A school-based cross-sectional study that aims to generate context-specific evidence on how weight status is related to resilience, health behaviour, and quality of life among Indian adolescents.

Primary Objective

To assess differences in overall resilience (total score of Adolescent Resilience score from ARQ49) between normal-weight and overweight/obese Indian adolescents aged 14-16 years.

Secondary Objectives

1. To compare differences in Adolescent Resilience Questionnaire (ARQ49) subscale scores between normal-weight and overweight/obese adolescents. The internal resilience factors assessed by the ARQ49 include confidence, emotional insight, negative cognition, social skills, empathy, and tolerance, while the external resilience factors include family connectedness, family availability, peer connectedness, peer availability, supportive school environment, school connectedness, and community connectedness.

2. To assess differences in internal resilience factors (diet self-efficacy, physical activity self-efficacy, self-esteem, and optimism) between normal-weight and overweight/obese adolescents and to examine parental nutrition knowledge as an external resilience resource and moderator in association analyses.

3. To compare dietary behaviors, physical activity patterns, and Pediatric Quality of Life Inventory (PedsQL) scores between normal-weight and overweight/obese adolescents.

4. To examine the associations among resilience, dietary and physical activity behaviors, and PedsQL within the overall sample and within different weight groups, and to evaluate parental nutrition knowledge as a moderator of the relationship between weight status and resilience or health outcomes.

   Exploratory Objective

5. To explore differences in resilience, health behaviors, and PedsQL between normal-weight and underweight Indian adolescents.

Study hypotheses

The investigators hypothesized that adolescents with overweight/obesity, compared with their normal-weight peers, would demonstrate lower scores on total resilience (primary outcome), as well as on internal and external resilience indices; report lower diet self-efficacy, physical activity self-efficacy, self-esteem, and optimism; report less frequent health-promoting behaviors (including lower fruit and vegetable intake and fewer days achieving ≥ 60 min/day of moderate-to-vigorous physical activity); and report lower PedsQL scores.

Parental nutrition knowledge will not be treated as a between-group outcome; instead, it will be tested as a moderator in association analyses, examining whether parental nutrition knowledge influences the relationship between weight status and resilience or health outcomes.

Furthermore, the investigators hypothesized that higher resilience scores would be positively associated with healthier dietary behaviors, greater physical activity participation, and higher PedsQL scores across the overall sample, with these associations expected to hold true within both normal-weight and overweight/obese groups. In addition, analyses involving underweight adolescents will be exploratory and descriptive in nature. We will explore whether underweight adolescents show different levels of resilience, health behaviors, and HRQoL compared with adolescents with normal weight.

Childhood and adolescent obesity is associated with adverse physical, psychological, and social outcomes, including reduced health-related quality of life (HRQoL). In India, the coexistence of underweight and overweight highlights the need to examine behavioural and psychosocial factors alongside anthropometric measures.

Resilience, defined as the capacity to adapt to stress and challenges, is a multidimensional construct encompassing individual, family, peer, school, and community domains. Internal resilience-related traits such as diet and physical activity self-efficacy, self-esteem, and optimism may influence adolescents' health behaviours and well-being. However, evidence examining these factors together, particularly in relation to weight status among Indian adolescents, remains limited.

This study is a school-based cross-sectional investigation conducted among adolescents aged 14-16 years in Kolkata, India. The primary objective is to assess differences in overall resilience (ARQ49 total score) between normal-weight and overweight/obese adolescents. Secondary objectives include comparing internal resilience-related traits, dietary behaviours, physical activity patterns, and HRQoL (PedsQL), and examining associations among these variables within the overall sample. An exploratory objective assesses similar outcomes among underweight adolescents.

Participants are recruited from public and private secondary schools using non-probability and snowball sampling through existing professional networks. One parent or guardian per adolescent participates to provide data on parental nutrition knowledge and related contextual factors.

Data collection includes validated self-administered questionnaires and anthropometric measurements (height and weight) to calculate BMI-for-age z-scores using international standards. Statistical analyses include group comparisons across weight categories and multivariable models examining associations among resilience, health behaviours, parental factors, and HRQoL, accounting for clustering at the school level.

This study aims to generate context-specific evidence on how psychosocial resilience and behavioural factors relate to weight status and well-being among Indian adolescents.

Eligibility Criteria

Inclusion Criteria:

• Adolescents aged 14 to 16 years
• Studying in grades 8, 9, or 10
• Enrolled in participating secondary schools in Kolkata, India
• Able to provide assent, with written consent from a parent or legal guardian
• One parent or guardian willing to participate in the parent survey

Exclusion Criteria:

• Age below 14 years or above 16 years
• Not enrolled in grades 8, 9, or 10
• No parental/legal guardian consent or no adolescent assent
• Incomplete eligibility for participation in the survey procedures

School-going Indian adolescents aged 14 to 16 years, studying in grades 8 to 10 in secondary schools in Kolkata, India. Participants were recruited from public and private schools. One parent or guardian of each participating adolescent was also invited to participate. Weight status categories (underweight, normal weight, and overweight/obese) were defined analytically using BMI-for-age z-scores based on IOTF cut-offs.

Individual participant data will not be shared publicly because the study involves adolescent participants and linked parent data, and open sharing would raise ethical and privacy concerns. De-identified data may be considered upon reasonable request, subject to review by the research team, applicable ethical approvals, and a data-sharing agreement, in accordance with Maastricht University data governance requirements.