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which is characterized by rapid growth and development as well as continuous changes in their bodies&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Body image is usually assessed by figure drawings or questionnaires&#44; which are further classified based on satisfaction with one&#39;s own body&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">3</span></a> Most commonly based on cross-sectional studies&#44; the prevalence of body dissatisfaction can be as high as 71&#37; among adolescents&#44; especially in female and overweight subjects&#46;<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">4</span></a> Others reported that the prevalence of body image dissatisfaction in developed countries ranges between 16&#37; and 55&#37; in boys and from 35&#37; to 81&#37; in girls&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">5</span></a> In Brazil&#44; national data on this topic is scarce&#44; and considering that body image may play an important role in managing and maintaining a healthy body weight&#44; identifying which are the factors associated with distorted body image can be key in promoting a healthy weight at this age range&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Usually&#44; girls aspire to become thinner while boys tend to desire an athletic body shape&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">6&#44;7</span></a> Incorrect recognition of body weight status as well as negative body image is a threat to weight control as it may be associated with unhealthy behaviors and psychosocial morbidities&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">8&#44;9</span></a> According to a prospective study carried out in the United States&#44; a fourfold increased incidence of eating disorders was observed among female adolescents with body dissatisfaction&#46;<a class="elsevierStyleCrossRef" href="#bib0185"><span class="elsevierStyleSup">8</span></a> Adolescents dissatisfied with their body image commonly report more complaints of psychosocial health problems such as difficulty to sleep at night or nightmares&#44; feeling nervous&#44; stressed or depressed&#44; having low self-esteem and low quality of life&#46;<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">9</span></a> Social pressures resulting in the discrepancy between actual&#44; self-perceived and desired ideal body weight constitute a risk to mental health among adolescents&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">The purpose of this study is to evaluate the agreement between body weight self-perception and nutritional status in a large&#44; nationwide sample of Brazilian adolescents enrolled in the Study of Cardiovascular Risk in Adolescents &#40;ERICA&#41;&#46; Furthermore&#44; we sought to assess the risk factors for underestimation and overestimation between the BMI-for-age category and self-perceived body image&#44; as well as to evaluate the prevalence and associated factors for dissatisfaction with body weight among Brazilian adolescents&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Design and data collection</span><p id="par0025" class="elsevierStylePara elsevierViewall">The sample comprised adolescents participating in the ERICA&#44; a multicenter&#44; cross-sectional&#44; school-based countrywide study&#46; Data collection was held between February 2013 and November 2014&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> A total of 71&#44;740 adolescents aged 12&#8211;17 years enrolled in public and private schools of 273 Brazilian municipalities with more than 100&#44;000 inhabitants who have undergone assessment of anthropometric measures and fully completed the questionnaire were included&#46; The response rate in the ERICA was 72&#37; and further details can be found elsewhere&#46;<a class="elsevierStyleCrossRef" href="#bib0205"><span class="elsevierStyleSup">12</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Details of the sampling procedures and data reliability are reported elsewhere&#46;<a class="elsevierStyleCrossRef" href="#bib0210"><span class="elsevierStyleSup">13</span></a> Briefly put&#44; schools were selected with a proportional probability based on the number of students and inversely proportional to the distance between the municipality and the capital of the state&#46; Clusters were selected at three levels&#58; in the first level we selected schools as described above&#59; in the second level we selected three classes per school with different combinations of scheduled time at school &#40;morning and afternoon&#41; and grades &#40;from elementary to high school&#41;&#59; and in the third level we considered classes&#46; All students in the selected classes were invited to participate in the ERICA&#44; signing the agreement of participation&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> The ERICA was approved by Research Ethics Committees in all 27 states in Brazil&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Self-reported variables</span><p id="par0035" class="elsevierStylePara elsevierViewall">The study protocol has been fully described elsewhere&#46;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">11</span></a> Data were obtained by a self-administered structured questionnaire inserted into an electronic data collector &#40;personal digital assistant &#8211; LG&#174; GM750Q&#41;&#44; with information on sociodemographic characteristics&#44; physical activity level&#44; common mental disorders &#40;CMD&#41;&#44; body image self-perception and body weight satisfaction&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">To assess adolescents&#8217; body weight satisfaction we used the following question&#58; &#8220;Are you satisfied with your current body weight&#63;&#8221; The answer options were &#8220;yes&#8221; or &#8220;no&#8221;&#46; Those who answered &#8220;yes&#8221; in the last question were considered with &#8220;Ideal&#8221; body image self-perception&#46; For those who answered &#8220;no&#8221; the following question was used&#58; &#8220;In your opinion&#44; how is your current body weight&#63;&#8221; The answer options were &#8220;Below the ideal&#8221;&#44; &#8220;Above the ideal&#8221; or &#8220;Far above the ideal&#8221;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Screening for CMD was performed using the 12-item General Health Questionnaire &#40;GHQ-12&#41;&#44; an instrument that has 12 questions with four possible responses for each&#44; and the respondents were asked to choose only one response that best fits how they have been feeling recently&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">14&#44;15</span></a> The first two responses &#40;&#8220;Not at all&#8221; and &#8220;No more than usual&#8221;&#41; were scored zero&#44; whereas the last two &#40;&#8220;A little more than usual&#8221; and &#8220;Much more than usual&#8221;&#41; were scored one point each&#46; A score of zero on each item was considered negative&#44; whereas a score of one point was considered positive for the presence of the symptom&#46; This questionnaire is quick to administer and has psychometric properties comparable to its longer versions&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a> A lower score represents a better health condition&#59; a score equal or higher than three is indicative of positive screening for the presence of CMD&#46;<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">16</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Physical activity was assessed with an adapted version of the Self-Administered Physical Activity Checklist&#44;<a class="elsevierStyleCrossRef" href="#bib0230"><span class="elsevierStyleSup">17</span></a> which consists of a list of 24 activities with moderate-to-vigorous intensity&#46; Participants were asked to report the frequency &#40;in days&#41; and duration &#40;in hours and minutes&#41; of engagement in each of these activities during the last seven days&#46; To determine the weekly amount of time spent in moderate-to-vigorous physical activity &#40;MVPA&#41;&#44; we multiplied self-reported duration and frequency for each activity listed and then categorized them in &#60;300<span class="elsevierStyleHsp" style=""></span>min&#47;week or &#8805;300<span class="elsevierStyleHsp" style=""></span>min&#47;week&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">18</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The other variables assessed as covariates were sex&#44; age &#40;in full years&#41;&#44; skin color &#40;white&#44; black&#44; brown and others&#41; and socioeconomic status&#44; which was characterized using a similar criteria used in the Brazilian census&#44;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">19</span></a> which includes data regarding consumer goods and parental education&#46; The scores range from 0 to 46 and higher scores indicate higher socioeconomic status&#46; This score was categorized into levels according to recommendation of the instrument&#58; A &#40;35&#8211;46 points&#41;&#44; B &#40;23&#8211;34 points&#41;&#44; C &#40;14&#8211;22 points&#41;&#44; D &#40;8&#8211;13 points&#41; and E &#40;0&#8211;7 points&#41;&#46; Classes D and E were regrouped in the same category&#44; due to low frequency&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Anthropometric measurements</span><p id="par0060" class="elsevierStylePara elsevierViewall">Anthropometric measurements were obtained with individuals wearing light clothing and no shoes&#46; Height &#40;m&#41; was measured using a calibrated stadiometer &#40;stadiometer Alturexata&#174;&#44; Minas Gerais&#44; Brazil&#41;&#46; Weight &#40;kg&#41; was measured using a digital scale &#40;model P150m&#44; 200<span class="elsevierStyleHsp" style=""></span>kg capacity&#44; L&#237;der&#174;&#44; S&#227;o Paulo&#44; Brazil&#41;&#46; Body mass index &#40;BMI&#41; was calculated by weight &#40;kg&#41; divided by the squared height &#40;m&#41;&#46; The World Health Organization reference curves were used to classify the nutritional status&#44; using the BMI-for-age according to sex&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">20</span></a> Cutoff values were as follows&#58; malnutrition&#44; BMI <span class="elsevierStyleItalic">Z</span>-score &#60;&#8722;3&#59; low weight&#44; BMI <span class="elsevierStyleItalic">Z</span>-score &#8805;&#8722;3 and &#60;&#8722;1&#59; normal weight&#44; BMI <span class="elsevierStyleItalic">Z</span>-score &#8805;&#8722;1 and &#8804;1&#59; overweight&#44; BMI <span class="elsevierStyleItalic">Z</span>-score &#62;1 and &#8804;2&#59; obesity&#44; BMI <span class="elsevierStyleItalic">Z</span>-score &#62;2&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">Variables were described using mean and standard deviation or prevalence and 95&#37; confidence interval &#40;CI&#41;&#46; To compare means&#44; Student&#39;s <span class="elsevierStyleItalic">t</span> test was used&#46; For testing associations between categorical variables the Chi-squared test was performed&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">To evaluate the agreement between self-perceived body image and nutritional status&#44; categories were matched with nutritional status as follows&#58; malnutrition or low weight<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>below the ideal&#59; normal weight<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>ideal&#59; overweight or obesity<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>above or far above the ideal&#46; Kappa coefficient &#40;<span class="elsevierStyleItalic">k</span>&#41; was calculated to evaluate the degree of agreement between BMI categories and body image perception&#46; The kappa coefficient is a measure of agreement&#58; <span class="elsevierStyleItalic">k</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1 is perfect agreement&#44; while <span class="elsevierStyleItalic">k</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0 represents no agreement beyond chance&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Multinomial logistic regression was used to explore the association between covariates and combinations between self-perceived body image and BMI &#40;agreement&#44; underestimation and overestimation&#41;&#46; The adjusted models for sex&#44; age&#44; skin color&#44; economic class&#44; BMI&#44; physical activity&#44; and CMD were built with only one level of the input variables&#44; which were taken from those with less influence to obtain the final model&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">The associations between dissatisfaction with body weight and exposure variables were investigated using multivariable Poisson regression models&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">All analyses were conducted in Stata 14&#46;0 software with a significance level of 5&#37;&#44; by using the survey &#40;<span class="elsevierStyleItalic">svy</span>&#41; command to consider the expansion and complexity of sample design&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Ethics approval and consent to participate</span><p id="par0090" class="elsevierStylePara elsevierViewall">This study was conducted according to the principles of the Helsinki declaration&#46; Permission to conduct the study was obtained in all states and local Departments of Education and in all schools&#46; All adolescents agreed in writing to participate in the study&#59; five states also requested an informed consent form signed by the parent or legal guardian&#44; according to the determination of the respective Research Ethics Committee or State Secretariat of Education&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Results</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0105">Sample characteristics</span><p id="par0095" class="elsevierStylePara elsevierViewall">Of the 71&#44;740 students evaluated&#44; 95&#46;0&#37; were adolescents from state capitals&#44; and 83&#46;0&#37; attended public schools&#46; Girls accounted for 55&#46;0&#37; of the sample&#59; 37&#46;0&#37; of the whole sample were in the 14&#8211;15 year-old age group&#59; most reported brown &#40;47&#46;0&#37;&#41; or white &#40;39&#46;0&#37;&#41; skin color&#59; and most came from families in the intermediate &#40;B and C&#41; economic classes &#40;86&#46;0&#37;&#41;&#46; Fifty-one percent of adolescents were considered physically active&#46; Two and a half percent of the students were classified as underweight&#44; 72&#46;0&#37; of students had normal weight&#44; 17&#46;0&#37; were overweight&#44; and 8&#46;5&#37; were obese&#46; The GHQ-12 mean score was 2&#46;10 &#40;SE<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;25&#41; points&#44; and prevalence of a positive screening for CMD was 30&#46;0&#37;&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Agreement between self-perceived body image and measured BMI</span><p id="par0100" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a> shows the distribution of self-perceived body image across BMI categories in the whole sample and by sex&#46; Overall&#44; adolescents with overweight&#47;obesity were those who better recognize their body image&#46; On the other hand&#44; adolescents with underweight showed a higher prevalence of body image misperception&#46; Sixty-six percent of adolescents rightly matched their BMI-for-age category with their self-perceived body image &#40;kappa<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;37&#41;&#46; In general&#44; the agreement between self-perceived body image and measured BMI was reasonable&#44; as showed in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0105" class="elsevierStylePara elsevierViewall">In the sample&#44; approximately 20&#46;0&#37; of the adolescents overestimated and 13&#46;5&#37; underestimated their actual weight status&#46; <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the associated factors with body image misperception&#46; Boys were more likely to overestimate their body image compared to girls&#46; Analyzing by age&#44; older adolescents &#40;16&#8211;17 years&#41; were more likely to present a body image misperception when compared to younger adolescents&#46; A positive screening for CMD increases the odds ratio for both overestimation and underestimation of self-perceived body image&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Dissatisfaction with body weight</span><p id="par0110" class="elsevierStylePara elsevierViewall">The prevalence of adolescents dissatisfied with their body weight was 45&#46;0&#37; &#40;95&#37; CI 44&#46;0&#8211;46&#46;0&#41;&#46; <a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> summarizes the prevalence and prevalence ratios of adolescents dissatisfied with their body weight according to independent variables&#46; Girls reported dissatisfaction with their body weight more frequently than boys&#46; Significant higher adjusted prevalence ratios for body dissatisfaction were observed in older adolescents&#44; those with underweight or overweight&#47;obesity&#44; those who were physically inactive and with positive score for CMD&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Discussion</span><p id="par0115" class="elsevierStylePara elsevierViewall">In this study&#44; three out of ten Brazilian students showed misperception about their body image&#44; which was associated with sex&#44; age and a positive screening for CMD&#46; We also observed that the degree of agreement between BMI categories and self-perceived body image was moderate&#46; In addition&#44; 45&#37; of the adolescents reported dissatisfaction with their body weight&#44; an observation that was more frequent among girls&#44; older adolescents&#44; those who were classified as underweight&#44; overweight or obese&#44; those who were physically inactive&#44; and with a positive screening for CMD&#46;</p><p id="par0120" class="elsevierStylePara elsevierViewall">Despite the importance of self-perceived body image for psychological and general health&#44; few studies have investigated the agreement between different measurements of self-perceived body image and nutritional status according to BMI&#44; especially in adolescents from developing countries&#46; In our study&#44; the higher kappa coefficients were observed in younger students and adolescents from lower-income families &#40;classes D&#8211;E&#41;&#46; A previous study also reported a lower discordant weight perception among younger adolescents&#59; however&#44; low income was a risk factor for dissatisfaction&#44; especially among girls&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">21</span></a> Our results may be different from previous observational studies because we used data from a developing country with pronounced inequalities&#46; Therefore&#44; body image in minorities should be further explored in order to better understand the peculiarities of these groups and their relationship with body satisfaction during adolescence&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">We observed that boys were significantly more likely to overestimate their current weight status&#44; while girls were more likely to underestimate it&#46; These findings are in accordance with previous studies about body image misperception among adolescents&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">10</span></a> However&#44; another study involving 6863 Chinese adolescents from middle and high school classes found that girls more often considered themselves to be heavier in relation to their male counterparts&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">22</span></a> The increased adiposity during puberty may play a role for higher dissatisfaction among girls compared to boys&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">23</span></a> Other factors like body reference images commonly used in mass media and more recently in social media can affect how adolescents perceive themselves&#44; and consequently influence the desire of women and men in relation to the ideal body shape in different cultures&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">24</span></a></p><p id="par0130" class="elsevierStylePara elsevierViewall">In this study&#44; the positive screening for CMD was related with body image misperception and body weight dissatisfaction&#46; Body weight dissatisfaction was 10&#37; more frequent in adolescents with CMD&#59; in addition&#44; these students are more likely to underestimate &#40;59&#37;&#41; and overestimate &#40;27&#37;&#41; their self-perceived body image&#46; One out of three adolescents showed a positive screening for CMD in ERICA&#44; similarly to what was observed in a previous study from a developing country&#46;<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">25</span></a> Another study involving Brazilian adolescents observed a higher prevalence of CMD among those unsatisfied with their body weight&#44; especially for those desiring to be fatter&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">26</span></a> More recently&#44; in addition to the classical pathway described to link obesity and CMD&#44; another suggestion was that body image could mediate this association&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">27</span></a> Thus&#44; the role of body image and body satisfaction in the development of CMD among adolescents should be further investigated&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">It is challenging to determine what levels of body weight dissatisfaction should be considered acceptable among adolescents&#46; The prevalence of dissatisfaction described in our study was relatively higher as compared to that of developed countries&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a> Nonetheless&#44; we observed that female sex&#44; higher age&#44; BMI extremes &#40;underweight and overweight&#41;&#44; physical inactivity&#44; and CMD were associated with body weight dissatisfaction&#46; The associations between body weight dissatisfaction with female sex and overweight&#47;obesity in adolescents are already well established&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">28</span></a> In relation to physical activity&#44; most published studies suggest that being physically active is associated with better overall self-esteem&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">29</span></a> However&#44; the association of physical activity with body satisfaction is probably dependent on body weight&#59; specifically&#44; body weight seems to have a greater effect when physical activity levels are low&#59; however&#44; this effect could be reduced with an increase in physical activity levels&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Our study has some limitations&#46; This study reports cross-sectional findings&#44; thus not being able to establish cause-effect relationships&#46; Secondly&#44; self-administered questionnaires were used to access some of the covariates &#40;i&#46;e&#46; CMD and physical activity&#41;&#46; It is also important to note that in the case of the questionnaire used to screen CMD&#44; diagnosis was not possible&#46; The use of questionnaires could introduce bias&#59; however&#44; non-differential measurement error commonly attenuates rather than increases the apparent magnitude of associations&#46; Finally&#44; as multinomial logistic regression analysis defines one reference group to the detriment of all others&#44; this could be considered a limitation&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">Evidently&#44; the strength of this study is its large representative sample from a developing country&#46; Furthermore&#44; actual weight and height were measured by trained interviewers through standardized protocols&#46; Our study extends previous observations analyzing data from a multiethnic sample of adolescents from a developing country&#44; especially if we consider that cultural and economic variables play a role in body image perception&#46; Also&#44; our observations may have implications for public health&#46; We observed that both misperception and dissatisfaction with body weight were associated with positive screening for CMD&#44; which commonly starts during adolescence&#46; Thus&#44; body image should be considered in interventions aimed to improve mental health among adolescents&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">In Brazilian adolescents&#44; a moderate agreement between actual weight status and self-perceived body image was found&#46; Overweight&#47;obese adolescents showed higher proportion of correct body image self-perception&#44; while boys were more likely than girls to overestimate their current weight status&#44; and girls were more likely to underestimate their current weight status&#46; Students with body image misperception and those dissatisfied with their body weight were more likely to present a positive screening for CMD&#46; These findings highlight the association between body dissatisfaction and psychological well-being and underscore the importance of including mental health assessment in adolescents reporting a misperception about their body image&#46; Prospective studies are required in order to establish what levels of body dissatisfaction are worrisome among adolescents&#44; as well as the influence of age&#44; gender&#44; ethnicity&#44; and CMD&#46; The identification of these factors may support the development of health system prevention programs in Brazil and other middle-income countries&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Funding</span><p id="par0155" class="elsevierStylePara elsevierViewall">This study was supported by the Brazilian Ministry of Health &#40;Science and Technology Department&#41; and the Brazilian Ministry of Science and Technology &#40;Financiadora de Estudos e Projetos &#8211; Finep and Conselho Nacional de Pesquisa &#8211; CNPq&#41; &#40;grants&#58; Finep&#58; 01090421&#59; CNPq&#58; 565037&#47;2010-2 and 405009&#47;2012-7&#41;&#59; and by the Fundo de Incentivo &#224; Pesquisa do Hospital de Cl&#237;nicas de Porto Alegre &#40;FIPE &#8211; HCPA &#8211; Process&#58; 09-098&#41;&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Conflicts of interest</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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              "identificador" => "sec0045"
              "titulo" => "Sample characteristics"
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            1 => array:2 [
              "identificador" => "sec0050"
              "titulo" => "Agreement between self-perceived body image and measured BMI"
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            2 => array:2 [
              "identificador" => "sec0055"
              "titulo" => "Dissatisfaction with body weight"
            ]
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          "titulo" => "Discussion"
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          "titulo" => "Funding"
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          "identificador" => "sec0070"
          "titulo" => "Conflicts of interest"
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        10 => array:2 [
          "identificador" => "xack443645"
          "titulo" => "Acknowledgements"
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        11 => array:1 [
          "titulo" => "References"
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    ]
    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2018-04-25"
    "fechaAceptado" => "2018-07-13"
    "PalabrasClave" => array:2 [
      "en" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Keywords"
          "identificador" => "xpalclavsec1192243"
          "palabras" => array:6 [
            0 => "Adolescents"
            1 => "Self-perceived body image"
            2 => "Body dissatisfaction"
            3 => "Body image perception"
            4 => "General Health Questionnaire"
            5 => "Mental health"
          ]
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        0 => array:4 [
          "clase" => "keyword"
          "titulo" => "Palavras-chave"
          "identificador" => "xpalclavsec1192242"
          "palabras" => array:6 [
            0 => "Adolescentes"
            1 => "Auto-imagem corporal"
            2 => "Insatisfa&#231;&#227;o com o corpo"
            3 => "Percep&#231;&#227;o da imagem corporal"
            4 => "Question&#225;rio de Sa&#250;de Geral"
            5 => "Sa&#250;de Mental"
          ]
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      ]
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    "resumen" => array:2 [
      "en" => array:3 [
        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The purpose of this study was to evaluate the agreement and risk factors for underestimation and overestimation between nutritional status and self-perceived body image and to assess the prevalence and associated factors for dissatisfaction with body weight among Brazilian adolescents&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Students aged 12&#8211;17 years participating in the Study of Cardiovascular Risk in Adolescents &#40;&#8220;ERICA&#8221;&#41;&#44; a multicenter&#44; cross-sectional&#44; school-based country-wide study&#44; were included &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>71&#44;740&#41;&#46; Variables assessed as covariates were sex&#44; age&#44; skin color&#44; socioeconomic status&#44; and common mental disorders &#40;screened by the General Health Questionnaire&#44; GHQ-12&#41;&#46; Multinomial logistic regression was used to explore the association between covariates and combinations between self-perceived body image and body mass index &#40;agreement&#44; underestimation and overestimation&#41;&#46; The associations between dissatisfaction with body weight and exposure variables were investigated using multivariable Poisson regression models&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Approximately 66&#37; students rightly matched their body mass index with self-perceived weight &#40;kappa coefficient was 0&#46;38 for boys and 0&#46;35 for girls&#41;&#46; Agreement was higher among younger students and adolescents from low income households&#46; Male sex&#44; older age&#44; and GHQ-12 score &#8805;3 were associated with weight overestimation&#46; Prevalence of dissatisfaction with body weight was 45&#46;0&#37; &#40;95&#37; CI&#58; 44&#46;0&#8211;46&#46;0&#41;&#44; and higher among girls&#44; older adolescents&#44; those with underweight or overweight&#47;obesity&#44; as well as those who were physically inactive and with GHQ-12 &#8805;3&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Most of the sample rightly self-perceived their body image according to body mass index&#46; Students with body image misperception and those dissatisfied with their weight were more likely to present a positive screening for common mental disorders&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Objectives"
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          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Methods"
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      "pt" => array:3 [
        "titulo" => "Resumo"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivos</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">A finalidade deste estudo foi avaliar a concord&#226;ncia e os fatores de risco para subestima&#231;&#227;o e superestima&#231;&#227;o entre o estado nutricional e a autoimagem corporal e para avaliar a preval&#234;ncia e os fatores associados &#224; insatisfa&#231;&#227;o com o peso corporal entre adolescentes brasileiros&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">M&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Foram inclu&#237;dos estudantes entre 12 e 17 anos que participavam do Estudo de Riscos Cardiovasculares em Adolescentes &#40;&#8220;ERICA&#8221;&#41;&#44; um estudo multic&#234;ntrico&#44; transversal&#44; nacional e de base escolar &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>71&#46;740&#41;&#46; As vari&#225;veis analisadas como covari&#225;veis foram sexo&#44; idade&#44; cor da pele&#44; situa&#231;&#227;o socioecon&#244;mica e transtornos mentais comuns &#40;triados pelo Question&#225;rio de Sa&#250;de Geral&#44; QSG-12&#41;&#46; A regress&#227;o log&#237;stica multinomial foi usada para explorar a associa&#231;&#227;o entre as covari&#225;veis e as combina&#231;&#245;es entre a autoimagem corporal e o &#237;ndice de massa corporal &#40;concord&#226;ncia&#44; subestima&#231;&#227;o e superestima&#231;&#227;o&#41;&#46; As associa&#231;&#245;es entre a insatisfa&#231;&#227;o com o peso corporal e as vari&#225;veis de exposi&#231;&#227;o foram investigadas com os modelos multivari&#225;veis de regress&#227;o de Poisson&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Aproximadamente 66&#37; dos estudantes associaram corretamente seu &#237;ndice de massa corporal com o peso autopercebido &#40;o coeficiente kappa foi 0&#44;38 para meninos e 0&#44;35 para meninas&#41;&#46; A concord&#226;ncia foi maior entre jovens e adolescentes de baixa renda&#46; Sexo masculino&#44; adolescentes mais velhos e um escore QSG 12 &#8805;<span class="elsevierStyleHsp" style=""></span>3 foram associados &#224; superestima&#231;&#227;o do peso&#46; A preval&#234;ncia de insatisfa&#231;&#227;o com o peso corporal foi 45&#44;0&#37; &#40;IC de 95&#37;&#58; 44&#44;0-46&#44;0&#41;&#44; maior entre meninas&#44; adolescentes mais velhos&#44; aqueles abaixo do peso ou com sobrepeso&#47;obesidade&#44; fisicamente inativos e com QSG-12 &#8805;3&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclus&#245;es</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A maior parte da amostra associou corretamente sua imagem corporal de acordo com o &#237;ndice de massa corporal&#46; Estudantes com distor&#231;&#227;o da autoimagem corporal e aqueles insatisfeitos com seu peso foram mais propensos a apresentar rastreamento positivo para transtornos mentais comuns&#46;</p></span>"
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            "titulo" => "M&#233;todos"
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            "identificador" => "abst0035"
            "titulo" => "Resultados"
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          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclus&#245;es"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0025">Please cite this article as&#58; Moehlecke M&#44; Blume CA&#44; Cureau FV&#44; Kieling C&#44; Schaan BD&#46; Self-perceived body image&#44; dissatisfaction with body weight and nutritional status of Brazilian adolescents&#58; a nationwide study&#46; J Pediatr &#40;Rio J&#41;&#46; 2020&#59;96&#58;76&#8211;83&#46;</p>"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Distribution of self-perceived body image across body mass index categories in the whole sample and according to sex&#46; ERICA&#44; Brazil&#44; 2013&#8211;2014&#46;</p>"
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          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">BMI&#44; body mass index&#59; ERICA&#44; Study of Cardiovascular Risks in Adolescents&#59; GHQ-12&#44; General Health Questionnaire&#46;</p>"
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