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INTRODUCTION
Childhood obesity has become a global public health problem of growing concern in industrialized nations
1,2, around 55% of obese children go on to be obese in adolescence and around 80% of obese adolescents will still be obese in adulthood 3. In general, overweight and obesity are assumed to be the result of an increase in caloric and fat intake. On the other hand, there is supporting evidence that excessive sugar intake by soft drinks, increased portion size, and steady decline in physical activity have been playing major roles in the rising rates of obesity all around the world 4. This situation has worsened over the years, primarily because children engage in academic activities more often than in activities which generate physical and psychosocial well-being.
School-age obesity is associated with psychosocial problems such as deficiencies in social co-existence and quality of life 5. It has been observed that obese children tend to have affective problems, mainly low self-esteem, body dissatisfaction, and depression 5 6 7 8-9, which affect their academic performance, as well as social and family interactions. In addition, obese children with declining levels of self-esteem present significantly higher rates of sadness, loneliness, and anxiety, and are more likely to engage in high-risk behaviors such as smoking or alcohol consumption 10. Therefore, diagnosis, prevention, and treatment are common health policies in many countries, making research on their characteristics a priority.
Children with emotional and behavioral problems have a high risk of academic failure 11, which is evident in Primary school. With the added problems of self-esteem produced by childhood obesity 12, the situation becomes more complex due to high percentages of obese schoolchildren globally. Therefore, their participation in the Physical Education (PE) class is affected, generating a vicious circle of sedentary lifestyle.
An effective strategy for the prevention and treatment of childhood obesity includes a modification of PE curricula in schools, which has demonstrated consistent changes in the quantity of physical activity (PA) and student motivation, producing beneficial effects on quality of life 13 as well as other biomarkers 14,15. Adequate exposure to PE effectively contributes to a healthier lifestyle of children during their lifespan. However, many PE programs do not comply with recommendations in terms of class times and intensity 16 and do not exhibit equal participation of all students. In many cases, obese children are excluded and these participants perceive the PE classes to be too competitive and demotivating 17. However, there is no clearly established evidence to corroborate the perception of overweight and obese schoolchildren regarding their participation in the PE class. Therefore, the main objective of this study was to evaluate the perception of obese schoolchildren concerning their participation in PE class and to determine their self-esteem compared with overweight and normal weight groups.
MATERIAL AND METHODS
This cross-sectional study involved 656 schoolchildren, 284 females (43%) and 372 males (57%), between eleven and 14 years of age, from the Araucania region (Chile). The sample was selected for convenience purposes, and assessments were made regarding age, sex, anthropometric variables, self-esteem, and perception of participation in PE class.
Inclusion criteria required that participants presented informed consent from their parents and themselves to take part in the study, be enrolled in the school being studied, and be between eleven and 14 years of age. Students with physical, sensory, or intellectual disabilities were excluded.
INSTRUMENTS
Body mass (kg) was evaluated using a Tanita scale, Scale Plus model UM-028 (Tokyo, Japan). Students were evaluated with bare feet and with the least amount of clothing possible. Size (m) was estimated with a Seca® model 214 height rod (Hamburg, Germany), graduated in mm. Body mass index (BMI), obtained by dividing body weight by size in square meters (kg/m2), was used to estimate the degree of obesity according to the international rating criteria provided by the Center for Disease Control and Prevention to verify corresponding ages and percentiles related to sex. Childhood obesity is defined as having a BMI equal to or greater than the 95th percentile for children of the same age and sex, and being overweight is defined as having a BMI between the 85th and the 95th percentile 2.
Waist circumference (WC) was measured using a Seca® model 201 (Hamburg, Germany) tape measure at umbilical scar level 18. The waist to height ratio (WHtR) was obtained by dividing the WC by the height and is used as a tool to estimate fat accumulation in the central area of the body. A ratio greater than 0.5 indicates an increased cardiometabolic risk 19.
To measure self-esteem, the TAE-Student: Self-Esteem Test 20 was used, via a general self-report in relation to norms established by age. A point is added for each positive answer and 0 points are awarded for negative answers. The sum of the gross score is transformed to a T score according to norms by age. The students are then identified according to the following categories: normal self-esteem = score ≥ 40 points; low self-esteem = score between 30 and 39 points; and very low self-esteem = score ≤ 29 points. The level of internal consistency reached in this questionnaire presented a Cronbach's alpha = 0.83.
Two questions from the TAE-Student test were selected to determine the participation of children in PE classes:
- "In PE class...
PROCEDURE
Previously trained research assistants visited selected schools during the 2017 Chilean school year and carried out the assessments on the children who presented parental and their own consent. Anthropometric assessments were carried out in a favorable space facilitated by the school with optimum temperature and reliable privacy. The evaluations took place during Physical Education classes and in the morning.
STATISTICAL ANALYSIS
The statistical analysis was performed with the SPSS v 23.0 software. The continuous variables showed parametric distributions and were expressed as the mean ± standard deviation. Between-group differences were determined using a one-way analysis of variance (ANOVA). To compare weight groups, ANOVA was conducted with a post-hoc analysis (Bonferroni method). A Chi-square test was performed for the comparison of proportions between groups. A p-value < 0.05 was considered as statistically significant.
RESULTS
There were no differences between the proportions by corporal status between boys and girls (p = 0.746). Self-esteem (p = 0.018) was higher in boys (Table 1).
Table I. Comparison of study variables according to sex
The values shown represent the mean ± standard deviation; p values < 0.05 are statistically significant. BM: body mass; BMI: body mass index; WC: waist circumference; and WHtR: waist-to-height ratio.
Overall, 45% of participants were normal weight (n = 292), 35% were overweight (n = 228), and 20% were obese (n = 136). Obese schoolchildren presented significantly lower levels of self-esteem, followed by the overweight group (Table 2). Obese schoolchildren had the highest proportion of schoolchildren with low self-esteem (53%), followed by the overweight group (32%), and finally the normal weight group (22%) (p < 0.001) (Fig. 1).
Table II. Comparison of variables according to corporal status
The values shown represent the mean ± standard deviation; p values < 0.05 are statistically significant. Different superscript symbols indicate differences between groups. BM: body mass; BMI: body mass index; WC: waist circumference; and WHtR: waist-to-height ratio.
There was a relationship between obesity and the following sentence: "I am the last one they choose for games and in games and sports". In total, 48.53% of obese schoolchildren answered affirmatively, followed by 29.8% for the overweight group and 28.1% for the normal weight group (p < 0.001) (Fig. 2). With respect to the sentence "In games and sports, I look instead of playing", 57.4% of obese schoolchildren responded positively, compared with 34.6% of the overweight group (p = 0.024) (Fig. 3).
Figure 2. Comparison according to corporal status in relation to the Physical Education class: "I'm the last one they choose for game."
DISCUSSION
The primary objective of this research was to evaluate the perception of obese schoolchildren concerning their participation in PE classes, and to determine their self-esteem compared with overweight and normal weight groups. Our primary finding is that schoolchildren with obesity showed lower levels of self-esteem and felt excluded in PE classes.
In this study, obese schoolchildren perceived a low participation in PE classes. Additionally, they felt that they were the last one chosen for games and sports and watched while others played. These results are similar to those reported in another sample of schoolchildren, where those classified as overweight and obese had lower levels of self-esteem, specifically with respect to athletic competition and physical appearance compared with students classified as normal weight 21. This shows that PE classes are not integrative and inclusive; on the contrary, those who are overweight and obese feel discriminated against. However, the research reported that providing a supportive PE class environment that promotes equality can potentially increase the enjoyment of PE class among youth 22. Since PE programs aim to promote PA and reach most school-aged youth (20), this is a major concern, because obesity is perceived as a barrier to participation in PE class.
The declining time for PE observed in Latin American schools may play an important role in the prevalence of overweight and obese schoolchildren in Latin America 23. Because students spend large amounts of time at school, there is great potential for increasing energy expenditure through school-based programs and well-structured lessons, providing substantial opportunities to increase moderate-to-vigorous PA. Given that overweight and obese children need support and encouragement to exercise, PE in school represents a major context where the enjoyment of exercise should be stimulated 17. The main elements of the positive interventions in PE class have included staff capacitating (PE specialists and/or classroom teachers), changes in the PE curricula, provision of equipment and materials, and adjustment of the interventions to target specific populations 23. Some studies have shown that schools have made progress in improving school-provided food and physical activity environments but that much more work is needed 24, specifically with respect to inclusion in PE classes for schoolchildren with obesity.
In this study, a high percentage of obese students had low or very low self-esteem, which suggests that obesity is associated with low or very low self-esteem. In children, a differential effect of obesity on self-esteem has been observed in problems of externalization and social perception related to bullying behaviors 25. Research conducted in Australian students of a similar age to those in the present study reported that obesity affects the self-perception of children who enter adolescence, especially for females 26. Low self-esteem is a negative result since it is associated with family problems, less perceived social support and depression, and is considered to be a predictor of higher suicide rates 27 28-29. Conversely, higher self-esteem was related to many positive mental health aspects such as positive perceptions, academic achievements, and persistence 12.
Finally, an important point of the present study is that self-esteem was higher in boys, consistent with results of a study conducted with a sample of students from public schools in Norway 30,31 and in Britain 32. Low levels of self-esteem have a negative role in association with adolescents' life dissatisfaction, and negative emotional health and well-being, and this relationship is equally strong regardless of gender and age.
LIMITATIONS
The main limitation of the current study is not to compare the perception of obese schoolchildren about their PE class involvement with data from any valid and direct method of assessment (i.e., participation and intensity). Additionally, the involvement during the PE classes and self-esteem levels were not controlled according to PA levels. Altogether will be controlled in future studies.
CONCLUSION
The results of this study revealed that schoolchildren with obesity feel excluded from PE classes, and show low levels of self-esteem, compared with normal weight groups. It is important to consider that today's education seeks to carry out integrative and inclusive activities, where everyone can participate. If we consider that PE classes are key to the development of a healthy life in the future, the present investigation shows that in this study, schoolchildren with obesity do not feel integrated in the classes, therefore, would not be fulfilling the objectives of this subject.
