Eating Behaviors 7 (2006) 161 – 175

Weight concerns, body image, depression and anxiety in

Swedish adolescents
Tord Ivarsson a,b,T, Per Svalander c, Oeystein Litlere d, Lauri Nevonen e
a
Department of Child- and Adolescent Psychiatry Centre, Queen Silvia Children’s Hospital SE-416 85, Göteborg University,
Göteborg, Sweden
b
The Regional Center for Child and Adolescent Psychiatry (R.BUP), Oslo, Norway
c
Varberg kommun, Sweden
d
Child guidance clinic Skene Vårdcentral, Skene
e
Child and Adolescent Psychiatry Centre, Queen Silvia children’s Hospital, Göteborg, Sweden
Received 9 March 2005; received in revised form 27 June 2005; accepted 3 August 2005

Abstract

Objectives: To assess weight problems and correlates in respect of body image, depression, anxiety and
demographic background factors.
Method: 405 Swedish adolescents were assessed in respect of Body Mass Index (BMI), biographical data, the
Body Esteem Scale for Adolescents and Adults (BESAA), the Multidimensional Anxiety Scale for Children
(MASC) and the Children’s Depression Inventory (CDI).
Results: Boys were in the positive and girls in the negative direction from ideal BMI for age and gender. Girls and
boys differed in respect of CDI, MASC and of BESAA where girls generally were shifted in the bpathologicalQ
direction.
Discussion: The adolescents’ own positive attitude to slimness, negative mood (girls), and anxiety symptoms that
reflect social fears (boys) and physical aspects of anxiety (girls and boys) were important correlates of lower BMI

T Corresponding author. Child- and Adolescent Psychiatry Centre, Queen Silvia Children’s Hospital SE-416 85, Göteborg
University, Göteborg, Sweden.
E-mail address: tord.ivarsson@vgregion.se (T. Ivarsson).

1471-0153/$ - see front matter D 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.eatbeh.2005.08.005
162 T. Ivarsson et al. / Eating Behaviors 7 (2006) 161–175

than ideal. Adolescent cultural norms need to be addressed in preventive work. However, in girls’ separation
anxiety might be a protective factor against underweight. In girls, overweight seems to be associated with negative
self-esteem.
D 2005 Elsevier Ltd. All rights reserved.

Keywords: BMI; Body esteem; Anxiety; Depression; Eating behaviour; Underweight

1. Introduction

Appearance plays an important role for adolescent’s self-esteem and body weight is one factor that
determines attractiveness (Tomori & Rus-Makovec, 2000). Current body ideals promote slimness for
women and muscularity for males (Grogan, 1999) and consequently, females have reported a desire to be
thinner while males wanted to be heavier (Mintz & Betz, 1986; Waaddegaard & Petersen, 2002). School
based studies have indicated that females were more concerned about their weight than males.
Danielsson (1998) found that about 40–50% of 13–14 year old females in Sweden considered
themselves too fat whereas the numbers for males were 20–25% and Edlund, Hallqvist and Sjoden
(1994) found that about 50% of the 14-year-old females in Sweden had practiced dieting during their
lifetime. Thus, weight concerns and weight problems among adolescents in current western cultures are
common (Garner, Olmsted, Polivy, & Garfinkel, 1984) and dieting is one strategy to reach the goal of
getting an attractive body and a better self-esteem. Dieting has, unfortunately, been implicated as a
triggering factor in eating disorders.
The development of body image is culturally bound by what is desirable and attractive and girls tend
to view their bodies as aesthetic and decorative while boys view their bodies as active and functional
(Wilfley & Rodin, 1995), thus indicating gender differences in this respect. Body image and body
dissatisfaction has long been associated with weight and eating related problems and is included as a
criterion in The Diagnostic and Statistical Manual of Mental Disorders IV for eating disorders (American
Psychiatric Association, 1994). Body image disturbance in this sense, can be defined as any form of
affective, cognitive, behavioural, or perceptual disturbance that is directly concerned with an aspect of
physical appearance (Thompson, 1995). Body dissatisfaction for both men and women as well as for
adolescents has been shown to be correlated with Body Mass Index (BMI) (Smolak, 2004).
Mood (e.g. depression) and anxiety symptoms are ostensibly a common consequence of starvation
among people with or without eating disorders and found to be highly correlated with weight and body
image disturbances (Cooper & Goodyer, 1997). Also, anxiety disorders (e.g. social phobia and
obsessive–compulsive disorder) have been found to occur frequently in patients with diagnosed eating
disorders. In only a small minority of cases was the mood and anxiety disturbance preceded by the eating
disorders, which strongly marks that, the disturbances were a consequence of the eating disorder (Cooper
& Goodyer, 1997; Ivarsson, Rastam, Wentz, Gillberg, & Gillberg, 2000). Both mood- and anxiety
disorders have generally been found to be associated with socioeconomic (Cohen, Pine, Must, Kasen, &
Brook, 1998; Twenge & Nolen-Hoeksema, 2002) and family adversity (Goodyer & Altham, 1991) as is
somatic ill health (Cohen et al., 1998), another possible source of weight concerns.
Prospective studies of adolescents have found that weight concerns (Killen et al., 1996), body image
disturbance (Furnham, Badmin, & Sneade, 2002), and depression (Button, Loan, Davies, & Sonuga-
Barke, 1997) each has contributed to the risk of developing an eating disorder (Lau, 2000).
 T. Ivarsson et al. / Eating Behaviors 7 (2006) 161–175 163

Are there gender differences in terms of weight problems, body image, depression and anxiety? Studies
have revealed that adolescent girls experience greater problems with weight concerns (Taylor et al., 1998),
and depression than boys as found in international (Fleming & Offord, 1990; Verhulst, Prince, Vervuurt-Poot,
& de Jong, 1989) and in Swedish (Ivarsson & Gillberg, 1997; Olsson & von Knorring, 1997) studies.
However, when adolescent girls who were concerned about being too fat were compared with boys who were
dissatisfied with being too fat and having a limited amount of muscles, the frequency of body dissatisfaction
was equal (McCabe & Ricciardelli, 2004). Moreover, Woodside et al. (2001), in a Canadian population based
study, found a lack of psychological differences between females and males with an eating disorder. Also,
there seems to be similarities between females and males with a confirmed eating disorder in the natural
history and diagnosis of the disorder but the aetiology is still unclear (Andersen, 1995).
Understanding the relationships between weight concerns, body image disturbances, depression and
anxiety among adolescents in the general population might contribute to our understanding of who might
be at risk of developing an eating disorder. The aim with the present study is therefore to investigate the
relation between weight problems in terms of deviance from ideal BMI, body image, depression, anxiety
and some health correlates among a representative sample of Swedish adolescents.

2. Methods

2.1. Subjects

The study group consists of 405 adolescents (192 boys and 210 girls (mean age 14.6 and 14.7 years,
respectively, n.s.)—missing data as to gender 3 individuals). Due to practical limitations, we could not
sample all senior high school programs but tried to make it representative of both theoretically and
practically inclined programs (both are included within the senior high school system). Although no
formal stratification or cluster sampling was used, the adolescents were selected from four different
schools so that the adolescents should be reasonably representative of Swedish adolescents and the
global distribution of gender would not be skewed, as some high school programs leading to practical
professions have more male students and programs leading to university studies more female students, as
was the case in our study (v 2 (4, N = 402) = 29.24, p b .0001).1 Both inner city, suburban and rural areas
were tapped so as to include adolescents of both higher and lower socioeconomic status and to include
(and somewhat over-sample) adolescents of non-Swedish ethnicity. Two hundred and eighty three pupils
attended junior high school (130 boys and 153 girls). Numbers and age per form were: first form
(n = 105, mean age = 13.0, SD = .17); 2nd form (n = 90, mean age = 14.0, SD = .24); 3rd form (n = 89,
mean age = 15.0, SD = .18). We recruited slightly more adolescents (62 boys and 57 girls) in the first
form of senior high school (n = 120, mean age = 16.2, SD = .91).
The socioeconomic status (SES) of the adolescents was assessed through the Hollingshead (1975)
nine factor socioeconomic index. As can be seen from Table 1, there was a significant relationship
between the ethnical origin and SES in that adolescents of Swedish origin were more likely to belong to
the medium (3–7) to high (N 7) levels of SES while adolescent of non Swedish or mixed descent were
more likely to belong to the medium to low (b 3) levels. The difference was statistically significant (v 2

1
The senior high school programs and their gender distribution can be obtained from the author.
164 T. Ivarsson et al. / Eating Behaviors 7 (2006) 161–175

Table 1
Socioeconomic status versus ethnicity based on Hollingshead 9-factor index
Socioeconomic index Ethnicity Total
All Swedish Swedish + migrant All migrant
Low 21 19 7 47
Medium 182 32 32 246
Highest 54 3 6 63
Total 257 54 45 356

(4, N = 402) = 32.35, p b .0001). This is consistent with recent data from Statistics Sweden (Statistics
Sweden (SCB), 2002). There were no differences with regard to SES across gender nor were there any
differences as regards living with both biological parents or not and SES. We over sampled adolescents
of non/Swedish ethnicity in that for both boys (14.3%) and for girls (17.7) we had higher frequencies
than those found in the general population (9% and 9%, respectively, both p b .0001).
A majority (67.7%) of the adolescents lived with their parents, the largest minority lived with their
mothers (14.3%), almost one in ten (10.6%) lived alternately with their mother and father, a few (2.7%)
lived with their fathers and finally a few (2.2%) lived in other arrangements. Seven (1.7%) of the
adolescents did not respond to this question.
In order to control for major health problems, the adolescents were also asked about their health/
presence of any handicaps (positive response: 47 adolescents (28 girls and 19 boys)/negative response
352 adolescents (181 girls and 171 boys, n.s.), and whether they had had contact with any healthcare
officers (school or general) (positive response: 137 adolescents (84 girls and 53 boys)/negative response:
256 adolescents (122 girls and 134 boys), (v 2 (1, N = 393) = 6.67, p b .01).

2.2. Measures

2.2.1. BESAA
Mendelson et al. developed this scale to assess the body image of the respondents. The BESAA is a self-
rating scale that contains positive and negative assertions about the body and the person’s appearance. It is
adapted for ages 12–25 years and provides a general assessment of satisfaction and views about the body
using 5-point Likert type of scales going from 0 (never) to 4 (always). Negative items are reversed so that a
high score always is associated with a positive value judgment of the body. Mendelson et al. factor analysed
the scale and stated that the statements can be divided into three groups—subscales—within a wider
concept, that of body-esteem. The three subscales are: Appearance (BE-appearance), attribution (BE-
attribution) and weight (BE-weight or BE-weight satisfaction). The appearance factor (10 statements) deal
with general feelings around one’s looks (e.g. bMy looks makes me upsetQ. The Attribution factor (5
statements) concerns the persons’ beliefs about how others perceive his/her looks (e.g. bMy looks makes
boys/girls attracted to meQ) and the weight factor (8 statements) assesses perceptions of one’s own weight
and to which extent one would like to change it (e.g. bI am satisfied with my weightQ).
The Canadian normative study, found alpha values for the different subscales to be: a = .81 for the
attribution factor; a = .95 for the weight factor; and a = .93 for the appearance factor, in summary, quite
substantial values (Mendelson, Mendelson, & White, 2001). BESAA has been shown to have good test–
retest reliability, three months after the first test (Mendelson et al., 2001). The test–retest correlations were
.83 for the attribution factor, .89 for the appearance factor and .92 for the weight factor ( p b .001).
 T. Ivarsson et al. / Eating Behaviors 7 (2006) 161–175 165

The homogeneity of the Swedish translation of the BESAA was tested by Johansson and Kallmin
(1998), who, in a study of 117 girls in junior and senior high school found an a = .77 for the appearance
factor, a = .76 for the attribution factor, and a = .75 for the weight factor.
AS one would expect, significant gender differences have been shown in respect of Weight and
Appearance, in that girls have scored lower than boys (Mendelson et al., 2001). Also, body mass index
(BMI) has been shown to be strongly associated with the BESAA subscale Weight, in that girls with
high BMI have been associated with low scores (Mendelson et al., 2001).

2.2.2. Children’s depression inventory

The CDI is a self-rating scale modelled on the Beck Depression Inventory (Beck, Ward, Mendelson,
Mock, & Erbaugh, 1961) and adapted to young people 7–17 years of age. The depressive symptoms
assessed include cognitive, affective, somatic and behavioural aspects and the 27 items are scored from 0
to 2 where, 0 means the symptom is not present, 1 the symptom is present and mild while a 2 the
symptoms are present and marked. The CDI takes about 10–20 min to fill in. The CDI contains five
subscales: Negative mood, Interpersonal problems, Ineffectiveness, Anhedonia and Negative Self-
Esteem. The CDI was translated to the Swedish language by a bilingual translator and normative data
and reliability data for children 8–13 years of age (Larsson & Melin, 1992) in accordance with an
agreement between Dr. Kovacs and Dr. Larsson. The current study is included in this agreement.
Normative data for adolescents from the current study will be published shortly (Ivarsson, Svalander, &
Litlere, 2004).

2.2.3. MASC
The scale was developed by March (1997) for use with anxious children and adolescents. It is a 39
item inventory, and in the present study we have only utilised the self-rating version, tapping anxiety
from four main domains: Physical symptoms (with subscales Tense/restless and Somatic/autonomic);
Social Anxiety (with subscales Humiliation/rejection and Performing in public); Separation Anxiety (no
subscales) and Harm Avoidance (with subscales Perfectionism and Anxious coping). Reliability and
validity data from an American sample has been published (March, Parker, Sullivan, Stallings, &
Conners, 1997; March & Sullivan, 1999). Swedish norms will presently be published from the current
sample (Ivarsson, in press). The MASC items are scored by the respondent on a scale ranging from 0 to
3, where 0 means that the symptom never applies; 1 that the symptom applies rarely; a 2 that the
symptom applies sometimes; and a 3 that the symptom applies often.

2.3. Procedure

Two last year psychology students (third and fourth author) visited the school, informed teachers and
pupils and distributed the questionnaires and supervised the adolescents when filling it in. We tried to
reduce attrition by giving a second chance for pupils who were not in school on the day of the study.
Thus, six adolescents were bsavedQ to the study. The questionnaire was filled in anonymously, and each
questionnaire was given a special code number.
The questionnaire consisted of four parts: part one concerning personal and socioeconomic information;
part two contained the Children’s Depression Inventory (CDI (Kovacs, 1983, 1992)); part three the
Mendelson Body-Esteem Scale for Adolescents and Adults (BESAA; (Mendelson et al., 2001)); and part
four the Multidimensional Anxiety Scale for Children (MASC) (March, 1997). Due to a typographical
166 T. Ivarsson et al. / Eating Behaviors 7 (2006) 161–175

error the MASC did not contain item number 21 (I try to do things that others will like). The item was
replaced with the mean of the other three items of that subscale (Perfectionism).
Part One of the questionnaire also contained items where the adolescents, could note their gender, age,
living arrangements, fathers and mothers work, ethnical origin of mother and father, any illness or handicap
and whether they had contact with the health care system. They were also asked to note their height and
weight. The Body Mass Index was computed for every adolescent and an ideal BMI for his or her age was
noted in accordance with the current Swedish norms (Albertsson-Wikland & Karlberg, 1994). Thus,
subtracting the ideal from the actual BMI gave every individual a score (plus or minus), which indicated
how far the adolescent was from his/her ideal BMI. The growth norms describe on an average how the BMI
changes across childhood and adolescence for the two genders (Albertsson-Wikland & Karlberg, 1994).
Thus, ideal BMI for an adolescent is here defined as the mean BMI for that gender and age.

3. Results

3.1. Deviance from normal BMI

Deviance from normal BMI (actual BMI minus ideal (or average) BMI for gender and age) was quite
common in this population (Fig. 1 and Table 2).
As can be seen in Fig. 1 and Table 2, girls had a slight shift in the negative direction (deviance of
mean from norm for age and gender (m = 5.2%, SD = 100% (of raw SD = 2.58) while boys were shifted
in the positive direction (m = + 36.1%, SD = 100% (of raw SD = 2.52) (t(184) = 4.92, p = .0001).
There were quite large gender differences across most of the psychological measures (Table 2).
Mostly, girls had higher scores on the CDI and on the MASC (except one subscale) than boys.

3.2. Family and socioeconomic factors

There were no differences in adolescents who had separated parents (n = 117) as compared to the others
(n = 263) on the BMI deviance measure, but there were some differences on the psychological measures.
Adolescents from intact families tended to score somewhat higher than those from separated families on the
BESAA total score (m = 60.0, SD = 15.8, SD = 15.8 and m = 56.8, SD = 18.2, SD = 18.2, t(385) = 1.76,
p = .079), respectively, largely because the they scored higher on BE Weight (m = 21.2, SD = 7.4 and m =
19.5, SD = 9.0, t(385) = 2.0, p = .046), respectively. There were greater differences as regards the CDI total
score, where adolescents from intact families scored lower than those from separated families (m = 8.1,
SD = 5.6 and m = 10.5, SD = 7.6, respectively, t(174.5) = 3.14, p = .002)). The CDI subscales that contributed
most strongly were Interpersonal Problems (m = .90, SD = .8 and m = .50, SD = 1.1, t(167.1) = 3.55, p = .001),
respectively, Anhedonia (m = 3.2, SD = 2.1 and m = 2.5, SD = 2.6, t(190.2) = 2.77, p = .006), respectively,
Negative Self-Esteem (m = 1.74, SD = 2.3 and m = 1.26, SD = 1.8, t(177.1) = 2.62, p = .009), respectively, and
Ineffectiveness (m = 2.05, SD = 1.5 and m = 1.6, SD = 1.7, t(382) = 2.47, p = .014), respectively, while
Negative Mood (m = 2.6, SD = 1.8 and m = 2.2, SD = 2.3, t(186.3) = 1.70, p = .091), respectively, contributed
less. On the MASC total score there was no difference in this respect (m = 35.8, SD = 13.0 and m = 34.7,
SD = 15.4, n.s.), respectively. However, there was a difference on the MASC subscale level where
adolescents from intact families scored significantly higher than those from separated families on Separation
Anxiety (m = 4.1, SD = 3.3 and m = 3.0, SD = 3.0, t(378) = 3.26, p b .001), respectively.
 T. Ivarsson et al. / Eating Behaviors 7 (2006) 161–175 167

Males
40

30
Frequency

20

10

0 Mean = 36.1
Std. Dev. = 100.0
-100.0 0.0 100.0 200.0 300.0 400.0 N = 185
Difference between real and ideal BMI in percent of SD
(2.52)

Females

40

30
Frequency

20

10

0 Mean = -5.2
Std. Dev. = 100.0
-200.0 -100.0 0.0 100.0 200.0 300.0 400.0 N = 198
Difference between real and ideal BMI in percent of SD
(2.58)

Fig. 1. Deviance from normal BMI for age and gender.

Adolescents of Swedish ethnicity tended to deviate from normal BMI for gender and age in the
positive direction and those of other ethnicities deviated in the negative direction (m = .48, SD = 2.6,
SD = 2.4 and m = .21, t(381) = 1.94, p b .053) while the Swedish adolescents rated their bodies more
negatively than those from abroad: BESAA total score (m = 57.5, SD = 16.2 and m = 67.5, SD = 15.7,
t(394) = 4.56, p b .0001), respectively; and subscales BE Appearance (m = 26.3, SD = 7.6 and m = 30.7,
168 T. Ivarsson et al. / Eating Behaviors 7 (2006) 161–175

Table 2
Descriptive data for BMI, BESAA, CDI and MASC
Measure Gender n Mean SD t (df ) = x p gender difference
BMI Boys 185 20.4 2.74 t(381) = 2.91 .004
Girls 198 19.6 2.50
BESAA appearance Boys 188 28.8 6.99 t(391.4) = 4.51 .0001
Girls 206 25.4 7.98
BESAA attribution Boys 188 11.3 3.93 t(392) = .12 n.s.
Girls 206 11.3 3.60
BESAA weight Boys 188 23.4 6.46 t(380.8) = 6.71 .0001
Girls 206 18.3 8.43
BESAA total score Boys 188 63.5 14.82 t(392) = 5.26 .0001
Girls 206 55.0 17.03
CDI negative mood Boys 184 1.8 1.58 t(374.7) = 6.15 .0001
Girls 206 2.9 2.12
CDI interpersonal problems Boys 185 .60 .94 t(389) = .85 n.s.
Girls 206 .68 .93
CDI ineffectiveness Boys 185 1.5 1.34 t(389) = 2.59 .010
Girls 206 1.9 1.69
CDI anhedonia Boys 185 2.6 2.25 t(389) = 1.38 n.s.
Girls 206 2.9 2.36
CDI negative self-esteem Boys 185 1.1 1.20 t(376.3) = 4.37 .0001
Girls 207 1.7 1.63
CDI total score Boys 184 7.5 5.27 t(377.6) = 4.19 .0001
Girls 206 10.1 6.98
MASC physical symptoms (P/S) Boys 184 6.6 5.20 t(381.6) = 4.46 .0001
Girls 203 9.2 6.32
P/S tense/restless Boys 184 3.8 2.94 t(384.8) = 3.37 .0001
Girls 203 4.9 3.32
P/S somatic/autonomic Boys 184 2.8 2.71 t(375.8) = 4.88 .0001
Girls 203 4.3 3.51
Social anxiety (SA) Boys 184 7.8 4.87 t(385) = 4.32 .0001
Girls 203 10.1 5.62
SA humiliation/rejection Boys 184 3.8 2.89 t(377.7) = 4.55 .0001
Girls 203 5.4 3.67
SA performing in public Boys 184 3.9 2.58 t(385) = 2.94 .003
Girls 203 4.7 2.77
Harm avoidance (HA) Boys 184 14.6 4.40 t(385) = .60 n.s.
Girls 203 14.9 4.61
HA perfectionism Boys 184 8.0 2.42 t(385) = 1.90 .058
Girls 203 7.5 2.60
HA anxious coping Boys 184 6.6 2.89 t(385) = 2.57 .01
Girls 203 7.3 2.93
MASC total score Boys 184 31.9 12.17 t(385) = 5.14 .0001
Girls 203 38.9 14.20
Gender differences where equal variances could not be assumed can be seen where dfs are below 385.
A Bonferroni correction for multiple comparisons cautions us to regard p-values above .005 as significant.
 T. Ivarsson et al. / Eating Behaviors 7 (2006) 161–175 169

SD = 7.2, t(394) = 4.58, p b .0001), respectively; BE Attribution (m = 10.9, SD = 3.6 and m = 13.2,
SD = 4.0, t(394) = 4.58, p b .0001), respectively; and BE Weight (m = 20.2, SD = 8.0 and m = 23.6,
SD = 7.0, t(394) = 3.2, p b .002), respectively. Swedish adolescents had more negative self-esteem than
those of other ethnicities (m = 1.5, SD = 1.5 and m = 1.1, SD = 1.1, t(381) = 1.94, p b .047), respectively,
but less negative mood (m = 2.3, SD = 1.9 and m = 2.8, SD = 2.1, t(390) = 1.97, p b .05), respectively,
while CDI total scores did not differ.
Socioeconomic status was not correlated (Pearson Bivariate r) with deviance from ideal BMI, nor
with any of the psychological measures.

3.3. Illness or handicap/contact with health system

There were no differences regarding those who stated that they had an illness or a handicap (n = 46) as
compared to those who stated that they had not (n = 347) as regards deviance from ideal BMI (m = .55,
SD = 2.9 and m = .34, SD = 2.6, n.s.). Nor were there any substantial differences with regard to the BESAA
Total Score (m = 54.1, SD = 16.5 and m = 59.7, SD = 16.5, t(391) = 2.17, p = .03), respectively, where by
and large the Appearance subscale was the single significant contributing subscale (m = 24.5, SD = 7.6 and
m = 27.3, SD = 7.7, t(391) = 2.33, p = .02), respectively, although there was a tendency for BESAA Weight
also to contribute (m = 18.8, SD = 8.8 and m = 21.0, SD = 7.8, t(391) = 2.17, p = .08), respectively) while the
Attribution subscale did not differ (m = 10.8, SD = 3.8 and m = 11.4, SD = 3.6, respectively, n.s.). There
was a tendency for adolescents with illness or handicap to score higher on the CDI Self-Esteem subscale
than those without (m = 1.8, SD = 1.7 and m = 1.4, SD = 1.4, t(390) = 1.76, p = .08), respectively. However,
there were small differences on the other CDI subscales, as on the CDI Total Score (m = 10.2, SD = 6.6 and
m = 8.7, SD = 6.3, t(388) = 1.57, p = .12, respectively). Also, there was a tendency for adolescents with
illness or handicap to score higher on the MASC Physical symptoms subscale than those who had not
(m = 9.6, SD = 16.3 and m = 7.8, SD = 5.9, t(384) = 1.93, p = .06) respectively, because of correspondingly
higher scores on its component subscale Somatic–Autonomic (m = 4.7, SD = 3.3 and m = 3.5, SD = 3.2,
t(384) = 2.50, p = .02) respectively). However, there were small differences on the other MASC subscales,
as on the MASC Total Score (m = 36.8, SD = 15.5 and m = 35.5, SD = 13.4, n.s., respectively).
There were no associations to speak of as regards contacts with the health care system and deviance from
ideal BMI, the BESAA and subscales, and the CDI and subscales. However, those responding af-
firmatively scored substantially higher as compared to those who responded negatively on the MASC
(m = 38.3, SD = 14.4 and m = 34.2, SD = 13.0, t(378) = 2.85, p = .005), respectively, and on two of the
MASC subscales: Physical symptoms (m = 9.6, SD = 6.2 and m = 7.2, SD = 5.6, t(248.9) = 2.96, p = .0001),
respectively, with corresponding subscales Tense/restless (m = 5.0, SD = 3.2 and m = 4.0, SD = 3.1, res-
pectively, t(378) = 2.96, p = .003) and Somatic/autonomic (m = 4.5, SD = 3.5 and m = 3.1, SD = 3.0,
respectively, t(238.3) = 3.91, p = .0001); and Social Anxiety (m = 9.9, SD = 5.6 and m = 8.7, SD = 5.2,
t(378) = 2.1, p = .04), respectively, where the corresponding subscale Humiliation/rejection contributed
(m = 5.3, SD = 3.5 and m = 4.4, SD = 3.3, respectively, t(378) = 2.51, p = .013) while Performing in Public
(m = 4.6, SD = 2.8 and m = 4.3, SD = 2.7, n.s.), respectively, did not.

3.4. Predicting deviance from normal BMI

The correlation among the variables was substantial. We used multiple regression analysis with
backward stepwise elimination procedures to sort out the variables that were important predictors to
170 T. Ivarsson et al. / Eating Behaviors 7 (2006) 161–175

Table 3
Deviance from ideal BMI predicted through the BESAA, CDI and MASC subscales (raw scores) regression analysis with
backward stepwise elimination procedure, all but the following subscales
Term B SE t p
2
Regression girls Initial ANOVA R = .27 SE = 2.35 df = 15,169 F = 4.17 .0001
Final ANOVA R 2 = .25 SE = 2.32 df = 7,177 F = 8.45 .0001
Constant 2.21 .71 3.12 .0001
CDI bnegative moodQ .25 .11 2.24 .027
CDI bnegative self-esteemQ .32 .11 1.74 .084
MASC btense/restlessQ .19 .06 2.97 .003
MASC bseparation anxietyQ .14 .06 2.45 .027
BE bappearanceQ .10 .04 2.46 .02
BE battributionQ .12 .06 2.17 .031
BESAA bweightb .16 .03 5.76 .0001

Regression boys Initial ANOVA R 2 = .125 SE = 2.31 df = 15,153 F = 1.46 n.s.

Final ANOVA R 2 = .10 SE = 2.31 df = 3,168 F = 6.05 .001
Constant 4.18 .87 4.81 .0001
BESAA bweightQ .10 .03 3.15 .0001
MASC bhumiliation/rejectionQ .14 .07 3.63 .051
MASC btense/restlessQ .13 .07 1.96 .056

negative BMI deviance, i.e., the contribution of depression and anxiety and the adolescents’ attitudes to
their body to their deviance from ideal BMI, controlling for common correlates of depression, anxiety
and somatic ill health/ contact with health system, e.g., SES, ethnicity and family intactness. These latter
factors were not significant as compared with gender, depression, anxiety and body estimation. Then,
hierarchically ordered scales and subscales were entered into the regression analysis for the two genders
separately. None of the predictors that were entered simultaneously had Pearson bivariate correlations
above r = .80 (a common limit for predictor inter-correlations to render a significant multi-collinearity
problem). CDI and the MASC total scores were weak predictors, explaining a mere 11% and 5% (for
girls, respectively, boys) of the variance. Using the CDI-, BESAA and MASC inter-mediate level
subscales as predictors, better prediction was possible for girls (R 2 = .24) but not so for boys (R 2 = .06).
Finally, all BESAA, CDI and MASC subscales were entered into the stepwise elimination regression
analysis. Some subscales did not contribute and those subscales that were retained in the analysis can be
found in Table 3.

4. Discussion

This is to our knowledge the first study which relates deviance from ideal BMI for gender and age to
aspects of body estimation, depression and anxiety contemporaneously. Given the level of debate in
current society over the weight problem, too little has yet been written on the contribution of psy-
chiatric problems to the issue. Aspects as body ideals (e.g., slimness in females (Grogan, 1999) and
muscularity in males (Mintz & Betz, 1986; Waaddegaard & Petersen, 2002) has been a source of
current interest and aspects of the current teenage culture has been seen as important facets of the
problem (Wilfley & Rodin, 1995).
 T. Ivarsson et al. / Eating Behaviors 7 (2006) 161–175 171

4.1. Main findings

Our findings indicate that both adolescent boys and girls were shifted from the current norms
(Albertsson-Wikland & Karlberg, 1994) in respect of weight problems, boys mostly in the positive
and girls in the negative direction thus indicating that previous findings (Grogan, 1999; Mintz &
Betz, 1986; Waaddegaard & Petersen, 2002) are evident also in this population.
As can be seen from the descriptive data in Table 2, there were substantial differences among girls and
boys in respect of their body estimation, where boys had a more positive attitude to their appearance and
to their weight than girls, findings in consonance with previous both Swedish (Danielsson, 1998) and
international (Garner et al., 1984; Taylor et al., 1998) studies. However there were no gender differences
in respect of attribution to others. As expected, girls also had more depressive symptoms than boys
(except anhedonia and interpersonal problems where differences fell short of statistical significance),
gender differences being a common finding in previous studies (Allgood-Merten, Lewinsohn, & Hops,
1990; Angold, Costello, & Worthman, 1998; Cohen, Cohen, Kasen, & Velez, 1993; Ivarsson & Gillberg,
1997; Ivarsson, Gillberg, Arvidsson, & Broberg, 2002; Fleming & Offord, 1990; Verhulst et al., 1989).
For more detailed data on gender differences in this sample, see (Ivarsson et al., in press).
Girls also had more anxieties than boys (except in respect of Perfectionism where boys had higher
scores) also a common finding (Cohen et al., 1993; March & Sullivan, 1999; March et al., 1997; Simonoff
et al., 1997). More detailed data on gender differences on the MASC in this sample can be found in
(Ivarsson, in press).
The main finding of our study was that girls and boys seem both to have similarities and differences in
respect of the contribution of anxieties, depression and body estimation to the presence of weight
problems, i.e. lower than normal BMI for age and gender.
Girls and boys are similar in that the more positive attitude they had to their weight, the more likely
they were to have lower BMI than the average, in line with previous findings (Smolak, 2004). This
means also that girls and boys who had a lower BMI than ideal for gender and age were satisfied with
their weight. Thus in all, adolescents seemed to endorse the current slim ideals. This is in accordance
with the findings of Mintz and Betz (1986) as regards adolescent females but in some contrast to the
findings of (Waaddegaard & Petersen, 2002) who noted that males wanted to be heavier.
However, as regards the relationship between deviance from ideal BMI and psychiatric symptom
scales, there were gender differences.
First, lower than normal BMI was associated with depressed mood in girls while overweight was
associated with negative self-esteem and no CDI scales contributed to boys BMI deviance. This is in
accordance with previous findings, that depression and deviant weight occur together usually by the
eating disorder preceding the depression (Cooper & Goodyer, 1997; Ivarsson et al., 2000). As regards
anxieties, both girls and boys scoring high on the Tense/restless MASC subscale tended to have lower
BMIs’ than their ideal BMI. Thus, a lower BMI is associated with overt physical signs of anxiety.
Also, girls who scored high on the MASC bSeparation AnxietyQ subscale were associated with a
deviance from ideal BMI in the positive direction, an unexpected finding. However, given that the
items comprising this subscale are in the direction of dependence, our finding might indicate that girls
who are dependent are somewhat protected from the extremities of the slimness ideal. Future studies
will be needed to see if this is substantiated or a chance finding in this population.
Boys, in contrast who had high scores on social fears of Humiliation/rejection tended to have a
negative deviance from ideal BMI, a result that seems more in line with the attitude to their weight. This
172 T. Ivarsson et al. / Eating Behaviors 7 (2006) 161–175

was in accordance with the current slim ideals about weight and the adolescents’ well-known wish for
conformity with the adolescent sub-culture. However, it goes against the findings of Mintz and Betz
(1986) and Waaddegaard and Petersen (2002) who noted that males wanted to be heavier.
One should be cautious in viewing these findings as indicative of a relationship between anxiety
disorders and deviance from ideal BMI or for that matter as a cause of eating disorders. However, our
findings may indicate a vulnerability leading to the later association of a manifest eating disorder and
anxiety disorders which has been observed previously (Cooper & Goodyer, 1997). The gender difference
in respect of the different anxieties of girls and boys contrast, against the findings of Woodside’s clinical
study (Woodside et al., 2001). However, the difference might be accounted for by the different kinds of
populations studied, clinical versus general population.
Other possible sources of BMI deviance and differences among the scales and subscales (family
intactness, medical problems, socioeconomic status and ethnicity) did not contribute once the attitudes the
BESAA measures, the depressive symptoms the CDI uncovers, and the anxieties the MASC assesses had
been accounted for.

4.2. Limitations

It is not our contention that this study covered all aspects that would be needed to understand this issue.
We do not assert that we have covered all possible psychiatric symptoms that might influence deviance
from ideal BMI. The use of a broadband scale like the Youth Self Report (Achenbach, 1991) or a semi-
structured psychiatric interview (e.g. the Kiddie-SADS) might have contributed aspects that the current
study does not approach. The absence of parental ratings/reports is also a decisive shortcoming of the
study. Also, the measures included did not address personality problems from a broader perspective, nor
eating behaviours. Moreover, using self-reported reports of weight, height, gender and of age introduces
errors in all components in the BMI, and in the deviance from ideal BMI for age and gender computations.
The sample size is not large enough for decreasing these error components adequately. Thus, reliablity
concerns is the main threat to the validity of our main focus of the study, that of deviance from normal
BMI for age and gender. Moreover, the design of the study precludes any conclusions as to how these
aspects of psychiatric problems relate to cultural issues and a cross-sectional study cannot illumine issues
of causality. Thus, the word prediction should not be viewed as synonymous with causality, but rather as a
statistical prediction that indicates possible research foci using better research designs.

4.3. Strengths

It is a strength of the study to include a fairly representative sample of adolescents from different
school programs and to have taken steps to minimize attrition from school absenteeism by giving a
second chance. However, the study did not try to find school dropouts, nor adolescents who did not
show up on the second visit by the researchers.

5. Conclusions

In conclusion, weight problems as measured from ideal BMI for gender and age indicated that
adolescents endorsed the current ideal of a slim body. The psychiatric correlates of the deviance, mainly
 T. Ivarsson et al. / Eating Behaviors 7 (2006) 161–175 173

the presence of specific symptoms of depression and anxiety will have to be replicated but indicate some
gender differences. If substantiated, the findings may have implications for preventive work in school
health settings.

Acknowledgments

We would like to thank Dr. March and Dr. Kovacs for the permission to use their respective scales in
the study.

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