Body Image and Body Shape Perception of Adolescents with Intellectual Disabilities Compared to Students Without Disabilities: Obesity

Jpn. J. Spec. Educ., 49(6), 755―768, 2012.

Brief Note

Body Image and Body Shape Perception of Adolescents With Intellectual Disabilities Compared to Students Without Disabilities: Obesity

＊, ＊＊＊ Ayumu YOSHIOKA and Kazunori TAKEDA

The present study examines obesity in adolescents with intellectual disabilities from the perspective of the body image and body shape perception of adolescents with intellectual disabilities and their parents. It also aims to obtain basic information that can be put to practical use in health education. The participants in the study, male adolescents with intellectual disabilities (n ＝39) who were enrolled in a special needs education high school for students with intellectual disabilities, and male high school students without disabilities (n ＝37) who were enrolled in a regular high school, completed a questionnaire, as did the parents of all the students. The results revealed no signi⁄cant di‹erences in body image or body shape perception between the parents of the adolescents with intellectual disabilities and the parents of the high school students without intellectual disabilities. In contrast, a signi⁄cant di‹erence was found in body image and body shape perception between the parents of obese and non-obese adolescents with intellectual disabilities. These di‹erences should be considered when health education is being implemented in high schools and other locations.

Key Words: obesity, body image, body shape perception, parents, adolescents with intellectual disabilities

Introduction

In the past 65 years in Japan, the nature of disease has been changing due to the rapid westernization of lifestyle patterns that followed World War II. Lifestyle-related diseases, as a percentage of all diseases, are increasing even in children (Hara, 2008). The most common lifestyle-related disease a‹ecting children is obesity (Hara, 2008). Because of the high rates at which childhood obesity translates into adult obesity, and because adult obesity causes various health problems, including heart disease, and increases mortality risk (Mossberg, 1989; Must, Jacques, Dallal, Bajema, & Dietz, 1992), it is extremely important to

＊ Graduate School of Comprehensive Human Sciences, University of Tsukuba ＊＊ Hyogo Prefectural Special Needs Education School for the Visually Impaired

— 755 — A. Yoshioka & K. Takeda teach appropriate lifestyle habits early, in order to prevent obesity during childhood. Previous studies have reported that the proportion of students who are obese is signi⁄cantly higher among adolescents with intellectual disabilities than among adolescents without intellectual disabilities (Naka & Kotani, 2003; Stewart, Van de Ven, Katsarou, Rentziou, Doran, Jackson, Reilly, & Wilson, 2009). Most of these are simple obesity with a primary factor of an imbalance between calories burned and calories consumed due to a lack of exercise and over-eating (Hara, Egawa, Nakasita, Yamanishi, & Shimoda, 2001; Naka & Kotani, 2003). In addition, other factors characteristic of adolescents with intellectual disabilities have also been reported as potentially having an impact, such as a low level of ambition or awareness of health improvements because of the individual’s intellectual disability and the tendency to eat sweets in order to avoid or resolve feelings of mental instability (Hara et al., 2001). However, during puberty, in addition to lifestyle habits, body self-image also has a considerable impact on body shape and health. Studies have shown that dissatisfaction with one’s own body shape during puberty can lead to problems later on, in the extreme in the form of suicide or suicide attempts (Rodríguez- Cano, Beato-Fernández, & Llario, 2006). Thus, the formation of an appropriate body image during puberty is extremely important in promoting healthy growth and development. Studies of children have reported that the formation of body image during childhood may be impacted by the body image of the parent to whom children are most closely attached, most commonly, their mother (Ebara, 2011). Because adolescents with intellectual disabilities tend to be more dependent on their parents in their everyday living activities than adolescents without intellectual disabilities are, they can likewise be expected to be signi⁄cantly impacted by their parents’ views on health (Hara et al., 2001). Thus, when implementing health education to prevent obesity in adolescents with intellectual disabilities, it is essential to look not at only the body image of the adolescents themselves, but also at the body image of their parents and at their parents’ perception of their children’s body shapes. Thus far, many studies have reported that obesity among adolescents with intellectual disabilities represents simple obesity (Hara et al., 2001; Naka & Kotani, 2003), but no studies that the present authors could locate have asked detailed questions regarding those adolescents’ own body images and body shape perceptions, or their parents’ body images and perceptions of their children’s body shapes. Similarly, we found no studies that have tried to identify the relation between these perceptions and obesity. Adolescents with intellectual disabilities enrolled in special needs education high schools for students with intellectual disabilities have higher rates of obesity than children with intellectual disabilities when in elementary and junior high school. It has been shown that a high-calorie diet and inactive lifestyle increases obesity after students with intellec-

— 756 — Obesity in Adolescents With Intellectual Disabilities tual disabilities graduate from high school (Naka & Kotani, 2003; Takahata & Musashi, 1997). Thus, properly teaching healthy lifestyle habits and an awareness of health-related issues while students are still enrolled in high school is an important way to improve the quality of life (QOL) of adolescents with intellectual disabilities after they graduate. In order to obtain basic material for implementing health education programs in schools, homes, and communities for the purpose of preventing lifestyle-related diseases among adolescents with intellectual disabilities and their parents, the present study examines the body image and body shape perceptions of adolescents with intellectual disabilities enrolled in a special needs education high school for students with intellectual disabilities and their parents, and aims to show how these are related to obesity in adolescents with intellectual disabilities.

Method

Participants Questionnaires were distributed to 61 male adolescents with intellectual disabilities who were enrolled in a special needs education high school for students with intellectual disabilities, and their parents; of these, 39 returned usable replies. For the comparison group, questionnaires were distributed to 48 male high school students without intellectual disabilities who were enrolled in a regular high school, and their parents, of whom 37 returned usable replies. High rates of obesity have been reported among both male and female adolescents with intellectual disabilities (Naka & Kotani, 2003; Stewart et al., 2009), but the present study examined only males and their parents, i.e., exclud- ing females, as females’ body shape changes much more than males’, due to the secondary sex characteristics associated with puberty.

Survey Method and Period The participants were asked to complete an anonymous questionnaire on body image and body shape perception. The question items were prepared with reference to the methods proposed by Bell, Kirkpatrick, and Rinn (1986) and Fujita, Suzuki, Kuriiwa, Watanabe, Ohyama, and Nakamura (2002). We asked that the parents of the adolescents with intellectual disabilities help their sons complete the questionnaire by entering their sons’ responses to the questions asked on the questionnaire. At the high school, we prepared one questionnaire for students and another for the parents, and asked the high school students without intellectual disabilities to complete the former and their parents to complete the latter. Questionnaires were distributed to and collected from the schools between June and September 2010.

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Survey Content Basic attributes. Questions were asked regarding the height and weight of the adolescents with and without intellectual disabilities who were participating in the study, as well as about any clinical conditions relating to the disabilities of the adolescents with intellectual disabilities. The survey also asked the parents about their own height and weight. Body image and body shape perception of the adolescents with and without intellectual disabilities. The survey was conducted using Collins’ (1991) body image diagram (hereafter, body image diagram, Fig. 1). The adolescents with and without intellectual disabilities were asked to select the body image that you think is most ideal for you from among the body images shown in the diagram. On this question, we only tabulated those responses that the parents said were genuine re¤ections of the opinions of the adolescents with intellectual disabilities. The parents’ body image and body shape perception. The parents were asked, “Which body shape is the ideal body shape for your son?” and “Which body shape would be the healthiest for your son?” They selected their answers from among the body images shown in Fig. 1. In addition, in order to be able to exam- ine the parents’ general body shape perceptions, the survey asked them to select from among the body images shown in the diagram those that re¤ected the following: a male who you think is too fat, a female who you think is too fat, a male who you think is too skinny, and a female who you think is too skinny.

FIG. 1 Collins’ (1991) Body Image Diagram

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The parents’ perceptions of their sons’ health. The parents were also asked whether they had ever paid particular attention to their son’s everyday lifestyle habits in an e‹ort to manage their son’s health.

Analysis Obesity determination. The heights and weights recorded on the questionnaire were used to calculate the body mass index (BMI, kg/m2) for each respon- dent (the adolescents with and without intellectual disabilities and their parents), and, based on the report by Cole, Bellizzi, Flegal, and Dietz (2000), used a BMI of 25 or higher as the de⁄nition of obesity. That de⁄nition of obesity has been established by the Japan Society for the Study of Obesity (JASSO), and is widely used in Japan. Description of the analysis. A comparison was performed to assess any di‹erences in body image and body shape perceptions between the adolescents with and without intellectual disabilities, and between the parents of both of those groups (Analysis 1). The adolescents with intellectual disabilities were then divided into two groups, obese and non-obese, based on their BMI, and the same comparison was conducted (Analysis 2). Statistical analysis. To compare obesity rates and the perceptions of the parents, Fisher’s exact probability test was used. To compare the responses to the body image questions, the Mann-Whitney U-test was used. In order to perform the analysis using the Mann-Whitney U-test, the body images in the body image diagram were numbered from 1 to 7. If the participants gave an answer such as “somewhere between images 2 and 3,” an intermedi- ate number, 2.5, was used in the analysis. The analyses were done with StatMate IV (ATMS, Tokyo, Japan). Two-tailed tests were used for all items, and p values less than .05 were considered to be statistically signi⁄cant. A p value of between .05 and .10 was considered to be trending toward statistical signi⁄cance.

Ethical Considerations The present study was approved by the University of Tsukuba Graduate School of Comprehensive Human Sciences Research Ethics Committee. Participa- tion in the study was voluntary. The participants were informed in writing that their responses on the questionnaire constituted their consent to participate in the study.

Results

Clinical Conditions of the Adolescents With Intellectual Disabilities Valid responses as to the diagnosed clinical condition were received from the parents of the 39 adolescents with intellectual disabilities. Analysis of the known clinical conditions causing their disabilities revealed the following: 16 had

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TABLE 1 Comparison of the Percentage of Obese Respondents Among the Adolescents With and Without Intellectual Disabilities and Their Parents Adolescents with Participants without intellectual intellectual disabilities p value disabilities（n ＝39）（n ＝37） Percentage of obese adolescents n（%） 11（29.7） 3 （8.6）＊ Percentage of obese fathers n（%） 11（33.3） 12（37.5） Percentage of obese mothers n（%） 1 （3.2） 5（13.9） Note. *p ＜.05. only intellectual disabilities, 14 had autism or autistic tendencies, 4 had some other type of pervasive developmental disorder (PDD), and 5 had Down syndrome.

Comparison of Obesity Among the Adolescents With Intellectual Disabilities and the High School Students Without Disabilities The percentage of obese individuals among the adolescents with intellectual disabilities was compared to that among the students without intellectual disabilities. Data could not be obtained from 2 of the 39 adolescents with intellectual disabilities. Among the 37 remaining participants, 11 (29.7%) were obese. Data also could not be obtained from 2 of the 37 high school students without intellectual disabilities. Of the 35 remaining participants without intellectual disabilities, 3 (8.6%) were obese. The percentage of obese boys among the students without intellectual disabilities was signi⁄cantly lower than that among the adolescents with intellectual disabilities (p ＜.05, Table 1).

Comparison of Body Image and Body Shape Perception Among the Adolescents With and Without Intellectual Disabilities When asked about their ideal body shape, body image 3 was selected by the largest percentage of the adolescents both with and without intellectual disabilities, with no signi⁄cant di‹erence between the two groups (U ＝458.5, p ＞.10).

Comparison of Obesity Rates, Body Image, Body Shape Perception, and Attitude Toward Their Sons’ Health Among the Parents of the Adolescents With and Without Intellectual Disabilities An examination of the participants’ parents revealed no signi⁄cant di‹erence in body shape between the parents of the adolescents with intellectual disabilities and the parents of the students without intellectual disabilities, either between the fathers (p ＞.10) or the mothers (p ＞.10, Table 1). Next, the body image and body shape perception of the parents were examined. The highest percentage of the parents of the adolescents with intellectual disabilities selected body images 3 and 4 as the ideal body shape for their own son (44.7% each, or a total of 89.4% selected one of these two images),

— 760 — Obesity in Adolescents With Intellectual Disabilities whereas the image selected by the highest percentage of the parents of the participants without intellectual disabilities (67.6%) was body image 3. The di‹erence in the response distributions between the two sets of parents was marginally signi⁄cant (U ＝548.5, .05＜ p ＜.10, Fig. 2). The highest percentage of the parents of the adolescents with intellectual disabilities (52.6%) selected body image 4 as a healthy body shape for their own son, whereas the highest percentage of the parents of the participants without intellectual disabilities (59.5%) selected body image 3 as a healthy body shape for their own son. The di‹erence in the response distributions between the two sets of parents was marginally signi⁄cant (U ＝564.0, .05 ＜ p ＜ .10, Fig. 3). When the general body shape perception of the parents conducted using the same body image diagram was compared, no signi⁄cant di‹erence (p ＞.10) was found between the parents of the adolescents with and without intellectual disabilities with regard to any of the questions (a male who you think is too fat, a female who you think is too fat, a male who you think is too skinny, and a female who you think is too skinny). The parents were also asked whether they had ever paid particular attention to their son’s everyday lifestyle habits. The results showed that the percentage of parents indicating that they had paid attention was 79.5% among the parents of the adolescents with intellectual disabilities, and 70.3% among the parents of the participants without intellectual disabilities, with no signi⁄cant di‹erences between groups (p ＞.10).

FIG. 2 Comparison of the Ideal Body Shape Selected for Their Own Sons by the Parents of Adolescents With and Without Intellectual Disabilities (.05 ＜ p ＜.10)

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Comparison of Body Image and Body Shape Perception Between the Adolescents With Intellectual Disabilities Who Are and Are Not Obese The adolescents with intellectual disabilities were divided into two groups, obese and non-obese, based on their BMI, and the data analyzed in order to determine whether there was a di‹erence between the two groups in selection of their ideal body shape. The results showed that most of the respondents in the obese group selected body image 4, whereas most of the respondents in the non- obese group selected body image 3, but di‹erences between the groups were not signi⁄cant (U ＝35.0, p ＞.10).

Comparison of Obesity Rates, Body Image, Body Shape Perception, and Attitudes Toward Their Sons’ Health Between the Parents of the Adolescents With Intellectual Disabilities Who Are and Are Not Obese A comparison was made between the percentage of obese parents among the parents of the adolescents with intellectual disabilities who were obese (the obese group) and the adolescents with intellectual disabilities who were not obese (the non-obese group). The percentage of fathers who were obese among the fathers of the obese group was 54.5%, whereas the percentage of fathers who were obese among the fathers of the non-obese group was 19.0%. The fathers of the obese group showed a trend toward a higher obesity rate, but the di‹erence was not signi⁄cant (.05 ＜ p ＜ .10). The percentage of mothers who were obese was not signi⁄cantly di‹erent in the two groups (p ＞.10). Next, the body image and body shape perception of the parents were examined. The results showed that the percentage of the parents of the obese group who selected body image 4 as the ideal body shape for their own son was

FIG. 3 Comparison of the Healthy Body Shape Selected for Their Own Sons by the Parents of Adolescents With and Without Intellectual Disabilities (.05 ＜ p ＜.10)

— 762 — Obesity in Adolescents With Intellectual Disabilities the highest (80.0%), whereas the percentage of the parents of the non-obese group who selected body image 3 as the ideal body shape for their own son was the highest (57.7%). A signi⁄cant di‹erence was seen in the response distributions of both sets of parents (U ＝59.0, p ＜.01, Fig. 4). The percentage of the parents of the obese group who selected body image 4 as a healthy body shape for their own son was the highest (90.0%), whereas the percentage of parents of the non-obese group who selected body image 3 as a

FIG. 4 Comparison of the Ideal Body Shape for Their Own Sons Selected by the Parents of Obese and Non-Obese Adolescents With Intellectual Disabilities (p ＜.01)

FIG. 5 Comparison of the Healthy Body Shape for Their Own Sons Selected by the Parents of Obese and Non-Obese Adolescents With Intellectual Disabilities (p ＜.01)

— 763 — A. Yoshioka & K. Takeda healthy body shape for their own son was the highest (61.5%). A signi⁄cant di‹erence was found in the response distributions of both sets of parents (U ＝57.5, p ＜.01, Fig. 5). In the comparison of the general body shape perception of the parents, no signi⁄cant di‹erence was found between the parents of the obese group and the non-obese group with regard to any of the questions regarding a male who you think is too fat, a female who you think is too fat, a male who you think is too skinny, and a female who you think is too skinny (p ＞.10). The results regarding the parents’ attitudes toward their sons’ health revealed that the percentage of parents indicating that they had paid attention to their son’s lifestyle habits tended to be higher among the parents of the obese group. The percentage was 100% among the parents of the obese group, compared with 69.2% among the parents of the non-obese group (.05 ＜ p ＜ .10).

Discussion

The results of the present study revealed a higher rate of obesity among the adolescents with intellectual disabilities than among the students without intellectual disabilities. This is consistent with the ⁄ndings of Naka and Kotani (2003), and rea›rms the need for better obesity prevention measures, including e‹orts to promote good lifestyle habits, targeting adolescents with intellectual disabilities. With regard to body image and body shape perception of the participants, no signi⁄cant di‹erences were found in the ideal body shape reported for themselves by the adolescents with and without intellectual disabilities. Thus, adolescents with intellectual disabilities, who have higher rates of obesity, identify the same body shape as an ideal body image as their counterparts without disabilities. However, the adolescents with intellectual disabilities in the present study were at di‹erent levels of intellectual development, and, because a parent- administered questionnaire was used, it was di›cult to relate their detailed assess- ments to the results with respect to body image and body shape perceptions. In other words, when the adolescents with intellectual disabilities were asked to select the ideal body shape for themselves, it is possible that some of them, because of their level of intellectual development, found it di›cult to under- stand the meaning of “ideal body shape”. That this factor was not considered is a limitation of the present study. No signi⁄cant di‹erence in general body shape perception was observed between the parents of the adolescents with and without intellectual disabilities. In a comparison of body image, such as the ideal body shape or a healthy body shape, for their own son, the parents of the adolescents with intellectual disabilities tended to select more obese body shapes than the parents of the participants without intellectual disabilities did, but the di‹erences did not reach statistical signi⁄cance.

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Studies have reported that parents tend to be overprotective of their disabled children (Gau, Chiu, Soong, & Lee, 2008; Holmbeck, Johnson, Wills, McKernon, Rose, Erklin, & Kemper, 2002). However, the present study did not obtain a signi⁄cant di‹erence in body image or body shape perception between the parents of the adolescents with and without intellectual disabilities, thus suggesting that these parents of adolescents with intellectual disabilities were not overprotective of their sons regarding obese body shapes. In addition, the parents of the adolescents with intellectual disabilities were found to pay as much attention to their sons’ everyday lifestyle habits as the parents of participants without intellectual disabilities did. Further study is needed to identify factors related to obesity among adolescents with intellectual disabilities. In the comparison between the obese and non-obese adolescents with intellectual disabilities and between the parents of the obese and non-obese adolescents with intellectual disabilities, the percentage of fathers who were obese tended to be higher among the fathers of the obese group than among the fathers of the non-obese group. Some previous studies have reported that there is a relationship between the body shape of parents and their children (Manios, Moschonis, Grammatikaki, Anastasiadou, & Liarigkovinos, 2010; Whitaker, Wright, Pepe, Seidel, & Dietz, 1997). However, the present study did not observe a signi⁄cant di‹erence in the percentage of obese parents between the parents of the obese and non-obese adolescents with intellectual disabilities. Further study is needed to investigate the relation between the body shapes of parents and of their children with intellectual disabilities. No signi⁄cant di‹erence was found between the obese and non-obese groups with regard to the ideal body shape reported by the adolescents with intellectual disabilities. The ideal body shape selected by the obese adolescents with intellectual disabilities was the same as that selected by their non-obese counterparts and also by the participants without intellectual disabilities. However, as stated above, the adolescents with intellectual disabilities in the present study were at di‹erent levels of intellectual development, and how the abstract concept of “ideal body shape” was interpreted by these adolescents with intellectual disabilities is an open issue. On the other hand, with regard to the body image and body shape perception of the parents of the adolescents with intellectual disabilities, no signi⁄cant di‹erences were found in the general body shape perception between the parents of the obese group of adolescents with intellectual disabilities and the parents of the non-obese group, but signi⁄cant di‹erences were found in responses regarding the ideal and healthy body shapes reported by those parents for their own sons. Parents of the obese group selected more obese body shapes as ideal and healthy shapes for their sons. This result suggests that, among parents of adolescents with intellectual disabilities, parents’ acceptance of more obese body shapes may be closely related to the obesity of their children with

— 765 — A. Yoshioka & K. Takeda intellectual disabilities. As noted above, some previous studies have reported that there is a relationship between the body shapes of parents and their children (Manios et al., 2010; Whitaker et al., 1997), and it is possible that the parents’ biased body shape perception may have had some e‹ect on the obesity of their sons with intellectual disabilities. Because adolescents with intellectual disabilities tend to be dependent on their parents for their everyday living activities, their parents’ views on health are likely to have an impact on them (Hara et al., 2001). Thus, when health education is o‹ered starting around puberty or adolescence for the purpose of preventing lifestyle-related diseases among adolescents with intellectual disabilities, it is important to provide support not only to the adolescents, but also to their parents, so to ensure that the parents are equipped to manage their children’s health based on accurate information.

Conclusions

A signi⁄cantly higher rate of obesity was found among the adolescents with intellectual disabilities than among the participants without intellectual disabilities. On the other hand, the adolescents with and without intellectual disabilities tended to choose the same ideal body shape. Furthermore, no signi⁄cant di‹erences in body image or body shape perception were observed between the parents of the adolescents with and without intellectual disabilities. On the other hand, the parents of the obese adolescents with intellectual disabilities were found to accept more obese body shapes for their sons than were the parents of the non-obese adolescents with intellectual disabilities. The present study showed that, among the parents of adolescents with intellectual disabilities, parents’ acceptance of obesity has some relation to their son’s body shape, and suggests that such characteristics of parents of youth with intellectual disabilities should be considered when implementing health education for the purpose of reducing the risk of lifestyle-related diseases, including obesity, among adolescents with intellectual disabilities.

Acknowledgments

We thank all of those at the special needs education schools and the other high school that were involved in this study for their cooperation.

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─ Received August 8, 2011; Accepted February 18, 2012 ─

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