
5(0
52)
26
6(0
63)
01
7(0
21)
05
010
31
4(0
68)
31
4(0
68)
00
6(0
13)
00
0D
ale
yet
al2006
28
31
7(0
33)
32
3(0
02
SE)
NA
NA
30
33
2(0
37)
32
3(0
02
SE)
NA
NA
Danie
lsen
etal2013
16
25
9(0
30)
24
6(0
41)
01
2(0
17)
03
616
24
9(0
27)
25
3(0
29)
00
5(0
15)
01
4D
eBar
etal2012
105
20
0(0
34)
18
8(0
41)
NA
03
2103
20
0(0
33)
19
4(0
38)
NA
01
7L
och
rie
etal2013
29
21
9(0
40)
20
6(0
52)
01
2(0
20)
02
818
20
7(0
40)
20
5(0
43)
00
2(0
11)
00
5L
ubans
etal2012
54
19
3(0
61)
18
0(0
68)
NA
02
068
18
5(0
59)
18
0(0
67)
NA
00
8M
ellin
etal1987
37
1365
aN
A
59
(67
5)a
NA
29
1295
aN
A
03
(66
1)a
NA
Morg
an
etal2012
19
NA
NA
04
2(0
91)b
NA
21
NA
NA
00
3(0
87)b
NA
Neu
mark
-Szt
ain
eret
al2010
85
321
(61
)b322
(62
)bN
A
00
279
310
(53
)b314
(55
)bN
A
00
7
Nguyen
etal2012
(wit
hA
TC
)57
20
3(0
37)
19
7(0
42)
00
8(0
19)
01
5
Nguyen
etal2012
(wit
hout
AT
C)
50
20
2(0
29)
19
4(0
32)
00
9(0
17)
02
6
Sach
eret
al2010
20
NA
23
7(0
52)
02
2(0
27)
NA
24
NA
26
0(0
54)
00
1(0
20)
NA
Wadden
etal1990
3gro
ups
com
bin
ed47
352
b339
bN
AN
A
Note
D
ata
pre
sente
das
report
edin
ori
gin
al
paper
sA
llw
eight
outc
om
esre
port
edas
body
mass
index
(BM
I)z-
score
unle
ssoth
erw
ise
state
d
SDfrac14
standar
ddev
iati
on
NAfrac14
data
not
pro
vid
ed
unab
leto
be
calc
ula
ted
SEfrac14
Sta
ndard
Err
or
report
edra
ther
than
Sta
ndard
Dev
iati
onE
ffec
tsi
zefrac14
Cohen
rsquosdB
old
font
indic
ate
sw
her
eef
fect
size
was
smal
l(0
20)
or
gre
ate
raR
elati
ve
wei
ght
bB
MI
388 Murray Dordevic and Bonham
Dow
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icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Quantitative Data AnalysisDifferences between intervention and control groupsfor change in self-esteem are presented in Figure 2aThis analysis included seven intervention groups(nfrac14 191) and seven control groups (nfrac14 132) with
interventions or intensive treatment phases rangingfrom 9 weeks to 6 months in duration A moderatelevel of the variation across studies was owing to het-erogeneity (I2frac14464 Higgins Thompson Deeksamp Altman 2003) The overall summary effect showed
Figure 2 Comparison between intervention and control groups for the change in adolescent self-esteem effect size (a) andbody mass index z-score (b) following multicomponent weight management interventions SMD frac14 standard mean differ-ence WMD frac14 weighted mean difference
The Impact of Weight Management on Self-Esteem 389
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no effect on self-esteem as a result of interventionSMD of 027 (95 confidence interval 004 059)zfrac14 169 and pfrac14 092 However all studies exceptone favored the intervention for improvements in self-esteem
The difference between intervention and controlgroups for change in BMI z-score is illustrated inFigure 2b This analysis included five interventiongroups (nfrac14 135) and five control groups (nfrac14 82) withinterventions ranging from 9 weeks to 6 months induration Heterogeneity in this sample was low(I2frac14177 Higgins et al 2003) and the overall sum-mary effect was 017 (022 011) BMI z-scorepoints (zfrac14613 and plt 001) indicating statisticallysignificant weight loss following MWMI
Discussion
The purpose of this review was to examine the effectof MWMIs on self-esteem in overweight and obeseadolescents Increased self-esteem is proposed as a keyfactor for maintaining long-term weight management(Elfhag amp Rossner 2005 French et al 1995Roberts 2006) A secondary outcome of this reviewwas to examine the impact of MWMIs on weight lossand whether this was associated with improvements inself-esteem
The meta-analysis showed no difference in self-esteem between the intervention and control groupsHowever six of the seven studies in the meta-analysisfavored the intervention over control for improve-ments in self-esteem and four of the six studies notincluded in the meta-analysis found significant im-provements in self-esteem following intervention Thelatter of these findings are similar to those of an earlierreview (Lowry et al 2007) that showed improve-ments in self-esteem following weight managementinterventions in a pediatric population particularlywhen certain intervention features were presentSimilarly a number of intervention features that con-tributed to an increased likelihood of improving self-esteem were identified in this review
Improvements in self-esteem regardless of weightloss have been demonstrated in children who tookpart in weight management interventions thatincluded a focus on building self-esteem and it is rec-ommended that this be a focus of all pediatric weightmanagement interventions (Lowry et al 2007) Yetthe majority of studies identified in this review did notinclude building self-esteem as a key aspect of theirintervention Nguyen Shrewsbury et al (2012)described the greatest focus on self-esteem (one75-min group session focused on building self-esteem)and also resulted in the largest treatment effect (057)and a significant improvement in self-esteem (NguyenShrewsbury et al 2012) A focus on similar topics
such as body image social support and managing bul-lying may also contribute to improvements in self-esteem (Croker et al 2012 Pierce amp Wardle 1997Tiggemann 2005) however these findings highlightthe lack of uptake of these recommendations
Among overweight and obese youth reductions inself-esteem are often observed in domains of physicalappearance and physical ability (Franklin DenyerSteinbeck Caterson amp Hill 2006 French et al1995 Latzer amp Stein 2013 Lowry et al 2007)Particularly for adolescent girls body image is a keyconcern (Cave Fildes Luckett amp Wearring 2015)and comprises a large portion of global self-esteem(Lowry et al 2007 Pesa Syre amp Jones 2000)However weight loss and associated changes in phys-ical appearance do not necessarily reflect improve-ments in self-esteem (Lowry et al 2007) Changes inbody-esteem often occur more rapidly than changes inglobal self-esteem as a result of weight management(Lowry et al 2007) This may explain the lack ofchange observed in global self-esteem in this meta-analysis and highlights the need to also include body-esteem (or physical self-esteem) as a focus and out-come of weight management interventions foradolescents
Parental involvement in adolescent weight manage-ment interventions is a critical component for success-ful weight loss and may also be important forimproving self-esteem (Lowry et al 2007) Weight-related teasing from family is shown to be negativelyassociated with self-esteem in overweight adolescentswhereas family connectedness was positively associ-ated with adolescent self-esteem (Fulkerson StraussNeumark-Sztainer Story amp Boutelle 2007) The in-clusion of parents in weight management interventionsfosters a safer and more encouraging home environ-ment for the adolescent (Lowry et al 2007) which isassociated with increased self-esteem in nonover-weight children (Marx amp Neumark-Sztainer 2005)All studies in the present review baring one includedparents in the intervention Parental involvementshould continue to be a key component of weightmanagement interventions to ensure a supportivehome environment for the adolescent to help fosterpositive self-esteem
Weight management interventions that used agroup setting to target self-esteem have shown im-provements in self-esteem without significant weightchange (Lowry et al 2007 Sherman AlexanderGomez Kim amp Marole 1992) The ability of the peergroup setting to provide opportunities for bondingsupport feelings of belonging development of peer-based skills and positive peer exchanges is key toincreasing self-esteem (Lowry et al 2007) The im-portance of this element is being acknowledged in the
390 Murray Dordevic and Bonham
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field with all the studies in this review baring twousing group sessions in their intervention
Measures of self-esteem are self-reported and there-fore subjective Responses to questionnaires are likelyto be influenced by individual (eg age gender) andenvironmental (eg cultural group socioeconomicstatus) factors (Khanlou 2004) Changes followinginterventions may represent genuine long-termchanges in self-esteem or may be due to short-termfluctuations in self-esteem in response to specificevents (eg winning a sporting event or performanceon a test at school) (Kernis 1993) While validatedtools were used to measure self-esteem in all studies itwas difficult to conclude whether outcomes were en-tirely dependent on the intervention without inclusionof a no-treatment control group
The variety of self-esteem assessment tools also addsto the difficulty of interpretation Across the 13 studies inthis review five different tools were used with differentquestions and different scales Even within tools therewere different scales used to report the results (RosenbergSelf-esteem Scale) and different versions of the same ques-tionnaire (Harterrsquos Self-perception Profile for ChildrenHarterrsquos Self-perception Profile for Adolescents) HarterrsquosSelf-Perception Profile (Harterrsquos Self-perception Profilefor Adolescents for adolescents) which measures ninesubscales of self-esteem including physical self-esteem issuggested as the most appropriate measure for adolescentself-esteem (Lowry et al 2007) It was also the mostcommonly used tool among papers included in this re-view While Cohenrsquos d effect sizes were used to stand-ardize results in this review the consistent use of one toolwould provide the ability to compare raw self-esteemscores and create a stronger analysis in the future
Results from this review support evidence thatMWMIs induce weight loss in overweight and obeseadolescents (Hoelscher Kirk Ritchie ampCunningham-Sabo 2013 Kelly amp Melnyk 2008Luttikhuis et al 2009) The change in BMI z-score inthe present meta-analysis (017 [022 011]) wassimilar to the clinically meaningful weight loss re-ported in the 2009 Cochrane Review in children 12years at 6 months follow up from a lifestyle weightmanagement intervention (014 [017 012])(Luttikhuis et al 2009) Jelalian Mehlenbeck Lloyd-Richardson Birmaher and Wing (2006) and WalkerGately Bewick and Hill (2003) have demonstratedassociations between weight loss and increased self-esteem in overweight and obese adolescents after at-tending a weight-management intervention Similarlyin the present review a strong positive relationship be-tween treatment effects for weight loss and improve-ment in self-esteem was identified However itremains unclear whether the improvement in self-esteem was as a result of successful weight loss orwhether it was a contributing factor toward successful
weight loss Nonetheless building self-esteem shouldbe a key focus of MWMIs as improved self-esteem ap-
pears to be linked to enhanced weight lossA key strength of this review was that all included
studies had strong designs and presented level II evi-dence (Coleman et al 2009) However to further elu-
cidate the role of self-esteem in adolescent weightmanagement future research should consider power-
ing studies to detect changes in psychosocial as well asphysiological outcomes Only one study in this reviewwas powered to detect a change in psychosocial out-
comes (Daley et al 2006) which may explain thelack of significant results observed for self-esteem
Additionally a large number of included studies didnot describe their method of handling withdrawals or
use blinding to prevent the introduction of bias Toimprove confidence in the effectiveness of MWMIs
and reduce the risk of bias future studies should bedesigned with concealed allocation and document andreport in detail the flow of participants
Identification of intervention components that im-
prove self-esteem is important for future weight man-agement intervention design Included interventionswere heterogeneous offering different levels of diet-
ary physical activity and behavioral interventionwhich may have collectively or individually influenced
the results Inconsistent reporting of intervention andcomparator conditions make it difficult to elucidate
the components that contributed to improvements inself-esteem Future studies should report intervention
and comparator procedures in adequate detail so thatsuccessful components can be identified and repli-cated These limitations highlight areas for improve-
ment to develop best-practice guidelines forundertaking and evaluating MWMIs in adolescents to
enhance self-esteem
Conclusion
Overweight and obese adolescents experience low
self-esteem largely owing to poor body image yetthis meta-analysis found no improvement in self-esteem even with significant weight loss Although it
was noted that interventions that had larger effects onself-esteem also had larger effects on weight loss The
incorporation of intervention components that wereidentified to contribute to improvements in self-
esteem may assist future weight management interven-tions to improve the self-esteem of overweight and
obese adolescents Furthermore a consistent measureof self-esteem would enable easier interpretation ofself-esteem scores and comparison of results across
studies to improve our understanding of the relation-ship between self-esteem and weight management in
adolescents
The Impact of Weight Management on Self-Esteem 391
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Supplementary Data
Supplementary data can be found at httpwwwjpepsy
oxfordjournalsorg
Acknowledgments
The authors would like to acknowledge Dr Zoe Davidson
for her assistance in performing the meta-analyses
Funding
This work was supported by an Australian GovernmentResearch Training Program Scholarship
Conflicts of interest none declared
References
Academy of Nutrition and Dietetics (2012) Evidence ana-lysis manual Steps in the academy evidence analysis pro-cess Chicago IL ADA Research and Strategic Business
DevelopmentBrennan L Walkley J Fraser S F Greenway K amp
Wilks R (2008) Motivational interviewing and cognitivebehaviour therapy in the treatment of adolescent over-
weight and obesity Study design and methodologyContemporary Clinical Trials 29 359ndash375
Brennan L Walkley J Wilks R Fraser S F amp
Greenway K (2013) Physiological and behavioural out-comes of a randomised controlled trial of a cognitive be-havioural lifestyle intervention for overweight and obese
adolescents Obesity Research and Clinical Practice 7e23ndashe41
Brennan L Wilks R Walkley J Fraser S F amp
Greenway K (2012) Treatment acceptability and psycho-social outcomes of a randomised controlled trial of a cog-nitive behavioural lifestyle intervention for overweight and
obese adolescents Behaviour Change 29 36ndash62Cave L Fildes J Luckett G amp Wearring A (2015)
Mission Australiarsquos 2015 youth survey report MissionAustralia
Coleman K Norris S Weston A Grimmer-Somers KHillier S Merlin T Salisbury J (2009) NHMRCadditional levels of evidence and grades for recommenda-tions for developers of guidelines (Vol Stage 2Consultation) Australia National Health and Medical
Research CouncilCroker H Viner R M Nicholls D Haroun D
Chadwick P Edwards C Wardle J (2012) Family-based behavioural treatment of childhood obesity in a UK
national health service setting Randomized controlledtrial International Journal of Obesity 36 16ndash26 doi
101038ijo2011182Daley A J Copeland R J Wright N P Roalfe A amp
Wales J K H (2006) Exercise therapy as a treatment forpsychopathologic conditions in obese and morbidly obese
adolescents A randomized controlled trial Pediatrics118 2126ndash2134
Danielsen Y S Nordhus I H Julıusson P B Maelighle Mamp Pallesen S (2013) Effect of a family-based cognitive
behavioural intervention on body mass index self-esteem
and symptoms of depression in children with obesity (aged
7mdash13) A randomised waiting list controlled trial ObesityResearch amp Clinical Practice 7 e116ndashe128
DeBar L L Stevens V J Perrin N Wu P Pearson J ampJo B (2012) A primary care-based multicomponent life-
style intervention for overweight adolescent femalesPediatrics 129 e611ndashe620
Elfhag K amp Rossner S (2005) Who succeeds in maintain-ing weight loss A conceptual review of factors associated
with weight loss maintenance and weight regain ObesityReviews 6 67ndash85
Franklin J Denyer G Steinbeck K S Caterson I D ampHill A J (2006) Obesity and risk of low self-esteem Astatewide survey of Australian children Pediatrics 118
2481ndash2487French S A Story M amp Perry C L (1995) Self-esteem
and obesity in children and adolescents A literature re-view Obesity Research 3 479ndash490
Fulkerson J Strauss J Neumark-Sztainer D Story M
amp Boutelle K (2007) Correlates of psychosocial well-being among overweight adolescents The role of the fam-ily Journal of Consulting and Clinical Psychology 75
181ndash186Griffiths L J Parsons T J amp Hill A J (2010) Self-es-
teem and quality of life in obese children and adolescentsA systematic review International Journal of PediatricObesity 5 282ndash304
Harter S (1993) Causes and consequences of low self-
esteem in children and adolescents In R F Baumeister(Ed) Self-esteemmdashThe puzzle of low self-regard (pp87ndash116) USA Springer
Higgins J Thompson S Deeks J amp Altman D (2003)
Measuring inconsistency in meta-analyses BMJ 327557ndash560
Hoelscher D M Kirk S Ritchie L amp Cunningham-Sabo L (2013) Position of the Academy of Nutrition and
Dietetics Interventions for the prevention and treatmentof pediatric overweight and obesity Journal of theAcademy of Nutrition and Dietetics 113 1375ndash1394
Jelalian E Mehlenbeck R Lloyd-Richardson EBirmaher V amp Wing R (2006) lsquoAdventure therapyrsquo
combined with cognitivebehavioral treatment for over-weight adolescents International Journal of Obesity 3031ndash39
Kelly S A amp Melnyk B M (2008) Systematic review of
multicomponent interventions with overweight middleadolescents implications for clinical practice and researchWorldviews on Evidence-Based Nursing 5 113ndash135
Kernis M (1993) The roles of stability and level of self-
esteem in psychological functioning In R Baumeister(Ed) Self-esteem (pp 167ndash182) USA Springer
Khanlou N (2004) Influences on adolescent self-esteem inmulticultural Canadian secondary schools Public HealthNursing 21 404ndash411
Kohn M Rees J M Brill S Fonseca H Jacobson M
Katzman D K Schneider M (2006) Preventing andtreating adolescent obesity A position paper of the Societyfor Adolescent Medicine Journal of Adolescent Health
38 784ndash787Kornman K P Shrewsbury V A Chou A C Ngyuen
B Lee A Orsquoconnor J Baur L A (2010) Electronic
392 Murray Dordevic and Bonham
Dow
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icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
therapeutic contact for adolescent weight management
The Loozit study Telemedicine and E-Health 16
678ndash685Latzer Y amp Stein D (2013) A review of the psychological
and familial perspectives of childhood obesity Journal of
Eating Disorders 1 7Lobstein T Baur L amp Uauy R (2004) Obesity in chil-
dren and young people a crisis in public health Obesity
Reviews 5(Suppl 1) 4ndash104Lochrie A S Wysocki T Hossain J Milkes A Antal
H Buckloh L Lang J (2013) The effects of a family-
based intervention (FBI) for overweightobese children on
health and psychological functioning Clinical Practice in
Pediatric Psychology 1 159ndash170 doi httpdxdoiorg
101037cpp0000020Lowry K W Sallinen B amp Janicke D (2007) The effects
of weight management programs on self-esteem in pediat-
ric overweight populations Journal of Pediatric
Psychology 32 1179ndash1195Lubans D R Morgan P J Okely A D Dewar D
Collins C E Batterham M Plotnikoff R C (2012)
Preventing obesity among adolescent girls One-year out-
comes of the nutrition and enjoyable activity for teen girls
(NEAT Girls) cluster randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
821ndash827Luttikhuis H Baur L Jansen H Shrewsbury V
Orsquomalley C Stolk R amp Summerbell C (2009)
Interventions for treating obesity in children (Review)
Cochrane Database of Systematic Reviews 3 1ndash57Marx R D amp Neumark-Sztainer D (2005) Questions amp
Answers Eating Disorders The Journal of Treatment amp
Prevention 13 491ndash495McClure A C Tanksi S E Kingsbury J Gerrard M amp
Sargent J D (2010) Characteristics associated with low
self-esteem among US adolescents Academic Pediatrics
10 238ndash244Mellin L M Slinkard L A amp Irwin C E (1987)
Adolescent obesity intervention Validation of the
SHAPEDOWN program Journal of the American Dietetic
Association 87 333ndash338Mission Australia (2012) Youth Survey 2012 SydneyMoher D Shamseer L Clarke M Ghersi D Liberati
A Petticrew M PRISMA-P Group (2015) Preferred
reporting items for systematic review and meta-analysis
protocols (PRISMA-P) 2015 statement Systematic
Reviews 4 1Morgan P Saunders K amp Lubans D (2012) Improving
physical self-perception in adolescent boys from disadvan-
taged schools Psychological outcomes from the Physical
Activity Leaders randomized controlled trial Pediatric
Obesity 7 e27ndashe32 doi httpdxdoiorg101111j
2047-6310201200050xNational Health and Medical Reasearch Council (2013)
Clinical practice guidelines for the management of over-
weight and obesity in adults adolescents and children in
Australia Australia NHMRC Australian Government
Department of HealthNational Institutes for Health and Care Excellence (2013)
Managing overweight and obesity among children and
young people lifestyle weight management services NICE
public health guidance United Kingdom 47 NICENeumark-Sztainer D R Friend S E Flattum C F
Hannan P J Story M T Bauer K W Petrich C A
(2010) New moves-preventing weight-related problems in
adolescent girls A group-randomized study American
Journal of Preventive Medicine 39 421ndash432Nguyen B McGregor K A Orsquoconnor J Shrewsbury V
A Lee A Steinbeck K S Baur L A (2012)
Recruitment challenges and recommendations for adoles-
cent obesity trials Journal of Paediatrics and Child
Health 48 38ndash43Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Hill A J Shah S Baur L A (2013) Two-year
outcomes of an adjunctive telephone coaching and elec-
tronic contact intervention for adolescent weight-loss
maintenance the Loozit randomized controlled trial
International Journal of Obesity 37 468ndash472Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2012) Twelve-month
outcomes of the Loozit randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
170ndash177Ogden C L Carroll M D Kit B K amp Flegal K M
(2014) Prevalence of childhood and adult obesity in the
United States 2011-2012 Journal of the American
Medical Association 311 806ndash814Pesa J A Syre T R amp Jones E (2000) Psychosocial dif-
ferences associated with body weight among female ado-
lescents The importance of body image Journal of
Adolescent Health 26 330ndash337Pierce J W amp Wardle J (1997) Cause and effect beliefs
and self-esteem of overweight children Journal of Child
Psychology and Psychiatry 38 645ndash650 doi 101111
j1469-76101997tb01691xRoberts J E (2006) Self-esteem from a clinical perspective
In M H Kernis (Ed) Self-esteem issues and answers A
sourcebook of current perspectives Psychology Press
Taylor amp Francis New York and Hove (pp 298ndash305)
Psychology PressSacher P M Kolotourou M Chadwick P M Cole T J
Lawson M S Lucas A amp Singhal A (2010)
Randomized controlled trial of the MEND program A
family-based community intervention for childhood obes-
ity Obesity 18(Suppl 1) S62ndashS68 doi httpdxdoiorg
101038oby2009433Sanders R H Han A Baker J S amp Cobley S (2015)
Childhood obesity and its physical and psychological co-
morbidities a systematic review of Australian children and
adolescents Eur J Pediatr 174 715ndash746Sherman J B Alexander M A Gomez D Kim M amp
Marole P (1992) Intervention program for obese school chil-
dren Journal of Community Health Nursing 9 183ndash190Shrewsbury V A Nguyen B Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2011) Short-term
outcomes of community-based adolescent weight manage-
ment The LoozitVR
Study BMC Pediatrics 11 13Shrewsbury V A Orsquoconnor J Steinbeck K S Stevenson
K Lee A Hill A J Baur L A (2009) A randomised
controlled trial of a community-based healthy lifestyle
The Impact of Weight Management on Self-Esteem 393
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
program for overweight and obese adolescents TheLoozitV
R
study protocol BMC Public Health 9 119Strauss R S (2000) Childhood obesity and self-esteem
Pediatrics 105 5Tiggemann M (2005) Body dissatisfaction and adolescent
self-esteem Prospective findings Body Image 2 129ndash135doi httpdxdoiorg101016jbodyim200503006
Wadden T A Stunkard A J Rich L Rubin C JSweidel G amp McKinney S (1990) Obesity in black ado-lescent girls A controlled clinical trial of treatment by diet
behaviour modification and parental support Pediatrics85 345ndash352
Walker L Gately P Bewick B amp Hill A (2003)Childrenrsquos weight-loss camps psychological benefit orjeopardy International Journal of Obesity 27 748ndash754
World Health Organization (2014) Maternal newbornchild and adolescent health Adolescent developmentRetrieved from httpwwwwhointmaternal_child_adolescenttopicsadolescencedeven Retrieved 28 May2014
394 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
- jsw101-TF1
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- jsw101-TF9
- jsw101-TF10
- jsw101-TF11
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)B
MI
Nguyen
etal
2013A
ust
ralia
35
Posi
tive
55
(36
)m
ale
sand
96
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)fe
-m
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yea
rsover
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ght
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oder
ate
lyobes
eB
MI
z-sc
ore
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ndash25
(BM
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per
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IIn
terv
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don
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ryto
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lf-e
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vati
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and
self
-re
gula
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sions
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mIn
terv
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ived
Addit
ional
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apeu
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ct(A
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)fo
rtnig
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out
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tenance
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ions
incl
uded
C
A
sabove
wit
hout
the
AT
C
Buildin
gposi
tive
self
-est
eem
was
the
focu
sof
ase
ssio
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Phase
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seven
wee
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Phase
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2to
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ingro
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dappro
xev
ery
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onth
sA
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Fort
nig
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phone
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ing
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ions
and
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Se
mes
sages
Hart
errsquos
Sel
fPer
cepti
on
Pro
file
for
Adole
scen
ts(s
elf-
este
em)
BM
Iz-
score
Sach
eret
al2010
Unit
edK
ingdom
31
Posi
tive
21
(48
)m
ale
sand
23
(52
)fe
-m
ale
s10ndash12
yea
rsB
MI
gt98th
per
centi
le
IPart
icip
ants
and
thei
rfa
milie
sat-
tended
gro
up
sess
ions
focu
sing
on
be-
havio
rch
ange
nutr
itio
nand
physi
calact
ivit
ySes
sion
conte
nt
focu
sed
on
buildin
gsk
ills
tom
ain
tain
long-t
erm
beh
avio
rch
anges
Follow
ing
trea
tmen
tfa
milie
sw
ere
giv
ena
12-w
eek
free
fam
ily
swim
pass
C
W
ait
-lis
t
No
spec
ific
men
-ti
on
of
self
-es
teem
Eig
hte
en2-h
rse
ssio
ns
over
9w
eeks
Follow
up
12
month
sfr
om
base
line
Hart
errsquos
Sel
f-Per
cepti
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Pro
file
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Childre
n(s
elf-
este
em)
BM
Iz-
score
The Impact of Weight Management on Self-Esteem 385
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self-esteem was observed following four MWMIsacross three studies (Croker et al 2012 Danielsenet al 2013 Nguyen Shrewsbury et al 2012) Fivestudies showed no effect on adolescent self-esteem fol-lowing MWMI (Brennan et al 2012 DeBar et al2012 Lochrie et al 2013 Lubans et al 2012Neumark-Sztainer et al 2010) No positive effects onself-esteem were observed in any of the controlgroups One wait-listed control group (Croker et al2012) showed a small negative effect on self-esteem
Mixed results were also observed in the studies forwhich an effect size could not be calculatedImprovements in adolescent self-esteem were observedfollowing MWMIs by Daley et al (2006) Mellin et al(1987) Sacher et al (2010) and Wadden et al(1990) However only Daley et al (2006) reportedthat this change was different to that observed in thecontrol group No changes in self-esteem were de-tected following intervention by Morgan et al (2012)although a significant decline in self-esteem wasobserved in the wait-listed control group who receivedthe normal school curriculum throughout the studyperiod
Multicomponent Weight ManagementInterventions Improve Weight Outcomes inAdolescentsOf the 13 included studies there were 14 groups whoreceived a MWMI and 11 no-treatment controlgroups Of these effect sizes were able to be calculatedfor nine intervention groups and seven control groups(Table III) Seven intervention groups had small to me-dium positive effects indicating successful weight loss(Brennan et al 2012 Croker et al 2012 Danielsenet al 2013 DeBar et al 2012 Lochrie et al 2013Lubans et al 2012 Nguyen Shrewsbury et al2012) and two intervention groups had no effect(Neumark-Sztainer et al 2010 Nguyen Shrewsburyet al 2012) All seven control groups showed no ef-fect on weight
Of the studies for which effect size could not be cal-culated the results were similar Mellin et al (1987)Morgan et al (2012) Sacher et al (2010) andWadden et al (1990) all observed significant weightloss following intervention Morgan et al (2012) andSacher et al (2010) also showed that these changeswere significantly different to changes observed in thecontrol groups No studies observed significant weightchange in the control groups
Correlation Between Self-Esteem Improvementand Weight Loss Effect SizesThere is a strong (rfrac14 641 R2frac140410) positive linearrelationship between effect sizes for self-esteem im-provement and weight loss across all intervention andcontrol groups (pfrac14 008)T
ab
leI
(co
nti
nu
ed
)
Stu
dy
(auth
or
yea
rlo
cati
on)
Quali
tyra
ting
Part
icip
ants
Inte
rven
tions
Focu
son
self
-est
eem
Dura
tion
Outc
om
em
easu
res
Wadden
etal
1990U
nit
edSta
tes3
6
Posi
tive
47
(100
)fe
male
s12ndash16
yea
rsat
least
10-k
gover
wei
ght
IIn
terv
enti
on
cover
eddie
tand
eati
ng
patt
erns
modif
yin
gse
lf-d
efea
ting
thoughts
and
incr
easi
ng
physi
calac-
tivit
yH
om
ework
ass
ignm
ents
and
ince
nti
ves
aw
ard
sw
ere
use
dto
en-
coura
ge
part
icip
ati
onT
her
ew
ere
thre
edif
fere
nt
inte
rven
tion
gro
ups
who
rece
ived
this
trea
tmen
tch
ild
only
ch
ild
and
moth
erto
get
her
ch
ild
and
moth
erse
para
tely
C
N
ocl
ear
contr
olgro
upse
eabove
No
spec
ific
men
-ti
on
of
self
-es
teem
Six
teen
wee
kly
1-h
rle
ssons
No
follow
up
Pie
rs-H
arr
issc
ale
(sel
f-es
teem
)B
MI
Note
B
MIfrac14
body
mass
index
Ifrac14
inte
rven
tionCfrac14
Com
par
ato
rC
om
par
ato
rgro
ups
that
rece
ived
an
inte
rven
tion
wer
etr
eate
das
inte
rven
tion
gro
ups
for
the
purp
ose
of
anal
ysi
sin
this
revie
w
Stu
die
sare
list
edin
alp
habet
icalord
erin
all
table
s
386 Murray Dordevic and Bonham
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Tab
leIIS
elf
-Est
ee
mO
utc
om
es
of
Mu
ltic
om
po
ne
nt
We
igh
tM
an
ag
em
en
tIn
terv
en
tio
ns
Co
mp
are
dW
ith
Co
ntr
ols
in
Ov
erw
eig
ht
an
dO
be
seA
do
lesc
en
ts
Auth
or
yea
rIn
terv
enti
on
gro
ups
Contr
olgro
ups
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
Bre
nnan
etal2012
20
215
(54
)a206
(63
)a
21
1(4
78)a
01
514
188
(47
)a192
(47
)a06
4(3
91)a
00
9C
roker
etal2012
13
26
9(0
57)b
29
5(0
45)b
03
6(0
39)b
05
110
29
0(0
61)b
26
8(0
52)b
00
2(0
59)b
03
9D
ale
yet
al2006
28
24
2(0
56)b
26
1(0
08
SE)b
NA
NA
30
24
9(0
49)b
25
6(0
10
SE)b
NA
NA
Danie
lsen
etal2013
16
28
8(0
52)b
31
7(0
53)b
02
9(0
53)b
05
516
31
1(0
57)b
30
6(0
59)b
00
5(0
37)b
00
9D
eBar
etal2012
105
23
9(0
26)a
24
0(0
25)a
NA
00
4103
24
1(0
27)a
23
9(0
25)a
NA
00
8L
och
rie
etal2013
29
183
(50
2)b
191
(44
8)b
07
3(4
51)b
01
718
199
(34
6)b
199
(34
3)b
00
0(3
11)b
00
0L
ubans
etal2012
54
40
3(1
12)c
40
6(1
32)c
NA
00
268
40
4(0
99)c
42
3(0
98)c
NA
01
9M
ellin
etal1987
37
NA
NA
08
8(1
50)a
NA
29
NA
NA
05
2(1
34)a
NA
Morg
an
etal2012
19
NA
NA
00
8(0
48)d
NA
21
NA
NA
02
6(0
47)d
NA
Neu
mark
-Szt
ain
eret
al2010
85
152
(34
)b151
(29
)bN
A
00
379
141
(34
)b140
(34
)bN
A
00
3
Nguyen
etal2012
(wit
hA
TC
)57
25
8(0
76)b
27
7(0
63)b
01
9(0
67)b
02
7
Nguyen
etal2012
(wit
hout
AT
C)
50
25
9(0
58)b
29
3(0
61)b
01
9(0
51)b
05
7
Sach
eret
al2010
20
NA
32
5(0
68)b
02
5(0
66)b
NA
24
NA
30
4(0
75)b
01
1(0
74)b
NA
Wadden
etal1990
3gro
ups
com
bin
ed47
576
e599
eN
AN
A
Note
D
ata
pre
sente
das
report
edin
ori
gin
alpaper
sSDfrac14
standard
dev
iati
onN
Afrac14
data
not
pro
vid
edu
nab
leto
be
calc
ula
ted
SEfrac14
Sta
ndard
erro
rnot
Sta
ndard
Dev
iati
onE
ffec
tsi
zefrac14
Cohen
rsquosdB
old
font
indic
ate
sw
her
eef
fect
size
was
small
(02
0)
or
gre
ate
raR
ose
nber
gse
lf-e
stee
msc
ale
(gen
erally
score
dfr
om
0[l
ow
est
self
-est
eem
]to
30
[hig
hes
tse
lf-e
stee
m])
bH
art
errsquos
SPPA
SPPC
(gen
erally
score
d1
[low
est
self
-est
eem
]to
4[h
ighes
tse
lf-e
stee
m])
cM
ars
hrsquos
Physi
calSel
f-D
escr
ipti
on
Ques
tionnair
e
dPhysi
calSel
f-Per
cepti
on
Pro
file
for
Adole
scen
ts
ePie
rs-H
arr
isSel
f-C
once
pt
Sca
le
Sco
ring
range
sunav
ailab
lehig
her
valu
eeq
uals
hig
her
self
-est
eem
The Impact of Weight Management on Self-Esteem 387
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Tab
leIII
We
igh
tO
utc
om
es
of
Mu
ltic
om
po
ne
nt
We
igh
tM
an
ag
em
en
tIn
terv
en
tio
ns
Co
mp
are
dW
ith
Co
ntr
ols
in
Ov
erw
eig
ht
an
dO
be
seA
do
lesc
en
ts
Auth
or
yea
rIn
terv
enti
on
gro
ups
Contr
olgro
ups
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
Bre
nnan
etal2012
20
20
8(0
37)
19
9(0
46)
02
0(0
18)
02
214
20
8(0
40)
20
9(0
39)
00
1(0
12)
00
3C
roker
etal2012
13
29
5(0
52)
26
6(0
63)
01
7(0
21)
05
010
31
4(0
68)
31
4(0
68)
00
6(0
13)
00
0D
ale
yet
al2006
28
31
7(0
33)
32
3(0
02
SE)
NA
NA
30
33
2(0
37)
32
3(0
02
SE)
NA
NA
Danie
lsen
etal2013
16
25
9(0
30)
24
6(0
41)
01
2(0
17)
03
616
24
9(0
27)
25
3(0
29)
00
5(0
15)
01
4D
eBar
etal2012
105
20
0(0
34)
18
8(0
41)
NA
03
2103
20
0(0
33)
19
4(0
38)
NA
01
7L
och
rie
etal2013
29
21
9(0
40)
20
6(0
52)
01
2(0
20)
02
818
20
7(0
40)
20
5(0
43)
00
2(0
11)
00
5L
ubans
etal2012
54
19
3(0
61)
18
0(0
68)
NA
02
068
18
5(0
59)
18
0(0
67)
NA
00
8M
ellin
etal1987
37
1365
aN
A
59
(67
5)a
NA
29
1295
aN
A
03
(66
1)a
NA
Morg
an
etal2012
19
NA
NA
04
2(0
91)b
NA
21
NA
NA
00
3(0
87)b
NA
Neu
mark
-Szt
ain
eret
al2010
85
321
(61
)b322
(62
)bN
A
00
279
310
(53
)b314
(55
)bN
A
00
7
Nguyen
etal2012
(wit
hA
TC
)57
20
3(0
37)
19
7(0
42)
00
8(0
19)
01
5
Nguyen
etal2012
(wit
hout
AT
C)
50
20
2(0
29)
19
4(0
32)
00
9(0
17)
02
6
Sach
eret
al2010
20
NA
23
7(0
52)
02
2(0
27)
NA
24
NA
26
0(0
54)
00
1(0
20)
NA
Wadden
etal1990
3gro
ups
com
bin
ed47
352
b339
bN
AN
A
Note
D
ata
pre
sente
das
report
edin
ori
gin
al
paper
sA
llw
eight
outc
om
esre
port
edas
body
mass
index
(BM
I)z-
score
unle
ssoth
erw
ise
state
d
SDfrac14
standar
ddev
iati
on
NAfrac14
data
not
pro
vid
ed
unab
leto
be
calc
ula
ted
SEfrac14
Sta
ndard
Err
or
report
edra
ther
than
Sta
ndard
Dev
iati
onE
ffec
tsi
zefrac14
Cohen
rsquosdB
old
font
indic
ate
sw
her
eef
fect
size
was
smal
l(0
20)
or
gre
ate
raR
elati
ve
wei
ght
bB
MI
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Quantitative Data AnalysisDifferences between intervention and control groupsfor change in self-esteem are presented in Figure 2aThis analysis included seven intervention groups(nfrac14 191) and seven control groups (nfrac14 132) with
interventions or intensive treatment phases rangingfrom 9 weeks to 6 months in duration A moderatelevel of the variation across studies was owing to het-erogeneity (I2frac14464 Higgins Thompson Deeksamp Altman 2003) The overall summary effect showed
Figure 2 Comparison between intervention and control groups for the change in adolescent self-esteem effect size (a) andbody mass index z-score (b) following multicomponent weight management interventions SMD frac14 standard mean differ-ence WMD frac14 weighted mean difference
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no effect on self-esteem as a result of interventionSMD of 027 (95 confidence interval 004 059)zfrac14 169 and pfrac14 092 However all studies exceptone favored the intervention for improvements in self-esteem
The difference between intervention and controlgroups for change in BMI z-score is illustrated inFigure 2b This analysis included five interventiongroups (nfrac14 135) and five control groups (nfrac14 82) withinterventions ranging from 9 weeks to 6 months induration Heterogeneity in this sample was low(I2frac14177 Higgins et al 2003) and the overall sum-mary effect was 017 (022 011) BMI z-scorepoints (zfrac14613 and plt 001) indicating statisticallysignificant weight loss following MWMI
Discussion
The purpose of this review was to examine the effectof MWMIs on self-esteem in overweight and obeseadolescents Increased self-esteem is proposed as a keyfactor for maintaining long-term weight management(Elfhag amp Rossner 2005 French et al 1995Roberts 2006) A secondary outcome of this reviewwas to examine the impact of MWMIs on weight lossand whether this was associated with improvements inself-esteem
The meta-analysis showed no difference in self-esteem between the intervention and control groupsHowever six of the seven studies in the meta-analysisfavored the intervention over control for improve-ments in self-esteem and four of the six studies notincluded in the meta-analysis found significant im-provements in self-esteem following intervention Thelatter of these findings are similar to those of an earlierreview (Lowry et al 2007) that showed improve-ments in self-esteem following weight managementinterventions in a pediatric population particularlywhen certain intervention features were presentSimilarly a number of intervention features that con-tributed to an increased likelihood of improving self-esteem were identified in this review
Improvements in self-esteem regardless of weightloss have been demonstrated in children who tookpart in weight management interventions thatincluded a focus on building self-esteem and it is rec-ommended that this be a focus of all pediatric weightmanagement interventions (Lowry et al 2007) Yetthe majority of studies identified in this review did notinclude building self-esteem as a key aspect of theirintervention Nguyen Shrewsbury et al (2012)described the greatest focus on self-esteem (one75-min group session focused on building self-esteem)and also resulted in the largest treatment effect (057)and a significant improvement in self-esteem (NguyenShrewsbury et al 2012) A focus on similar topics
such as body image social support and managing bul-lying may also contribute to improvements in self-esteem (Croker et al 2012 Pierce amp Wardle 1997Tiggemann 2005) however these findings highlightthe lack of uptake of these recommendations
Among overweight and obese youth reductions inself-esteem are often observed in domains of physicalappearance and physical ability (Franklin DenyerSteinbeck Caterson amp Hill 2006 French et al1995 Latzer amp Stein 2013 Lowry et al 2007)Particularly for adolescent girls body image is a keyconcern (Cave Fildes Luckett amp Wearring 2015)and comprises a large portion of global self-esteem(Lowry et al 2007 Pesa Syre amp Jones 2000)However weight loss and associated changes in phys-ical appearance do not necessarily reflect improve-ments in self-esteem (Lowry et al 2007) Changes inbody-esteem often occur more rapidly than changes inglobal self-esteem as a result of weight management(Lowry et al 2007) This may explain the lack ofchange observed in global self-esteem in this meta-analysis and highlights the need to also include body-esteem (or physical self-esteem) as a focus and out-come of weight management interventions foradolescents
Parental involvement in adolescent weight manage-ment interventions is a critical component for success-ful weight loss and may also be important forimproving self-esteem (Lowry et al 2007) Weight-related teasing from family is shown to be negativelyassociated with self-esteem in overweight adolescentswhereas family connectedness was positively associ-ated with adolescent self-esteem (Fulkerson StraussNeumark-Sztainer Story amp Boutelle 2007) The in-clusion of parents in weight management interventionsfosters a safer and more encouraging home environ-ment for the adolescent (Lowry et al 2007) which isassociated with increased self-esteem in nonover-weight children (Marx amp Neumark-Sztainer 2005)All studies in the present review baring one includedparents in the intervention Parental involvementshould continue to be a key component of weightmanagement interventions to ensure a supportivehome environment for the adolescent to help fosterpositive self-esteem
Weight management interventions that used agroup setting to target self-esteem have shown im-provements in self-esteem without significant weightchange (Lowry et al 2007 Sherman AlexanderGomez Kim amp Marole 1992) The ability of the peergroup setting to provide opportunities for bondingsupport feelings of belonging development of peer-based skills and positive peer exchanges is key toincreasing self-esteem (Lowry et al 2007) The im-portance of this element is being acknowledged in the
390 Murray Dordevic and Bonham
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ington user on 14 February 2019
field with all the studies in this review baring twousing group sessions in their intervention
Measures of self-esteem are self-reported and there-fore subjective Responses to questionnaires are likelyto be influenced by individual (eg age gender) andenvironmental (eg cultural group socioeconomicstatus) factors (Khanlou 2004) Changes followinginterventions may represent genuine long-termchanges in self-esteem or may be due to short-termfluctuations in self-esteem in response to specificevents (eg winning a sporting event or performanceon a test at school) (Kernis 1993) While validatedtools were used to measure self-esteem in all studies itwas difficult to conclude whether outcomes were en-tirely dependent on the intervention without inclusionof a no-treatment control group
The variety of self-esteem assessment tools also addsto the difficulty of interpretation Across the 13 studies inthis review five different tools were used with differentquestions and different scales Even within tools therewere different scales used to report the results (RosenbergSelf-esteem Scale) and different versions of the same ques-tionnaire (Harterrsquos Self-perception Profile for ChildrenHarterrsquos Self-perception Profile for Adolescents) HarterrsquosSelf-Perception Profile (Harterrsquos Self-perception Profilefor Adolescents for adolescents) which measures ninesubscales of self-esteem including physical self-esteem issuggested as the most appropriate measure for adolescentself-esteem (Lowry et al 2007) It was also the mostcommonly used tool among papers included in this re-view While Cohenrsquos d effect sizes were used to stand-ardize results in this review the consistent use of one toolwould provide the ability to compare raw self-esteemscores and create a stronger analysis in the future
Results from this review support evidence thatMWMIs induce weight loss in overweight and obeseadolescents (Hoelscher Kirk Ritchie ampCunningham-Sabo 2013 Kelly amp Melnyk 2008Luttikhuis et al 2009) The change in BMI z-score inthe present meta-analysis (017 [022 011]) wassimilar to the clinically meaningful weight loss re-ported in the 2009 Cochrane Review in children 12years at 6 months follow up from a lifestyle weightmanagement intervention (014 [017 012])(Luttikhuis et al 2009) Jelalian Mehlenbeck Lloyd-Richardson Birmaher and Wing (2006) and WalkerGately Bewick and Hill (2003) have demonstratedassociations between weight loss and increased self-esteem in overweight and obese adolescents after at-tending a weight-management intervention Similarlyin the present review a strong positive relationship be-tween treatment effects for weight loss and improve-ment in self-esteem was identified However itremains unclear whether the improvement in self-esteem was as a result of successful weight loss orwhether it was a contributing factor toward successful
weight loss Nonetheless building self-esteem shouldbe a key focus of MWMIs as improved self-esteem ap-
pears to be linked to enhanced weight lossA key strength of this review was that all included
studies had strong designs and presented level II evi-dence (Coleman et al 2009) However to further elu-
cidate the role of self-esteem in adolescent weightmanagement future research should consider power-
ing studies to detect changes in psychosocial as well asphysiological outcomes Only one study in this reviewwas powered to detect a change in psychosocial out-
comes (Daley et al 2006) which may explain thelack of significant results observed for self-esteem
Additionally a large number of included studies didnot describe their method of handling withdrawals or
use blinding to prevent the introduction of bias Toimprove confidence in the effectiveness of MWMIs
and reduce the risk of bias future studies should bedesigned with concealed allocation and document andreport in detail the flow of participants
Identification of intervention components that im-
prove self-esteem is important for future weight man-agement intervention design Included interventionswere heterogeneous offering different levels of diet-
ary physical activity and behavioral interventionwhich may have collectively or individually influenced
the results Inconsistent reporting of intervention andcomparator conditions make it difficult to elucidate
the components that contributed to improvements inself-esteem Future studies should report intervention
and comparator procedures in adequate detail so thatsuccessful components can be identified and repli-cated These limitations highlight areas for improve-
ment to develop best-practice guidelines forundertaking and evaluating MWMIs in adolescents to
enhance self-esteem
Conclusion
Overweight and obese adolescents experience low
self-esteem largely owing to poor body image yetthis meta-analysis found no improvement in self-esteem even with significant weight loss Although it
was noted that interventions that had larger effects onself-esteem also had larger effects on weight loss The
incorporation of intervention components that wereidentified to contribute to improvements in self-
esteem may assist future weight management interven-tions to improve the self-esteem of overweight and
obese adolescents Furthermore a consistent measureof self-esteem would enable easier interpretation ofself-esteem scores and comparison of results across
studies to improve our understanding of the relation-ship between self-esteem and weight management in
adolescents
The Impact of Weight Management on Self-Esteem 391
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Supplementary Data
Supplementary data can be found at httpwwwjpepsy
oxfordjournalsorg
Acknowledgments
The authors would like to acknowledge Dr Zoe Davidson
for her assistance in performing the meta-analyses
Funding
This work was supported by an Australian GovernmentResearch Training Program Scholarship
Conflicts of interest none declared
References
Academy of Nutrition and Dietetics (2012) Evidence ana-lysis manual Steps in the academy evidence analysis pro-cess Chicago IL ADA Research and Strategic Business
DevelopmentBrennan L Walkley J Fraser S F Greenway K amp
Wilks R (2008) Motivational interviewing and cognitivebehaviour therapy in the treatment of adolescent over-
weight and obesity Study design and methodologyContemporary Clinical Trials 29 359ndash375
Brennan L Walkley J Wilks R Fraser S F amp
Greenway K (2013) Physiological and behavioural out-comes of a randomised controlled trial of a cognitive be-havioural lifestyle intervention for overweight and obese
adolescents Obesity Research and Clinical Practice 7e23ndashe41
Brennan L Wilks R Walkley J Fraser S F amp
Greenway K (2012) Treatment acceptability and psycho-social outcomes of a randomised controlled trial of a cog-nitive behavioural lifestyle intervention for overweight and
obese adolescents Behaviour Change 29 36ndash62Cave L Fildes J Luckett G amp Wearring A (2015)
Mission Australiarsquos 2015 youth survey report MissionAustralia
Coleman K Norris S Weston A Grimmer-Somers KHillier S Merlin T Salisbury J (2009) NHMRCadditional levels of evidence and grades for recommenda-tions for developers of guidelines (Vol Stage 2Consultation) Australia National Health and Medical
Research CouncilCroker H Viner R M Nicholls D Haroun D
Chadwick P Edwards C Wardle J (2012) Family-based behavioural treatment of childhood obesity in a UK
national health service setting Randomized controlledtrial International Journal of Obesity 36 16ndash26 doi
101038ijo2011182Daley A J Copeland R J Wright N P Roalfe A amp
Wales J K H (2006) Exercise therapy as a treatment forpsychopathologic conditions in obese and morbidly obese
adolescents A randomized controlled trial Pediatrics118 2126ndash2134
Danielsen Y S Nordhus I H Julıusson P B Maelighle Mamp Pallesen S (2013) Effect of a family-based cognitive
behavioural intervention on body mass index self-esteem
and symptoms of depression in children with obesity (aged
7mdash13) A randomised waiting list controlled trial ObesityResearch amp Clinical Practice 7 e116ndashe128
DeBar L L Stevens V J Perrin N Wu P Pearson J ampJo B (2012) A primary care-based multicomponent life-
style intervention for overweight adolescent femalesPediatrics 129 e611ndashe620
Elfhag K amp Rossner S (2005) Who succeeds in maintain-ing weight loss A conceptual review of factors associated
with weight loss maintenance and weight regain ObesityReviews 6 67ndash85
Franklin J Denyer G Steinbeck K S Caterson I D ampHill A J (2006) Obesity and risk of low self-esteem Astatewide survey of Australian children Pediatrics 118
2481ndash2487French S A Story M amp Perry C L (1995) Self-esteem
and obesity in children and adolescents A literature re-view Obesity Research 3 479ndash490
Fulkerson J Strauss J Neumark-Sztainer D Story M
amp Boutelle K (2007) Correlates of psychosocial well-being among overweight adolescents The role of the fam-ily Journal of Consulting and Clinical Psychology 75
181ndash186Griffiths L J Parsons T J amp Hill A J (2010) Self-es-
teem and quality of life in obese children and adolescentsA systematic review International Journal of PediatricObesity 5 282ndash304
Harter S (1993) Causes and consequences of low self-
esteem in children and adolescents In R F Baumeister(Ed) Self-esteemmdashThe puzzle of low self-regard (pp87ndash116) USA Springer
Higgins J Thompson S Deeks J amp Altman D (2003)
Measuring inconsistency in meta-analyses BMJ 327557ndash560
Hoelscher D M Kirk S Ritchie L amp Cunningham-Sabo L (2013) Position of the Academy of Nutrition and
Dietetics Interventions for the prevention and treatmentof pediatric overweight and obesity Journal of theAcademy of Nutrition and Dietetics 113 1375ndash1394
Jelalian E Mehlenbeck R Lloyd-Richardson EBirmaher V amp Wing R (2006) lsquoAdventure therapyrsquo
combined with cognitivebehavioral treatment for over-weight adolescents International Journal of Obesity 3031ndash39
Kelly S A amp Melnyk B M (2008) Systematic review of
multicomponent interventions with overweight middleadolescents implications for clinical practice and researchWorldviews on Evidence-Based Nursing 5 113ndash135
Kernis M (1993) The roles of stability and level of self-
esteem in psychological functioning In R Baumeister(Ed) Self-esteem (pp 167ndash182) USA Springer
Khanlou N (2004) Influences on adolescent self-esteem inmulticultural Canadian secondary schools Public HealthNursing 21 404ndash411
Kohn M Rees J M Brill S Fonseca H Jacobson M
Katzman D K Schneider M (2006) Preventing andtreating adolescent obesity A position paper of the Societyfor Adolescent Medicine Journal of Adolescent Health
38 784ndash787Kornman K P Shrewsbury V A Chou A C Ngyuen
B Lee A Orsquoconnor J Baur L A (2010) Electronic
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nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
therapeutic contact for adolescent weight management
The Loozit study Telemedicine and E-Health 16
678ndash685Latzer Y amp Stein D (2013) A review of the psychological
and familial perspectives of childhood obesity Journal of
Eating Disorders 1 7Lobstein T Baur L amp Uauy R (2004) Obesity in chil-
dren and young people a crisis in public health Obesity
Reviews 5(Suppl 1) 4ndash104Lochrie A S Wysocki T Hossain J Milkes A Antal
H Buckloh L Lang J (2013) The effects of a family-
based intervention (FBI) for overweightobese children on
health and psychological functioning Clinical Practice in
Pediatric Psychology 1 159ndash170 doi httpdxdoiorg
101037cpp0000020Lowry K W Sallinen B amp Janicke D (2007) The effects
of weight management programs on self-esteem in pediat-
ric overweight populations Journal of Pediatric
Psychology 32 1179ndash1195Lubans D R Morgan P J Okely A D Dewar D
Collins C E Batterham M Plotnikoff R C (2012)
Preventing obesity among adolescent girls One-year out-
comes of the nutrition and enjoyable activity for teen girls
(NEAT Girls) cluster randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
821ndash827Luttikhuis H Baur L Jansen H Shrewsbury V
Orsquomalley C Stolk R amp Summerbell C (2009)
Interventions for treating obesity in children (Review)
Cochrane Database of Systematic Reviews 3 1ndash57Marx R D amp Neumark-Sztainer D (2005) Questions amp
Answers Eating Disorders The Journal of Treatment amp
Prevention 13 491ndash495McClure A C Tanksi S E Kingsbury J Gerrard M amp
Sargent J D (2010) Characteristics associated with low
self-esteem among US adolescents Academic Pediatrics
10 238ndash244Mellin L M Slinkard L A amp Irwin C E (1987)
Adolescent obesity intervention Validation of the
SHAPEDOWN program Journal of the American Dietetic
Association 87 333ndash338Mission Australia (2012) Youth Survey 2012 SydneyMoher D Shamseer L Clarke M Ghersi D Liberati
A Petticrew M PRISMA-P Group (2015) Preferred
reporting items for systematic review and meta-analysis
protocols (PRISMA-P) 2015 statement Systematic
Reviews 4 1Morgan P Saunders K amp Lubans D (2012) Improving
physical self-perception in adolescent boys from disadvan-
taged schools Psychological outcomes from the Physical
Activity Leaders randomized controlled trial Pediatric
Obesity 7 e27ndashe32 doi httpdxdoiorg101111j
2047-6310201200050xNational Health and Medical Reasearch Council (2013)
Clinical practice guidelines for the management of over-
weight and obesity in adults adolescents and children in
Australia Australia NHMRC Australian Government
Department of HealthNational Institutes for Health and Care Excellence (2013)
Managing overweight and obesity among children and
young people lifestyle weight management services NICE
public health guidance United Kingdom 47 NICENeumark-Sztainer D R Friend S E Flattum C F
Hannan P J Story M T Bauer K W Petrich C A
(2010) New moves-preventing weight-related problems in
adolescent girls A group-randomized study American
Journal of Preventive Medicine 39 421ndash432Nguyen B McGregor K A Orsquoconnor J Shrewsbury V
A Lee A Steinbeck K S Baur L A (2012)
Recruitment challenges and recommendations for adoles-
cent obesity trials Journal of Paediatrics and Child
Health 48 38ndash43Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Hill A J Shah S Baur L A (2013) Two-year
outcomes of an adjunctive telephone coaching and elec-
tronic contact intervention for adolescent weight-loss
maintenance the Loozit randomized controlled trial
International Journal of Obesity 37 468ndash472Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2012) Twelve-month
outcomes of the Loozit randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
170ndash177Ogden C L Carroll M D Kit B K amp Flegal K M
(2014) Prevalence of childhood and adult obesity in the
United States 2011-2012 Journal of the American
Medical Association 311 806ndash814Pesa J A Syre T R amp Jones E (2000) Psychosocial dif-
ferences associated with body weight among female ado-
lescents The importance of body image Journal of
Adolescent Health 26 330ndash337Pierce J W amp Wardle J (1997) Cause and effect beliefs
and self-esteem of overweight children Journal of Child
Psychology and Psychiatry 38 645ndash650 doi 101111
j1469-76101997tb01691xRoberts J E (2006) Self-esteem from a clinical perspective
In M H Kernis (Ed) Self-esteem issues and answers A
sourcebook of current perspectives Psychology Press
Taylor amp Francis New York and Hove (pp 298ndash305)
Psychology PressSacher P M Kolotourou M Chadwick P M Cole T J
Lawson M S Lucas A amp Singhal A (2010)
Randomized controlled trial of the MEND program A
family-based community intervention for childhood obes-
ity Obesity 18(Suppl 1) S62ndashS68 doi httpdxdoiorg
101038oby2009433Sanders R H Han A Baker J S amp Cobley S (2015)
Childhood obesity and its physical and psychological co-
morbidities a systematic review of Australian children and
adolescents Eur J Pediatr 174 715ndash746Sherman J B Alexander M A Gomez D Kim M amp
Marole P (1992) Intervention program for obese school chil-
dren Journal of Community Health Nursing 9 183ndash190Shrewsbury V A Nguyen B Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2011) Short-term
outcomes of community-based adolescent weight manage-
ment The LoozitVR
Study BMC Pediatrics 11 13Shrewsbury V A Orsquoconnor J Steinbeck K S Stevenson
K Lee A Hill A J Baur L A (2009) A randomised
controlled trial of a community-based healthy lifestyle
The Impact of Weight Management on Self-Esteem 393
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
program for overweight and obese adolescents TheLoozitV
R
study protocol BMC Public Health 9 119Strauss R S (2000) Childhood obesity and self-esteem
Pediatrics 105 5Tiggemann M (2005) Body dissatisfaction and adolescent
self-esteem Prospective findings Body Image 2 129ndash135doi httpdxdoiorg101016jbodyim200503006
Wadden T A Stunkard A J Rich L Rubin C JSweidel G amp McKinney S (1990) Obesity in black ado-lescent girls A controlled clinical trial of treatment by diet
behaviour modification and parental support Pediatrics85 345ndash352
Walker L Gately P Bewick B amp Hill A (2003)Childrenrsquos weight-loss camps psychological benefit orjeopardy International Journal of Obesity 27 748ndash754
World Health Organization (2014) Maternal newbornchild and adolescent health Adolescent developmentRetrieved from httpwwwwhointmaternal_child_adolescenttopicsadolescencedeven Retrieved 28 May2014
394 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
- jsw101-TF1
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- jsw101-TF9
- jsw101-TF10
- jsw101-TF11
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Sel
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35
Posi
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)fe
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ore
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ndash25
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terv
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ional
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uded
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A
sabove
wit
hout
the
AT
C
Buildin
gposi
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self
-est
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ase
ssio
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wee
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ery
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Fort
nig
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ions
and
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Hart
errsquos
Sel
fPer
cepti
on
Pro
file
for
Adole
scen
ts(s
elf-
este
em)
BM
Iz-
score
Sach
eret
al2010
Unit
edK
ingdom
31
Posi
tive
21
(48
)m
ale
sand
23
(52
)fe
-m
ale
s10ndash12
yea
rsB
MI
gt98th
per
centi
le
IPart
icip
ants
and
thei
rfa
milie
sat-
tended
gro
up
sess
ions
focu
sing
on
be-
havio
rch
ange
nutr
itio
nand
physi
calact
ivit
ySes
sion
conte
nt
focu
sed
on
buildin
gsk
ills
tom
ain
tain
long-t
erm
beh
avio
rch
anges
Follow
ing
trea
tmen
tfa
milie
sw
ere
giv
ena
12-w
eek
free
fam
ily
swim
pass
C
W
ait
-lis
t
No
spec
ific
men
-ti
on
of
self
-es
teem
Eig
hte
en2-h
rse
ssio
ns
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eeks
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up
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om
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Hart
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Pro
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Childre
n(s
elf-
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score
The Impact of Weight Management on Self-Esteem 385
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self-esteem was observed following four MWMIsacross three studies (Croker et al 2012 Danielsenet al 2013 Nguyen Shrewsbury et al 2012) Fivestudies showed no effect on adolescent self-esteem fol-lowing MWMI (Brennan et al 2012 DeBar et al2012 Lochrie et al 2013 Lubans et al 2012Neumark-Sztainer et al 2010) No positive effects onself-esteem were observed in any of the controlgroups One wait-listed control group (Croker et al2012) showed a small negative effect on self-esteem
Mixed results were also observed in the studies forwhich an effect size could not be calculatedImprovements in adolescent self-esteem were observedfollowing MWMIs by Daley et al (2006) Mellin et al(1987) Sacher et al (2010) and Wadden et al(1990) However only Daley et al (2006) reportedthat this change was different to that observed in thecontrol group No changes in self-esteem were de-tected following intervention by Morgan et al (2012)although a significant decline in self-esteem wasobserved in the wait-listed control group who receivedthe normal school curriculum throughout the studyperiod
Multicomponent Weight ManagementInterventions Improve Weight Outcomes inAdolescentsOf the 13 included studies there were 14 groups whoreceived a MWMI and 11 no-treatment controlgroups Of these effect sizes were able to be calculatedfor nine intervention groups and seven control groups(Table III) Seven intervention groups had small to me-dium positive effects indicating successful weight loss(Brennan et al 2012 Croker et al 2012 Danielsenet al 2013 DeBar et al 2012 Lochrie et al 2013Lubans et al 2012 Nguyen Shrewsbury et al2012) and two intervention groups had no effect(Neumark-Sztainer et al 2010 Nguyen Shrewsburyet al 2012) All seven control groups showed no ef-fect on weight
Of the studies for which effect size could not be cal-culated the results were similar Mellin et al (1987)Morgan et al (2012) Sacher et al (2010) andWadden et al (1990) all observed significant weightloss following intervention Morgan et al (2012) andSacher et al (2010) also showed that these changeswere significantly different to changes observed in thecontrol groups No studies observed significant weightchange in the control groups
Correlation Between Self-Esteem Improvementand Weight Loss Effect SizesThere is a strong (rfrac14 641 R2frac140410) positive linearrelationship between effect sizes for self-esteem im-provement and weight loss across all intervention andcontrol groups (pfrac14 008)T
ab
leI
(co
nti
nu
ed
)
Stu
dy
(auth
or
yea
rlo
cati
on)
Quali
tyra
ting
Part
icip
ants
Inte
rven
tions
Focu
son
self
-est
eem
Dura
tion
Outc
om
em
easu
res
Wadden
etal
1990U
nit
edSta
tes3
6
Posi
tive
47
(100
)fe
male
s12ndash16
yea
rsat
least
10-k
gover
wei
ght
IIn
terv
enti
on
cover
eddie
tand
eati
ng
patt
erns
modif
yin
gse
lf-d
efea
ting
thoughts
and
incr
easi
ng
physi
calac-
tivit
yH
om
ework
ass
ignm
ents
and
ince
nti
ves
aw
ard
sw
ere
use
dto
en-
coura
ge
part
icip
ati
onT
her
ew
ere
thre
edif
fere
nt
inte
rven
tion
gro
ups
who
rece
ived
this
trea
tmen
tch
ild
only
ch
ild
and
moth
erto
get
her
ch
ild
and
moth
erse
para
tely
C
N
ocl
ear
contr
olgro
upse
eabove
No
spec
ific
men
-ti
on
of
self
-es
teem
Six
teen
wee
kly
1-h
rle
ssons
No
follow
up
Pie
rs-H
arr
issc
ale
(sel
f-es
teem
)B
MI
Note
B
MIfrac14
body
mass
index
Ifrac14
inte
rven
tionCfrac14
Com
par
ato
rC
om
par
ato
rgro
ups
that
rece
ived
an
inte
rven
tion
wer
etr
eate
das
inte
rven
tion
gro
ups
for
the
purp
ose
of
anal
ysi
sin
this
revie
w
Stu
die
sare
list
edin
alp
habet
icalord
erin
all
table
s
386 Murray Dordevic and Bonham
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Tab
leIIS
elf
-Est
ee
mO
utc
om
es
of
Mu
ltic
om
po
ne
nt
We
igh
tM
an
ag
em
en
tIn
terv
en
tio
ns
Co
mp
are
dW
ith
Co
ntr
ols
in
Ov
erw
eig
ht
an
dO
be
seA
do
lesc
en
ts
Auth
or
yea
rIn
terv
enti
on
gro
ups
Contr
olgro
ups
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
Bre
nnan
etal2012
20
215
(54
)a206
(63
)a
21
1(4
78)a
01
514
188
(47
)a192
(47
)a06
4(3
91)a
00
9C
roker
etal2012
13
26
9(0
57)b
29
5(0
45)b
03
6(0
39)b
05
110
29
0(0
61)b
26
8(0
52)b
00
2(0
59)b
03
9D
ale
yet
al2006
28
24
2(0
56)b
26
1(0
08
SE)b
NA
NA
30
24
9(0
49)b
25
6(0
10
SE)b
NA
NA
Danie
lsen
etal2013
16
28
8(0
52)b
31
7(0
53)b
02
9(0
53)b
05
516
31
1(0
57)b
30
6(0
59)b
00
5(0
37)b
00
9D
eBar
etal2012
105
23
9(0
26)a
24
0(0
25)a
NA
00
4103
24
1(0
27)a
23
9(0
25)a
NA
00
8L
och
rie
etal2013
29
183
(50
2)b
191
(44
8)b
07
3(4
51)b
01
718
199
(34
6)b
199
(34
3)b
00
0(3
11)b
00
0L
ubans
etal2012
54
40
3(1
12)c
40
6(1
32)c
NA
00
268
40
4(0
99)c
42
3(0
98)c
NA
01
9M
ellin
etal1987
37
NA
NA
08
8(1
50)a
NA
29
NA
NA
05
2(1
34)a
NA
Morg
an
etal2012
19
NA
NA
00
8(0
48)d
NA
21
NA
NA
02
6(0
47)d
NA
Neu
mark
-Szt
ain
eret
al2010
85
152
(34
)b151
(29
)bN
A
00
379
141
(34
)b140
(34
)bN
A
00
3
Nguyen
etal2012
(wit
hA
TC
)57
25
8(0
76)b
27
7(0
63)b
01
9(0
67)b
02
7
Nguyen
etal2012
(wit
hout
AT
C)
50
25
9(0
58)b
29
3(0
61)b
01
9(0
51)b
05
7
Sach
eret
al2010
20
NA
32
5(0
68)b
02
5(0
66)b
NA
24
NA
30
4(0
75)b
01
1(0
74)b
NA
Wadden
etal1990
3gro
ups
com
bin
ed47
576
e599
eN
AN
A
Note
D
ata
pre
sente
das
report
edin
ori
gin
alpaper
sSDfrac14
standard
dev
iati
onN
Afrac14
data
not
pro
vid
edu
nab
leto
be
calc
ula
ted
SEfrac14
Sta
ndard
erro
rnot
Sta
ndard
Dev
iati
onE
ffec
tsi
zefrac14
Cohen
rsquosdB
old
font
indic
ate
sw
her
eef
fect
size
was
small
(02
0)
or
gre
ate
raR
ose
nber
gse
lf-e
stee
msc
ale
(gen
erally
score
dfr
om
0[l
ow
est
self
-est
eem
]to
30
[hig
hes
tse
lf-e
stee
m])
bH
art
errsquos
SPPA
SPPC
(gen
erally
score
d1
[low
est
self
-est
eem
]to
4[h
ighes
tse
lf-e
stee
m])
cM
ars
hrsquos
Physi
calSel
f-D
escr
ipti
on
Ques
tionnair
e
dPhysi
calSel
f-Per
cepti
on
Pro
file
for
Adole
scen
ts
ePie
rs-H
arr
isSel
f-C
once
pt
Sca
le
Sco
ring
range
sunav
ailab
lehig
her
valu
eeq
uals
hig
her
self
-est
eem
The Impact of Weight Management on Self-Esteem 387
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Tab
leIII
We
igh
tO
utc
om
es
of
Mu
ltic
om
po
ne
nt
We
igh
tM
an
ag
em
en
tIn
terv
en
tio
ns
Co
mp
are
dW
ith
Co
ntr
ols
in
Ov
erw
eig
ht
an
dO
be
seA
do
lesc
en
ts
Auth
or
yea
rIn
terv
enti
on
gro
ups
Contr
olgro
ups
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
Bre
nnan
etal2012
20
20
8(0
37)
19
9(0
46)
02
0(0
18)
02
214
20
8(0
40)
20
9(0
39)
00
1(0
12)
00
3C
roker
etal2012
13
29
5(0
52)
26
6(0
63)
01
7(0
21)
05
010
31
4(0
68)
31
4(0
68)
00
6(0
13)
00
0D
ale
yet
al2006
28
31
7(0
33)
32
3(0
02
SE)
NA
NA
30
33
2(0
37)
32
3(0
02
SE)
NA
NA
Danie
lsen
etal2013
16
25
9(0
30)
24
6(0
41)
01
2(0
17)
03
616
24
9(0
27)
25
3(0
29)
00
5(0
15)
01
4D
eBar
etal2012
105
20
0(0
34)
18
8(0
41)
NA
03
2103
20
0(0
33)
19
4(0
38)
NA
01
7L
och
rie
etal2013
29
21
9(0
40)
20
6(0
52)
01
2(0
20)
02
818
20
7(0
40)
20
5(0
43)
00
2(0
11)
00
5L
ubans
etal2012
54
19
3(0
61)
18
0(0
68)
NA
02
068
18
5(0
59)
18
0(0
67)
NA
00
8M
ellin
etal1987
37
1365
aN
A
59
(67
5)a
NA
29
1295
aN
A
03
(66
1)a
NA
Morg
an
etal2012
19
NA
NA
04
2(0
91)b
NA
21
NA
NA
00
3(0
87)b
NA
Neu
mark
-Szt
ain
eret
al2010
85
321
(61
)b322
(62
)bN
A
00
279
310
(53
)b314
(55
)bN
A
00
7
Nguyen
etal2012
(wit
hA
TC
)57
20
3(0
37)
19
7(0
42)
00
8(0
19)
01
5
Nguyen
etal2012
(wit
hout
AT
C)
50
20
2(0
29)
19
4(0
32)
00
9(0
17)
02
6
Sach
eret
al2010
20
NA
23
7(0
52)
02
2(0
27)
NA
24
NA
26
0(0
54)
00
1(0
20)
NA
Wadden
etal1990
3gro
ups
com
bin
ed47
352
b339
bN
AN
A
Note
D
ata
pre
sente
das
report
edin
ori
gin
al
paper
sA
llw
eight
outc
om
esre
port
edas
body
mass
index
(BM
I)z-
score
unle
ssoth
erw
ise
state
d
SDfrac14
standar
ddev
iati
on
NAfrac14
data
not
pro
vid
ed
unab
leto
be
calc
ula
ted
SEfrac14
Sta
ndard
Err
or
report
edra
ther
than
Sta
ndard
Dev
iati
onE
ffec
tsi
zefrac14
Cohen
rsquosdB
old
font
indic
ate
sw
her
eef
fect
size
was
smal
l(0
20)
or
gre
ate
raR
elati
ve
wei
ght
bB
MI
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Quantitative Data AnalysisDifferences between intervention and control groupsfor change in self-esteem are presented in Figure 2aThis analysis included seven intervention groups(nfrac14 191) and seven control groups (nfrac14 132) with
interventions or intensive treatment phases rangingfrom 9 weeks to 6 months in duration A moderatelevel of the variation across studies was owing to het-erogeneity (I2frac14464 Higgins Thompson Deeksamp Altman 2003) The overall summary effect showed
Figure 2 Comparison between intervention and control groups for the change in adolescent self-esteem effect size (a) andbody mass index z-score (b) following multicomponent weight management interventions SMD frac14 standard mean differ-ence WMD frac14 weighted mean difference
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no effect on self-esteem as a result of interventionSMD of 027 (95 confidence interval 004 059)zfrac14 169 and pfrac14 092 However all studies exceptone favored the intervention for improvements in self-esteem
The difference between intervention and controlgroups for change in BMI z-score is illustrated inFigure 2b This analysis included five interventiongroups (nfrac14 135) and five control groups (nfrac14 82) withinterventions ranging from 9 weeks to 6 months induration Heterogeneity in this sample was low(I2frac14177 Higgins et al 2003) and the overall sum-mary effect was 017 (022 011) BMI z-scorepoints (zfrac14613 and plt 001) indicating statisticallysignificant weight loss following MWMI
Discussion
The purpose of this review was to examine the effectof MWMIs on self-esteem in overweight and obeseadolescents Increased self-esteem is proposed as a keyfactor for maintaining long-term weight management(Elfhag amp Rossner 2005 French et al 1995Roberts 2006) A secondary outcome of this reviewwas to examine the impact of MWMIs on weight lossand whether this was associated with improvements inself-esteem
The meta-analysis showed no difference in self-esteem between the intervention and control groupsHowever six of the seven studies in the meta-analysisfavored the intervention over control for improve-ments in self-esteem and four of the six studies notincluded in the meta-analysis found significant im-provements in self-esteem following intervention Thelatter of these findings are similar to those of an earlierreview (Lowry et al 2007) that showed improve-ments in self-esteem following weight managementinterventions in a pediatric population particularlywhen certain intervention features were presentSimilarly a number of intervention features that con-tributed to an increased likelihood of improving self-esteem were identified in this review
Improvements in self-esteem regardless of weightloss have been demonstrated in children who tookpart in weight management interventions thatincluded a focus on building self-esteem and it is rec-ommended that this be a focus of all pediatric weightmanagement interventions (Lowry et al 2007) Yetthe majority of studies identified in this review did notinclude building self-esteem as a key aspect of theirintervention Nguyen Shrewsbury et al (2012)described the greatest focus on self-esteem (one75-min group session focused on building self-esteem)and also resulted in the largest treatment effect (057)and a significant improvement in self-esteem (NguyenShrewsbury et al 2012) A focus on similar topics
such as body image social support and managing bul-lying may also contribute to improvements in self-esteem (Croker et al 2012 Pierce amp Wardle 1997Tiggemann 2005) however these findings highlightthe lack of uptake of these recommendations
Among overweight and obese youth reductions inself-esteem are often observed in domains of physicalappearance and physical ability (Franklin DenyerSteinbeck Caterson amp Hill 2006 French et al1995 Latzer amp Stein 2013 Lowry et al 2007)Particularly for adolescent girls body image is a keyconcern (Cave Fildes Luckett amp Wearring 2015)and comprises a large portion of global self-esteem(Lowry et al 2007 Pesa Syre amp Jones 2000)However weight loss and associated changes in phys-ical appearance do not necessarily reflect improve-ments in self-esteem (Lowry et al 2007) Changes inbody-esteem often occur more rapidly than changes inglobal self-esteem as a result of weight management(Lowry et al 2007) This may explain the lack ofchange observed in global self-esteem in this meta-analysis and highlights the need to also include body-esteem (or physical self-esteem) as a focus and out-come of weight management interventions foradolescents
Parental involvement in adolescent weight manage-ment interventions is a critical component for success-ful weight loss and may also be important forimproving self-esteem (Lowry et al 2007) Weight-related teasing from family is shown to be negativelyassociated with self-esteem in overweight adolescentswhereas family connectedness was positively associ-ated with adolescent self-esteem (Fulkerson StraussNeumark-Sztainer Story amp Boutelle 2007) The in-clusion of parents in weight management interventionsfosters a safer and more encouraging home environ-ment for the adolescent (Lowry et al 2007) which isassociated with increased self-esteem in nonover-weight children (Marx amp Neumark-Sztainer 2005)All studies in the present review baring one includedparents in the intervention Parental involvementshould continue to be a key component of weightmanagement interventions to ensure a supportivehome environment for the adolescent to help fosterpositive self-esteem
Weight management interventions that used agroup setting to target self-esteem have shown im-provements in self-esteem without significant weightchange (Lowry et al 2007 Sherman AlexanderGomez Kim amp Marole 1992) The ability of the peergroup setting to provide opportunities for bondingsupport feelings of belonging development of peer-based skills and positive peer exchanges is key toincreasing self-esteem (Lowry et al 2007) The im-portance of this element is being acknowledged in the
390 Murray Dordevic and Bonham
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field with all the studies in this review baring twousing group sessions in their intervention
Measures of self-esteem are self-reported and there-fore subjective Responses to questionnaires are likelyto be influenced by individual (eg age gender) andenvironmental (eg cultural group socioeconomicstatus) factors (Khanlou 2004) Changes followinginterventions may represent genuine long-termchanges in self-esteem or may be due to short-termfluctuations in self-esteem in response to specificevents (eg winning a sporting event or performanceon a test at school) (Kernis 1993) While validatedtools were used to measure self-esteem in all studies itwas difficult to conclude whether outcomes were en-tirely dependent on the intervention without inclusionof a no-treatment control group
The variety of self-esteem assessment tools also addsto the difficulty of interpretation Across the 13 studies inthis review five different tools were used with differentquestions and different scales Even within tools therewere different scales used to report the results (RosenbergSelf-esteem Scale) and different versions of the same ques-tionnaire (Harterrsquos Self-perception Profile for ChildrenHarterrsquos Self-perception Profile for Adolescents) HarterrsquosSelf-Perception Profile (Harterrsquos Self-perception Profilefor Adolescents for adolescents) which measures ninesubscales of self-esteem including physical self-esteem issuggested as the most appropriate measure for adolescentself-esteem (Lowry et al 2007) It was also the mostcommonly used tool among papers included in this re-view While Cohenrsquos d effect sizes were used to stand-ardize results in this review the consistent use of one toolwould provide the ability to compare raw self-esteemscores and create a stronger analysis in the future
Results from this review support evidence thatMWMIs induce weight loss in overweight and obeseadolescents (Hoelscher Kirk Ritchie ampCunningham-Sabo 2013 Kelly amp Melnyk 2008Luttikhuis et al 2009) The change in BMI z-score inthe present meta-analysis (017 [022 011]) wassimilar to the clinically meaningful weight loss re-ported in the 2009 Cochrane Review in children 12years at 6 months follow up from a lifestyle weightmanagement intervention (014 [017 012])(Luttikhuis et al 2009) Jelalian Mehlenbeck Lloyd-Richardson Birmaher and Wing (2006) and WalkerGately Bewick and Hill (2003) have demonstratedassociations between weight loss and increased self-esteem in overweight and obese adolescents after at-tending a weight-management intervention Similarlyin the present review a strong positive relationship be-tween treatment effects for weight loss and improve-ment in self-esteem was identified However itremains unclear whether the improvement in self-esteem was as a result of successful weight loss orwhether it was a contributing factor toward successful
weight loss Nonetheless building self-esteem shouldbe a key focus of MWMIs as improved self-esteem ap-
pears to be linked to enhanced weight lossA key strength of this review was that all included
studies had strong designs and presented level II evi-dence (Coleman et al 2009) However to further elu-
cidate the role of self-esteem in adolescent weightmanagement future research should consider power-
ing studies to detect changes in psychosocial as well asphysiological outcomes Only one study in this reviewwas powered to detect a change in psychosocial out-
comes (Daley et al 2006) which may explain thelack of significant results observed for self-esteem
Additionally a large number of included studies didnot describe their method of handling withdrawals or
use blinding to prevent the introduction of bias Toimprove confidence in the effectiveness of MWMIs
and reduce the risk of bias future studies should bedesigned with concealed allocation and document andreport in detail the flow of participants
Identification of intervention components that im-
prove self-esteem is important for future weight man-agement intervention design Included interventionswere heterogeneous offering different levels of diet-
ary physical activity and behavioral interventionwhich may have collectively or individually influenced
the results Inconsistent reporting of intervention andcomparator conditions make it difficult to elucidate
the components that contributed to improvements inself-esteem Future studies should report intervention
and comparator procedures in adequate detail so thatsuccessful components can be identified and repli-cated These limitations highlight areas for improve-
ment to develop best-practice guidelines forundertaking and evaluating MWMIs in adolescents to
enhance self-esteem
Conclusion
Overweight and obese adolescents experience low
self-esteem largely owing to poor body image yetthis meta-analysis found no improvement in self-esteem even with significant weight loss Although it
was noted that interventions that had larger effects onself-esteem also had larger effects on weight loss The
incorporation of intervention components that wereidentified to contribute to improvements in self-
esteem may assist future weight management interven-tions to improve the self-esteem of overweight and
obese adolescents Furthermore a consistent measureof self-esteem would enable easier interpretation ofself-esteem scores and comparison of results across
studies to improve our understanding of the relation-ship between self-esteem and weight management in
adolescents
The Impact of Weight Management on Self-Esteem 391
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icoupcomjpepsyarticle-abstract4243793065789 by U
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Supplementary Data
Supplementary data can be found at httpwwwjpepsy
oxfordjournalsorg
Acknowledgments
The authors would like to acknowledge Dr Zoe Davidson
for her assistance in performing the meta-analyses
Funding
This work was supported by an Australian GovernmentResearch Training Program Scholarship
Conflicts of interest none declared
References
Academy of Nutrition and Dietetics (2012) Evidence ana-lysis manual Steps in the academy evidence analysis pro-cess Chicago IL ADA Research and Strategic Business
DevelopmentBrennan L Walkley J Fraser S F Greenway K amp
Wilks R (2008) Motivational interviewing and cognitivebehaviour therapy in the treatment of adolescent over-
weight and obesity Study design and methodologyContemporary Clinical Trials 29 359ndash375
Brennan L Walkley J Wilks R Fraser S F amp
Greenway K (2013) Physiological and behavioural out-comes of a randomised controlled trial of a cognitive be-havioural lifestyle intervention for overweight and obese
adolescents Obesity Research and Clinical Practice 7e23ndashe41
Brennan L Wilks R Walkley J Fraser S F amp
Greenway K (2012) Treatment acceptability and psycho-social outcomes of a randomised controlled trial of a cog-nitive behavioural lifestyle intervention for overweight and
obese adolescents Behaviour Change 29 36ndash62Cave L Fildes J Luckett G amp Wearring A (2015)
Mission Australiarsquos 2015 youth survey report MissionAustralia
Coleman K Norris S Weston A Grimmer-Somers KHillier S Merlin T Salisbury J (2009) NHMRCadditional levels of evidence and grades for recommenda-tions for developers of guidelines (Vol Stage 2Consultation) Australia National Health and Medical
Research CouncilCroker H Viner R M Nicholls D Haroun D
Chadwick P Edwards C Wardle J (2012) Family-based behavioural treatment of childhood obesity in a UK
national health service setting Randomized controlledtrial International Journal of Obesity 36 16ndash26 doi
101038ijo2011182Daley A J Copeland R J Wright N P Roalfe A amp
Wales J K H (2006) Exercise therapy as a treatment forpsychopathologic conditions in obese and morbidly obese
adolescents A randomized controlled trial Pediatrics118 2126ndash2134
Danielsen Y S Nordhus I H Julıusson P B Maelighle Mamp Pallesen S (2013) Effect of a family-based cognitive
behavioural intervention on body mass index self-esteem
and symptoms of depression in children with obesity (aged
7mdash13) A randomised waiting list controlled trial ObesityResearch amp Clinical Practice 7 e116ndashe128
DeBar L L Stevens V J Perrin N Wu P Pearson J ampJo B (2012) A primary care-based multicomponent life-
style intervention for overweight adolescent femalesPediatrics 129 e611ndashe620
Elfhag K amp Rossner S (2005) Who succeeds in maintain-ing weight loss A conceptual review of factors associated
with weight loss maintenance and weight regain ObesityReviews 6 67ndash85
Franklin J Denyer G Steinbeck K S Caterson I D ampHill A J (2006) Obesity and risk of low self-esteem Astatewide survey of Australian children Pediatrics 118
2481ndash2487French S A Story M amp Perry C L (1995) Self-esteem
and obesity in children and adolescents A literature re-view Obesity Research 3 479ndash490
Fulkerson J Strauss J Neumark-Sztainer D Story M
amp Boutelle K (2007) Correlates of psychosocial well-being among overweight adolescents The role of the fam-ily Journal of Consulting and Clinical Psychology 75
181ndash186Griffiths L J Parsons T J amp Hill A J (2010) Self-es-
teem and quality of life in obese children and adolescentsA systematic review International Journal of PediatricObesity 5 282ndash304
Harter S (1993) Causes and consequences of low self-
esteem in children and adolescents In R F Baumeister(Ed) Self-esteemmdashThe puzzle of low self-regard (pp87ndash116) USA Springer
Higgins J Thompson S Deeks J amp Altman D (2003)
Measuring inconsistency in meta-analyses BMJ 327557ndash560
Hoelscher D M Kirk S Ritchie L amp Cunningham-Sabo L (2013) Position of the Academy of Nutrition and
Dietetics Interventions for the prevention and treatmentof pediatric overweight and obesity Journal of theAcademy of Nutrition and Dietetics 113 1375ndash1394
Jelalian E Mehlenbeck R Lloyd-Richardson EBirmaher V amp Wing R (2006) lsquoAdventure therapyrsquo
combined with cognitivebehavioral treatment for over-weight adolescents International Journal of Obesity 3031ndash39
Kelly S A amp Melnyk B M (2008) Systematic review of
multicomponent interventions with overweight middleadolescents implications for clinical practice and researchWorldviews on Evidence-Based Nursing 5 113ndash135
Kernis M (1993) The roles of stability and level of self-
esteem in psychological functioning In R Baumeister(Ed) Self-esteem (pp 167ndash182) USA Springer
Khanlou N (2004) Influences on adolescent self-esteem inmulticultural Canadian secondary schools Public HealthNursing 21 404ndash411
Kohn M Rees J M Brill S Fonseca H Jacobson M
Katzman D K Schneider M (2006) Preventing andtreating adolescent obesity A position paper of the Societyfor Adolescent Medicine Journal of Adolescent Health
38 784ndash787Kornman K P Shrewsbury V A Chou A C Ngyuen
B Lee A Orsquoconnor J Baur L A (2010) Electronic
392 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
therapeutic contact for adolescent weight management
The Loozit study Telemedicine and E-Health 16
678ndash685Latzer Y amp Stein D (2013) A review of the psychological
and familial perspectives of childhood obesity Journal of
Eating Disorders 1 7Lobstein T Baur L amp Uauy R (2004) Obesity in chil-
dren and young people a crisis in public health Obesity
Reviews 5(Suppl 1) 4ndash104Lochrie A S Wysocki T Hossain J Milkes A Antal
H Buckloh L Lang J (2013) The effects of a family-
based intervention (FBI) for overweightobese children on
health and psychological functioning Clinical Practice in
Pediatric Psychology 1 159ndash170 doi httpdxdoiorg
101037cpp0000020Lowry K W Sallinen B amp Janicke D (2007) The effects
of weight management programs on self-esteem in pediat-
ric overweight populations Journal of Pediatric
Psychology 32 1179ndash1195Lubans D R Morgan P J Okely A D Dewar D
Collins C E Batterham M Plotnikoff R C (2012)
Preventing obesity among adolescent girls One-year out-
comes of the nutrition and enjoyable activity for teen girls
(NEAT Girls) cluster randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
821ndash827Luttikhuis H Baur L Jansen H Shrewsbury V
Orsquomalley C Stolk R amp Summerbell C (2009)
Interventions for treating obesity in children (Review)
Cochrane Database of Systematic Reviews 3 1ndash57Marx R D amp Neumark-Sztainer D (2005) Questions amp
Answers Eating Disorders The Journal of Treatment amp
Prevention 13 491ndash495McClure A C Tanksi S E Kingsbury J Gerrard M amp
Sargent J D (2010) Characteristics associated with low
self-esteem among US adolescents Academic Pediatrics
10 238ndash244Mellin L M Slinkard L A amp Irwin C E (1987)
Adolescent obesity intervention Validation of the
SHAPEDOWN program Journal of the American Dietetic
Association 87 333ndash338Mission Australia (2012) Youth Survey 2012 SydneyMoher D Shamseer L Clarke M Ghersi D Liberati
A Petticrew M PRISMA-P Group (2015) Preferred
reporting items for systematic review and meta-analysis
protocols (PRISMA-P) 2015 statement Systematic
Reviews 4 1Morgan P Saunders K amp Lubans D (2012) Improving
physical self-perception in adolescent boys from disadvan-
taged schools Psychological outcomes from the Physical
Activity Leaders randomized controlled trial Pediatric
Obesity 7 e27ndashe32 doi httpdxdoiorg101111j
2047-6310201200050xNational Health and Medical Reasearch Council (2013)
Clinical practice guidelines for the management of over-
weight and obesity in adults adolescents and children in
Australia Australia NHMRC Australian Government
Department of HealthNational Institutes for Health and Care Excellence (2013)
Managing overweight and obesity among children and
young people lifestyle weight management services NICE
public health guidance United Kingdom 47 NICENeumark-Sztainer D R Friend S E Flattum C F
Hannan P J Story M T Bauer K W Petrich C A
(2010) New moves-preventing weight-related problems in
adolescent girls A group-randomized study American
Journal of Preventive Medicine 39 421ndash432Nguyen B McGregor K A Orsquoconnor J Shrewsbury V
A Lee A Steinbeck K S Baur L A (2012)
Recruitment challenges and recommendations for adoles-
cent obesity trials Journal of Paediatrics and Child
Health 48 38ndash43Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Hill A J Shah S Baur L A (2013) Two-year
outcomes of an adjunctive telephone coaching and elec-
tronic contact intervention for adolescent weight-loss
maintenance the Loozit randomized controlled trial
International Journal of Obesity 37 468ndash472Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2012) Twelve-month
outcomes of the Loozit randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
170ndash177Ogden C L Carroll M D Kit B K amp Flegal K M
(2014) Prevalence of childhood and adult obesity in the
United States 2011-2012 Journal of the American
Medical Association 311 806ndash814Pesa J A Syre T R amp Jones E (2000) Psychosocial dif-
ferences associated with body weight among female ado-
lescents The importance of body image Journal of
Adolescent Health 26 330ndash337Pierce J W amp Wardle J (1997) Cause and effect beliefs
and self-esteem of overweight children Journal of Child
Psychology and Psychiatry 38 645ndash650 doi 101111
j1469-76101997tb01691xRoberts J E (2006) Self-esteem from a clinical perspective
In M H Kernis (Ed) Self-esteem issues and answers A
sourcebook of current perspectives Psychology Press
Taylor amp Francis New York and Hove (pp 298ndash305)
Psychology PressSacher P M Kolotourou M Chadwick P M Cole T J
Lawson M S Lucas A amp Singhal A (2010)
Randomized controlled trial of the MEND program A
family-based community intervention for childhood obes-
ity Obesity 18(Suppl 1) S62ndashS68 doi httpdxdoiorg
101038oby2009433Sanders R H Han A Baker J S amp Cobley S (2015)
Childhood obesity and its physical and psychological co-
morbidities a systematic review of Australian children and
adolescents Eur J Pediatr 174 715ndash746Sherman J B Alexander M A Gomez D Kim M amp
Marole P (1992) Intervention program for obese school chil-
dren Journal of Community Health Nursing 9 183ndash190Shrewsbury V A Nguyen B Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2011) Short-term
outcomes of community-based adolescent weight manage-
ment The LoozitVR
Study BMC Pediatrics 11 13Shrewsbury V A Orsquoconnor J Steinbeck K S Stevenson
K Lee A Hill A J Baur L A (2009) A randomised
controlled trial of a community-based healthy lifestyle
The Impact of Weight Management on Self-Esteem 393
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
program for overweight and obese adolescents TheLoozitV
R
study protocol BMC Public Health 9 119Strauss R S (2000) Childhood obesity and self-esteem
Pediatrics 105 5Tiggemann M (2005) Body dissatisfaction and adolescent
self-esteem Prospective findings Body Image 2 129ndash135doi httpdxdoiorg101016jbodyim200503006
Wadden T A Stunkard A J Rich L Rubin C JSweidel G amp McKinney S (1990) Obesity in black ado-lescent girls A controlled clinical trial of treatment by diet
behaviour modification and parental support Pediatrics85 345ndash352
Walker L Gately P Bewick B amp Hill A (2003)Childrenrsquos weight-loss camps psychological benefit orjeopardy International Journal of Obesity 27 748ndash754
World Health Organization (2014) Maternal newbornchild and adolescent health Adolescent developmentRetrieved from httpwwwwhointmaternal_child_adolescenttopicsadolescencedeven Retrieved 28 May2014
394 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
- jsw101-TF1
- jsw101-TF2
- jsw101-TF3
- jsw101-TF4
- jsw101-TF5
- jsw101-TF6
- jsw101-TF7
- jsw101-TF8
- jsw101-TF9
- jsw101-TF10
- jsw101-TF11
-
Tab
leI
(co
nti
nu
ed
)
Stu
dy
(auth
or
yea
rlo
cati
on)
Quali
tyra
ting
Part
icip
ants
Inte
rven
tions
Focu
son
self
-est
eem
Dura
tion
Outc
om
em
easu
res
Morg
an
etal
2012A
ust
ralia
30
Neu
tral
40
(100
)m
ale
s13ndash16
yea
rs
BM
I
85th
per
centi
le
ISch
ool-
base
din
terv
enti
on
incl
udin
gen
hance
dsp
ort
sess
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physi
calac-
tivit
yand
nutr
itio
nhandbooks
wit
hhom
e-base
dch
allen
ges
and
inte
r-act
ive
sem
inars
on
nutr
itio
nand
physi
calact
ivit
ybeh
avio
rsand
leader
ship
C
W
ait
list
No
spec
ific
men
-ti
on
of
self
-es
teem
3-m
onth
inte
rven
tion
Follow
up
6m
onth
sfr
om
base
line
Physi
calSel
f-Per
cepti
on
Pro
file
Adole
scen
tver
-si
on
(sel
f-es
teem
)B
MI
Neu
mark
-Szt
ain
eret
al2010
USA
(27)
Neu
tral
164
(100
)fe
-m
ale
s13ndash18
yea
rsB
MI
85th
per
centi
le
Iphysi
calact
ivit
yn
utr
itio
ns
oci
alsu
p-
port
sel
f-em
pow
erm
ent
less
ons
at
schoolw
ith
rela
ted
lett
ers
sent
hom
eto
pare
nts
alo
ng
wit
hin
div
idualm
o-
tivati
onalin
terv
iew
ing
sess
ions
toen
-co
ura
ge
goal-
sett
ingFollow
edby
lunch
tim
ese
ssio
ns
duri
ng
the
main
-te
nance
per
iod
and
a1-d
ay
pare
ntndash
daughte
rre
trea
tC
A
llgir
lsphysi
calact
ivit
ycl
ass
wit
hin
norm
alsc
hoolcu
rric
ulu
m
One
of
the
pro
-gra
mobje
ctiv
esw
as
toen
hance
aposi
tive
self
-fo
cus
and
ses-
sions
focu
sed
on
self
-em
pow
erm
ent
Phase
1mdash
daily
less
ons
at
schoolfo
r16
wee
ks
Sev
enin
div
idualse
ssio
ns
ever
y3ndash4
wee
ks
thro
ughout
inte
rven
tion
Phase
2mdash
wee
kly
lunch
tim
ese
ssio
ns
for
rem
ain
-der
of
schoolyea
r(
5m
onth
s)
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
(sel
f-es
teem
)B
MI
Nguyen
etal
2013A
ust
ralia
35
Posi
tive
55
(36
)m
ale
sand
96
(64
)fe
-m
ale
s13ndash16
yea
rsover
wei
ght
tom
oder
ate
lyobes
eB
MI
z-sc
ore
10
ndash25
(BM
I84ndash99th
per
centi
le)
IIn
terv
enti
on
base
don
the
soci
alco
g-
nit
ive
theo
ryto
modif
yse
lf-e
ffica
cy
moti
vati
onper
sever
ance
and
self
-re
gula
tionSes
sions
focu
sed
on
phys-
icalact
ivit
yhea
thy
eati
nggoalse
t-ti
ngst
ress
managem
ent
and
buildin
gse
lf-e
stee
mIn
terv
enti
on
gro
up
rece
ived
Addit
ional
Ther
apeu
tic
Conta
ct(A
TC
)fo
rtnig
htl
yth
rough-
out
the
main
tenance
per
iodPare
nt
sess
ions
incl
uded
C
A
sabove
wit
hout
the
AT
C
Buildin
gposi
tive
self
-est
eem
was
the
focu
sof
ase
ssio
n
Phase
1mdash
seven
wee
kly
75-m
ingro
up
sess
ions
Phase
2mdash
from
2to
24
month
sfive
60-m
ingro
up
sess
ions
hel
dappro
xev
ery
3m
onth
sA
TC
Fort
nig
htl
yte
le-
phone
coach
ing
sess
ions
and
SM
Se
mes
sages
Hart
errsquos
Sel
fPer
cepti
on
Pro
file
for
Adole
scen
ts(s
elf-
este
em)
BM
Iz-
score
Sach
eret
al2010
Unit
edK
ingdom
31
Posi
tive
21
(48
)m
ale
sand
23
(52
)fe
-m
ale
s10ndash12
yea
rsB
MI
gt98th
per
centi
le
IPart
icip
ants
and
thei
rfa
milie
sat-
tended
gro
up
sess
ions
focu
sing
on
be-
havio
rch
ange
nutr
itio
nand
physi
calact
ivit
ySes
sion
conte
nt
focu
sed
on
buildin
gsk
ills
tom
ain
tain
long-t
erm
beh
avio
rch
anges
Follow
ing
trea
tmen
tfa
milie
sw
ere
giv
ena
12-w
eek
free
fam
ily
swim
pass
C
W
ait
-lis
t
No
spec
ific
men
-ti
on
of
self
-es
teem
Eig
hte
en2-h
rse
ssio
ns
over
9w
eeks
Follow
up
12
month
sfr
om
base
line
Hart
errsquos
Sel
f-Per
cepti
on
Pro
file
for
Childre
n(s
elf-
este
em)
BM
Iz-
score
The Impact of Weight Management on Self-Esteem 385
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
self-esteem was observed following four MWMIsacross three studies (Croker et al 2012 Danielsenet al 2013 Nguyen Shrewsbury et al 2012) Fivestudies showed no effect on adolescent self-esteem fol-lowing MWMI (Brennan et al 2012 DeBar et al2012 Lochrie et al 2013 Lubans et al 2012Neumark-Sztainer et al 2010) No positive effects onself-esteem were observed in any of the controlgroups One wait-listed control group (Croker et al2012) showed a small negative effect on self-esteem
Mixed results were also observed in the studies forwhich an effect size could not be calculatedImprovements in adolescent self-esteem were observedfollowing MWMIs by Daley et al (2006) Mellin et al(1987) Sacher et al (2010) and Wadden et al(1990) However only Daley et al (2006) reportedthat this change was different to that observed in thecontrol group No changes in self-esteem were de-tected following intervention by Morgan et al (2012)although a significant decline in self-esteem wasobserved in the wait-listed control group who receivedthe normal school curriculum throughout the studyperiod
Multicomponent Weight ManagementInterventions Improve Weight Outcomes inAdolescentsOf the 13 included studies there were 14 groups whoreceived a MWMI and 11 no-treatment controlgroups Of these effect sizes were able to be calculatedfor nine intervention groups and seven control groups(Table III) Seven intervention groups had small to me-dium positive effects indicating successful weight loss(Brennan et al 2012 Croker et al 2012 Danielsenet al 2013 DeBar et al 2012 Lochrie et al 2013Lubans et al 2012 Nguyen Shrewsbury et al2012) and two intervention groups had no effect(Neumark-Sztainer et al 2010 Nguyen Shrewsburyet al 2012) All seven control groups showed no ef-fect on weight
Of the studies for which effect size could not be cal-culated the results were similar Mellin et al (1987)Morgan et al (2012) Sacher et al (2010) andWadden et al (1990) all observed significant weightloss following intervention Morgan et al (2012) andSacher et al (2010) also showed that these changeswere significantly different to changes observed in thecontrol groups No studies observed significant weightchange in the control groups
Correlation Between Self-Esteem Improvementand Weight Loss Effect SizesThere is a strong (rfrac14 641 R2frac140410) positive linearrelationship between effect sizes for self-esteem im-provement and weight loss across all intervention andcontrol groups (pfrac14 008)T
ab
leI
(co
nti
nu
ed
)
Stu
dy
(auth
or
yea
rlo
cati
on)
Quali
tyra
ting
Part
icip
ants
Inte
rven
tions
Focu
son
self
-est
eem
Dura
tion
Outc
om
em
easu
res
Wadden
etal
1990U
nit
edSta
tes3
6
Posi
tive
47
(100
)fe
male
s12ndash16
yea
rsat
least
10-k
gover
wei
ght
IIn
terv
enti
on
cover
eddie
tand
eati
ng
patt
erns
modif
yin
gse
lf-d
efea
ting
thoughts
and
incr
easi
ng
physi
calac-
tivit
yH
om
ework
ass
ignm
ents
and
ince
nti
ves
aw
ard
sw
ere
use
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s
386 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Tab
leIIS
elf
-Est
ee
mO
utc
om
es
of
Mu
ltic
om
po
ne
nt
We
igh
tM
an
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tIn
terv
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Co
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Ov
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seA
do
lesc
en
ts
Auth
or
yea
rIn
terv
enti
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gro
ups
Contr
olgro
ups
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
nPre
-mea
n(S
D)
Post
-mea
n(S
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Change
mea
n(S
D)
Eff
ect
size
Bre
nnan
etal2012
20
215
(54
)a206
(63
)a
21
1(4
78)a
01
514
188
(47
)a192
(47
)a06
4(3
91)a
00
9C
roker
etal2012
13
26
9(0
57)b
29
5(0
45)b
03
6(0
39)b
05
110
29
0(0
61)b
26
8(0
52)b
00
2(0
59)b
03
9D
ale
yet
al2006
28
24
2(0
56)b
26
1(0
08
SE)b
NA
NA
30
24
9(0
49)b
25
6(0
10
SE)b
NA
NA
Danie
lsen
etal2013
16
28
8(0
52)b
31
7(0
53)b
02
9(0
53)b
05
516
31
1(0
57)b
30
6(0
59)b
00
5(0
37)b
00
9D
eBar
etal2012
105
23
9(0
26)a
24
0(0
25)a
NA
00
4103
24
1(0
27)a
23
9(0
25)a
NA
00
8L
och
rie
etal2013
29
183
(50
2)b
191
(44
8)b
07
3(4
51)b
01
718
199
(34
6)b
199
(34
3)b
00
0(3
11)b
00
0L
ubans
etal2012
54
40
3(1
12)c
40
6(1
32)c
NA
00
268
40
4(0
99)c
42
3(0
98)c
NA
01
9M
ellin
etal1987
37
NA
NA
08
8(1
50)a
NA
29
NA
NA
05
2(1
34)a
NA
Morg
an
etal2012
19
NA
NA
00
8(0
48)d
NA
21
NA
NA
02
6(0
47)d
NA
Neu
mark
-Szt
ain
eret
al2010
85
152
(34
)b151
(29
)bN
A
00
379
141
(34
)b140
(34
)bN
A
00
3
Nguyen
etal2012
(wit
hA
TC
)57
25
8(0
76)b
27
7(0
63)b
01
9(0
67)b
02
7
Nguyen
etal2012
(wit
hout
AT
C)
50
25
9(0
58)b
29
3(0
61)b
01
9(0
51)b
05
7
Sach
eret
al2010
20
NA
32
5(0
68)b
02
5(0
66)b
NA
24
NA
30
4(0
75)b
01
1(0
74)b
NA
Wadden
etal1990
3gro
ups
com
bin
ed47
576
e599
eN
AN
A
Note
D
ata
pre
sente
das
report
edin
ori
gin
alpaper
sSDfrac14
standard
dev
iati
onN
Afrac14
data
not
pro
vid
edu
nab
leto
be
calc
ula
ted
SEfrac14
Sta
ndard
erro
rnot
Sta
ndard
Dev
iati
onE
ffec
tsi
zefrac14
Cohen
rsquosdB
old
font
indic
ate
sw
her
eef
fect
size
was
small
(02
0)
or
gre
ate
raR
ose
nber
gse
lf-e
stee
msc
ale
(gen
erally
score
dfr
om
0[l
ow
est
self
-est
eem
]to
30
[hig
hes
tse
lf-e
stee
m])
bH
art
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SPPA
SPPC
(gen
erally
score
d1
[low
est
self
-est
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]to
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ighes
tse
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cM
ars
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Physi
calSel
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ipti
on
Ques
tionnair
e
dPhysi
calSel
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cepti
on
Pro
file
for
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ts
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Sca
le
Sco
ring
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sunav
ailab
lehig
her
valu
eeq
uals
hig
her
self
-est
eem
The Impact of Weight Management on Self-Esteem 387
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Tab
leIII
We
igh
tO
utc
om
es
of
Mu
ltic
om
po
ne
nt
We
igh
tM
an
ag
em
en
tIn
terv
en
tio
ns
Co
mp
are
dW
ith
Co
ntr
ols
in
Ov
erw
eig
ht
an
dO
be
seA
do
lesc
en
ts
Auth
or
yea
rIn
terv
enti
on
gro
ups
Contr
olgro
ups
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
Bre
nnan
etal2012
20
20
8(0
37)
19
9(0
46)
02
0(0
18)
02
214
20
8(0
40)
20
9(0
39)
00
1(0
12)
00
3C
roker
etal2012
13
29
5(0
52)
26
6(0
63)
01
7(0
21)
05
010
31
4(0
68)
31
4(0
68)
00
6(0
13)
00
0D
ale
yet
al2006
28
31
7(0
33)
32
3(0
02
SE)
NA
NA
30
33
2(0
37)
32
3(0
02
SE)
NA
NA
Danie
lsen
etal2013
16
25
9(0
30)
24
6(0
41)
01
2(0
17)
03
616
24
9(0
27)
25
3(0
29)
00
5(0
15)
01
4D
eBar
etal2012
105
20
0(0
34)
18
8(0
41)
NA
03
2103
20
0(0
33)
19
4(0
38)
NA
01
7L
och
rie
etal2013
29
21
9(0
40)
20
6(0
52)
01
2(0
20)
02
818
20
7(0
40)
20
5(0
43)
00
2(0
11)
00
5L
ubans
etal2012
54
19
3(0
61)
18
0(0
68)
NA
02
068
18
5(0
59)
18
0(0
67)
NA
00
8M
ellin
etal1987
37
1365
aN
A
59
(67
5)a
NA
29
1295
aN
A
03
(66
1)a
NA
Morg
an
etal2012
19
NA
NA
04
2(0
91)b
NA
21
NA
NA
00
3(0
87)b
NA
Neu
mark
-Szt
ain
eret
al2010
85
321
(61
)b322
(62
)bN
A
00
279
310
(53
)b314
(55
)bN
A
00
7
Nguyen
etal2012
(wit
hA
TC
)57
20
3(0
37)
19
7(0
42)
00
8(0
19)
01
5
Nguyen
etal2012
(wit
hout
AT
C)
50
20
2(0
29)
19
4(0
32)
00
9(0
17)
02
6
Sach
eret
al2010
20
NA
23
7(0
52)
02
2(0
27)
NA
24
NA
26
0(0
54)
00
1(0
20)
NA
Wadden
etal1990
3gro
ups
com
bin
ed47
352
b339
bN
AN
A
Note
D
ata
pre
sente
das
report
edin
ori
gin
al
paper
sA
llw
eight
outc
om
esre
port
edas
body
mass
index
(BM
I)z-
score
unle
ssoth
erw
ise
state
d
SDfrac14
standar
ddev
iati
on
NAfrac14
data
not
pro
vid
ed
unab
leto
be
calc
ula
ted
SEfrac14
Sta
ndard
Err
or
report
edra
ther
than
Sta
ndard
Dev
iati
onE
ffec
tsi
zefrac14
Cohen
rsquosdB
old
font
indic
ate
sw
her
eef
fect
size
was
smal
l(0
20)
or
gre
ate
raR
elati
ve
wei
ght
bB
MI
388 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Quantitative Data AnalysisDifferences between intervention and control groupsfor change in self-esteem are presented in Figure 2aThis analysis included seven intervention groups(nfrac14 191) and seven control groups (nfrac14 132) with
interventions or intensive treatment phases rangingfrom 9 weeks to 6 months in duration A moderatelevel of the variation across studies was owing to het-erogeneity (I2frac14464 Higgins Thompson Deeksamp Altman 2003) The overall summary effect showed
Figure 2 Comparison between intervention and control groups for the change in adolescent self-esteem effect size (a) andbody mass index z-score (b) following multicomponent weight management interventions SMD frac14 standard mean differ-ence WMD frac14 weighted mean difference
The Impact of Weight Management on Self-Esteem 389
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no effect on self-esteem as a result of interventionSMD of 027 (95 confidence interval 004 059)zfrac14 169 and pfrac14 092 However all studies exceptone favored the intervention for improvements in self-esteem
The difference between intervention and controlgroups for change in BMI z-score is illustrated inFigure 2b This analysis included five interventiongroups (nfrac14 135) and five control groups (nfrac14 82) withinterventions ranging from 9 weeks to 6 months induration Heterogeneity in this sample was low(I2frac14177 Higgins et al 2003) and the overall sum-mary effect was 017 (022 011) BMI z-scorepoints (zfrac14613 and plt 001) indicating statisticallysignificant weight loss following MWMI
Discussion
The purpose of this review was to examine the effectof MWMIs on self-esteem in overweight and obeseadolescents Increased self-esteem is proposed as a keyfactor for maintaining long-term weight management(Elfhag amp Rossner 2005 French et al 1995Roberts 2006) A secondary outcome of this reviewwas to examine the impact of MWMIs on weight lossand whether this was associated with improvements inself-esteem
The meta-analysis showed no difference in self-esteem between the intervention and control groupsHowever six of the seven studies in the meta-analysisfavored the intervention over control for improve-ments in self-esteem and four of the six studies notincluded in the meta-analysis found significant im-provements in self-esteem following intervention Thelatter of these findings are similar to those of an earlierreview (Lowry et al 2007) that showed improve-ments in self-esteem following weight managementinterventions in a pediatric population particularlywhen certain intervention features were presentSimilarly a number of intervention features that con-tributed to an increased likelihood of improving self-esteem were identified in this review
Improvements in self-esteem regardless of weightloss have been demonstrated in children who tookpart in weight management interventions thatincluded a focus on building self-esteem and it is rec-ommended that this be a focus of all pediatric weightmanagement interventions (Lowry et al 2007) Yetthe majority of studies identified in this review did notinclude building self-esteem as a key aspect of theirintervention Nguyen Shrewsbury et al (2012)described the greatest focus on self-esteem (one75-min group session focused on building self-esteem)and also resulted in the largest treatment effect (057)and a significant improvement in self-esteem (NguyenShrewsbury et al 2012) A focus on similar topics
such as body image social support and managing bul-lying may also contribute to improvements in self-esteem (Croker et al 2012 Pierce amp Wardle 1997Tiggemann 2005) however these findings highlightthe lack of uptake of these recommendations
Among overweight and obese youth reductions inself-esteem are often observed in domains of physicalappearance and physical ability (Franklin DenyerSteinbeck Caterson amp Hill 2006 French et al1995 Latzer amp Stein 2013 Lowry et al 2007)Particularly for adolescent girls body image is a keyconcern (Cave Fildes Luckett amp Wearring 2015)and comprises a large portion of global self-esteem(Lowry et al 2007 Pesa Syre amp Jones 2000)However weight loss and associated changes in phys-ical appearance do not necessarily reflect improve-ments in self-esteem (Lowry et al 2007) Changes inbody-esteem often occur more rapidly than changes inglobal self-esteem as a result of weight management(Lowry et al 2007) This may explain the lack ofchange observed in global self-esteem in this meta-analysis and highlights the need to also include body-esteem (or physical self-esteem) as a focus and out-come of weight management interventions foradolescents
Parental involvement in adolescent weight manage-ment interventions is a critical component for success-ful weight loss and may also be important forimproving self-esteem (Lowry et al 2007) Weight-related teasing from family is shown to be negativelyassociated with self-esteem in overweight adolescentswhereas family connectedness was positively associ-ated with adolescent self-esteem (Fulkerson StraussNeumark-Sztainer Story amp Boutelle 2007) The in-clusion of parents in weight management interventionsfosters a safer and more encouraging home environ-ment for the adolescent (Lowry et al 2007) which isassociated with increased self-esteem in nonover-weight children (Marx amp Neumark-Sztainer 2005)All studies in the present review baring one includedparents in the intervention Parental involvementshould continue to be a key component of weightmanagement interventions to ensure a supportivehome environment for the adolescent to help fosterpositive self-esteem
Weight management interventions that used agroup setting to target self-esteem have shown im-provements in self-esteem without significant weightchange (Lowry et al 2007 Sherman AlexanderGomez Kim amp Marole 1992) The ability of the peergroup setting to provide opportunities for bondingsupport feelings of belonging development of peer-based skills and positive peer exchanges is key toincreasing self-esteem (Lowry et al 2007) The im-portance of this element is being acknowledged in the
390 Murray Dordevic and Bonham
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field with all the studies in this review baring twousing group sessions in their intervention
Measures of self-esteem are self-reported and there-fore subjective Responses to questionnaires are likelyto be influenced by individual (eg age gender) andenvironmental (eg cultural group socioeconomicstatus) factors (Khanlou 2004) Changes followinginterventions may represent genuine long-termchanges in self-esteem or may be due to short-termfluctuations in self-esteem in response to specificevents (eg winning a sporting event or performanceon a test at school) (Kernis 1993) While validatedtools were used to measure self-esteem in all studies itwas difficult to conclude whether outcomes were en-tirely dependent on the intervention without inclusionof a no-treatment control group
The variety of self-esteem assessment tools also addsto the difficulty of interpretation Across the 13 studies inthis review five different tools were used with differentquestions and different scales Even within tools therewere different scales used to report the results (RosenbergSelf-esteem Scale) and different versions of the same ques-tionnaire (Harterrsquos Self-perception Profile for ChildrenHarterrsquos Self-perception Profile for Adolescents) HarterrsquosSelf-Perception Profile (Harterrsquos Self-perception Profilefor Adolescents for adolescents) which measures ninesubscales of self-esteem including physical self-esteem issuggested as the most appropriate measure for adolescentself-esteem (Lowry et al 2007) It was also the mostcommonly used tool among papers included in this re-view While Cohenrsquos d effect sizes were used to stand-ardize results in this review the consistent use of one toolwould provide the ability to compare raw self-esteemscores and create a stronger analysis in the future
Results from this review support evidence thatMWMIs induce weight loss in overweight and obeseadolescents (Hoelscher Kirk Ritchie ampCunningham-Sabo 2013 Kelly amp Melnyk 2008Luttikhuis et al 2009) The change in BMI z-score inthe present meta-analysis (017 [022 011]) wassimilar to the clinically meaningful weight loss re-ported in the 2009 Cochrane Review in children 12years at 6 months follow up from a lifestyle weightmanagement intervention (014 [017 012])(Luttikhuis et al 2009) Jelalian Mehlenbeck Lloyd-Richardson Birmaher and Wing (2006) and WalkerGately Bewick and Hill (2003) have demonstratedassociations between weight loss and increased self-esteem in overweight and obese adolescents after at-tending a weight-management intervention Similarlyin the present review a strong positive relationship be-tween treatment effects for weight loss and improve-ment in self-esteem was identified However itremains unclear whether the improvement in self-esteem was as a result of successful weight loss orwhether it was a contributing factor toward successful
weight loss Nonetheless building self-esteem shouldbe a key focus of MWMIs as improved self-esteem ap-
pears to be linked to enhanced weight lossA key strength of this review was that all included
studies had strong designs and presented level II evi-dence (Coleman et al 2009) However to further elu-
cidate the role of self-esteem in adolescent weightmanagement future research should consider power-
ing studies to detect changes in psychosocial as well asphysiological outcomes Only one study in this reviewwas powered to detect a change in psychosocial out-
comes (Daley et al 2006) which may explain thelack of significant results observed for self-esteem
Additionally a large number of included studies didnot describe their method of handling withdrawals or
use blinding to prevent the introduction of bias Toimprove confidence in the effectiveness of MWMIs
and reduce the risk of bias future studies should bedesigned with concealed allocation and document andreport in detail the flow of participants
Identification of intervention components that im-
prove self-esteem is important for future weight man-agement intervention design Included interventionswere heterogeneous offering different levels of diet-
ary physical activity and behavioral interventionwhich may have collectively or individually influenced
the results Inconsistent reporting of intervention andcomparator conditions make it difficult to elucidate
the components that contributed to improvements inself-esteem Future studies should report intervention
and comparator procedures in adequate detail so thatsuccessful components can be identified and repli-cated These limitations highlight areas for improve-
ment to develop best-practice guidelines forundertaking and evaluating MWMIs in adolescents to
enhance self-esteem
Conclusion
Overweight and obese adolescents experience low
self-esteem largely owing to poor body image yetthis meta-analysis found no improvement in self-esteem even with significant weight loss Although it
was noted that interventions that had larger effects onself-esteem also had larger effects on weight loss The
incorporation of intervention components that wereidentified to contribute to improvements in self-
esteem may assist future weight management interven-tions to improve the self-esteem of overweight and
obese adolescents Furthermore a consistent measureof self-esteem would enable easier interpretation ofself-esteem scores and comparison of results across
studies to improve our understanding of the relation-ship between self-esteem and weight management in
adolescents
The Impact of Weight Management on Self-Esteem 391
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Supplementary Data
Supplementary data can be found at httpwwwjpepsy
oxfordjournalsorg
Acknowledgments
The authors would like to acknowledge Dr Zoe Davidson
for her assistance in performing the meta-analyses
Funding
This work was supported by an Australian GovernmentResearch Training Program Scholarship
Conflicts of interest none declared
References
Academy of Nutrition and Dietetics (2012) Evidence ana-lysis manual Steps in the academy evidence analysis pro-cess Chicago IL ADA Research and Strategic Business
DevelopmentBrennan L Walkley J Fraser S F Greenway K amp
Wilks R (2008) Motivational interviewing and cognitivebehaviour therapy in the treatment of adolescent over-
weight and obesity Study design and methodologyContemporary Clinical Trials 29 359ndash375
Brennan L Walkley J Wilks R Fraser S F amp
Greenway K (2013) Physiological and behavioural out-comes of a randomised controlled trial of a cognitive be-havioural lifestyle intervention for overweight and obese
adolescents Obesity Research and Clinical Practice 7e23ndashe41
Brennan L Wilks R Walkley J Fraser S F amp
Greenway K (2012) Treatment acceptability and psycho-social outcomes of a randomised controlled trial of a cog-nitive behavioural lifestyle intervention for overweight and
obese adolescents Behaviour Change 29 36ndash62Cave L Fildes J Luckett G amp Wearring A (2015)
Mission Australiarsquos 2015 youth survey report MissionAustralia
Coleman K Norris S Weston A Grimmer-Somers KHillier S Merlin T Salisbury J (2009) NHMRCadditional levels of evidence and grades for recommenda-tions for developers of guidelines (Vol Stage 2Consultation) Australia National Health and Medical
Research CouncilCroker H Viner R M Nicholls D Haroun D
Chadwick P Edwards C Wardle J (2012) Family-based behavioural treatment of childhood obesity in a UK
national health service setting Randomized controlledtrial International Journal of Obesity 36 16ndash26 doi
101038ijo2011182Daley A J Copeland R J Wright N P Roalfe A amp
Wales J K H (2006) Exercise therapy as a treatment forpsychopathologic conditions in obese and morbidly obese
adolescents A randomized controlled trial Pediatrics118 2126ndash2134
Danielsen Y S Nordhus I H Julıusson P B Maelighle Mamp Pallesen S (2013) Effect of a family-based cognitive
behavioural intervention on body mass index self-esteem
and symptoms of depression in children with obesity (aged
7mdash13) A randomised waiting list controlled trial ObesityResearch amp Clinical Practice 7 e116ndashe128
DeBar L L Stevens V J Perrin N Wu P Pearson J ampJo B (2012) A primary care-based multicomponent life-
style intervention for overweight adolescent femalesPediatrics 129 e611ndashe620
Elfhag K amp Rossner S (2005) Who succeeds in maintain-ing weight loss A conceptual review of factors associated
with weight loss maintenance and weight regain ObesityReviews 6 67ndash85
Franklin J Denyer G Steinbeck K S Caterson I D ampHill A J (2006) Obesity and risk of low self-esteem Astatewide survey of Australian children Pediatrics 118
2481ndash2487French S A Story M amp Perry C L (1995) Self-esteem
and obesity in children and adolescents A literature re-view Obesity Research 3 479ndash490
Fulkerson J Strauss J Neumark-Sztainer D Story M
amp Boutelle K (2007) Correlates of psychosocial well-being among overweight adolescents The role of the fam-ily Journal of Consulting and Clinical Psychology 75
181ndash186Griffiths L J Parsons T J amp Hill A J (2010) Self-es-
teem and quality of life in obese children and adolescentsA systematic review International Journal of PediatricObesity 5 282ndash304
Harter S (1993) Causes and consequences of low self-
esteem in children and adolescents In R F Baumeister(Ed) Self-esteemmdashThe puzzle of low self-regard (pp87ndash116) USA Springer
Higgins J Thompson S Deeks J amp Altman D (2003)
Measuring inconsistency in meta-analyses BMJ 327557ndash560
Hoelscher D M Kirk S Ritchie L amp Cunningham-Sabo L (2013) Position of the Academy of Nutrition and
Dietetics Interventions for the prevention and treatmentof pediatric overweight and obesity Journal of theAcademy of Nutrition and Dietetics 113 1375ndash1394
Jelalian E Mehlenbeck R Lloyd-Richardson EBirmaher V amp Wing R (2006) lsquoAdventure therapyrsquo
combined with cognitivebehavioral treatment for over-weight adolescents International Journal of Obesity 3031ndash39
Kelly S A amp Melnyk B M (2008) Systematic review of
multicomponent interventions with overweight middleadolescents implications for clinical practice and researchWorldviews on Evidence-Based Nursing 5 113ndash135
Kernis M (1993) The roles of stability and level of self-
esteem in psychological functioning In R Baumeister(Ed) Self-esteem (pp 167ndash182) USA Springer
Khanlou N (2004) Influences on adolescent self-esteem inmulticultural Canadian secondary schools Public HealthNursing 21 404ndash411
Kohn M Rees J M Brill S Fonseca H Jacobson M
Katzman D K Schneider M (2006) Preventing andtreating adolescent obesity A position paper of the Societyfor Adolescent Medicine Journal of Adolescent Health
38 784ndash787Kornman K P Shrewsbury V A Chou A C Ngyuen
B Lee A Orsquoconnor J Baur L A (2010) Electronic
392 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
therapeutic contact for adolescent weight management
The Loozit study Telemedicine and E-Health 16
678ndash685Latzer Y amp Stein D (2013) A review of the psychological
and familial perspectives of childhood obesity Journal of
Eating Disorders 1 7Lobstein T Baur L amp Uauy R (2004) Obesity in chil-
dren and young people a crisis in public health Obesity
Reviews 5(Suppl 1) 4ndash104Lochrie A S Wysocki T Hossain J Milkes A Antal
H Buckloh L Lang J (2013) The effects of a family-
based intervention (FBI) for overweightobese children on
health and psychological functioning Clinical Practice in
Pediatric Psychology 1 159ndash170 doi httpdxdoiorg
101037cpp0000020Lowry K W Sallinen B amp Janicke D (2007) The effects
of weight management programs on self-esteem in pediat-
ric overweight populations Journal of Pediatric
Psychology 32 1179ndash1195Lubans D R Morgan P J Okely A D Dewar D
Collins C E Batterham M Plotnikoff R C (2012)
Preventing obesity among adolescent girls One-year out-
comes of the nutrition and enjoyable activity for teen girls
(NEAT Girls) cluster randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
821ndash827Luttikhuis H Baur L Jansen H Shrewsbury V
Orsquomalley C Stolk R amp Summerbell C (2009)
Interventions for treating obesity in children (Review)
Cochrane Database of Systematic Reviews 3 1ndash57Marx R D amp Neumark-Sztainer D (2005) Questions amp
Answers Eating Disorders The Journal of Treatment amp
Prevention 13 491ndash495McClure A C Tanksi S E Kingsbury J Gerrard M amp
Sargent J D (2010) Characteristics associated with low
self-esteem among US adolescents Academic Pediatrics
10 238ndash244Mellin L M Slinkard L A amp Irwin C E (1987)
Adolescent obesity intervention Validation of the
SHAPEDOWN program Journal of the American Dietetic
Association 87 333ndash338Mission Australia (2012) Youth Survey 2012 SydneyMoher D Shamseer L Clarke M Ghersi D Liberati
A Petticrew M PRISMA-P Group (2015) Preferred
reporting items for systematic review and meta-analysis
protocols (PRISMA-P) 2015 statement Systematic
Reviews 4 1Morgan P Saunders K amp Lubans D (2012) Improving
physical self-perception in adolescent boys from disadvan-
taged schools Psychological outcomes from the Physical
Activity Leaders randomized controlled trial Pediatric
Obesity 7 e27ndashe32 doi httpdxdoiorg101111j
2047-6310201200050xNational Health and Medical Reasearch Council (2013)
Clinical practice guidelines for the management of over-
weight and obesity in adults adolescents and children in
Australia Australia NHMRC Australian Government
Department of HealthNational Institutes for Health and Care Excellence (2013)
Managing overweight and obesity among children and
young people lifestyle weight management services NICE
public health guidance United Kingdom 47 NICENeumark-Sztainer D R Friend S E Flattum C F
Hannan P J Story M T Bauer K W Petrich C A
(2010) New moves-preventing weight-related problems in
adolescent girls A group-randomized study American
Journal of Preventive Medicine 39 421ndash432Nguyen B McGregor K A Orsquoconnor J Shrewsbury V
A Lee A Steinbeck K S Baur L A (2012)
Recruitment challenges and recommendations for adoles-
cent obesity trials Journal of Paediatrics and Child
Health 48 38ndash43Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Hill A J Shah S Baur L A (2013) Two-year
outcomes of an adjunctive telephone coaching and elec-
tronic contact intervention for adolescent weight-loss
maintenance the Loozit randomized controlled trial
International Journal of Obesity 37 468ndash472Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2012) Twelve-month
outcomes of the Loozit randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
170ndash177Ogden C L Carroll M D Kit B K amp Flegal K M
(2014) Prevalence of childhood and adult obesity in the
United States 2011-2012 Journal of the American
Medical Association 311 806ndash814Pesa J A Syre T R amp Jones E (2000) Psychosocial dif-
ferences associated with body weight among female ado-
lescents The importance of body image Journal of
Adolescent Health 26 330ndash337Pierce J W amp Wardle J (1997) Cause and effect beliefs
and self-esteem of overweight children Journal of Child
Psychology and Psychiatry 38 645ndash650 doi 101111
j1469-76101997tb01691xRoberts J E (2006) Self-esteem from a clinical perspective
In M H Kernis (Ed) Self-esteem issues and answers A
sourcebook of current perspectives Psychology Press
Taylor amp Francis New York and Hove (pp 298ndash305)
Psychology PressSacher P M Kolotourou M Chadwick P M Cole T J
Lawson M S Lucas A amp Singhal A (2010)
Randomized controlled trial of the MEND program A
family-based community intervention for childhood obes-
ity Obesity 18(Suppl 1) S62ndashS68 doi httpdxdoiorg
101038oby2009433Sanders R H Han A Baker J S amp Cobley S (2015)
Childhood obesity and its physical and psychological co-
morbidities a systematic review of Australian children and
adolescents Eur J Pediatr 174 715ndash746Sherman J B Alexander M A Gomez D Kim M amp
Marole P (1992) Intervention program for obese school chil-
dren Journal of Community Health Nursing 9 183ndash190Shrewsbury V A Nguyen B Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2011) Short-term
outcomes of community-based adolescent weight manage-
ment The LoozitVR
Study BMC Pediatrics 11 13Shrewsbury V A Orsquoconnor J Steinbeck K S Stevenson
K Lee A Hill A J Baur L A (2009) A randomised
controlled trial of a community-based healthy lifestyle
The Impact of Weight Management on Self-Esteem 393
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
program for overweight and obese adolescents TheLoozitV
R
study protocol BMC Public Health 9 119Strauss R S (2000) Childhood obesity and self-esteem
Pediatrics 105 5Tiggemann M (2005) Body dissatisfaction and adolescent
self-esteem Prospective findings Body Image 2 129ndash135doi httpdxdoiorg101016jbodyim200503006
Wadden T A Stunkard A J Rich L Rubin C JSweidel G amp McKinney S (1990) Obesity in black ado-lescent girls A controlled clinical trial of treatment by diet
behaviour modification and parental support Pediatrics85 345ndash352
Walker L Gately P Bewick B amp Hill A (2003)Childrenrsquos weight-loss camps psychological benefit orjeopardy International Journal of Obesity 27 748ndash754
World Health Organization (2014) Maternal newbornchild and adolescent health Adolescent developmentRetrieved from httpwwwwhointmaternal_child_adolescenttopicsadolescencedeven Retrieved 28 May2014
394 Murray Dordevic and Bonham
Dow
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icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
- jsw101-TF1
- jsw101-TF2
- jsw101-TF3
- jsw101-TF4
- jsw101-TF5
- jsw101-TF6
- jsw101-TF7
- jsw101-TF8
- jsw101-TF9
- jsw101-TF10
- jsw101-TF11
-
self-esteem was observed following four MWMIsacross three studies (Croker et al 2012 Danielsenet al 2013 Nguyen Shrewsbury et al 2012) Fivestudies showed no effect on adolescent self-esteem fol-lowing MWMI (Brennan et al 2012 DeBar et al2012 Lochrie et al 2013 Lubans et al 2012Neumark-Sztainer et al 2010) No positive effects onself-esteem were observed in any of the controlgroups One wait-listed control group (Croker et al2012) showed a small negative effect on self-esteem
Mixed results were also observed in the studies forwhich an effect size could not be calculatedImprovements in adolescent self-esteem were observedfollowing MWMIs by Daley et al (2006) Mellin et al(1987) Sacher et al (2010) and Wadden et al(1990) However only Daley et al (2006) reportedthat this change was different to that observed in thecontrol group No changes in self-esteem were de-tected following intervention by Morgan et al (2012)although a significant decline in self-esteem wasobserved in the wait-listed control group who receivedthe normal school curriculum throughout the studyperiod
Multicomponent Weight ManagementInterventions Improve Weight Outcomes inAdolescentsOf the 13 included studies there were 14 groups whoreceived a MWMI and 11 no-treatment controlgroups Of these effect sizes were able to be calculatedfor nine intervention groups and seven control groups(Table III) Seven intervention groups had small to me-dium positive effects indicating successful weight loss(Brennan et al 2012 Croker et al 2012 Danielsenet al 2013 DeBar et al 2012 Lochrie et al 2013Lubans et al 2012 Nguyen Shrewsbury et al2012) and two intervention groups had no effect(Neumark-Sztainer et al 2010 Nguyen Shrewsburyet al 2012) All seven control groups showed no ef-fect on weight
Of the studies for which effect size could not be cal-culated the results were similar Mellin et al (1987)Morgan et al (2012) Sacher et al (2010) andWadden et al (1990) all observed significant weightloss following intervention Morgan et al (2012) andSacher et al (2010) also showed that these changeswere significantly different to changes observed in thecontrol groups No studies observed significant weightchange in the control groups
Correlation Between Self-Esteem Improvementand Weight Loss Effect SizesThere is a strong (rfrac14 641 R2frac140410) positive linearrelationship between effect sizes for self-esteem im-provement and weight loss across all intervention andcontrol groups (pfrac14 008)T
ab
leI
(co
nti
nu
ed
)
Stu
dy
(auth
or
yea
rlo
cati
on)
Quali
tyra
ting
Part
icip
ants
Inte
rven
tions
Focu
son
self
-est
eem
Dura
tion
Outc
om
em
easu
res
Wadden
etal
1990U
nit
edSta
tes3
6
Posi
tive
47
(100
)fe
male
s12ndash16
yea
rsat
least
10-k
gover
wei
ght
IIn
terv
enti
on
cover
eddie
tand
eati
ng
patt
erns
modif
yin
gse
lf-d
efea
ting
thoughts
and
incr
easi
ng
physi
calac-
tivit
yH
om
ework
ass
ignm
ents
and
ince
nti
ves
aw
ard
sw
ere
use
dto
en-
coura
ge
part
icip
ati
onT
her
ew
ere
thre
edif
fere
nt
inte
rven
tion
gro
ups
who
rece
ived
this
trea
tmen
tch
ild
only
ch
ild
and
moth
erto
get
her
ch
ild
and
moth
erse
para
tely
C
N
ocl
ear
contr
olgro
upse
eabove
No
spec
ific
men
-ti
on
of
self
-es
teem
Six
teen
wee
kly
1-h
rle
ssons
No
follow
up
Pie
rs-H
arr
issc
ale
(sel
f-es
teem
)B
MI
Note
B
MIfrac14
body
mass
index
Ifrac14
inte
rven
tionCfrac14
Com
par
ato
rC
om
par
ato
rgro
ups
that
rece
ived
an
inte
rven
tion
wer
etr
eate
das
inte
rven
tion
gro
ups
for
the
purp
ose
of
anal
ysi
sin
this
revie
w
Stu
die
sare
list
edin
alp
habet
icalord
erin
all
table
s
386 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Tab
leIIS
elf
-Est
ee
mO
utc
om
es
of
Mu
ltic
om
po
ne
nt
We
igh
tM
an
ag
em
en
tIn
terv
en
tio
ns
Co
mp
are
dW
ith
Co
ntr
ols
in
Ov
erw
eig
ht
an
dO
be
seA
do
lesc
en
ts
Auth
or
yea
rIn
terv
enti
on
gro
ups
Contr
olgro
ups
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
Bre
nnan
etal2012
20
215
(54
)a206
(63
)a
21
1(4
78)a
01
514
188
(47
)a192
(47
)a06
4(3
91)a
00
9C
roker
etal2012
13
26
9(0
57)b
29
5(0
45)b
03
6(0
39)b
05
110
29
0(0
61)b
26
8(0
52)b
00
2(0
59)b
03
9D
ale
yet
al2006
28
24
2(0
56)b
26
1(0
08
SE)b
NA
NA
30
24
9(0
49)b
25
6(0
10
SE)b
NA
NA
Danie
lsen
etal2013
16
28
8(0
52)b
31
7(0
53)b
02
9(0
53)b
05
516
31
1(0
57)b
30
6(0
59)b
00
5(0
37)b
00
9D
eBar
etal2012
105
23
9(0
26)a
24
0(0
25)a
NA
00
4103
24
1(0
27)a
23
9(0
25)a
NA
00
8L
och
rie
etal2013
29
183
(50
2)b
191
(44
8)b
07
3(4
51)b
01
718
199
(34
6)b
199
(34
3)b
00
0(3
11)b
00
0L
ubans
etal2012
54
40
3(1
12)c
40
6(1
32)c
NA
00
268
40
4(0
99)c
42
3(0
98)c
NA
01
9M
ellin
etal1987
37
NA
NA
08
8(1
50)a
NA
29
NA
NA
05
2(1
34)a
NA
Morg
an
etal2012
19
NA
NA
00
8(0
48)d
NA
21
NA
NA
02
6(0
47)d
NA
Neu
mark
-Szt
ain
eret
al2010
85
152
(34
)b151
(29
)bN
A
00
379
141
(34
)b140
(34
)bN
A
00
3
Nguyen
etal2012
(wit
hA
TC
)57
25
8(0
76)b
27
7(0
63)b
01
9(0
67)b
02
7
Nguyen
etal2012
(wit
hout
AT
C)
50
25
9(0
58)b
29
3(0
61)b
01
9(0
51)b
05
7
Sach
eret
al2010
20
NA
32
5(0
68)b
02
5(0
66)b
NA
24
NA
30
4(0
75)b
01
1(0
74)b
NA
Wadden
etal1990
3gro
ups
com
bin
ed47
576
e599
eN
AN
A
Note
D
ata
pre
sente
das
report
edin
ori
gin
alpaper
sSDfrac14
standard
dev
iati
onN
Afrac14
data
not
pro
vid
edu
nab
leto
be
calc
ula
ted
SEfrac14
Sta
ndard
erro
rnot
Sta
ndard
Dev
iati
onE
ffec
tsi
zefrac14
Cohen
rsquosdB
old
font
indic
ate
sw
her
eef
fect
size
was
small
(02
0)
or
gre
ate
raR
ose
nber
gse
lf-e
stee
msc
ale
(gen
erally
score
dfr
om
0[l
ow
est
self
-est
eem
]to
30
[hig
hes
tse
lf-e
stee
m])
bH
art
errsquos
SPPA
SPPC
(gen
erally
score
d1
[low
est
self
-est
eem
]to
4[h
ighes
tse
lf-e
stee
m])
cM
ars
hrsquos
Physi
calSel
f-D
escr
ipti
on
Ques
tionnair
e
dPhysi
calSel
f-Per
cepti
on
Pro
file
for
Adole
scen
ts
ePie
rs-H
arr
isSel
f-C
once
pt
Sca
le
Sco
ring
range
sunav
ailab
lehig
her
valu
eeq
uals
hig
her
self
-est
eem
The Impact of Weight Management on Self-Esteem 387
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Tab
leIII
We
igh
tO
utc
om
es
of
Mu
ltic
om
po
ne
nt
We
igh
tM
an
ag
em
en
tIn
terv
en
tio
ns
Co
mp
are
dW
ith
Co
ntr
ols
in
Ov
erw
eig
ht
an
dO
be
seA
do
lesc
en
ts
Auth
or
yea
rIn
terv
enti
on
gro
ups
Contr
olgro
ups
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
Bre
nnan
etal2012
20
20
8(0
37)
19
9(0
46)
02
0(0
18)
02
214
20
8(0
40)
20
9(0
39)
00
1(0
12)
00
3C
roker
etal2012
13
29
5(0
52)
26
6(0
63)
01
7(0
21)
05
010
31
4(0
68)
31
4(0
68)
00
6(0
13)
00
0D
ale
yet
al2006
28
31
7(0
33)
32
3(0
02
SE)
NA
NA
30
33
2(0
37)
32
3(0
02
SE)
NA
NA
Danie
lsen
etal2013
16
25
9(0
30)
24
6(0
41)
01
2(0
17)
03
616
24
9(0
27)
25
3(0
29)
00
5(0
15)
01
4D
eBar
etal2012
105
20
0(0
34)
18
8(0
41)
NA
03
2103
20
0(0
33)
19
4(0
38)
NA
01
7L
och
rie
etal2013
29
21
9(0
40)
20
6(0
52)
01
2(0
20)
02
818
20
7(0
40)
20
5(0
43)
00
2(0
11)
00
5L
ubans
etal2012
54
19
3(0
61)
18
0(0
68)
NA
02
068
18
5(0
59)
18
0(0
67)
NA
00
8M
ellin
etal1987
37
1365
aN
A
59
(67
5)a
NA
29
1295
aN
A
03
(66
1)a
NA
Morg
an
etal2012
19
NA
NA
04
2(0
91)b
NA
21
NA
NA
00
3(0
87)b
NA
Neu
mark
-Szt
ain
eret
al2010
85
321
(61
)b322
(62
)bN
A
00
279
310
(53
)b314
(55
)bN
A
00
7
Nguyen
etal2012
(wit
hA
TC
)57
20
3(0
37)
19
7(0
42)
00
8(0
19)
01
5
Nguyen
etal2012
(wit
hout
AT
C)
50
20
2(0
29)
19
4(0
32)
00
9(0
17)
02
6
Sach
eret
al2010
20
NA
23
7(0
52)
02
2(0
27)
NA
24
NA
26
0(0
54)
00
1(0
20)
NA
Wadden
etal1990
3gro
ups
com
bin
ed47
352
b339
bN
AN
A
Note
D
ata
pre
sente
das
report
edin
ori
gin
al
paper
sA
llw
eight
outc
om
esre
port
edas
body
mass
index
(BM
I)z-
score
unle
ssoth
erw
ise
state
d
SDfrac14
standar
ddev
iati
on
NAfrac14
data
not
pro
vid
ed
unab
leto
be
calc
ula
ted
SEfrac14
Sta
ndard
Err
or
report
edra
ther
than
Sta
ndard
Dev
iati
onE
ffec
tsi
zefrac14
Cohen
rsquosdB
old
font
indic
ate
sw
her
eef
fect
size
was
smal
l(0
20)
or
gre
ate
raR
elati
ve
wei
ght
bB
MI
388 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Quantitative Data AnalysisDifferences between intervention and control groupsfor change in self-esteem are presented in Figure 2aThis analysis included seven intervention groups(nfrac14 191) and seven control groups (nfrac14 132) with
interventions or intensive treatment phases rangingfrom 9 weeks to 6 months in duration A moderatelevel of the variation across studies was owing to het-erogeneity (I2frac14464 Higgins Thompson Deeksamp Altman 2003) The overall summary effect showed
Figure 2 Comparison between intervention and control groups for the change in adolescent self-esteem effect size (a) andbody mass index z-score (b) following multicomponent weight management interventions SMD frac14 standard mean differ-ence WMD frac14 weighted mean difference
The Impact of Weight Management on Self-Esteem 389
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icoupcomjpepsyarticle-abstract4243793065789 by U
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arolina at wilm
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no effect on self-esteem as a result of interventionSMD of 027 (95 confidence interval 004 059)zfrac14 169 and pfrac14 092 However all studies exceptone favored the intervention for improvements in self-esteem
The difference between intervention and controlgroups for change in BMI z-score is illustrated inFigure 2b This analysis included five interventiongroups (nfrac14 135) and five control groups (nfrac14 82) withinterventions ranging from 9 weeks to 6 months induration Heterogeneity in this sample was low(I2frac14177 Higgins et al 2003) and the overall sum-mary effect was 017 (022 011) BMI z-scorepoints (zfrac14613 and plt 001) indicating statisticallysignificant weight loss following MWMI
Discussion
The purpose of this review was to examine the effectof MWMIs on self-esteem in overweight and obeseadolescents Increased self-esteem is proposed as a keyfactor for maintaining long-term weight management(Elfhag amp Rossner 2005 French et al 1995Roberts 2006) A secondary outcome of this reviewwas to examine the impact of MWMIs on weight lossand whether this was associated with improvements inself-esteem
The meta-analysis showed no difference in self-esteem between the intervention and control groupsHowever six of the seven studies in the meta-analysisfavored the intervention over control for improve-ments in self-esteem and four of the six studies notincluded in the meta-analysis found significant im-provements in self-esteem following intervention Thelatter of these findings are similar to those of an earlierreview (Lowry et al 2007) that showed improve-ments in self-esteem following weight managementinterventions in a pediatric population particularlywhen certain intervention features were presentSimilarly a number of intervention features that con-tributed to an increased likelihood of improving self-esteem were identified in this review
Improvements in self-esteem regardless of weightloss have been demonstrated in children who tookpart in weight management interventions thatincluded a focus on building self-esteem and it is rec-ommended that this be a focus of all pediatric weightmanagement interventions (Lowry et al 2007) Yetthe majority of studies identified in this review did notinclude building self-esteem as a key aspect of theirintervention Nguyen Shrewsbury et al (2012)described the greatest focus on self-esteem (one75-min group session focused on building self-esteem)and also resulted in the largest treatment effect (057)and a significant improvement in self-esteem (NguyenShrewsbury et al 2012) A focus on similar topics
such as body image social support and managing bul-lying may also contribute to improvements in self-esteem (Croker et al 2012 Pierce amp Wardle 1997Tiggemann 2005) however these findings highlightthe lack of uptake of these recommendations
Among overweight and obese youth reductions inself-esteem are often observed in domains of physicalappearance and physical ability (Franklin DenyerSteinbeck Caterson amp Hill 2006 French et al1995 Latzer amp Stein 2013 Lowry et al 2007)Particularly for adolescent girls body image is a keyconcern (Cave Fildes Luckett amp Wearring 2015)and comprises a large portion of global self-esteem(Lowry et al 2007 Pesa Syre amp Jones 2000)However weight loss and associated changes in phys-ical appearance do not necessarily reflect improve-ments in self-esteem (Lowry et al 2007) Changes inbody-esteem often occur more rapidly than changes inglobal self-esteem as a result of weight management(Lowry et al 2007) This may explain the lack ofchange observed in global self-esteem in this meta-analysis and highlights the need to also include body-esteem (or physical self-esteem) as a focus and out-come of weight management interventions foradolescents
Parental involvement in adolescent weight manage-ment interventions is a critical component for success-ful weight loss and may also be important forimproving self-esteem (Lowry et al 2007) Weight-related teasing from family is shown to be negativelyassociated with self-esteem in overweight adolescentswhereas family connectedness was positively associ-ated with adolescent self-esteem (Fulkerson StraussNeumark-Sztainer Story amp Boutelle 2007) The in-clusion of parents in weight management interventionsfosters a safer and more encouraging home environ-ment for the adolescent (Lowry et al 2007) which isassociated with increased self-esteem in nonover-weight children (Marx amp Neumark-Sztainer 2005)All studies in the present review baring one includedparents in the intervention Parental involvementshould continue to be a key component of weightmanagement interventions to ensure a supportivehome environment for the adolescent to help fosterpositive self-esteem
Weight management interventions that used agroup setting to target self-esteem have shown im-provements in self-esteem without significant weightchange (Lowry et al 2007 Sherman AlexanderGomez Kim amp Marole 1992) The ability of the peergroup setting to provide opportunities for bondingsupport feelings of belonging development of peer-based skills and positive peer exchanges is key toincreasing self-esteem (Lowry et al 2007) The im-portance of this element is being acknowledged in the
390 Murray Dordevic and Bonham
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field with all the studies in this review baring twousing group sessions in their intervention
Measures of self-esteem are self-reported and there-fore subjective Responses to questionnaires are likelyto be influenced by individual (eg age gender) andenvironmental (eg cultural group socioeconomicstatus) factors (Khanlou 2004) Changes followinginterventions may represent genuine long-termchanges in self-esteem or may be due to short-termfluctuations in self-esteem in response to specificevents (eg winning a sporting event or performanceon a test at school) (Kernis 1993) While validatedtools were used to measure self-esteem in all studies itwas difficult to conclude whether outcomes were en-tirely dependent on the intervention without inclusionof a no-treatment control group
The variety of self-esteem assessment tools also addsto the difficulty of interpretation Across the 13 studies inthis review five different tools were used with differentquestions and different scales Even within tools therewere different scales used to report the results (RosenbergSelf-esteem Scale) and different versions of the same ques-tionnaire (Harterrsquos Self-perception Profile for ChildrenHarterrsquos Self-perception Profile for Adolescents) HarterrsquosSelf-Perception Profile (Harterrsquos Self-perception Profilefor Adolescents for adolescents) which measures ninesubscales of self-esteem including physical self-esteem issuggested as the most appropriate measure for adolescentself-esteem (Lowry et al 2007) It was also the mostcommonly used tool among papers included in this re-view While Cohenrsquos d effect sizes were used to stand-ardize results in this review the consistent use of one toolwould provide the ability to compare raw self-esteemscores and create a stronger analysis in the future
Results from this review support evidence thatMWMIs induce weight loss in overweight and obeseadolescents (Hoelscher Kirk Ritchie ampCunningham-Sabo 2013 Kelly amp Melnyk 2008Luttikhuis et al 2009) The change in BMI z-score inthe present meta-analysis (017 [022 011]) wassimilar to the clinically meaningful weight loss re-ported in the 2009 Cochrane Review in children 12years at 6 months follow up from a lifestyle weightmanagement intervention (014 [017 012])(Luttikhuis et al 2009) Jelalian Mehlenbeck Lloyd-Richardson Birmaher and Wing (2006) and WalkerGately Bewick and Hill (2003) have demonstratedassociations between weight loss and increased self-esteem in overweight and obese adolescents after at-tending a weight-management intervention Similarlyin the present review a strong positive relationship be-tween treatment effects for weight loss and improve-ment in self-esteem was identified However itremains unclear whether the improvement in self-esteem was as a result of successful weight loss orwhether it was a contributing factor toward successful
weight loss Nonetheless building self-esteem shouldbe a key focus of MWMIs as improved self-esteem ap-
pears to be linked to enhanced weight lossA key strength of this review was that all included
studies had strong designs and presented level II evi-dence (Coleman et al 2009) However to further elu-
cidate the role of self-esteem in adolescent weightmanagement future research should consider power-
ing studies to detect changes in psychosocial as well asphysiological outcomes Only one study in this reviewwas powered to detect a change in psychosocial out-
comes (Daley et al 2006) which may explain thelack of significant results observed for self-esteem
Additionally a large number of included studies didnot describe their method of handling withdrawals or
use blinding to prevent the introduction of bias Toimprove confidence in the effectiveness of MWMIs
and reduce the risk of bias future studies should bedesigned with concealed allocation and document andreport in detail the flow of participants
Identification of intervention components that im-
prove self-esteem is important for future weight man-agement intervention design Included interventionswere heterogeneous offering different levels of diet-
ary physical activity and behavioral interventionwhich may have collectively or individually influenced
the results Inconsistent reporting of intervention andcomparator conditions make it difficult to elucidate
the components that contributed to improvements inself-esteem Future studies should report intervention
and comparator procedures in adequate detail so thatsuccessful components can be identified and repli-cated These limitations highlight areas for improve-
ment to develop best-practice guidelines forundertaking and evaluating MWMIs in adolescents to
enhance self-esteem
Conclusion
Overweight and obese adolescents experience low
self-esteem largely owing to poor body image yetthis meta-analysis found no improvement in self-esteem even with significant weight loss Although it
was noted that interventions that had larger effects onself-esteem also had larger effects on weight loss The
incorporation of intervention components that wereidentified to contribute to improvements in self-
esteem may assist future weight management interven-tions to improve the self-esteem of overweight and
obese adolescents Furthermore a consistent measureof self-esteem would enable easier interpretation ofself-esteem scores and comparison of results across
studies to improve our understanding of the relation-ship between self-esteem and weight management in
adolescents
The Impact of Weight Management on Self-Esteem 391
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Supplementary Data
Supplementary data can be found at httpwwwjpepsy
oxfordjournalsorg
Acknowledgments
The authors would like to acknowledge Dr Zoe Davidson
for her assistance in performing the meta-analyses
Funding
This work was supported by an Australian GovernmentResearch Training Program Scholarship
Conflicts of interest none declared
References
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DevelopmentBrennan L Walkley J Fraser S F Greenway K amp
Wilks R (2008) Motivational interviewing and cognitivebehaviour therapy in the treatment of adolescent over-
weight and obesity Study design and methodologyContemporary Clinical Trials 29 359ndash375
Brennan L Walkley J Wilks R Fraser S F amp
Greenway K (2013) Physiological and behavioural out-comes of a randomised controlled trial of a cognitive be-havioural lifestyle intervention for overweight and obese
adolescents Obesity Research and Clinical Practice 7e23ndashe41
Brennan L Wilks R Walkley J Fraser S F amp
Greenway K (2012) Treatment acceptability and psycho-social outcomes of a randomised controlled trial of a cog-nitive behavioural lifestyle intervention for overweight and
obese adolescents Behaviour Change 29 36ndash62Cave L Fildes J Luckett G amp Wearring A (2015)
Mission Australiarsquos 2015 youth survey report MissionAustralia
Coleman K Norris S Weston A Grimmer-Somers KHillier S Merlin T Salisbury J (2009) NHMRCadditional levels of evidence and grades for recommenda-tions for developers of guidelines (Vol Stage 2Consultation) Australia National Health and Medical
Research CouncilCroker H Viner R M Nicholls D Haroun D
Chadwick P Edwards C Wardle J (2012) Family-based behavioural treatment of childhood obesity in a UK
national health service setting Randomized controlledtrial International Journal of Obesity 36 16ndash26 doi
101038ijo2011182Daley A J Copeland R J Wright N P Roalfe A amp
Wales J K H (2006) Exercise therapy as a treatment forpsychopathologic conditions in obese and morbidly obese
adolescents A randomized controlled trial Pediatrics118 2126ndash2134
Danielsen Y S Nordhus I H Julıusson P B Maelighle Mamp Pallesen S (2013) Effect of a family-based cognitive
behavioural intervention on body mass index self-esteem
and symptoms of depression in children with obesity (aged
7mdash13) A randomised waiting list controlled trial ObesityResearch amp Clinical Practice 7 e116ndashe128
DeBar L L Stevens V J Perrin N Wu P Pearson J ampJo B (2012) A primary care-based multicomponent life-
style intervention for overweight adolescent femalesPediatrics 129 e611ndashe620
Elfhag K amp Rossner S (2005) Who succeeds in maintain-ing weight loss A conceptual review of factors associated
with weight loss maintenance and weight regain ObesityReviews 6 67ndash85
Franklin J Denyer G Steinbeck K S Caterson I D ampHill A J (2006) Obesity and risk of low self-esteem Astatewide survey of Australian children Pediatrics 118
2481ndash2487French S A Story M amp Perry C L (1995) Self-esteem
and obesity in children and adolescents A literature re-view Obesity Research 3 479ndash490
Fulkerson J Strauss J Neumark-Sztainer D Story M
amp Boutelle K (2007) Correlates of psychosocial well-being among overweight adolescents The role of the fam-ily Journal of Consulting and Clinical Psychology 75
181ndash186Griffiths L J Parsons T J amp Hill A J (2010) Self-es-
teem and quality of life in obese children and adolescentsA systematic review International Journal of PediatricObesity 5 282ndash304
Harter S (1993) Causes and consequences of low self-
esteem in children and adolescents In R F Baumeister(Ed) Self-esteemmdashThe puzzle of low self-regard (pp87ndash116) USA Springer
Higgins J Thompson S Deeks J amp Altman D (2003)
Measuring inconsistency in meta-analyses BMJ 327557ndash560
Hoelscher D M Kirk S Ritchie L amp Cunningham-Sabo L (2013) Position of the Academy of Nutrition and
Dietetics Interventions for the prevention and treatmentof pediatric overweight and obesity Journal of theAcademy of Nutrition and Dietetics 113 1375ndash1394
Jelalian E Mehlenbeck R Lloyd-Richardson EBirmaher V amp Wing R (2006) lsquoAdventure therapyrsquo
combined with cognitivebehavioral treatment for over-weight adolescents International Journal of Obesity 3031ndash39
Kelly S A amp Melnyk B M (2008) Systematic review of
multicomponent interventions with overweight middleadolescents implications for clinical practice and researchWorldviews on Evidence-Based Nursing 5 113ndash135
Kernis M (1993) The roles of stability and level of self-
esteem in psychological functioning In R Baumeister(Ed) Self-esteem (pp 167ndash182) USA Springer
Khanlou N (2004) Influences on adolescent self-esteem inmulticultural Canadian secondary schools Public HealthNursing 21 404ndash411
Kohn M Rees J M Brill S Fonseca H Jacobson M
Katzman D K Schneider M (2006) Preventing andtreating adolescent obesity A position paper of the Societyfor Adolescent Medicine Journal of Adolescent Health
38 784ndash787Kornman K P Shrewsbury V A Chou A C Ngyuen
B Lee A Orsquoconnor J Baur L A (2010) Electronic
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arolina at wilm
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therapeutic contact for adolescent weight management
The Loozit study Telemedicine and E-Health 16
678ndash685Latzer Y amp Stein D (2013) A review of the psychological
and familial perspectives of childhood obesity Journal of
Eating Disorders 1 7Lobstein T Baur L amp Uauy R (2004) Obesity in chil-
dren and young people a crisis in public health Obesity
Reviews 5(Suppl 1) 4ndash104Lochrie A S Wysocki T Hossain J Milkes A Antal
H Buckloh L Lang J (2013) The effects of a family-
based intervention (FBI) for overweightobese children on
health and psychological functioning Clinical Practice in
Pediatric Psychology 1 159ndash170 doi httpdxdoiorg
101037cpp0000020Lowry K W Sallinen B amp Janicke D (2007) The effects
of weight management programs on self-esteem in pediat-
ric overweight populations Journal of Pediatric
Psychology 32 1179ndash1195Lubans D R Morgan P J Okely A D Dewar D
Collins C E Batterham M Plotnikoff R C (2012)
Preventing obesity among adolescent girls One-year out-
comes of the nutrition and enjoyable activity for teen girls
(NEAT Girls) cluster randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
821ndash827Luttikhuis H Baur L Jansen H Shrewsbury V
Orsquomalley C Stolk R amp Summerbell C (2009)
Interventions for treating obesity in children (Review)
Cochrane Database of Systematic Reviews 3 1ndash57Marx R D amp Neumark-Sztainer D (2005) Questions amp
Answers Eating Disorders The Journal of Treatment amp
Prevention 13 491ndash495McClure A C Tanksi S E Kingsbury J Gerrard M amp
Sargent J D (2010) Characteristics associated with low
self-esteem among US adolescents Academic Pediatrics
10 238ndash244Mellin L M Slinkard L A amp Irwin C E (1987)
Adolescent obesity intervention Validation of the
SHAPEDOWN program Journal of the American Dietetic
Association 87 333ndash338Mission Australia (2012) Youth Survey 2012 SydneyMoher D Shamseer L Clarke M Ghersi D Liberati
A Petticrew M PRISMA-P Group (2015) Preferred
reporting items for systematic review and meta-analysis
protocols (PRISMA-P) 2015 statement Systematic
Reviews 4 1Morgan P Saunders K amp Lubans D (2012) Improving
physical self-perception in adolescent boys from disadvan-
taged schools Psychological outcomes from the Physical
Activity Leaders randomized controlled trial Pediatric
Obesity 7 e27ndashe32 doi httpdxdoiorg101111j
2047-6310201200050xNational Health and Medical Reasearch Council (2013)
Clinical practice guidelines for the management of over-
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Australia Australia NHMRC Australian Government
Department of HealthNational Institutes for Health and Care Excellence (2013)
Managing overweight and obesity among children and
young people lifestyle weight management services NICE
public health guidance United Kingdom 47 NICENeumark-Sztainer D R Friend S E Flattum C F
Hannan P J Story M T Bauer K W Petrich C A
(2010) New moves-preventing weight-related problems in
adolescent girls A group-randomized study American
Journal of Preventive Medicine 39 421ndash432Nguyen B McGregor K A Orsquoconnor J Shrewsbury V
A Lee A Steinbeck K S Baur L A (2012)
Recruitment challenges and recommendations for adoles-
cent obesity trials Journal of Paediatrics and Child
Health 48 38ndash43Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Hill A J Shah S Baur L A (2013) Two-year
outcomes of an adjunctive telephone coaching and elec-
tronic contact intervention for adolescent weight-loss
maintenance the Loozit randomized controlled trial
International Journal of Obesity 37 468ndash472Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2012) Twelve-month
outcomes of the Loozit randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
170ndash177Ogden C L Carroll M D Kit B K amp Flegal K M
(2014) Prevalence of childhood and adult obesity in the
United States 2011-2012 Journal of the American
Medical Association 311 806ndash814Pesa J A Syre T R amp Jones E (2000) Psychosocial dif-
ferences associated with body weight among female ado-
lescents The importance of body image Journal of
Adolescent Health 26 330ndash337Pierce J W amp Wardle J (1997) Cause and effect beliefs
and self-esteem of overweight children Journal of Child
Psychology and Psychiatry 38 645ndash650 doi 101111
j1469-76101997tb01691xRoberts J E (2006) Self-esteem from a clinical perspective
In M H Kernis (Ed) Self-esteem issues and answers A
sourcebook of current perspectives Psychology Press
Taylor amp Francis New York and Hove (pp 298ndash305)
Psychology PressSacher P M Kolotourou M Chadwick P M Cole T J
Lawson M S Lucas A amp Singhal A (2010)
Randomized controlled trial of the MEND program A
family-based community intervention for childhood obes-
ity Obesity 18(Suppl 1) S62ndashS68 doi httpdxdoiorg
101038oby2009433Sanders R H Han A Baker J S amp Cobley S (2015)
Childhood obesity and its physical and psychological co-
morbidities a systematic review of Australian children and
adolescents Eur J Pediatr 174 715ndash746Sherman J B Alexander M A Gomez D Kim M amp
Marole P (1992) Intervention program for obese school chil-
dren Journal of Community Health Nursing 9 183ndash190Shrewsbury V A Nguyen B Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2011) Short-term
outcomes of community-based adolescent weight manage-
ment The LoozitVR
Study BMC Pediatrics 11 13Shrewsbury V A Orsquoconnor J Steinbeck K S Stevenson
K Lee A Hill A J Baur L A (2009) A randomised
controlled trial of a community-based healthy lifestyle
The Impact of Weight Management on Self-Esteem 393
Dow
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icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
program for overweight and obese adolescents TheLoozitV
R
study protocol BMC Public Health 9 119Strauss R S (2000) Childhood obesity and self-esteem
Pediatrics 105 5Tiggemann M (2005) Body dissatisfaction and adolescent
self-esteem Prospective findings Body Image 2 129ndash135doi httpdxdoiorg101016jbodyim200503006
Wadden T A Stunkard A J Rich L Rubin C JSweidel G amp McKinney S (1990) Obesity in black ado-lescent girls A controlled clinical trial of treatment by diet
behaviour modification and parental support Pediatrics85 345ndash352
Walker L Gately P Bewick B amp Hill A (2003)Childrenrsquos weight-loss camps psychological benefit orjeopardy International Journal of Obesity 27 748ndash754
World Health Organization (2014) Maternal newbornchild and adolescent health Adolescent developmentRetrieved from httpwwwwhointmaternal_child_adolescenttopicsadolescencedeven Retrieved 28 May2014
394 Murray Dordevic and Bonham
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nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
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arolina at wilm
ington user on 14 February 2019
- jsw101-TF1
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- jsw101-TF9
- jsw101-TF10
- jsw101-TF11
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elf
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of
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The Impact of Weight Management on Self-Esteem 387
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Tab
leIII
We
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tO
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of
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po
ne
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We
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n(S
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Eff
ect
size
Bre
nnan
etal2012
20
20
8(0
37)
19
9(0
46)
02
0(0
18)
02
214
20
8(0
40)
20
9(0
39)
00
1(0
12)
00
3C
roker
etal2012
13
29
5(0
52)
26
6(0
63)
01
7(0
21)
05
010
31
4(0
68)
31
4(0
68)
00
6(0
13)
00
0D
ale
yet
al2006
28
31
7(0
33)
32
3(0
02
SE)
NA
NA
30
33
2(0
37)
32
3(0
02
SE)
NA
NA
Danie
lsen
etal2013
16
25
9(0
30)
24
6(0
41)
01
2(0
17)
03
616
24
9(0
27)
25
3(0
29)
00
5(0
15)
01
4D
eBar
etal2012
105
20
0(0
34)
18
8(0
41)
NA
03
2103
20
0(0
33)
19
4(0
38)
NA
01
7L
och
rie
etal2013
29
21
9(0
40)
20
6(0
52)
01
2(0
20)
02
818
20
7(0
40)
20
5(0
43)
00
2(0
11)
00
5L
ubans
etal2012
54
19
3(0
61)
18
0(0
68)
NA
02
068
18
5(0
59)
18
0(0
67)
NA
00
8M
ellin
etal1987
37
1365
aN
A
59
(67
5)a
NA
29
1295
aN
A
03
(66
1)a
NA
Morg
an
etal2012
19
NA
NA
04
2(0
91)b
NA
21
NA
NA
00
3(0
87)b
NA
Neu
mark
-Szt
ain
eret
al2010
85
321
(61
)b322
(62
)bN
A
00
279
310
(53
)b314
(55
)bN
A
00
7
Nguyen
etal2012
(wit
hA
TC
)57
20
3(0
37)
19
7(0
42)
00
8(0
19)
01
5
Nguyen
etal2012
(wit
hout
AT
C)
50
20
2(0
29)
19
4(0
32)
00
9(0
17)
02
6
Sach
eret
al2010
20
NA
23
7(0
52)
02
2(0
27)
NA
24
NA
26
0(0
54)
00
1(0
20)
NA
Wadden
etal1990
3gro
ups
com
bin
ed47
352
b339
bN
AN
A
Note
D
ata
pre
sente
das
report
edin
ori
gin
al
paper
sA
llw
eight
outc
om
esre
port
edas
body
mass
index
(BM
I)z-
score
unle
ssoth
erw
ise
state
d
SDfrac14
standar
ddev
iati
on
NAfrac14
data
not
pro
vid
ed
unab
leto
be
calc
ula
ted
SEfrac14
Sta
ndard
Err
or
report
edra
ther
than
Sta
ndard
Dev
iati
onE
ffec
tsi
zefrac14
Cohen
rsquosdB
old
font
indic
ate
sw
her
eef
fect
size
was
smal
l(0
20)
or
gre
ate
raR
elati
ve
wei
ght
bB
MI
388 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Quantitative Data AnalysisDifferences between intervention and control groupsfor change in self-esteem are presented in Figure 2aThis analysis included seven intervention groups(nfrac14 191) and seven control groups (nfrac14 132) with
interventions or intensive treatment phases rangingfrom 9 weeks to 6 months in duration A moderatelevel of the variation across studies was owing to het-erogeneity (I2frac14464 Higgins Thompson Deeksamp Altman 2003) The overall summary effect showed
Figure 2 Comparison between intervention and control groups for the change in adolescent self-esteem effect size (a) andbody mass index z-score (b) following multicomponent weight management interventions SMD frac14 standard mean differ-ence WMD frac14 weighted mean difference
The Impact of Weight Management on Self-Esteem 389
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
no effect on self-esteem as a result of interventionSMD of 027 (95 confidence interval 004 059)zfrac14 169 and pfrac14 092 However all studies exceptone favored the intervention for improvements in self-esteem
The difference between intervention and controlgroups for change in BMI z-score is illustrated inFigure 2b This analysis included five interventiongroups (nfrac14 135) and five control groups (nfrac14 82) withinterventions ranging from 9 weeks to 6 months induration Heterogeneity in this sample was low(I2frac14177 Higgins et al 2003) and the overall sum-mary effect was 017 (022 011) BMI z-scorepoints (zfrac14613 and plt 001) indicating statisticallysignificant weight loss following MWMI
Discussion
The purpose of this review was to examine the effectof MWMIs on self-esteem in overweight and obeseadolescents Increased self-esteem is proposed as a keyfactor for maintaining long-term weight management(Elfhag amp Rossner 2005 French et al 1995Roberts 2006) A secondary outcome of this reviewwas to examine the impact of MWMIs on weight lossand whether this was associated with improvements inself-esteem
The meta-analysis showed no difference in self-esteem between the intervention and control groupsHowever six of the seven studies in the meta-analysisfavored the intervention over control for improve-ments in self-esteem and four of the six studies notincluded in the meta-analysis found significant im-provements in self-esteem following intervention Thelatter of these findings are similar to those of an earlierreview (Lowry et al 2007) that showed improve-ments in self-esteem following weight managementinterventions in a pediatric population particularlywhen certain intervention features were presentSimilarly a number of intervention features that con-tributed to an increased likelihood of improving self-esteem were identified in this review
Improvements in self-esteem regardless of weightloss have been demonstrated in children who tookpart in weight management interventions thatincluded a focus on building self-esteem and it is rec-ommended that this be a focus of all pediatric weightmanagement interventions (Lowry et al 2007) Yetthe majority of studies identified in this review did notinclude building self-esteem as a key aspect of theirintervention Nguyen Shrewsbury et al (2012)described the greatest focus on self-esteem (one75-min group session focused on building self-esteem)and also resulted in the largest treatment effect (057)and a significant improvement in self-esteem (NguyenShrewsbury et al 2012) A focus on similar topics
such as body image social support and managing bul-lying may also contribute to improvements in self-esteem (Croker et al 2012 Pierce amp Wardle 1997Tiggemann 2005) however these findings highlightthe lack of uptake of these recommendations
Among overweight and obese youth reductions inself-esteem are often observed in domains of physicalappearance and physical ability (Franklin DenyerSteinbeck Caterson amp Hill 2006 French et al1995 Latzer amp Stein 2013 Lowry et al 2007)Particularly for adolescent girls body image is a keyconcern (Cave Fildes Luckett amp Wearring 2015)and comprises a large portion of global self-esteem(Lowry et al 2007 Pesa Syre amp Jones 2000)However weight loss and associated changes in phys-ical appearance do not necessarily reflect improve-ments in self-esteem (Lowry et al 2007) Changes inbody-esteem often occur more rapidly than changes inglobal self-esteem as a result of weight management(Lowry et al 2007) This may explain the lack ofchange observed in global self-esteem in this meta-analysis and highlights the need to also include body-esteem (or physical self-esteem) as a focus and out-come of weight management interventions foradolescents
Parental involvement in adolescent weight manage-ment interventions is a critical component for success-ful weight loss and may also be important forimproving self-esteem (Lowry et al 2007) Weight-related teasing from family is shown to be negativelyassociated with self-esteem in overweight adolescentswhereas family connectedness was positively associ-ated with adolescent self-esteem (Fulkerson StraussNeumark-Sztainer Story amp Boutelle 2007) The in-clusion of parents in weight management interventionsfosters a safer and more encouraging home environ-ment for the adolescent (Lowry et al 2007) which isassociated with increased self-esteem in nonover-weight children (Marx amp Neumark-Sztainer 2005)All studies in the present review baring one includedparents in the intervention Parental involvementshould continue to be a key component of weightmanagement interventions to ensure a supportivehome environment for the adolescent to help fosterpositive self-esteem
Weight management interventions that used agroup setting to target self-esteem have shown im-provements in self-esteem without significant weightchange (Lowry et al 2007 Sherman AlexanderGomez Kim amp Marole 1992) The ability of the peergroup setting to provide opportunities for bondingsupport feelings of belonging development of peer-based skills and positive peer exchanges is key toincreasing self-esteem (Lowry et al 2007) The im-portance of this element is being acknowledged in the
390 Murray Dordevic and Bonham
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arolina at wilm
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field with all the studies in this review baring twousing group sessions in their intervention
Measures of self-esteem are self-reported and there-fore subjective Responses to questionnaires are likelyto be influenced by individual (eg age gender) andenvironmental (eg cultural group socioeconomicstatus) factors (Khanlou 2004) Changes followinginterventions may represent genuine long-termchanges in self-esteem or may be due to short-termfluctuations in self-esteem in response to specificevents (eg winning a sporting event or performanceon a test at school) (Kernis 1993) While validatedtools were used to measure self-esteem in all studies itwas difficult to conclude whether outcomes were en-tirely dependent on the intervention without inclusionof a no-treatment control group
The variety of self-esteem assessment tools also addsto the difficulty of interpretation Across the 13 studies inthis review five different tools were used with differentquestions and different scales Even within tools therewere different scales used to report the results (RosenbergSelf-esteem Scale) and different versions of the same ques-tionnaire (Harterrsquos Self-perception Profile for ChildrenHarterrsquos Self-perception Profile for Adolescents) HarterrsquosSelf-Perception Profile (Harterrsquos Self-perception Profilefor Adolescents for adolescents) which measures ninesubscales of self-esteem including physical self-esteem issuggested as the most appropriate measure for adolescentself-esteem (Lowry et al 2007) It was also the mostcommonly used tool among papers included in this re-view While Cohenrsquos d effect sizes were used to stand-ardize results in this review the consistent use of one toolwould provide the ability to compare raw self-esteemscores and create a stronger analysis in the future
Results from this review support evidence thatMWMIs induce weight loss in overweight and obeseadolescents (Hoelscher Kirk Ritchie ampCunningham-Sabo 2013 Kelly amp Melnyk 2008Luttikhuis et al 2009) The change in BMI z-score inthe present meta-analysis (017 [022 011]) wassimilar to the clinically meaningful weight loss re-ported in the 2009 Cochrane Review in children 12years at 6 months follow up from a lifestyle weightmanagement intervention (014 [017 012])(Luttikhuis et al 2009) Jelalian Mehlenbeck Lloyd-Richardson Birmaher and Wing (2006) and WalkerGately Bewick and Hill (2003) have demonstratedassociations between weight loss and increased self-esteem in overweight and obese adolescents after at-tending a weight-management intervention Similarlyin the present review a strong positive relationship be-tween treatment effects for weight loss and improve-ment in self-esteem was identified However itremains unclear whether the improvement in self-esteem was as a result of successful weight loss orwhether it was a contributing factor toward successful
weight loss Nonetheless building self-esteem shouldbe a key focus of MWMIs as improved self-esteem ap-
pears to be linked to enhanced weight lossA key strength of this review was that all included
studies had strong designs and presented level II evi-dence (Coleman et al 2009) However to further elu-
cidate the role of self-esteem in adolescent weightmanagement future research should consider power-
ing studies to detect changes in psychosocial as well asphysiological outcomes Only one study in this reviewwas powered to detect a change in psychosocial out-
comes (Daley et al 2006) which may explain thelack of significant results observed for self-esteem
Additionally a large number of included studies didnot describe their method of handling withdrawals or
use blinding to prevent the introduction of bias Toimprove confidence in the effectiveness of MWMIs
and reduce the risk of bias future studies should bedesigned with concealed allocation and document andreport in detail the flow of participants
Identification of intervention components that im-
prove self-esteem is important for future weight man-agement intervention design Included interventionswere heterogeneous offering different levels of diet-
ary physical activity and behavioral interventionwhich may have collectively or individually influenced
the results Inconsistent reporting of intervention andcomparator conditions make it difficult to elucidate
the components that contributed to improvements inself-esteem Future studies should report intervention
and comparator procedures in adequate detail so thatsuccessful components can be identified and repli-cated These limitations highlight areas for improve-
ment to develop best-practice guidelines forundertaking and evaluating MWMIs in adolescents to
enhance self-esteem
Conclusion
Overweight and obese adolescents experience low
self-esteem largely owing to poor body image yetthis meta-analysis found no improvement in self-esteem even with significant weight loss Although it
was noted that interventions that had larger effects onself-esteem also had larger effects on weight loss The
incorporation of intervention components that wereidentified to contribute to improvements in self-
esteem may assist future weight management interven-tions to improve the self-esteem of overweight and
obese adolescents Furthermore a consistent measureof self-esteem would enable easier interpretation ofself-esteem scores and comparison of results across
studies to improve our understanding of the relation-ship between self-esteem and weight management in
adolescents
The Impact of Weight Management on Self-Esteem 391
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
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Supplementary Data
Supplementary data can be found at httpwwwjpepsy
oxfordjournalsorg
Acknowledgments
The authors would like to acknowledge Dr Zoe Davidson
for her assistance in performing the meta-analyses
Funding
This work was supported by an Australian GovernmentResearch Training Program Scholarship
Conflicts of interest none declared
References
Academy of Nutrition and Dietetics (2012) Evidence ana-lysis manual Steps in the academy evidence analysis pro-cess Chicago IL ADA Research and Strategic Business
DevelopmentBrennan L Walkley J Fraser S F Greenway K amp
Wilks R (2008) Motivational interviewing and cognitivebehaviour therapy in the treatment of adolescent over-
weight and obesity Study design and methodologyContemporary Clinical Trials 29 359ndash375
Brennan L Walkley J Wilks R Fraser S F amp
Greenway K (2013) Physiological and behavioural out-comes of a randomised controlled trial of a cognitive be-havioural lifestyle intervention for overweight and obese
adolescents Obesity Research and Clinical Practice 7e23ndashe41
Brennan L Wilks R Walkley J Fraser S F amp
Greenway K (2012) Treatment acceptability and psycho-social outcomes of a randomised controlled trial of a cog-nitive behavioural lifestyle intervention for overweight and
obese adolescents Behaviour Change 29 36ndash62Cave L Fildes J Luckett G amp Wearring A (2015)
Mission Australiarsquos 2015 youth survey report MissionAustralia
Coleman K Norris S Weston A Grimmer-Somers KHillier S Merlin T Salisbury J (2009) NHMRCadditional levels of evidence and grades for recommenda-tions for developers of guidelines (Vol Stage 2Consultation) Australia National Health and Medical
Research CouncilCroker H Viner R M Nicholls D Haroun D
Chadwick P Edwards C Wardle J (2012) Family-based behavioural treatment of childhood obesity in a UK
national health service setting Randomized controlledtrial International Journal of Obesity 36 16ndash26 doi
101038ijo2011182Daley A J Copeland R J Wright N P Roalfe A amp
Wales J K H (2006) Exercise therapy as a treatment forpsychopathologic conditions in obese and morbidly obese
adolescents A randomized controlled trial Pediatrics118 2126ndash2134
Danielsen Y S Nordhus I H Julıusson P B Maelighle Mamp Pallesen S (2013) Effect of a family-based cognitive
behavioural intervention on body mass index self-esteem
and symptoms of depression in children with obesity (aged
7mdash13) A randomised waiting list controlled trial ObesityResearch amp Clinical Practice 7 e116ndashe128
DeBar L L Stevens V J Perrin N Wu P Pearson J ampJo B (2012) A primary care-based multicomponent life-
style intervention for overweight adolescent femalesPediatrics 129 e611ndashe620
Elfhag K amp Rossner S (2005) Who succeeds in maintain-ing weight loss A conceptual review of factors associated
with weight loss maintenance and weight regain ObesityReviews 6 67ndash85
Franklin J Denyer G Steinbeck K S Caterson I D ampHill A J (2006) Obesity and risk of low self-esteem Astatewide survey of Australian children Pediatrics 118
2481ndash2487French S A Story M amp Perry C L (1995) Self-esteem
and obesity in children and adolescents A literature re-view Obesity Research 3 479ndash490
Fulkerson J Strauss J Neumark-Sztainer D Story M
amp Boutelle K (2007) Correlates of psychosocial well-being among overweight adolescents The role of the fam-ily Journal of Consulting and Clinical Psychology 75
181ndash186Griffiths L J Parsons T J amp Hill A J (2010) Self-es-
teem and quality of life in obese children and adolescentsA systematic review International Journal of PediatricObesity 5 282ndash304
Harter S (1993) Causes and consequences of low self-
esteem in children and adolescents In R F Baumeister(Ed) Self-esteemmdashThe puzzle of low self-regard (pp87ndash116) USA Springer
Higgins J Thompson S Deeks J amp Altman D (2003)
Measuring inconsistency in meta-analyses BMJ 327557ndash560
Hoelscher D M Kirk S Ritchie L amp Cunningham-Sabo L (2013) Position of the Academy of Nutrition and
Dietetics Interventions for the prevention and treatmentof pediatric overweight and obesity Journal of theAcademy of Nutrition and Dietetics 113 1375ndash1394
Jelalian E Mehlenbeck R Lloyd-Richardson EBirmaher V amp Wing R (2006) lsquoAdventure therapyrsquo
combined with cognitivebehavioral treatment for over-weight adolescents International Journal of Obesity 3031ndash39
Kelly S A amp Melnyk B M (2008) Systematic review of
multicomponent interventions with overweight middleadolescents implications for clinical practice and researchWorldviews on Evidence-Based Nursing 5 113ndash135
Kernis M (1993) The roles of stability and level of self-
esteem in psychological functioning In R Baumeister(Ed) Self-esteem (pp 167ndash182) USA Springer
Khanlou N (2004) Influences on adolescent self-esteem inmulticultural Canadian secondary schools Public HealthNursing 21 404ndash411
Kohn M Rees J M Brill S Fonseca H Jacobson M
Katzman D K Schneider M (2006) Preventing andtreating adolescent obesity A position paper of the Societyfor Adolescent Medicine Journal of Adolescent Health
38 784ndash787Kornman K P Shrewsbury V A Chou A C Ngyuen
B Lee A Orsquoconnor J Baur L A (2010) Electronic
392 Murray Dordevic and Bonham
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icoupcomjpepsyarticle-abstract4243793065789 by U
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arolina at wilm
ington user on 14 February 2019
therapeutic contact for adolescent weight management
The Loozit study Telemedicine and E-Health 16
678ndash685Latzer Y amp Stein D (2013) A review of the psychological
and familial perspectives of childhood obesity Journal of
Eating Disorders 1 7Lobstein T Baur L amp Uauy R (2004) Obesity in chil-
dren and young people a crisis in public health Obesity
Reviews 5(Suppl 1) 4ndash104Lochrie A S Wysocki T Hossain J Milkes A Antal
H Buckloh L Lang J (2013) The effects of a family-
based intervention (FBI) for overweightobese children on
health and psychological functioning Clinical Practice in
Pediatric Psychology 1 159ndash170 doi httpdxdoiorg
101037cpp0000020Lowry K W Sallinen B amp Janicke D (2007) The effects
of weight management programs on self-esteem in pediat-
ric overweight populations Journal of Pediatric
Psychology 32 1179ndash1195Lubans D R Morgan P J Okely A D Dewar D
Collins C E Batterham M Plotnikoff R C (2012)
Preventing obesity among adolescent girls One-year out-
comes of the nutrition and enjoyable activity for teen girls
(NEAT Girls) cluster randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
821ndash827Luttikhuis H Baur L Jansen H Shrewsbury V
Orsquomalley C Stolk R amp Summerbell C (2009)
Interventions for treating obesity in children (Review)
Cochrane Database of Systematic Reviews 3 1ndash57Marx R D amp Neumark-Sztainer D (2005) Questions amp
Answers Eating Disorders The Journal of Treatment amp
Prevention 13 491ndash495McClure A C Tanksi S E Kingsbury J Gerrard M amp
Sargent J D (2010) Characteristics associated with low
self-esteem among US adolescents Academic Pediatrics
10 238ndash244Mellin L M Slinkard L A amp Irwin C E (1987)
Adolescent obesity intervention Validation of the
SHAPEDOWN program Journal of the American Dietetic
Association 87 333ndash338Mission Australia (2012) Youth Survey 2012 SydneyMoher D Shamseer L Clarke M Ghersi D Liberati
A Petticrew M PRISMA-P Group (2015) Preferred
reporting items for systematic review and meta-analysis
protocols (PRISMA-P) 2015 statement Systematic
Reviews 4 1Morgan P Saunders K amp Lubans D (2012) Improving
physical self-perception in adolescent boys from disadvan-
taged schools Psychological outcomes from the Physical
Activity Leaders randomized controlled trial Pediatric
Obesity 7 e27ndashe32 doi httpdxdoiorg101111j
2047-6310201200050xNational Health and Medical Reasearch Council (2013)
Clinical practice guidelines for the management of over-
weight and obesity in adults adolescents and children in
Australia Australia NHMRC Australian Government
Department of HealthNational Institutes for Health and Care Excellence (2013)
Managing overweight and obesity among children and
young people lifestyle weight management services NICE
public health guidance United Kingdom 47 NICENeumark-Sztainer D R Friend S E Flattum C F
Hannan P J Story M T Bauer K W Petrich C A
(2010) New moves-preventing weight-related problems in
adolescent girls A group-randomized study American
Journal of Preventive Medicine 39 421ndash432Nguyen B McGregor K A Orsquoconnor J Shrewsbury V
A Lee A Steinbeck K S Baur L A (2012)
Recruitment challenges and recommendations for adoles-
cent obesity trials Journal of Paediatrics and Child
Health 48 38ndash43Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Hill A J Shah S Baur L A (2013) Two-year
outcomes of an adjunctive telephone coaching and elec-
tronic contact intervention for adolescent weight-loss
maintenance the Loozit randomized controlled trial
International Journal of Obesity 37 468ndash472Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2012) Twelve-month
outcomes of the Loozit randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
170ndash177Ogden C L Carroll M D Kit B K amp Flegal K M
(2014) Prevalence of childhood and adult obesity in the
United States 2011-2012 Journal of the American
Medical Association 311 806ndash814Pesa J A Syre T R amp Jones E (2000) Psychosocial dif-
ferences associated with body weight among female ado-
lescents The importance of body image Journal of
Adolescent Health 26 330ndash337Pierce J W amp Wardle J (1997) Cause and effect beliefs
and self-esteem of overweight children Journal of Child
Psychology and Psychiatry 38 645ndash650 doi 101111
j1469-76101997tb01691xRoberts J E (2006) Self-esteem from a clinical perspective
In M H Kernis (Ed) Self-esteem issues and answers A
sourcebook of current perspectives Psychology Press
Taylor amp Francis New York and Hove (pp 298ndash305)
Psychology PressSacher P M Kolotourou M Chadwick P M Cole T J
Lawson M S Lucas A amp Singhal A (2010)
Randomized controlled trial of the MEND program A
family-based community intervention for childhood obes-
ity Obesity 18(Suppl 1) S62ndashS68 doi httpdxdoiorg
101038oby2009433Sanders R H Han A Baker J S amp Cobley S (2015)
Childhood obesity and its physical and psychological co-
morbidities a systematic review of Australian children and
adolescents Eur J Pediatr 174 715ndash746Sherman J B Alexander M A Gomez D Kim M amp
Marole P (1992) Intervention program for obese school chil-
dren Journal of Community Health Nursing 9 183ndash190Shrewsbury V A Nguyen B Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2011) Short-term
outcomes of community-based adolescent weight manage-
ment The LoozitVR
Study BMC Pediatrics 11 13Shrewsbury V A Orsquoconnor J Steinbeck K S Stevenson
K Lee A Hill A J Baur L A (2009) A randomised
controlled trial of a community-based healthy lifestyle
The Impact of Weight Management on Self-Esteem 393
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
program for overweight and obese adolescents TheLoozitV
R
study protocol BMC Public Health 9 119Strauss R S (2000) Childhood obesity and self-esteem
Pediatrics 105 5Tiggemann M (2005) Body dissatisfaction and adolescent
self-esteem Prospective findings Body Image 2 129ndash135doi httpdxdoiorg101016jbodyim200503006
Wadden T A Stunkard A J Rich L Rubin C JSweidel G amp McKinney S (1990) Obesity in black ado-lescent girls A controlled clinical trial of treatment by diet
behaviour modification and parental support Pediatrics85 345ndash352
Walker L Gately P Bewick B amp Hill A (2003)Childrenrsquos weight-loss camps psychological benefit orjeopardy International Journal of Obesity 27 748ndash754
World Health Organization (2014) Maternal newbornchild and adolescent health Adolescent developmentRetrieved from httpwwwwhointmaternal_child_adolescenttopicsadolescencedeven Retrieved 28 May2014
394 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
- jsw101-TF1
- jsw101-TF2
- jsw101-TF3
- jsw101-TF4
- jsw101-TF5
- jsw101-TF6
- jsw101-TF7
- jsw101-TF8
- jsw101-TF9
- jsw101-TF10
- jsw101-TF11
-
Tab
leIII
We
igh
tO
utc
om
es
of
Mu
ltic
om
po
ne
nt
We
igh
tM
an
ag
em
en
tIn
terv
en
tio
ns
Co
mp
are
dW
ith
Co
ntr
ols
in
Ov
erw
eig
ht
an
dO
be
seA
do
lesc
en
ts
Auth
or
yea
rIn
terv
enti
on
gro
ups
Contr
olgro
ups
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
nPre
-mea
n(S
D)
Post
-mea
n(S
D)
Change
mea
n(S
D)
Eff
ect
size
Bre
nnan
etal2012
20
20
8(0
37)
19
9(0
46)
02
0(0
18)
02
214
20
8(0
40)
20
9(0
39)
00
1(0
12)
00
3C
roker
etal2012
13
29
5(0
52)
26
6(0
63)
01
7(0
21)
05
010
31
4(0
68)
31
4(0
68)
00
6(0
13)
00
0D
ale
yet
al2006
28
31
7(0
33)
32
3(0
02
SE)
NA
NA
30
33
2(0
37)
32
3(0
02
SE)
NA
NA
Danie
lsen
etal2013
16
25
9(0
30)
24
6(0
41)
01
2(0
17)
03
616
24
9(0
27)
25
3(0
29)
00
5(0
15)
01
4D
eBar
etal2012
105
20
0(0
34)
18
8(0
41)
NA
03
2103
20
0(0
33)
19
4(0
38)
NA
01
7L
och
rie
etal2013
29
21
9(0
40)
20
6(0
52)
01
2(0
20)
02
818
20
7(0
40)
20
5(0
43)
00
2(0
11)
00
5L
ubans
etal2012
54
19
3(0
61)
18
0(0
68)
NA
02
068
18
5(0
59)
18
0(0
67)
NA
00
8M
ellin
etal1987
37
1365
aN
A
59
(67
5)a
NA
29
1295
aN
A
03
(66
1)a
NA
Morg
an
etal2012
19
NA
NA
04
2(0
91)b
NA
21
NA
NA
00
3(0
87)b
NA
Neu
mark
-Szt
ain
eret
al2010
85
321
(61
)b322
(62
)bN
A
00
279
310
(53
)b314
(55
)bN
A
00
7
Nguyen
etal2012
(wit
hA
TC
)57
20
3(0
37)
19
7(0
42)
00
8(0
19)
01
5
Nguyen
etal2012
(wit
hout
AT
C)
50
20
2(0
29)
19
4(0
32)
00
9(0
17)
02
6
Sach
eret
al2010
20
NA
23
7(0
52)
02
2(0
27)
NA
24
NA
26
0(0
54)
00
1(0
20)
NA
Wadden
etal1990
3gro
ups
com
bin
ed47
352
b339
bN
AN
A
Note
D
ata
pre
sente
das
report
edin
ori
gin
al
paper
sA
llw
eight
outc
om
esre
port
edas
body
mass
index
(BM
I)z-
score
unle
ssoth
erw
ise
state
d
SDfrac14
standar
ddev
iati
on
NAfrac14
data
not
pro
vid
ed
unab
leto
be
calc
ula
ted
SEfrac14
Sta
ndard
Err
or
report
edra
ther
than
Sta
ndard
Dev
iati
onE
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tsi
zefrac14
Cohen
rsquosdB
old
font
indic
ate
sw
her
eef
fect
size
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l(0
20)
or
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ate
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ve
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ght
bB
MI
388 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Quantitative Data AnalysisDifferences between intervention and control groupsfor change in self-esteem are presented in Figure 2aThis analysis included seven intervention groups(nfrac14 191) and seven control groups (nfrac14 132) with
interventions or intensive treatment phases rangingfrom 9 weeks to 6 months in duration A moderatelevel of the variation across studies was owing to het-erogeneity (I2frac14464 Higgins Thompson Deeksamp Altman 2003) The overall summary effect showed
Figure 2 Comparison between intervention and control groups for the change in adolescent self-esteem effect size (a) andbody mass index z-score (b) following multicomponent weight management interventions SMD frac14 standard mean differ-ence WMD frac14 weighted mean difference
The Impact of Weight Management on Self-Esteem 389
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
no effect on self-esteem as a result of interventionSMD of 027 (95 confidence interval 004 059)zfrac14 169 and pfrac14 092 However all studies exceptone favored the intervention for improvements in self-esteem
The difference between intervention and controlgroups for change in BMI z-score is illustrated inFigure 2b This analysis included five interventiongroups (nfrac14 135) and five control groups (nfrac14 82) withinterventions ranging from 9 weeks to 6 months induration Heterogeneity in this sample was low(I2frac14177 Higgins et al 2003) and the overall sum-mary effect was 017 (022 011) BMI z-scorepoints (zfrac14613 and plt 001) indicating statisticallysignificant weight loss following MWMI
Discussion
The purpose of this review was to examine the effectof MWMIs on self-esteem in overweight and obeseadolescents Increased self-esteem is proposed as a keyfactor for maintaining long-term weight management(Elfhag amp Rossner 2005 French et al 1995Roberts 2006) A secondary outcome of this reviewwas to examine the impact of MWMIs on weight lossand whether this was associated with improvements inself-esteem
The meta-analysis showed no difference in self-esteem between the intervention and control groupsHowever six of the seven studies in the meta-analysisfavored the intervention over control for improve-ments in self-esteem and four of the six studies notincluded in the meta-analysis found significant im-provements in self-esteem following intervention Thelatter of these findings are similar to those of an earlierreview (Lowry et al 2007) that showed improve-ments in self-esteem following weight managementinterventions in a pediatric population particularlywhen certain intervention features were presentSimilarly a number of intervention features that con-tributed to an increased likelihood of improving self-esteem were identified in this review
Improvements in self-esteem regardless of weightloss have been demonstrated in children who tookpart in weight management interventions thatincluded a focus on building self-esteem and it is rec-ommended that this be a focus of all pediatric weightmanagement interventions (Lowry et al 2007) Yetthe majority of studies identified in this review did notinclude building self-esteem as a key aspect of theirintervention Nguyen Shrewsbury et al (2012)described the greatest focus on self-esteem (one75-min group session focused on building self-esteem)and also resulted in the largest treatment effect (057)and a significant improvement in self-esteem (NguyenShrewsbury et al 2012) A focus on similar topics
such as body image social support and managing bul-lying may also contribute to improvements in self-esteem (Croker et al 2012 Pierce amp Wardle 1997Tiggemann 2005) however these findings highlightthe lack of uptake of these recommendations
Among overweight and obese youth reductions inself-esteem are often observed in domains of physicalappearance and physical ability (Franklin DenyerSteinbeck Caterson amp Hill 2006 French et al1995 Latzer amp Stein 2013 Lowry et al 2007)Particularly for adolescent girls body image is a keyconcern (Cave Fildes Luckett amp Wearring 2015)and comprises a large portion of global self-esteem(Lowry et al 2007 Pesa Syre amp Jones 2000)However weight loss and associated changes in phys-ical appearance do not necessarily reflect improve-ments in self-esteem (Lowry et al 2007) Changes inbody-esteem often occur more rapidly than changes inglobal self-esteem as a result of weight management(Lowry et al 2007) This may explain the lack ofchange observed in global self-esteem in this meta-analysis and highlights the need to also include body-esteem (or physical self-esteem) as a focus and out-come of weight management interventions foradolescents
Parental involvement in adolescent weight manage-ment interventions is a critical component for success-ful weight loss and may also be important forimproving self-esteem (Lowry et al 2007) Weight-related teasing from family is shown to be negativelyassociated with self-esteem in overweight adolescentswhereas family connectedness was positively associ-ated with adolescent self-esteem (Fulkerson StraussNeumark-Sztainer Story amp Boutelle 2007) The in-clusion of parents in weight management interventionsfosters a safer and more encouraging home environ-ment for the adolescent (Lowry et al 2007) which isassociated with increased self-esteem in nonover-weight children (Marx amp Neumark-Sztainer 2005)All studies in the present review baring one includedparents in the intervention Parental involvementshould continue to be a key component of weightmanagement interventions to ensure a supportivehome environment for the adolescent to help fosterpositive self-esteem
Weight management interventions that used agroup setting to target self-esteem have shown im-provements in self-esteem without significant weightchange (Lowry et al 2007 Sherman AlexanderGomez Kim amp Marole 1992) The ability of the peergroup setting to provide opportunities for bondingsupport feelings of belonging development of peer-based skills and positive peer exchanges is key toincreasing self-esteem (Lowry et al 2007) The im-portance of this element is being acknowledged in the
390 Murray Dordevic and Bonham
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field with all the studies in this review baring twousing group sessions in their intervention
Measures of self-esteem are self-reported and there-fore subjective Responses to questionnaires are likelyto be influenced by individual (eg age gender) andenvironmental (eg cultural group socioeconomicstatus) factors (Khanlou 2004) Changes followinginterventions may represent genuine long-termchanges in self-esteem or may be due to short-termfluctuations in self-esteem in response to specificevents (eg winning a sporting event or performanceon a test at school) (Kernis 1993) While validatedtools were used to measure self-esteem in all studies itwas difficult to conclude whether outcomes were en-tirely dependent on the intervention without inclusionof a no-treatment control group
The variety of self-esteem assessment tools also addsto the difficulty of interpretation Across the 13 studies inthis review five different tools were used with differentquestions and different scales Even within tools therewere different scales used to report the results (RosenbergSelf-esteem Scale) and different versions of the same ques-tionnaire (Harterrsquos Self-perception Profile for ChildrenHarterrsquos Self-perception Profile for Adolescents) HarterrsquosSelf-Perception Profile (Harterrsquos Self-perception Profilefor Adolescents for adolescents) which measures ninesubscales of self-esteem including physical self-esteem issuggested as the most appropriate measure for adolescentself-esteem (Lowry et al 2007) It was also the mostcommonly used tool among papers included in this re-view While Cohenrsquos d effect sizes were used to stand-ardize results in this review the consistent use of one toolwould provide the ability to compare raw self-esteemscores and create a stronger analysis in the future
Results from this review support evidence thatMWMIs induce weight loss in overweight and obeseadolescents (Hoelscher Kirk Ritchie ampCunningham-Sabo 2013 Kelly amp Melnyk 2008Luttikhuis et al 2009) The change in BMI z-score inthe present meta-analysis (017 [022 011]) wassimilar to the clinically meaningful weight loss re-ported in the 2009 Cochrane Review in children 12years at 6 months follow up from a lifestyle weightmanagement intervention (014 [017 012])(Luttikhuis et al 2009) Jelalian Mehlenbeck Lloyd-Richardson Birmaher and Wing (2006) and WalkerGately Bewick and Hill (2003) have demonstratedassociations between weight loss and increased self-esteem in overweight and obese adolescents after at-tending a weight-management intervention Similarlyin the present review a strong positive relationship be-tween treatment effects for weight loss and improve-ment in self-esteem was identified However itremains unclear whether the improvement in self-esteem was as a result of successful weight loss orwhether it was a contributing factor toward successful
weight loss Nonetheless building self-esteem shouldbe a key focus of MWMIs as improved self-esteem ap-
pears to be linked to enhanced weight lossA key strength of this review was that all included
studies had strong designs and presented level II evi-dence (Coleman et al 2009) However to further elu-
cidate the role of self-esteem in adolescent weightmanagement future research should consider power-
ing studies to detect changes in psychosocial as well asphysiological outcomes Only one study in this reviewwas powered to detect a change in psychosocial out-
comes (Daley et al 2006) which may explain thelack of significant results observed for self-esteem
Additionally a large number of included studies didnot describe their method of handling withdrawals or
use blinding to prevent the introduction of bias Toimprove confidence in the effectiveness of MWMIs
and reduce the risk of bias future studies should bedesigned with concealed allocation and document andreport in detail the flow of participants
Identification of intervention components that im-
prove self-esteem is important for future weight man-agement intervention design Included interventionswere heterogeneous offering different levels of diet-
ary physical activity and behavioral interventionwhich may have collectively or individually influenced
the results Inconsistent reporting of intervention andcomparator conditions make it difficult to elucidate
the components that contributed to improvements inself-esteem Future studies should report intervention
and comparator procedures in adequate detail so thatsuccessful components can be identified and repli-cated These limitations highlight areas for improve-
ment to develop best-practice guidelines forundertaking and evaluating MWMIs in adolescents to
enhance self-esteem
Conclusion
Overweight and obese adolescents experience low
self-esteem largely owing to poor body image yetthis meta-analysis found no improvement in self-esteem even with significant weight loss Although it
was noted that interventions that had larger effects onself-esteem also had larger effects on weight loss The
incorporation of intervention components that wereidentified to contribute to improvements in self-
esteem may assist future weight management interven-tions to improve the self-esteem of overweight and
obese adolescents Furthermore a consistent measureof self-esteem would enable easier interpretation ofself-esteem scores and comparison of results across
studies to improve our understanding of the relation-ship between self-esteem and weight management in
adolescents
The Impact of Weight Management on Self-Esteem 391
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Supplementary Data
Supplementary data can be found at httpwwwjpepsy
oxfordjournalsorg
Acknowledgments
The authors would like to acknowledge Dr Zoe Davidson
for her assistance in performing the meta-analyses
Funding
This work was supported by an Australian GovernmentResearch Training Program Scholarship
Conflicts of interest none declared
References
Academy of Nutrition and Dietetics (2012) Evidence ana-lysis manual Steps in the academy evidence analysis pro-cess Chicago IL ADA Research and Strategic Business
DevelopmentBrennan L Walkley J Fraser S F Greenway K amp
Wilks R (2008) Motivational interviewing and cognitivebehaviour therapy in the treatment of adolescent over-
weight and obesity Study design and methodologyContemporary Clinical Trials 29 359ndash375
Brennan L Walkley J Wilks R Fraser S F amp
Greenway K (2013) Physiological and behavioural out-comes of a randomised controlled trial of a cognitive be-havioural lifestyle intervention for overweight and obese
adolescents Obesity Research and Clinical Practice 7e23ndashe41
Brennan L Wilks R Walkley J Fraser S F amp
Greenway K (2012) Treatment acceptability and psycho-social outcomes of a randomised controlled trial of a cog-nitive behavioural lifestyle intervention for overweight and
obese adolescents Behaviour Change 29 36ndash62Cave L Fildes J Luckett G amp Wearring A (2015)
Mission Australiarsquos 2015 youth survey report MissionAustralia
Coleman K Norris S Weston A Grimmer-Somers KHillier S Merlin T Salisbury J (2009) NHMRCadditional levels of evidence and grades for recommenda-tions for developers of guidelines (Vol Stage 2Consultation) Australia National Health and Medical
Research CouncilCroker H Viner R M Nicholls D Haroun D
Chadwick P Edwards C Wardle J (2012) Family-based behavioural treatment of childhood obesity in a UK
national health service setting Randomized controlledtrial International Journal of Obesity 36 16ndash26 doi
101038ijo2011182Daley A J Copeland R J Wright N P Roalfe A amp
Wales J K H (2006) Exercise therapy as a treatment forpsychopathologic conditions in obese and morbidly obese
adolescents A randomized controlled trial Pediatrics118 2126ndash2134
Danielsen Y S Nordhus I H Julıusson P B Maelighle Mamp Pallesen S (2013) Effect of a family-based cognitive
behavioural intervention on body mass index self-esteem
and symptoms of depression in children with obesity (aged
7mdash13) A randomised waiting list controlled trial ObesityResearch amp Clinical Practice 7 e116ndashe128
DeBar L L Stevens V J Perrin N Wu P Pearson J ampJo B (2012) A primary care-based multicomponent life-
style intervention for overweight adolescent femalesPediatrics 129 e611ndashe620
Elfhag K amp Rossner S (2005) Who succeeds in maintain-ing weight loss A conceptual review of factors associated
with weight loss maintenance and weight regain ObesityReviews 6 67ndash85
Franklin J Denyer G Steinbeck K S Caterson I D ampHill A J (2006) Obesity and risk of low self-esteem Astatewide survey of Australian children Pediatrics 118
2481ndash2487French S A Story M amp Perry C L (1995) Self-esteem
and obesity in children and adolescents A literature re-view Obesity Research 3 479ndash490
Fulkerson J Strauss J Neumark-Sztainer D Story M
amp Boutelle K (2007) Correlates of psychosocial well-being among overweight adolescents The role of the fam-ily Journal of Consulting and Clinical Psychology 75
181ndash186Griffiths L J Parsons T J amp Hill A J (2010) Self-es-
teem and quality of life in obese children and adolescentsA systematic review International Journal of PediatricObesity 5 282ndash304
Harter S (1993) Causes and consequences of low self-
esteem in children and adolescents In R F Baumeister(Ed) Self-esteemmdashThe puzzle of low self-regard (pp87ndash116) USA Springer
Higgins J Thompson S Deeks J amp Altman D (2003)
Measuring inconsistency in meta-analyses BMJ 327557ndash560
Hoelscher D M Kirk S Ritchie L amp Cunningham-Sabo L (2013) Position of the Academy of Nutrition and
Dietetics Interventions for the prevention and treatmentof pediatric overweight and obesity Journal of theAcademy of Nutrition and Dietetics 113 1375ndash1394
Jelalian E Mehlenbeck R Lloyd-Richardson EBirmaher V amp Wing R (2006) lsquoAdventure therapyrsquo
combined with cognitivebehavioral treatment for over-weight adolescents International Journal of Obesity 3031ndash39
Kelly S A amp Melnyk B M (2008) Systematic review of
multicomponent interventions with overweight middleadolescents implications for clinical practice and researchWorldviews on Evidence-Based Nursing 5 113ndash135
Kernis M (1993) The roles of stability and level of self-
esteem in psychological functioning In R Baumeister(Ed) Self-esteem (pp 167ndash182) USA Springer
Khanlou N (2004) Influences on adolescent self-esteem inmulticultural Canadian secondary schools Public HealthNursing 21 404ndash411
Kohn M Rees J M Brill S Fonseca H Jacobson M
Katzman D K Schneider M (2006) Preventing andtreating adolescent obesity A position paper of the Societyfor Adolescent Medicine Journal of Adolescent Health
38 784ndash787Kornman K P Shrewsbury V A Chou A C Ngyuen
B Lee A Orsquoconnor J Baur L A (2010) Electronic
392 Murray Dordevic and Bonham
Dow
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icoupcomjpepsyarticle-abstract4243793065789 by U
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arolina at wilm
ington user on 14 February 2019
therapeutic contact for adolescent weight management
The Loozit study Telemedicine and E-Health 16
678ndash685Latzer Y amp Stein D (2013) A review of the psychological
and familial perspectives of childhood obesity Journal of
Eating Disorders 1 7Lobstein T Baur L amp Uauy R (2004) Obesity in chil-
dren and young people a crisis in public health Obesity
Reviews 5(Suppl 1) 4ndash104Lochrie A S Wysocki T Hossain J Milkes A Antal
H Buckloh L Lang J (2013) The effects of a family-
based intervention (FBI) for overweightobese children on
health and psychological functioning Clinical Practice in
Pediatric Psychology 1 159ndash170 doi httpdxdoiorg
101037cpp0000020Lowry K W Sallinen B amp Janicke D (2007) The effects
of weight management programs on self-esteem in pediat-
ric overweight populations Journal of Pediatric
Psychology 32 1179ndash1195Lubans D R Morgan P J Okely A D Dewar D
Collins C E Batterham M Plotnikoff R C (2012)
Preventing obesity among adolescent girls One-year out-
comes of the nutrition and enjoyable activity for teen girls
(NEAT Girls) cluster randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
821ndash827Luttikhuis H Baur L Jansen H Shrewsbury V
Orsquomalley C Stolk R amp Summerbell C (2009)
Interventions for treating obesity in children (Review)
Cochrane Database of Systematic Reviews 3 1ndash57Marx R D amp Neumark-Sztainer D (2005) Questions amp
Answers Eating Disorders The Journal of Treatment amp
Prevention 13 491ndash495McClure A C Tanksi S E Kingsbury J Gerrard M amp
Sargent J D (2010) Characteristics associated with low
self-esteem among US adolescents Academic Pediatrics
10 238ndash244Mellin L M Slinkard L A amp Irwin C E (1987)
Adolescent obesity intervention Validation of the
SHAPEDOWN program Journal of the American Dietetic
Association 87 333ndash338Mission Australia (2012) Youth Survey 2012 SydneyMoher D Shamseer L Clarke M Ghersi D Liberati
A Petticrew M PRISMA-P Group (2015) Preferred
reporting items for systematic review and meta-analysis
protocols (PRISMA-P) 2015 statement Systematic
Reviews 4 1Morgan P Saunders K amp Lubans D (2012) Improving
physical self-perception in adolescent boys from disadvan-
taged schools Psychological outcomes from the Physical
Activity Leaders randomized controlled trial Pediatric
Obesity 7 e27ndashe32 doi httpdxdoiorg101111j
2047-6310201200050xNational Health and Medical Reasearch Council (2013)
Clinical practice guidelines for the management of over-
weight and obesity in adults adolescents and children in
Australia Australia NHMRC Australian Government
Department of HealthNational Institutes for Health and Care Excellence (2013)
Managing overweight and obesity among children and
young people lifestyle weight management services NICE
public health guidance United Kingdom 47 NICENeumark-Sztainer D R Friend S E Flattum C F
Hannan P J Story M T Bauer K W Petrich C A
(2010) New moves-preventing weight-related problems in
adolescent girls A group-randomized study American
Journal of Preventive Medicine 39 421ndash432Nguyen B McGregor K A Orsquoconnor J Shrewsbury V
A Lee A Steinbeck K S Baur L A (2012)
Recruitment challenges and recommendations for adoles-
cent obesity trials Journal of Paediatrics and Child
Health 48 38ndash43Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Hill A J Shah S Baur L A (2013) Two-year
outcomes of an adjunctive telephone coaching and elec-
tronic contact intervention for adolescent weight-loss
maintenance the Loozit randomized controlled trial
International Journal of Obesity 37 468ndash472Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2012) Twelve-month
outcomes of the Loozit randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
170ndash177Ogden C L Carroll M D Kit B K amp Flegal K M
(2014) Prevalence of childhood and adult obesity in the
United States 2011-2012 Journal of the American
Medical Association 311 806ndash814Pesa J A Syre T R amp Jones E (2000) Psychosocial dif-
ferences associated with body weight among female ado-
lescents The importance of body image Journal of
Adolescent Health 26 330ndash337Pierce J W amp Wardle J (1997) Cause and effect beliefs
and self-esteem of overweight children Journal of Child
Psychology and Psychiatry 38 645ndash650 doi 101111
j1469-76101997tb01691xRoberts J E (2006) Self-esteem from a clinical perspective
In M H Kernis (Ed) Self-esteem issues and answers A
sourcebook of current perspectives Psychology Press
Taylor amp Francis New York and Hove (pp 298ndash305)
Psychology PressSacher P M Kolotourou M Chadwick P M Cole T J
Lawson M S Lucas A amp Singhal A (2010)
Randomized controlled trial of the MEND program A
family-based community intervention for childhood obes-
ity Obesity 18(Suppl 1) S62ndashS68 doi httpdxdoiorg
101038oby2009433Sanders R H Han A Baker J S amp Cobley S (2015)
Childhood obesity and its physical and psychological co-
morbidities a systematic review of Australian children and
adolescents Eur J Pediatr 174 715ndash746Sherman J B Alexander M A Gomez D Kim M amp
Marole P (1992) Intervention program for obese school chil-
dren Journal of Community Health Nursing 9 183ndash190Shrewsbury V A Nguyen B Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2011) Short-term
outcomes of community-based adolescent weight manage-
ment The LoozitVR
Study BMC Pediatrics 11 13Shrewsbury V A Orsquoconnor J Steinbeck K S Stevenson
K Lee A Hill A J Baur L A (2009) A randomised
controlled trial of a community-based healthy lifestyle
The Impact of Weight Management on Self-Esteem 393
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
program for overweight and obese adolescents TheLoozitV
R
study protocol BMC Public Health 9 119Strauss R S (2000) Childhood obesity and self-esteem
Pediatrics 105 5Tiggemann M (2005) Body dissatisfaction and adolescent
self-esteem Prospective findings Body Image 2 129ndash135doi httpdxdoiorg101016jbodyim200503006
Wadden T A Stunkard A J Rich L Rubin C JSweidel G amp McKinney S (1990) Obesity in black ado-lescent girls A controlled clinical trial of treatment by diet
behaviour modification and parental support Pediatrics85 345ndash352
Walker L Gately P Bewick B amp Hill A (2003)Childrenrsquos weight-loss camps psychological benefit orjeopardy International Journal of Obesity 27 748ndash754
World Health Organization (2014) Maternal newbornchild and adolescent health Adolescent developmentRetrieved from httpwwwwhointmaternal_child_adolescenttopicsadolescencedeven Retrieved 28 May2014
394 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
- jsw101-TF1
- jsw101-TF2
- jsw101-TF3
- jsw101-TF4
- jsw101-TF5
- jsw101-TF6
- jsw101-TF7
- jsw101-TF8
- jsw101-TF9
- jsw101-TF10
- jsw101-TF11
-
Quantitative Data AnalysisDifferences between intervention and control groupsfor change in self-esteem are presented in Figure 2aThis analysis included seven intervention groups(nfrac14 191) and seven control groups (nfrac14 132) with
interventions or intensive treatment phases rangingfrom 9 weeks to 6 months in duration A moderatelevel of the variation across studies was owing to het-erogeneity (I2frac14464 Higgins Thompson Deeksamp Altman 2003) The overall summary effect showed
Figure 2 Comparison between intervention and control groups for the change in adolescent self-esteem effect size (a) andbody mass index z-score (b) following multicomponent weight management interventions SMD frac14 standard mean differ-ence WMD frac14 weighted mean difference
The Impact of Weight Management on Self-Esteem 389
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
no effect on self-esteem as a result of interventionSMD of 027 (95 confidence interval 004 059)zfrac14 169 and pfrac14 092 However all studies exceptone favored the intervention for improvements in self-esteem
The difference between intervention and controlgroups for change in BMI z-score is illustrated inFigure 2b This analysis included five interventiongroups (nfrac14 135) and five control groups (nfrac14 82) withinterventions ranging from 9 weeks to 6 months induration Heterogeneity in this sample was low(I2frac14177 Higgins et al 2003) and the overall sum-mary effect was 017 (022 011) BMI z-scorepoints (zfrac14613 and plt 001) indicating statisticallysignificant weight loss following MWMI
Discussion
The purpose of this review was to examine the effectof MWMIs on self-esteem in overweight and obeseadolescents Increased self-esteem is proposed as a keyfactor for maintaining long-term weight management(Elfhag amp Rossner 2005 French et al 1995Roberts 2006) A secondary outcome of this reviewwas to examine the impact of MWMIs on weight lossand whether this was associated with improvements inself-esteem
The meta-analysis showed no difference in self-esteem between the intervention and control groupsHowever six of the seven studies in the meta-analysisfavored the intervention over control for improve-ments in self-esteem and four of the six studies notincluded in the meta-analysis found significant im-provements in self-esteem following intervention Thelatter of these findings are similar to those of an earlierreview (Lowry et al 2007) that showed improve-ments in self-esteem following weight managementinterventions in a pediatric population particularlywhen certain intervention features were presentSimilarly a number of intervention features that con-tributed to an increased likelihood of improving self-esteem were identified in this review
Improvements in self-esteem regardless of weightloss have been demonstrated in children who tookpart in weight management interventions thatincluded a focus on building self-esteem and it is rec-ommended that this be a focus of all pediatric weightmanagement interventions (Lowry et al 2007) Yetthe majority of studies identified in this review did notinclude building self-esteem as a key aspect of theirintervention Nguyen Shrewsbury et al (2012)described the greatest focus on self-esteem (one75-min group session focused on building self-esteem)and also resulted in the largest treatment effect (057)and a significant improvement in self-esteem (NguyenShrewsbury et al 2012) A focus on similar topics
such as body image social support and managing bul-lying may also contribute to improvements in self-esteem (Croker et al 2012 Pierce amp Wardle 1997Tiggemann 2005) however these findings highlightthe lack of uptake of these recommendations
Among overweight and obese youth reductions inself-esteem are often observed in domains of physicalappearance and physical ability (Franklin DenyerSteinbeck Caterson amp Hill 2006 French et al1995 Latzer amp Stein 2013 Lowry et al 2007)Particularly for adolescent girls body image is a keyconcern (Cave Fildes Luckett amp Wearring 2015)and comprises a large portion of global self-esteem(Lowry et al 2007 Pesa Syre amp Jones 2000)However weight loss and associated changes in phys-ical appearance do not necessarily reflect improve-ments in self-esteem (Lowry et al 2007) Changes inbody-esteem often occur more rapidly than changes inglobal self-esteem as a result of weight management(Lowry et al 2007) This may explain the lack ofchange observed in global self-esteem in this meta-analysis and highlights the need to also include body-esteem (or physical self-esteem) as a focus and out-come of weight management interventions foradolescents
Parental involvement in adolescent weight manage-ment interventions is a critical component for success-ful weight loss and may also be important forimproving self-esteem (Lowry et al 2007) Weight-related teasing from family is shown to be negativelyassociated with self-esteem in overweight adolescentswhereas family connectedness was positively associ-ated with adolescent self-esteem (Fulkerson StraussNeumark-Sztainer Story amp Boutelle 2007) The in-clusion of parents in weight management interventionsfosters a safer and more encouraging home environ-ment for the adolescent (Lowry et al 2007) which isassociated with increased self-esteem in nonover-weight children (Marx amp Neumark-Sztainer 2005)All studies in the present review baring one includedparents in the intervention Parental involvementshould continue to be a key component of weightmanagement interventions to ensure a supportivehome environment for the adolescent to help fosterpositive self-esteem
Weight management interventions that used agroup setting to target self-esteem have shown im-provements in self-esteem without significant weightchange (Lowry et al 2007 Sherman AlexanderGomez Kim amp Marole 1992) The ability of the peergroup setting to provide opportunities for bondingsupport feelings of belonging development of peer-based skills and positive peer exchanges is key toincreasing self-esteem (Lowry et al 2007) The im-portance of this element is being acknowledged in the
390 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
field with all the studies in this review baring twousing group sessions in their intervention
Measures of self-esteem are self-reported and there-fore subjective Responses to questionnaires are likelyto be influenced by individual (eg age gender) andenvironmental (eg cultural group socioeconomicstatus) factors (Khanlou 2004) Changes followinginterventions may represent genuine long-termchanges in self-esteem or may be due to short-termfluctuations in self-esteem in response to specificevents (eg winning a sporting event or performanceon a test at school) (Kernis 1993) While validatedtools were used to measure self-esteem in all studies itwas difficult to conclude whether outcomes were en-tirely dependent on the intervention without inclusionof a no-treatment control group
The variety of self-esteem assessment tools also addsto the difficulty of interpretation Across the 13 studies inthis review five different tools were used with differentquestions and different scales Even within tools therewere different scales used to report the results (RosenbergSelf-esteem Scale) and different versions of the same ques-tionnaire (Harterrsquos Self-perception Profile for ChildrenHarterrsquos Self-perception Profile for Adolescents) HarterrsquosSelf-Perception Profile (Harterrsquos Self-perception Profilefor Adolescents for adolescents) which measures ninesubscales of self-esteem including physical self-esteem issuggested as the most appropriate measure for adolescentself-esteem (Lowry et al 2007) It was also the mostcommonly used tool among papers included in this re-view While Cohenrsquos d effect sizes were used to stand-ardize results in this review the consistent use of one toolwould provide the ability to compare raw self-esteemscores and create a stronger analysis in the future
Results from this review support evidence thatMWMIs induce weight loss in overweight and obeseadolescents (Hoelscher Kirk Ritchie ampCunningham-Sabo 2013 Kelly amp Melnyk 2008Luttikhuis et al 2009) The change in BMI z-score inthe present meta-analysis (017 [022 011]) wassimilar to the clinically meaningful weight loss re-ported in the 2009 Cochrane Review in children 12years at 6 months follow up from a lifestyle weightmanagement intervention (014 [017 012])(Luttikhuis et al 2009) Jelalian Mehlenbeck Lloyd-Richardson Birmaher and Wing (2006) and WalkerGately Bewick and Hill (2003) have demonstratedassociations between weight loss and increased self-esteem in overweight and obese adolescents after at-tending a weight-management intervention Similarlyin the present review a strong positive relationship be-tween treatment effects for weight loss and improve-ment in self-esteem was identified However itremains unclear whether the improvement in self-esteem was as a result of successful weight loss orwhether it was a contributing factor toward successful
weight loss Nonetheless building self-esteem shouldbe a key focus of MWMIs as improved self-esteem ap-
pears to be linked to enhanced weight lossA key strength of this review was that all included
studies had strong designs and presented level II evi-dence (Coleman et al 2009) However to further elu-
cidate the role of self-esteem in adolescent weightmanagement future research should consider power-
ing studies to detect changes in psychosocial as well asphysiological outcomes Only one study in this reviewwas powered to detect a change in psychosocial out-
comes (Daley et al 2006) which may explain thelack of significant results observed for self-esteem
Additionally a large number of included studies didnot describe their method of handling withdrawals or
use blinding to prevent the introduction of bias Toimprove confidence in the effectiveness of MWMIs
and reduce the risk of bias future studies should bedesigned with concealed allocation and document andreport in detail the flow of participants
Identification of intervention components that im-
prove self-esteem is important for future weight man-agement intervention design Included interventionswere heterogeneous offering different levels of diet-
ary physical activity and behavioral interventionwhich may have collectively or individually influenced
the results Inconsistent reporting of intervention andcomparator conditions make it difficult to elucidate
the components that contributed to improvements inself-esteem Future studies should report intervention
and comparator procedures in adequate detail so thatsuccessful components can be identified and repli-cated These limitations highlight areas for improve-
ment to develop best-practice guidelines forundertaking and evaluating MWMIs in adolescents to
enhance self-esteem
Conclusion
Overweight and obese adolescents experience low
self-esteem largely owing to poor body image yetthis meta-analysis found no improvement in self-esteem even with significant weight loss Although it
was noted that interventions that had larger effects onself-esteem also had larger effects on weight loss The
incorporation of intervention components that wereidentified to contribute to improvements in self-
esteem may assist future weight management interven-tions to improve the self-esteem of overweight and
obese adolescents Furthermore a consistent measureof self-esteem would enable easier interpretation ofself-esteem scores and comparison of results across
studies to improve our understanding of the relation-ship between self-esteem and weight management in
adolescents
The Impact of Weight Management on Self-Esteem 391
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Supplementary Data
Supplementary data can be found at httpwwwjpepsy
oxfordjournalsorg
Acknowledgments
The authors would like to acknowledge Dr Zoe Davidson
for her assistance in performing the meta-analyses
Funding
This work was supported by an Australian GovernmentResearch Training Program Scholarship
Conflicts of interest none declared
References
Academy of Nutrition and Dietetics (2012) Evidence ana-lysis manual Steps in the academy evidence analysis pro-cess Chicago IL ADA Research and Strategic Business
DevelopmentBrennan L Walkley J Fraser S F Greenway K amp
Wilks R (2008) Motivational interviewing and cognitivebehaviour therapy in the treatment of adolescent over-
weight and obesity Study design and methodologyContemporary Clinical Trials 29 359ndash375
Brennan L Walkley J Wilks R Fraser S F amp
Greenway K (2013) Physiological and behavioural out-comes of a randomised controlled trial of a cognitive be-havioural lifestyle intervention for overweight and obese
adolescents Obesity Research and Clinical Practice 7e23ndashe41
Brennan L Wilks R Walkley J Fraser S F amp
Greenway K (2012) Treatment acceptability and psycho-social outcomes of a randomised controlled trial of a cog-nitive behavioural lifestyle intervention for overweight and
obese adolescents Behaviour Change 29 36ndash62Cave L Fildes J Luckett G amp Wearring A (2015)
Mission Australiarsquos 2015 youth survey report MissionAustralia
Coleman K Norris S Weston A Grimmer-Somers KHillier S Merlin T Salisbury J (2009) NHMRCadditional levels of evidence and grades for recommenda-tions for developers of guidelines (Vol Stage 2Consultation) Australia National Health and Medical
Research CouncilCroker H Viner R M Nicholls D Haroun D
Chadwick P Edwards C Wardle J (2012) Family-based behavioural treatment of childhood obesity in a UK
national health service setting Randomized controlledtrial International Journal of Obesity 36 16ndash26 doi
101038ijo2011182Daley A J Copeland R J Wright N P Roalfe A amp
Wales J K H (2006) Exercise therapy as a treatment forpsychopathologic conditions in obese and morbidly obese
adolescents A randomized controlled trial Pediatrics118 2126ndash2134
Danielsen Y S Nordhus I H Julıusson P B Maelighle Mamp Pallesen S (2013) Effect of a family-based cognitive
behavioural intervention on body mass index self-esteem
and symptoms of depression in children with obesity (aged
7mdash13) A randomised waiting list controlled trial ObesityResearch amp Clinical Practice 7 e116ndashe128
DeBar L L Stevens V J Perrin N Wu P Pearson J ampJo B (2012) A primary care-based multicomponent life-
style intervention for overweight adolescent femalesPediatrics 129 e611ndashe620
Elfhag K amp Rossner S (2005) Who succeeds in maintain-ing weight loss A conceptual review of factors associated
with weight loss maintenance and weight regain ObesityReviews 6 67ndash85
Franklin J Denyer G Steinbeck K S Caterson I D ampHill A J (2006) Obesity and risk of low self-esteem Astatewide survey of Australian children Pediatrics 118
2481ndash2487French S A Story M amp Perry C L (1995) Self-esteem
and obesity in children and adolescents A literature re-view Obesity Research 3 479ndash490
Fulkerson J Strauss J Neumark-Sztainer D Story M
amp Boutelle K (2007) Correlates of psychosocial well-being among overweight adolescents The role of the fam-ily Journal of Consulting and Clinical Psychology 75
181ndash186Griffiths L J Parsons T J amp Hill A J (2010) Self-es-
teem and quality of life in obese children and adolescentsA systematic review International Journal of PediatricObesity 5 282ndash304
Harter S (1993) Causes and consequences of low self-
esteem in children and adolescents In R F Baumeister(Ed) Self-esteemmdashThe puzzle of low self-regard (pp87ndash116) USA Springer
Higgins J Thompson S Deeks J amp Altman D (2003)
Measuring inconsistency in meta-analyses BMJ 327557ndash560
Hoelscher D M Kirk S Ritchie L amp Cunningham-Sabo L (2013) Position of the Academy of Nutrition and
Dietetics Interventions for the prevention and treatmentof pediatric overweight and obesity Journal of theAcademy of Nutrition and Dietetics 113 1375ndash1394
Jelalian E Mehlenbeck R Lloyd-Richardson EBirmaher V amp Wing R (2006) lsquoAdventure therapyrsquo
combined with cognitivebehavioral treatment for over-weight adolescents International Journal of Obesity 3031ndash39
Kelly S A amp Melnyk B M (2008) Systematic review of
multicomponent interventions with overweight middleadolescents implications for clinical practice and researchWorldviews on Evidence-Based Nursing 5 113ndash135
Kernis M (1993) The roles of stability and level of self-
esteem in psychological functioning In R Baumeister(Ed) Self-esteem (pp 167ndash182) USA Springer
Khanlou N (2004) Influences on adolescent self-esteem inmulticultural Canadian secondary schools Public HealthNursing 21 404ndash411
Kohn M Rees J M Brill S Fonseca H Jacobson M
Katzman D K Schneider M (2006) Preventing andtreating adolescent obesity A position paper of the Societyfor Adolescent Medicine Journal of Adolescent Health
38 784ndash787Kornman K P Shrewsbury V A Chou A C Ngyuen
B Lee A Orsquoconnor J Baur L A (2010) Electronic
392 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
therapeutic contact for adolescent weight management
The Loozit study Telemedicine and E-Health 16
678ndash685Latzer Y amp Stein D (2013) A review of the psychological
and familial perspectives of childhood obesity Journal of
Eating Disorders 1 7Lobstein T Baur L amp Uauy R (2004) Obesity in chil-
dren and young people a crisis in public health Obesity
Reviews 5(Suppl 1) 4ndash104Lochrie A S Wysocki T Hossain J Milkes A Antal
H Buckloh L Lang J (2013) The effects of a family-
based intervention (FBI) for overweightobese children on
health and psychological functioning Clinical Practice in
Pediatric Psychology 1 159ndash170 doi httpdxdoiorg
101037cpp0000020Lowry K W Sallinen B amp Janicke D (2007) The effects
of weight management programs on self-esteem in pediat-
ric overweight populations Journal of Pediatric
Psychology 32 1179ndash1195Lubans D R Morgan P J Okely A D Dewar D
Collins C E Batterham M Plotnikoff R C (2012)
Preventing obesity among adolescent girls One-year out-
comes of the nutrition and enjoyable activity for teen girls
(NEAT Girls) cluster randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
821ndash827Luttikhuis H Baur L Jansen H Shrewsbury V
Orsquomalley C Stolk R amp Summerbell C (2009)
Interventions for treating obesity in children (Review)
Cochrane Database of Systematic Reviews 3 1ndash57Marx R D amp Neumark-Sztainer D (2005) Questions amp
Answers Eating Disorders The Journal of Treatment amp
Prevention 13 491ndash495McClure A C Tanksi S E Kingsbury J Gerrard M amp
Sargent J D (2010) Characteristics associated with low
self-esteem among US adolescents Academic Pediatrics
10 238ndash244Mellin L M Slinkard L A amp Irwin C E (1987)
Adolescent obesity intervention Validation of the
SHAPEDOWN program Journal of the American Dietetic
Association 87 333ndash338Mission Australia (2012) Youth Survey 2012 SydneyMoher D Shamseer L Clarke M Ghersi D Liberati
A Petticrew M PRISMA-P Group (2015) Preferred
reporting items for systematic review and meta-analysis
protocols (PRISMA-P) 2015 statement Systematic
Reviews 4 1Morgan P Saunders K amp Lubans D (2012) Improving
physical self-perception in adolescent boys from disadvan-
taged schools Psychological outcomes from the Physical
Activity Leaders randomized controlled trial Pediatric
Obesity 7 e27ndashe32 doi httpdxdoiorg101111j
2047-6310201200050xNational Health and Medical Reasearch Council (2013)
Clinical practice guidelines for the management of over-
weight and obesity in adults adolescents and children in
Australia Australia NHMRC Australian Government
Department of HealthNational Institutes for Health and Care Excellence (2013)
Managing overweight and obesity among children and
young people lifestyle weight management services NICE
public health guidance United Kingdom 47 NICENeumark-Sztainer D R Friend S E Flattum C F
Hannan P J Story M T Bauer K W Petrich C A
(2010) New moves-preventing weight-related problems in
adolescent girls A group-randomized study American
Journal of Preventive Medicine 39 421ndash432Nguyen B McGregor K A Orsquoconnor J Shrewsbury V
A Lee A Steinbeck K S Baur L A (2012)
Recruitment challenges and recommendations for adoles-
cent obesity trials Journal of Paediatrics and Child
Health 48 38ndash43Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Hill A J Shah S Baur L A (2013) Two-year
outcomes of an adjunctive telephone coaching and elec-
tronic contact intervention for adolescent weight-loss
maintenance the Loozit randomized controlled trial
International Journal of Obesity 37 468ndash472Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2012) Twelve-month
outcomes of the Loozit randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
170ndash177Ogden C L Carroll M D Kit B K amp Flegal K M
(2014) Prevalence of childhood and adult obesity in the
United States 2011-2012 Journal of the American
Medical Association 311 806ndash814Pesa J A Syre T R amp Jones E (2000) Psychosocial dif-
ferences associated with body weight among female ado-
lescents The importance of body image Journal of
Adolescent Health 26 330ndash337Pierce J W amp Wardle J (1997) Cause and effect beliefs
and self-esteem of overweight children Journal of Child
Psychology and Psychiatry 38 645ndash650 doi 101111
j1469-76101997tb01691xRoberts J E (2006) Self-esteem from a clinical perspective
In M H Kernis (Ed) Self-esteem issues and answers A
sourcebook of current perspectives Psychology Press
Taylor amp Francis New York and Hove (pp 298ndash305)
Psychology PressSacher P M Kolotourou M Chadwick P M Cole T J
Lawson M S Lucas A amp Singhal A (2010)
Randomized controlled trial of the MEND program A
family-based community intervention for childhood obes-
ity Obesity 18(Suppl 1) S62ndashS68 doi httpdxdoiorg
101038oby2009433Sanders R H Han A Baker J S amp Cobley S (2015)
Childhood obesity and its physical and psychological co-
morbidities a systematic review of Australian children and
adolescents Eur J Pediatr 174 715ndash746Sherman J B Alexander M A Gomez D Kim M amp
Marole P (1992) Intervention program for obese school chil-
dren Journal of Community Health Nursing 9 183ndash190Shrewsbury V A Nguyen B Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2011) Short-term
outcomes of community-based adolescent weight manage-
ment The LoozitVR
Study BMC Pediatrics 11 13Shrewsbury V A Orsquoconnor J Steinbeck K S Stevenson
K Lee A Hill A J Baur L A (2009) A randomised
controlled trial of a community-based healthy lifestyle
The Impact of Weight Management on Self-Esteem 393
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
program for overweight and obese adolescents TheLoozitV
R
study protocol BMC Public Health 9 119Strauss R S (2000) Childhood obesity and self-esteem
Pediatrics 105 5Tiggemann M (2005) Body dissatisfaction and adolescent
self-esteem Prospective findings Body Image 2 129ndash135doi httpdxdoiorg101016jbodyim200503006
Wadden T A Stunkard A J Rich L Rubin C JSweidel G amp McKinney S (1990) Obesity in black ado-lescent girls A controlled clinical trial of treatment by diet
behaviour modification and parental support Pediatrics85 345ndash352
Walker L Gately P Bewick B amp Hill A (2003)Childrenrsquos weight-loss camps psychological benefit orjeopardy International Journal of Obesity 27 748ndash754
World Health Organization (2014) Maternal newbornchild and adolescent health Adolescent developmentRetrieved from httpwwwwhointmaternal_child_adolescenttopicsadolescencedeven Retrieved 28 May2014
394 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
- jsw101-TF1
- jsw101-TF2
- jsw101-TF3
- jsw101-TF4
- jsw101-TF5
- jsw101-TF6
- jsw101-TF7
- jsw101-TF8
- jsw101-TF9
- jsw101-TF10
- jsw101-TF11
-
no effect on self-esteem as a result of interventionSMD of 027 (95 confidence interval 004 059)zfrac14 169 and pfrac14 092 However all studies exceptone favored the intervention for improvements in self-esteem
The difference between intervention and controlgroups for change in BMI z-score is illustrated inFigure 2b This analysis included five interventiongroups (nfrac14 135) and five control groups (nfrac14 82) withinterventions ranging from 9 weeks to 6 months induration Heterogeneity in this sample was low(I2frac14177 Higgins et al 2003) and the overall sum-mary effect was 017 (022 011) BMI z-scorepoints (zfrac14613 and plt 001) indicating statisticallysignificant weight loss following MWMI
Discussion
The purpose of this review was to examine the effectof MWMIs on self-esteem in overweight and obeseadolescents Increased self-esteem is proposed as a keyfactor for maintaining long-term weight management(Elfhag amp Rossner 2005 French et al 1995Roberts 2006) A secondary outcome of this reviewwas to examine the impact of MWMIs on weight lossand whether this was associated with improvements inself-esteem
The meta-analysis showed no difference in self-esteem between the intervention and control groupsHowever six of the seven studies in the meta-analysisfavored the intervention over control for improve-ments in self-esteem and four of the six studies notincluded in the meta-analysis found significant im-provements in self-esteem following intervention Thelatter of these findings are similar to those of an earlierreview (Lowry et al 2007) that showed improve-ments in self-esteem following weight managementinterventions in a pediatric population particularlywhen certain intervention features were presentSimilarly a number of intervention features that con-tributed to an increased likelihood of improving self-esteem were identified in this review
Improvements in self-esteem regardless of weightloss have been demonstrated in children who tookpart in weight management interventions thatincluded a focus on building self-esteem and it is rec-ommended that this be a focus of all pediatric weightmanagement interventions (Lowry et al 2007) Yetthe majority of studies identified in this review did notinclude building self-esteem as a key aspect of theirintervention Nguyen Shrewsbury et al (2012)described the greatest focus on self-esteem (one75-min group session focused on building self-esteem)and also resulted in the largest treatment effect (057)and a significant improvement in self-esteem (NguyenShrewsbury et al 2012) A focus on similar topics
such as body image social support and managing bul-lying may also contribute to improvements in self-esteem (Croker et al 2012 Pierce amp Wardle 1997Tiggemann 2005) however these findings highlightthe lack of uptake of these recommendations
Among overweight and obese youth reductions inself-esteem are often observed in domains of physicalappearance and physical ability (Franklin DenyerSteinbeck Caterson amp Hill 2006 French et al1995 Latzer amp Stein 2013 Lowry et al 2007)Particularly for adolescent girls body image is a keyconcern (Cave Fildes Luckett amp Wearring 2015)and comprises a large portion of global self-esteem(Lowry et al 2007 Pesa Syre amp Jones 2000)However weight loss and associated changes in phys-ical appearance do not necessarily reflect improve-ments in self-esteem (Lowry et al 2007) Changes inbody-esteem often occur more rapidly than changes inglobal self-esteem as a result of weight management(Lowry et al 2007) This may explain the lack ofchange observed in global self-esteem in this meta-analysis and highlights the need to also include body-esteem (or physical self-esteem) as a focus and out-come of weight management interventions foradolescents
Parental involvement in adolescent weight manage-ment interventions is a critical component for success-ful weight loss and may also be important forimproving self-esteem (Lowry et al 2007) Weight-related teasing from family is shown to be negativelyassociated with self-esteem in overweight adolescentswhereas family connectedness was positively associ-ated with adolescent self-esteem (Fulkerson StraussNeumark-Sztainer Story amp Boutelle 2007) The in-clusion of parents in weight management interventionsfosters a safer and more encouraging home environ-ment for the adolescent (Lowry et al 2007) which isassociated with increased self-esteem in nonover-weight children (Marx amp Neumark-Sztainer 2005)All studies in the present review baring one includedparents in the intervention Parental involvementshould continue to be a key component of weightmanagement interventions to ensure a supportivehome environment for the adolescent to help fosterpositive self-esteem
Weight management interventions that used agroup setting to target self-esteem have shown im-provements in self-esteem without significant weightchange (Lowry et al 2007 Sherman AlexanderGomez Kim amp Marole 1992) The ability of the peergroup setting to provide opportunities for bondingsupport feelings of belonging development of peer-based skills and positive peer exchanges is key toincreasing self-esteem (Lowry et al 2007) The im-portance of this element is being acknowledged in the
390 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
field with all the studies in this review baring twousing group sessions in their intervention
Measures of self-esteem are self-reported and there-fore subjective Responses to questionnaires are likelyto be influenced by individual (eg age gender) andenvironmental (eg cultural group socioeconomicstatus) factors (Khanlou 2004) Changes followinginterventions may represent genuine long-termchanges in self-esteem or may be due to short-termfluctuations in self-esteem in response to specificevents (eg winning a sporting event or performanceon a test at school) (Kernis 1993) While validatedtools were used to measure self-esteem in all studies itwas difficult to conclude whether outcomes were en-tirely dependent on the intervention without inclusionof a no-treatment control group
The variety of self-esteem assessment tools also addsto the difficulty of interpretation Across the 13 studies inthis review five different tools were used with differentquestions and different scales Even within tools therewere different scales used to report the results (RosenbergSelf-esteem Scale) and different versions of the same ques-tionnaire (Harterrsquos Self-perception Profile for ChildrenHarterrsquos Self-perception Profile for Adolescents) HarterrsquosSelf-Perception Profile (Harterrsquos Self-perception Profilefor Adolescents for adolescents) which measures ninesubscales of self-esteem including physical self-esteem issuggested as the most appropriate measure for adolescentself-esteem (Lowry et al 2007) It was also the mostcommonly used tool among papers included in this re-view While Cohenrsquos d effect sizes were used to stand-ardize results in this review the consistent use of one toolwould provide the ability to compare raw self-esteemscores and create a stronger analysis in the future
Results from this review support evidence thatMWMIs induce weight loss in overweight and obeseadolescents (Hoelscher Kirk Ritchie ampCunningham-Sabo 2013 Kelly amp Melnyk 2008Luttikhuis et al 2009) The change in BMI z-score inthe present meta-analysis (017 [022 011]) wassimilar to the clinically meaningful weight loss re-ported in the 2009 Cochrane Review in children 12years at 6 months follow up from a lifestyle weightmanagement intervention (014 [017 012])(Luttikhuis et al 2009) Jelalian Mehlenbeck Lloyd-Richardson Birmaher and Wing (2006) and WalkerGately Bewick and Hill (2003) have demonstratedassociations between weight loss and increased self-esteem in overweight and obese adolescents after at-tending a weight-management intervention Similarlyin the present review a strong positive relationship be-tween treatment effects for weight loss and improve-ment in self-esteem was identified However itremains unclear whether the improvement in self-esteem was as a result of successful weight loss orwhether it was a contributing factor toward successful
weight loss Nonetheless building self-esteem shouldbe a key focus of MWMIs as improved self-esteem ap-
pears to be linked to enhanced weight lossA key strength of this review was that all included
studies had strong designs and presented level II evi-dence (Coleman et al 2009) However to further elu-
cidate the role of self-esteem in adolescent weightmanagement future research should consider power-
ing studies to detect changes in psychosocial as well asphysiological outcomes Only one study in this reviewwas powered to detect a change in psychosocial out-
comes (Daley et al 2006) which may explain thelack of significant results observed for self-esteem
Additionally a large number of included studies didnot describe their method of handling withdrawals or
use blinding to prevent the introduction of bias Toimprove confidence in the effectiveness of MWMIs
and reduce the risk of bias future studies should bedesigned with concealed allocation and document andreport in detail the flow of participants
Identification of intervention components that im-
prove self-esteem is important for future weight man-agement intervention design Included interventionswere heterogeneous offering different levels of diet-
ary physical activity and behavioral interventionwhich may have collectively or individually influenced
the results Inconsistent reporting of intervention andcomparator conditions make it difficult to elucidate
the components that contributed to improvements inself-esteem Future studies should report intervention
and comparator procedures in adequate detail so thatsuccessful components can be identified and repli-cated These limitations highlight areas for improve-
ment to develop best-practice guidelines forundertaking and evaluating MWMIs in adolescents to
enhance self-esteem
Conclusion
Overweight and obese adolescents experience low
self-esteem largely owing to poor body image yetthis meta-analysis found no improvement in self-esteem even with significant weight loss Although it
was noted that interventions that had larger effects onself-esteem also had larger effects on weight loss The
incorporation of intervention components that wereidentified to contribute to improvements in self-
esteem may assist future weight management interven-tions to improve the self-esteem of overweight and
obese adolescents Furthermore a consistent measureof self-esteem would enable easier interpretation ofself-esteem scores and comparison of results across
studies to improve our understanding of the relation-ship between self-esteem and weight management in
adolescents
The Impact of Weight Management on Self-Esteem 391
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Supplementary Data
Supplementary data can be found at httpwwwjpepsy
oxfordjournalsorg
Acknowledgments
The authors would like to acknowledge Dr Zoe Davidson
for her assistance in performing the meta-analyses
Funding
This work was supported by an Australian GovernmentResearch Training Program Scholarship
Conflicts of interest none declared
References
Academy of Nutrition and Dietetics (2012) Evidence ana-lysis manual Steps in the academy evidence analysis pro-cess Chicago IL ADA Research and Strategic Business
DevelopmentBrennan L Walkley J Fraser S F Greenway K amp
Wilks R (2008) Motivational interviewing and cognitivebehaviour therapy in the treatment of adolescent over-
weight and obesity Study design and methodologyContemporary Clinical Trials 29 359ndash375
Brennan L Walkley J Wilks R Fraser S F amp
Greenway K (2013) Physiological and behavioural out-comes of a randomised controlled trial of a cognitive be-havioural lifestyle intervention for overweight and obese
adolescents Obesity Research and Clinical Practice 7e23ndashe41
Brennan L Wilks R Walkley J Fraser S F amp
Greenway K (2012) Treatment acceptability and psycho-social outcomes of a randomised controlled trial of a cog-nitive behavioural lifestyle intervention for overweight and
obese adolescents Behaviour Change 29 36ndash62Cave L Fildes J Luckett G amp Wearring A (2015)
Mission Australiarsquos 2015 youth survey report MissionAustralia
Coleman K Norris S Weston A Grimmer-Somers KHillier S Merlin T Salisbury J (2009) NHMRCadditional levels of evidence and grades for recommenda-tions for developers of guidelines (Vol Stage 2Consultation) Australia National Health and Medical
Research CouncilCroker H Viner R M Nicholls D Haroun D
Chadwick P Edwards C Wardle J (2012) Family-based behavioural treatment of childhood obesity in a UK
national health service setting Randomized controlledtrial International Journal of Obesity 36 16ndash26 doi
101038ijo2011182Daley A J Copeland R J Wright N P Roalfe A amp
Wales J K H (2006) Exercise therapy as a treatment forpsychopathologic conditions in obese and morbidly obese
adolescents A randomized controlled trial Pediatrics118 2126ndash2134
Danielsen Y S Nordhus I H Julıusson P B Maelighle Mamp Pallesen S (2013) Effect of a family-based cognitive
behavioural intervention on body mass index self-esteem
and symptoms of depression in children with obesity (aged
7mdash13) A randomised waiting list controlled trial ObesityResearch amp Clinical Practice 7 e116ndashe128
DeBar L L Stevens V J Perrin N Wu P Pearson J ampJo B (2012) A primary care-based multicomponent life-
style intervention for overweight adolescent femalesPediatrics 129 e611ndashe620
Elfhag K amp Rossner S (2005) Who succeeds in maintain-ing weight loss A conceptual review of factors associated
with weight loss maintenance and weight regain ObesityReviews 6 67ndash85
Franklin J Denyer G Steinbeck K S Caterson I D ampHill A J (2006) Obesity and risk of low self-esteem Astatewide survey of Australian children Pediatrics 118
2481ndash2487French S A Story M amp Perry C L (1995) Self-esteem
and obesity in children and adolescents A literature re-view Obesity Research 3 479ndash490
Fulkerson J Strauss J Neumark-Sztainer D Story M
amp Boutelle K (2007) Correlates of psychosocial well-being among overweight adolescents The role of the fam-ily Journal of Consulting and Clinical Psychology 75
181ndash186Griffiths L J Parsons T J amp Hill A J (2010) Self-es-
teem and quality of life in obese children and adolescentsA systematic review International Journal of PediatricObesity 5 282ndash304
Harter S (1993) Causes and consequences of low self-
esteem in children and adolescents In R F Baumeister(Ed) Self-esteemmdashThe puzzle of low self-regard (pp87ndash116) USA Springer
Higgins J Thompson S Deeks J amp Altman D (2003)
Measuring inconsistency in meta-analyses BMJ 327557ndash560
Hoelscher D M Kirk S Ritchie L amp Cunningham-Sabo L (2013) Position of the Academy of Nutrition and
Dietetics Interventions for the prevention and treatmentof pediatric overweight and obesity Journal of theAcademy of Nutrition and Dietetics 113 1375ndash1394
Jelalian E Mehlenbeck R Lloyd-Richardson EBirmaher V amp Wing R (2006) lsquoAdventure therapyrsquo
combined with cognitivebehavioral treatment for over-weight adolescents International Journal of Obesity 3031ndash39
Kelly S A amp Melnyk B M (2008) Systematic review of
multicomponent interventions with overweight middleadolescents implications for clinical practice and researchWorldviews on Evidence-Based Nursing 5 113ndash135
Kernis M (1993) The roles of stability and level of self-
esteem in psychological functioning In R Baumeister(Ed) Self-esteem (pp 167ndash182) USA Springer
Khanlou N (2004) Influences on adolescent self-esteem inmulticultural Canadian secondary schools Public HealthNursing 21 404ndash411
Kohn M Rees J M Brill S Fonseca H Jacobson M
Katzman D K Schneider M (2006) Preventing andtreating adolescent obesity A position paper of the Societyfor Adolescent Medicine Journal of Adolescent Health
38 784ndash787Kornman K P Shrewsbury V A Chou A C Ngyuen
B Lee A Orsquoconnor J Baur L A (2010) Electronic
392 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
therapeutic contact for adolescent weight management
The Loozit study Telemedicine and E-Health 16
678ndash685Latzer Y amp Stein D (2013) A review of the psychological
and familial perspectives of childhood obesity Journal of
Eating Disorders 1 7Lobstein T Baur L amp Uauy R (2004) Obesity in chil-
dren and young people a crisis in public health Obesity
Reviews 5(Suppl 1) 4ndash104Lochrie A S Wysocki T Hossain J Milkes A Antal
H Buckloh L Lang J (2013) The effects of a family-
based intervention (FBI) for overweightobese children on
health and psychological functioning Clinical Practice in
Pediatric Psychology 1 159ndash170 doi httpdxdoiorg
101037cpp0000020Lowry K W Sallinen B amp Janicke D (2007) The effects
of weight management programs on self-esteem in pediat-
ric overweight populations Journal of Pediatric
Psychology 32 1179ndash1195Lubans D R Morgan P J Okely A D Dewar D
Collins C E Batterham M Plotnikoff R C (2012)
Preventing obesity among adolescent girls One-year out-
comes of the nutrition and enjoyable activity for teen girls
(NEAT Girls) cluster randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
821ndash827Luttikhuis H Baur L Jansen H Shrewsbury V
Orsquomalley C Stolk R amp Summerbell C (2009)
Interventions for treating obesity in children (Review)
Cochrane Database of Systematic Reviews 3 1ndash57Marx R D amp Neumark-Sztainer D (2005) Questions amp
Answers Eating Disorders The Journal of Treatment amp
Prevention 13 491ndash495McClure A C Tanksi S E Kingsbury J Gerrard M amp
Sargent J D (2010) Characteristics associated with low
self-esteem among US adolescents Academic Pediatrics
10 238ndash244Mellin L M Slinkard L A amp Irwin C E (1987)
Adolescent obesity intervention Validation of the
SHAPEDOWN program Journal of the American Dietetic
Association 87 333ndash338Mission Australia (2012) Youth Survey 2012 SydneyMoher D Shamseer L Clarke M Ghersi D Liberati
A Petticrew M PRISMA-P Group (2015) Preferred
reporting items for systematic review and meta-analysis
protocols (PRISMA-P) 2015 statement Systematic
Reviews 4 1Morgan P Saunders K amp Lubans D (2012) Improving
physical self-perception in adolescent boys from disadvan-
taged schools Psychological outcomes from the Physical
Activity Leaders randomized controlled trial Pediatric
Obesity 7 e27ndashe32 doi httpdxdoiorg101111j
2047-6310201200050xNational Health and Medical Reasearch Council (2013)
Clinical practice guidelines for the management of over-
weight and obesity in adults adolescents and children in
Australia Australia NHMRC Australian Government
Department of HealthNational Institutes for Health and Care Excellence (2013)
Managing overweight and obesity among children and
young people lifestyle weight management services NICE
public health guidance United Kingdom 47 NICENeumark-Sztainer D R Friend S E Flattum C F
Hannan P J Story M T Bauer K W Petrich C A
(2010) New moves-preventing weight-related problems in
adolescent girls A group-randomized study American
Journal of Preventive Medicine 39 421ndash432Nguyen B McGregor K A Orsquoconnor J Shrewsbury V
A Lee A Steinbeck K S Baur L A (2012)
Recruitment challenges and recommendations for adoles-
cent obesity trials Journal of Paediatrics and Child
Health 48 38ndash43Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Hill A J Shah S Baur L A (2013) Two-year
outcomes of an adjunctive telephone coaching and elec-
tronic contact intervention for adolescent weight-loss
maintenance the Loozit randomized controlled trial
International Journal of Obesity 37 468ndash472Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2012) Twelve-month
outcomes of the Loozit randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
170ndash177Ogden C L Carroll M D Kit B K amp Flegal K M
(2014) Prevalence of childhood and adult obesity in the
United States 2011-2012 Journal of the American
Medical Association 311 806ndash814Pesa J A Syre T R amp Jones E (2000) Psychosocial dif-
ferences associated with body weight among female ado-
lescents The importance of body image Journal of
Adolescent Health 26 330ndash337Pierce J W amp Wardle J (1997) Cause and effect beliefs
and self-esteem of overweight children Journal of Child
Psychology and Psychiatry 38 645ndash650 doi 101111
j1469-76101997tb01691xRoberts J E (2006) Self-esteem from a clinical perspective
In M H Kernis (Ed) Self-esteem issues and answers A
sourcebook of current perspectives Psychology Press
Taylor amp Francis New York and Hove (pp 298ndash305)
Psychology PressSacher P M Kolotourou M Chadwick P M Cole T J
Lawson M S Lucas A amp Singhal A (2010)
Randomized controlled trial of the MEND program A
family-based community intervention for childhood obes-
ity Obesity 18(Suppl 1) S62ndashS68 doi httpdxdoiorg
101038oby2009433Sanders R H Han A Baker J S amp Cobley S (2015)
Childhood obesity and its physical and psychological co-
morbidities a systematic review of Australian children and
adolescents Eur J Pediatr 174 715ndash746Sherman J B Alexander M A Gomez D Kim M amp
Marole P (1992) Intervention program for obese school chil-
dren Journal of Community Health Nursing 9 183ndash190Shrewsbury V A Nguyen B Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2011) Short-term
outcomes of community-based adolescent weight manage-
ment The LoozitVR
Study BMC Pediatrics 11 13Shrewsbury V A Orsquoconnor J Steinbeck K S Stevenson
K Lee A Hill A J Baur L A (2009) A randomised
controlled trial of a community-based healthy lifestyle
The Impact of Weight Management on Self-Esteem 393
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
program for overweight and obese adolescents TheLoozitV
R
study protocol BMC Public Health 9 119Strauss R S (2000) Childhood obesity and self-esteem
Pediatrics 105 5Tiggemann M (2005) Body dissatisfaction and adolescent
self-esteem Prospective findings Body Image 2 129ndash135doi httpdxdoiorg101016jbodyim200503006
Wadden T A Stunkard A J Rich L Rubin C JSweidel G amp McKinney S (1990) Obesity in black ado-lescent girls A controlled clinical trial of treatment by diet
behaviour modification and parental support Pediatrics85 345ndash352
Walker L Gately P Bewick B amp Hill A (2003)Childrenrsquos weight-loss camps psychological benefit orjeopardy International Journal of Obesity 27 748ndash754
World Health Organization (2014) Maternal newbornchild and adolescent health Adolescent developmentRetrieved from httpwwwwhointmaternal_child_adolescenttopicsadolescencedeven Retrieved 28 May2014
394 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
- jsw101-TF1
- jsw101-TF2
- jsw101-TF3
- jsw101-TF4
- jsw101-TF5
- jsw101-TF6
- jsw101-TF7
- jsw101-TF8
- jsw101-TF9
- jsw101-TF10
- jsw101-TF11
-
field with all the studies in this review baring twousing group sessions in their intervention
Measures of self-esteem are self-reported and there-fore subjective Responses to questionnaires are likelyto be influenced by individual (eg age gender) andenvironmental (eg cultural group socioeconomicstatus) factors (Khanlou 2004) Changes followinginterventions may represent genuine long-termchanges in self-esteem or may be due to short-termfluctuations in self-esteem in response to specificevents (eg winning a sporting event or performanceon a test at school) (Kernis 1993) While validatedtools were used to measure self-esteem in all studies itwas difficult to conclude whether outcomes were en-tirely dependent on the intervention without inclusionof a no-treatment control group
The variety of self-esteem assessment tools also addsto the difficulty of interpretation Across the 13 studies inthis review five different tools were used with differentquestions and different scales Even within tools therewere different scales used to report the results (RosenbergSelf-esteem Scale) and different versions of the same ques-tionnaire (Harterrsquos Self-perception Profile for ChildrenHarterrsquos Self-perception Profile for Adolescents) HarterrsquosSelf-Perception Profile (Harterrsquos Self-perception Profilefor Adolescents for adolescents) which measures ninesubscales of self-esteem including physical self-esteem issuggested as the most appropriate measure for adolescentself-esteem (Lowry et al 2007) It was also the mostcommonly used tool among papers included in this re-view While Cohenrsquos d effect sizes were used to stand-ardize results in this review the consistent use of one toolwould provide the ability to compare raw self-esteemscores and create a stronger analysis in the future
Results from this review support evidence thatMWMIs induce weight loss in overweight and obeseadolescents (Hoelscher Kirk Ritchie ampCunningham-Sabo 2013 Kelly amp Melnyk 2008Luttikhuis et al 2009) The change in BMI z-score inthe present meta-analysis (017 [022 011]) wassimilar to the clinically meaningful weight loss re-ported in the 2009 Cochrane Review in children 12years at 6 months follow up from a lifestyle weightmanagement intervention (014 [017 012])(Luttikhuis et al 2009) Jelalian Mehlenbeck Lloyd-Richardson Birmaher and Wing (2006) and WalkerGately Bewick and Hill (2003) have demonstratedassociations between weight loss and increased self-esteem in overweight and obese adolescents after at-tending a weight-management intervention Similarlyin the present review a strong positive relationship be-tween treatment effects for weight loss and improve-ment in self-esteem was identified However itremains unclear whether the improvement in self-esteem was as a result of successful weight loss orwhether it was a contributing factor toward successful
weight loss Nonetheless building self-esteem shouldbe a key focus of MWMIs as improved self-esteem ap-
pears to be linked to enhanced weight lossA key strength of this review was that all included
studies had strong designs and presented level II evi-dence (Coleman et al 2009) However to further elu-
cidate the role of self-esteem in adolescent weightmanagement future research should consider power-
ing studies to detect changes in psychosocial as well asphysiological outcomes Only one study in this reviewwas powered to detect a change in psychosocial out-
comes (Daley et al 2006) which may explain thelack of significant results observed for self-esteem
Additionally a large number of included studies didnot describe their method of handling withdrawals or
use blinding to prevent the introduction of bias Toimprove confidence in the effectiveness of MWMIs
and reduce the risk of bias future studies should bedesigned with concealed allocation and document andreport in detail the flow of participants
Identification of intervention components that im-
prove self-esteem is important for future weight man-agement intervention design Included interventionswere heterogeneous offering different levels of diet-
ary physical activity and behavioral interventionwhich may have collectively or individually influenced
the results Inconsistent reporting of intervention andcomparator conditions make it difficult to elucidate
the components that contributed to improvements inself-esteem Future studies should report intervention
and comparator procedures in adequate detail so thatsuccessful components can be identified and repli-cated These limitations highlight areas for improve-
ment to develop best-practice guidelines forundertaking and evaluating MWMIs in adolescents to
enhance self-esteem
Conclusion
Overweight and obese adolescents experience low
self-esteem largely owing to poor body image yetthis meta-analysis found no improvement in self-esteem even with significant weight loss Although it
was noted that interventions that had larger effects onself-esteem also had larger effects on weight loss The
incorporation of intervention components that wereidentified to contribute to improvements in self-
esteem may assist future weight management interven-tions to improve the self-esteem of overweight and
obese adolescents Furthermore a consistent measureof self-esteem would enable easier interpretation ofself-esteem scores and comparison of results across
studies to improve our understanding of the relation-ship between self-esteem and weight management in
adolescents
The Impact of Weight Management on Self-Esteem 391
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
Supplementary Data
Supplementary data can be found at httpwwwjpepsy
oxfordjournalsorg
Acknowledgments
The authors would like to acknowledge Dr Zoe Davidson
for her assistance in performing the meta-analyses
Funding
This work was supported by an Australian GovernmentResearch Training Program Scholarship
Conflicts of interest none declared
References
Academy of Nutrition and Dietetics (2012) Evidence ana-lysis manual Steps in the academy evidence analysis pro-cess Chicago IL ADA Research and Strategic Business
DevelopmentBrennan L Walkley J Fraser S F Greenway K amp
Wilks R (2008) Motivational interviewing and cognitivebehaviour therapy in the treatment of adolescent over-
weight and obesity Study design and methodologyContemporary Clinical Trials 29 359ndash375
Brennan L Walkley J Wilks R Fraser S F amp
Greenway K (2013) Physiological and behavioural out-comes of a randomised controlled trial of a cognitive be-havioural lifestyle intervention for overweight and obese
adolescents Obesity Research and Clinical Practice 7e23ndashe41
Brennan L Wilks R Walkley J Fraser S F amp
Greenway K (2012) Treatment acceptability and psycho-social outcomes of a randomised controlled trial of a cog-nitive behavioural lifestyle intervention for overweight and
obese adolescents Behaviour Change 29 36ndash62Cave L Fildes J Luckett G amp Wearring A (2015)
Mission Australiarsquos 2015 youth survey report MissionAustralia
Coleman K Norris S Weston A Grimmer-Somers KHillier S Merlin T Salisbury J (2009) NHMRCadditional levels of evidence and grades for recommenda-tions for developers of guidelines (Vol Stage 2Consultation) Australia National Health and Medical
Research CouncilCroker H Viner R M Nicholls D Haroun D
Chadwick P Edwards C Wardle J (2012) Family-based behavioural treatment of childhood obesity in a UK
national health service setting Randomized controlledtrial International Journal of Obesity 36 16ndash26 doi
101038ijo2011182Daley A J Copeland R J Wright N P Roalfe A amp
Wales J K H (2006) Exercise therapy as a treatment forpsychopathologic conditions in obese and morbidly obese
adolescents A randomized controlled trial Pediatrics118 2126ndash2134
Danielsen Y S Nordhus I H Julıusson P B Maelighle Mamp Pallesen S (2013) Effect of a family-based cognitive
behavioural intervention on body mass index self-esteem
and symptoms of depression in children with obesity (aged
7mdash13) A randomised waiting list controlled trial ObesityResearch amp Clinical Practice 7 e116ndashe128
DeBar L L Stevens V J Perrin N Wu P Pearson J ampJo B (2012) A primary care-based multicomponent life-
style intervention for overweight adolescent femalesPediatrics 129 e611ndashe620
Elfhag K amp Rossner S (2005) Who succeeds in maintain-ing weight loss A conceptual review of factors associated
with weight loss maintenance and weight regain ObesityReviews 6 67ndash85
Franklin J Denyer G Steinbeck K S Caterson I D ampHill A J (2006) Obesity and risk of low self-esteem Astatewide survey of Australian children Pediatrics 118
2481ndash2487French S A Story M amp Perry C L (1995) Self-esteem
and obesity in children and adolescents A literature re-view Obesity Research 3 479ndash490
Fulkerson J Strauss J Neumark-Sztainer D Story M
amp Boutelle K (2007) Correlates of psychosocial well-being among overweight adolescents The role of the fam-ily Journal of Consulting and Clinical Psychology 75
181ndash186Griffiths L J Parsons T J amp Hill A J (2010) Self-es-
teem and quality of life in obese children and adolescentsA systematic review International Journal of PediatricObesity 5 282ndash304
Harter S (1993) Causes and consequences of low self-
esteem in children and adolescents In R F Baumeister(Ed) Self-esteemmdashThe puzzle of low self-regard (pp87ndash116) USA Springer
Higgins J Thompson S Deeks J amp Altman D (2003)
Measuring inconsistency in meta-analyses BMJ 327557ndash560
Hoelscher D M Kirk S Ritchie L amp Cunningham-Sabo L (2013) Position of the Academy of Nutrition and
Dietetics Interventions for the prevention and treatmentof pediatric overweight and obesity Journal of theAcademy of Nutrition and Dietetics 113 1375ndash1394
Jelalian E Mehlenbeck R Lloyd-Richardson EBirmaher V amp Wing R (2006) lsquoAdventure therapyrsquo
combined with cognitivebehavioral treatment for over-weight adolescents International Journal of Obesity 3031ndash39
Kelly S A amp Melnyk B M (2008) Systematic review of
multicomponent interventions with overweight middleadolescents implications for clinical practice and researchWorldviews on Evidence-Based Nursing 5 113ndash135
Kernis M (1993) The roles of stability and level of self-
esteem in psychological functioning In R Baumeister(Ed) Self-esteem (pp 167ndash182) USA Springer
Khanlou N (2004) Influences on adolescent self-esteem inmulticultural Canadian secondary schools Public HealthNursing 21 404ndash411
Kohn M Rees J M Brill S Fonseca H Jacobson M
Katzman D K Schneider M (2006) Preventing andtreating adolescent obesity A position paper of the Societyfor Adolescent Medicine Journal of Adolescent Health
38 784ndash787Kornman K P Shrewsbury V A Chou A C Ngyuen
B Lee A Orsquoconnor J Baur L A (2010) Electronic
392 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
therapeutic contact for adolescent weight management
The Loozit study Telemedicine and E-Health 16
678ndash685Latzer Y amp Stein D (2013) A review of the psychological
and familial perspectives of childhood obesity Journal of
Eating Disorders 1 7Lobstein T Baur L amp Uauy R (2004) Obesity in chil-
dren and young people a crisis in public health Obesity
Reviews 5(Suppl 1) 4ndash104Lochrie A S Wysocki T Hossain J Milkes A Antal
H Buckloh L Lang J (2013) The effects of a family-
based intervention (FBI) for overweightobese children on
health and psychological functioning Clinical Practice in
Pediatric Psychology 1 159ndash170 doi httpdxdoiorg
101037cpp0000020Lowry K W Sallinen B amp Janicke D (2007) The effects
of weight management programs on self-esteem in pediat-
ric overweight populations Journal of Pediatric
Psychology 32 1179ndash1195Lubans D R Morgan P J Okely A D Dewar D
Collins C E Batterham M Plotnikoff R C (2012)
Preventing obesity among adolescent girls One-year out-
comes of the nutrition and enjoyable activity for teen girls
(NEAT Girls) cluster randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
821ndash827Luttikhuis H Baur L Jansen H Shrewsbury V
Orsquomalley C Stolk R amp Summerbell C (2009)
Interventions for treating obesity in children (Review)
Cochrane Database of Systematic Reviews 3 1ndash57Marx R D amp Neumark-Sztainer D (2005) Questions amp
Answers Eating Disorders The Journal of Treatment amp
Prevention 13 491ndash495McClure A C Tanksi S E Kingsbury J Gerrard M amp
Sargent J D (2010) Characteristics associated with low
self-esteem among US adolescents Academic Pediatrics
10 238ndash244Mellin L M Slinkard L A amp Irwin C E (1987)
Adolescent obesity intervention Validation of the
SHAPEDOWN program Journal of the American Dietetic
Association 87 333ndash338Mission Australia (2012) Youth Survey 2012 SydneyMoher D Shamseer L Clarke M Ghersi D Liberati
A Petticrew M PRISMA-P Group (2015) Preferred
reporting items for systematic review and meta-analysis
protocols (PRISMA-P) 2015 statement Systematic
Reviews 4 1Morgan P Saunders K amp Lubans D (2012) Improving
physical self-perception in adolescent boys from disadvan-
taged schools Psychological outcomes from the Physical
Activity Leaders randomized controlled trial Pediatric
Obesity 7 e27ndashe32 doi httpdxdoiorg101111j
2047-6310201200050xNational Health and Medical Reasearch Council (2013)
Clinical practice guidelines for the management of over-
weight and obesity in adults adolescents and children in
Australia Australia NHMRC Australian Government
Department of HealthNational Institutes for Health and Care Excellence (2013)
Managing overweight and obesity among children and
young people lifestyle weight management services NICE
public health guidance United Kingdom 47 NICENeumark-Sztainer D R Friend S E Flattum C F
Hannan P J Story M T Bauer K W Petrich C A
(2010) New moves-preventing weight-related problems in
adolescent girls A group-randomized study American
Journal of Preventive Medicine 39 421ndash432Nguyen B McGregor K A Orsquoconnor J Shrewsbury V
A Lee A Steinbeck K S Baur L A (2012)
Recruitment challenges and recommendations for adoles-
cent obesity trials Journal of Paediatrics and Child
Health 48 38ndash43Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Hill A J Shah S Baur L A (2013) Two-year
outcomes of an adjunctive telephone coaching and elec-
tronic contact intervention for adolescent weight-loss
maintenance the Loozit randomized controlled trial
International Journal of Obesity 37 468ndash472Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2012) Twelve-month
outcomes of the Loozit randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
170ndash177Ogden C L Carroll M D Kit B K amp Flegal K M
(2014) Prevalence of childhood and adult obesity in the
United States 2011-2012 Journal of the American
Medical Association 311 806ndash814Pesa J A Syre T R amp Jones E (2000) Psychosocial dif-
ferences associated with body weight among female ado-
lescents The importance of body image Journal of
Adolescent Health 26 330ndash337Pierce J W amp Wardle J (1997) Cause and effect beliefs
and self-esteem of overweight children Journal of Child
Psychology and Psychiatry 38 645ndash650 doi 101111
j1469-76101997tb01691xRoberts J E (2006) Self-esteem from a clinical perspective
In M H Kernis (Ed) Self-esteem issues and answers A
sourcebook of current perspectives Psychology Press
Taylor amp Francis New York and Hove (pp 298ndash305)
Psychology PressSacher P M Kolotourou M Chadwick P M Cole T J
Lawson M S Lucas A amp Singhal A (2010)
Randomized controlled trial of the MEND program A
family-based community intervention for childhood obes-
ity Obesity 18(Suppl 1) S62ndashS68 doi httpdxdoiorg
101038oby2009433Sanders R H Han A Baker J S amp Cobley S (2015)
Childhood obesity and its physical and psychological co-
morbidities a systematic review of Australian children and
adolescents Eur J Pediatr 174 715ndash746Sherman J B Alexander M A Gomez D Kim M amp
Marole P (1992) Intervention program for obese school chil-
dren Journal of Community Health Nursing 9 183ndash190Shrewsbury V A Nguyen B Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2011) Short-term
outcomes of community-based adolescent weight manage-
ment The LoozitVR
Study BMC Pediatrics 11 13Shrewsbury V A Orsquoconnor J Steinbeck K S Stevenson
K Lee A Hill A J Baur L A (2009) A randomised
controlled trial of a community-based healthy lifestyle
The Impact of Weight Management on Self-Esteem 393
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
program for overweight and obese adolescents TheLoozitV
R
study protocol BMC Public Health 9 119Strauss R S (2000) Childhood obesity and self-esteem
Pediatrics 105 5Tiggemann M (2005) Body dissatisfaction and adolescent
self-esteem Prospective findings Body Image 2 129ndash135doi httpdxdoiorg101016jbodyim200503006
Wadden T A Stunkard A J Rich L Rubin C JSweidel G amp McKinney S (1990) Obesity in black ado-lescent girls A controlled clinical trial of treatment by diet
behaviour modification and parental support Pediatrics85 345ndash352
Walker L Gately P Bewick B amp Hill A (2003)Childrenrsquos weight-loss camps psychological benefit orjeopardy International Journal of Obesity 27 748ndash754
World Health Organization (2014) Maternal newbornchild and adolescent health Adolescent developmentRetrieved from httpwwwwhointmaternal_child_adolescenttopicsadolescencedeven Retrieved 28 May2014
394 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
- jsw101-TF1
- jsw101-TF2
- jsw101-TF3
- jsw101-TF4
- jsw101-TF5
- jsw101-TF6
- jsw101-TF7
- jsw101-TF8
- jsw101-TF9
- jsw101-TF10
- jsw101-TF11
-
Supplementary Data
Supplementary data can be found at httpwwwjpepsy
oxfordjournalsorg
Acknowledgments
The authors would like to acknowledge Dr Zoe Davidson
for her assistance in performing the meta-analyses
Funding
This work was supported by an Australian GovernmentResearch Training Program Scholarship
Conflicts of interest none declared
References
Academy of Nutrition and Dietetics (2012) Evidence ana-lysis manual Steps in the academy evidence analysis pro-cess Chicago IL ADA Research and Strategic Business
DevelopmentBrennan L Walkley J Fraser S F Greenway K amp
Wilks R (2008) Motivational interviewing and cognitivebehaviour therapy in the treatment of adolescent over-
weight and obesity Study design and methodologyContemporary Clinical Trials 29 359ndash375
Brennan L Walkley J Wilks R Fraser S F amp
Greenway K (2013) Physiological and behavioural out-comes of a randomised controlled trial of a cognitive be-havioural lifestyle intervention for overweight and obese
adolescents Obesity Research and Clinical Practice 7e23ndashe41
Brennan L Wilks R Walkley J Fraser S F amp
Greenway K (2012) Treatment acceptability and psycho-social outcomes of a randomised controlled trial of a cog-nitive behavioural lifestyle intervention for overweight and
obese adolescents Behaviour Change 29 36ndash62Cave L Fildes J Luckett G amp Wearring A (2015)
Mission Australiarsquos 2015 youth survey report MissionAustralia
Coleman K Norris S Weston A Grimmer-Somers KHillier S Merlin T Salisbury J (2009) NHMRCadditional levels of evidence and grades for recommenda-tions for developers of guidelines (Vol Stage 2Consultation) Australia National Health and Medical
Research CouncilCroker H Viner R M Nicholls D Haroun D
Chadwick P Edwards C Wardle J (2012) Family-based behavioural treatment of childhood obesity in a UK
national health service setting Randomized controlledtrial International Journal of Obesity 36 16ndash26 doi
101038ijo2011182Daley A J Copeland R J Wright N P Roalfe A amp
Wales J K H (2006) Exercise therapy as a treatment forpsychopathologic conditions in obese and morbidly obese
adolescents A randomized controlled trial Pediatrics118 2126ndash2134
Danielsen Y S Nordhus I H Julıusson P B Maelighle Mamp Pallesen S (2013) Effect of a family-based cognitive
behavioural intervention on body mass index self-esteem
and symptoms of depression in children with obesity (aged
7mdash13) A randomised waiting list controlled trial ObesityResearch amp Clinical Practice 7 e116ndashe128
DeBar L L Stevens V J Perrin N Wu P Pearson J ampJo B (2012) A primary care-based multicomponent life-
style intervention for overweight adolescent femalesPediatrics 129 e611ndashe620
Elfhag K amp Rossner S (2005) Who succeeds in maintain-ing weight loss A conceptual review of factors associated
with weight loss maintenance and weight regain ObesityReviews 6 67ndash85
Franklin J Denyer G Steinbeck K S Caterson I D ampHill A J (2006) Obesity and risk of low self-esteem Astatewide survey of Australian children Pediatrics 118
2481ndash2487French S A Story M amp Perry C L (1995) Self-esteem
and obesity in children and adolescents A literature re-view Obesity Research 3 479ndash490
Fulkerson J Strauss J Neumark-Sztainer D Story M
amp Boutelle K (2007) Correlates of psychosocial well-being among overweight adolescents The role of the fam-ily Journal of Consulting and Clinical Psychology 75
181ndash186Griffiths L J Parsons T J amp Hill A J (2010) Self-es-
teem and quality of life in obese children and adolescentsA systematic review International Journal of PediatricObesity 5 282ndash304
Harter S (1993) Causes and consequences of low self-
esteem in children and adolescents In R F Baumeister(Ed) Self-esteemmdashThe puzzle of low self-regard (pp87ndash116) USA Springer
Higgins J Thompson S Deeks J amp Altman D (2003)
Measuring inconsistency in meta-analyses BMJ 327557ndash560
Hoelscher D M Kirk S Ritchie L amp Cunningham-Sabo L (2013) Position of the Academy of Nutrition and
Dietetics Interventions for the prevention and treatmentof pediatric overweight and obesity Journal of theAcademy of Nutrition and Dietetics 113 1375ndash1394
Jelalian E Mehlenbeck R Lloyd-Richardson EBirmaher V amp Wing R (2006) lsquoAdventure therapyrsquo
combined with cognitivebehavioral treatment for over-weight adolescents International Journal of Obesity 3031ndash39
Kelly S A amp Melnyk B M (2008) Systematic review of
multicomponent interventions with overweight middleadolescents implications for clinical practice and researchWorldviews on Evidence-Based Nursing 5 113ndash135
Kernis M (1993) The roles of stability and level of self-
esteem in psychological functioning In R Baumeister(Ed) Self-esteem (pp 167ndash182) USA Springer
Khanlou N (2004) Influences on adolescent self-esteem inmulticultural Canadian secondary schools Public HealthNursing 21 404ndash411
Kohn M Rees J M Brill S Fonseca H Jacobson M
Katzman D K Schneider M (2006) Preventing andtreating adolescent obesity A position paper of the Societyfor Adolescent Medicine Journal of Adolescent Health
38 784ndash787Kornman K P Shrewsbury V A Chou A C Ngyuen
B Lee A Orsquoconnor J Baur L A (2010) Electronic
392 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
therapeutic contact for adolescent weight management
The Loozit study Telemedicine and E-Health 16
678ndash685Latzer Y amp Stein D (2013) A review of the psychological
and familial perspectives of childhood obesity Journal of
Eating Disorders 1 7Lobstein T Baur L amp Uauy R (2004) Obesity in chil-
dren and young people a crisis in public health Obesity
Reviews 5(Suppl 1) 4ndash104Lochrie A S Wysocki T Hossain J Milkes A Antal
H Buckloh L Lang J (2013) The effects of a family-
based intervention (FBI) for overweightobese children on
health and psychological functioning Clinical Practice in
Pediatric Psychology 1 159ndash170 doi httpdxdoiorg
101037cpp0000020Lowry K W Sallinen B amp Janicke D (2007) The effects
of weight management programs on self-esteem in pediat-
ric overweight populations Journal of Pediatric
Psychology 32 1179ndash1195Lubans D R Morgan P J Okely A D Dewar D
Collins C E Batterham M Plotnikoff R C (2012)
Preventing obesity among adolescent girls One-year out-
comes of the nutrition and enjoyable activity for teen girls
(NEAT Girls) cluster randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
821ndash827Luttikhuis H Baur L Jansen H Shrewsbury V
Orsquomalley C Stolk R amp Summerbell C (2009)
Interventions for treating obesity in children (Review)
Cochrane Database of Systematic Reviews 3 1ndash57Marx R D amp Neumark-Sztainer D (2005) Questions amp
Answers Eating Disorders The Journal of Treatment amp
Prevention 13 491ndash495McClure A C Tanksi S E Kingsbury J Gerrard M amp
Sargent J D (2010) Characteristics associated with low
self-esteem among US adolescents Academic Pediatrics
10 238ndash244Mellin L M Slinkard L A amp Irwin C E (1987)
Adolescent obesity intervention Validation of the
SHAPEDOWN program Journal of the American Dietetic
Association 87 333ndash338Mission Australia (2012) Youth Survey 2012 SydneyMoher D Shamseer L Clarke M Ghersi D Liberati
A Petticrew M PRISMA-P Group (2015) Preferred
reporting items for systematic review and meta-analysis
protocols (PRISMA-P) 2015 statement Systematic
Reviews 4 1Morgan P Saunders K amp Lubans D (2012) Improving
physical self-perception in adolescent boys from disadvan-
taged schools Psychological outcomes from the Physical
Activity Leaders randomized controlled trial Pediatric
Obesity 7 e27ndashe32 doi httpdxdoiorg101111j
2047-6310201200050xNational Health and Medical Reasearch Council (2013)
Clinical practice guidelines for the management of over-
weight and obesity in adults adolescents and children in
Australia Australia NHMRC Australian Government
Department of HealthNational Institutes for Health and Care Excellence (2013)
Managing overweight and obesity among children and
young people lifestyle weight management services NICE
public health guidance United Kingdom 47 NICENeumark-Sztainer D R Friend S E Flattum C F
Hannan P J Story M T Bauer K W Petrich C A
(2010) New moves-preventing weight-related problems in
adolescent girls A group-randomized study American
Journal of Preventive Medicine 39 421ndash432Nguyen B McGregor K A Orsquoconnor J Shrewsbury V
A Lee A Steinbeck K S Baur L A (2012)
Recruitment challenges and recommendations for adoles-
cent obesity trials Journal of Paediatrics and Child
Health 48 38ndash43Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Hill A J Shah S Baur L A (2013) Two-year
outcomes of an adjunctive telephone coaching and elec-
tronic contact intervention for adolescent weight-loss
maintenance the Loozit randomized controlled trial
International Journal of Obesity 37 468ndash472Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2012) Twelve-month
outcomes of the Loozit randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
170ndash177Ogden C L Carroll M D Kit B K amp Flegal K M
(2014) Prevalence of childhood and adult obesity in the
United States 2011-2012 Journal of the American
Medical Association 311 806ndash814Pesa J A Syre T R amp Jones E (2000) Psychosocial dif-
ferences associated with body weight among female ado-
lescents The importance of body image Journal of
Adolescent Health 26 330ndash337Pierce J W amp Wardle J (1997) Cause and effect beliefs
and self-esteem of overweight children Journal of Child
Psychology and Psychiatry 38 645ndash650 doi 101111
j1469-76101997tb01691xRoberts J E (2006) Self-esteem from a clinical perspective
In M H Kernis (Ed) Self-esteem issues and answers A
sourcebook of current perspectives Psychology Press
Taylor amp Francis New York and Hove (pp 298ndash305)
Psychology PressSacher P M Kolotourou M Chadwick P M Cole T J
Lawson M S Lucas A amp Singhal A (2010)
Randomized controlled trial of the MEND program A
family-based community intervention for childhood obes-
ity Obesity 18(Suppl 1) S62ndashS68 doi httpdxdoiorg
101038oby2009433Sanders R H Han A Baker J S amp Cobley S (2015)
Childhood obesity and its physical and psychological co-
morbidities a systematic review of Australian children and
adolescents Eur J Pediatr 174 715ndash746Sherman J B Alexander M A Gomez D Kim M amp
Marole P (1992) Intervention program for obese school chil-
dren Journal of Community Health Nursing 9 183ndash190Shrewsbury V A Nguyen B Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2011) Short-term
outcomes of community-based adolescent weight manage-
ment The LoozitVR
Study BMC Pediatrics 11 13Shrewsbury V A Orsquoconnor J Steinbeck K S Stevenson
K Lee A Hill A J Baur L A (2009) A randomised
controlled trial of a community-based healthy lifestyle
The Impact of Weight Management on Self-Esteem 393
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
program for overweight and obese adolescents TheLoozitV
R
study protocol BMC Public Health 9 119Strauss R S (2000) Childhood obesity and self-esteem
Pediatrics 105 5Tiggemann M (2005) Body dissatisfaction and adolescent
self-esteem Prospective findings Body Image 2 129ndash135doi httpdxdoiorg101016jbodyim200503006
Wadden T A Stunkard A J Rich L Rubin C JSweidel G amp McKinney S (1990) Obesity in black ado-lescent girls A controlled clinical trial of treatment by diet
behaviour modification and parental support Pediatrics85 345ndash352
Walker L Gately P Bewick B amp Hill A (2003)Childrenrsquos weight-loss camps psychological benefit orjeopardy International Journal of Obesity 27 748ndash754
World Health Organization (2014) Maternal newbornchild and adolescent health Adolescent developmentRetrieved from httpwwwwhointmaternal_child_adolescenttopicsadolescencedeven Retrieved 28 May2014
394 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
- jsw101-TF1
- jsw101-TF2
- jsw101-TF3
- jsw101-TF4
- jsw101-TF5
- jsw101-TF6
- jsw101-TF7
- jsw101-TF8
- jsw101-TF9
- jsw101-TF10
- jsw101-TF11
-
therapeutic contact for adolescent weight management
The Loozit study Telemedicine and E-Health 16
678ndash685Latzer Y amp Stein D (2013) A review of the psychological
and familial perspectives of childhood obesity Journal of
Eating Disorders 1 7Lobstein T Baur L amp Uauy R (2004) Obesity in chil-
dren and young people a crisis in public health Obesity
Reviews 5(Suppl 1) 4ndash104Lochrie A S Wysocki T Hossain J Milkes A Antal
H Buckloh L Lang J (2013) The effects of a family-
based intervention (FBI) for overweightobese children on
health and psychological functioning Clinical Practice in
Pediatric Psychology 1 159ndash170 doi httpdxdoiorg
101037cpp0000020Lowry K W Sallinen B amp Janicke D (2007) The effects
of weight management programs on self-esteem in pediat-
ric overweight populations Journal of Pediatric
Psychology 32 1179ndash1195Lubans D R Morgan P J Okely A D Dewar D
Collins C E Batterham M Plotnikoff R C (2012)
Preventing obesity among adolescent girls One-year out-
comes of the nutrition and enjoyable activity for teen girls
(NEAT Girls) cluster randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
821ndash827Luttikhuis H Baur L Jansen H Shrewsbury V
Orsquomalley C Stolk R amp Summerbell C (2009)
Interventions for treating obesity in children (Review)
Cochrane Database of Systematic Reviews 3 1ndash57Marx R D amp Neumark-Sztainer D (2005) Questions amp
Answers Eating Disorders The Journal of Treatment amp
Prevention 13 491ndash495McClure A C Tanksi S E Kingsbury J Gerrard M amp
Sargent J D (2010) Characteristics associated with low
self-esteem among US adolescents Academic Pediatrics
10 238ndash244Mellin L M Slinkard L A amp Irwin C E (1987)
Adolescent obesity intervention Validation of the
SHAPEDOWN program Journal of the American Dietetic
Association 87 333ndash338Mission Australia (2012) Youth Survey 2012 SydneyMoher D Shamseer L Clarke M Ghersi D Liberati
A Petticrew M PRISMA-P Group (2015) Preferred
reporting items for systematic review and meta-analysis
protocols (PRISMA-P) 2015 statement Systematic
Reviews 4 1Morgan P Saunders K amp Lubans D (2012) Improving
physical self-perception in adolescent boys from disadvan-
taged schools Psychological outcomes from the Physical
Activity Leaders randomized controlled trial Pediatric
Obesity 7 e27ndashe32 doi httpdxdoiorg101111j
2047-6310201200050xNational Health and Medical Reasearch Council (2013)
Clinical practice guidelines for the management of over-
weight and obesity in adults adolescents and children in
Australia Australia NHMRC Australian Government
Department of HealthNational Institutes for Health and Care Excellence (2013)
Managing overweight and obesity among children and
young people lifestyle weight management services NICE
public health guidance United Kingdom 47 NICENeumark-Sztainer D R Friend S E Flattum C F
Hannan P J Story M T Bauer K W Petrich C A
(2010) New moves-preventing weight-related problems in
adolescent girls A group-randomized study American
Journal of Preventive Medicine 39 421ndash432Nguyen B McGregor K A Orsquoconnor J Shrewsbury V
A Lee A Steinbeck K S Baur L A (2012)
Recruitment challenges and recommendations for adoles-
cent obesity trials Journal of Paediatrics and Child
Health 48 38ndash43Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Hill A J Shah S Baur L A (2013) Two-year
outcomes of an adjunctive telephone coaching and elec-
tronic contact intervention for adolescent weight-loss
maintenance the Loozit randomized controlled trial
International Journal of Obesity 37 468ndash472Nguyen B Shrewsbury V A Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2012) Twelve-month
outcomes of the Loozit randomized controlled trial
Archives of Pediatrics and Adolescent Medicine 166
170ndash177Ogden C L Carroll M D Kit B K amp Flegal K M
(2014) Prevalence of childhood and adult obesity in the
United States 2011-2012 Journal of the American
Medical Association 311 806ndash814Pesa J A Syre T R amp Jones E (2000) Psychosocial dif-
ferences associated with body weight among female ado-
lescents The importance of body image Journal of
Adolescent Health 26 330ndash337Pierce J W amp Wardle J (1997) Cause and effect beliefs
and self-esteem of overweight children Journal of Child
Psychology and Psychiatry 38 645ndash650 doi 101111
j1469-76101997tb01691xRoberts J E (2006) Self-esteem from a clinical perspective
In M H Kernis (Ed) Self-esteem issues and answers A
sourcebook of current perspectives Psychology Press
Taylor amp Francis New York and Hove (pp 298ndash305)
Psychology PressSacher P M Kolotourou M Chadwick P M Cole T J
Lawson M S Lucas A amp Singhal A (2010)
Randomized controlled trial of the MEND program A
family-based community intervention for childhood obes-
ity Obesity 18(Suppl 1) S62ndashS68 doi httpdxdoiorg
101038oby2009433Sanders R H Han A Baker J S amp Cobley S (2015)
Childhood obesity and its physical and psychological co-
morbidities a systematic review of Australian children and
adolescents Eur J Pediatr 174 715ndash746Sherman J B Alexander M A Gomez D Kim M amp
Marole P (1992) Intervention program for obese school chil-
dren Journal of Community Health Nursing 9 183ndash190Shrewsbury V A Nguyen B Orsquoconnor J Steinbeck K
S Lee A Hill A J Baur L A (2011) Short-term
outcomes of community-based adolescent weight manage-
ment The LoozitVR
Study BMC Pediatrics 11 13Shrewsbury V A Orsquoconnor J Steinbeck K S Stevenson
K Lee A Hill A J Baur L A (2009) A randomised
controlled trial of a community-based healthy lifestyle
The Impact of Weight Management on Self-Esteem 393
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
program for overweight and obese adolescents TheLoozitV
R
study protocol BMC Public Health 9 119Strauss R S (2000) Childhood obesity and self-esteem
Pediatrics 105 5Tiggemann M (2005) Body dissatisfaction and adolescent
self-esteem Prospective findings Body Image 2 129ndash135doi httpdxdoiorg101016jbodyim200503006
Wadden T A Stunkard A J Rich L Rubin C JSweidel G amp McKinney S (1990) Obesity in black ado-lescent girls A controlled clinical trial of treatment by diet
behaviour modification and parental support Pediatrics85 345ndash352
Walker L Gately P Bewick B amp Hill A (2003)Childrenrsquos weight-loss camps psychological benefit orjeopardy International Journal of Obesity 27 748ndash754
World Health Organization (2014) Maternal newbornchild and adolescent health Adolescent developmentRetrieved from httpwwwwhointmaternal_child_adolescenttopicsadolescencedeven Retrieved 28 May2014
394 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
- jsw101-TF1
- jsw101-TF2
- jsw101-TF3
- jsw101-TF4
- jsw101-TF5
- jsw101-TF6
- jsw101-TF7
- jsw101-TF8
- jsw101-TF9
- jsw101-TF10
- jsw101-TF11
-
program for overweight and obese adolescents TheLoozitV
R
study protocol BMC Public Health 9 119Strauss R S (2000) Childhood obesity and self-esteem
Pediatrics 105 5Tiggemann M (2005) Body dissatisfaction and adolescent
self-esteem Prospective findings Body Image 2 129ndash135doi httpdxdoiorg101016jbodyim200503006
Wadden T A Stunkard A J Rich L Rubin C JSweidel G amp McKinney S (1990) Obesity in black ado-lescent girls A controlled clinical trial of treatment by diet
behaviour modification and parental support Pediatrics85 345ndash352
Walker L Gately P Bewick B amp Hill A (2003)Childrenrsquos weight-loss camps psychological benefit orjeopardy International Journal of Obesity 27 748ndash754
World Health Organization (2014) Maternal newbornchild and adolescent health Adolescent developmentRetrieved from httpwwwwhointmaternal_child_adolescenttopicsadolescencedeven Retrieved 28 May2014
394 Murray Dordevic and Bonham
Dow
nloaded from httpsacadem
icoupcomjpepsyarticle-abstract4243793065789 by U
niversity of North C
arolina at wilm
ington user on 14 February 2019
- jsw101-TF1
- jsw101-TF2
- jsw101-TF3
- jsw101-TF4
- jsw101-TF5
- jsw101-TF6
- jsw101-TF7
- jsw101-TF8
- jsw101-TF9
- jsw101-TF10
- jsw101-TF11
-