JPED Journal

Introduction

Today's popular culture emphasizes appearance-oriented happiness and this situation threatens the body image satisfaction of individuals of all ages. Body image is a multidimensional concept that encompasses how an individual perceives, thinks, feels and behaves towards their own body [1]. According to the generally accepted classification, body image consists of two main dimensions: perceptual and attitudinal [2]. The perceptual dimension includes the accuracy of the estimation of body size and shape. The attitudinal dimension refers to body satisfaction or dissatisfaction, which expresses feelings and thoughts about one's body [2]. In the body image literature, most research has focused on body dissatisfaction in young girls and women [3,4]. However, in recent years, this interest has shifted to research on the development of body image in children.

There is evidence that perceptual and attitudinal dimensions of body image develop in children at an early age. In studies on the perceptual dimension, it has been observed that children as young as three years of age gain awareness of their own body size and the body size of others and also have stigmas about body size [5]. Correct perception of body size in children is important for them to have a healthy body image. Impairment in body size perception may lead to the opposite results. Distortion in body size perception can be seen as "underestimation" or "overestimation" of body size. Underestimation of body size is related to the individual's perception that his/her body size is smaller than it actually is. However, overestimation describes an individual's perception that their body size is larger than their actual size.

Children and adolescents with impaired body perception appear to be more prone to suffer from body dissatisfaction, which can lead to higher levels of psychological stress [6,7]. Impaired body size perception is considered a symptom and a strong marker for the development of eating disorders. It has also been associated with other disorders such as depression [8,9]. Misperceptions of being overweight in healthy-weight adolescents have been found to lead to unnecessary weight control behaviors [10]. However, accurate perceptions in overweight children are associated with weight control activities such as weight loss attempts or exercise to lose weight [11]. Impaired body perception in children has been observed to pose a risk for physical and mental health.

There is evidence that body dissatisfaction, which is the attitudinal dimension of body image in children, develops in early childhood [12]. found that body image concerns are valid in young girls aged 5-8 years. Body size dissatisfaction stems from the difference between the child's self-perceived body size and the ideal body size. It has been reported that 40-50% of 6-12 year old children are dissatisfied with their appearance [13]. Another study found that nearly 50% of 7-12 year olds would like to be thinner. Although there are differences in body dissatisfaction between boys and girls, there has recently been a growing trend of dissatisfaction among young men [14]. Longitudinal research has shown that body dissatisfaction in late childhood and adolescence is associated with increased negative affect [15,16], reduced physical activity levels [17], unhealthy weight control behaviors [17], and the development of eating disorders (e.g., anorexia, bulimia) [15]. Obesity is also linked to increased body dissatisfaction. A 10-year longitudinal study of 1,902 male and female adolescents found that body dissatisfaction increased as body mass index (BMI) increased in participants from middle school to high school to young adulthood [18]. Early intervention in body dissatisfaction in children will be a preventive measure for more serious health problems that may occur in the future.

Body image issues are considered a public problem due to their short- and long-term consequences on the health of children and adolescents. Despite this, there has been little research on body perception and satisfaction in children in both national and general literature [7,8,19]. The current study aims to investigate body satisfaction and the prevalence of overestimating (underweight and normal weight school children) or underestimating (obese school children) body size in primary school children. School age is typically the time when habits and behaviors are formed that can last throughout adulthood [20]. Therefore, knowing the prevalence of body dissatisfaction and body image inaccuracies in children can help formulate strategies and treatment plans to prevent body image problems and eating disorders in schools.

Methods

Participants

Parental consent was obtained from 561 children in grades 2, 3, and 4 of 7 elementary schools in the Beypazarı district of Ankara, Turkey. The participants included in the study were between the ages of 7 and 10 years (mean age = 8.79 ± .81 years; 50.98% boys), and all completed the measures detailed below.

Procedures

Parents of all 2nd-4th grade students were sent parental consent and detailed information about the study through the school. The contact information of the researcher was provided on the parental consent page and parents were encouraged to contact the researcher with any questions about the study. Within the scope of the school's arrangement, all approved participants completed the Children's Body Image Scale (CBIS) before having their anthropometric measurements taken one morning of the regular school day. All measurements were conducted by the researcher in the school counseling service room as a one-on-one interview with the children. All measurements and protocols were approved by Eskişehir Osmangazi University Social and Human Sciences Scientific Research and Publication Ethics Board (TN: 2020-26, Date: 26.02.2020).

Measurements

Anthropometry

 Height and body mass were measured barefoot with an accuracy of 0.1 cm and 0.1 kg, respectively. A wall-mounted meter was used for height and an electronic scale was used to measure body mass. Children's height and weight were calculated in kg/m2 for standard Body mass index (BMI) z-scores according to age and gender (World Health Organization (WHO), 2011).

Children's Body Image Scale (CBIS): The CBIS was designed to assess self-perceived current and ideal body size in children aged 7 to 12 years [21]. The gender-specific scale consists of seven child figures, each representing a BMI range from the 3rd to 97th percentile.

The scale is presented in ascending order, with the corresponding BMI range for boys for each percentile range on the scale (with a category number assigned to each child figure) being (1) 14.0-14.6 (3^rd percentile), (2) 14.7-. 15.5 (10^th percentile), (3) 15.6-16.5 (25^th percentile), (4) 16.6-18.5 (50^th percentile), (5) 18.6-24.9 (75^th percentile), (6) 25.0-28.4 (90^th percentile) and (7) 28.5-29.0 (97^th percentile), for girls (1) 13.0-13.5 (3^rd percentile), (2) percentile), (2) 13.6-14.9 (10^th percentile), (3) 15.0-16.6 (25^th percentile), (4) 16.7-17.7 (50^th percentile), (5) 17.8-19.4 (75^th percentile), (6) 19.5-24.6 (90^th percentile) and (7) 24.7-28.5 (97^th percentile).

According to the international BMI classification for children, the numbered figures of CBIS for boys are "underweight" in (figure a and b "normal" in figures c and d, "overweight" in figure e, and "obese" in figures f and g. For girls, "underweight" is figures a and b, "normal" is figures c, d and e, "overweight" is figure e, and "obese" is (Figure 1) [23]. Prior to the anthropomorphic measures, participants were asked to indicate the child figure that best represented the body size they thought represented them (their perceived body size) and their ideal body size (the body size they would like to be). The CBIS showed good construct validity and test-retest reliability (r = .76 and .85 for boys and girls, respectively) [23,24] conducted a validity and reliability study of the scale in Turkish culture (r = .70).

Figure 1: [23] Children's Body Image Scale Figure Rating Scale (with blurred face).

Based on the category number assigned to each CBIS child figure, body size satisfaction was assessed by calculating the difference between participants' perceived body size and their ratings of ideal body dimensions (i.e. 'perceived minus ideal'). Directional interpretation was completed according to whether the difference was positive or negative. For body size estimation, each participant's actual BMI was categorized into one of the seven child figures in the CBIS, referred to as 'BMI categories' in this study. Participants' body size estimation was categorized by grouping the data into 'correct estimate' (when the category number for perceived size was the same as the actual size), 'underestimate' (when the category number for perceived size was lower), and 'overestimate' (when the category number for perceived size was higher than the actual size).

Results

The relationship between gender and BMI categories for actual, perceived and ideal BMI was analyzed by applying chi-square analysis (Table 1).

Table 1: The Relationship between Actual, Perceived and Ideal BMI Categories and Gender.

When the distribution of actual BMI categories is analyzed, a significant relationship was found between actual BMI and gender (p<0,05).  Analyzing the distribution of perceived BMI categories, no significant relationship could be found between perceived BMI and gender (p>0,05). When the distribution of ideal BMI categories is analyzed, a significant relationship was identified between Ideal BMI and gender (p>0,05). The results of the dependent groups t-test conducted to determine the actual BMI and perceived BMI category averages and whether the difference between these averages is significant in different grades in gender discrimination are given (Table 2).

Table 2: The Relationship between Actual BMI and Perceived BMI Category Means in Different Grades by Gender;*p<0,05

As can be seen in the table above, while there is a significant difference between the means of actual BMI and perceived BMI categories in 2^nd, 3^rd and 4^th grade boys (p<0.05), there is no significant difference between the means of actual BMI and perceived BMI categories in 2nd, 3rd and 4th grade girls (p>0.05). In 2^nd, 3^rd and 4^th grade boys, the means of perceived BMI categories were significantly greater than the means of actual BMI categories.

The results of the dependent groups t-test conducted to determine whether the difference between the perceived BMI category averages and the ideal BMI category averages in different grades in terms of gender is significant are given (Table 3).

Table 3: Relationship between Perceived BMI and Ideal BMI Averages in Different Grades by Gender

*p<0,05.

As can be seen in the table, there is a significant difference between the averages of perceived BMI categories and ideal BMI categories in 2^nd, 3^rd and 4^th grade girls and 3^rd grade boys (p<0.05).  There is no significant difference between the means of perceived body image and ideal body image in 2^nd and 4^th grade boys (p>0.05). In 2^nd, 3^rd and 4^th grade girls and 3^rd grade boys, the means of perceived BMI categories are significantly greater than the means of ideal BMI categories (Table 4).

Table 4: What percentage of the girls chose a perceived BMI category that was larger than, smaller than, or the same as their actual BMI category?

Among girls, 22.4% of those who perceive the BMI category as 1 are actually 1. The real BMI category of the remaining 77.8% is larger than their perception. Among those who perceived BMI category as 2, 56% had an actual BMI category of 2. 32% have a BMI category larger than their perception and 12% have a BMI category smaller than their perception. 42.1% of those who perceived their BMI category as 3 also had an actual BMI category of 3. 18.4% had a BMI category larger than their perception and 39.5% had a BMI category smaller than their perception. 11% of those who perceive their BMI category as 4 also have an actual BMI category of 4. 24% had a BMI category larger than their perception and 65% had a BMI category smaller than their perception. 15.7% of those who perceive their BMI category as 5 have an actual BMI category of 5. 47.1% have a BMI category larger than their perception and 37.3% have a BMI category smaller than their perception. Among those who perceived their BMI category as 6, 60% had an actual BMI category of 6. 40% had a BMI category larger than their perception, while no one had a BMI category smaller than their perception (Table 5).

Table 5: What percentage of the boys selected the perceived BMI category as larger, smaller or the same category than the actual BMI category?

Among boys, 30.8% of those who perceive their BMI category as 1 also have an actual BMI category of 1. The actual BMI category of the remaining 69.2% is larger than their perception. Among those who perceived BMI category as 2, 29.2% had an actual BMI category of 2. 50% have a BMI category larger than their perception and 12% have a BMI category smaller than their perception. Among those who perceived their BMI category as 3, 42.1% had an actual BMI category of 3. 18.4% had a BMI category larger than their perception and 20.8% had a BMI category smaller than their perception. 28% of those who perceive their BMI category as 4 also have an actual BMI category of 4. 3% had a BMI category larger than their perception and 68.9% had a BMI category smaller than their perception.

Among those who perceive their BMI category as 5, 46.9% have an actual BMI category of 5. 8.2% have a BMI category larger than their perception and 44.9% have a BMI category smaller than their perception. Among those who perceived BMI category as 6, 14.3% had an actual BMI category of 6. 8.2% had a BMI category larger than their perception and 44.9% had a BMI category smaller than their perception. Of the 2 people who perceived their BMI category as 7, one had an actual BMI category of 6 and the other had an actual BMI category of 4 (Table 6).

Table 6: What percentage of the girls chose as their ideal BMI category a BMI category larger than, smaller than, or the same as their perceived BMI category?.

Among girls, 36.8% of those with a perceived BMI category of 1 also have an ideal BMI of 1. The ideal category of the remaining 63.2% is larger than their perception. Among those whose perceived BMI category was 2, 20% had an ideal BMI category of 2. The ideal BMI category of the remaining 48% is higher than the perceived BMI category and 32% is lower than the perceived BMI category. The ideal BMI category of 32.9% of those with a perceived BMI category of 3 is also 3. The ideal BMI category of the remaining 35.5% is higher than perceived, while 31.6% is lower than perceived. Among those with a perceived BMI category of 4, 52.5% also had an ideal BMI category of 4. The ideal BMI category of the remaining 10.1% is higher than their perception and 37.4% is lower than their perception.

Among those with a perceived BMI category of 5, 9.8% also had an ideal BMI category of 5. No one has a BMI category higher than their perceived BMI, while 90.2% have a BMI category lower than their perceived BMI. None of those with a perceived BMI category of 6 had the same ideal BMI category. All of them had an ideal BMI category lower than their perception. None of the participant girls made a choice from the perceived BMI category 7 (Table 7).

Table 7: What percentage of the boys chose as their ideal BMI category a BMI category that was larger than, smaller than, or the same as their perceived BMI category?

Among the boys, 23.1% of those with a perceived BMI category of 1 also had an ideal BMI category of 1. The ideal BMI category of the remaining 76.9% is larger than their perception. The ideal BMI category of 29.2% of those whose perceived BMI category is 2 is also 2. The ideal BMI category of the remaining 66.7% is higher than their perception and 4.22% is lower than their perception. The ideal BMI category of 32.8% of those whose perceived BMI category is 3 is also 3. The ideal BMI category of the remaining 48.3% is higher than their perception and 19% is lower than their perception. The ideal BMI category of 63.1% of those with a perceived BMI category of 4 is also 4. Of the rest, 18.5% had a BMI category higher than their perception and 18.5% had a BMI category lower than their perception.

The ideal BMI category of 22.4% of those with a perceived BMI of 5 is also 5. The rate of those whose ideal BMI category is higher than their perception is 2%, while 75.5% have a lower BMI category than their perception. Those with a perceived BMI category of 6 did not have the same ideal BMI category. All of them have an ideal BMI category lower than their perception. None of those with a perceived BMI category of 7 had the same ideal BMI category. All of them have a lower ideal BMI category than they perceive.

Discussion

This study was conducted to investigate the accuracy of body size satisfaction and perception among Turkish primary school children. As a result of the study, it was observed that the mean of perceived body mass index (BMI) categories of boys was significantly larger than the mean of actual BMI categories in all grade levels (2^nd, 3^rd and 4^th grade). This suggests that boys overestimate their body size and do not have a realistic body size compared to girls. It is supported by previous studies that boys are less successful than girls in estimating their body size [25,26].  On the contrary, however, some previous research shows that boys estimate body size more accurately than girls [27,28] or that body size misestimation is approximately equal across genders [29]. It is hypothesized that the tendency of Turkish boys to overestimate their body size may be due to the fact that in Turkish culture, boys' being molded and overweight is a desirable characteristic associated with power. In a study conducted by on Turkish obese children aged 7-14 years and their parents, it was found that mothers wanted their daughters to be thin and normal and their sons to be normal and slightly fat [30]. The correct perception of body size is important for healthy eating habits and body satisfaction for both healthy weight and overweight and obese children, and therefore, it is seen that school-based preventive and preventive studies are needed for the formation of correct weight perception.

One of the important findings of this study was that children in the actual BMI normal category were able to make more accurate estimates of their body size compared to underweight, overweight and obese children. Only 60% of the overweight girls correctly estimated their body size, whereas none of the obese girls estimated their body size in the obese category. As previously reported by [31], weight status was found to be effective in body perception in children. Weight was a determinant in the studies of [32,33], who confirmed that overweight and obese boys and girls misjudged and underestimated their body size. There are several possible explanations for this. A number of studies have shown that although parents of 'normal' healthy weight children rarely underestimate their children's weight status, parents of overweight or obese children do not perceive their children's weight status as overweight [34,35]. Another possible reason could be the "visual adaptation" theory proposed by [36]. This can be explained as an overweight child's tendency to perceive his/her own weight as normal due to the high number of overweight individuals in the family and close environment where he/she grew up.

At all grade levels, girls' ideal body size was significantly smaller than their perceived body size. A negative self-evaluation of body size is typically experienced as a result of internalizing a thin body size as ideal and not achieving the desired thin body size [37]. Especially among girls, negative adjectives have been associated with overweight figures and positive adjectives with thinner figures [38]. Children's exposure to ideal thin body appearances through their social environment and the media may have led to the internalization of the thinness ideal. Some well-supported theories emphasize the importance of social comparison processes when making evaluations [36]. It can be hypothesized that when children make judgments about physical attributes such as body size, they are often influenced by social comparisons or "norm-based" information.

Another striking finding of the study was that 90% of girls and 75% of boys who perceived themselves as overweight and obese chose thinner body sizes as their ideal body size. This shows that body dissatisfaction is at a high level in children of overweight and obese people. The positive relationship between body dissatisfaction and weight status in children is supported by previous research results [39]. Negative beliefs about weight (weight stigma), exposure to peer ridicule, low self-esteem, and loneliness are some of the reasons why children who perceive themselves as overweight want to have thinner bodies [40,41]. Children who perceive themselves as overweight and want to be thinner are at high risk of using unhealthy weight control methods to lose weight [42,43]. This finding suggests that school-based preventive measures are needed for children's health development and positive self-perceptions.

Limitations

Our study has several limitations. First, the analysis included cross-sectional data, so causality cannot be inferred from our results. Conducting research with children can be challenging, but every effort was made in this study to minimize potential problems. The sample size is relatively small for quantitative data. The multidimensional nature of body image, the complexity of its assessment, and the limitation of valid and reliable measurement tools that can measure body image in children made the assessment difficult. In this study, anthropometric measurements and figural scale were used. Therefore, only unidimensional body satisfaction based on body size perception could be measured. It was limited in terms of learning satisfaction with specific features of the body. This limitation can be overcome with future qualitative research. In addition, this sample includes only Turkish primary school children and the data may not be generalizable to other groups of children.

Conclusion

The findings from this study emphasize the importance of understanding body size perception and body size dissatisfaction in children aged 8-10. The findings highlight the need for continued research to develop multiple research methods and culturally appropriate assessment tools for body image assessment. An important implication of this research is that it emphasizes the need for research to understand the reasons for children's body size perception and body dissatisfaction, which varies by weight status and gender. The fact that body dissatisfaction and body size misperception observed in children are likely to occur in disordered eating behaviors that can potentially be carried into adulthood emphasizes the need for preventive programs to develop healthy body size perception and positive body perception in primary schools.

Conflict of Interest Statement

The current research does not have a conflict of interest with any institution or person.

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