
==== Front
Tunis Med
Tunis Med
Tunis Med
La Tunisie Médicale
0041-4131
2724-7031
Tunisian Society of Medical Sciences

Article
Surcharge pondérale chez les lycéens : Relation avec la santé mentale et les facteurs socio-démographiques
Weight excess among high-school students: Relation with mental health and sociodemographic factorsOuni Ferdaous 112
Ghammam Rim 332
Benfredj Sihem 332
Zammit Nawel 332
Eleuch Israr 33
Chelly Souhir 334
Kalboussi Houda 335
Maatoug Jihen 332
Harrabi Imed 332
Ghannem Hassen 332
1. Doctoral Commission "Health Science", Faculty of Medicine of Sousse, University of Sousse, Sousse, Tunisia
2. Farhat Hached Hospital, Department of Epidemiology (LR19SP03), 4000,Sousse, Tunisia
3. University of Sousse, Faculty of Medicine of Sousse ,4000, Sousse, Tunisia
4. Farhat Hached hospital, Hospital Hygiene Service, 4000, Sousse, Tunisie.
5. Farhat Hached Hospital, Department of occupational Health, (LR19SP03), 4000, Sousse, Tunisia
3 2023
05 3 2023
102 3 139145
2022
https://creativecommons.org/licenses/by-nc-nd/4.0/ This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 Unported License. To view a copy of this license, visit https://creativecommons.org/licenses/by-nc-nd/4.0/
RESUME

Introduction: La prévalence croissante de l'obésité chez les adolescents représente un défi complexe de santé publique. Des études récentes révèlent une augmentation de la consommation de substances addictives chez les adolescents, avec des addictions non liées aux substances. Les adolescents en surpoids sont particulièrement susceptibles à ces comportements à risque. La Tunisie, en transition démographique, n'est pas épargnée de ce phénomène, avec une prévalence en augmentation inquiétante. Objectif: Notre travail visait à évaluer la prévalence de l'obésité chez les adolescents et à explorer les liens entre les facteurs sociodémographiques, la santé mentale et le surpoids. Méthodes : Une étude transversale a été menée auprès d'un échantillon d'adolescents tunisiens des lycées de Sousse. Les participants à l'étude ont été recrutés par un échantillonnage stratifié proportionnel. Résultats: Notre étude comprenait 1399étudiants, majoritairement féminins, avec un âge moyen de 17±1,5 ans. L'IMC (Indice de Masse Corporelle) moyen était de 22,7±4,1kg/m². Selon les critères de l'International Obesity Task Force (IOTF), 20,4% étaient en surpoids et 7% étaient obèses, aboutissant à une prévalence globale de surcharge pondérale de 27,4%. Les filles présentaient une prévalence plus élevée de surcharge pondérale par rapport aux garçons. L'analyse multivariée a identifié des facteurs associés au surpoids et à l'obésité, notamment une profession libre de la mère (ORa=2,13,[1,5-3,35],p <0,001), une activité physique régulière (ORa=0,61,[0,47-0,80], p <0,001), une utilisation d'internet ≥2heures(ORa=0,70, ,[0,5-0,9], p=0,045), une consommation quotidienne de fruits et légumes (ORa =1,51,[1,15-1,97],p=0,003), une alexithymie possible (ORa=1,55,[1,07-2,22],p=0,018), une anxiété probable (ORa=1,28,[0,87-1,89],p=0,007), une anxiété très probable (ORa=1,61,[1,14-2,2],p=0,037), et une utilisation problématique du Facebook (ORa=0,67,[0,5-0,8],p=0,006). Conclusion: La compréhension des facteurs liés à la surcharge pondérale dans notre contexte social et culturel est cruciale pour développer des stratégies efficaces. Accorder une attention particulière à la santé mentale et aux comportements addictifs revêt une importance capitale. Les interventions devraient adopter une approche multisectorielle, se concentrant spécifiquement sur les mères actives au sein de l'environnement socio-familial des adolescents. Il est également essentiel de prendre en compte la santé mentale, en mettant particulièrement l'accent sur des aspects tels que l'alexithymie et l'anxiété.

ABSTRACT

Introduction: The escalating prevalence of adolescent obesity represents a complex public health challenge, influenced by interactions of environmental, socio-economic, and behavioral factors. Recent studies reveal a surge in addictive substance use among adolescents, with non-substance addictions. Overweight adolescents are particularly susceptible to risky behaviors. Tunisia is not exempt from this issue, facing a rapidly increasing prevalence. Aim: Our work aimed to assess the prevalence of obesity among adolescents and to explore the connections between sociodemographic factors, mental health, and overweight in this demographic group. Methods: A cross-sectional study was led among sample of Tunisian high school adolescents from Sousse. We enrolled study participants through proportional stratified sampling. Results: Our study included 1399students, predominantly female, with an average age of 17±1.5 years. The average BMI (Body Mass Index) was 22.7±4.1 kg/m². According to the International Obesity Task Force (IOTF), 20.4% were overweight, and 7% were obese, resulting in an overall weight excess prevalence of 27.4%. Girls exhibited a higher weight excess prevalence compared to boys. Multivariate analysis identified factors associated with overweight and obesity, including maternal self-employment(aOR=2.13,[1.35-3.35];p <0.001), regular physical activity (aOR=0.61,[0.47-0.8];p <0.001), internet usage ≥2 hours (aOR=0.70,[0.50-0.99];p=0.045), daily fruit-vegetable consumption (aOR=1.51,[1.15-1.97]; p=0.003), possible alexithymia (aOR=1.55,[1.07-2.22];p=0.018), probable anxiety (aOR=1.28,[0.87-1.89]; p=0.007), very probable anxiety (aOR=1.61,[1.14-2.2]; p=0.037), and problematic Facebook-use (aOR=0.67,[0.50-0.89]; p=0.006). Conclusion: Understanding factors tied to excess weight in our social and cultural context is crucial in shaping effective public health strategies. Interventions should adopt a multisectoral approach specifically targeting working mothers within the adolescent's socio-familial environment. It is fundamental also to address mental health concerns, with a particular focus on alexithymia and anxiety.

Mots clés

Obésité
surcharge pondérale
santé mentale
addiction
adolescents
Keywords

obesity
overweight
mental health
addiction
adolescent
==== Body
pmcIntroduction

Adolescence, a crucial transitional phase in human development, involves significant physical, psychological, and social changes, often setting the foundation for lifelong health behaviors (1).

The increasing prevalence of obesity among adolescents has become a substantial and intricate public health issue (2,3).

Its contemporary landscape is marked by a complicated interaction of genetic, environmental, socioeconomic, and behavioral factors (4 ).

Recent studies highlight a growing trend among adolescents, particularly those facing challenges, toward the use of addictive substances such as tobacco, cannabis, and alcohol (5).

Non-substance addictions, such as those related to social media, video games, and cyber addiction, have also been observed (6–8).

A substantial body of research supports the notion that overweight adolescents are more susceptible to engage in these risky behaviors (7 ).

Tunisia is currently undergoing a demographic and epidemiological transition marked by the emergence of non-communicable diseases(9).

This shift is accompanied by a concerning increase in the prevalence of these diseases (10,11).

Moreover, the changing landscape has influenced the lifestyle choices of young Tunisians, who are progressively adopting Western habits, including reduced physical activity and a high-calorie diet (12).

Notably, in 2014, approximately 16.1% of urban Tunisian adolescents were found to be overweight (11).

These overweight adolescents often reported a decline in their quality of life and encountered mental health issues (13).

Recognizing the serious consequences of this trend, it is imperative to carry out thorough screening for obesity, taking into account its physical and psychological dimensions, and to explore the factors associated with it.

Our work aimed to assess the prevalence of obesity in adolescents and to explore the connections between sociodemographic factors, mental health, and obesity/overweight in this demographic group.

methods

We conducted a cross-sectional study among high school students in 2018 in the region of Sousse, Tunisia.

A self-administered, anonymous questionnaire in Arabic was distributed during classroom sessions.

Anthropometric measurements were obtained through physical examinations made by trained professionals.

Body weight was recorded with a portable electronic scale, precise to 100 grams.

Height was measured using a portable wall-mounted stadiometer, accurate to 0.5 cm.

To ensure an adequate sample size, we aimed for 1095 participants, considering a reported smoking prevalence of 26% (14).

This was then increased to 1314 to account for an estimated non-response rate of 20%.

We employed a two-stage proportional sampling approach, selecting three delegations within the city of Sousse: Sousse-city, Sousse-Jawhara, and Sousse-Riadh.

To determine the body mass index, we calculated the ratio of body weight to height squared and expressed in kg/m².

To assess the weight status, data defined by the International Obesity Task Force (IOTF) (15, 16 ).

Based on the criteria of the International Obesity Task Force (IOTF), the BMI threshold values defining overweight and obesity were those proposed by Cole et al (15,16).

An adolescent is considered overweight or obese if his/her BMI is equal to or greater than the threshold values for age and gender (15 ).

Concerning the tobacco use we defined smoker as the consumption of at least one cigarette in the past month (17).

Alcohol consumption, reflecting individuals who had consumed alcohol at least once in their lifetime (18).

Problematic use of Facebook was evaluated utilizing a condensed version of the Bergen Facebook Addiction Scale (BFAS) (19), while problematic use of video games was assessed through a translated and validated 21-item videogame addiction scale (20).

The presence of anxiety disorder was determined using the SCARED-C scale (21).

Depression was evaluated with the Arabic version of the "" Beck Depression Inventory-II" scale (BDI-II scale) (22).

Additionally, alexithymia was measured using the validated "The twenty-item Toronto Alexithymia Scale," and self-esteem was assessed by the Rosenberg Selfesteem Scale (RSE) (23).

Statistical analysis: We used SPSS software version 11 to analyze the data.

To compare percentages and means among independent samples, we employed the chi-squared (χ2) test and Student's t-test, as appropriate.

For multivariate analysis, we conducted binary logistic regression, where the dependent variable was coded as 1 for "" yes" and 0 for ""no" to indicate the presence of overweight.

The results concerning the risk associated with overweight were reported as adjusted odds ratios (aOR) along with their corresponding 95% confidence intervals.

Ethical consideration:

The research protocol, questionnaire, and consent form were approved by the ethics committee at "" Farhat Hached" University Hospital in Sousse.

We also obtained written consent from the parents of the students before collecting data, and the students had the choice to participate or not.

Importantly, our study posed no risks to the participants.

results

Our sample consisted of 1,399 students, with a response rate of 89.9%.

We observed a female predominance making up 60.5% of the total (with a sex ratio=0.65).

The average age was 17±1.5 years.

Among the participants, 38.2% fell within the 14-16 age group, while 37.1% were older than 17 years (table 1).

Nearly one-quarter of the students were in their fourth year of secondary school, and 26.3% were in their first year, with 29% of them having experienced repeating a year

In terms of parental occupation, approximately one-third of the students' fathers were employed as state officers, while half of the students' mothers were homemakers.

Regarding parental education, 41.6% of the participants'fathers held university degrees, along with 36.5% of the participants' mothers.

Details of the sociodemographic characteristics of the study population can be found in Table1.

Table 1 : Sociodemographic Characteristics and Their Association with Weight Status among Participants in Sousse High Schools during 2018

Total

	Normal weight n (%)

	Overweight n (%)

	OR (IC95%)

	p

	
Gender

					
Female

	846 (60.5)

	592 (70)

	254 (30)

	1.41 (1.10-1.82)

	p=0.006

	
Male

	553 (39.5)

	424 (76.7)

	129 (23.3)

		0.209

	
Level of Education

					
1st year

	368 (26.3)

	261 (25.7)

	107 (27.9)

		0.209

	
2nd year

	304 (21.7)

	231 (22.7)

	73 (19.1)

	0.77 (0.55-1.09)

		
3rd year

	354 (25.3)

	264 (26.0)

	90 (25.4)

	0.83 (0.61-1.14)

		
4th year

	373 (26.7)

	260 (25.6)

	113 (29.5)

	1.06 (0.77-1.45)

		
Repeating a Grade

					
Yes

	992 (29.1)

	291 (28.6)

	116 (30.3)

	1.08 (0.83-1.39)

	0.546

	
No

	407 (70.9)

	725 (71.4)

	267 (69.7)

		
Mother’s Education Level

					
Illiterate or Primary

	390 (28.1)

	307 (30.4)

	83 (21.8)

		0.005

	
Secondary

	491 (35.4)

	350 (34.8)

	141 (37.1)

	1.49 (1.09-2.04)

		
Higher Education

	506 (36.5)

	350 (34.8)

	156 (41.1)

	1.65 (1.21-2.24)

		
Father’s Education Level

					
Illiterate or Primary

	330 (23.8)

	244 (24.2)

	351 (34.9)

		0.666

	
Secondary

	480 (34.6)

	351 (34.9)

	129 (33.9)

	1.05 (0.80-1.49)

		
Higher Education

	576 (41.6)

	411 (40.9)

	165 (43.2)

	1.14 (0.88-1.60)

		
Mother’s Occupation

					
Homemaker

	703 (50.8)

	523 (52.1)

	180 (47.4)

		0.030

	
Manual Worker

	121 (8.7)

	92 (9.2)

	29 (7.6)

	0.94 (0.60-1.48)

		
Self-Employed

	106 (7.7)

	64 (6.4)

	42 (11.1)

	1.97 (1.28-3.01)

		
State officers

	328 (23.7)

	234 (23.3)

	94 (24.7)

	1.20 (0.89-1.62)

		
Manager/Executive

	125 (9.1)

	90 (9.0)

	35 (9.2)

	1.16 (0.76-1.79)

		
Father’s Occupation

					
Unemployed

	129 (9.6)

	93 (9.5)

	36 (9.4)

		0.946

	
Manual Worker

	211 (15.7)

	157 (16.0)

	54 (14.9)

	0.88 (0.52-1.41)

		
Self-Employed

	377 (28.0)

	270 (27.5)

	107 (29.5)

	1.02 (0.65-1.62)

		
State officers

	394 (29.9)

	295 (30.0)

	105 (28.9)

	0.90 (0.62-1.49)

		
Manager/Executive

	229 (17.0)

	168 (17.1)

	61 (16.8)

	0.94 (0.56-1.53)

		

The average BMI in our sample was 22.7±4.1 kg/m².

According to the International Obesity Task Force(IOTF) criteria, 20.4% of the participants were classified as overweight (95% CI: 18.3%–22.3%), and 7% were classified as obese (95% CI: 5.6%–8.4%).

This means that the overall prevalence of weight excess was 27.4% (95% CI: 25.0%–29.7%).

Girls had a higher prevalence of weight excess compared to boys, with 30% of girls being in the weight excess category as opposed to 23.3% of boys.

This gender difference was statistically significant (OR=1.41; 95% CI:1.10-1.82; p=0.006) (table 1).

When considering addictive behaviors, we noticed a significant association between the consumption of at least one of the three forms of smoking and weight status (OR=0.67; 95% CI: 0.49-0.92; p=0.014) (table 2).

In contrast, tobacco use did not differ between the obese/overweight group (13.1%) and the normal weight group(p=0.48).

A significantly higher level of problematic Facebook use was observed in the normal weight group compared to the overweight-obese group (17.6% vs. 12.8%, p=0.02).

A similar trend was noted for video gaming, although it was not statistically significant (p=0.09) (table 2).

Regarding mental health, several observations were made.

Anxiety was significantly more frequent among students with overweight or obesity compared to those with normal weight (p=0.006) (table 2).

Additionally, the prevalence of potentially moderate to severe depression was slightly higher among obese or overweight students compared to those with normal weight, but this difference did not reach statistical significance (p=0.169).

It's worth noting that no significant differences were observed in terms of alexithymia and self-esteem among students with varying weight statues (table 3).

After conducting a multivariate analysis, we identified several factors associated with overweight and obese adolescents.

Specifically, these factors included the mother's self-employment (aOR=2.13, p< 0.001), regular physical activity (aOR=0.61, p< 0.001), internet usage time ≥2 hours (aOR=0.70, p=0.045), consumption of the recommended 5 fruits and vegetables per day (aOR=1.51, p=0.003), possible alexithymia (aOR=1.55, p=0.018), probable and very probable anxiety (aOR=1.28, p=0.007; aOR=1.61, p=0.037), and problematic use of Facebook(aOR=0.67, p=0.006)(table 3).

Table 2 : Weight Status Association with Lifestyle Habits, Addictive Behaviors, and Mental Health of participants in Sousse High Schools during 2018

	Total

	Normal weight n (%)

	Overweight n (%)

	OR (IC95%)

	p

	
Regular Physical Activity

	Yes

	449(45.1)

	128(33.9)

	0.62(0.49-0.79)

	<0.001

	
	No

	546(54.9)

	250(66.1)

	-

		
Time Spent on the Internet per Day

	< 2 hours

	137(14.5)

	73(20.3)

	-

	0.011

	
	≥ 2 hours

	806(85.5)

	286(79.7)

	0.66(0.50-0.90)

		
Consumption of 5 fruits and vegetables/day

	Yes

	312(31.3)

	144(37.9)

	1.34(1.05-1.71)

	0.021

	
	No

	684(68.7)

	236(62.1)

	-

		
Fast Food Consumption

	Less than 3 days/week

	744(74.6)

	291(77.0)

	0.88(0.74-1.25)

	0.401

	
	3 days or more/week

	253(25.4)

	87(23.0)

	-

		
Consumption of at least one of the 3 forms of smoking

	Yes

	215(22.5)

	60(16.3)

	0.67(0.49-0.92)

	0.014

	
	No

	741(77.5)

	307(83.7)

	-

		
E-Cigarettes

	Yes

	132(13.5)

	40(10.8)

	0.77(0.53-1.12)

	0.178

	
	No

	844(86.5)

	331(89.2)

	-

		
Hookah

	Yes

	116(11.8)

	32(8.5)

	0.69(0.46-1.05)

	0.083

	
	No

	868(88.2)

	344(91.5)

	-

		
Drug use

	Yes

	76(7.5)

	22(5.8)

	1.33(0.81-2.16)

	0.259

	
	No

	936(92.5)

	359(94.2)

	-

		
Alcohol consumption

	Yes

	100(9.9)

	40(10.5)

	1.06(0.72-1.57)

	0.754

	
	No

	907(90.1)

	341(89.5)

	-

		
Facebook use

	Problematic

	179(17.6)

	49(12.8)

	0.69(0.49-0.96)

	0.029

	
	Non problematic

	837(82.4)

	334(87.2)

	-

		
Video gaming

	Problematic

	372(36.6)

	122(31.9)

	0.81(0.63-1.04)

	0.097

	
	Non problematic

	644(63.4)

	261(68.1)

	-

		
Depression

	Moderate to Severe

	428(42.1)

	177(46.2)

	1.18(0.93-1.49)

	0.169

	
	Minor or Absent

	588(57.9)

	206(53.8)

	-

		
Anxiety Disorder

	No

	351(34.5)

	99(25.8)

	-

		
	Possible

	195(19.2)

	76(19.8)

	1.38(0.98-1.95)

	0.006

	
	Very probable

	470(46.3)

	208(54.3)

	1.57(1.19-2.07)

		
Alexithymia

	No

	300(29.5)

	91(23.8)

	-

	0.036

	
	Possible

	234(23.0)

	109(28.5)

	1.54(1.11-2.13)

		
	Very probable

	482(47.4)

	183(47.8)

	1.25(0.94-1.67)

		
Self esteem

	Week

	361(35.5)

	147(38.4)

	-

	0.611

	
	Moderate

	425(41.8)

	154(40.2)

	0.90(0.51-1.01)

		
	High

	230(22.6)

	82(21.4)

	0.87(0.24-1.35)

		

Table 3 : Multivariate study of factors associated with overweight among participants in secondary schools in the Sousse region during 2018

	ORa	IC95% ORa	P	
Regular physical activity

	0.61

	0.47-0.80

	<0.001

	
Consumption of 5 fruits and vegetables per day

	1.51

	1.15-1.97

	0.003

	
Mother’s occupation

			0.022

	
Homemaker

				
Worker

	1.01

	0.62-1.64

	0.971

	
Self-employed

	2.13

	1.35-3.35

	<0.001

	
State officer

	1.23

	0.90-1.68

	0.196

	
Manager / executive

	1.02

	0.64-1.60

	0.942

	
Alexithymia

			0.061

	
No

				
Possible

	1.55

	1.07-2.22

	0.018

	
Very probable

	1.27

	0.88-1.81

	0.196

	
Anxiety

			0.024

	
No

				
Probable

	1.28

	0.87-1.89

	0.007

	
Very probable

	1.61

	1.14-2.26

	0.037

	
Problematic use of Facebook

	0.67

	0.50-0.89

	0.006

	
Internet usage time ≥ 2 hours

	0.70

	0.50-0.99

	0.045

	

discussion

The surging occurrence of obesity among adolescents in this decade is emerging as a significant and pressing public health plight (1 ).

Our study focused on determining the prevalence of overweight and obesity, as well as understanding the connections between sociodemographic factors, mental health, and obesity.

A cross-sectional study was conducted with 1,399 participants, revealing that 27.4% were overweight, 20.4% were classified as overweight, and 7% as obese.

Our findings showed that girls had a significantly higher prevalence of excess weight compared to boys.

In the multivariate analysis, key factors associated with excess weight included maternal profession, physical activity, fruit and vegetable consumption, Facebook use, anxiety and alexithymia .

Despite the scarcity of national data in terms of obesity rates among adolescents, there are some insightful Tunisian studies that have documented this pressing public health concern over the course of several years

In 2005, a national study conducted by Aounallah Skhiri et al. (24) involving 2,872 adolescents aged 15 to 19 years unveiled comparatively lower prevalence rates of overweight and obesity when juxtaposed with the findings of our present study.

The respective prevalence figures stood at 19% and 4.3% using WHO/NCHS criteria and 15% and 2.6% using IOTF references (24).

Boukthir et al. (25) embarked on a descriptive study comprising schoolchildren in Tunis, ranging in age from 6 to 12 years during the year 2011 (25).

The prevalence of overweight was recorded at 19.7%, with obesity standing at 5.7% as per IOTF criteria (25).

Meanwhile, the Obesity-Metabolic Syndrome Research Unit in Sfax undertook a study in 2010-2011 aimed at ascertaining the prevalence of overweight and obesity among a cohort of school-age children aged 9 to 12, residing in the city of Sfax (26).

In accordance with IOTF criteria, this study reported prevalence figures lower than those in our study, with obesity recorded at 2.4% and overweight at 6.3% (26).

Globally, the WHO reported that the current prevalence is ten times higher than in the 1970s, reaching 213 million children and adolescents aged 5 to 19 in 2016 (27).

The current prevalence of excess weight in adolescents varied globally(28).

High-prevalence countries (exceeding 20%) included developed countries like those in North America(28).

As well as some developing countries in the Middle East (Kuwait, Egypt, Lebanon) (28).

Our findings indicate that 27.4% of adolescents in our study were overweight, placing Tunisia among high-prevalence countries.

This difference could be attributed to the fact that in some Middle Eastern countries, socioeconomic, behavioral, and cultural beliefs supported the increase of obesity (29).

According to our study, overweight was significantly associated with gender.

Our study identified a predominance of overweight among females.

This female preponderance our findings align with past trends but oppose the current global trajectory (4).

the World Health Organization (WHO) report published in March 2023 for the European regions, overweight and obesity are more common among boys (4).

In total, the prevalence of overweight and obesity is 31% among boys and 28% among girls.

Among the 16 countries that collected data through the COSI Initiative for multiple age groups, the prevalence of obesity increases with age among boys (4).

Additionally, the distribution of excess weight by gender have been observed in different countries, including Saudi Arabia (30), Italy (31), the Islamic Republic of Iran (30), Kuwait (30), and others, where prevalence rates were higher in boys than in girls.

Similar to our distribution several epidemiological studies conducted worldwide in the last decade, have consistently shown a tendency toward higher rates of overweight among adolescent females (32).

Consistent with our study, the NHANES I study conducted in the United States by Must et al. (33) found that obesity was more prevalent among adolescent girls. These variations in prevalence between genders across different populations can be attributed to cultural, sociodemographic, and economic factors (34).

Our research uncovers a noteworthy link between maternal employment and childhood obesity.

Despite the societal advantages of maternal employment, our findings suggest a doubling of obesity risk in children when mothers work as freelancers or managers.

The literature supports the idea that time constraints on working mothers may impact their ability to oversee healthy meals, potentially resulting in increased consumption of processed foods by children (35).

Furthermore, extended maternal work hours have been linked to increased BMI in offspring, likely due to decreased opportunities for physical activity and parental supervision over dietary choices (36).

Our study, after multivariate analysis, demonstrated a relationship between problematic Facebook use and excess weight.

This may be explained firstly by Body Image Concerns.

Adolescents with obesity may experience heightened concerns about body image, potentially leading to a decreased interest in or avoidance of social media platforms where body image is often emphasized (37).

Faced with likely dissatisfaction with their body image, overweight adolescents may avoid posting photos on Facebook (selfies) and consequently use Facebook less (38).

Also for obese adolescents searching for weight loss guidance on Facebook, benefit from the algorithm's focus on success stories, exercise routines, and healthy food choices.

This curated content, while not encompassing the full spectrum of weight loss experiences, can still indirectly raise awareness about healthy living(39).

Other studies have established a positive relationship between time spent on Facebook and weight gain (40).

In secondary schools, the use of "" social media" (Instagram, Facebook), time spent watching television, and time spent playing video games by children were significantly related to weight status (38, 40).

At the same time, Griffiths et al. (41) mentioned that obesity is linked to victimization and social isolation.

Our study revealed that approximately half of overweight adolescents exhibited a high likelihood of anxiety, with significantly higher overall anxiety scores compared to those with normal weight (42).

These findings align with Pinhas-Hamiel et al.'s observations, where they found no statistically significant relationship between BMI and depressive symptoms in obese adolescents (43).

Contrast, a meta-analysis of 17 studies concluded that depression is positively associated with a high BMI (44).

Regarding the link between anxiety, very probable alexithymia, and overweight, other studies have reported results similar to ours (45 ,46).

Morales et al. found a higher prevalence of these factors among overweight youth compared to those with normal weight (46).

Overweight youth in the United States reported more anxiety symptoms than their normal-weight peers (47).

Delvin et al. suggested that obesity affected individuals with mental disorders and serious mental illnesses, particularly anxiety disorders and alexithymia (48).

Obese or overweight children are at a significant risk of low self-esteem, depression, and anxiety (49).

Moreover, they are exposed to discrimination and stigma, which can result in isolation, reduced physical activity, and worsened overweight (49 ).

Conversely, mental health issues could lead to obesity, especially in cases of depressive syndrome, where psychomotor slowing and associated appetite disturbances contribute to weight gain (50).

Similarly, anxiety disorders, such as panic disorder, agoraphobia, or social phobia, can lead to weight gain due to social isolation, inactivity, and avoidance behaviors (50).

In a literature review, McElroy et al. concluded that certain medications prescribed for mental health issues could lead to weight gain (51 ).

Obese children and adolescents were more likely to develop mood disorders and bipolar disorders diagnosed in adulthood (42).

At the closure of our analysis, it's crucial to consider some methodological factors when interpreting our findings.

The cross-sectional design limits establishing causal relationships, highlighting the need for future longitudinal and qualitative investigations.

Despite this limitation, the robust sample size and random selection method support sample representativeness.

The questionnaire, in Arabic, underwent rigorous pre-testing and anonymous selfadministration to ensure comprehension and minimize under-reporting.

These measures enhance the statistical power of our study and reduce potential biases.

conclusion

Gaining insights into the factors associated with excess weight in our social and cultural context can assist public health stakeholders, including primary care physicians, in formulating a comprehensive strategy for preventing excessive weight.

It's imperative to address mental health issues and addictive behaviors, recognizing their significance in this context .

Intervention effort should not be confined to individual approaches but should encompass the child's socio-familial environment in a multi-sectoral approach.
==== Refs
References

Crone EA Achterberg M Prosocial development in adolescence Current Opinion in Psychology 2022 Apr 1 44 220 225 34749238
strategy_english_web.pdf [Internet] 2019 Aug 6 Available from: https://www.who.int/dietphysicalactivity/strategy/eb11344/strategy_english_web.pdf
Reilly JJ Tackling the obesity epidemic: new approaches Arch Dis Child 2006 Sep 91 9 724 726 16923855
World Obesity Atlas 2023 - Futuribles [Internet] 2023 Oct 31 Available from: https://www.futuribles.com/world-obesity-atlas-2023/
Adolescent and young adult health [Internet] 2023 Dec 23 Available from: https://www.who.int/news-room/fact-sheets/detail/adolescents-health-risks-and-solutions
WHO | Facts and figures on childhood obesity [Internet] 2019 Aug 5 Available from: http://www.who.int/end-childhood-obesity/facts/en/
WHO | 10 facts on obesity [Internet] 2019 Jul 23 Available from: http://www.who.int/features/factfiles/obesity/en/
Obesity | WHO | Regional Office for Africa [Internet] 2019 Jul 23 Available from: https://www.afro.who.int/health-topics/obesity
Romdhane HB Khaldi R Oueslati A Skhiri H Transition épidémiologique et transition alimentaire et nutritionnelle en Tunisie. 23
Mirmiran P Sherafat Kazemzadeh R Jalali Farahani S Azizi F Childhood obesity in the Middle East: a review. East Mediterr Health J 2010 Sep 1 16 9 1009 1017 21218730
Maatoug J Fredj SB Msakni Z Dendana E Sahli J Harrabi I Challenges and results of a school-based intervention to manage excess weight among school children in Tunisia 2012–2014. International Journal of Adolescent Medicine and Health 2017 Apr 1 29 2 Available from: http://www.degruyter.com/view/j/ijamh.2017.29.issue-2/ijamh-2015-0035/ijamh-2015-0035.xml
Hajem DS Hsairi PM LE SYSTEME NATIONAL D’INFORMATION SUR LES CAUSES DE DECES : DIAGNOSTIC DE SITUATION ET PRINCIPAUX RESULTATS. 17
Aounallah-Skhiri H Romdhane HB Maire B Elkhdim H Eymard S Delpeuch F Health and behaviours of Tunisian school youth in an era of rapid epidemiological transition. Eastern Mediterranean Health Journal 2009 15 5 14
Groupe Pompidou Enquêtes MedSPAD. Available from: https://www.coe.int/fr/web/pompidou/mednet/medspad [cited 2021 Nov 8]
Cole TJ Bellizzi MC Flegal KM Dietz WH Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 2000 May 6 320 7244 1240 10797032
Group WMGRS WHO Child Growth Standards: Length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: Methods and development. Organization GWH 2006 312 Available from: http://www.who.int/childgrowth/standards/Technical_report.pdf
Tabac Available from: https://www.who.int/fr/news-room/fact-sheets/detail/tobacco [cited 2019 Nov 6]
Hodgkins CC Cahill KS Seraphine AE Frostpineda K Gold MS Adolescent Drug Addiction Treatment and Weight Gain. Journal of Addictive Diseases 2004 Jul 29 23 3 55 65
Andreassen CS Torsheim T Brunborg GS Pallesen S Development of a Facebook Addiction Scale Psychol Rep 2012 Apr 110 2 501 22662404
Lemmens JS Valkenburg PM Peter J Development and validation of a game addiction scale for adolescents 2009
Birmaher B Khetarpal S Brent D Cully M Balach L Kaufman J Neer SM The Screen for Chid Anxiety Related Emotional Disorders (SCARED): scale construction and psychometric characteristics Journal of the American Academy of Child and Adolescent Psychiatry 1997 36 545 553 9100430
West Julia An Arabic Validation of a Depression Inventory Internet 1985
Parker JDA Taylor GJ Bagby RM The 20-Item Toronto Alexithymia Scale: III. Reliability and factorial validity in a community population Journal of Psychosomatic Research 2003 Sep 55 3 269 275 12932802
Aounallah-Skhiri H Romdhane HB Traissac P Eymard-Duvernay S Delpeuch F Achour N Nutritional status of Tunisian adolescents: associated gender, environmental and socio-economic factors Public Health Nutr 2008 Dec 11 12 1306 1317 18561866
Boukthir S Essaddam L Mazigh Mrad S Ben Hassine L Gannouni S Nessib F Prevalence and risk factors of overweight and obesity in elementary schoolchildren in the metropolitan region of Tunis, Tunisia La Tunisie Médicale 2011 89 1 50 54 21267829
Regaieg S Charfi N Trabelsi L Kamoun M Feki H Yaich S Prévalence et facteurs de risque du surpoids et de l’obésité dans une population d’enfants scolarisés en milieu urbain à Sfax, Tunisie Pan Afr Med J 2014
Obesity and overweight Internet
Prévalence et tendances mondiales - The Free Obesity eBook Available from: https://ebook.ecog-obesity.eu/fr/epidemiologie-prevention-europe/prevalence-et-tendances-mondiales/ 2023
Elzein H Hamadeh S Prevalence and Etiology: Middle East and North Africa (MENA) Countries In: Moreno LA, Pigeot I, Ahrens W, editors. Epidemiology of Obesity in Children and Adolescents: Prevalence and Etiology Springer 2011 Springer Series on Epidemiology and Public Health 127 152
High Obesity Rates In The Middle East And North Africa Available from: https://www.worldatlas.com/articles/high-obesity-rates-in-the-middle-east-and-north-africa.html 2019
Surpoids et régime alimentaire chez l’adolescent : étude dans les collèges du département des Hauts-de-Seine Available from: https://www.em-consulte.com/en/article/36682 2020
Rodriguez R Mowrer J Romo J Aleman A Weffer SE Ortiz RM Ethnic and gender disparities in adolescent obesity and elevated systolic blood pressure in a rural US population Clin Pediatr (Phila) 2010 49 9 876 884 20522603
Must A Dallal GE Dietz WH Reference data for obesity: 85th and 95th percentiles of body mass index (wt/ht2) and triceps skinfold thickness American Journal of Clinical Nutrition 1991 53 839 846 2008861
Bellizzi MC Prevalence of childhood and adolescent overweight and obesity in Asian and European countries In: Chen C, Dietz WH, eds. Obesity in childhood and adolescence. (Nestle Nutrition Workshop Series. Pediatric Program. Volume 49.) Lippincott Williams and Wilkins 2002 23 35
Brown JE Broom DH Nicholson JM Bittman M Do working mothers raise couch potato kids? Maternal employment and children’s lifestyle behaviours and weight in early childhood Soc Sci Med 2010 70 11 1816 1824 20299142
Lamerz A Kuepper-Nybelen J Wehle C Bruning N Trost-Brinkhues G Brenner H Social class, parental education, and obesity prevalence in a study of six-year-old children in Germany. Int J Obes (Lond) 2005 29 4 373 380 15768043
Weight status and body image perceptions in adolescents: current perspectives PMC 2023
Khajeheian D Colabi AM Ahmad Kharman Shah NB Bt Wan Mohamed Radzi CWJ Jenatabadi HS Effect of Social Media on Child Obesity: Application of Structural Equation Modeling with the Taguchi Method. Int J Environ Res Public Health 2018 July 15 7
Modrzejewska A Czepczor-Bernat K Modrzejewska J Roszkowska A Zembura M Matusik P #childhoodobesity – A brief literature review of the role of social media in body image shaping and eating patterns among children and adolescents. Front Pediatr 2022 August 10
Delfour M Moreau A Laconi S Goutaudier N Chabrol H Utilisation problématique de Facebook à l’adolescence et au jeune âge adulte. Neuropsychiatrie de l’Enfance et de l’Adolescence 63 4 244 249
Griffiths LJ Page AS The impact of weight-related victimization on peer relationships: The female adolescent perspective. Obesity 2008 16 S39 S39 S45 18978762
Psychological consequences of childhood obesity: psychiatric comorbidity and prevention Adolescent Health, Medicine and Therapeutics 2016
Pinhas-Hamiel O Health-related quality of life among children and adolescents: association with obesity. International journal of obesity 2006 30 267 272 16231035
de Wit L Luppino F van Straten A Penninx B Zitman F Cuijpers P Depression and obesity: A meta-analysis of community-based studies. Psychiatry Res 2010 178 230 235 20462641
Vander Wal J.S. Unhealthy weight control behaviors among adolescents J. Health Psychol. 2012 17 110 120 21652614
Morales L.S. Edwards T.C. Flores Y. Barr L. Patrick D.L. Measurement properties of a multicultural weight-specific quality-of-life instrument for children and adolescents Qual. Life Res. 2011 20 215 224 20820926
Flores Y.N. Contreras Z.A. Ramírez-Palacios P. Morales L.S. Edwards T.C. Gallegos-Carrillo K. Increased Prevalence of Psychosocial, Behavioral, and Socio-Environmental Risk Factors among Overweight and Obese Youths in Mexico and the United States Int J Environ Res Public Health 2019 April 9
Devlin M.J. Yanovski S.Z. Wilson G.T. Obesity: what mental health professionals need to know Am J Psychiatry 2000 June 157 6 854 866 10831462
Must A. Strauss R.S. Risks and consequences of childhood and adolescent obesity Int J Obes Relat Metab Disord 1999 23 Suppl 2 2 11
Moreno L.A. Pigeot I. Ahrens W. Epidemiology of Obesity in Children and Adolescents: Prevalence and Etiology Springer Science & Business Media 2011 502
McElroy S.L. et al. Are mood disorders and obesity related? A Review for the mental health professional Journal of Clinical Psychiatry 2004 65 5 634 651 15163249
