Cognitive Emotion Regulation Strategies in Chinese Adolescents with Overweight and Obesity

Abstract

Background:

The relationship between psychological factors and obesity has become a hot topic in psychosomatic research. The aim of this study was to examine the characteristics of cognitive emotion regulation (CER) strategies in Chinese adolescents with different weight status.

Methods:

Using stratified random cluster sampling, 700 and 321 adolescents were defined as adolescents with overweight status and obese status, respectively. One thousand and twenty-one adolescents with normal-weight status were also selected. All participants completed a general questionnaire and Chinese version of the Cognitive Emotion Regulation Questionnaire.

Results:

Adolescents in the obesity group obtained the highest scores on self-blame and rumination in three groups, and those from the obesity group obtained lower scores on acceptance, positive refocusing, and positive reappraisal than those from normal group (ps < 0.05). Cognitive emotion regulation strategies had a significant impact on BMI, accounting for 32.0% variance (p < 0.001). Higher scores on self-blame and rumination were associated with higher BMI, but greater acceptance and positive refocusing were associated with lower BMI (ps < 0.05).

Conclusion:

Self-blame, rumination, acceptance, and positive refocusing have considerable effects on BMI in Chinese adolescents. The causal relationship of CER strategies and BMI should be explained more accurately and thoroughly to prevent and intervene in cases of adolescent obesity.

Background

As a chronic, multidimensional problem, obesity is a serious long-term health risk currently faced by adolescents. During the past several decades, the prevalence of overweight and obesity among adolescents appears to be rising rapidly in many countries around the world.^1–5 In 1988–1994, 10.5% of U.S. adolescents aged 12–19 years were obese, which increased to 15.5% and 18.4% in 2000 and 2010, respectively.^1–2 In Chinese adolescents aged 13–18 years, the prevalence of overweight and obesity in large cities was 1.1% and 0.1%, respectively, in 1985, compared with 11.3% and 4.0%, respectively, in 2000.⁴ Moreover, the prevalence of overweight and obesity was 11.9% and 6.2%%, respectively, among 10- through 17-year-olds in a recent survey in Shanghai.⁵

Overweight and obesity in childhood and adolescence may lead to many physical problems. Adolescents with overweight status and obese status are predictors of adult obesity, and the relative risk of obesity in adulthood appears to increase with the age of the obese child or adolescent.^6,7 In addition, overweight and obesity are major risk factors for the development of hypertension, hyperlipidemia, and type 2 diabetes.^8–10 Meanwhile, overweight and obesity in adolescents may also be related to psychosocial adverse outcomes. Obese children and adolescents may encounter prejudice and systematic discrimination because of their weight, which often begins from an early age.^11,12 Therefore, it is critical to explore the risk factors of overweight and obesity among children and adolescents to take further action to prevent adolescent obesity, which can benefit the physical and mental development of adolescents.

It is generally agreed that the etiologies of obesity in the adolescent years are usually multifactorial and frequently exogenous. For example, excessive food intake and sedentary behaviors are focal contributors to the development and maintenance of obesity in children and adolescents.^13–15 In recent years, more and more researchers have focused on the relationship between psychological factors on weight status in adolescents, especially cognition and emotional self-regulation.^16–19 On the one hand, after reviewing the existing studies focusing on the relationship between obesity and cognition, Smith et al. suggested obesity is associated with cognitive deficits in children, adolescents, and adults, especially in executive function. Meanwhile, they also pointed out that weight gain may result from a neurological predisposition characterized by reduced executive function, and in turn, obesity itself has a compounding negative impact on the brain.²⁰ On the other hand, Graziano et al. found that early behavioral and emotional self-regulation difficulties represent significant individual risk factors for the development of pediatric obesity.²¹ Shortly thereafter, another study explored the relationship between emotions, the desire to eat, and binge eating and found that the emotion most often reported preceding a binge was anger. Feelings of loneliness, disgust, exhaustion, or shame lead to binge eating behavior with the highest probability.²²

From the literature above, we can acknowledge that cognition, emotion, and self-regulation skills are closely associated with the development of overweight and obesity. Because of these associations found in the literature, we choose to examine the relationship between weight status and another psychological variable—cognitive emotion regulation (CER). As a brand new perspective on coping style, recognizing the importance of the cognitive component in the coping process, CER strategies were considered a cognitive way of managing the intake of emotionally arousing information, which encompasses a broad range of cognitive, behavioral, emotional, and physiological responses.^23,24 Adaptive CER strategies are central to well-being and successful functioning, and necessary for the initiation, motivation, and organization of adaptive behaviors, but maladaptive strategies can lead to maladaptive behaviors and are not conducive to individual rehabilitation.²⁵ Therefore, a greater understanding of the relationship between CER strategies and weight status in adolescents would benefit prevention and intervention efforts for children and adolescents faced with obesity.

This study had two objectives: (1) to examine the characteristics of CER strategies among adolescents with normal weight, overweight, and obese status, which were confirmed by the cutoff points for BMI for overweight and obesity in the Chinese BMI [BMI = weight in kilograms/(height in meters)²] reference conducted by the Group of China Obesity Task Force (GCOTF),²⁶ and (2) to explore the effects of CER strategies on BMI in adolescents. The hypothesis of this study suggested that normal-weight status individuals may use more adaptive CER strategies, but less maladaptive ones than overweight and obese individuals. Moreover, the hypothesis also suggested that CER strategies can predict BMI in Chinese adolescents significantly.

Methods

Procedure

This study was part of a large research project examining risk behaviors and their related factors in Chinese adolescents. The experimental procedures of this study were approved by the Ethics Committee of Second Xiangya Hospital, Central South University. A stratified random cluster sampling was used in the project during 2010–2012. Participants were recruited from middle schools in urban areas located across seven geographic districts in China. These cities included Changsha, Chengdu, Guangzhou, Langfang, Shenyang, Suzhou, and Yinchuan.

A total of 8692 participants signed written informed consent forms and completed a general questionnaire, the Chinese version of the Cognitive Emotion Regulation Questionnaire (CERQ-C), and others scales. Meanwhile, all participants' height and weight were measured by trained research staff using the same types of equipment. Height was measured without shoes to the nearest 0.5 cm using a standard stadiometer, and weight was measured to the nearest 0.1 kg with minimal clothes and no shoes using a calibrated mechanical step scale. Fifty percent of the participants were boys (n = 4346). According to the cutoff points for BMI for overweight and obesity by sex in the Chinese BMI reference conducted by GCOTF,²⁶ a total of 700 adolescents were defined as overweight and 321 adolescents were defined as obese, leaving 7671 participants as normal-weight status. Meanwhile, considering not only the huge difference of sample size but also the proportions of gender and age in overweight, obese, and normal-weight status groups, 1021 adolescents with normal-weight status were selected randomly as the normal group who matched with the overweight and obese participants in age and gender variables.

Participants

The participants of this study include three groups: (1) overweight group: 700 adolescents were defined as overweight. The mean age of the participants in this group was 15.06 [standard deviation (SD) = 1.95, range = 11–20], and 500 (71.43%) were boys. The mean weight of these students was 68.75 kg (SD = 9.43, range = 35.1–91.6), and the mean height was 1.67 m (SD = 0.09, range = 1.29–1.88). (2) Obesity group: 321 adolescents were defined as obese. Two hundred and thirty students (71.65%) were boys. The mean age of the participants was 14.50 (SD = 1.93, range = 11–19), the mean weight was 80.90 kg (SD = 10.73, range = 52.2–99.4), and the mean height was 1.65 m (SD = 0.09, range = 1.32–1.88). (3) Normal group: 1021 normal-weight status adolescents were selected as the normal group, who matched with overweight and obesity participants in age and gender variables. Seven hundred and thirty students (71.50%) were boys. The mean age of the participants was 14.92 (SD = 1.80, range = 11–20), the mean weight was 52.04 kg (SD = 9.12, range = 26.7–75.8), and the mean height was 1.66 m (SD = 0.09, range = 1.35–1.93). More detailed information is presented in Table 1.

Table 1.

The Sociodemographic Characteristics of the Samples [n (%)]

	Normal	Overweight	Obesity
Total	1021	700	321
Gender
Male	730 (71.50)	500 (71.43)	230 (71.65)
Female	291 (28.50)	200 (28.57)	91 (28.35)
Age
≤12	141 (13.81)	88 (12.57)	53 (16.51)
13	163 (15.96)	98 (14.00)	65 (20.25)
14	146 (14.30)	88 (12.57)	58 (18.07)
15	151 (14.79)	108 (15.43)	43 (13.40)
16	179 (17.53)	133 (19.00)	46 (14.33)
17	140 (13.70)	112 (16.00)	28 (8.72)
≥18	101 (9.90)	73 (10.43)	28 (8.72)
Race
Han	976 (95.59)	650 (92.86)	305 (95.02)
Minority	45 (4.41)	50 (7.14)	16 (4.98)
Single-child status
Singletons	684 (66.99)	516 (73.71)	232 (72.27)
Nonsingletons	337 (33.01)	184 (26.29)	89 (27.73)
Parental marital status
Married	923 (90.40)	645 (92.14)	284 (88.47)
Divorced	49 (4.80)	34 (4.86)	14 (4.36)
Widowed	28 (2.74)	12 (1.71)	9 (2.80)
Remarried	21 (2.06)	9 (1.29)	14 (4.36)

Measures

General questionnaire

The general questionnaire collected data on the following parameters: age, gender, grade, ethnicity, singleton or having siblings, and parental marital status.

CER questionnaire

The 36-item CERQ was used to measure CER strategies that individuals may use, which contains nine conceptually distinct subscales: five adaptive strategy subscales (acceptance, positive refocusing, refocusing on planning, positive reappraisal, and putting into perspective) and four maladaptive strategies subscales (self-blame, rumination, catastrophizing, and blaming others).²³ Responses to items are measured on a five-point Likert scale ranging from 1 [(almost) never] to 5 [(almost) always], with a higher subscale score indicating greater use of a specific cognitive strategy. The CERQ and CERQ-C have demonstrated good reliability and validity,^27–29 and were widely used in many different samples.^30–32 In this study, CERQ-C subscale scores exhibited moderate-to-strong internal consistency (Cronbach's alpha, 0.83–0.92).

Body mass index

Because the amount of body fat in an individual is difficult to quantify directly, BMI [BMI = weight in kilograms/(height in meters)²] has been widely used to measure obesity in adults worldwide, which is a simple, inexpensive, and reasonably objective method of indirectly estimating total subcutaneous and visceral fat content.^33,34 Unlike in adults, BMI varies substantially by age and gender during childhood and adolescence.^35,36 Different references based on weight-for-height indexes have been proposed to classify child and adolescent body weight status, and these references vary considerably.^36–38 In 2004, the GCOTF determined a gender- and age-specific Chinese BMI reference based on other international references on the cutoffs of overweight and obesity in children and adolescents.²⁶ The specific BMI cutoffs for defining overweight and obesity in Chinese adolescent aged 12–18 years are presented in Table 2. In this study, the cutoff points for BMI for overweight and obesity by sex and gender in the Chinese BMI reference were used to define overweight and obesity.

Table 2.

The Cutoffs for BMI for Overweight and Obesity in China Published by the Group of China Obesity Task Force

	Overweight		Obesity
Age (years)	Male	Female	Male	Female
12	21.0	21.9	24.7	24.5
13	21.9	22.6	25.7	25.6
14	22.6	23.0	26.4	26.3
15	23.1	23.4	26.9	26.9
16	23.5	23.7	27.4	27.4
17	23.8	23.8	27.8	27.7
18	24.0	24.0	28.0	28.0

Statistical Analysis

Descriptive analyses, one-way analysis of variance (ANOVA) analyses, and regression analyses were performed using SPSS software (ver. 15.0; SPSS, Inc., Chicago, IL). ANOVA was performed to investigate the characteristics of CER strategies among normal, overweight, and obese adolescent groups, which was followed by post hoc comparison using the Fisher least square difference test. Hierarchical regression analyses were performed to examine the impact of nine CER strategies on BMI after controlling for sociodemographic variables. Categorical variables were coded into dichotomous variables by the following dummy-coding schemes in hierarchical regression analyses: Gender: “0” girls and “1” boys. Race: “0” Han Chinese ethnicity and “1” ethnic minorities. Single-child status: “0” nonsingletons and “1” singletons. Parental marital status: “0” married or in a committed relationship and “1” divorced or widowed. Sociodemographic variables (e.g., age, gender, race, single-child status, and parental marital status) were entered into the first regression equation and nine CER strategies into the second regression equation. Forced entry was used for all variables. Collinearity between independent variables was tested based on variance inflation factors and tolerances.³⁹ Data are reported as mean values with SDs. Statistical analyses were generally performed with a 5% level of significance.

Results

Characteristics of CER Strategies among Three Groups

Table 3 shows the results of CER strategy comparisons among three groups. There were significant group differences in self-blame (F = 48.23, p < 0.001), acceptance (F = 3.57, p < 0.05), rumination (F = 24.58, p < 0.001), positive refocusing (F = 4.08, p < 0.05), and positive reappraisal (F = 3.18, p < 0.05). Adolescents in the obesity group obtained the highest scores on self-blame and rumination in the three groups, and those from the overweight group obtained higher scores on the two subscales above than adolescents the from normal group (ps < 0.05). Adolescents from the normal group obtained higher scores on acceptance, positive refocusing, and positive reappraisal than those from the obesity group (ps < 0.05). There was no significant difference in the other four CER strategies (p > 0.05).

Table 3.

Comparison of Cognitive Emotion Regulation Strategy Scores among Normal, Overweight, and Obese Adolescents (Mean ± Standard Deviation)

Cognitive emotion regulation strategies	Total (n = 2042)	Normal (1) (n = 1021)	Overweight (2) (n = 700)	Obesity (3) (n = 321)	F (2, 2039)	LSD
Self-blame	10.01 ± 4.61	8.18 ± 3.89	10.32 ± 3.54	13.13 ± 4.80	48.23^***	3 > 2 > 1
Acceptance	12.27 ± 4.23	12.48 ± 3.93	12.19 ± 4.47	11.77 ± 4.58	3.57^*	1 > 3
Rumination	9.18 ± 4.83	7.90 ± 4.07	10.73 ± 4.36	11.69 ± 4.08	24.58^***	3 > 2 > 1
Positive refocusing	11.45 ± 4.29	11.67 ± 4.11	11.37 ± 4.47	10.90 ± 4.44	4.08^*	1 > 3
Refocus on planning	12.79 ± 4.46	12.88 ± 4.17	12.89 ± 4.79	12.31 ± 4.57	2.22	—
Positive reappraisal	12.71 ± 4.41	12.80 ± 4.17	12.84 ± 4.69	12.14 ± 4.47	3.18^*	1 > 3
Putting into perspective	9.27 ± 3.54	9.41 ± 3.38	9.19 ± 3.65	8.96 ± 3.76	2.28	—
Catastrophizing	7.83 ± 3.79	7.83 ± 3.70	7.81 ± 3.91	7.88 ± 3.85	0.03	—
Blaming others	8.71 ± 3.70	8.82 ± 3.54	8.56 ± 3.83	8.63 ± 3.89	1.10	—

p < 0.05; ^***p < 0.001.

LSD, least-significant difference.

Impacts of CER Strategies on BMI

The effects of the CER strategies on BMI were examined after controlling for sociodemographic variables (Table 4). In model 1, sociodemographic variables had a significant impact on BMI (F = 4.60, p < 0.001); they accounted for 0.9% of the variance in BMI. Age (β = 0.07, p < 0.01) and single-child status (β = 0.05, p < 0.05) had positive impacts on BMI, but gender (β = −0.05, p < 0.05) had negative impacts on BMI. In model 2, the sociodemographic variables and nine CER strategies had a significant impact on BMI (F = 72.61, p < 0.001), accounting for 32.9% of variance. After controlling the effects of sociodemographic variables, greater self-blame (β = 0.41, p < 0.001) and rumination (β = 0.30, p < 0.001) were associated with higher BMI, but greater acceptance (β = −0.17, p < 0.001) and positive refocusing (β = −0.11, p < 0.001) were associated with lower BMI.

Table 4.

Summary of Regression Analysis with Sociodemographic and Psychological Variables on BMI

	Model 1				Model 2
	B	SE	β	t	B	SE	β	t
Sociodemographic variables
Age	0.18	0.05	0.07	3.27^**	0.21	0.05	0.09	4.72^***
Gender	−0.49	0.23	−0.05	−2.15^*	−0.51	0.19	−0.05	−2.74^**
Race	0.74	0.45	0.04	1.66	0.56	0.37	0.03	1.52
Single-child status	0.52	0.22	0.05	2.33^*	0.30	0.18	0.03	1.64
Parental marital status	−0.21	0.35	−0.01	−0.61	−0.55	0.29	−0.04	−1.91
Psychological variables
Self-blame					0.40	0.02	0.41	18.81^***
Acceptance					−0.18	0.03	−0.17	−6.69^***
Rumination					0.28	0.02	0.30	13.46^***
Positive refocusing					−0.12	0.03	−0.11	−4.58^***
Refocus on planning					−0.01	0.04	−0.01	−0.39
Positive reappraisal					0.01	0.03	0.01	0.20
Putting into perspective					−0.06	0.03	−0.05	−1.93
Catastrophizing					−0.03	0.03	−0.02	−0.81
Blaming others					−0.00	0.03	−0.00	−0.07
F(p)	4.60 (<0.001)				72.61 (<0.001)
R²	0.011				0.334
Adjusted R²	0.009				0.329
ΔR²	—				0.320

p < 0.05; ^**p < 0.01; ^***p < 0.001.

Discussion

In this study, not only the characteristics of cognitive motion regulation strategies in normal-weight status, overweight, and obese adolescents were examined but also, the effects of CER strategies on BMI in adolescents were explored for the first time. These findings can be summarized as follows:

Several sociodemographic variables were found to have impacts on BMI in Chinese adolescents. In this study, age was found to be positively correlated with BMI in Chinese children and adolescents aged 11–20 years, which is consistent with previous studies. In all BMI references for child and adolescents, including the Chinese BMI reference, an increased BMI in adolescents is associated with increase in age.^26,36–38

Chinese “singletons” are a special population related to the family planning policy; they are much different from nonsingletons in many aspects, such as personality traits, social communication, life goals, and so on. In this study, being a singleton increased chances of a higher BMI in Chinese children and adolescents. The reason may be that the singletons may have obtained larger portions from parents who possess a traditional belief that excess body fat represents health and prosperity. School-based BMI screening should be taken in China, which can offer great potential to improve parental awareness of a health risk screening and knowledge about healthy lifestyles, such as restricting child food intake.⁴⁰

Male gender was found to correlate with lower BMI in this study, which conflicts with the existing BMI references in which the cutoff scores for overweight and obesity in boys are higher than those in girls.^26,36–38 The contradictory results may be caused by imbalances of the sample sizes in regard to gender. To balance the sample size between overweight, obese, and normal-weight status in statistical analysis, only 1021 adolescents were selected randomly from 7671 participants as normal-weight status group, who matched with overweight and obesity participants in age and gender variables. The future study may give a more comprehensive consideration of this limitation; similar sample sizes for male and female gender groups should be recommended. Moreover, compared to girls, more boys were defined as overweight or obese in this study. The reason for this difference may be that girls have higher levels of psychological maturity referring cognition, emotion, and behaviors than boys. Compared to boys, girls are more likely to emphasize the importance of connection-oriented goals, seek support, express their emotions, and ruminate in response to stress.⁴¹ Thus, girls have more effective methods to regulate their cognition and emotion, which may lead to less excessive eating. Besides, Sinton and Birch reported that girl's appearance schemas scores were associated with perceptions of parental influence on weight concerns, appearance-related interactions with other girls, and awareness of media messages.⁴² With the popularity of health-related knowledge, almost everyone knows the disadvantage of overweight and obesity. Parental influence and media messages may lead girls to pay more and more attention to their weight status and try to control their weight.

The theoretical hypnosis suggests that adaptive CER strategies, including acceptance, positive refocusing, and positive reappraisal, are central to successful functioning and necessary for the initiation, motivation, and organization of adaptive behaviors, but maladaptive strategies, including self-blame, rumination, and catastrophizing, can lead to maladaptive behaviors and are not conducive to individual rehabilitation.^27–28,43 In this study, CER strategies are indeed correlated with BMI in Chinese adolescents, which is consistent with the hypothesis. On the one hand, normal subjects are more likely to adopt acceptance, positive refocusing, and positive reappraisal strategies than obese participants, and they use less self-blame and rumination strategies than overweight and obese participants. On the other hand, acceptance and positive refocusing have negative impacts on BMI, but self-blame and rumination have positive impacts on BMI in Chinese children and adolescents. The results given previously prove that not all the CER strategies affect adolescents' BMI. Self-blame, rumination, acceptance, and positive refocusing have considerable effects on BMI in Chinese adolescents.

The existing studies reported that cognition and emotional self-regulation were closely related to individual's weight status in different populations.^16–19 Although it was testified that early emotional self-regulation difficulties represent significant individual risk factors for the development of pediatric obesity,²¹ cognition is a crucial and component in the process of self-regulation, which cannot be ignored. Smith et al. found that a neurological predisposition characterized by reduced executive function may lead to weight gain, and in turn, obesity itself has a compounding negative impact on the brain.²⁰ This study acknowledged, for the first time, the relationship between the combined effects of cognition, emotional regulation, and weight status. The existing weight control intervention for adolescents mainly focused on the inappropriate behavior and cognition, especially cognitive behavioral therapy.^44–45 The findings of this study provide a new perspective to treat and prevent obesity in adolescents. In the future, interventions emphasizing the training of cognitive and emotional regulation skill, especially learning acceptance, positive refocusing, and positive reappraisal, can be carried out, which overweight and obese adolescent can benefit not only in weight status itself but also in mental health.

Limitations

There are some important limitations of this study that should warrant attention. First, although BMI is a reasonably objective method of indirectly quantifying the amount of body fat, it is still a rough and inaccurate method to estimate the total subcutaneous and visceral fat content. Future research may consider using multiple indicators to measure the amount of body fat in adolescents to make the results more reliable and credible. Second, because we conducted a cross-sectional and correlational study, but not a longitudinal or causal research, these results cannot infer that CER strategies play a causal role in the development of adolescent obesity. Further studies should be long-term follow-up studies, which would enable more exploration of the relationship between CER strategies and obesity in children and adolescents, and would provide stronger evidence enabling the inference of causality.

Conclusion

In this study, we found for the first time that adolescents with normal-weight status used more coping strategies, such as acceptance, positive refocusing, and positive reappraisal, than obese ones, while they use less self-blame and rumination strategies than overweight and obese participants. Meanwhile, we also found that acceptance and positive refocusing have negative effects on BMI, but self-blame and rumination have positive effects on BMI in Chinese adolescents. In addition, being a singleton may be a risk factor for overweight and obesity in children and adolescents. The relationship of CER strategies and BMI should be explained accurately and thoroughly to prevent and treat children and adolescents' overweight and obesity from a psychological perspective.

Footnotes

Acknowledgments

All phases of this study were supported by grants from the National Key Technologies R&D Program in the 11th 5-year plan of China (2009BAI77B02). The authors would like to thank the staff of the seven research centers for their work in data collection, and the participants for their time and effort.

Author Disclosure Statement

No competing financial interests exist.

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