Moderating Effects of Student Engagement on the Relationship Between Weight Bias Internalization and Depressive Symptoms Among Adolescent Girls With Higher Weight

Abstract

This study aimed to examine the moderating effect of student engagement between weight bias internalization and depressive symptoms in Korean adolescent girls with higher weight. Ninety-nine girls with higher weight (≥85th body mass index percentile) in early adolescence (aged 12–14 years) participated in this cross-sectional study. Weight bias internalization, student engagement, and the interaction between these variables were significantly associated with depressive symptoms. Furthermore, a simple slope analysis indicates that higher student engagement was associated with more significant relief in depressive symptoms. Thus, promoting higher student engagement with family and school support may help reduce depressive symptoms related to weight bias internalization in adolescent girls with higher weight. Therefore, family- and school-based programs are required to enhance student engagement in adolescent girls with higher weight.

Keywords

adolescents internalized weight bias student engagement depression

Introduction

Weight bias is a widely prevalent form of discrimination (Durso & Latner, 2008). The most common targets are individuals with higher weight (e.g. overweight or obesity). People with higher weight are perceived as lazy, less intelligent, mean, and uncontrolled (Puhl & King, 2013). This mistreatment causes psychological problems, including low self-esteem and depressive symptoms (Fields et al., 2021; Mustillo et al., 2013). Additionally, internalizing societal beliefs and unfavorable attitudes toward higher weight, called weight bias internalization (WBI), adversely impacts individuals with higher weight. For example, a person with a higher weight may engage in self-devaluation by applying negative stereotypes to themselves (Durso & Latner, 2008; Pearl & Puhl, 2018; Zuba & Warschburger, 2017). Considering the mediating role of WBI between weight and psychological health, WBI is significantly associated with psychological health problems among individuals with higher weight (Gmeiner & Warschburger, 2020).

Individuals who perceive themselves as having a higher weight have a greater propensity to internalize weight-based stereotypes and negative attitudes than those who consider themselves to be in the normal range. (Decker et al., 2018). Early adolescence is a developmental period associated with an increased likelihood of overestimating weight and concern over appearance (Ra et al., 2017). Thus, young adolescents might have increased WBI. Adolescent girls are especially likely to accept and follow social standards regarding body weight and appearance (Magallares & Morales, 2013). Korean society, in particular, with its traditional Confucian culture, has stricter weight standards for females than males. Therefore, Korean women, including adolescent girls, feel compelled to maintain an ideal weight and appearance, such as a lean body shape (Ra & Kim, 2021). In a previous study of Korean girls in early adolescence, even normal-weight adolescent girls reported higher WBI compared with adolescent girls in Germany (Pötzsch et al., 2018; Ra & Kim, 2021), Thus, younger adolescent Korean girls with higher weight might be at a higher risk of WBI than adolescent girls in Western countries.

Low self-esteem and body dissatisfaction from WBI can contribute to depressive symptoms (Papadopoulos & Brennan, 2015; Purton et al., 2019). In this sense, WBI is considered a significant factor that influences the development of depressive symptoms in adolescent girls (Zuba & Warschburger, 2017). In addition, the findings of cross-sectional studies with adolescents in the United States show that higher weight is positively associated with depressive symptoms exclusively in females (Needham & Crosnoe, 2005). Similar findings were reported for Korean adolescent girls with higher weight (Lim & Kim, 2017). Thus, in early adolescence, Korean girls with higher weight might experience increased depressive symptoms associated with WBI.

However, according to the psychological mediation framework (Hatzenbuehler, 2009), social/interpersonal factors (e.g., social isolation) control the effects of distal bias-related stressors such as discrimination due to psychological health problems, including depression with symptoms of depressive episodes lasting more than 2 weeks (e.g., depressed mood) (Malhi & Mann, 2018). School is vital to society, as adolescents spend most of their time therein. In addition, school is a common context in which adolescents with higher weight experience weight stigma (Lessard & Juvonen, 2020). In previous studies, adolescents with higher weight reported more maladjustment in school, including increased emotional problems than their average-weight peers (Juvonen et al., 2018).

Student disengagement vis-à-vis school engender psychological health problems via maladjustment in school such as impaired emotion regulation and poor conflict resolution skills (Yu et al., 2016). On the other hand, increased student engagement through support and satisfying psychological needs by parents, teachers, and peers was beneficial for relieving depression (Yu et al., 2016). Furthermore, student’s emotional engagement (emotional connectedness to a school) was inversely associated with depression in adolescents who experienced bullying (Jiang & Dong, 2020). Thus, student engagement might be significantly associated with the depressive symptoms of adolescent girls with higher weight.

In addition, a stress-buffering model reveals that social and emotional ties can protect against stressors that cause psychological health problems (Cohen & Wills, 1985). Furthermore, previous studies also found that attachment with peers and positive relationships with teachers had moderating effects between bullying experience and depression in children and adolescents (Lee et al., 2021; Price et al., 2019). Brewis and Bruening (2018) also reported the moderating effects of a social connection with peers between weight shame and depressive symptoms in late adolescence. They suggested that emotional engagement in school, with positive relationships, prevents and relieves depressive symptoms related to body shame. Thus, a higher degree of student engagement (cognitive and emotional engagement to school) may control the adverse effects of WBI on depressive symptoms (as a moderating effect) of girls with higher weight in early adolescence.

Venta et al. (2019) also proposed that student engagement could act as a buffer to protect adolescents from psychological distress. They suggest further studies to identify the mechanisms through which such engagement contributes to adolescent well-being. However, the moderating effects of school factors, such as student engagement, were rarely identified (Zhang et al., 2022). Moreover, research has yet to investigate the effects of student engagement (including moderating ones) between WBI and adolescents’ psychological health. Thus, this study aimed to examine the moderating effect of student engagement on the relationship between WBI and depressive symptoms among Korean girls with higher weight in early adolescence. Furthermore, this study hypothesized that student engagement would moderate the associated effect of WBI on depressive symptoms of Korean girls with higher weight in early adolescence.

Methods

Design

This study adopted a cross-sectional design. Ninety-nine girls with higher weight in early adolescence (aged 12–14 years) were recruited from two middle schools in Daejeon, a metropolitan area of South Korea, using the convenience sampling method. The participants were selected based on the following criteria: (1) could answer the questionnaires without any help; (2) had overweight (≥85th and <95th percentile) and obesity (≥95th percentile), which were evaluated with body mass index (BMI) percentiles. BMI was calculated using objectively measured height and weight (m²/kg). Then, the BMI value was transformed into a percentile according to the Korean national growth chart for children and adolescents (Kim et al., 2018); (3) currently did not have any diagnosed physical and psychosocial health problems that could influence self-report; and (4) participants and their legal guardians gave written informed consent for voluntary participation in the study. Using G*Power 3.13, a sample size of 77 was estimated to satisfy the following conditions: (1) effect size = 0.15, (2) alpha level = 0.05, and (3) power = 0.80. Thus, our sample size of 99 participants was satisfactory.

Measurements

Weight Bias Internalization

Weight Bias Internalization was evaluated using the Weight Bias Internalization Scale, initially developed by Durso and Latner (2008) and translated into Korean by Ra and Kim (2021). It includes 11 items rated on a 7-point Likert scale (1–7 points). A higher mean item score indicates a higher WBI. Ra and Kim (2021) confirmed the validity of the measurement translated into Korean through a study with Korean adolescent girls in early adolescence. Cronbach’s α was .90 in the study by Durso and Latner (2008) and .87 by Ra and Kim (2021). Cronbach’s α in this study was .92.

Depressive Symptoms

Depressive symptoms were evaluated using the Korean version of the Children’s Depression Inventory, which includes 27 items rated on a 3-point Likert scale (0–2 points; Cho & Lee, 1990). A higher score out of the total score of 54 indicates increased depressive symptoms. Cronbach’s α was .88 in the study by Cho and Lee (1990) and .91 in this study.

Student Engagement

Student engagement is evaluated using the Student Engagement Instrument, which measures school-related cognitive and emotional engagement. It was developed initially by Appleton et al. (2006) and translated into Korean by Ra and Jung (2018), and it includes 35 items rated on a 4-point Likert scale (1–4 points). A higher total score out of the possible score of 140 indicates higher student engagement. The validity of the measurement translated into Korean was confirmed through a study of younger Korean adolescents (Ra & Jung, 2018). Cronbach’s α was .94 in Appleton et al.’s (2006) and Ra and Jung’s (2018) studies. However, it was .90 in this study.

Procedure

Data were collected from June to July 2019 by the researcher and a trained research assistant of doctoral-level nurses. To recruit participants, the researcher posted a notice on the bulletin boards of schools with the consent of the school authorities. Adolescents who wished to participate in the study were asked to contact the researcher via phone. After obtaining the participants’ permission, the research assistant delivered and collected self-reported electronic questionnaires, explained the purpose of this study, and provided verbal and text-message instructions for the questionnaires directly on the participants’ cell phones. A total of 117 questionnaires were distributed. Finally, 99 questionnaires were returned (84.6% response rate) and included in the statistical analysis.

Ethical Considerations

The Institutional Review Board of C University (approval no. 201903-SB-030–01) approved all study procedures. The researcher and a trained research assistant explained that participation was voluntary in this study. Participants could withdraw from the study at any stage, their rights would be respected, and all the information collected would be utilized confidentially and only for this study. The participants and their legal guardians who agreed to participate provided written informed consent. Participants were given electronic cards worth 20,000 won, which could be used at convenience stores.

Statistical Analysis

SPSS Version 26 (SPSS Inc., Chicago, IL, USA) was used for statistical analyses for descriptive analysis and Pearson correlation coefficients. The descriptive analysis included the variables’ frequency, percentage, mean, and standard deviation (SD). In addition, Pearson correlation coefficients were used to test associations among WBI, student engagement, depressive symptoms, and the moderating effect of student engagement between WBI and depressive symptoms.

The main and interactive effects of the variables of interest were tested using regression-based statistical moderation analysis (Model 1) in Hayes’ PROCESS macro (Version 3) for SPSS to verify the moderating effects of student engagement on the WBI–depressive symptom association. According to the simple slope analysis using the Johnson-Neyman method, student engagement was low (−1 SD from the average), average, or high (+1 SD from the average) after mean centering. The effect of WBI on depressive symptoms was analyzed based on high or low student engagement.

Results

Table 1 displays participants’ demographic characteristics, WBI, student engagement, and depressive symptoms. In addition, Table 2 displays correlations between WBI, student engagement, and depressive symptoms.

Table 1.

Demographic Characteristics, Weight Bias Internalization, Student Engagement, and Depressive Symptoms of Participants.

Characteristics	Categories	n (%)	M (SD)
Demographic Characteristics
Age (years)			13.54 (0.86)
Body mass index percentile	Overweight	45 (45.5)
Body mass index percentile	Obese	54 (54.5)
Perceived own weight	Normal weight	2 (2.0)
	Overweight	41 (41.4)
	Obese	56 (56.6)
Experience of weight related teasing in a month	Yes	31 (31.3)
Experience of weight related teasing in a month	No	68 (68.7)
Father’s education level	≤Middle school	13 (13.1)
	High school	42 (42.4)
	≥Junior college	44 (44.5)
Mother’s education level	≤Middle school	9 (9.1)
	High school	42 (42.4)
	≥Junior college	48 (48.5)
Perceived economic level of family	High	8 (8.1)
	Middle	81 (81.8)
	Low	10 (10.1)
Weight bias internalization			3.92 (1.36)
Student engagement			102.16 (13.57)
Depressive symptoms			14.53 (9.00)

Note. N = 99, M = mean, SD = standard deviation.

Table 2.

Correlations between Weight Bias Internalization, Student Engagement, and Depressive Symptoms.

Variables	Weight Bias Internalization	Student Engagement	Depressive Symptoms
Variables	r
Weight bias internalization	1	−.32^**	.52^**
Student engagement		1	−.56^**
Depressive symptoms			1

Note. r = correlation coefficient.

^**p < 0.01.

Moderating Effect of Student Engagement on Weight Bias Internalization–Depressive Symptoms Association

Table 3 shows that higher WBI was associated with increased depressive symptoms (b = .25, t = 9.17, p < .001), while higher student engagement was associated with decreased depressive symptoms (b = −.28, t = −11.00, p < .001). Additionally, the interaction between WBI and student engagement was significantly associated with depressive symptoms (b = −.005, t = −2.62, p = .0092). Their interaction explained 45.4% of the variance in depressive symptoms. The regression model was good fit with variables (F = 56.10, p < .001).

Table 3.

Results of Regression Model Predicting Depressive Symptoms.

Characteristic	b [95% CI]	SE	t	p
Constant	13.39 [12.72, 14.06]	.34	39.24	<.001
Weight bias internalization (centered)	.25 [.19, .30]	.03	9.17	<.001
Student engagement (centered)	−.28 [−.33, −.23]	.03	−11.00	<.001
Weight bias internalization x Student engagement	−.005 [−.008, −.001]	.002	−2.62	.0092

Note. N = 99; Adjusted R² = 0.454; CI = confidence interval.

According to the simple slope analysis results, student engagement showed a moderating effect on the association between WBI and depressive symptoms (Figure 1). The adolescents with higher student engagement showed significantly decreased depressive symptoms than those with lower student engagement.

Figure 1.

Effect of interaction between weight bias internalization and student engagement on depressive symptoms in Korean adolescent girls with higher weight.

Discussion

This study examined the moderating effect of student engagement between WBI and depressive symptoms of young adolescent Korean girls with higher weights. According to the results, WBI had a positive association with depressive symptoms in adolescent girls. In contrast, student engagement was negatively associated with adolescent girls’ depressive symptoms. In addition, student engagement showed a moderating effect between WBI and depressive symptoms. Thus, high student engagement might buffer the adverse effects of WBI on depressive symptoms.

According to a model proposed by Ratcliffe and Ellison (2015), WBI is formed due to the influence of a weight-stigmatizing environment (e.g., social pressure to be thin) and maintained through individual factors, including beliefs about others' evaluation of individuals with higher weight. Sarigiani et al. (2020) also mentioned that internalization of the ideal body appearance (thin and slender body for females) might be significantly problematic for females with higher weight, for whom gaining an ideal body appearance would require extreme weight loss efforts and those who have experienced weight stigma. Furthermore, as early to mid-adolescence is a period of prosocial identity formation, higher weight was found to contribute to depressive symptoms in adolescent girls through internalization of weight-biased labeling by parents and friends (Mustillo et al., 2013).

Additionally, children and adolescents with higher weights are more likely to be ignored and excluded from school activities and social networks (Puhl et al., 2011). Individuals with higher weights also tend to avoid social activities to relieve anxiety developed through repeated weight stigma experiences (Ratcliffe & Ellison, 2015). As a result, adolescents with higher weight experience less socialization and friendships in school than their average-weight peers (Puhl & King, 2013). A previous study with children and adolescents aged 9–18 found that WBI is significantly influenced by weight discrimination in school, resulting in low self-esteem associated with depressive symptoms (Fields et al., 2021). Thus, WBI formed with frequent experience of weight stigma and decreased engagement in school may result in depressive symptoms in adolescents with higher weight.

Through student engagement, young people participate in and identify with school activities (Christenson et al., 2012). Therefore, positive changes in student engagement, such as stronger feelings of school belonging (emotional engagement), are associated with decreased depressive symptoms (Wang et al., 2015). Similarly, low emotional connectedness to school as emotional engagement is associated with increased depressive symptoms (Olivier et al., 2020). Furthermore, in a previous study with immigrated adolescents at risk of discrimination, decreased emotional engagement was associated with psychological health problems (conduct problems). However, increased emotional engagement was associated with increased resilience and prosocial behavior. Although insufficient research is available to support the existence of a causal connection between student engagement and adolescent well-being (Venta et al., 2019), student engagement is considered an essential contributor to psychological health of adolescents, who spend extended time in school.

Furthermore, Zhang et al. (2022) reported the moderating effects of emotional connectedness to schools between perceived interparental conflict and depression in adolescents. High emotional connectedness to school would buffer the adverse effects of perceived interparental conflict on depression in adolescents (Zhang et al., 2022). In a study with adolescents with interpersonal problems (e.g., bullying perpetration, isolation), emotional connectedness to school was also beneficial for relieving depressive symptoms with buffering effects (Foster et al., 2017). According to previous studies, well-developed emotional connectedness to schools resulted in increased self-esteem, self-acceptance, and high adaptive functioning, which might connect to ameliorating depressive symptoms (Foster et al., 2017; Zhang et al., 2022). Thus, Zhang et al. (2022) proposed that emotional connectedness to school as a component of student engagement might be an essential resource for improving coping with stressors. In addition, according to the social support buffering model, emotional connectedness to schools was a vital source of social support, compensating for emotional stress from social exclusion (Szkody & Mckinney, 2019). Thus, improving student engagement focused on increased emotional connectedness to schools might be essential for relieving emotional stress associated with depressive symptoms in adolescents with higher weight. Foster et al. (2017) also suggested that enhancing emotional connectedness to schools should be the primary target of early intervention for improving the psychological health of socially vulnerable adolescents. Thus, improved student engagement (emotional engagement) may be important for relieving depressive symptoms in adolescents with higher weight.

Implications of Research

Lessard and Juvonen (2020) suggested creating a school atmosphere that is accepting of weight diversity to improve student engagement of adolescents with higher weight. In addition, discrimination by teachers decreases emotional engagement in school, leading to increased depressive symptoms in adolescents (Jiang & Dong, 2020). In this connection, Nutter et al. (2019) emphasized developing weight-bias reduction interventions targeting teachers. Furthermore, in a systematic review, education to correct inadequate knowledge regarding the causes and controllability of excessive weight gain was recommended for decreased negative beliefs and attitudes toward individuals with higher weight (Talumaa et al., 2022). Thus, education programs should focus on body weight determinants and the adverse effects of weight bias on adolescents’ psychological health. Student engagement was also enhanced with the parental monitoring of emotional distress, peer rejection, and academic failure in adolescents through cooperation with schools (Stormshak et al., 2010). Thus, tutoring and skill training for parents with parent–school involvement might be necessary for the increased student engagement of adolescents. In these contexts, healthcare providers in schools and communities should maintain awareness and develop effective school and family-based strategies for improving student engagement to relieve depressive symptoms of adolescents with higher weight.

Limitations of Research

This study has some limitations. First, convenience sampling was used for recruiting participants. This method has limitations for generalizing study findings among all adolescent girls with higher weight in Korea. Future studies should use randomized sampling methods. Second, the study tested the hypothesis with Korean girls affected by higher weight in early adolescence. However, the significance of the effect of student engagement might differ according to race, adiposity, and developmental stage in adolescence. Third, this study only focused on the moderating effect of student engagement between WBI and depressive symptoms. Further studies are needed to verify the moderating effects of other psychosocial factors.

Conclusion

Based on these results, depressive symptoms of adolescents associated with WBI might be relieved by enhanced emotional engagement in school as student engagement. Considering the effects of school atmosphere, teachers, parents, school and family-based strategies and programs for enhancing student engagement should be developed to improve depressive symptoms and promote psychological health.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article: The author declares that the research was conducted without any commercial or financial relationships that could be construed as a potential conflict of interest.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study was supported by a National Research Foundation of Korea (NRF) grant, funded by the Korean government (Ministry of Science and ICT) (2021R1A2C100682811).

ORCID iD

Jin Suk Ra

Author Biography

Jin Suk Ra is currently a professor of child nursing at Chungnam National University, South Korea. She has been conducting research on body image and weight perception of children and adolescents with overweight and obesity for about 10 years.

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