Body Appreciation in Light of Psychological, Health- and Weight-Related Variables Among Female Adolescents

Recent research has begun to focus on positive body image and how this can be supported in adolescence. Body appreciation is a key element of positive body image, and has been associated with self-reported health status, weight-related concern, family factors and psychological variables such as self-esteem. In this study we explored these associations among Hungarian adolescent females. Female high school students from two major towns in Csongrád county, Hungary (N = 454; age range from 14 to 20; M = 16.3 years, SD = 1.2) completed questionnaires assessing body appreciation, self-esteem, optimism, life satisfaction and health- and weight-related variables. Analyses revealed that body appreciation was most strongly related to self-esteem, as well as being positively associated with life satisfaction, self-perceived health, being in control of diet, and engagement in sport. Conversely, binge drinking, engaging in slimming behaviors and having eating disorders in the family were negatively associated with body appreciation. These findings provide some indications of factors that might be targetted in health education programs aiming to promote positive body image and to develop resilience against body dissatisfaction in this demographic group. Such programs should also include information of nutrition and media literacy.


Present Study
In summary, there is a growing focus on positive body image and constructs such as body appreciation.
The current study was conducted in Hungary where the prevalence of obesity and overweight has increased significantly in the past decades, with the nation now occupying a top position not only in European but also in Organisation for Economic Co-operation and Development (OECD) health rankings (OECD, 2017). Further, despite the serious health statistics for conditions in which nutrition and obesity might play a decisive role (Rurik et al., 2016), body image and body appreciation are under-investigated and no effective preventive programs are available for the general population, let alone for adolescents who are in a pivotal life stage for the development of positive body image (Voelker, Reel, & Greenleaf, 2015).
Our study focuses on Hungarian female adolescents who form a vulnerable group of the population not only since they tend to be especially critical about their weight, but also they are receptive to health messages as well. Thus our findings will be useful in informing the development of a health education program. In light of the literature reviewed above, we anticipated that self-esteem, optimism, life satisfaction, good/excellent self-perceived health, diet control and engagement in sport would be positively associated with body appreciation, while BMI, engagement in slimming behaviors, substance use and the presence of overweight or eating disorders in the family would be negatively related to female adolescents' body appreciation.

Method Participants and Procedure
Data were collected in Szeged and Hódmezővásárhely, two major towns in Csongrád county, Hungary between March and June 2018. The sample consisted of 454 female adolescents (age range from 14 to 20 years; M = 16.3, SD = 1.2) who studied in different high schools (with a majority of girls, such as specialization of health care or arts) of these two towns. Just over one third (34.4%) of the participants were from grade 9, 33% were from grade 10, 21.4% were from grade 11, and 11.4% were from grade 12. Some classes were unisex and in mixed gender classes only females were asked to participate. Of the 500 students invited to participate, 30 declined. Sixteen others were absent on the day the surveys were administered, giving a response rate of 92%. Wood-Barcalow, 2015). Using principal component analysis only one component was extracted with a relatively high variance (68.1%) explained. Items measure resondents' acceptance and favourable opinions of, and respect for their bodies (e.g., "Despite its imperfections, I still like my body"). Summed scores were used in the analyses where higher scores reflect higher levels of body appreciation. The Cronbach alpha coefficient of reliability in our sample was excellent (α = .93), similar to the level reported for the original version.

Satisfaction With Life
Life satisfaction was measured using the Hungarian validated and adapted version (Martos, Sallay, Désfalvy, Szabó, & Ittzés, 2014) of the Satisfaction With Life Scale (Diener, Emmons, Larsen, & Griffin, 1985). Participants indicated how strongly they agreed with each of the five items using a response format ranging from 1 (strongly disagree) to 7 (strongly agree). Higher scores reflect higher levels of life satisfaction. The scale was reliable with a Cronbach's alpha of .83 with the current sample.

Optimism
Dispositional optimism was measured using the Hungarian validated version (Béri & Köteles, 2010) of the Life Orientation Test (LOT-R; Scheier & Carver, 1985). The LOT-R consists of ten items (three inverse, plus four filler items that are not scored as part of the scale) assessing generalized expectancies for positive versus negative outcomes. Participants were asked to indicate their level of agreement with each statement using a five-point response scale ranging from 0 (strongly disagree) to 4 (strongly disagree). This scale was reliable with a Cronbach's alpha of .74.

Self-Esteem
Self-esteem was measured by the Hungarian validated and adapted version (Sallay, Martos, Földvári, Szabó, & Ittzés, 2014) of Rosenberg's 10-item self-esteem scale (Rosenberg, 1979). Respondents were asked to indicate their level of agreement with each item (five of which are reverse scored) using a scale ranging from 1 (strongly disagree) to 4 (strongly agree). After reverse scoring the five negatively worded items, responses were summed. Higher scores indicate higher self-esteem. The scale was reliable with a Cronbach's alpha of .88.

Weight-Related Questions
Besides calculating BMI based on the students' self-reported height and weight, we also asked them about the presence of overweight and eating disorders in the family and whether they are currently on a slimming diet and, whether they take care of their own diet (no/yes).

Health Behavior
In terms of other health-related variables, we asked about sporting (no/yes), frequency of smoking, drinking and binge drinking over the last three months (on 6-point scales) as well how they evaluate their own health (self-perceived health in dichotomized form: fair/poor or good/excellent).

Statistical Analysis
SPSS program (Version 22.0.) was used for the analyses. A significance level of .05 was set. Descriptive statistics were calculated and a correlation matrix for the study variables was produced. The contribution of psychological, and weight-and health-related variables in body appreciation was assessed by multiple linear Piko,Obál,& Mellor 679 regression models separately, then in combination. Collinearity diagnostics of the multiple linear regression models were also conducted to examine the reliability of the models.  (1.14)
In terms of the connections between the psychological and health-and weight-related variables, some significant correlations need also be highlighted. Although BMI did not correlate with any of the other psychological variables, it was associated with the presence of overweight in the family (r = .23, p < .001) and the tendency to engage in slimming behaviors (r = .21, p < .001). Those reporting higher BMI rated their own health worse (r = -.24, p < .001). Diet control showed positive correlations with the psychological variables, sporting engagement, and self-perceived health, but also with dieting to lose weight. Sporting engagement, besides being positively correlated with the psychological variables, was negatively related to slimming behavior. There were negative correlations between slimming behaviors and two psychological variables other than body appreciation, optimism and self-esteem (r = -.14, p < .01 in each case). Finally, both overweight and eating disorders in the family were negatively correlated with the psychological variables; the correlations were stronger in the latter case (see Table 1). Table 2 displays the multiple regression models exploring the contribution of psychological and health-and weight-related variables in female adolescents' body appreciation, including the collinearity statistics. In the first model, the roles of psychological variables were explored. Self-esteem proved to be the strongest predictor (β = 0.59, p < .001). Satisfaction with life played a less role (β = 0.19, p < .001) and optimism the least (β = 0.09, p < .05). Altogether, these variables accounted for 58 percent of the total variance in body appreciation scores.

Multiple Regression Analysis
However, self-esteem accounted for the majority of this (54%).  Piko,Obál,& Mellor 681 In the second model, the contributions of health-and weight-related variables were tested. In this model, only 22% of the variance in body appreciation was accounted for. Self-perceived health (β = 0.24, p < .001) played the greatest role, but eating disorders in the family (β = -0.18, p < .001), dieting to lose weight (β = -0.16, p < .001) and binge drinking (β = -0.12, p < .05) were also all negatively related to body appreciation, while sporting was weakly but positively associated (β = 0.09, p < .05).
The reliability of the models was further examined with Variance Inflation Factor (VIF) indices and tolerance values. The VIF values were within the acceptable VIF range (below 2).

Discussion
Although body image receives considerable attention in literature, to date more studies have focused on negative body image than on positive aspects, such as body appreciation (Voelker et al., 2015). This is particularly critical in female adolescents for whom developing positive attitudes towards their body can prevent eating disorders and distorted body image later. In health promotion programs, developing and supporting a positive body image can be a key focus. Therefore, in this paper we concentrated on psychological, weightand health-related contributors to body appreciation in a sample of Hungarian female adolescents. Some of these variables may serve as protective factors, while others may elevate the risk of lower levels of body appreciation.
Our findings support previous suggestions that body appreciation is closely connected to self-esteem: having a higher level of self-esteem may contribute to a positive approach to our body and vice versa (Alleva et al., 2016;Frisén & Holmqvist, 2010;Wood-Barcalow, Tylka, & Augustus-Horvath, 2010). Previous studies also reported a close association between these two variables (Alleva et al., 2016;Razmus & Razmus, 2017). The other two psychological variables played lesser roles in body appreciation than we had expected: satisfaction with life was positively but relatively weakly related, and optimism even less so. Previous studies reported stronger connections with these variables (Alcaraz-Ibáñez et al., 2017;Frisén & Holmqvist, 2010;Wood-Barcalow et al., 2010). While bidirectional associations between body appreciation and these two variables were relatively stronger, in multiple regression analyses their role became weaker. This is likely because self-esteem, as the dominant variable supressed their role in body appreciation. Future research is needed to further clarify these associations and to identify other psychological variables that may contribute to body appreciation among adolescent girls.
Our results also confirmed that body appreciation is closely related to subjective evaluations of health (Meland, Haugland, & Breidablik, 2006). Those participants who perceived their own health to be good or excellent also displayed higher level of body appreciation. Health behavior also played a role, particularly sporting engagement: those who were engaged in sports reported better body appreciation. This is in concordance with previous research findings (e.g., Homan & Tylka, 2014). However, while previous studies also found a Body Appreciation Among Female Adolescents 682 relationship between smoking, drinking and body appreciation (Dumitrescu et al., 2008;Jones et al., 2018;Kennedy et al., 2019;Neumark-Sztainer et al., 2006), we found only a slight negative association with binge drinking, with those who engaged in binge drinking tending to be less appreciative of their own body. Although cause-and-effect relationships cannot be identified here, we may hypothesize that those who do not appreciate their own body do not take care of it in an appropriate way. The difference between smoking and binge drinking may be both practical and cultural: While negative impacts of binge drinking can be directly experienced by adolescents, smoking can contribute to longer term health consequences. In addition, female smoking is much more accepted in Hungary than female binge drinking. Another finding also supports interpretation of self care in relation to body image: those who reported higher levels of body appreciation also tended to take care of their diet. This is consonant with other findings (Neumark-Sztainer et al., 2006).
Finally, the role of family has also been implicated in the development of either positive or negative attitudes towards our body (Arroyo et al., 2017;Sonneville et al., 2012;Webb et al., 2018). Our results emphasized the role of eating disorders in the family; the presence of such problems may lead to lower body appreciation among female adolescents. The bivariate relationships suggest that those who reported eating disorders in the family also scored lower on the life satisfaction, self-esteem and optimism scales, and also tended to slim themselves. More research is necessary to gain deeper insight into these associations. In addition, there was a slight but negative correlation between body appreciation and overweight in the family; however, in multivariate analyses it became nonsignificant.
As mentioned above, due to the cross-sectional nature of our research, cause-and-effect relationships cannot be determined from our data. A second limitation is that we relied on self-report for our data. While this is not necessarily a significant issue for the psychological variables, it may have impacted on the reliabilty of our measurement of variables such as BMI, family history of eating problems and engagement in health behaviors.
Further, some of the values of correlation and regression coefficients are rather weak. Finally, due to specific cultural context, generalizability of our study may be limited.
There are several contributions of our study to the current literature. Most importantly, confirming the strong association between self-esteem and female adolescents' body appreciation, our study indicates a need for future research to explore other psychological variables that might also be related to positive body image. In addition, our results also draw the attention to the potential role of family factors (e.g., overweight and eating disorder in the family) in the development of adolescents' body image. Although qualitative studies can more deeply explore the mechanisms underpinning these associations, our data provide evidence of them. Third, our results also emphasize that sporting and binge drinking may play opposite roles in forming body appreciation among girls.
Furthermore, an important strength of our paper is that our findings highlight the difference in associations of various types of substance use with body image, in that while binge drinking is associated, smoking is not, perhaps due to its social acceptance and its delayed health consequences. Finally, we believe that using a sample of Hungarian adolescents is also a strength since to our best knowledge, body appreciation has not yet been explored in this culture. Piko,Obál,& Mellor 683 Conclusions Adolescence is an important life stage when both body image and self-esteem are very vulnerable, particularly among female adolescents. It is important to detect both risk and protective factors that are related to girls' body appreciation and to help them to develop a healthy attitude towards their body. Our study indicates that 1) there is a close association between female adolescents' body appreciation and their self-esteem; 2) the association between body appreciation and life statisfaction is also positive, but much weaker; 3) self-perceived health, diet control and engagement in sport are positively related to body appreciation, while binge drinking, dieting to lose weight, and eating disorders in the family may be negative contributors; 4) BMI plays a very limited role in teenager girls' body appreciation. More research is needed to further clarify the role of the family, and other psychological variables should be included in the studies of this nature.
While body image concerns, eating problems and obesity among adolescents have became targets of health education programs over the last decades in Western Europe, United States, Canada and Australia (Yager & O'Dea, 2010), no similar program has been developed in Hungary. Therefore, research of body image among adolescents -particularly female adolescents in Hungary-should be prioritized in order to inform the development of effective health education programs that focus on positive body image. Such programs should also include information of nutrition and media literacy, strengthening self-esteem and resilience.

Funding
The authors have no funding to report.