European Journal of Cardiovascular Medicine

Child and adolescent obesity has increased worldwide over recent decades; in 2022 an estimated 390 million youth aged 5–19 years were overweight, including 160 million living with obesity. [1] Parallel to weight trends, body image dissatisfaction (BID)—a negative evaluation of one’s body—remains prevalent and is associated with depression, anxiety, disordered eating, and lower quality of life. [4,5,9] Recent large-scale syntheses estimate global pediatric obesity with regional heterogeneity, while school-based surveillance across dozens of countries shows high proportions of adolescents perceiving themselves as “too fat,” especially girls. [2,3]

A complicating feature is weight misperception—discordance between BMI-defined status and perceived weight. Data across many countries (2002–2018) indicate rising underestimation of weight status over time; misperception is associated with both reduced engagement in healthy behaviors and greater psychological distress. [6] Additionally, weight-based teasing (a form of weight stigma) independently predicts depressive and anxiety symptoms beyond actual weight. [8]

We frame the “double burden” as the co-occurrence of (a) excess weight and (b) BID—conceptually distinct from the traditional “double burden of malnutrition.” From a public health perspective, adolescents with this profile may be at heightened risk for unhealthy weight-control behaviors and poor mental health, warranting integrated, stigma-free prevention.

Aim and Objectives

Aim: To examine the adolescent double burden of obesity and BID and its correlates, and to position findings within the recent international evidence base.

Objectives:
1) Estimate the prevalence of overweight/obesity, BID, and weight misperception.
2) Identify correlates of BID (sex, BMI category, weight-teasing, social media use, physical activity, socioeconomic factors).
3) Assess whether the “double burden” group has higher depressive symptoms and unhealthy weight-control behaviors than other groups.
4) Compare results with recent multi-country and national studies.

Study Design and Setting: Cross-sectional school-based survey of adolescents (12–18 years). To provide a complete, submission-ready template, we report results using a synthetic dataset (N=1,240) constructed to reflect plausible distributions and associations reported by current literature and surveillance (e.g., WHO growth reference, JAMA Pediatrics 2024, HBSC 2021/22). [1–3]

Participants and Sampling: Two-stage cluster sampling of schools and classes is specified (urban/suburban mix). Inclusion: enrolled students aged 12–18; exclusion: chronic conditions affecting growth/appetite. Target sample: ~1,200 to ensure ≥80% power to detect odds ratio ≥1.5 for BID vs normal weight at α=0.05.

Measures: Anthropometry used WHO BMI-for-age z-scores; overweight >+1SD to ≤+2SD; obesity >+2SD. [1] BID was defined by discrepancy (≥1 silhouette step) between perceived current and ideal figure. [4] Weight perception and misperception contrasted BMI categories with self-classification (underweight/about right/overweight). [3,6] Weight-based teasing frequency in the past year was recorded. [8] Social media use (hours/day), physical activity (≥150 min/week), depressive symptoms (PHQ-A ≥10), and unhealthy weight-control behaviors (fasting ≥24 h, pills/laxatives, self-induced vomiting in last 30 d) were measured. Sociodemographics included age, sex, parental education, and a household assets index.

Statistical Analysis: Descriptive statistics summarize characteristics and prevalences. Weight misperception is shown as a 3×3 matrix. Logistic regression models estimate unadjusted and adjusted odds ratios (AORs) for BID with covariates: sex, BMI category, teasing, social media, physical activity, SES, and age. A four-level double-burden variable (non-obese & satisfied; non-obese & BID; obese & satisfied; obese & BID) is cross-tabulated with depressive symptoms and unhealthy weight-control behaviors; chi-square tests and risk differences (RD) are reported. Two-sided α=0.05.

Ethics: For applied use, obtain ethics approval and informed consent/assent. The present manuscript uses a synthetic dataset solely to demonstrate methods and reporting.

See Tables 1–6 for descriptive statistics, misperception matrix, correlates of BID, and double-burden analyses with adverse outcomes.

Table 1. Participant Characteristics (N=1,240)

Inference: Half met activity recommendations; a third reported heavy social-media use; one in four reported weight-based teasing.

Table 2. Prevalence of Weight Status and Body Image Dissatisfaction (BID)

Inference: BID affects ~6 in 10 adolescents, with higher prevalence in girls; overweight/obesity is more common in boys.

Table 3. Weight Misperception Matrix (% within BMI category)

Inference: One-fifth of normal-weight youth over-perceived as overweight; ~1 in 5 with excess weight perceived “about right” or underweight.

Table 4. Correlates of Body Image Dissatisfaction (BID): Logistic Regression

Inference: Sex, excess weight, teasing, and high social-media exposure independently predict BID; adequate physical activity is protective.

Table 5. “Double Burden” Groups and Adverse Outcomes

Inference: The double-burden group shows the highest depressive symptoms and unhealthy weight-control behaviors.

Table 6. Comparison With Recent Studies

Principal Findings: We found high BID prevalence (~59%), with higher levels among girls; overweight/obesity affected ~28%, more common among boys. Weight misperception was substantial in both directions.

 BID was independently associated with excess weight, weight-based teasing, and heavier social media use, while physical activity showed a modest protective association. The double-burden group (overweight/obese + BID) had markedly greater depressive symptoms and unhealthy weight-controlbehaviors.

Comparison with Other Studies: Sex-specific differences mirror HBSC (gender gap in self-perceived “too fat”) and Indian/Asian studies where boys often desire muscularity and girls thinness. [3,9] Elevated risk with weight-based teasing parallels findings from large school-based cohorts. [8] The protective association of physical activity echoes evidence synthesized by Gualdi-Russo et al., though results can be mixed. [4] Our misperception matrix aligns with time-trend evidence showing increased underestimation as population weight distributions shift. [6]

Public Health Implications: Interventions should pair healthy weight promotion with body-image literacy and anti-stigma approaches; screen for weight-based teasing and internalized weight bias, address misperception through growth-chart–based counseling, consider the role of digital environments, and promote inclusive, enjoyable movement.

Equity-focused surveillance is essential.[1–4,6,8,9]

Strengths and Limitations: Strengths include alignment with contemporary definitions and measures, explicit modeling of misperception and teasing, and comparative synthesis with recent sources. Limitations: numeric results are illustrative (synthetic), cross-sectional design limits causal inference, and BID measurement varies by instrument.

Future Directions: Longitudinal, multi-country cohorts should clarify causal pathways among BMI, BID, social media exposure, teasing, and mental health. Trials of school-based, stigma-free programs integrating nutrition, physical activity, media literacy, and body-image components are warranted.

The double burden of excess weight and body image dissatisfaction is common and consequential. Prevention and care must move beyond weight-centric messages to center well-being, stigma-free counseling, and mental health—screening for teasing and depressive symptoms, correcting misperceptions, promoting enjoyable activity, and cultivating resilient body image. Population-level actions (food environments, marketing restrictions, school policies) should proceed in parallel with adolescent-friendly services.

1. World Health Organization. Obesity and overweight. Fact sheet; 7 May 2025. Available from: WHO website.
2. Zhang X, Liu J, Ni Y, Yi C, Fang Y, Ning Q, et al. Global Prevalence of Overweight and Obesity in Children and Adolescents: A Systematic Review and Meta-analysis. JAMA Pediatr. 2024;178(8):800–813. doi:10.1001/jamapediatrics.2024.1576.
3. WHO Regional Office for Europe. A focus on adolescent physical activity, eating behaviours, weight status and body image: HBSC international report 2021/2022. 23 May 2024. ISBN: 9789289061056.
4. Gualdi-Russo E, Rinaldo N, et al. Physical Activity and Body Image Perception in Adolescents: A Systematic Review. Int J Environ Res Public Health. 2022;19(19).
5. Baker JH, Maes HH, Lissner L, Aggen SH, Lichtenstein P, Kendler KS. Body dissatisfaction in adolescent boys. Psychol Med. 2019;49(9):1570–80.
6. Geraets AFJ, et al. Cross-national time trends in adolescent body weight perception and the role of overweight/obesity prevalence (2002–2018). Child Adolesc Obes. 2023;6(1).
7. Tebar WR; Toselli S, et al. (summarized within [4]). Evidence that overweight/obesity is associated with higher BID; physical activity sometimes protective.
8. Gu W, Yu X, Tan Y, Yu Z, Zhu J, et al. Association between weight, weight perception, weight teasing and mental health among adolescents. Child Adolesc Psychiatry Ment Health. 2024;18:39.
9. Mohapatra D, Kataria D, Pemde HK. Disordered eating behaviors, body dissatisfaction and determinants in Indian adolescents. Indian J Psychiatry. 2024;66(2).