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PEDIATRICS Vol. 107 No. 6 June 2001, p. e92

ELECTRONIC ARTICLE:
Body Image and Dieting Behavior in Cystic Fibrosis

Received Jul 3, 2000; accepted Jan 24, 2001.

Helen Truby* and Susan J. PaxtonDagger

From the * School of Biomedical and Life Sciences, University of Surrey, Surrey, United Kingdom; and Dagger  Department of Psychology, University of Melbourne, Victoria, Australia.

Objective.  To examine the relationship between pulmonary function, nutritional status, body image, and eating attitudes in children with cystic fibrosis (CF) compared with healthy controls.

Method.  Seventy-six children with CF (39 girls) and 153 healthy control children (82 girls) were recruited. All children were between 7 and 12 years of age. After being weighed and measured, participants undertook a structured 1-to-1 interview. Four measures were used to assess body image: body size (perception and satisfaction) were ascertained using the Children's Body Image Scale (CBIS), which uses photographs of children of various body mass index (BMI) representative of the range of BMI percentiles for children 7 to 12 years of age. Body size satisfaction was measured by the response to the questions, "Do you think your body is 1) much too thin, 2) too thin, 3) just right, 4) too fat, and 5) much too fat?" Body weight satisfaction was measured by the question, "Would you like your body to be 1) much thinner, 2) a little bit thinner, 3) stay the same, 4) a little bit fatter, and 5) much fatter?" Global self-esteem was measured using the children's version of the Rosenberg Self-Esteem Scale and Body Esteem Scale using a 24-item scale. Dieting behavior was measured by asking directly about previous weight control behaviors, use of the Dutch Eating Behavior-Restraint Scale (DEBQ-R), and, in children who acknowledged previous dieting behavior, the Children's Eating Attitude Test (ChEAT) was additionally administered.

Results.  Both girls and boys with CF had significantly reduced BMI percentiles compared with control children. Boys with CF did not have a significantly different BMI compared with girls with CF. There were significant positive correlations between forced expiratory volume in 1 second (FEV1) (% of predicted) and BMI percentile in girls (r = .35) and boys (r = .50) with CF. Body image perceptions in boys and girls with CF were examined in relation to the healthy control group using 2 (CF and control groups) by 2 (male and female) analysis of variance. The interaction effect was examined to explore the prediction that girls compared with boys with CF would have greater acceptance of their body shape and less desire to become larger. There were no differences between groups or sex in body esteem. On the CBIS body dissatisfaction score, children with CF were significantly more likely to perceive their ideal body size as a little larger than their current size while control children desired a smaller body size than their current size. CF children had a significantly lower mean score for body size satisfaction (an item assessing perception being too thin) and a significantly higher mean score on body weight satisfaction. There was a significant main effect of gender for only 1 measure, difference between the CBIS body dissatisfaction score, with girls being more likely to nominate a smaller ideal than their current figure. There were no significant interaction effects. Of children with CF and a low BMI (<= 10th percentile), 25% of girls and 38% of boys thought they were too thin. Fewer girls (19%) than boys (38%) would have liked to be fatter. The CF group had significantly lower mean scores on the DEBQ-R scale compared with controls. Of the children with CF completing the ChEAT (n = 13), none obtained a score of clinical significance compared with 6 (4%) for controls. To examine predictors of BMI a multiple regression analysis was conducted separately for boys and girls with CF and control boys and girls in which the dependent variable was BMI and the independent variables were FEV1 (% of predicted) (in CF children only), body esteem, self-esteem, and body dissatisfaction score. In the case of boys with CF, the regression equation was significant (Adjusted R2 = 0.30). In the case of girls with CF, the regression equation was significant (Adjusted R2 = 0.25) with body dissatisfaction making a significant independent contribution. For control boys the regression equation was significant (Adjusted R2 = 0.18). Variables making a significant contribution to the equation were body esteem and body dissatisfaction. Finally, for control girls the regression equation was significant (Adjusted R2 = 0.13). The only variable to make a significant contribution to the equation was body dissatisfaction.

Discussion.  Children with CF had very similar body esteem and general self-esteem as controls. A consideration of body image constructs does reveal group differences between perception and satisfaction with body size between groups. Children with CF were more likely to perceive their body size as larger than it actually was and have greater satisfaction with their current body size in contrast to control children. The girls and boys with CF with a higher BMI frequently selected a smaller body size as their ideal. Control children displayed a large degree of body dissatisfaction, selecting an ideal figure smaller than their own and the desire to be thinner. Given the likely positive health consequences of being larger, it is encouraging that children with CF are not adopting the desire to be thinner, widely held by their healthy peers. However, this may be attributable to the fact that CF children are thinner than average and so fit the prevailing body shape ideal. These analyses do not support the prediction that more girls with CF would be satisfied with their body size compared with boys but do provide information of clinical importance as it indicates that some children with CF, although perceiving themselves to be thin, do not necessarily wish to be any fatter and they may not be motivated to eat the high-energy diet recommended. Clinicians need to be aware of the possibility that medical targets for growth for individuals may not be in concordance with their desires and determining the child's point of view may be helpful in identifying an appropriate individual intervention. The finding that body dissatisfaction is an independent predictor of nutritional status (BMI) in controls and girls with CF suggests children's own concepts of their body size is important. Encouraging positive body and self-esteem and focusing attention away from weight gain and more toward achieving optimum growth may be a useful strategy for clinicians working with this population.  Key words:  cystic fibrosis, nutrition, body image, dieting.