Abstract
-
Purpose
Weight loss behaviors are common among Korean female adolescents and are often influenced by distorted body image and sociocultural pressures, leading some to unhealthy practices. This study examined biological, psychological, and social factors associated with weight loss behaviors using Engel’s biopsychosocial model.
-
Methods
This secondary analysis utilized data from the 19th Korea Youth Risk Behavior Survey (2023), focusing on 21,632 female middle and high school students. Logistic regression was conducted to analyze associations between weight loss behaviors and biopsychosocial variables such as body mass index (BMI), grade level, stress, anxiety, body image distortion, smoking, and nutrition education experience.
-
Results
Among female adolescents, 46.5% reported having attempted weight loss. In logistic regression analysis, biological factors (grade level and BMI percentile), psychological factors (perceived stress, distorted body image, generalized anxiety disorder risk, and smoking), and social factors (nutrition education) were significantly associated with weight loss behaviors. Key predictors included being in middle school (odds ratio [OR], 1.22), higher BMI, elevated stress, distorted body image (OR, 1.90), generalized anxiety, smoking (OR, 1.53), and lack of nutrition education (OR, 1.10). Psychological factors, especially body image distortion and emotional distress, emerged as major contributors to weight loss behaviors.
-
Conclusion
Weight loss behaviors among Korean female adolescents are influenced by complex biopsychosocial factors beyond physical health concerns. Nursing interventions should incorporate emotional regulation, body image education, and school-based health literacy programs. Early identification through multidimensional assessment is crucial for effective prevention.
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Key words: Adolescent health; Biopsychosocial models; Body image; Female; Weight loss
INTRODUCTION
1. Background
Adolescence is a transitional period from childhood to adulthood, characterized by secondary sexual maturation, physical growth, and psychological development [
1]. During this period, female adolescents experience increased secretion of estrogen and progesterone, leading to greater fat accumulation in the hips and thighs [
2]. Despite being underweight or having a normal weight, many adolescents tend to overestimate their body size, leading to distorted body image perceptions [
3].
In modern society, where thinness is idealized, such distorted perceptions can lead to dissatisfaction with one's body shape and trigger weight-loss behaviors [
4]. Among Korean adolescents, female students were more likely to perceive their weight as overweight (56.4%) compared to male students (43.6%). Among these, 68.7% of female students reported engaging in weight loss behaviors using inappropriate methods [
5].
Given the prevalence of diet-related content, these adolescents are more likely to attempt harmful weight-control practices, which may lead to health issues [
6]. Such practices include extreme fasting, mono diets (e. g., eating only one type of food), unprescribed diet pills, and self-induced vomiting. These methods are often associated with caloric restriction and nutritional imbalances, resulting in anemia, osteoporosis, and menstrual irregularities [
7].
Thus, identifying female adolescents at risk of engaging in inappropriate weight control behaviors and investigating the factors influencing these behaviors is essential to prevent potential health problems and enable early interventions.
Engel [
8] proposed the biopsychosocial model, which conceptualizes health behavior as a result of multidimensional interactions among biological, psychological, and social factors. Based on the model by Engel [
8], prior research has identified that the likelihood of engaging in weight-loss behaviors increases with higher grade levels [
5] and greater levels of obesity [
9]. Psychologically, female adolescents experiencing higher stress levels [
10], negative body image [
9], or frequent anxiety [
11] are more likely to engage in weight control behaviors. Additionally, smoking adolescents were more likely to engage in weight loss behaviors compared to non-smokers [
12].
From a social perspective, adolescents who have not received nutrition education [
13], who report high academic performance, or who come from higher socioeconomic backgrounds [
14] were more likely to engage in weight control attempts.
However, previous studies have several limitations: many do not distinguish between genders [
5], or focus solely on a specific grade level [
3], resulting in insufficient research specifically targeting female adolescents. Thus, there is a pressing need for multidimensional research on female adolescents’ weight control behaviors, especially considering the importance of this life stage in developing lifelong health trajectories.
Accordingly, this study aims to explore the factors influencing weight-loss behaviors in female adolescents using the biopsychosocial model by Engel [
8], thereby identifying multidimensional determinants of such behaviors.
The purpose of this study is to examine the influencing factors related to weight-loss behaviors among female adolescents. The specific objectives are as follows: (1) to identify the presence or absence of weight-loss behaviors among female adolescents; (2) to determine the biological, psychological, and social characteristics associated with weight-loss behaviors; and (3) to analyze the relevant influencing factors on weight-loss behaviors based on the biopsychosocial characteristics of female adolescents.
METHODS
Ethical statements: This study was approved by the Institutional Review Board (IRB) of Pai Chai University (IRB No. 2-1040766-AB-N-01-R-2024-12). The requirement for informed consent was waived owing to the retrospective nature of the study.
1. Study Design
This study is a secondary data analysis using raw data from the 19th Korea Youth Risk Behavior Survey (KYRBS) conducted in 2023. The reporting of this study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines [
15].
The KYRBS is an anonymous, self-administered online survey conducted to assess the health behaviors of Korean adolescents enrolled in grades 7 to 12. The 19th KYRBS surveyed 52,880 students from 399 middle schools and 400 high schools. For the purpose of this study, data from 21,632 female students who responded to items related to weight-loss behavior were analyzed.
3. Measures
The 2023 KYRBS questionnaire included items related to weight-loss behaviors in female adolescents. Variables were classified into biological factors (grade, BMI), psychological factors (stress level, body image distortion, anxiety, smoking), and sociological factors (nutrition education, academic achievement level, and household economic status).
1) Dependent variable: weight loss behavior status among female adolescents
Weight loss behavior status among female adolescents was assessed based on their response to the question: “Have you made any effort to control your weight in the past 30 days?” Participants who reported having made efforts to reduce their weight during this period were classified as exhibiting “weight loss behavior.” Conversely, those who reported making no effort to control their weight, attempting to gain weight, or attempting to maintain their current weight were classified as “not engaging in weight loss behavior.”
2) Independent variables
(1) Biological factors
Biological factors influencing weight loss behavior among female adolescents included school grade and body mass index (BMI) percentile. School grade was categorized as either middle school or high school. BMI percentile was calculated based on self-reported height (cm) and weight (kg), and assessed using the 2017 Korean National Growth Charts for children and adolescents. According to the BMI percentile classification, individuals were categorized as underweight (<5th percentile), normal weight (5th to <85th percentile), overweight (85th to <95th percentile), or obese (≥95th percentile) [
16].
(2) Psychological factors
Psychological factors associated with weight loss behaviors among female adolescents included perceived stress, body image distortion, anxiety, and current smoking status. Perceived stress was assessed using a single-item question asking about the usual level of stress perceived, and responses were categorized as high, moderate, or low.
Body image distortion was identified by comparing adolescents’ actual BMI classification with their responses to the question, “How do you perceive your body shape?” Participants were classified as having distorted body image if they were underweight however perceived themselves as average, slightly overweight, or very overweight, or if they were of normal weight however perceived themselves as slightly overweight or very overweight. Those whose body perception matched their actual BMI category were categorized as having a normal body image.
Anxiety was measured using the Generalized Anxiety Disorder-7 (GAD-7) screening tool. The GAD-7 includes seven items rated on a 4-point Likert scale (0 to 3), yielding a total score ranging from 0 to 21. Participants scoring ≥10 were classified as the high-risk group for generalized anxiety disorder (GAD), while those scoring <10 were considered the low-risk group [
17].
Current smoking status was determined based on responses to the question, “In the past 30 days, on how many days did you smoke at least one cigarette?” Participants who reported no smoking days were classified as “non-smokers,” while those who reported smoking on one or more days were categorized as “current smokers.”
(3) Social factors
Social factors influencing weight loss behaviors among female adolescents included nutrition education, academic achievement, and perceived household economic status. Nutrition education was assessed with a single item asking whether the respondent had received any education on nutrition and eating habits during the past 12 months. This included education received during school classes, through broadcast programs, or in school-wide lectures. Participants who reported receiving such education were categorized as “received,” while those who had not were categorized as “not received.”
Academic achievement level and perceived household economic status were each categorized into three groups: high, medium, and low.
4. Data Analysis
The raw data from the 19th KYRBS were collected using a stratified multistage cluster sampling method. Accordingly, analyses were conducted using a complex sample analysis module that accounted for stratification variables, clustering, and sampling weights. All statistical analyses were performed using IBM SPSS Statistics ver. 25.0 (IBM Corp.).
Descriptive statistics were used to analyze the prevalence of weight loss behaviors among female adolescents and their associations with biological, psychological, and social variables. To examine the factors associated with weight loss behaviors, logistic regression analysis was performed. A two-tailed significance level of .05 was considered statistically significant.
RESULTS
1. Prevalence of Weight Loss Behaviors and Characteristics of Associated Biological, Psychological, and Social Factors
Among the 21,632 Korean female adolescents included in this study, 46.5% (n=10,143) reported having attempted weight loss. The characteristics of biological, psychological, and social factors associated with weight loss behaviors are presented in
Table 1.
Biological factors showed that 47.4% (n=10,250) of participants were high school students, while 52.6% (n=11,382) were middle school students. Approximately 67.5% (n=14,546) of the participants were categorized as having a normal body weight.
In terms of psychological factors, 44.1% (n=9,538) of participants reported experiencing high levels of stress, 25.4% (n=5,527) exhibited distorted perceptions by overestimating their body weight, and 16.3% (n=3,493) were classified as being at high risk for GAD. Additionally, 2.7% (n=606) of participants reported currently smoking.
Regarding social factors, 48.7% (n=10,416) of the participants reported not having received any form of nutrition education. Furthermore, 80.8% (n=17,428) reported a moderate level of academic achievement, and 87.6% (n=19,014) indicated a moderate level of household economic status.
2. Factors Associated with Weight Loss Behaviors by Biological, Psychological, and Social Variables among Female Adolescents
Regarding biological factors, adolescents in middle school were 1.22 times more likely to attempt weight loss compared to those in high school (adjusted odds ratio [aOR], 1.22; 95% confidence interval [CI], 1.13–1.32;
p<.001) (
Table 2).
With respect to body weight status, compared with underweight adolescents, those who were obese were 14.48 times more likely to engage in weight loss behaviors (aOR, 14.48; 95% CI, 12.45–16.85; p<.001), those who were overweight were 12.15 times more likely (aOR, 12.15; 95% CI, 10.45–14.12; p<.001), and those of normal weight were 5.49 times more likely (aOR, 5.49; 95% CI, 4.86–6.20; p<.001) to attempt weight loss.
Regarding psychological factors, adolescents reporting high levels of perceived stress were 1.43 times more likely to attempt weight loss (aOR, 1.43; 95% CI, 1.31–1.62; p<.001) than those with low stress levels, and those with moderate levels of stress were 1.22 times more likely (aOR, 1.22; 95% CI, 1.27–1.60; p<.001).
Adolescents with distorted body image were 1.90 times more likely to attempt weight loss compared to those without distortion (aOR, 1.90; 95% CI, 1.76–2.05; p<.001). Those classified as being at high risk for GAD showed a higher likelihood of weight loss attempts (aOR, 1.15; 95% CI, 1.03–1.27; p=.011). Additionally, adolescents who reported current smoking had 1.53 times higher odds of weight loss behavior (aOR, 1.53; 95% CI, 1.25–1.86; p<.001) compared to nonsmokers.
With regard to social factors, adolescents who had not received nutrition education in the past year were 1.10 times more likely to attempt weight loss than those who had (aOR, 1.10; 95% CI, 1.04–1.17; p=.002). No statistically significant associations were found between weight loss behaviors and perceived academic achievement or family socioeconomic status (p>.050).
DISCUSSION
This study analyzed biological, psychological, and social factors associated with weight loss behaviors among Korean female adolescents using data from the 19th KYRBS (2023). A total of 46.5% of participants reported having attempted weight loss, a substantially higher rate than that reported by male adolescents, reaffirming the existence of gender-specific patterns in adolescent weight control behaviors [
18]. The findings highlight a multidimensional phenomenon in which developmental stage, psychological vulnerability, and sociocultural environment interact to influence weight loss behaviors.
First, biological factors showed that middle school students were 1.22 times more likely to attempt weight loss compared to high school students. This difference extends beyond chronological age, reflecting the combined influence of physiological changes and social responses occurring during early to mid-puberty. In this stage, increased estrogen secretion leads to a rapid rise in body fat percentage, with notable fat accumulation in the hips and abdomen. Although these changes are part of normal biological development, they are often socially interpreted as “gaining weight,” contributing to negative self-evaluations [
19]. Moreover, Korean middle school girls are frequently exposed to appearance-based comparisons and evaluations—through peers, social media, and popular culture—rather than receiving accurate education about bodily changes [
20,
21]. This heightened perception of discrepancy between their developing bodies and the “ideal figure” portrayed in the media may trigger early engagement in dieting behaviors. These findings suggest that early adolescence is a critical period for the initiation of weight loss attempts. During this stage, normal pubertal changes may be perceived as weight gain, leading to early engagement in weight control behaviors. In addition, appearance-based evaluations from peers and media may further reinforce such behaviors.
Therefore, future research should examine developmental differences in weight control behaviors across adolescence and identify factors associated with early initiation. In practice, it is important to provide early adolescents with education on normal pubertal changes and healthy weight management, with an emphasis on promoting healthy lifestyle behaviors rather than weight reduction.
A higher BMI percentile increased the likelihood of weight loss attempts more than fourteenfold. This association appears to be driven not only by the health risks of overweight and obesity but also by the psychosocial consequences of weight stigma and discrimination [
22,
23]. Adolescents with higher BMI are more likely to experience appearance-based teasing and social exclusion from peers, which can lead to diminished self-esteem and appearance-focused self-control behaviors [
22,
23]. Furthermore, weight-related comments from family members or teachers may function as additional sources of pressure to change behavior [
24]. Notably, previous research has indicated that adolescents in the overweight/obese category are more likely to adopt unhealthy weight control methods such as severe dietary restriction, fasting, excessive exercise, or the use of diet pills [
25]. Therefore, nurses should assess not only BMI but also the underlying motivations, methods, and psychological states associated with weight control attempts, and design tailored interventions that address the developmental sensitivities of this population. For middle school girls in particular, reframing weight control in terms of “health promotion” rather than “appearance management” is critical.
Second, psychological factors emerged as the most multifaceted domain in this study. Perceived stress was a significant predictor of weight loss behavior, suggesting that adolescents may use dieting as a coping mechanism to regain a sense of control amid the triple pressures of academic competition, peer relationships, and appearance evaluation [
25]. In the Korean context, where educational systems emphasize high-stakes examinations, girls often face the dual burden of excelling academically while meeting societal expectations for appearance [
21]. While dieting may offer immediate gratification, it can also perpetuate a cycle of disordered eating, depression, and body dissatisfaction over time [
26].
Distorted body image was associated with nearly double the odds of attempting weight loss. Consistent with prior findings, subjective perceptions of body shape were more influential than objective BMI in determining weight control behavior [
20,
21]. The Korean media environment reinforces the narrative that “slimness equals success and self-discipline,” leading many adolescents with a healthy weight to perceive themselves as overweight [
20,
21]. This misperception may result in unnecessary dieting and nutritional imbalance. In nursing practice, early identification of body image distortion and the promotion of critical media literacy are essential preventive strategies.
High risk for GAD was also significantly related to weight loss attempts. Anxiety can heighten self-surveillance and strict control over appearance, which in turn may lead to restrictive eating and excessive exercise [
27,
28]. Adolescents with higher social anxiety may attempt more rigid body control to avoid negative peer evaluation. School nurses should utilize standardized screening tools such as the GAD-7 for early detection and implement integrated interventions that combine psychological counseling with body positivity education.
Smoking was associated with a 1.53-fold increase in the likelihood of weight loss attempts, suggesting that adolescents may internalize the misconception that smoking functions as an appetite suppressant or may hold maladaptive health beliefs linking smoking with appearance control [
29]. This tendency was particularly pronounced among adolescents with higher BMI, suggesting that smoking may function as a psychologically motivated weight control strategy rather than merely a risk-taking behavior [
29]. Although smoking involves biological addiction, prior studies grounded in the biopsychosocial model suggest that adolescent smoking is strongly motivated by psychological factors such as stress coping and weight control concerns; therefore, smoking was classified as a psychological factor in the present study [
8,
29]. Accordingly, effective nursing interventions should integrate smoking cessation programs with counseling aimed at dismantling these harmful beliefs and reframing weight control behaviors toward health-oriented approaches.
Taken together, psychological factors did not operate in isolation; rather, stress, body image distortion, anxiety, and smoking interacted synergistically to reinforce weight loss behaviors. This underscores the need for nursing interventions that target clusters of psychological variables, rather than addressing each factor in isolation.
Third, social factors indicated that the absence of school-based nutrition education within the past 12 months increased the likelihood of weight loss attempts. Nutrition education extends beyond delivering dietary knowledge; it plays a crucial role in redefining healthy weight management standards and correcting misinformation about dieting (e.g., extreme calorie restriction, single-food diets) [
13]. In Korea, however, nutrition education remains limited in frequency, participation, and content diversity [
30]. Given that social media platforms such as YouTube and Instagram are often the primary sources of dieting information for adolescents [
31], integrating media literacy and self-reflection into nutrition education is essential. School nurses are well-positioned to lead the design and delivery of such programs, and peer-led education models may further enhance their reach and effectiveness.
In conclusion, this study demonstrates that weight loss behaviors among female adolescents are shaped by the interplay of biological, psychological, and social factors. For school nursing practice, these findings highlight the need for comprehensive, developmentally tailored interventions that integrate physical, psychological, and sociocultural components of health promotion.
This study has several limitations. First, due to its cross-sectional design, causal relationships between biopsychosocial factors and weight loss behaviors cannot be determined. Second, because data were obtained from self-reported questionnaires, recall and social desirability bias may have influenced the responses. Third, specific weight control methods such as fasting or use of diet pills were not analyzed, limiting differentiation between healthy and unhealthy behaviors. Fourth, sociocultural influences unique to Korean adolescents, such as media exposure and peer comparison, were not quantitatively measured. Finally, although the KYRBS employs a nationally representative stratified multistage sampling design with appropriate weighting, the findings may not be generalizable to adolescents who are not enrolled in school, such as out-of-school youth.
Despite these limitations, the findings carry significant clinical and social implications for school health and nursing interventions. School nurses are in a key position to identify adolescents at risk of unhealthy weight control behaviors through early screening for stress, anxiety, and body image distortion. Integrating psychosocial counseling with body positivity education can help prevent maladaptive dieting and foster emotional resilience. Furthermore, incorporating nutrition education, media literacy, and peer-support programs into school-based health initiatives can empower adolescents to develop realistic body perceptions and sustain healthy lifestyle habits. These findings emphasize the need for interdisciplinary collaboration among nurses, teachers, and families to build a supportive school environment that nurtures both physical and psychological well-being among female adolescents.
CONCLUSION
This study examined factors influencing weight loss behaviors among Korean female adolescents using data from the 19th KYRBS (2023) within the framework of the biopsychosocial model. A total of 46.5% of the study participants reported attempting weight loss in the past 30 days, underscoring that these behaviors are driven by complex psychosocial dynamics rather than solely by health management goals.
Biologically, being a middle school student and having a higher BMI markedly increased the likelihood of engaging in weight loss behaviors. Psychologically, high perceived stress, distorted body image, elevated anxiety, and current smoking status were strongly associated with such behaviors, with body image distortion and emotional instability emerging as maladaptive drivers of weight control. Socially, participation in nutrition education functioned as a protective factor, highlighting the critical role of structured, accurate health information in shaping healthy weight management practices.
These findings suggest that adolescent weight loss behaviors should be understood within an integrated developmental and psychosocial framework. For nursing practice, this calls for multidimensional assessment systems that evaluate not only the occurrence but also the underlying motivations and methods of weight control. School nurse-led interventions that enhance emotional resilience, promote body positivity, and strengthen health literacy are essential to mitigating unhealthy weight control patterns. Future research should employ longitudinal and qualitative approaches to elucidate the developmental trajectories and contextual influences on adolescent weight management, thereby informing the design of tailored, evidence-based nursing interventions.
ARTICLE INFORMATION
Table 1.Characteristics of weight loss behaviors and associated biological, psychological, and social factors among Korean female adolescents (N=21,632)
|
Characteristic |
Category |
No. (%)a)
|
|
Dependent variable |
|
|
|
Weight loss efforts (in the past 30 days) |
Yes |
10,143 (46.5) |
|
No |
11,489 (53.5) |
|
Independent variable |
|
|
|
Biological factors |
|
|
|
Grade |
High school |
10,250 (47.4) |
|
Middle school |
11,382 (52.6) |
|
Adiposity |
Obese |
2,301 (10.2) |
|
Overweight |
2,071 (9.5) |
|
Normal weight |
14,546 (67.5) |
|
Underweight |
2,714 (12.8) |
|
Psychological factors |
|
|
|
Perceived stress |
High |
9,538 (44.1) |
|
Middle |
9,484 (44.0) |
|
Low |
2,610 (11.9) |
|
Body image distortion |
Yes |
5,527 (25.4) |
|
No |
16,105 (74.6) |
|
Generalized anxiety disorder |
High risk |
3,493 (16.3) |
|
Low risk |
18,139 (83.7) |
|
Current smoking (in the past 30 days) |
Yes |
606 (2.7) |
|
No |
21,026 (97.3) |
|
Social factors |
|
|
|
Nutrition education (in the past year) |
No |
10,416 (48.7) |
|
Yes |
11,216 (51.3) |
|
Perceived academic achievement |
High |
2,367 (10.9) |
|
Middle |
17,428 (80.8) |
|
Low |
1,837 (8.3) |
|
Perceived family socioeconomic status |
High |
2,211 (10.6) |
|
Middle |
19,014 (87.6) |
|
Low |
407 (1.8) |
Table 2.Factors associated with weight loss behaviors according to biological, psychological, and social variables among Korean female adolescents (N=21,632)
|
Variable |
Category |
aOR (95% CI) |
p
|
|
Biological factors |
|
|
|
|
Grade (ref: high school) |
Middle school |
1.22 (1.13–1.32) |
<.001 |
|
Adiposity (ref: underweight) |
Obese |
14.48 (12.45–16.85) |
<.001 |
|
Over weight |
12.15 (10.45–14.12) |
<.001 |
|
Normal weight |
5.49 (4.86–6.20) |
<.001 |
|
Psychological factors |
|
|
|
|
Perceived stress (ref: low) |
High |
1.43 (1.31–1.62) |
<.001 |
|
Moderate |
1.22 (1.27–1.60) |
<.001 |
|
Body image distortion (ref: no) |
Yes |
1.90 (1.76–2.05) |
<.001 |
|
Generalized anxiety disorder (ref: low risk) |
High risk |
1.15 (1.03–1.27) |
.011 |
|
Current smoking (in the past 30 days) (ref: no) |
Yes |
1.53 (1.25–1.86) |
<.001 |
|
Social factors |
|
|
|
|
Nutrition education (in the past year) (ref: yes) |
No |
1.10 (1.04–1.17) |
.002 |
|
Perceived academic achievement (ref: low) |
High |
0.88 (0.76–1.02) |
.097 |
|
Middle |
1.06 (0.94–1.19) |
.346 |
|
Perceived family socioeconomic status (ref: low) |
High |
0.95 (0.73–1.23) |
.701 |
|
Middle |
0.86 (0.68–1.09) |
.204 |
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