J Child Fam Stud (2017) 26:1799–1807 DOI 10.1007/s10826-017-0720-x

ORIGINAL PAPER

Depression Moderates the Relationship between Body Image and Health-Related Quality of Life in Adolescent Girls Jin Suk Ra1 Yoon Hee Cho2 ●

Published online: 23 May 2017 © Springer Science+Business Media New York 2017

Abstract Body image can predict health-related quality of life (HRQoL) in adolescent girls through self-esteem and psychological well-being. Additionally, depression is a significant predictor of adolescents’ HRQoL and is associated with body image. Therefore, we investigated whether the relationship between body image and HRQoL in adolescent girls is moderated by depression. In this crosssectional study, adolescent girls’ body image, depression, and HRQoL (n = 385, age: 12–15 years) were measured through self-report questionnaires. Multiple regression and simple slope analyses were conducted to examine the moderating effect of depression. Body image was positively correlated with HRQoL, whereas depression was negatively correlated with body image and HRQoL. Body image, depression, and their interaction explained 44.9% of the variance in HRQoL. Simple slope analysis showed that a more positive body image was associated with higher HRQoL among adolescent girls without depressive symptoms, but was not significantly related to HRQoL for adolescents with depressive symptoms. The moderating effect of depression was confirmed. In conclusion, screening for depression is recommended for adolescent girls prior to implementing body image interventions in schools and the community that are aimed at improving HRQoL. Furthermore, health care providers in schools and the community should provide psychological support for depression along with body image interventions to improve the HRQoL of

* Yoon Hee Cho [email protected] 1

College of Nursing, Chungnam National University, Daejeon, South Korea

2

College of Nursing, Dankook University, Cheonan, South Korea

girls in schools and the community. In particular, for girls with depressive symptoms, depression management should be conducted beforehand. Keywords Adolescent Body image Depression Quality of life ●

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Introduction Quality of life (QoL) is an individual’s perception of their position in life in the context of the culture and value system in which they live and in relation to their goals, expectations, standards, and concerns (The World Health Organization Quality of Life Group 1994). Petracci and Cavrini (2013) have described health-related quality of life (HRQoL) of children and adolescents as a multidimensional concept with core dimensions of individual experience, including physical function, psychological well-being, social interaction, and school performance. According to the Program for International Student Assessment (Organization for Economic Cooperation and Development [OECD], 2016), Korean adolescents show outstanding academic performance. This excellent achievement is associated with a social climate that emphasizes academic achievement with the belief that higher academic performance may assure social success and happiness in the future. However, the life satisfaction of Korean adolescents was ranked the lowest among 34 OECD countries (OECD 2016). As life satisfaction is considered an important indicator for adolescents’ psychological well-being in HRQoL (Oberle et al. 2011), high life satisfaction of adolescents has psychosocially protective effects against stressful life events (Suldo and Huebner 2004), which contribute to a decrease of

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psychological health issues in adolescents, such as suicide attempts (Sun and Shek 2012). When we consider that the primary cause of death among Korean adolescents changed from vehicle accidents in 2002 to suicide in 2012 (Korea Ministry of Health and Centers for Disease Control and Prevention 2014), life satisfaction, and furthermore, the HRQoL of Korean adolescents, seems to be considerably low. In particular, adolescent girls’ HRQoL is lower than that of adolescent boys in Korea (Yi and Kim 2013), which may be related to socially required gender-based beliefs and gender roles in Korea (Yi and Kim 2013). Traditionally, Korean society, which has a confucian culture, requires females to uphold social standards more than males. Moreover, Korean females are expected to possess socially standardized and ideal characteristics, which include characteristics of their appearance (Kim 2008). In this context, Korean females tend to be more concerned with their body shape and experience stress from weight gain more than males (Kim 2007). Adolescent girls with socially undesirable weight and appearance might experience lower life satisfaction, more negative selfperception from external pressure to control weight, and less social acceptance through social interaction with close others, such as parents, peers, and teachers, than adolescent boys (Forste and Moore 2012). Positive self-concept and satisfaction with social relationships have strong associations with HRQoL of adolescents (Yi and Kim 2013). Thus, Korean adolescent girls would be a group more vulnerable for low HRQoL, associated with strict gender norms including weight and appearance, when compared to adolescent boys. In these contexts, the identification of, and interventions for, factors associated with HRQoL are important for guaranteeing the life satisfaction and happiness of Korean adolescent girls. Typically, body image has a greater impact on adolescent girls’ physical, psychological, and social health (Lee and Lee 2016; Paxton et al. 2006). Body image can predict adolescents’ HRQoL through self-esteem and psychological well-being (Haraldstad et al. 2011). Previous studies have consistently reported body image as a strong determinant of HRQoL in healthy (Haraldstad et al. 2011) and chronically ill adolescents (e.g., cancer and obesity; Gouveia et al. 2014). Additionally, depression is a significant predictor of adolescents’ HRQoL (BarcelosFerreira et al. 2013; Di Battista et al. 2014) and is associated with body image in adolescence (El Ansari et al. 2014). A positive body image appears to relieve depression (Akkaya et al. 2011; Bhatnagar et al. 2013) and improve HRQoL (Bonsergent et al. 2012; Kolodziejczyk et al. 2015). Kenzik et al. (2015) also proposed that depressive symptoms can mediate the relationships between psychosocial factors (e.g. optimism) and HRQoL in hematopoietic stem cell transplant survivors. In the same vein, regarding the mediating

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effects of depression, a negative body image in Korean adolescents is associated with vulnerable psychological well-being (e.g., suicidal ideation; Noh and Choi 2009). In this context, there may be a significant association between body image, depression, and HRQoL. Furthermore, depression could be considered a mediator between body image and HRQoL. However, a significant association between body image and QoL or HRQoL has not been found in women and adolescent girls with risk for psychological distress regarding change in their appearance. According to McClelland et al. (2015), while women with non-visceral diseases and breast cancer reported significant improvements in emotional QoL with body image improvement, no improvement was observed in breast cancer patients with visceral diseases associated with worse recurrence outcomes and increased risk of death (Zabora et al. 2001). Furthermore, body image was not associated with QoL in Jordanian breast-cancer survivors whose psychological wellbeing was lower compared to patients in Western countries (Abu-Helalah et al. 2014). Likewise, Paxton (2013) found that adolescent girls with more severe baseline depression had significantly worse symptoms after a body image intervention than girls without diagnosable depression. These previous findings of the association between body image and QoL or HRQoL are heterogeneous; thus, generalization is limited. Such inconsistency is considered indicative of effect modification (one specific moderator) or of a complex interaction between variables (Baron and Kenny 1986). In particular, Nigatu et al. (2016) have reported interaction effects between obesity and depression on HRQoL. According to this study, among a population with depression, non-obese individuals did not show better mental HRQoL than those exhibiting obesity. However, this relationship was not seen in non-depressed individuals, as those without obesity reported significantly better mental HRQoL than those exhibiting obesity. When we consider that decreased HRQoL among obese people might result from negative body image rather than increased body mass index (Heshmat et al. 2015), depression might be the potential moderator of the association between body image and HRQoL. In the same vein, Devaraj and Lewis (2010) have also reported that the effects of a body image intervention on QoL varied across adolescent girls according to depressive symptom severity. Furthermore, they suggested that it is necessary to examine the role of depression in explaining the relationship between body image and HRQoL in adolescent girls. Thus, we hypothesized that depression has a moderator effect on the relationship between body image and HRQoL in adolescent girls. The specific aims of this study were to test the potential effects of depression as a moderator between body image and HRQoL in adolescent girls.

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Method

parents (90.9%) had a dual income and primary caregiver of the participants (98.7%) was mother.

Participants Procedures Adolescent girls, aged 12–15 years (n = 385) were recruited from five middle schools in D province in the Republic of Korea by convenience sampling (the school principals gave permission for the study). One class from each grade of the middle schools was selected by a simple random sampling method using random selection software (Excel Random Sample Software, 7.0). Students from each class were selected using the convenience sampling method according to some eligibility criteria. The eligibility criteria were (1) the ability to read and answer the questionnaires without assistance, (2) having no current medical diagnosis of body image disorders (e.g., body dysmorphic disorder, eating disorder) or mental illness (e.g., major depression) that would affect the level of body image or depressive symptoms, and (3) participants and parents/guardians providing written consent to participate in the study. Table 1 shows the participants’ demographic characteristics. The average age was 13.99 (SD = 0.54). Of the 385 participants, 85.0% were normal weight; 92.5% were dissatisfied on current weight. Most adolescent girls (84.2%) did not have chronic health problems. Most of participants (97.0%) lived in communities with a middle level of socioeconomic status. Almost every participant (98.2%) lived with their parents in a nuclear family. Most of their Table 1 Demographics characteristics of subjects (N = 385) Characteristics

Categories

n (%)

1st

118 (30.6)

2nd

141 (36.6)

3rd

126 (32.8)

Age (years) Grade

Body mass index (percentile)

Satisfaction on current weight

M (SD) 13.99 (0.54)

Underweight Normal weight

24 (6.2) 327 (85.0)

Overweight

20 (5.2)

Obese

14 (3.6)

Satisfied Dissatisfied

29 (7.5) Desired 336 (87.3) to weight loss Desired 20 (5.2) to weight gain

Chronic health problems

Yes

61 (15.8)

No

324 (84.2)

Perceived economic level

High

39 (10.1)

Middle

282 (73.2)

Low

64 (16.7)

This study used a survey research method with a crosssectional design. Data were collected using selfadministered questionnaires. Using G*Power 3.13 (Faul et al. 2009) to calculate the statistical power, it was determined that 130 participants were required to detect a small effect (d = 0.15) in the primary outcomes with a power of 0.90, significance level of 0.05 (two-tailed), and three independent variables (body image, depression, the interaction between body image and depression). Data were collected from March to May 2015, by two postgraduate nurse coordinators. Informed consent was obtained from all participants before study enrollment. Adolescents provided assent and parents/guardians provided written informed consent. All research procedures were approved by the College of Nursing, E University Institutional Review Board (EUIRB 2015-49). Measures Body image Body image was assessed using the Korean version of the Body Esteem Scale (Lee 2001)—originally developed by Mendelson et al. (1997)—that demonstrates validity and reliability. It comprises 23 self-report items with four response statements (scores range from 1–4 points). The possible total score ranges from 23–92 points, with higher scores indicating a more positive body image. In a previous study with Korean adolescent girls in high schools, mean score of body image was 53.8 points (Lim et al. 2014). In Mendelson, Mendelson, and White’s study (2001), the testretest correlation was high (r = 0.83−0.92). Cronbach’s alpha was 0.92 in Lee’s (2001) study and 0.91 in this study. The Korean version of the instrument has been previously validated for the evaluation of body image in adolescents (Lee and Kim 2006; Lim et al. 2014). In Korean adolescents, body image assessed with the instrument was positively correlated with self-esteem and life satisfaction scores (Lee and Kim 2006; Lim et al. 2014). Depression Depression was assessed using the Children’s Depression Inventory (Kovacs 1981), which was translated and tested for validity and reliability with Korean children by Cho and Lee (1990). It comprises 27 self-report items with three response statements (scored 0–2 points) representing varying levels of depression in the 2 weeks prior to assessment.

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Total scores range from 0–54, with higher scores indicating greater severity; scores greater than 19 are considered suggestive of depressive symptoms (Cho and Lee 1990). In Cho and Lee’s study (1990), the split-half reliability was 0.71 and inter-item correlation was 0.21. Cronbach’s alpha was 0.88 in Cho and Lee’s (1990) study and 0.89 in the present study. The total score of the Korean version of the instrument was significantly correlated with subscale score of anxiety/depression in the Child Behavior Checklist in Korean children and adolescents (Shin et al. 2008). HRQoL According to Petracci and Cavrini (2013), HRQoL is a multidimensional concept with core dimensions of individual experience, including physical functioning, psychological well-being, social interaction, and school or work performance. The HRQoL was assessed using KIDSCREEN-10 (Ravens-Sieberer et al. 2010), which is a validated and widely used tool for monitoring global HRQoL among 8- to 18-year-olds. It comprises 10 items that assess HRQoL in physical activities and health, general mood and feeling about themselves, family and free time, friends, school, and learning during the previous week (e.g.,“Have you felt full of energy?,” “Have you felt sad?,” “Have you had enough time for yourself?,” “Have your parents treated you fairly?,” Have you had fun with your friends?,” and “Are you doing well at school?”). Items are scored on a five-point Likert scale for the frequency of a behavior or feeling (1 = never; 2 = almost never; 3 = sometimes; 4 = almost always; and 5 = always) or intensity of an attitude (1 = not at all; 2 = slightly; 3 = moderately; 4 = very; and 5 = extremely). The score for each dimension is transformed into a T-score (M = 50, SD = 10) and higher scores indicated better HRQoL. The test-retest reliability assessed with the intra-class correlation coefficient was 0.70, which is considered an acceptable value for group comparisons (Ravens-Sieberer et al. 2010). Cronbach’s alpha was 0.82 in the original study (Ravens-Sieberer et al. 2010) and 0.78 in this study. The validity of the instrument has been evaluated with Asian children, such as Iranian and Korean children (Nik-Azi et al. 2014; Ra and Gang 2016). In Korean children, HRQoL assessed with the instrument has been found to be negatively correlated with depression and positively correlated with physical activity (Ra and Gang 2016).

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depression moderates the relationship between body image and HRQoL. Subsequently, multiple regressions were performed to develop predictive models. Thus, the assumptions of the regression analyses were tested using Pearson’s correlation coefficients, variance inflation factors, and tolerance for multicollinearity. The Cook’s distance for detecting outliers, Durbin-Watson statistic, and the distribution of standardized residuals were included. A simple slope analysis, using the Johnson-Neyman method (Hayes 2013), was conducted to verify the moderating effect of depression by dividing participants into two groups (with or without depressive symptoms) based on the cutoff depression score of 19. Body image level was categorized as low (1 SD below the mean), at the mean, or high (1 SD above the mean) after mean centering. Then, the conditional effect of body image on HRQoL was analyzed with or without depressive symptoms. Statistical analyses were performed using SPSS version 22 (IBM Corp., Armonk, NY).

Results The mean depression score across the groups was 12.78 (SD = 7.67, range: 0–48), and 69 adolescents (17.9%) had depressive symptoms based on cut off score (19 points) of the Children’s Depression Inventory. The mean body image score was 38.08 (SD = 13.04, range: 3–77) and mean HRQoL score was 38.82 (SD = 5.37, range: 23.97–59.85). Body image was positively correlated with HRQoL (r = 0.461, p < 0.001), and depression was negatively correlated with body image (r = −0.526, p < 0.001) and HRQoL (r = −0.638, p < 0.001; Table 2). With the adolescent girls, a higher body image score was associated with higher HRQoL (β = 0.160, t = 3.557, p = 0.004), while depression was negatively associated with HRQoL (β = −0.599, t = −12.749, p < 0.001). Additionally, the interaction between body image and depression had a significant association with HRQoL (β = −0.148, t = −3.700, p = 0.002). Depression, body image, and their interaction explained 44.9% of the variance (Table 3). Simple slope analysis showed that depression moderated the relationship between body image and HRQoL (Figure 1). A positive body image was related to higher HRQoL Table 2 Correlations between body image, depression, and HRQoL Variables

Data Analyses Descriptive statistics (frequencies, means, and SD) were used to summarize the data. Pearson’s correlations were calculated to compare the relationships between body image, depression, and HRQoL, and to determine whether

Body image Depression HRQoL

Body image 1 −0.526*** 0.461***

HRQoL health related quality of life ***p < 0.001

Depression

1 −0.638***

J Child Fam Stud (2017) 26:1799–1807 Table 3 Linear model of predictors of HRQoL

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Characteristic

B

SE B

Constant

38.423 [37.968, 38.879]

0.232

Body image (centered)

0.067 [0.024, 0.111]

0.019

ß

t

p

165.815

<0.001

0.160

3.557

0.004

Depression (centered)

−0.420 [−0.484, −0.355]

0.033

−0.599

−12.749

<0.001

Body image × depression

−0.008 [−0.011, −0.002]

0.002

−0.148

−3.700

0.002

Adjusted R = 0.449 with whole adolescent girls 2

HRQoL

HRQoL health related quality of life

Body image

Fig. 1 Interaction between body image and depression on HRQoL in adolescent girls; depression as a moderator

in girls without depressive symptoms (b = 0.152, t = 5.757, p < 0.001), while body image was not significantly related to HRQoL in girls with depressive symptoms (b = 0.017, t = 0.423, p = 0.673). In a subanalysis according to the girls’ school grade, it was found that regardless of grade, body image, depression, and the interaction between body image and depression were associated with HRQoL. In addition, depression had a moderating effect between body image and HRQoL. A positive body image was related to higher HRQoL in girls without depressive symptoms (1st grade b = 0.182, t = 3.815, p = 0.002; 2nd grade b = 0.136, t = 3.129, p = 0.002; 3rd grade b = 0.110, t = 2.300, p = 0.023), while body image was not significantly related to HRQoL in girls with depressive symptoms (1st grade b = 0.037, t = 0.905, p = 0.367; 2nd grade b = 0.001, t = 0.010, p = 0.991; 3rd grade b = 0.004, t = 0.109, p = 0.913).

Discussion This study examined the influence of body image and depression on adolescent girls’ HRQoL and the moderating

effects of depression. We found that Korean adolescent girls had a low level of body image. In addition, body image and depression had significant interaction effects on HRQoL. Furthermore, depression moderated the relationship between body image and HRQoL. Adolescence is a critical period in the development of body image (Lawler and Nixon 2011). Substantial physical, social, and cognitive changes experienced during adolescence contribute to a heightened awareness of one’s body (Ata et al. 2007). In particular, individuals in early adolescence might be especially sensitive to the perception of others’ evaluation and social norms regarding their body size and shape (Chung 2010). Body image of Korean adolescent girls in middle school from our study was more negative than adolescent girls in high school reported by a previous study (Lim et al. 2014). Moreover, since appearance is a major evaluative dimension for girls, they tend to respond more strongly than boys to the media’s body ideal. Physiological changes during puberty differ from this ideal and precipitate body dissatisfaction (Knauss et al. 2007). In particular, Korean society tends to value physical appearance in the evaluation of individual competence and superiority (Chung 2010; Lee et al. 2008). Furthermore, a thin body shape and westernized physical appearance is likely to be the criteria of beauty among females in Korean society (Lee et al. 2008). In particular, adolescent girls are concerned about their body shape and weight more than adolescent boys in the confucian culture that emphasizes social expectations related to the ideal image of women (Lee et al. 2008). Thus, negative body image may be widespread among adolescent girls. Consistent with previous studies, body image and depression were found to be significantly associated with HRQoL in Korean adolescent girls. Research across age groups from children to adults has found a negative relationship between body image and HRQoL (Gouveia et al. 2014; Haraldstad et al. 2011; Teo et al. 2015). A negative body image has been found to be correlated with dissatisfaction with physical attractiveness, interpersonal relationships, and psychological distress, such as anxiety (Demuth et al. 2012). Moreover, a negative body image in adolescence is associated with low physical activity

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(Neumark-Sztainer et al. 2006), eating disorders (Hatata et al. 2009), depression (Chung 2010), suicidal ideation (Brausch and Decker 2014), and externalized problematic behaviors, such as aggression (Gilliland et al. 2007). In addition, a negative association between depression and HRQoL has been observed (Barcelos-Ferreira et al. 2013; Di Battista et al. 2014). Adolescent depression can result in negative effects on physical health, such as obesity (Castillo et al. 2014), and adverse social and academic outcomes (Elmelid et al. 2015; Frojd et al. 2008). Adolescents with depressive symptoms also have high risk of suicide (du Roscoat et al. 2016; Park et al. 2014). As the most prevalent mental health problem, approximately 32% of Korean adolescent girls have depressive symptoms (Korea Ministry of Health and Centers for Disease Control and Prevention 2014), which is at a more severe level compared to the prevalence in Korean adolescent boys (22%) and U.S. adolescents (10.7%; Korea Ministry of Health and Centers for Disease Control and Prevention 2014; Substance Abuse and Mental Health Services Administration 2014). Thus, an intervention for negative body image and depression is important for HRQoL improvement among Korean adolescent girls. Interestingly, in our study, a positive body image did not improve HRQoL among depressive adolescents, but it was significantly associated with higher HRQoL among adolescent girls who did not have depressive symptoms. According to Segal et al. (2004), negative emotion has a stronger influence on individual well-being than body dissatisfaction. White (2000) also proposed a model in which perceived appearance changes lead to body image emotions, such as depression. Finally, these negative emotions are directly connected to adverse psychosocial responses, such as social isolation and self-abasement. In particular, these negative responses, due to psychological distress and negative thoughts, were greater in people who place greater importance on their appearance (White 2000). Thus, psychological health issues, such as depression, would have a more significant association with HRQoL than body image in adolescent girls. In the same vein, undesirable weight (e.g. underweight and obesity) was associated with decreased HRQoL among people with abnormal psychosocial functioning, while the association between undesirable weight and HRQoL was not significant among people with normal psychosocial functioning (Renzaho et al. 2010). In this connection, Renzaho et al. (2010) proposed effects of underlying factors, such as severity and persistence of depression between weight status and HRQoL. Negative effects of undesirable weight on HRQoL result from negative body image regarding subjective evaluation of weight, but not objective evaluations, such as body mass index (Haraldstad et al. 2011; Wille et al. 2008). Thus, depression might have a moderating effect

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between body image and HRQoL, with an interaction effect with body image. In this context, McVey et al. (2004) proposed the need to enhance the positive mindset of girls to improve their psychological well-being. Abu-Helalah et al. (2014) also recommended psychological screening and consultation to improve QoL after observing that QoL is associated with breast cancer patients’ psychological status but not body image. In conclusion, the HRQoL of Korean adolescent girls was associated with body image and depression. Furthermore, depression was a factor associated with HRQoL and a moderator between body image and HRQoL among these girls. Thus, screening for depression is recommended for adolescent girls in schools and the community that are aimed at improving HRQoL. In addition, health care providers in schools and the community should provide psychological support for depression to improve the HRQoL of the girls with risk for body image disturbance in schools and the community. In particular, for girls with depressive symptoms, depression management should be performed in advance. In a previous study, Bessell and Moss (2007) also emphasized interventions focusing on psychosocial factors for individuals at risk of a negative body image. Our study’s limitations should be considered when interpreting the findings. First, the use of convenience sampling limits the generalizability of the results among Korean adolescent girls. Thus, future research should employ randomized sampling to verify these results. Second, we excluded from our sample adolescent girls with a current medical diagnosis of body image disorders. It was thought that inclusion of adolescents with body image disorder in the sample might disturb association between variables in a majority of sample of adolescent girls without body image disorder. Thus, our results reflected relations among variables in adolescent girls without body image disorder. Furthers studies are needed to test moderating effects of depression between body image disorder and HRQoL among adolescent girls with body image disorder. Third, the influence of body image and depression on HRQoL should be explored through experimental studies to assess the effectiveness of HRQoL strategies in this age group. Fourth, our study was conducted to test the influence of depression as a moderator between body image and HRQoL only with adolescent girls in Korean society. Thus, the moderating effect of depression needs to be examined with adolescents in other societies that have different social expectations and impacts on the appearance of girls. Fifth, our study focused on depression as a potential moderator between body image and HRQoL. Thus, further identification of other psychosocial factors that moderate the relationship between body image and HRQoL is also recommended.

J Child Fam Stud (2017) 26:1799–1807 Research Funding This study was supported by 2015 research fund of Chungnam National University. Author Contributions J.S.R. designed and executed the study, analyzed the data, and collaborated with writing the paper. Y.H.C: collaborated with the design and the data analyses and wrote the paper.

Compliance with Ethical Standards Conflict of Interest ing interests.

The authors declare that they have no compet-

References Abu-Helalah, M., Al-Hanaqta, M., Alshraideh, H., Abdulbaqi, N., & Hijazeen, J. (2014). Quality of life and psychological well-being of breast cancer survivors in Jordan. Asian Pacific Journal of Cancer Prevention, 15(14), 5927–5936. Akkaya, N., Atalay, N. S., Selcuk, S. T., Akkaya, S., & Ardic, F. (2011). Impact of body image on quality of life and mood in mastectomized patients and amputees in Turkey. Asian Pacific Journal of Cancer Prevention, 12(10), 2669–2673. Ata, R. N., Ludden, A. B., & Lally, M. M. (2007). The effects of gender and family, friend, and media influences on eating behaviors and body image during adolescence. Journal of Youth and Adolescence, 36(8), 1024–1037. Barcelos-Ferreira, R., Nakano, E. Y., Steffens, D. C., & Bottino, C. M. (2013). Quality of life and physical activity associated to lower prevalence of depression in community-dwelling elderly subjects from Sao Paulo. Journal of Affective Disorders, 150(2), 616–622. Baron, R. M., & Kenny, D. A. (1986). The moderator-mediator variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51(6), 1173–1182. Bessell, A., & Moss, T. P. (2007). Evaluating the effectiveness of psychosocial interventions for individuals with visible differences: A systematic review of the empirical literature. Body Image, 4, 227–238. Bhatnagar, K. A., Wisniewski, L., Solomon, M., & Heinberg, L. (2013). Effectiveness and feasibility of cognitive-behavioral group intervention for body image disturbance in women with eating disorders. Journal of Clinical Psychology, 69(1), 1–13. Bonsergent, E., Benie-Bi, J., Baumann, C., Agrinier, N., Tessier, S., Thilly, N., & Briançon, S. (2012). Effect of gender on the association between weight status and health-related quality of life in adolescents. BMC Public Health, 12, 997–1004. Brausch, A. M., & Decker, K. M. (2014). Self-esteem and social support as moderators of depression, body image, and disordered eating for suicidal ideation in adolescents. Journal of Abnormal Child Psychology, 42, 779–789. Castillo, F., Francis, L., Wylie-Rosett, J., & Isasi, C. R. (2014). Depressive symptoms are associated with excess weight and unhealthier lifestyle behaviors in urban adolescents. Childhood Obesity, 10, 400–407. Cho, S. C., & Lee, Y. S. (1990). Development of the Korean form of the Kovac’s Children’s Depression Inventory. Journal of the Korean Neuropsychiatric Association, 29, 943–956. Chung, Y. J. (2010). Relationships between body image attitude and its correlates in early adolescence. Journal of Korean Academy of Family Medicine, 48(5), 103–117. Demuth, A., Czerniak, U., Krzykała, M., & Ziółkowska-Łajp, E. (2012). Subjective assessment of body image by middle-aged

1805 men and women. Studies in Physical Culture and Tourism, 19, 25–29. Devaraj, S., & Lewis, V. (2010). Enhancing positive body image in women: An evaluation of a group intervention program. Journal of Applied Biobehavioral Research, 15(2), 103–116. Di Battista, A., Godfrey, C., Soo, C., Catroppa, C., & Anderson, V. (2014). Depression and health related quality of life in adolescent survivors of a traumatic brain injury: A pilot study. PLoS One, 9 (7), e101842. du Roscoat, E., Legleye, S., Guignard, R., Husky, M., & Beck, F. (2016). Risk factors for suicide attempts and hospitalizations in a sample of 39,542 French adolescents. Journal of Affective Disorders, 190, 517–521. El Ansari, W., Dibba, E., & Stock, C. (2014). Body image concerns: Levels, correlates, and gender differences among students in the United Kingdoms. Central European Journal of Public Health, 22(2), 106–117. Elmelid, A., Stickley, A., Lindblad, F., Schwab-Stone, M., Henrich, C. C., & Ruchkin, V. (2015). Depressive symptoms, anxiety and academic motivation in youth: Do schools and families make a difference? Journal of Adolescence, 45, 174–182. Faul, F., Erdfelder, E., Buchner, A., & Lang, A. G. (2009). Statistical power analyses using G*Power 3.1: Tests for correlation and regression analyses. Behavior Research Methods, 41, 1149–1160. Frojd, S. A., Nissinen, E. S., Pelkonen, M. U., Marttunen, M. J., Koivisto, A. M., & Kaltiala-Heino, R. (2008). Depression and school performance in middle adolescent boys and girls. Journal of Adolescence, 31, 485–498. Eating and Weight Disorders, 20, 91–97. Forste, R., & Moore, E. (2012). Adolescent obesity and life satisfaction: Perceptions of self, peers, family, and school. Economics and Human Biology, 10, 385–394. Gilliland, M. J., Windle, M., Grunbaum, J. A., Yancey, A., Hoelscher, D., & Tortolero, S. R., et al. (2007). Body image and children’s mental health related behaviors: Results from the healthy passages study. Journal of Pediatric Psychology, 32(1), 30–41. Gouveia, M. J., Frontini, R., Canavarro, M. C., & Moreira, H. (2014). Quality of life and psychological functioning in pediatric obesity: The role of body image dissatisfaction between girls and boys of different ages. Quality of Life Research, 23(9), 2629–2638. Haraldstad, K., Christophersen, K. A., Eide, H., Nativg, G. K., & Helseth, S. (2011). Predictors of health-related quality of life in a sample of children and adolescents: A school survey. Journal of Clinical Nursing, 20(21–22), 3048–3056. Hatata, H., Awaad, M., El sheikh, M., & Refaat, G. (2009). Body image dissatisfaction and its relationships with psychiatric symptomatology, eating beliefs and self esteem in Egyptian female adolescents. Current Psychiatry, 16(2), 171–183. Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis: A regression-based approach. New York: The Guilford Press. Heshmat, R., Kelishadi, R., Motamed-Gorji, N., Motlagh, M. E., Ardalan, G., & Arifirad, T., et al. (2015). Association between body mass index and perceived weight status with self-rated health and life satisfaction in Iranian children and adolescents: The CASPIAN-III study. Quality of Life Research, 24, 263–272. Kenzik, K., Huang, I. C., Rizzo, J. D., Shenkman, E., & Wingard, J. (2015). Relationships among symptoms, psychological factors, and health-related quality of life in hematopoietic stem cell transplant survivors. Supportive Care in Cancer, 23, 797–807. Kim, E. J. (2008). Self-esteem according to differences between real and ideal body mass index in female college students. Journal of East-West Nursing Research, 14, 54–59. Kim, Y. J. (2007). Weight control and its related factors among children: A gender based approach. Family and Environment Research, 45, 113–122.

1806 Knauss, C., Paxton, S. J., & Alsaker, F. D. (2007). Relationships amongst body dissatisfaction, internalization of the media body ideal and perceived pressure from media in adolescent girls and boys. Body Image, 4(4), 353–360. Kolodziejczyk, J. K., Gutzmer, K., Wright, S. M., Arredondo, E. M., Hill, L., & Patrick, K., et al. (2015). Influence of specific individual and environmental variables on the relationship between body mass index and health-related quality of life in overweight and obese adolescents. Quality of Life Research, 24, 251–261. Korea Ministry of Health and Centers for Disease Control and Prevention. (2014). The 10th Korea Youth Risk Behavior Web-based Survey Statistics. Korea Centers for Disease and Prevention. Kovacs, M. (1981). Rating scale to assess depression in school aged children. ActaPaedopsychiatrica, 46, 305–315. Lawler, M., & Nixon, E. (2011). Body dissatisfaction among adolescent boys and girls: The effects of body mass, peer appearance culture and internalization of appearance ideals. Journal of Youth and Adolescence, 40(1), 59–71. Lee, J. (2001). Correlation among adolescents gender, obesity, others appraisal of their bodies and the adolescents body-esteem. Chungju, Korea: Korea National University of Education. Unpublished Master dissertation. Lee, A. Y., & Kim, J. (2006). Relationships among meaning of life, body image, self-esteem, altruism, and resilience in institutionalized adolescents. Studies on Korean Youth, 17, 159–183. Lee, J. L., Kwon, K. N., & Seo, H. W. (2008). Study of evaluate a social worth and body image perception in women junior and senior. Journal of Sport and Leisure Studies, 33, 615–626. Lee, J., & Lee, Y. (2016). The association of body image distortion with weight control behaviors, diet behaviors, physical activity, sadness, and suicidal ideation among Korean high school students: A cross-sectional study. BMC Public Health, 16, 39–48. Lim, H. J., Ki, H. M., Kim, E. J., Suh, Y. S., & Kim, D. H. (2014). The relationships of sex and body mass index to body esteem scale, self-esteem scale, depression in high school students from one high school in Daegu. Korean Journal of Family Practice, 4, 262–267. McClelland, S. I., Holland, K. J., & Griggs, J. J. (2015). Quality of life and metastatic breast cancer: The role of body image, disease site, and time since diagnosis. Quality of Life Research, 24(12), 2939–2943. McVey, G. L., Davis, R., Tweed, S., & Shaw, B. F. (2004). Evaluation of a school-based program designed to improve body image satisfaction, global self-esteem, and eating attitudes and behaviors: A replication study. The International Journal of Eating Disorders, 36, 1–11. Mendelson, B. K., Mendelson, M. J., Andrews, J., Balfour, L., & Bucholz, A. (1997). Three aspects of body esteem in adolescents and young adults: Differential relations with weight and selfesteem. Research in Child Development, 17(1), 145–160. Mendelson, B. K., Mendelson, M. J., & White, D. R. (2001). Bodyesteem scale for adolescents and adults. Journal of Personality Assessment, 76, 90–106. Neumark-Sztainer, D., Paxton, S. J., Hannan, P. J., Haines, J., & Story, M. (2006). Does body satisfaction matter? Five-year longitudinal associations between body satisfaction and health behaviors in adolescent females and males. Journal of Adolescent Health, 39 (2), 244–251. Nigatu, Y. T., Reijneveld, S. A., de Jonge, P., van Rossum, E., & Bültmann, U. (2016). The combined effects of obesity, abdominal obesity and major depression/anxiety on health-related aulity of life: The lifelines cohort study. PLoS ONE, 11, e0148871. Nik-Azi, A., Mohammad Reza Shairi, M. R., Naeinian, M. R., & Sadeghpour, A. (2014). The health-related quality of life 1ndex KIDSCREEN-10: Confirmatory factor analysis, convergent

J Child Fam Stud (2017) 26:1799–1807 validity and reliability in a sample of Iranian students. Child Indicators Research, 7, 407–420. Noh, H. L., & Choi, K. I. (2009). The effect of body image upon youths with suicide ideation: The mediating effects of stress and sense of depression. Studies on Korean Youth, 20, 141–165. Oberle, E., Schonert-Reichl, A., & Zumbo, B. D. (2011). Life satisfaction in early adolescence: Personal, neighbourhood, school, and peer influence. Journal of Youth and Adolescence, 40, 889–901. Organization for Economic Cooperation and Development. (2016). OECD Economic Survey: Korea 2016. Retrieved from http:// www.oecd.org/eco/surveys/economic-survey-Korea.htm. Park, B. C., Soo Im, J., & Strother Ratcliff, K. (2014). Rising youth suicide and the changing cultural context in South Korea. Crisis, 35(2), 102–109. Paxton, S. J. (2013). Body image, eating disorder and depressive symptom outcomes following a school-based body image prevention intervention: A one year follow-up study: Final research Report. Retrieved from http://www.beyondblue.org.au/docs/defa ult-source/research-project-files/bw0223.pdf?sfvrsn=4. Paxton, S. J., Neumark-Sztainer, D., Hannan, P. J., & Eisenberg, M. E. (2006). Body dissatisfaction prospectively predicts depressive mood and low self-esteem in adolescent girls and boys. Journal of Clinical Child and Adolescent Psychology, 35 (4), 539–549. Petracci, E., & Cavrini, G. (2013). The effect of weight status, lifestyle, and body image perception on health-related quality of life in children: A quantile approach. Quality of Life Research, 22, 2607–2615. Ra, J. S., & Gang, M. (2016). Depression moderates between physical activity and quality of life in low-income children. Applied Nursing Research, 29, e18–e22. Ravens-Sieberer, U., Erhart, M., Rajmil, L., Herdman, M., Auquier, P., & Bruil, J., European KIDSCREEN Group. (2010). Reliability, construct and criterion validity of the KIDSCREEN-10 score: A short measure for children and adolescents’ well-being and health-related quality of life. Quality of Life Research, 19, 1487–1500. Renzaho, A., Wooden, M., & Houng, B. (2010). Associations between body mass index and health-related quality of life among Australian adults. Quality of Life Research, 19, 515–520. Segal, Z. V., Teasdale, J. D., & Williams, J. M. G. (2004). Mindfulness-based cognitive therapy: Theoretical rationale and empirical status. In S. Hayes, V. Follette, M. Linehan (Eds.), Mindfulness and acceptance: Expanding the cognitivebehavioral tradition. New York: Guilford Press. Shin, Y. M., Cho, H., Lim, K. Y., & Cho, S. M. (2008). Predictors of self-reported depression in Korean children 9 to 12 years of age. Yonsei Medical Journal, 49, 37–45. Sun, R. C., & Shek, D. T. (2012). Positive youth development, life satisfaction and problem behaviour among Chinese adolescents in Hong Kong: A replication. Social Indicators Research, 105, 541–559. Substance Abuse and Mental Health Services Administration. (2014). Results from the 2013 national survey on drug use and health: Mental health findings. Rockville, MD: Substance Abuse and Mental Health Services Administraion. (NSDUH Series H-49, HHS Publication No. (SMA) 14-4887). Suldo, S. M., & Huebner, E. S. (2004). Does life satisfaction moderate the effects of stressful events on psychological behavior during adolescence? School Psychology Quarterly, 19, 93–105. Teo, I., Novy, D. M., Chang, D. W., Cox, M. G., & Fingeret, M. C. (2015). Examining pain, body image, and depressive symptoms in patients with lymphedema secondary to breast cancer. PsychoOncology, 24, 1377–1383.

J Child Fam Stud (2017) 26:1799–1807 The World Health Organization Quality of Life Group. (1994). Development of the WHOQOL: Rationale and current status. International Journal of Mental Health, 2, 24–56. White, C. A. (2000). Body image dimensions and cancer: A heuristic cognitive behavioural model. Psycho-Oncology, 9, 183–192. Wille, N., Erhart, M., Petersen, C., & Ravens-Sicberer, U. (2008). The impact of overweight and obesity on health-related quality of life

1807 in childhood–results from an intervention study. BMC Public Health, 8, 421–429. Yi, K., & Kim, K. (2013). Determinants of subjective quality of life of middle school students. Korean Journal of Sociology of Education, 23, 139–168. Zabora, J., BrintzenhofeSzoc, K., Curbow, B., Hooker, C., & Piantadosi, S. (2001). The prevalence of psychological distress by cancer site. Psychooncology, 10(1), 19–28.