Structure analysis of the Children's Eating Attitudes Test in overweight and at-risk for overweight children and adolescents

ADHD Symptoms and Obesity in Chinese Children and Adolescents: A Longitudinal Study With Abnormal Eating Behaviors as Moderating Factors

BACKGROUND

Emerging studies have explored the possibility of ADHD and associated abnormal eating behaviors as catalysts for obesity in children and adolescents. However, results were largely inconsistent. This study aims to explore the effects of ADHD and abnormal eating behaviors (including eating disorders, emotional eating, and bedtime eating) on obesity, and to assess the moderating role of abnormal eating behaviors between ADHD symptoms and BMI in Chinese children and adolescents.

METHODS

We recruited 546 grade 3 to 11 students and their parents by stratified random sampling from three primary schools and four middle schools in Shanghai, China. This study used parent-reported versions of the ADHD Rating Scale-IV to assess ADHD symptoms, the Eating Attitudes Test and the Children's Eating Attitude Test to assess eating disorder (ED) symptoms, and the Child Eating Behavior Questionnaire to collect information about other abnormal eating behaviors at baseline and at a follow-up survey 1 year later.

RESULTS

Hierarchical linear regression analysis revealed that ED played a moderating role in the relationship between ADHD symptoms and BMI in addition to age (β = .003, p = .008). The simple slope test showed that ADHD symptoms positively correlated with BMI ofs in the older age group with a high level of ED symptoms (β = .16, p < .001). Moreover, the baseline ED symptoms (β = .03, p = .032) and ADHD symptoms (β = .12, p = .015) increased the students' BMI one year later after controlling for confounding factors.

CONCLUSION

Findings of this study suggest that ADHD and ED symptoms raised the students' BMI separately. Moreover, ADHD and ED symptoms raised the students' BMI separately. Moreover, a combined high level of ADHD and ED symptoms is correlated with students' high BMI in the older age group.

Latent profiles of the feeding practices of caregivers of rural children with overweight and obesity and associations with child eating behaviors

Previous research has shown that food parenting practices, which vary within the context of sociocultural factors, are associated with child weight, eating behaviors, and body dissatisfaction. While parents typically engage in multiple food parenting practices, few studies have examined what subgroups or combinations of food parenting practices are associated with child health outcomes and sociocultural factors. The current study examined profiles of food parenting practices among school-age children with overweight/obesity (OW/OB) from rural communities and examined how they may be associated with sociocultural factors, child-eating habits, and health outcomes. The study included 270 children with OW/OB aged 8-12 (M_age = 10.36 years) and their caregivers. Caregivers completed a measure assessing perceptions of their feeding practices and sociocultural questionnaires. Children completed measures assessing disordered eating habits, weight control behaviors, and body dissatisfaction. Weight status was measured for caregivers and children with height and weight measurements. Latent variable mixture modeling (LVMM) was conducted. Three profiles emerged: (a) Lower Parental Involvement, (b) Higher Parental Involvement, and (c) Mixed Parental Involvement. Lower family income and non-White child race were related to membership in the "Higher Parental Involvement" profile. After controlling for income and child race, children in the "Mixed Parental Involvement" profile reported significantly higher body dissatisfaction than children in the "Lower Parental Involvement" profile. There are subgroups of caregivers of rural children with OW/OB that demonstrate various patterns of parent feeding practices, and these subgroups differ by income, race, and child body dissatisfaction. Future research should consider how caregiver-specific feeding practices may impact child eating behaviors and their body image development, as well as the impact cultural factors may have on parent feeding practices.

Children's Eating Attitudes Test (ChEAT): a validation study in Finnish children

PURPOSE

To validate the Children's Eating Attitudes Test (ChEAT) in the Finnish population.

MATERIALS AND METHODS

In total 339 children (age 10-15 years) from primary schools in Southern Finland were evaluated at two time points. They answered the ChEAT and SCOFF test questions, and had their weight, height and waist circumference measured. Retesting was performed 4-6 weeks later. Test-retest reliability was evaluated using intra-class correlation (ICC), and internal consistency was examined using Cronbach's alpha coefficient (C-alpha). ChEAT was cross-calibrated against SCOFF and background variables. Factor analysis was performed to examine the factor structure of ChEAT.

RESULTS

The 26-item ChEAT showed high internal consistency (C-alpha 0.79), however, a 24-item ChEAT showed even better internal consistency (C-alpha 0.84) and test-retest reliability (ICC 0.794). ChEAT scores demonstrated agreement with SCOFF scores (p < 0.01). The mean ChEAT score was higher in overweight children than normal weight (p < 0.001). Exploratory factor analysis yielded four factors (concerns about weight, limiting food intake, pressure to eat, and concerns about food), explaining 57.8% of the variance.

CONCLUSIONS

ChEAT is a valid and reliable tool for measuring eating attitudes in Finnish children. The 24-item ChEAT showed higher reliability than the 26-item ChEAT.

LEVEL OF EVIDENCE

Level 5, cross-sectional, descriptive study.

The relative importance of social anxiety facets on disordered eating in pediatric obesity

PURPOSE

Children with obesity demonstrate increased risk for eating disorders and internalizing psychopathology. Research in adults indicates unique facets of social anxiety differentially relate to eating pathology. These associations remain understudied in pediatric samples. The current study evaluated associations between social anxiety and disordered eating, and tested the relative importance of distinct social anxiety constructs-fear of negative evaluation, social anxiety in general situations, and social anxiety in new situations-for disordered eating in weight-loss treatment-seeking youth with obesity.

METHODS

One-hundred and thirty-five youth (M_age 12.6 years; Range 8-17 years; M_BMIz = 2.6) from a multidisciplinary outpatient pediatric obesity clinic completed questionnaires assessing dimensions of social anxiety and the Children's Eating Attitudes Test (ChEAT). Dominance analyses were used to evaluate the relative importance of social anxiety facets associated with ChEAT subscales.

RESULTS

Social anxiety subscales did not correlate with Dieting scores. Dominance analyses indicated Fear of Negative Evaluation (FNE) evinced complete dominance, thus, emerging as the most important predictor relative to other social anxiety components for Body/Weight Concern and Food Preoccupation. General dominance weights for FNE accounted for more than twice the shared and unique variance, relative to other independent variables within the Body/Weight Concern and Food Preoccupation models, respectively.

CONCLUSIONS

Unique facets of social anxiety differentially relate to disordered eating in youth with obesity. Findings suggest nuanced assessment of anxiety constructs, such as FNE, in pediatric obesity treatment settings may aid in identifying youth at risk for disordered eating attitudes and behaviors.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Assessment of eating attitudes and dieting behaviors in healthy children: Confirmatory factor analysis of the Children's Eating Attitudes Test

OBJECTIVE

The Children's Eating Attitudes Test (ChEAT) is a self-report questionnaire that is conventionally summarized with a single score to identify "problematic" eating attitudes, masking informative variability in different eating attitude domains. This study evaluated the empirical support for single- versus multifactor models of the ChEAT. For validation, we compared how well the single- versus multifactor-based scores predicted body mass index (BMI).

METHOD

Using data from 13,674 participants of the 11.5 year-follow-up of the Promotion of Breastfeeding Intervention Trial (PROBIT) in the Republic of Belarus, we conducted confirmatory factor analysis to evaluate the performance of 3- and 5-factor models, which were based on past studies, to a single-factor model representing the conventional summary of the ChEAT. We used cross-validated linear regression models and the reduction in mean squared error (MSE) to compare the prediction of BMI at 11.5 and 16 years by the conventional and confirmed factor-based ChEAT scores.

RESULTS

The 5-factor model, based on 14 of the original 26 ChEAT items, had good fit to the data whereas the 3- and single-factor models did not. The MSE for concurrent (11.5 years) BMI regressed on the 5-factor ChEAT summary was 35% lower than that of the single-score models, which reduced the MSE from the null model by only 1%-5%. The MSE for BMI at 16 years was 20% lower.

DISCUSSION

We found that a parsimonious 5-factor model of the ChEAT explained the data collected from healthy Belarusian children better than the conventional summary score and thus provides a more discriminating measure of eating attitudes.

Comparing disordered eating and feeding practices in African American and Caucasian treatment-seeking youth with obesity

OBJECTIVES

Examine racial differences in disordered eating and parental feeding in youth with obesity.

METHODS

A diverse sample of 131 treatment-seeking youth (M_age = 12.84 years; Range_age = 8-18 years; 65.6% African American, 34.4% Caucasian) with obesity (M_BMIz = 2.60) completed a disordered eating questionnaire; parents completed a questionnaire about feeding practices.

RESULTS

No significant differences in disordered eating between African American and Caucasian youth emerged. Significant differences were found on parent feeding where parents of African American children endorsed more frequent use of pressure to eat, including ensuring and monitoring enough is eaten.

CONCLUSIONS

Generally, comparisons of disordered eating and parent feeding practices between African American and Caucasian youth with obesity were not significant. Racial differences on some aspects of parental feeding practices were found. Future research should identify cultural factors impacting these differences. Clinical implications include providing culturally sensitive psychoeducation and interventions to address unhealthy feeding practices in diverse families.

Assessing the causal role of adiposity on disordered eating in childhood, adolescence, and adulthood: a Mendelian randomization analysis

Background: Observational studies have shown that higher body mass index (BMI) is associated with increased risk of developing disordered eating patterns. However, the causal direction of this relation remains ambiguous.Objective: We used Mendelian randomization (MR) to infer the direction of causality between BMI and disordered eating in childhood, adolescence, and adulthood.Design: MR analyses were conducted with a genetic score as an instrumental variable for BMI to assess the causal effect of BMI at age 7 y on disordered eating patterns at age 13 y with the use of data from the Avon Longitudinal Study of Parents and Children (ALSPAC) (n = 4473). To examine causality in the reverse direction, MR analyses were used to estimate the effect of the same disordered eating patterns at age 13 y on BMI at age 17 y via a split-sample approach in the ALSPAC. We also investigated the causal direction of the association between BMI and eating disorders (EDs) in adults via a two-sample MR approach and publically available genome-wide association study data.Results: MR results indicated that higher BMI at age 7 y likely causes higher levels of binge eating and overeating, weight and shape concerns, and weight-control behavior patterns in both males and females and food restriction in males at age 13 y. Furthermore, results suggested that higher levels of binge eating and overeating in males at age 13 y likely cause higher BMI at age 17 y. We showed no evidence of causality between BMI and EDs in adulthood in either direction.Conclusions: This study provides evidence to suggest a causal effect of higher BMI in childhood and increased risk of disordered eating at age 13 y. Furthermore, higher levels of binge eating and overeating may cause higher BMI in later life. These results encourage an exploration of the ways to break the causal chain between these complex phenotypes, which could inform and prevent disordered eating problems in adolescence.

Perceived Body Image, Eating Behavior, and Sedentary Activities and Body Mass Index Categories in Kuwaiti Female Adolescents

Background. The State of Kuwait has a growing obesity epidemic in both genders and all age groups; however, obesity rates in the young seem to be rising. Methods. We conducted a cross-sectional survey in 169 Kuwaiti female adolescents attending both private and public schools spanning the six governorates in the State of Kuwait in order to explore female adolescents' self-image, body dissatisfaction, type of school (private versus public), TV viewing, and computer games and their relationship to body mass index. Results. Approximately half the students classified as obese perceived their body image to lie in the normal range. Females in the obese category were the most dissatisfied with their body image, followed by those in the overweight category. Eating behavior, level of physical activity, school type, television viewing, computer/video usage, and desired BMI were not significantly associated with level of obesity. Conclusion. This study was one of the few studies to assess adolescent females' body image dissatisfaction in relation to obesity in the State of Kuwait. The results suggest that including body image dissatisfaction awareness into obesity prevention programs would be of value.

Dietary Intake and Eating-Related Cognitions Related to Sleep Among Adolescents Who Are Overweight or Obese

OBJECTIVE : To examine associations of sleep duration and regularity with dietary intake and eating-related cognitions among adolescents who are overweight/obese.  METHODS : Participants were 315 adolescents being evaluated through Healthy Kids, Healthy Weight. Outcomes were reported sleep duration and regularity (bedtime shift, wake-time shift, sleep duration shift). Major predictors were dietary intake (e.g., consumption of calories and sugar-sweetened beverages) and eating-related cognitions (food preoccupation, eating self-efficacy).  RESULTS : Findings were that staying up (i.e., bedtime shift) and sleeping in later (i.e., wake-time shift) on weekends compared with weekdays significantly relates to drinking more sugar-sweetened beverages, the latter for males. Sleeping in on weekends was related to greater food preoccupation.  CONCLUSIONS : Sleep regularity was the most important variable in its relationships with dietary intake. Evaluating sleep patterns and improving them with behavioral interventions should be considered as an additional weight loss strategy to promote dietary adherence.

Systematic review to identify and appraise outcome measures used to evaluate childhood obesity treatment interventions (CoOR): evidence of purpose, application, validity, reliability and sensitivity

BACKGROUND

Lack of uniformity in outcome measures used in evaluations of childhood obesity treatment interventions can impede the ability to assess effectiveness and limits comparisons across trials.

OBJECTIVE

To identify and appraise outcome measures to produce a framework of recommended measures for use in evaluations of childhood obesity treatment interventions.

DATA SOURCES

Eleven electronic databases were searched between August and December 2011, including MEDLINE; MEDLINE In-Process and Other Non-Indexed Citations; EMBASE; PsycINFO; Health Management Information Consortium (HMIC); Allied and Complementary Medicine Database (AMED); Global Health, Maternity and Infant Care (all Ovid); Cumulative Index to Nursing and Allied Health Literature (CINAHL) (EBSCOhost); Science Citation Index (SCI) [Web of Science (WoS)]; and The Cochrane Library (Wiley) - from the date of inception, with no language restrictions. This was supported by review of relevant grey literature and trial databases.

REVIEW METHODS

Two searches were conducted to identify (1) outcome measures and corresponding citations used in published childhood obesity treatment evaluations and (2) manuscripts describing the development and/or evaluation of the outcome measures used in the childhood intervention obesity evaluations. Search 1 search strategy (review of trials) was modelled on elements of a review by Luttikhuis et al. (Oude Luttikhuis H, Baur L, Jansen H, Shrewsbury VA, O'Malley C, Stolk RP, et al. Interventions for treating obesity in children. Cochrane Database Syst Rev 2009;1:CD001872). Search 2 strategy (methodology papers) was built on Terwee et al.'s search filter (Terwee CB, Jansma EP, Riphagen II, de Vet HCW. Development of a methodological PubMed search filter for finding studies on measurement properties of measurement instruments. Qual Life Res 2009;18:1115-23). Eligible papers were appraised for quality initially by the internal project team. This was followed by an external appraisal by expert collaborators in order to agree which outcome measures should be recommended for the Childhood obesity Outcomes Review (CoOR) outcome measures framework.

RESULTS

Three hundred and seventy-nine manuscripts describing 180 outcome measures met eligibility criteria. Appraisal of these resulted in the recommendation of 36 measures for the CoOR outcome measures framework. Recommended primary outcome measures were body mass index (BMI) and dual-energy X-ray absorptiometry (DXA). Experts did not advocate any self-reported measures where objective measurement was possible (e.g. physical activity). Physiological outcomes hold potential to be primary outcomes, as they are indicators of cardiovascular health, but without evidence of what constitutes a minimally importance difference they have remained as secondary outcomes (although the corresponding lack of evidence for BMI and DXA is acknowledged). No preference-based quality-of-life measures were identified that would enable economic evaluation via calculation of quality-adjusted life-years. Few measures reported evaluating responsiveness.

LIMITATIONS

Proposed recommended measures are fit for use as outcome measures within studies that evaluate childhood obesity treatment evaluations specifically. These may or may not be suitable for other study designs, and some excluded measures may be more suitable in other study designs.

CONCLUSIONS

The CoOR outcome measures framework provides clear guidance of recommended primary and secondary outcome measures. This will enhance comparability between treatment evaluations and ensure that appropriate measures are being used. Where possible, future work should focus on modification and evaluation of existing measures rather than development of tools de nova. In addition, it is recommended that a similar outcome measures framework is produced to support evaluation of adult obesity programmes.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Prospective associations of parental smoking, alcohol use, marital status, maternal satisfaction, and parental and childhood body mass index at 6.5 years with later problematic eating attitudes

BACKGROUND

Few studies have prospectively investigated whether early-life exposures are associated with pre-adolescent eating attitudes.

OBJECTIVE

The objective of this study is to prospectively investigate associations of parental smoking, alcohol use, marital status, measures of maternal satisfaction, self-reported parental body mass index (BMI) and clinically measured childhood BMI, assessed between birth and 6.5 years, with problematic eating attitudes at 11.5 years.

METHODS

Observational cohort analysis nested within the Promotion of Breastfeeding Intervention Trial, a cluster-randomised trial conducted in 31 maternity hospitals and affiliated polyclinics in Belarus. Our primary outcome was a Children's Eating Attitudes Test (ChEAT) score 22.5 (85th percentile), an indicator of problematic eating attitudes. We employed multivariable mixed logistic regression models, which allow inference at the individual level. We also performed instrumental variable (IV) analysis using parents' BMIs as instruments for the child's BMI, to assess whether associations could be explained by residual confounding or reverse causation.

SUBJECTS

Of the 17 046 infants enrolled between 1996 and 1997 across Belarus, 13 751 (80.7%) completed the ChEAT test at 11.5 years.

RESULTS

In fully adjusted models, overweight children at age 6.5 years had a 2.14-fold (95% confidence interval (CI): 1.82, 2.52) increased odds of having ChEAT scores 85th percentile at age 11.5 years, and those who were obese had a 3.89-fold (95% CI: 2.95, 5.14) increased odds compared with normal-weight children. Children of mothers or fathers who were themselves overweight or obese were more likely to score 85th percentile (P for trend 0.001). IV analysis was consistent with a child's BMI causally affecting future eating attitudes. There was little evidence that parental smoking, alcohol use, or marital status or maternal satisfaction were associated with eating attitudes.

CONCLUSION

In our large, prospective cohort in Belarus, both parental and childhood overweight and obesity at 6.5 years were associated with pre-adolescent problematic eating attitudes 5 years later.

The Eating Attitudes Test (EAT-26): Reliability and Validity in Spanish Female Samples

This paper focuses on the validation of the Spanish form of the Eating Attitudes Test (EAT-26; Garner, Olmsted, Bohr & Garfinkel, 1982) across two studies. Participants in Study 1 were 778 females recruited from community settings (aged 12-21). Study 2 included 86 females recruited from clinical and 86 females from community settings (aged 12-35). Results from Principal and Simultaneous Component Analyses showed a unidimensional structure of the EAT-26 item scores. Reliability analyses supported the internal consistency of the scale. Study 1 also explores the ability of the EAT-26 to discriminate between subjects with Eating Disorder (ED), Symptomatic or Asymptomatic by means of ROC analyses and using results from the Questionnaire for Eating Disorder Diagnoses (Q-EDD; Mintz, O'Halloran, Mulholland, & Schneider, 1997) as criterion. The EAT-26 demonstrated good specificity but insufficient sensitivity to detect a full or partial ED. Study 2 explores the ability of the questionnaire to discriminate between subjects with and without ED. The EAT-26 demonstrated good specificity and moderate sensitivity to detect ED. Clinical and theoretical implications of these results are discussed.

Body dissatisfaction and disordered eating attitudes in 7- to 11-year-old girls: testing a sociocultural model

We examined the sociocultural model of body dissatisfaction and disordered eating attitude development in young girls for the first time. According to the model, internalizing an unrealistically thin ideal body increases the risk of disordered eating via body dissatisfaction, dietary restraint, and depression. Girls aged 7-11 years (N=127) completed measures of thin-ideal internalization, body dissatisfaction, dieting, depression, and disordered eating attitudes. Participants' height and weight were measured and their body mass index calculated. Thin-ideal internalization predicted disordered eating attitudes indirectly via body dissatisfaction, dietary restraint, and depression; it also predicted disordered eating attitudes directly. Path analyses showed that a revised sociocultural model fit well with the data. These data show that a sociocultural framework for understanding disordered eating and body dissatisfaction in adults is useful, with minor modifications, in understanding the development of related attitudes in young girls.