Till about two decades ago, the issue of overweight was emerging as a public health concern primarily in children of high-income countries and western nations [1]. However, Asian countries such as India have caught up with this phenomenon. India is now being considered a fast weight-gaining nation that is, ironically, also struggling with malnutrition [2]. This paradox could be reflective of the recently emerging socio-economic trends in childhood obesity in India. According to various studies, the current prevalence of childhood overweight in India could range from 4% to 22% [3,4]

A total of 8130 students completed the survey with an overall response rate of 83%. Majority of the participants were males (58%). Students from grades 8, 9, and 10 were almost equally represented in the final sample (range 30-36%) (Table I). More than a quarter of students had depressive symptoms of hopelessness and sadness (26%), missed classes or school on ³1 day during the past month (28%), and reported that parents or guardians never/rarely checked to see if homework was done (40%), never/rarely understood problems and worries (25%), and never/rarely knew what students were doing with their free time (29%).

TABLE I Characteristics of the Study Population 

On the basis of self-reported height and weight, BMI for age and gender was computed. Based on BMI, students were grouped into two categories (overweight vs normal weight). In logistic regression analyses, this variable was treated as a dependent variable to compute the odds of association with selected psychosocial factors that were treated as independent variables. Nine independent factors were found to be associated with being overweight in the study participants. Students with fewer friends, those who felt sad, hopeless, and lonely most of time (depressive symptoms), those who could not stop worrying and had sleeplessness (anxiety symptoms), students with peers who were not kind or helpful, students with little parental involvement, and those who missed classes without permission were statistically significantly more likely to be overweight Table II. A final model was created to compute adjusted odds ratios by controlling the analysis for age, gender, and grade in school. After adjustment, the number of close friends, missing school, and social support from other students in the school did not remain significant predictors of whether or not a student was overweight Table II.

TABLE II Psychosocial Risk Factors Associated with Overweight

The damaging effect of being overweight on psychosocial health are undeniable. In this study sample, we report slightly higher prevalence of overweight among boys compared to girls, similar to previous studies from India [1,3,4]. The high prevalence of psychosocial distress and lack of social support reported in this study is disconcerting, due to the association of these risk factors with being overweight. Overweight children, on an average, tend to encounter lower levels of social acceptance, which can have lasting effects. For instance, the child can develop a negative body image, lower self-esteem and self-doubt that can create awkwardness in children; labeled "social insecurity". This social insecurity may result in children shunning public encounters; including but not limited to missing school days that can further impede academic progress [9-11]. Additionally, students reported unkind or non-helping nature of fellow students and lesser involvement of parents in routine life within the past month and these factors were associated with being overweight. Previous research has indicated the presence of neglect, stigma, bias, and discrimination against overweight/obese children, which can culminate into pervasive victimization, teasing, and bullying [10-12]. Reports of depression, anxiety, and suicidal thoughts have also been associated with abnormal weight in adolescents in western countries [10-13].

The results of this study should be viewed in light of several potential limitations. First, all data were self-reported which may have led to socially desirable responses from students. Second, this was an observational study wherein cause and effect relationships could not be established. Finally, even though the study included a large sample of students across India, the results cannot be generalized to the entire population of children in India.

Adolescent overweight and obesity are multifaceted issues that need to be addressed at several levels. Parental and school involvement can facilitate and motivate the practice of healthy behaviors such as quality nutrition, routine physical activity, and assessment of behavior change [13,14]. Pediatricians should routinely screen for obesity and associated psychological problems in children and follow-up with adequate preventive and curative remedies. A multi-dimensional approach is needed to tackle this problem because overweight and obesity in children may induce progressive withdrawal from social life, victimization by peers, constant expectation of rejection, and low self-esteem that can make children susceptible to chronic psychiatric diseases such as anxiety, depression, and eating disorders [14,15].