Increased Prevalence of Psychosocial, Behavioral, and Socio-Environmental Risk Factors among Overweight and Obese Youths in Mexico and the United States

The aim of this study was to examine various psychosocial, behavioral, and socio-environmental factors in a multiethnic sample of healthy-weight, overweight, and obese youths in the United States (US) and Mexico and determine differences by sex. We conducted a cross-sectional analysis of 633 youths aged 11–18 years who completed a self-reported questionnaire. Height and weight were measured to determine body mass index (BMI). Overweight and obese youth in both countries were significantly more likely to report a higher body image dissatisfaction (Odds Ratio (OR) = 1.67 and OR= 2.95, respectively), depressive symptoms (OR = 1.08 and OR = 1.12, respectively), perceive themselves as overweight (OR = 2.57) or obese (OR = 5.30), and a lower weight-specific quality of life (OR = 0.97 and OR = 0.95, respectively) than healthy-weight youth. Obese youth have lower healthy lifestyle priorities (OR = 0.75) and are less likely to be physically active (OR = 0.79) and eat breakfast (OR = 0.47) than healthy-weight youth. Additionally, overweight and obese youth are more likely to engage in weight control behaviors (OR = 5.19 and OR = 8.88, respectively) and restrained eating than healthy-weight youth. All the aforementioned results had a p-value of <0.05, which was considered statistically significant. The association between these factors and overweight or obesity remained significant after controlling for age, sex, race/ethnicity, and country. In conclusion, obesity was associated with a range of psychosocial, behavioral, and socio-environmental risk factors in both countries. Our findings support the need for multifactorial approaches when developing interventions to address the growing problem of obesity among youth in the US and Mexico.

the past 30 days, did you eat less food, fewer calories, or foods low in fat to lose weight or keep from gaining weight?; During the past 30 days, did you go without eating for 24 h or more (also called fasting) to lose weight or to keep from gaining weight?; and During the past 30 days, did you take any diet pills, powders, or liquids without a doctor's advice to lose weight or to keep from gaining weight? (Cronbach's α = 0.37).
Restrained eating behaviors. Ten items from the Dutch eating behavior questionnaire (DEBQ) were used to assess restrained eating behaviors [45]. The index score ranges from 1 to 5, with 5 indicating a higher frequency of restrained eating practices.

Socio-Environmental Factors
Perceived parental concern regarding adolescent weight. Youths' perception of their parents' concern regarding their weight and if they are getting sufficient physical activity was assessed with a two-item index on a 5-point scale, where 5 is the highest level of perceived parental concern. The following two items were used: How concerned are your parents about you becoming overweight? and How concerned are your parents about you not getting enough physical activity? (Cronbach's α = 0.75) [34].
Perceived parent body size. Two indices that represent how youth perceive their parents' body size were constructed using images of the PBIA, one for males and the other for females. Participants were asked to select the figure that is closest to the usual adult weight of their mother and father: Which number under the figures in the figure Box A is closest to the usual adult weight of your mother? and Which number under the figures in the figure Box B is closest to the usual adult weight of your father? The PBIA silhouettes were modified from Stunkard et al. [47] to include larger body shapes. The silhouettes range from underweight (BMI <19) to highly severe obesity (BMI >50) [48]. The 13-point response scale for each item depicts a spectrum of silhouettes with 1 representing underweight, and 13 representing extremely obese (Cronbach's α = 0.47) [38].
Mother/father healthy values. Perception of parent healthy values was evaluated using two items that ask how concerned your parents are about (1) staying fit and exercising and (2) losing weight or preventing weight gain: How much does your mother/father feel about staying fit and exercising (for herself/himself)? and How much does your mother feel about losing weight or keeping from gaining weight (for herself/himself)? Separate indices were constructed for mother and father health values, with each consisting of these two items (Cronbach's α = 0.73, 0.83, respectively). The response scale for these indices ranges from 1 to 4, with 4 as the highest level of concern [34].
Home availability of healthy foods. An index of fruit and vegetable availability in the home was created using two items that range from 1 to 4, with 4 indicating the highest frequency of healthy food availability in the home: Fruits and vegetables are available in my home . . . (1) Never, (2) Sometimes, (3) Usually, (4) Always, and Vegetables are served at dinner in my home . . . (1) Never, (2) Sometimes, (3) Usually, (4) Always. (Cronbach's α =0.69) [34].

Body Mass Index (BMI)
Height, weight, and waist circumference were measured by trained study staff. Participants were weighed to the nearest 0.1 kg while wearing minimal clothing using a calibrated electronic TANITA scale (model BC533; Tokyo, Japan). Height was determined to the nearest 0.1 cm using a conventional stadiometer, with the youth standing barefoot, with their shoulders in a normal position. BMI was determined to categorize participants as healthy-weight, overweight, or obese, based on the World Health Organization (WHO) age-and sex-specific classifications for youth aged 5 to 19 years [53].

Statistical Analysis
A descriptive analysis of various sociodemographic variables was conducted for the total study population by country of residence and BMI status. Psychosocial, behavioral, and socio-environmental factors were also examined by country of residence and BMI status. Differences between proportions were assessed using chi-square tests of homogeneity, and t-tests were used to calculate differences between means. Test for trend p-values were calculated to determine whether there was a linear association between the study variables and BMI status. Odds ratios and 95% confidence intervals for the association between psychosocial, behavioral, and socio-environmental factors and being overweight or obese were calculated using multinomial logistic regression. These results were adjusted for sex, age, race/ethnicity, and country of residence. Standardized odds ratios were determined to facilitate comparisons of the study variables since their score range varied considerably. Standardized odds ratios improve comparison and interpretability of the logistic regression results. Multinomial logistic regression models for males and females were also used to examine any differences by sex, after adjusting for age, race/ethnicity, and country. All p-values presented are 2-tailed and a p-value of <0.05 was considered statistically significant. All statistical analyses were performed using STATA software, version 12.0 (StataCorp LP, College Station, TX, USA).

Results
The sociodemographic characteristics of the study sample are compared by BMI status in Table 1. Of the 633 participants, 54% are 11-14 years of age, 46% are between 15 and 18 years old, 52% are female, 22% are African American, 25% are Caucasian, 24% are US Latinos, and 29% are youth who live in Mexico. Thirty percent of youth have a healthy BMI, 30% are overweight, and 40% are obese. Thirty-seven percent of participants are from Seattle, WA, 35% are from Los Angeles, CA, and 29% are from Cuernavaca, Mexico. Chi-square tests were used to assess differences by weight status for each of the study variables, separately by country. There are no significant differences by country of residence in terms of sociodemographic characteristics for each of the three BMI categories, except for education level among the US participants. (Table 1)   Table 1. Sample characteristics by body mass index (BMI) categories and country (n = 633).   Tables 2 and 3 compare the mean scores for various psychosocial, behavioral, and  socio-environmental variables, by country of residence and BMI status. Within the domain of  psychosocial factors, overweight or obese youth in Mexico and the US are more likely to report being  dissatisfied with their body image, to perceive themselves as overweight or obese, and to have lower weight-specific QOL scores than healthy-weight youth. However, overweight or obese youths in Mexico are not more likely to report more depressive symptoms than healthy-weight youths, unlike obese youths in the US, who are more likely to report depressive symptoms than healthy-weight youths (3.2 vs. 2.3, respectively). The presence of depressive symptoms is greater among healthy-weight, overweight, and obese youth in Mexico (3.1, 3.7, 3.9, respectively) than those in the US (2.1, 2.8, 3.2, respectively); and the weight-related QOL reported by overweight or obese youths in Mexico is lower than those in the US (65.1 and 52.9 vs. 78.1 and 67.0, respectively).
In terms of behavioral factors, obese youth in the US have lower healthy lifestyle priorities (3.0 vs. 3.1, respectively), are less physically active (1.6 vs. 1.8, respectively), and are less likely to eat breakfast (1.5, 1.6, respectively) than healthy-weight youth in the US. Overweight and obese participants in both countries are also significantly more likely to engage in weight control behaviors, such as exercise and restrained eating, as compared to healthy-weight youth. The only statistically significant socio-environmental factors reported by obese youths in both countries include being more likely to think that their parents are concerned about their weight and that their parents have a larger body size than healthy-weight youth. However, overweight youths in the US are not more likely to report that their parents are concerned about their weight, as compared to healthy weight youths (Tables 2 and 3). All the aforementioned results had a p-value of <0.05, which was considered statistically significant.  Tables 2 and 3 compare the mean scores for various psychosocial, behavioral, and socioenvironmental variables, by country of residence and BMI status. Within the domain of psychosocial factors, overweight or obese youth in Mexico and the US are more likely to report being dissatisfied with their body image, to perceive themselves as overweight or obese, and to have lower weightspecific QOL scores than healthy-weight youth. However, overweight or obese youths in Mexico are not more likely to report more depressive symptoms than healthy-weight youths, unlike obese youths in the US, who are more likely to report depressive symptoms than healthy-weight youths (3.2 vs. 2.3, respectively). The presence of depressive symptoms is greater among healthy-weight, overweight, and obese youth in Mexico (3.1, 3.7, 3.9, respectively) than those in the US (2.1, 2.8, 3.2, respectively); and the weight-related QOL reported by overweight or obese youths in Mexico is lower than those in the US (65.1 and 52.9 vs. 78.1 and 67.0, respectively).
In terms of behavioral factors, obese youth in the US have lower healthy lifestyle priorities (3.0 vs. 3.1, respectively), are less physically active (1.6 vs. 1.8, respectively), and are less likely to eat breakfast (1.5, 1.6, respectively) than healthy-weight youth in the US. Overweight and obese participants in both countries are also significantly more likely to engage in weight control behaviors, such as exercise and restrained eating, as compared to healthy-weight youth. The only statistically significant socio-environmental factors reported by obese youths in both countries include being more likely to think that their parents are concerned about their weight and that their parents have a larger body size than healthy-weight youth. However, overweight youths in the US are not more likely to report that their parents are concerned about their weight, as compared to healthy weight youths (Tables 2 and 3). All the aforementioned results had a p-value of <0.05, which was considered statistically significant.  Tables 2 and 3 compare the mean scores for various psychosocial, behavioral, and socioenvironmental variables, by country of residence and BMI status. Within the domain of psychosocial factors, overweight or obese youth in Mexico and the US are more likely to report being dissatisfied with their body image, to perceive themselves as overweight or obese, and to have lower weightspecific QOL scores than healthy-weight youth. However, overweight or obese youths in Mexico are not more likely to report more depressive symptoms than healthy-weight youths, unlike obese youths in the US, who are more likely to report depressive symptoms than healthy-weight youths (3.2 vs. 2.3, respectively). The presence of depressive symptoms is greater among healthy-weight, overweight, and obese youth in Mexico (3.1, 3.7, 3.9, respectively) than those in the US (2.1, 2.8, 3.2, respectively); and the weight-related QOL reported by overweight or obese youths in Mexico is lower than those in the US (65.1 and 52.9 vs. 78.1 and 67.0, respectively).
In terms of behavioral factors, obese youth in the US have lower healthy lifestyle priorities (3.0 vs. 3.1, respectively), are less physically active (1.6 vs. 1.8, respectively), and are less likely to eat breakfast (1.5, 1.6, respectively) than healthy-weight youth in the US. Overweight and obese participants in both countries are also significantly more likely to engage in weight control behaviors, such as exercise and restrained eating, as compared to healthy-weight youth. The only statistically significant socio-environmental factors reported by obese youths in both countries include being more likely to think that their parents are concerned about their weight and that their parents have a larger body size than healthy-weight youth. However, overweight youths in the US are not more likely to report that their parents are concerned about their weight, as compared to healthy weight youths (Tables 2 and 3). All the aforementioned results had a p-value of <0.05, which was considered statistically significant.

P trend
not more likely to report more depressive symptoms than healthy-weig youths in the US, who are more likely to report depressive symptoms than (3.2 vs. 2.3, respectively). The presence of depressive symptoms is greater overweight, and obese youth in Mexico (3.1, 3.7, 3.9, respectively) than thos respectively); and the weight-related QOL reported by overweight or obese y than those in the US (65.1 and 52.9 vs. 78.1 and 67.0, respectively). In terms of behavioral factors, obese youth in the US have lower health vs. 3.1, respectively), are less physically active (1.6 vs. 1.8, respectively), a breakfast (1.5, 1.6, respectively) than healthy-weight youth in the US. participants in both countries are also significantly more likely to engage in w such as exercise and restrained eating, as compared to healthy-weight you significant socio-environmental factors reported by obese youths in both more likely to think that their parents are concerned about their weight and larger body size than healthy-weight youth. However, overweight youths likely to report that their parents are concerned about their weight, as com youths (Tables 2 and 3). All the aforementioned results had a p-value of <0.0 statistically significant.  Tables 2 and 3 compare the mean scores for various psychosocial, behavioral, and socioenvironmental variables, by country of residence and BMI status. Within the domain of psychosocial factors, overweight or obese youth in Mexico and the US are more likely to report being dissatisfied with their body image, to perceive themselves as overweight or obese, and to have lower weightspecific QOL scores than healthy-weight youth. However, overweight or obese youths in Mexico are not more likely to report more depressive symptoms than healthy-weight youths, unlike obese youths in the US, who are more likely to report depressive symptoms than healthy-weight youths (3.2 vs. 2.3, respectively). The presence of depressive symptoms is greater among healthy-weight, overweight, and obese youth in Mexico (3.1, 3.7, 3.9, respectively) than those in the US (2.1, 2.8, 3.2, respectively); and the weight-related QOL reported by overweight or obese youths in Mexico is lower than those in the US (65.1 and 52.9 vs. 78.1 and 67.0, respectively).
In terms of behavioral factors, obese youth in the US have lower healthy lifestyle priorities (3.0 vs. 3.1, respectively), are less physically active (1.6 vs. 1.8, respectively), and are less likely to eat breakfast (1.5, 1.6, respectively) than healthy-weight youth in the US. Overweight and obese participants in both countries are also significantly more likely to engage in weight control behaviors, such as exercise and restrained eating, as compared to healthy-weight youth. The only statistically significant socio-environmental factors reported by obese youths in both countries include being more likely to think that their parents are concerned about their weight and that their parents have a larger body size than healthy-weight youth. However, overweight youths in the US are not more likely to report that their parents are concerned about their weight, as compared to healthy weight youths (Tables 2 and 3). All the aforementioned results had a p-value of <0.05, which was considered statistically significant. various psychosocial, behavioral, and socio-BMI status. Within the domain of psychosocial US are more likely to report being dissatisfied erweight or obese, and to have lower weightever, overweight or obese youths in Mexico are ms than healthy-weight youths, unlike obese ressive symptoms than healthy-weight youths e symptoms is greater among healthy-weight, respectively) than those in the US (2.1, 2.8, 3.2, overweight or obese youths in Mexico is lower espectively). e US have lower healthy lifestyle priorities (3.0 vs. 1.8, respectively), and are less likely to eat ht youth in the US. Overweight and obese re likely to engage in weight control behaviors, to healthy-weight youth. The only statistically obese youths in both countries include being bout their weight and that their parents have a er, overweight youths in the US are not more t their weight, as compared to healthy weight ts had a p-value of <0.05, which was considered ioral, and socio-environmental factors by BMI  Tables 2 and 3 compare the mean scores for various psychosocial, behavioral, and socioenvironmental variables, by country of residence and BMI status. Within the domain of psychosocial factors, overweight or obese youth in Mexico and the US are more likely to report being dissatisfied with their body image, to perceive themselves as overweight or obese, and to have lower weightspecific QOL scores than healthy-weight youth. However, overweight or obese youths in Mexico are not more likely to report more depressive symptoms than healthy-weight youths, unlike obese youths in the US, who are more likely to report depressive symptoms than healthy-weight youths (3.2 vs. 2.3, respectively). The presence of depressive symptoms is greater among healthy-weight, overweight, and obese youth in Mexico (3.1, 3.7, 3.9, respectively) than those in the US (2.1, 2.8, 3.2, respectively); and the weight-related QOL reported by overweight or obese youths in Mexico is lower than those in the US (65.1 and 52.9 vs. 78.1 and 67.0, respectively).
In terms of behavioral factors, obese youth in the US have lower healthy lifestyle priorities (3.0 vs. 3.1, respectively), are less physically active (1.6 vs. 1.8, respectively), and are less likely to eat breakfast (1.5, 1.6, respectively) than healthy-weight youth in the US. Overweight and obese participants in both countries are also significantly more likely to engage in weight control behaviors, such as exercise and restrained eating, as compared to healthy-weight youth. The only statistically significant socio-environmental factors reported by obese youths in both countries include being more likely to think that their parents are concerned about their weight and that their parents have a larger body size than healthy-weight youth. However, overweight youths in the US are not more likely to report that their parents are concerned about their weight, as compared to healthy weight youths (Tables 2 and 3). All the aforementioned results had a p-value of <0.05, which was considered statistically significant.  breakfast (1.5, 1.6, respectively) than healthy-weight youth in the US. Overweight and obese participants in both countries are also significantly more likely to engage in weight control behaviors, such as exercise and restrained eating, as compared to healthy-weight youth. The only statistically significant socio-environmental factors reported by obese youths in both countries include being more likely to think that their parents are concerned about their weight and that their parents have a larger body size than healthy-weight youth. However, overweight youths in the US are not more likely to report that their parents are concerned about their weight, as compared to healthy weight youths (Tables 2 and 3). All the aforementioned results had a p-value of <0.05, which was considered statistically significant.

P obese
breakfast (1.5, 1.6, respectively) than healthy-weight youth in the US. Overweight and obese participants in both countries are also significantly more likely to engage in weight control behaviors, such as exercise and restrained eating, as compared to healthy-weight youth. The only statistically significant socio-environmental factors reported by obese youths in both countries include being more likely to think that their parents are concerned about their weight and that their parents have a larger body size than healthy-weight youth. However, overweight youths in the US are not more likely to report that their parents are concerned about their weight, as compared to healthy weight youths (Tables 2 and 3). All the aforementioned results had a p-value of <0.05, which was considered statistically significant. likely to report that their parents are concerned about their weight, as compared to healthy weight youths (Tables 2 and 3). All the aforementioned results had a p-value of <0.05, which was considered statistically significant.

Differences between means were performed using t-tests;
likely to report that their parents are concerned about their weight, as compared to healthy weight youths (Tables 2 and 3). All the aforementioned results had a p-value of <0.05, which was considered statistically significant. The standardized and adjusted odds ratios for various psychosocial, behavioral, and socio-environmental factors, by BMI status, among youths in Mexico and the US (controlling for age, sex, race/ethnicity, and country of residence) are reported in Table 4. Overweight and obese youth have significantly greater odds of reporting body image dissatisfaction (OR = 1.67, OR = 2.95), having depressive symptoms (OR = 1.08, OR = 1.12), perceiving themselves as overweight or obese, and having a lower weight-specific QOL (OR = 0.97, OR = 0.95), than healthy-weight youth. Obese youth in both countries also have significantly lower odds of having healthy lifestyle priorities (OR = 0.75), being physically active (OR = 0.79), consuming fast food (OR = 0.68), and eating breakfast (OR = 0.47), than healthy-weight youth. Overweight and obese youth are significantly more likely to engage in weight control behaviors (OR = 5.19, OR = 8.88), such as exercise (OR = 1.99, OR = 2.12), as well as eating less, fewer calories, and lower-fat food (OR = 2.15, OR = 2.32) than healthy-weight youth. In addition, overweight and obese youth have significantly greater odds of restrained eating behaviors (OR = 1.86, OR = 2.35) than healthy-weight youth. Both groups are also significantly more likely to perceive their parent as overweight or obese (OR = 1.49, OR = 1.71), and obese youth have significantly greater odds of reporting that their parents are very concerned about their weight (OR = 1.56), compared to healthy-weight youth. The standardized odds ratio results indicate that the following psychosocial, behavioral, and socio-environmental factors are most significantly associated with overweight and obesity: Perceived body shape (OR = 6.31, OR = 25.89), restrained eating behaviors (OR = 1.7, OR = 2.08), and perceived parent body shape (OR = 1.88, OR = 2.34), respectively. The standardized odds ratios of measures with scales that have a wider range, such as the CDI-S (0-20) and the YQOL-W (0-100), show a stronger association with overweight and obesity, than the non-standardized odds ratios. (Table 4) All the aforementioned results had a p-value of <0.05, which was considered statistically significant. Table 4. Standardized and adjusted odds ratios for psychosocial, behavioral, and socio-environmental factors by BMI status, among youth in Mexico and the US (n = 633).

S_OR Overweight
such as exercise and restrained eating, as compared to healthy-weight youth. The only statistically significant socio-environmental factors reported by obese youths in both countries include being more likely to think that their parents are concerned about their weight and that their parents have a larger body size than healthy-weight youth. However, overweight youths in the US are not more likely to report that their parents are concerned about their weight, as compared to healthy weight youths (Tables 2 and 3). All the aforementioned results had a p-value of <0.05, which was considered statistically significant. Obese such as exercise and restrained eating, as compared to healthy-weight youth. The only statistically significant socio-environmental factors reported by obese youths in both countries include being more likely to think that their parents are concerned about their weight and that their parents have a larger body size than healthy-weight youth. However, overweight youths in the US are not more likely to report that their parents are concerned about their weight, as compared to healthy weight youths (Tables 2 and 3). All the aforementioned results had a p-value of <0.05, which was considered statistically significant.  1.08 (1.0, 1.2) ** 1. 44  1.12 (1.1, 1.2 s are also significantly more likely to engage in weight control behaviors, ed eating, as compared to healthy-weight youth. The only statistically ntal factors reported by obese youths in both countries include being r parents are concerned about their weight and that their parents have a y-weight youth. However, overweight youths in the US are not more rents are concerned about their weight, as compared to healthy weight he aforementioned results had a p-value of <0.05, which was considered arious psychosocial, behavioral, and socio-environmental factors by BMI Mexico (n = 181). ean scores for various psychosocial, behavioral, and socioof residence and BMI status. Within the domain of psychosocial Mexico and the US are more likely to report being dissatisfied hemselves as overweight or obese, and to have lower weightght youth. However, overweight or obese youths in Mexico are ressive symptoms than healthy-weight youths, unlike obese ly to report depressive symptoms than healthy-weight youths ce of depressive symptoms is greater among healthy-weight, ico (3.1, 3.7, 3.9, respectively) than those in the US (2.1, 2.8, 3.2, QOL reported by overweight or obese youths in Mexico is lower . 78.1 and 67.0, respectively). bese youth in the US have lower healthy lifestyle priorities (3.0 ally active (1.6 vs. 1.8, respectively), and are less likely to eat an healthy-weight youth in the US. Overweight and obese significantly more likely to engage in weight control behaviors, g, as compared to healthy-weight youth. The only statistically rs reported by obese youths in both countries include being are concerned about their weight and that their parents have a t youth. However, overweight youths in the US are not more concerned about their weight, as compared to healthy weight mentioned results had a p-value of <0.05, which was considered ychosocial, behavioral, and socio-environmental factors by BMI = 181). Healthy is reference category for comparison between BMI groups; ∞ Adjusted for age, gender, race/ethnicity, and country; * p-value ≤ 0.001; ** p-value < 0.05; significant results are in bold. Table 5 presents the logistic regression results for the psychosocial, behavioral, and socio-environmental factors, stratified by sex. Some important differences are observed by sex. For example, overweight or obese boys are more likely to report dissatisfaction with their body image (OR = 1.81 and OR = 3.21, respectively) than girls (OR = 1.59 and OR = 2.78, respectively). However, the presence of depressive symptoms is significantly greater among overweight and obese females (OR = 1.14 and OR = 1.16, respectively) but not among males. Girls are also more likely to perceive themselves as overweight or obese and "feel fat" (OR = 8.91 and OR = 34.28, respectively) than boys (OR = 7.14 and OR = 32.28, respectively). Obese females are significantly less likely to be physically active (OR = 0.72) and eat breakfast than healthy-weight females (OR = 0.40), but this association was not found to be significant among males. Overweight or obese males are more likely to engage in weight control behaviors (OR = 13.77 and OR = 12.69, respectively) than obese females (OR = 8.02), especially exercise (OR = 2.67 and OR = 2.59, respectively) and eating less/few calories/low-fat foods (OR = 3.40 and OR = 2.93, respectively). However, obese girls are significantly more likely to consume diet pills, powders or liquids (OR = 9.59) than boys ( Table 5). All the aforementioned results had a p-value of <0.05, which was considered statistically significant. Table 5. Association between psychosocial, behavioral, and socio-environmental factors and overweight or obesity, by sex (n = 633).

Female Male
Overweight kfast (1.5, 1.6, respectively) than healthy-weight youth in the US. Overweight and obese icipants in both countries are also significantly more likely to engage in weight control behaviors, as exercise and restrained eating, as compared to healthy-weight youth. The only statistically ificant socio-environmental factors reported by obese youths in both countries include being e likely to think that their parents are concerned about their weight and that their parents have a er body size than healthy-weight youth. However, overweight youths in the US are not more y to report that their parents are concerned about their weight, as compared to healthy weight ths (Tables 2 and 3). All the aforementioned results had a p-value of <0.05, which was considered stically significant. Obese breakfast (1.5, 1.6, respectively) than healthy-weight youth in the US. Overweight and obese participants in both countries are also significantly more likely to engage in weight control behaviors, such as exercise and restrained eating, as compared to healthy-weight youth. The only statistically significant socio-environmental factors reported by obese youths in both countries include being more likely to think that their parents are concerned about their weight and that their parents have a larger body size than healthy-weight youth. However, overweight youths in the US are not more likely to report that their parents are concerned about their weight, as compared to healthy weight youths (Tables 2 and 3). All the aforementioned results had a p-value of <0.05, which was considered statistically significant. Overweight breakfast (1.5, 1.6, respectively) than healthy-weight youth in the US. Overweight and obese participants in both countries are also significantly more likely to engage in weight control behaviors, such as exercise and restrained eating, as compared to healthy-weight youth. The only statistically significant socio-environmental factors reported by obese youths in both countries include being more likely to think that their parents are concerned about their weight and that their parents have a larger body size than healthy-weight youth. However, overweight youths in the US are not more likely to report that their parents are concerned about their weight, as compared to healthy weight youths (Tables 2 and 3). All the aforementioned results had a p-value of <0.05, which was considered statistically significant. Obese breakfast (1.5, 1.6, respectively) than healthy-weight youth in the US. Overweight and obese participants in both countries are also significantly more likely to engage in weight control behaviors, such as exercise and restrained eating, as compared to healthy-weight youth. The only statistically significant socio-environmental factors reported by obese youths in both countries include being more likely to think that their parents are concerned about their weight and that their parents have a larger body size than healthy-weight youth. However, overweight youths in the US are not more likely to report that their parents are concerned about their weight, as compared to healthy weight youths (Tables 2 and 3). All the aforementioned results had a p-value of <0.05, which was considered statistically significant. s psychosocial, behavioral, and sociotatus. Within the domain of psychosocial e more likely to report being dissatisfied ht or obese, and to have lower weightverweight or obese youths in Mexico are n healthy-weight youths, unlike obese symptoms than healthy-weight youths toms is greater among healthy-weight, tively) than those in the US (2.1, 2.8, 3.2, eight or obese youths in Mexico is lower ively). ave lower healthy lifestyle priorities (3.0 respectively), and are less likely to eat th in the US. Overweight and obese ly to engage in weight control behaviors, lthy-weight youth. The only statistically youths in both countries include being heir weight and that their parents have a rweight youths in the US are not more weight, as compared to healthy weight a p-value of <0.05, which was considered nd socio-environmental factors by BMI Healthy is reference category for comparison between BMI groups; ∞ Adjusted for age, race/ethnicity, and country; * p-value ≤ 0.001; ** p-value < 0.05; statistically significant results are in bold.

Discussion
The primary objective of this study was to examine the relevance of various psychosocial, behavioral, and socio-environmental factors among overweight and obese youth in the US and Mexico, and to determine differences by sex. We aimed to address gaps in the current research by studying factors in distinct domains among an ethnically diverse, bi-national sample of youth. Our results support the findings of other studies in the US that have examined similar factors within these three domains . However, as far as we know, our study is the first to explore the effects of multiple psychosocial factors, behavioral, and socio-environmental factors on overweight or obesity risk in a diverse sample of youth. By simultaneously examining all of these factors in one sample, we were able to contrast the relevance of different risk factors in a single large group, rather than across various studies, which may be difficult to compare. Additionally, to the best of our knowledge, this is one of the first studies to shed light on the association between psychosocial, behavioral, and socio-environmental factors and the presence of overweight or obesity among youth in Mexico and Latinos living in the US.
In our study, psychosocial factors, such as a higher rate of body image dissatisfaction, depressive symptoms, self-perception of overweight, and a lower weight-related QOL, were most strongly associated with overweight or obesity. These results are consistent with other studies, which found a higher prevalence of these factors among overweight or obese youth, as compared to healthy-weight youth [13][14][15]17,19,20]. We found that depressive symptoms are significantly associated with overweight or obesity among girls but not boys. Inconsistent gender differences have previously been reported for the relationship between depressive symptoms and obesity [14,17]. These mixed results could be attributable to variations in study design or assessment of depression [54], or due to the characteristics of the study sample. A meta-analysis of 17 studies concluded that depression is positively associated with BMI but only among females [54]. Interestingly, overweight or obese youths in Mexico did not report more depressive symptoms than healthy-weight youths, unlike obese youths in the US, who did report more depressive symptoms than healthy-weight youths. Our findings also indicate a higher prevalence of depressive symptoms among youths in Mexico than in the US.
In terms of self-perception regarding weight, overweight or obese girls were more likely to perceive themselves as overweight or obese than boys. Similar differences have been observed with adolescent girls being more likely to perceive themselves as overweight or obese than boys [13]. A recent study investigated brain activation using functional magnetic resonance imaging during a body perception task in healthy males and females. They found that images of their own bodies were more salient for the female participants and concluded that females may be more vulnerable than males to conditions involving own body perception [55]. Youths in Mexico reported higher scores for all the "self-perception regarding weight categories", than youths in the US. Obese adolescents have been shown to report a lower QOL [20], which was also found in this study, with overweight or obese youth reporting significantly lower weight-related QOL than healthy-weight youth. Additionally, the weight-related QOL reported by overweight or obese youths in Mexico was lower than in the US. Notably, self-reported QOL is lower in Mexico than in the US., regardless of weight status.
The multivariate analyses indicate that obese youth were less likely to have healthy lifestyle priorities, be physically active, or eat breakfast. However, when stratified by sex, only obese females were significantly less likely to engage in physical activity. Obese and overweight youth were twice as likely to report that they exercise for weight control, compared to healthy weight youths. There are contradictory findings regarding the effect of physical activity by gender, with one study showing a protective effect only among boys [14] and another only among girls [22]. By contrast, eating breakfast has shown a consistent protective effect for boys and girls in various studies, across different ethnic groups [14,26,27]. Our results also indicate that obese youth are less likely to consume breakfast, but when stratified by sex, this association only remained significant among obese females.
We found that obese males are less likely to report that they eat fast food, as compared to healthy-weight males. Additionally, overweight or obese youths in Mexico are less likely to eat fast food than their counterparts in the US. Previous studies have reported a negative association between eating fast food and obesity among males [27] and females [14,27]. However, other researchers have found that fast food consumption is associated with increased risk of obesity [28,29]. When relying on self-reported behaviors, there may be a higher likelihood of over reporting of socially desirable behaviors, which could explain the inverse association between fast food consumption and obesity observed in this study. Several weight control behaviors were also significantly associated with overweight and obesity in this study. There was a stronger association between weight control behaviors and BMI among males compared to females. Unhealthy weight control behaviors have been shown to predict weight gain in boys and girls [14,15,17,22]. Restrained eating was also found to be a risk factor for obesity in our study, which has previously been reported in other studies [17].
Socio-environmental factors were found to have the least significant associations with overweight or obesity. In this study, obese youth were more likely to believe that their parents are concerned about their weight, which has been previously reported in the literature [14,36]. Parental obesity has also been examined in various studies because children of obese parents may be at greater risk for obesity due to shared genetic and environmental factors [17,56]. In this study, youth who perceived their parents as heavier were more likely to be overweight or obese. Although parental health values and the availability of healthy foods at home have been reported to be significant in other studies [30,31,34,35], no significant associations were found in this study.
This study has some limitations, including that it is cross-sectional, and thus, no conclusions about the direction of causality can be made and there is a possibility of reporting bias. Participants were recruited by means of convenience sampling and might not be representative of their respective weight groups. Additionally, this is an exploratory study with a limited sample size for the participants in Mexico. Future studies should be conducted with a larger sample size that will allow for a higher significance threshold to be set for individual comparisons to compensate for the number of inferences being made. Other limitations include the specific measures that were collected using a self-reported questionnaire, a lack of validated measures, and the fact that some of the behavioral and socio-environmental indices, e.g., "healthy lifestyle priorities," "physically active," "mother/father healthy values," or "home availability of healthy foods", were created based on a limited number of variables and should be interpreted as preliminary findings. The information provided by the study participants was of a quantitative nature, so we were unable to determine the reason for some of the differences observed by sex or country of origin. Future studies should collect more qualitative data to investigate these differences. A strength of this study is that it explored the issue of overweight and obesity among an ethnically diverse group of youth in the US and Mexico, including African Americans and Latinos, who are disproportionately affected by obesity. Additionally, this study examined a breadth of risk factors that have not been analyzed in a comprehensive and comparative manner. Although some of the indices we created to measure eating behaviors do not have a high reliability score, the associations we observed support the expected relationships, especially when obesity is the main outcome variable. The use of indices in this study to combine various factors also allowed for a robust analysis of complex concepts.

Conclusions
The results of this bi-national study highlight some of the differences and similarities in various psychosocial, behavioral, and socio-environmental factors among a multiethnic sample of healthy-weight, overweight, and obese youths. We hope our findings help to demonstrate the importance of considering a wide range of risk and protective factors for obesity among adolescents, when planning future studies and interventions. Additionally, our results support the need for multifactorial approaches when developing interventions to address the growing problem of obesity among youth in the US and Mexico. Intervention programs should use an integrated approach that addresses several of these factors to help to reduce the alarmingly high rates of obesity among youth in the US and Mexico. More research is needed on how these factors may interact with each other to cause obesity, since many are interrelated. Our study paves the way for future studies to focus on adopting a transdisciplinary approach to identify and address important risk factors for obesity among youth.