The influence of anxiety-related emotional disorders and self-esteem on obesity among Chinese children

Study design and participants

This study used a non-experimental, cross-sectional research design to examine the relationship between anxiety-related emotional disorders, self-esteem, and obesity in Chinese children. The sample consisted of 136 children aged 6-12 years from Anhui Province, China. Participants were able to give informed consent from their parents. Exclusion criteria included the presence of any diagnosed psychiatric or neurological disorders as reported by the participants.

Measures

Obesity

The study used the “Chinese screening for overweight and obesity among school-age children and adolescents” from the “Health Industry Standards of the People’s Republic of China” to identify obesity. This standard is recommended by Dang et al.⁸ for its prioritization in diagnosing obesity in Chinese children. It has been widely adopted in research on obesity screening for children and adolescents in China, proving its effectiveness and reliability.⁹ According to China’s National Health Council’s standards for children aged 6-18, BMI is evaluated against age- and gender-specific thresholds: Overweight: BMI ≥ P85 threshold but < P95 threshold. Obesity: BMI ≥ P95 threshold.

Screen for Child Anxiety Related Disorders (SCARED)

The SCARED tool, closely related to the DSM, consists of 41 items. It effectively distinguishes between the five types of anxiety: Panic disorder, generalized anxiety disorder, separation anxiety disorder, social anxiety disorder, and school avoidance.¹⁰ The Chinese version, revised in 2008, is suitable for assessing anxiety symptoms in Chinese children and adolescents aged 6-18 years in China.¹¹ Its strong psychometric properties, including significant validity and reliability across various populations, have been well-documented in scholarly research.¹²

The Children’s Self-esteem Scale

The CSES, developed by Wei Yunhua, was administered to primary and secondary school students in China and has an internal consistency coefficient of 0.69, indicating high reliability.^13,14 It consists of 26 items scored on a 5-point Likert scale, with higher scores indicating higher self-esteem. The CSES includes reverse-scoring items and measures appearance, sports, ability, sense of achievement, discipline, and public morality/helping others. Scores are categorized into three groups: high self-esteem, middle group, and low self-esteem.

Data analysis

Preliminary analyses included descriptive statistics to summarize the sample characteristics and the main study variables. Pearson correlation analysis was used to explore the relationships between anxiety-related emotional disorders, self-esteem, and obesity. This analysis helped to identify the strength and direction of the associations between these variables, providing insight into how anxiety and self-esteem are related to obesity in children.

Multiple linear regression analysis was used to examine the extent to which anxiety-related emotional disorders and self-esteem predicted obesity. Panic disorder, generalized anxiety disorder, separation anxiety disorder, social anxiety disorder, and school avoidance were entered as independent variables and BMI score was the dependent variable. Beta coefficients, significance levels, and R-squared statistics were reported to describe the relationships between variables. Significance levels were set at p < .05 for all statistical tests.

Descriptive statistics

In this study, a random sampling method was employed to survey student counseling centers in Hefei City, Anhui Province. A total of 136 questionnaires were distributed. After removing invalid and incomplete responses, 121 valid questionnaires were collected. Table 1 shows the demographic information of participants. The students had a mean age of 9.68 years (SD = 1.59), with 55.4% boys and 44.6% girls participants.

The distribution of BMI weight status and anxiety symptoms in the sample is presented in Table 2. Among the sample, there were 60 non-overweight and non-obese children (49.6%), comprising 28 boys and 32 girls. There were 25 overweight children (20.7%), with 17 boys and 8 girls. The sample included 36 obese children (29.8%), consisting of 22 boys and 14 girls. The distribution of anxiety disorders among the children was as follows: 25 children (20.7%) had panic disorder, including 12 boys and 13 girls. Generalized anxiety disorder was present in 14 children (11.6%), with 7 boys and 7 girls. Separation anxiety disorder affected 41 children (33.9%), consisting of 22 boys and 19 girls. Social anxiety disorder was found in 20 children (16.5%), including 6 boys and 14 girls. School avoidance was observed in 20 children (14.0%), with 9 boys and 8 girls. In terms of self-esteem, 20 children (16.5%) had low self-esteem, including 11 boys and 9 girls. A moderate level of self-esteem was reported in 88 children (72.7%), comprising 50 boys and 38 girls. High self-esteem was noted in 13 children (10.7%), with 6 boys and 7 girls.

Reliability analysis

Reliability analysis of the anxiety and self-esteem scales yielded the following results: The anxiety scale, comprising 41 items, had a Cronbach’s α of 0.915, with a mean of 17.56 (SD = 12.520) which indicated very good reliability. The self-esteem scale, comprising 26 items, had a Cronbach’s α of 0.835, with a mean of 71.68 (SD = 14.312) which indicated good reliability.

Correlation analysis

Pearson correlation coefficient analysis is conducted to examine the first objective of the study, being the relationship between obesity (based on BMI scores) and anxiety disorder in Chinese children.

Table 4 shows the correlation analysis results of each variable. Correlation analysis reveals significant relationships between several variables. BMI shows a significant positive correlation with Panic Disorder (r=0.214*) and Separation Anxiety Disorder (r=0.223*), indicating that higher levels of these disorders are associated with higher BMI. Panic Disorder exhibits strong positive correlations with Generalized Anxiety Disorder (r=0.692**), Separation Anxiety Disorder (r=0.557**), Social Anxiety Disorder (r=0.399**), School Avoidance (r=0.520**), and Self-esteem (r=0.407**). These findings suggest that higher levels of one anxiety-related disorder are often accompanied by higher levels of other disorders and lower self-esteem. These correlations support Hypothesis 1 by demonstrating significant relationships between anxiety-related emotional disorders, self-esteem, and BMI scores.

Regression analysis

Table 5 presents the multiple linear regression analysis results, examining whether anxiety-related emotional disorders and self-esteem can significantly predict children’s obesity (BMI). The analysis, with BMI as the dependent variable, provides valuable insights into the predictors of BMI among children. Panic Disorder emerged as a significant predictor of higher BMI (B=0.597, p<0.01), indicating that increased levels of panic disorder are associated with higher BMI scores. Similarly, Separation Anxiety Disorder significantly predicts higher BMI (B=0.463, p<0.05), implying that higher levels of separation anxiety disorder are linked to increased BMI.

Conversely, Generalized Anxiety Disorder significantly predicts a lower BMI (B=-0.460, p<0.05), suggesting that higher levels of generalized anxiety disorder are associated with lower BMI scores. Additionally, School Avoidance is a significant predictor of lower BMI (B=-0.947, p<0.05), indicating that higher levels of school avoidance are associated with lower BMI scores. However, Social Anxiety Disorder and Self-esteem do not significantly predict BMI in this model.

These findings support Hypothesis 2, suggesting that anxiety-related emotional disorders and self-esteem can significantly predict obesity in children, The overall regression model explains 13.7% of the variance in BMI (R Square = 0.137, Adjusted R Square = 0.091), indicating that while these emotional disorders contribute to variations in BMI, a large proportion of the variance remains unexplained.

Discussion

The first aim of the current study is to assess the relationship between anxiety-related emotional disorders, self-esteem, and BMI (obesity) in children in China. The results of the current study showed a significant relationship between anxiety-related emotional disorders, self-esteem, and BMI (obesity).

This finding is consistent with most previous studies, such as Rofey et al.,¹⁵ who found that anxiety disorders are common among obese children and that both childhood depression and anxiety are associated with increasing BMI percentiles over time. Similarly, Patalay and Hardman¹⁶ observed that the association and interrelationship between BMI and internalized symptoms strengthen as children age. Research suggests a significant association between obesity and low self-esteem in Chinese children, with obese primary school children in China having lower self-esteem scores than their normal-weight peers.¹⁷ This association is particularly pronounced in girls, with overweight girls showing higher scores for depression symptoms. Body dissatisfaction partially explains the association between obesity and low self-esteem in both sexes.¹⁸ The relationship between obesity and self-esteem appears to strengthen as children progress through primary school.¹⁹ While some studies suggest that low self-esteem may precede the development of obesity,²⁰ others suggest that obesity is more likely to lead to low self-esteem,²¹ highlighting the need for early intervention in the management of childhood obesity.

The current study also examined the role of anxiety-related emotional disorders and self-esteem in predicting childhood obesity in China. Multiple regression analysis revealed that panic disorder and separation anxiety disorder significantly predicted higher BMI, indicating that children with these conditions were more likely to be obese. This is consistent with the findings of Haghighi et al.,²² who reported that children and adolescents with Panic Disorder had the highest mean BMI. Similarly, pre-adolescent Separation Anxiety symptoms are associated with increased BMI in adolescent boys, with the relationship mediated by emotional eating, hunger sensitivity, and difficulty regulating emotions.²³ In addition, early separation anxiety and a focused attachment style are significant predictors of body dissatisfaction in women with eating disorders, which may increase the risk of developing eating disorders.

In contrast, generalized anxiety disorder and school avoidance significantly predict lower BMI, meaning that children may be underweight, probably due to reduced appetite or avoidance behaviors that affect eating patterns. One study shows that Generalized Anxiety Disorder is the most common among school-aged children in China.²⁴

However, findings on the relationship between social anxiety disorder, self-esteem, and obesity are inconsistent in the literature. Social Anxiety Disorder and Self-Esteem did not significantly predict BMI in this study, possibly due to their complex or indirect effects not captured by the analysis. This finding contrasts with other literature suggesting that social appearance anxiety is negatively correlated with self-esteem, with BMI acting as a mediating factor.²⁵ Kornapalli et al.²⁶ found that body image concerns were negatively correlated with self-esteem and positively correlated with social anxiety, with significant BMI-related differences. Furthermore, Horenstein et al.²⁷ argued that Social Anxiety moderates the relationship between BMI and exercise avoidance motivation, particularly for those with higher BMIs. While these studies demonstrate associations between social anxiety, self-esteem, and BMI, they do not definitively establish the specific predictive value of social anxiety and self-esteem for BMI.

Furthermore, Sheinbein et al²⁸ mention in their study that the pathology of eating disorders in children is significantly correlated with anxiety symptoms in children. Children with obesity or eating disorders often have difficulty controlling their eating behavior, which leads to weight gain and associated negative emotions such as shame, guilt, and anxiety. In addition, T. Wang et al.²⁹ emphasized the importance of healthy weight status for the development of young children, particularly in terms of cognitive function. Moss et al.³⁰ mentioned that obesity may impair the activation of neurophysiological components that are essential for cognitive function, thus affecting children’s cognitive function. These studies again highlight the link between cognitive development in obese children and emotional problems such as anxiety and low self-esteem.

Limitation

The results of this study have important implications for clinical practice, educational settings, and public health policy, especially for children in China. However, some limitations of our study should be noted. First, this study uses cross-sectional data to assess associations between variables in childhood and cannot reveal causal relationships between variables. Second, all study variables except the BMI score were self-reported measurements, which introduces a degree of subjectivity. Additionally, the reliability analysis shows that the school avoidance scale needs improvement, and future studies should select larger samples and more reliable measurement tools. The sample was also limited to Hefei, Anhui Province, which may affect the generalizability of the findings. Finally, according to the biological ecological model, the environmental systems affecting the psychological and physical development of children and adolescents can be divided into micro, meso, extrinsic, and macro systems.³¹ Future studies could explore these aspects in more depth to identify other factors that combat psychological distress.

Summary

This study highlights significant relationships between anxiety-related emotional disorders, self-esteem, and obesity among children in Hefei City, Anhui Province. The results show that certain anxiety disorders, such as Panic Disorder and Separation Anxiety Disorder, are associated with higher BMI, while Generalized Anxiety Disorder and School Avoidance are linked to lower BMI. These findings underscore the importance of addressing mental health issues in obesity prevention and treatment. Despite the study’s limitations, it provides a valuable foundation for future research and offers insights for clinical practice, educational settings, and public health policies. Continued efforts to understand and address the interplay between mental health and obesity are crucial for promoting children’s overall well-being.