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Mechanisms of Self-Esteem Change in Overweight Children Participating in a Family-Based Weight-Management Program

Permanent Link: http://ufdc.ufl.edu/UFE0021127/00001

Material Information

Title: Mechanisms of Self-Esteem Change in Overweight Children Participating in a Family-Based Weight-Management Program
Physical Description: 1 online resource (120 p.)
Language: english
Creator: Walker, Kelly N
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: body, change, children, control, esteem, goal, image, intervention, locus, overweight, peer, self, victimization, weight
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Overweight in children and adolescents is a national epidemic with significant medical and psychosocial consequences. Weight management programs are strongly recommended for children and adolescents to reduce complications of overweight, but few programs have examined the effects of these programs on psychosocial outcomes, particularly self-esteem. The aims of this study were to examine self-esteem and determine which factors impact self-esteem in the context of a weight management program. Data for this study was gathered as part of a larger study comparing the effects of a parent-only family-based pediatric weight management program, a parent-plus-child family-based pediatric weight management program, and a wait list control group targeting rural children aged 8 -14 years of age. We found that the behavioral interventions, relative to control groups, did not impact self-esteem, although a significant improvement in self-esteem across time was observed for social, athletic, and global self-esteem. Gender differences were observed in self-esteem changes such that change in girls' physical self-esteem was predicted by improvements in body satisfaction. Reduction in peer victimization was associated with improvements in social and physical self-esteem. Weight status change, goal attainment, self-efficacy for healthy lifestyle behaviors, and locus of control did not appear to be associated with self-esteem in this study, although measurement limitations may have complicated these findings. Despite some researchers' concerns that weight management programs may have a negative impact on children and adolescent's psychosocial functioning, these findings suggest that participation in a pediatric weight management program does not adversely affect pediatric self-esteem.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Kelly N Walker.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Janicke, David M.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021127:00001

Permanent Link: http://ufdc.ufl.edu/UFE0021127/00001

Material Information

Title: Mechanisms of Self-Esteem Change in Overweight Children Participating in a Family-Based Weight-Management Program
Physical Description: 1 online resource (120 p.)
Language: english
Creator: Walker, Kelly N
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: body, change, children, control, esteem, goal, image, intervention, locus, overweight, peer, self, victimization, weight
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, Ph.D.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Overweight in children and adolescents is a national epidemic with significant medical and psychosocial consequences. Weight management programs are strongly recommended for children and adolescents to reduce complications of overweight, but few programs have examined the effects of these programs on psychosocial outcomes, particularly self-esteem. The aims of this study were to examine self-esteem and determine which factors impact self-esteem in the context of a weight management program. Data for this study was gathered as part of a larger study comparing the effects of a parent-only family-based pediatric weight management program, a parent-plus-child family-based pediatric weight management program, and a wait list control group targeting rural children aged 8 -14 years of age. We found that the behavioral interventions, relative to control groups, did not impact self-esteem, although a significant improvement in self-esteem across time was observed for social, athletic, and global self-esteem. Gender differences were observed in self-esteem changes such that change in girls' physical self-esteem was predicted by improvements in body satisfaction. Reduction in peer victimization was associated with improvements in social and physical self-esteem. Weight status change, goal attainment, self-efficacy for healthy lifestyle behaviors, and locus of control did not appear to be associated with self-esteem in this study, although measurement limitations may have complicated these findings. Despite some researchers' concerns that weight management programs may have a negative impact on children and adolescent's psychosocial functioning, these findings suggest that participation in a pediatric weight management program does not adversely affect pediatric self-esteem.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Kelly N Walker.
Thesis: Thesis (Ph.D.)--University of Florida, 2007.
Local: Adviser: Janicke, David M.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021127:00001


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MECHANISMS OF SELF-ESTEEM CHANGE IN OVERWEIGHT CHILDREN
PARTICIPATING IN A FAMILY-BASED WEIGHT MANAGEMENT PROGRAM




















By

KELLY WALKER


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA

2007

































2007 Kelly Walker
































To my father and mother, Arnold and Cheryl Walker; and my husband Paul for all their support
through the years.









ACKNOWLEDGMENTS

I would like to thank my chair, David M. Janicke, Ph.D., for all of his support and

supervision. His mentorship has been extremely valuable to me and I am greatly appreciative of

the time that he has devoted. I would also like to acknowledge the other members of my

committee, Michael Perri, Ph.D., Brenda Wiens, Ph.D., and Linda Bobroff, Ph.D., RD, LD/N,

for their assistance and feedback in preparing this dissertation.

The larger study from which this dissertation data collected was supported by a grant from

the National Institute for Diabetes and Digestive and Kidney Diseases R34 DK071555-01.

Additional supplemental funding for the preliminary pilot work for this study was supplied by

the Institute for Child and Adolescent Research and Evaluation at the University of Florida.

Finally, I am deeply grateful to all of my family and friends who have supported me in my

pursuit of higher education throughout the years. It has been a pleasure to have them join me

along this journey.









TABLE OF CONTENTS

page

A C K N O W L E D G M E N T S ..............................................................................................................4

L IST O F T A B L E S ............. ..... ............ ................................................................... . 8

L IST O F FIG U RE S ............................................................................... 9

A B STR A C T ........ ... ........ ... .. ................................................. ..... 10

CHAPTER

1 INTRODUCTION ............... ................. ........... .............................. 12

M medical Com plications .................. ................................... ........ .. ........ .... 13
Psychosocial Com plications ............................................................. ................... 14
A Brief Overview of Self-Esteem ........................................................................ 14
Self E steem in O verw eight Children .................................................... ................... ...... 15
Childhood Overweight and Weight Management Programs...............................................17
Pediatric Weight Management Programs and Self-Esteem............................ ..................20
Factors That May Impact Self-Esteem During Weight Management Programs ..................21
Im pact of Changes in W eight Status ........................................ .......................... 22
Impact of Behavioral Goal Achievement.................................................. .................. 23
Impact of Self-Efficacy for Healthy Lifestyle Behaviors....................................24
Im pact of L ocu s of C control ................................................................ ....... ................25
Im pact of P eer V victim ization........................................................................... ......... 26
Im pact of B ody Satisfaction ........................................ .............................................27
S u m m a ry ................. ............................................................... ................ 2 8
Current A im s and H ypotheses ........................................................................... 29
P rim ary A im s .......................................................................................29
Aim 1: To examine the impact of the intervention groups on self-esteem ..............29
Aim 2: To determine the impact of weight status change on self-esteem ...............29
S econ dary A im s..................................................... ...... ..... ...... ................ 2 9
Aim 3: To examine the impact of behavioral goal attainment on self-esteem.........29
Aim 4: To determine the impact of self-efficacy on weight status and self-
esteem ................................... .. .. ........ ..... ........... ........ ............ 2 9
Aim 5: To determine the impact of and association between weight-specific
locus of control, weight status, and self-esteem in overweight children..............30
Aim 6: To examine the impact of peer victimization on self-esteem .......... ......30
Aim 7: To examine the impact of body satisfaction on self-esteem ...................31

2 METHODS ....................... ......... ....... ..... ..............32

P artic ip an ts .........................................................................3 2
Inclusion Criteria ......... .. ....... ............................... 33
Exclusion Criteria................................................... 34









P ro c e d u re .......................................................................... 3 4
L location of Intervention ....... ................ ............................................ ............... 34
R e cru itm en t ..............................................................................3 5
Initial In-P person Screening ......... ..................... .......................................... ................... 35
Schedule for A ssessm ent......... ......... ........ .......... ......................... ............... 36
Interv mention ists ................................................................3 7
B asic Intervention Program ............................................... .. ................................ 37
Behavioral-Family Intervention (BFI) Group ...................................... ............... 39
Behavioral-Parent Intervention (BPI) Group ...................................... ............... 39
W ait-List C control (W L C ) G roup......................................................................... ...... 40
M e a su re s ................... ...................4...................0..........
Criterion M measure .................. .......... ......................... .......... .... .... .............. 40
Harter self-perception profile for children .................................... ............... 40
Predictor M measures ........................ .. ........................ .. ............. ........ 41
Demographic questionnaire...................... ...... .............................. 41
B ody h eight an d w eight......................................... .............................................4 1
D aily h ab it lo g ................... ...................4...................1.........
Group leader check in sheet ................................... .. ....... ..................42
Self-efficacy questionnaire for healthy lifestyle behavior choices ........................42
Modified weight locus of control scale ........................................ ...............43
Schwartz peer victim ization scale ...................................................................... 44
Children's body im age scale ............................................................................. 44

3 R E SU L T S .............. ... ................................................................49

A nalyses and Statistical Significance ......................................................... ............... 49
Prim ary A im s.............................. ..... ........ .... ...............................50
Aim 1: To Examine the Impact of the Intervention Groups on Self-Esteem ..................50
Aim 2: To Determine the Impact of Weight Status Change on Self-Esteem .............. 53
Secondary A im s.................................... ....... ..............................54
Aim 3: To Examine the Impact of Behavioral Goal Attainment on Self-Esteem ...........54
Aim 4: To Determine the Impact of Self-Efficacy on Weight Status and Self-
E steem .................. . ...... ................ .... ........ .... .................. 56
Aim 5: To Determine the Impact of and Association Between Weight-Specific
Locus of Control, Weight Status, and Self-Esteem in Overweight Children .............60
Aim 6: To Examine the Impact of Peer Victimization on Self-Esteem ..........................63
Aim 7: To Examine the Impact of Body Image on Self-Esteem.............................. 68

4 D IS C U S S IO N ....... ............................................................................ 8 0

Findings Regarding Self-Esteem Change................ ............... ....................80
Self-E steem in the Rural Population................................................ ............ ............... 85
M mechanism s of Self-Esteem Change ............. .................................. ............................. 86
Impact of Weight Status Change ........................ ............................ 86
Impact of Weight-Specific Locus of Control ..... ............................88
Im pact of Peer V victim ization.............. ................................ .................. ............... 88
Im pact of B ody D dissatisfaction ............................................... ............................ 90









Strengths of this Study ....................................................... ............ ...... ....... 92
Considerations and Lim stations ..................................................................................... 93
Implications for Clinical Intervention and Research............................................................94
S u m m ary ................................................................ .. ............................................... 9 6

APPENDIX

A DEMOGRAPHIC QUESTIONNAIRE...................... ...... ............................ 98

B MODIFIED WEIGHT LOCUS OF CONTROL..............................................................100

C D A IL Y H A B IT L O G ............................................................................. ........................ 10 1

D GROUP LEADER CHECK IN SHEET ..................................................... ..................104

E SELF EFFICACY QUESTIONNAIRE ........................................ ......................... 106

F SCHWARTZ PEER VICTIMIZATION SCALE ..................................... .................107

L IST O F R E F E R E N C E S ......................... ......... ..................................................................... 109

B IO G R A PH IC A L SK ETCH ............................... .................. .......... ..........................120
































7









LIST OF TABLES


Table page

2.1. Mean baseline characteristics of participants who completed pre-treatment and post-
treatm ent assess ent .................. ........................................ .. ...... .... 47

2.2. Frequency (and percentage) of participants who completed pre-treatment and post-
treatm ent assess ent .................. ......................................... .............. 48

3-1. Mean scores (standard deviations) of SPPC scores for children who completed pre-
treatment and post-treatment assessm ent ........................................................................ 77

3-2. Mean scores (and standard deviations) of impact variables for children who completed
pre-treatment and post-treatment assessments ....................... .... .............78

4-1. Harter normative mean scores and current study baseline mean scores for self-esteem
b y g en d er ................... ................................ ........................ ................ 9 7

4-2. Frequency of girls (total N = 50) with self-esteem ratings below normative values and
the number of girls that experienced improvements, no change, and decreases in self-
esteem across tim e. .........................................................................97

4-3. Frequency of boys (total N = 31) with self-esteem ratings below normative values and
the number of boys that experienced improvements, no change, and decreases in
self-esteem across tim e. .......................... ...... ..................... .... ........ ........ 97









LIST OF FIGURES


Figure p e

2-1. Screening, assessment and intervention participation in Project STORY ..............................46

3-1. Global self-esteem change by treatm ent condition...................................... .....................75

3-2. Social self-esteem change by treatment condition. ..................................... ............... 75

3-3. Athletic self-esteem change by treatment condition.................................... ............... 76

3-4. Body dissatisfaction change by treatment condition. .......................................................76









Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

MECHANISMS OF SELF-ESTEEM CHANGE IN OVERWEIGHT CHILDREN
PARTICIPATING IN A FAMILY-BASED WEIGHT MANAGEMENT PROGRAM
By

Kelly Walker

August 2007

Chair: David M. Janicke
Major: Psychology

Overweight in children and adolescents is a national epidemic with significant medical

and psychosocial consequences. Weight management programs are strongly recommended for

children and adolescents to reduce complications of overweight, but few programs have

examined the effects of these programs on psychosocial outcomes, particularly self-esteem. The

aims of this study were to examine self-esteem and determine which factors impact self-esteem

in the context of a weight management program. Data for this study was gathered as part of a

larger study comparing the effects of a 'parent-only' family-based pediatric weight management

program, a 'parent-plus-child' family-based pediatric weight management program, and a wait

list control group targeting rural children aged 8 -14 years of age. We found that the behavioral

interventions, relative to control groups, did not impact self-esteem, although a significant

improvement in global self-esteem across time was observed for social, athletic, and global self-

esteem. Gender differences were observed in self-esteem changes such that change in girls'

physical self-esteem was predicted by improvements in body satisfaction. Reduction in peer

victimization was associated with improvements in social and physical self-esteem. Weight

status change, goal attainment, self-efficacy for healthy lifestyle behaviors, and locus of control

did not appear to be associated with self-esteem in this study, although measurement limitations









may have complicated these findings. Despite some researchers' concerns that weight

management programs may have a negative impact on children and adolescent's psychosocial

functioning, these findings suggest that participation in a pediatric weight management program

does not adversely affect pediatric self-esteem.









CHAPTER 1
INTRODUCTION

Overweight in children and adolescents is a national epidemic. Recent estimates indicate

that over 33% of children and adolescents are either "at-risk" for overweight or overweight

(Ogden et al., 2006). Although adult overweight and obesity are defined by body mass index

(BMI) cutoffs, childhood obesity and overweight are defined according to a child's BMI

percentile based on revised Centers of Disease Control and Prevention (CDC) growth charts.

Specifically, children are classified as overweight if their BMI is at or above the 95th percentile

and considered "at-risk" for overweight if their BMI is between the 85th and 95th percentile for

gender and age (U.S. Department of Health and Human Services, 2001).

Obesity poses a particular concern in rural areas. Research examining rates of adult

obesity across levels of urbanization finds obesity rates to be higher in rural areas (Patterson,

Moore, Probst, & Shinogle, 2004). A comparison of childhood overweight rates in urban and

rural areas by McMurray and colleagues (1999) reports that children in rural areas have a 54.7%

increased risk of overweight compared to urban children. One reason for these differences may

be that individuals from rural locations, particularly those in the southeastern United States,

traditionally consume high fat and high calorie diets. Increased rates of sedentary behavior also

reduce the potential for activity levels to offset increased caloric consumption (Pearson & Lewis,

1998). Rural obesity is further complicated because individuals living in rural areas may be

medically underserved due to 1) limited health promotion programs, 2) higher rates of poverty

(Economic Research Services, 1993), 3) higher percentages of patients without health insurance

(Frenzen, 1993), and 4) lower numbers of health care providers. Thus, research targeting

overweight children in rural areas of the United States is a significant priority and an objective of









Healthy People 2010 (U.S. Department of Health and Human Services, 2000) and the U.S.

Surgeon General (U.S. Department of Health and Human Services, 2001).

Medical Complications

Children and adolescents who are overweight are at increased risk for significant medical

complications including increased risk of endocrine, pulmonary, orthopedic, gastroenterological,

and neurological concerns (American Academy of Pediatrics, 2003; Deckelbaum & Williams,

2001). Sixty percent of overweight children have at least one risk factor for cardiovascular

disease and 25% of overweight children have at least two risk factors including hypertension,

hyperlipidemia, and hyperinsulinemia (Strauss, 1999). Once considered "adult-onset" diabetes,

type 2 diabetes is another significant medical complication for overweight children and

adolescents (Goran, Ball, & Cruz, 2003) and accounts for 8-45% of all new cases of diabetes

(Dietz, 2004). The prevalence of metabolic syndrome also increases with the severity of obesity.

Metabolic syndrome is described as the link between insulin resistance and hypertension,

dyslipidemia, type 2 diabetes, and other metabolic abnormalities (Reaven, 1988) and cited by

some medical professionals to be a precursor of diabetes (Dietz, 2004). Metabolic syndrome is

also associated with an increased risk of cardiovascular disease in adults. Rates of metabolic

syndrome reach up to 50% in severely overweight children and increases in BMI have been

associated with increased risk of metabolic syndrome (Weiss et al., 2004). Child and adolescent

overweight status is associated with more severe obesity in adulthood and studies have suggested

that up to 80% of overweight adolescents become obese adults. This risk is especially prevalent

for girls (Dietz, 2004). Additionally, societal costs associated with child and adolescent

overweight have tripled in the last 20 years and annual overweight-related hospital costs for 6-17

year olds reach up to $127 million per year (Goran et al., 2003).









Psychosocial Complications

Psychosocial complications for overweight children and youth include social

stigmatization, peer victimization, depression, psychosocial maladjustment, and poorer body

image compared to their non-overweight peers (Sjoberg, Nilsson, & Leppert, 2005; Zametkin,

Zoon, Klein, & Munson, 2004; Zeller, Saelens, Roehrig, Kirk, & Daniels, 2004). The link

between poor self-esteem and pediatric overweight has received significant attention. Broadly

defined, self-esteem refers to the extent to which one values oneself as a person (Harter &

Whitesell, 2003). Poor self-esteem is a notable complication of pediatric overweight because

research links poorer self-esteem with negative consequences such as behavioral disorders,

negative or depressed mood, and other emotional concerns (Harter, 1993). Conversely, higher

self-esteem is associated with positive consequences (Shirk, Burwell, & Harter, 2003) and self-

esteem improvements also are associated with improvements in other areas of functioning, such

as a decrease in externalizing disorders (Haney & Durlak, 1998). Adverse effects of overweight

on self-esteem in childhood and adolescence have potential long-term implications given that

adolescent self-esteem may remain stable into adulthood (Harter & Whitesell, 2003).

A Brief Overview of Self-Esteem

A leading theory of self-esteem development by Harter (1985) combines James' theory

(1892) that self-esteem is the ratio of successes to aspirations and Cooley's theory (1902) that

self-esteem is the product of self-comparison against others (the "looking-glass" model).

However, Harter extends James' theory by asserting that the ratio of successes to aspirations

contributes to self-esteem only if competence in that domain is important to the individual.

Harter also theorizes that each individual has multiple types of self-esteem for specific areas of

functioning, such as academic competence, social competence, athletic competence, and so forth.

Global self-esteem, or overall self-worth, is not necessarily a summation of these different types









of self-esteem, but rather an overall perception including only those types of esteem in which

success is important to the individual. An example illustrating Harter's theory is an individual

who perceives herself to have poor academic performance compared against her peers'

performance. This would damage her self-esteem only if she perceives academic competence as

important, and have no effect on her self-esteem if she does not value academic competence.

Normative self-esteem development provides support for this theory. Self-esteem

development begins with the emergence of a sense of self as different from others (also known as

self awareness) in early childhood at approximately age one. Around pre-school age, children

begin to develop self-perception, which is largely positive and general at this point. School entry

then provides expanded opportunities for mastery and comparison experiences, consistent with

Cooley's "looking-glass" model of self-esteem. This is the point during which variability in self-

esteem begins to emerge along a positive and negative continuum. Self-esteem continues along

this pathway until the onset of puberty and adolescence, when most children experience a

normative dip in self-esteem as peer comparisons and "fitting in" become more important. Most

individuals then experience a rebound in self-esteem as they enter late adolescence and early

adulthood, when individualization increases and the importance of the beliefs of others

diminishes. Many researchers believe that this level of self-esteem then remains stable through

adulthood (Harter, 1999).

Self Esteem in Overweight Children

Over ten years ago, French and colleagues (1995) reported that overweight in children

was inversely associated with self-esteem and body-esteem, but noted that the association was

modest and that lower scores often still fell within normal ranges. A number of studies since that

time suggest that overweight children and adolescents report moderately lower levels of self-

esteem compared to non-overweight adolescents and children (Manus & Killeen, 1995; Pesa,









Syre, & Jones, 2000; Stradmeijer, Bosch, & Koops, 2000; Strauss, 2000). However, these

findings are not universal, as a number of other studies have not found an association between

self-esteem and weight status (Gortmaker, Must, Perrin, Sobol, & Dietz, 1993; Renman,

Engstrom, Silfverdal, & Aman, 1999; Rumpel & Harris, 1994; Swallen, Reither, Haas, & Meier,

2005). While a clear answer to this question may not exist, these findings point to the importance

of examining factors that may lead some children who are overweight to be at greater risk for

low self-esteem.

Although the data regarding the association between self-esteem and overweight is still

mixed, a group of factors appear to place overweight children at-risk for the development of poor

self-esteem. A review by Lowry, Sallinen, and Janicke (2007) examined potential moderating

factors to help clarify this association. The development of self-esteem in overweight children

compared to normative self-esteem development may differ in significant ways. Research

suggests that overweight children, particularly girls, experience larger dips in self-esteem in

adolescence than non-overweight children, perhaps due to the increasing importance of body

shape and size as a component of many adolescents' global self-esteem ratings. In addition to

gender and developmental differences, ethnicity also may interact with age and gender to impact

the association between overweight and self-esteem. Research has consistently found that

overweight White children experience poorer self-esteem than overweight African American

children (Kaplan & Wadden, 1986; Wilson, Sargent, & Dias, 1994; Brown et al., 1998; Strauss,

2000; Young-Hyman, Herman, Scott, & Schlundt, 2000; Young-Hyman, Schlundt, Herman-

Wenderoth, & Bozylinski, 2003; Kelly, Wall, Eisenberg, Story, & Neumark-Sztainer, 2005),

perhaps due to the fact that larger body sizes may be more culturally acceptable among some

African Americans (Wilson, Sargent, & Dias, 1994) and that African American parents may









misperceive their child's weight. Researchers also suggest that negative attitudes about weight

may not be communicated to overweight African-American children (Young-Hyman, Herman,

Scott, & Schlundt, 2000), which may lead to a more positive body image, (Kelly, Wall,

Eisenberg, Story & Neumark-Sztainer, 2005) and ultimately contribute to higher self-esteem.

Reports of self-esteem in overweight Hispanic children is mixed (Brewis, 2003; Mirza, Davis, &

Yanovski, 2005), and differences in this population appear to be linked to identification with

majority cultural standards of body shape (Lowry et al., 2007).

Other factors that may place overweight children at-risk for poorer self-esteem include a

high incidence of teasing and peer victimization (Strauss & Pollack, 2003; Young-Hyman et al.,

2003; Hayden-Wade et al., 2005; Sweeting, Wright, & Minnis, 2005; Stern et al., 2006;

Thompson et al., 2007) and internal attributions about weight status (Pierce & Wardle, 1997).

Additionally, positive social support may shield overweight children from decreases in self-

esteem (Strauss & Pollack, 2003; Dishman et al., 2006). While the data are still mixed as to the

association between global self-esteem and weight status, there is more evidence to support that

specific domains of self-esteem, such as physical, social, and athletic self-esteem are more likely

to be associated with overweight status. Given the influence of these factors on self-esteem in

cross-sectional studies and the implications for future psychosocial functioning, these data

highlight the need to examine self-esteem in the context of weight management programs.

Childhood Overweight and Weight Management Programs

Due to potentially severe medical complications, Expert Committee Recommendations

suggest that children with a BMI at or above the 95th percentile undergo treatment for overweight

(Barlow & Dietz, 1998). The committee also recommends that children and adolescents whose

BMI is within the 85th to 95th percentile for their height and weight undergo additional screening

for secondary complications including; 1) a family history of cardiovascular disorders,









hypercholesterolemia, or diabetes mellitus, 2) parental obesity, 3) high blood pressure, elevated

total cholesterol, a large recent increase in BMI, and/or 4) child-adolescent concerns regarding

weight status (Faith et al., 2001). Children or adolescents who present with one or more of the

previous complications are recommended to undergo treatment, while children without

secondary complications should be monitored annually. According to Expert Committee

Recommendations (Barlow & Dietz, 1998), treatment should include primary behavioral goals of

healthy eating and activity. Medical goals are also recommended if secondary complications are

present. Gradual, permanent weight goals and behavioral changes are recommended based on the

child's current weight status. Parent involvement is stressed as an essential component through

parent training techniques including praise, use of non-food rewards, daily family meals, and

maintaining a healthy, non-tempting home environment for the child. Support for these

recommendations are found in a review of empirically supported treatments in pediatric obesity

by Jelalian & Saelens (1999) which indicates that the essential components of childhood weight

management programs include behavioral modification, parent training, healthy dietary habits,

and increases in physical activity. Two studies utilizing treatment designs and components

relevant to this dissertation are reviewed below.

One program designated as a well-established treatment (Jelalian & Saelens, 1999) is

Epstein's Stop-Light Program (Epstein, Wing, & Valoski, 1985). This program combines dietary

reductions (changes in eating behaviors and food intake) along with lifestyle activity. The Stop-

Light Program is a simplified, child-friendly program that classifies foods into three categories:

"green," "yellow," and "red." "Green" foods have less than 2 grams of fat per serving, "yellow"

foods have between 2.0 and 4.9 grams of fat per serving, and "red" foods have 5.0 or more grams

of fat per ser ving (Epstein, Roemmich, & Raynor, 2001). Epstein and colleagues (2001) also









recommend increasing fruit and vegetable intake as this has been shown to be an effective way to

not only increase consumption of these foods, but also to decrease high fat and high calorie food

consumption. During Epstein's programs, parents and children work with group leaders to set

goals to reduce children and parents' "red" food consumption, to reduce daily caloric

consumption, and to increase their physical activity level. Physical activity changes are based on

"lifestyle activities" (such as walking), because the combination of lifestyle activities in weight

management programs with dietary interventions is shown to be more effective than dietary

interventions alone (Epstein & Goldfield, 1999). Data from Epstein's programs indicate that up

to 30% of children treated across four treatment interventions had reached non-obese status at

ten-year follow-up (Epstein, Valoski, Wing, & McCurley, 1994). An essential component of this

program is parent involvement. Interestingly, parents who attended the program demonstrated a

12% decrease in their own overweight status at five year follow-up and a 15% decrease in their

overweight status at ten year follow up (Epstein et al., 1994).

An alternative intervention model is presented by Golan and colleagues (Golan, Fainaru,

& Wizman, 1998; Golan, 2006). Golan suggests that the home environment is the most

important setting to shape children's dietary and activity behaviors and that parents are key

figures in making and maintaining changes in that environment. Golan and Crow (2004) suggest

that if parents are the main agents of change, then parents should be targeted in weight

management programs to change the home environment rather than targeting the child. Her

program does not target specific reductions in caloric intake and she considers her approach to be

"health centered" rather than "weight centered." Golan's research has examined the effectiveness

of her program by comparing a "parent-only" approach to a "child-only" or a "parent-plus-child"

intervention. Her research demonstrates positive results in both child and parent weight status









with the "parent-only" approach compared to the two other interventions (Golan, 2006). Golan

suggests that targeting the parent exclusively is more cost-effective and may buffer the child

from potential negative psychosocial consequences that may occur due to participation in a

weight management program.

Pediatric Weight Management Programs and Self-Esteem

Many studies have reported positive success in reducing weight status, reducing percent

overweight, and reducing medical complications such as risk factors for cardiovascular disease.

However, much less attention has been focused on the impact of these interventions on

psychosocial functioning, and in particular, pediatric self-esteem. This is a particularly important

question as researchers express concern regarding the impact of interventions for pediatric

overweight on self-esteem and whether or not weight management programs may do more harm

than good (O'Dea, 2005). Unfortunately, minimal or no outcome data on self-esteem for

intervention participants has been reported by many of the empirically supported treatments for

pediatric overweight.

Although Epstein and Golan have reported success in establishing long-term healthy

body weights in children, incomplete data are available related to psychosocial functioning of

children and parents involved in the programs. To our knowledge, Epstein and colleagues have

not published data on self-esteem values or self-esteem change for children who participate in

their intervention programs. Although Golan emphasizes the importance of self-esteem and

protecting children against potential adverse effects from participation, she only has reported

data concerning rates of disordered eating and not self-esteem changes for the children who

participate in her interventions.

While these two research groups have not reported the impact of their intervention

programs on child self-esteem, a recent review found that 20 published studies have reported









pre- and post-treatment self-esteem data in the context of a pediatric weight management

intervention program (Lowry et al., 2007). Of these, 17 studies report evidence of increases in

global self-esteem or components of self-esteem from pre- to post-treatment (Stoner & Fiorillo,

1976; Foster, Wadden, & Brownell, 1985; Mellin et al., 1987; Wadden, Stunkard,

Rich, Rubin, Sweidel, & McKinney, 1990; Sherman et al., 1992; Sahota et al., 2001; Jelalian &

Mehlenbeck, 2002; Braet et al., 2003; Brehm, Rourke, Cassell, & Sethuraman, 2003; Walker,

Gately, Bewick, & Hill, 2003; Barton et al., 2004; Braet et al., 2004 [2-year follow-up: Braet,

2006]; Edwards et al., 2005; Gately et al., 2005; Sacher et al., 2005; Savoye et al., 2005;

Jelalian, Mehlenbeck, Lloyd, Richardson, Birmaher, & Wing, 2006). Two studies report no

change in self-esteem or components of self-esteem (Rohrbacher, 1973; Thomas-Dobersen,

Butler-Simon, Fleshner, 1993) and only one study reports decreases in self-esteem (Cameron,

1999). However, this review is limited in that the number of pediatric weight management

programs that examine self-esteem at baseline and post-treatment is minimal compared to the

number of published pediatric weight management programs. Additionally, these 20 studies are

widely variable with respect to methodology, statistical examination of results, and inconsistent

reporting of demographic and outcome data, which makes drawing firm conclusions from these

studies difficult.

Factors That May Impact Self-Esteem During Weight Management Programs

This study sought to explain the differences in self-esteem changes by examining a

number of factors that theoretically may impact self-esteem in the context of a pediatric weight

management program. Cross-sectional research has indicated that gender differences exist in

self-esteem rates (Mendelson & White, 1985; Pesa et al., 2000; Israel & Ivanova, 2002), and it is

likely that self-esteem will change in girls and boys differently. However, no study has examined

gender differences in self-esteem within weight management interventions. Based on cross-









sectional research, differences based on age and ethnicity also exist, but, changes in self-esteem

are not fully explained by developmental and ethnicity differences alone. Other factors that may

influence self-esteem during a weight management intervention worthy of examination, with

particular relevance to this dissertation, include the impact of weight status change, behavioral

goal achievement, self-efficacy for healthy lifestyle behaviors, locus of control, peer

victimization, and body satisfaction.

Impact of Changes in Weight Status

Three studies provide support for an association between self-esteem change and weight

status change (Cameron, 1999; Walker et al., 2003; Jelalian et al., 2006). In these studies weight

status change was associated with athletic, physical, and global self-esteem. In the only study to

report a decrease in self-esteem from pre- to post-treatment, the pediatric participants did not

experience a statistically significant change in weight status and reported feelings of failure due

to their lack of success in meeting weight loss goals (Cameron, 1999). However, three older

studies reported no statistically significant association between self-esteem change and weight

status change (Rohrbacher, 1973; Stoner & Fiorillio, 1976; Wadden et al., 1990). Despite

findings of differences in self-esteem in overweight girls and boys cross sectionally, no study has

examined the impact of changes in weight status on self-esteem by gender for participants in a

weight management program. This mixed pattern of results makes it difficult to draw definitive

conclusions about the role of weight loss in self-esteem change subsequent to treatment, or the

direction of potential effect. Regardless of the direction or effect of weight status change on self-

esteem, it appears to be only one of a number of factors that may impact self-esteem in pediatric

weight management programs (Lowry et al., 2007).









Impact of Behavioral Goal Achievement

Goal achievement has been suggested to be another factor that may impact self-esteem

(Lowry et al., 2007). Research with children (not in the area of weight management) has

demonstrated that achieving short-term goals is associated with enhanced self-learning, increased

intrinsic interest in the subject at hand, a greater sense of mastery, and more personal self-

efficacy, whereas achieving long-term goals demonstrates no such associations (Bandura &

Schunk, 1981). In the context of weight management programs, behavioral goals to decrease the

consumption of high fat, high calorie foods or to increase physical activity may be seen as short-

term goals, whereas weight change may seen as a non-behavioral, long-term goal. The

association between short-term behavioral goal attainment (such as weekly dietary and physical

activity goals) and long-term outcomes (such as weight loss) has been clearly examined in adult

weight management programs (Bandura & Simon, 1977; Israel & Saccone, 1979). In fact,

researchers have recommended that future programs consider setting specific behavioral goals

for participants due to the increased success for participants who set and achieve behavioral

goals (Linde, Rothman, Baldwin, & Jeffery, 2006).

Minimal research has examined goal setting for pediatric participants in weight

management programs. Given the positive association between self-esteem and mastery

experiences in children, it is likely that goal setting may contribute to self-esteem as reaching

intervention goals may be perceived as a mastery experience. These short term successes may

also buffer potential disappointment if long-term weight status change goals are set and not

achieved. Support for this association may be found in the only study to report that pediatric

participants experienced a decrease in self-esteem pre- to post-treatment. In the study, children

reported feelings of failure due to their lack of success in meeting weight loss goals (Cameron,

1999), although this association was not examined statistically. These findings highlight the need









for programs to set directly achievable short-term goals, such as dietary and physical activity

changes, rather than indirect long-term goals, such as weight loss. They also highlight the need to

examine the impact of self-efficacy for healthy lifestyle behaviors on self-esteem change for

children participating in a weight management program.

Impact of Self-Efficacy for Healthy Lifestyle Behaviors

Self-efficacy is an individual's perception of how well he or she can achieve a behavior

and is considered to be a critical component of behavior change (from Social Learning Theory;

Bandura, 1977). Self-efficacy in children has been associated with academic functioning

(Bandura, Barbaranelli, Caprara, & Pastorelli, 1996), depressive symptoms (Bandura,

Barbaranelli, Caprara, & Pastorelli, 1999), and perceived occupational self-efficacy (Bandura,

Barbaranelli, Caprara, & Pastorelli, 2001). Research examining self-efficacy in overweight

children has indicated that overweight children are less confident of their ability to overcome

barriers to physical activity than non-overweight peers (Trost, Kerr, Ward, & Pate, 2001) and

that self-efficacy is a very important determinant of physical activity change in children

(Reynolds et al., 1990; Sallis et al., 1992; Trost, Pate, Ward, Saunders, & Riner, 1999).

Research examining self-efficacy for healthy lifestyle behaviors in the context of weight

management interventions is mixed. Substantial evidence exists in the adult literature outlining

the predictive association between high baseline self-efficacy and weight loss at post-treatment

(Forster & Jeffery, 1986; Strecher, DeVellis, Becker, & Rosenstock, 1986; Edell, Edington,

Herd, O'Brien, & Witkin, 1987; Stotland & Zuroff, 1991; Dennis & Goldberg, 1996; Linde,

Rothman, Baldwin, & Jeffery, 2006), and during six-week (Bernier & Avard, 1986), one-year,

and two-year follow-up (Jeffery et al., 1984). However, the evidence is very limited in pediatric

samples and only one study has reported that self-efficacy was an important factor in weight loss









efforts in a school-based program (Perry et al., 1990). No study in adult or pediatric populations

has examined the association between self-efficacy and self-esteem.

It is likely that as an individual's confidence or beliefs in his or her ability to perform a

behavior successfully increases, so may self-esteem. Success in short-term goal attainment may

lead to improvements in an individual's confidence, or self-efficacy. Although the path through

which self-efficacy impacts self-esteem may be via goal attainment and mastery experiences,

self-efficacy may also directly impact self-esteem by promoting more positive feelings towards

the self and the individual's abilities. This highlights the need to determine if increased self-

efficacy adds to the prediction of self-esteem above and beyond weight status and goal

achievement. However, no research exists examining the association between self-efficacy and

self-esteem for overweight children participating in weight management programs.

Impact of Locus of Control

An individual's sense of control of their weight, or locus of control, also has been linked to

pediatric self-esteem (Pierce & Waddle, 1997). Locus of control is defined as a person's

perceived responsibility for outcomes. Individuals with an internal locus of control believe that

their behaviors have an impact on their outcomes while those with an external locus of control

believe that external factors are responsible for their outcomes (Rotter, 1966). In a cross-

sectional study, Pierce and Wardle (1997) reported that overweight 9 to 11 year old children who

believed that they were responsible for their weight status had lower rates of self-esteem

compared to children who did not believe that they were responsible for their weight status.

Data from the adult literature have suggested that an internal locus of control at baseline is

associated with increased weight loss for obese adults participating in weight management

programs (Balch & Ross, 1975; Wallston, Wallston, Kaplan, & Maides, 1976), but that adults

with more internal attributions regarding their overweight status may experience lower self-









esteem during participation in weight management programs (Bryan & Tiggemann, 2001). In one

of the few studies examining locus of control change across a weight management program,

Tobias and MacDonald (1977) found that adult locus of control became more internalized during

their participation in a weight control program, which is understandable as most programs target

individual control over weight-related behaviors such as food intake and exercise. However, the

researchers did not examine the impact of this increasing internalization on self-esteem.

Research on locus of control in pediatric weight management is limited. It is possible that

some of these same mechanisms regarding locus of control in adult populations may generalize

to pediatric populations including; 1) associations between internal locus of control and

increased weight loss during intervention participation, 2) a trend for participants to experience

more internal locus of control during intervention participation, and 3) a possible association

between internal weight-specific locus of control and decreased self-esteem across the

intervention, particularly with limited weight loss success. The only weight management

intervention that reported decreases in self-esteem suggested that changes towards more internal

attributions regarding weight status may have contributed to self-esteem changes (Cameron,

1999). Specifically, Cameron suggests that overweight children may maintain self-worth by de-

emphasizing the value of weight status on their overall self-worth, and that placing a child in a

weight management program directly opposes and weakens those coping strategies. However,

this theory was not tested statistically in her treatment program, and none of the associations

from adult weight management literature has been examined in pediatric populations.

Impact of Peer Victimization

Cross-sectional studies have repeatedly described the deleterious impact of peer

victimization on self-esteem in overweight children. In a sample of 2,127 middle school children,

degree of overweight was associated with depressed mood, low self-esteem, and greater levels of









peer victimization (Sweeting, Wright, & Minnis, 2005). Weight-based teasing was negatively

associated with self-esteem in a sample of 117 African-American overweight youth (Young-

Hyman, Schlundt, Herman-Wenderoth, & Bozylinski, 2003), and this pattern has been found in

both Caucasian and African American samples (Stern et al., 2006). Researchers also have

reported that overweight children experience victimization that is focused on appearance and

body weight more than other characteristics. Furthermore, overweight children appear to be more

influenced by peers' negative comments and attributions about their appearance than non-

overweight youth (Hayden-Wade et al., 2005; Thompson et al., 2007).

Despite the well-documented association of peer victimization on self-esteem, no study

has examined how rates of peer victimization or changes in peer victimization may affect self-

esteem during participation in a weight management program. This is especially surprising given

that positive social support through sport and club participation has been suggested to be

associated with higher self-esteem independent of weight status (Strauss & Pollack, 2003;

Dishman et al., 2006) and that many weight management programs may utilize the group format

to buffer or diminish the negative effects of victimization and enhance self-esteem.

Impact of Body Satisfaction

Body satisfaction, also commonly referred to as body image, also has been linked to self-

esteem in overweight children. Body image is frequently associated with physical self-esteem,

particularly in Western cultures, but the two terms do represent different constructs (Lau, Lee,

Ransdell, Yu, & Sung, 2004). Body satisfaction differs from physical self-esteem in that in the

weight management literature body satisfaction most frequently refers to the discrepancy

between actual and ideal body size whereas physical self-esteem refers to an individual's

perceived judgment of physical appearance, which may be inclusive of more than just body size.

French and colleagues (1995) hypothesized that body image may influence a significant portion









of global self-esteem for overweight youth. However, this association has rarely been examined

statistically, despite mounting evidence that body image changes may account for and/or impact

self-esteem changes in cross-sectional samples (Pesa et al., 2000), or that changes in body

satisfaction may precede changes in global self-esteem. In studies examining self-esteem change,

improvements are frequently noted in body satisfaction (Rohrbacher, 1973; Stoner & Fiorillo,

1976; Thomas-Dobersen et al., 1993; Jelalian & Mehlenbeck, 2002; Braet et al., 2003; Walker et

al., 2003; Braet et al., 2004). This suggests that improvements in body satisfaction may be

another factor that could impact domains of self-esteem. However, this association has rarely

been examined in the context of pediatric weight management programs. Furthermore, gender

differences in the association between body satisfaction and self-esteem in weight management

programs has not been examined, despite the evidence that body satisfaction may have a greater

impact on the self-esteem of girls when compared to boys (Pesa et al., 2000).

Summary

In summary, childhood overweight is a significant public health concern, associated with

multiple medical and psychosocial consequences, particularly in rural areas (American Academy

of Pediatrics, 2003; Deckelbaum & Williams, 2001; Zametkin et al., 2004). Overweight children

are at greater risk for self-esteem deficits as compared to normal weight children (O'Dea &

Abraham, 1999; Stradmeijer, Bosch, & Koops, 2000; Strauss, 2000), and self-esteem deficits

appear to occur via the influence of several moderating factors (Lowry et al., 2007). Research

suggests that gender differences exist in self-esteem rates and self-esteem change for overweight

children. The impact of weight management programs on pediatric self-esteem has primarily

focused on the impact of weight change. Cross-sectional research examining the effects of goal

acquisition, self-efficacy, locus of control, peer victimization, and body satisfaction support the

need to examine how these factors may impact self-esteem for girls and boys participating in a









weight management program. The specific purpose of this study is to examine the effects of a

pediatric weight management program on self-esteem and possible mechanisms of change in

self-esteem, based on the factors highlighted previously. The aims and hypotheses are listed

below.

Current Aims and Hypotheses

Primary Aims

Aim 1: To examine the impact of the intervention groups on self-esteem

Hypothesis 1.1. We hypothesized that participants in the intervention groups (Behavioral

Family Intervention [BFI] and Behavioral Parent Intervention [BPI]) would experience greater

self-esteem improvements from pre-treatment to post-treatment relative to participants in the

control group (Wait List Control [WLC]).

Aim 2: To determine the impact of weight status change on self-esteem

Hypothesis 2.1. We hypothesized that improvements in child weight status would be

positively associated with greater self-esteem improvements from pre- to post-treatment.

Secondary Aims

Aim 3: To examine the impact of behavioral goal attainment on self-esteem

Hypothesis 3.1. We hypothesized that greater short term behavioral goal achievement (for

dietary and physical activity changes) would be associated with greater self-esteem

improvements from pre- to post-treatment.

Aim 4: To determine the impact of self-efficacy on weight status and self-esteem

Hypothesis 4.1. We hypothesized that greater pre-treatment child self-efficacy would be

positively related to improvements in child weight status from pre- to post-treatment.

Hypothesis 4.2. We hypothesized that greater pre-treatment child self-efficacy would be

positively related to greater self-esteem improvements from pre to post-treatment.









Hypothesis 4.3. We hypothesized that improvements in child self-efficacy from pre- to

post-treatment would be positively related to greater self-esteem improvements from pre- to

post-treatment.

Aim 5: To determine the impact of and association between weight-specific locus of control,
weight status, and self-esteem in overweight children

Hypothesis 5.1. We hypothesized that greater pre-treatment internal weight-specific locus

of control would be associated with poorer pre-treatment self-esteem.

Hypothesis 5.2. We hypothesized that participants in the intervention groups (BFI and

BPI) would experience changes toward more internal weight-specific locus of control from pre-

to post-treatment relative to participants in the control group (WLC).

Hypothesis 5.3. We hypothesized that the child's post-treatment weight-specific locus of

control would interact with change in child weight status such that 1) internal weight-specific

locus of control in ilh reduction in weight status during the weight management program would

be associated with greater self-esteem at post-treatment but that, 2) internal weight-specific locus

of control ii iihtt a reduction in weight status during the weight management program would be

associated with lower self-esteem at post-treatment.

Aim 6: To examine the impact of peer victimization on self-esteem

Hypothesis 6.1. We hypothesized that greater pre-treatment child-rated peer victimization

experiences would be associated with lower pre-treatment self-esteem.

Hypothesis 6.2. We hypothesized that reductions in child-rated peer victimization

experiences would be associated with greater self-esteem improvement.

Hypothesis 6.3. We hypothesized that greater post-treatment peer victimization

experiences would be associated with lower post-treatment self-esteem.









Aim 7: To examine the impact of body satisfaction on self-esteem

Hypothesis 7.1. We hypothesized that greater pre-treatment child-rated body

dissatisfaction would be associated with lower pre-treatment self-esteem.

Hypothesis 7.2. We hypothesized that participants in the intervention groups (BFI and

BPI) would experience greater reductions in ratings of body dissatisfaction from pre- to post-

treatment relative to participants in the control group (WLC).

Hypothesis 7.3. We hypothesized that reductions in child-rated body dissatisfaction would

be associated with greater self-esteem improvement.

Hypothesis 7.4. We hypothesized that greater post-treatment body dissatisfaction would

be associated with lower post-treatment self-esteem









CHAPTER 2
METHODS

Data for this study were collected as part of a larger intervention study, Sensible Treatment

for Overweight Rural Youth (Project STORY), which compared the impact of a Behavioral

Family-Based Intervention (BFI) and a Behavioral Parent-Based Intervention (BPI) on weight

status in overweight children in underserved rural settings. A Wait List Control (WLC) group

was used to compare the effects of the two interventions. The intervention utilized a modified

Stop-Light Diet (Epstein et al., 1985) and emphasized behavioral goals including reducing high

fat foods and high sugar beverages (i.e., red foods), increasing fruit and vegetable consumption,

and increasing physical activity rather than focusing primarily on weight loss. Parent and child

self-esteem and body satisfaction issues were addressed during the intervention with special

sessions focusing specifically on these concerns. For a full description of the design and methods

of the larger Project STORY, please refer to the methodology paper by Janicke and colleagues

(2007).

Participants

The 81 study participants who completed both pre-treatment and post-treatment

assessments were overweight children between 8 and 14 years old (M= 1.05, SD=1.6 years) and

their parents) or caretaker who volunteered to participate in a weight management program

designed to help children and parents adopt healthier lifestyle habits (dietary intake and physical

activity) and to improve their weight status. Figure 2-1 provides a flowchart outlining the process

by which participants were enrolled. Enrollment is described in more detail in the 'Recruitment'

section under 'Procedures.' T-tests were conducted to assess for differences at baseline between

participants who did (n = 81) and did not (n = 12) complete post-treatment assessments. The

participants who did not complete post-treatment assessment were comprised of significantly









more girls (75% female vs. 62% female; t = 2.597, df= 15, p = 0.020), were younger (M= 9.73

[SD= 1.74] vs. M= 11.07 [SD= 1.58]; t=2.701, df 91, p= 0.008), in a lower grade (M= 4.08

[SD = 1.88] vs. M= 5.65 [SD = 1.70]; t = 2.953, df= 91,p= 0.004), and heavier (z-scoreM=

2.48 [SD = .24] vs. M= 2.15 [SD = .41]; t= -2.708, df= 91,p = 0.008) than participants who did

complete post-treatment assessments. The two groups did not differ in ethnicity, parent marital

status, parent highest education, or family income. Furthermore, no significant differences

existed between baseline self-esteem ratings in any domain, or baseline ratings of weight-

specific locus of control, peer victimization, body dissatisfaction, or self-efficacy. Given that no

significant differences existed at baseline for self-esteem scores, only data from the 81

participants completing both assessment points were used in the analyses.

The resulting sample was primarily female (50 girls; 31 boys). The sample was moderately

diverse with 64 Caucasians (79%), seven African Americans (8.6%), six Hispanics (7.4%), two

Asian Americans (2.5%), and two Bi-racial participants (2.5%). The majority of families had

currently married parents (76%), and two adults in the home (69%). Many of the parents had

some college education (43%). The modal family income was between $20,000 39,999. All

child-parent dyads were randomized to one of three four-month behavioral weight management

interventions (family-based, parent-based, or wait-list control). Participants were recruited from

four medically underserved rural counties, with enrollments of 22-27 participants per county.

Tables 2-1 and 2-2 provide further baseline characteristics of participants.

Inclusion Criteria

Child criteria for participation included a BMI at or above the 85th percentile for sex and

age. Parent criteria for participation included being a parent or legal guardian living in the same

house as the child, 75 years old or younger, child and parent must live in the designated rural









area, and that the participating parent was primarily or equally responsible for food purchasing

and meal preparation.

Exclusion Criteria

Child and parent exclusion criteria included the presence of a medical condition that

contraindicated mild energy restriction or moderate physical activity, pregnancy in the

participantss, or if the child or parent was participating in another weight control program.

Another exclusion criterion was medication use including: antipsychotic medication, systemic

corticosteroids, prescription weight-loss medications, insulin, or other medications for diabetes.

Additional exclusion criteria included conditions or behaviors likely to affect the conduct of the

intervention such as: 1) parent or legal guardian unable to read English at the 5th grade level, 2)

unwilling to accept randomization, 3) unable to travel to Extension office for intervention

sessions, 4) likely to move out of the county within the next 18 months, 5) child or parent with

major psychiatric disorder, 6) child with major cognitive or developmental delay, or 7) or any

other condition/situation which in the opinion of staff would adversely affect participation in the

intervention.

Procedure

Location of Intervention

All interventions were provided at Cooperative Extension offices in north central Florida.

Cooperative Extension is a partnership among state, federal, and county governments with the

goal of providing scientific knowledge and expertise to the greater public. The Florida

Cooperative Extension Service is funded by the University of Florida and Florida A & M

University. Cooperative Extension offices were selected as the setting in which to provide the

interventions in order to enhance delivery of this program to the rural populations of interest by









providing the intervention in a trusted and established center directly in the participants'

communities.

Recruitment

Recruitment occurred during the three months prior to the intervention phase in each

county. A variety of recruitment methods were used including direct solicitation through mailers

to all families in counties with at least one child 8-13 years old. Additional recruitment efforts

included flyers provided to local physicians and pediatricians, presentations and flyers provided

to youth and community groups (e.g., church and youth groups), and flyers provided to public

health departments and school nurses for distribution. Each mailer, presentation, and flyer

provided potential participants with a toll-free telephone number that the family could call to

learn more about the study. A total of 154 families initially called to learn more about the study.

A trained recruiter then made follow-up phone calls to describe the study and perform a brief

phone screen to determine participant eligibility. Overall, 133 families met this first phase of

eligibility criteria. Families that expressed interest and met initial eligibility requirements were

scheduled for an in-person screening visit.

Initial In-Person Screening

Those families who met initial criteria and expressed interest during the initial phone

screen were scheduled for an initial in-person assessment approximately two to three months

prior to the beginning of the intervention in each county. During this visit, the study was

described in detail and informed consent for participation was obtained. All parents completed a

demographic and medical questionnaire for themselves and their child. Eligible families also

were measured for height and weight. Two "Physician Approval Forms" were given to each

interested family for their physician to complete. Families were required to return these approval

forms to the study investigator in order to clear the parent and child to participate in the









intervention. An examination by a licensed physician was provided free of charge if needed for

families with limited financial or healthcare resources.

Of the 133 families scheduled for an in-person screening visit, 111 families completed the

initial in-person screening. Of these, two families were excluded because they did not meet

eligibility criteria as the target child's body mass index (BMI) was below the 85th percentile for

height and weight according to age and gender normative data published by the Centers for

Disease Control and Prevention (CDC). See Figure 2.1 for participant flow through recruitment

and assessments.

Schedule for Assessment

Each parent/child dyad completed three assessment visits over the course of the study. The

first assessment occurred one to two weeks prior to the beginning of the intervention and served

as the "pre-treatment" assessment. A total of 109 families were scheduled for pre-treatment

assessment. Of these 101 families completed the pre-start assessment. Five families were

excluded due to child BMI below the 85th percentile for gender and age. Within each county

families were randomly assigned to treatment condition. Three families did not accept

randomization (WLC n = 2; BFI n = 1). Thus, a total of 93 families accepted randomization and

started treatment; Behavioral-Family Intervention (BFI; n = 33), Behavioral Parent Intervention

(BPI; n = 34), or Wait List Control (WLC; n = 26) group.

Post-treatment assessment occurred at the completion of the four-month intervention and

served as the "post-treatment" assessment. A total of 81 families completed pre- and post-

treatment assessment (BFI n = 31; BPI n = 29; WLC n = 21). A final assessment visit occurred at

six-months follow up to the intervention, or at 10-months following the beginning of the

intervention in each county. Participants in the BFI or BPI group participated in a four-month

intervention. The WLC group received the BFI intervention after post-treatment and six-month









follow-up. For the purposes of this study, only data from the "pre-treatment" and "post-

treatment" assessments were used. The six-month follow-up assessment point will not be

described in more detail. All assessment visits occurred at the local Cooperative Extension office

in participating counties.

Interventionists

Interventionists included Cooperative Extension agents and a trained doctoral level

psychologistss, doctoral level graduate student, or a licensed and registered nutritionist.

Cooperative Extension agents were included as interventionists with the philosophy that these

agents could be trained in the program and then provide the program to the community again in

the future in a cost-effective partnership. Cooperative extension agents have experience and

training delivering programs to children and families, as well as experience in nutrition

education. Every interventionist attended extensive training provided by the primary investigator

and consultants regarding the program philosophy, behavioral change techniques, group therapy

techniques, and goal setting. Each interventionist attended weekly supervision with the primary

investigator throughout each wave of treatment.

Basic Intervention Program

The intervention utilized a modified Stop-Light Diet (Epstein et al., 1985) and emphasized

behavioral goals including; reducing high fat foods and high sugar beverages (i.e., red foods),

increasing fruit and vegetable consumption, and increasing physical activity rather than focusing

primarily on weight loss. Each intervention followed a manualized treatment program to provide

participants with didactic information about healthy lifestyle habits, to provide information on

behavior change, and to maintain reliability across interventionists. During the program parents

and children worked with group leaders to set goals to reduce their consumption of high-fat

foods and increase fruit and vegetable intake.









Physical activity goals were targeted via a walking-based program. Parents and children

were given pedometers and worked with group leaders to increase their daily steps. A study by

Tudor-Locke and colleagues (2004) demonstrated that overweight children average

approximately 3,000 steps less per day than their normal weight peers. Thus, the goal of the

program was to increase steps for children and parents by approximately 3,000 steps per day

above their baseline level.

The program also addressed self-esteem and body image. At the time of this intervention,

little published research existed suggesting that previous childhood obesity interventions have

directly addressed strategies to increase self-esteem in children participating in weight-

management programs. In the current program, two sessions targeted self-esteem and body

image concerns for overweight children directly through child sessions (if applicable) and

indirectly through parent sessions. These sessions examined the impact of self-esteem and body

image on parents and children and helped the participants to increase their self-esteem and body

image through interactive activities during the session. Examples of these activities included

sessions on how to handle teasing, focusing on behaviors (i.e., red food consumption or physical

activity) instead of weight change, using positive self talk to build self-esteem, and parent

modeling of positive self-esteem and body image.

Behavioral strategies were incorporated throughout all aspects of the program to achieve

intervention goals and promote parent and child behavior change. Behavioral techniques have

been shown to be effective methods to promote individual change, particularly in weight

management settings (Jelalian & Saelens, 1999). Strategies used in this program included self-

monitoring, goal setting, shaping, stimulus control, behavioral contracting, contingent attention,

positive reinforcement, modeling, role playing, incentives, and portion size control (Janicke et









al., 2007). Group leaders worked carefully with each family to help them reach their goals

through 1) gradual reductions in red foods and increases in physical activity, 2) behavioral

contracting with children to reach food goals, activity goals, and family meal times, and 3)

additional parent management strategies for reaching behavioral goals and managing child

behavior.

Behavioral-Family Intervention (BFI) Group

The BFI groups consisted of concurrent parent and child sessions led by two trained group

leaders each in the child and parent group, for a total of four group leaders. Parents and children

participated in separate, but simultaneous groups, based on the superior findings of separating

the parents and children into different groups (Brownell, Kelman, & Stunkard, 1983). Each

week, the basic session format included parents and children meeting individually with the group

leaders to review the previous week's goals and problem solve any barriers that occurred. A brief

interactive didactic lesson then reviewed the current week's materials. In the child group this

lesson was followed by an active game or activity to reinforce the week's lesson. Finally, at the

conclusion of the session, the parents and children joined together with group leaders to set

behavioral goals for the upcoming week.

Behavioral-Parent Intervention (BPI) Group

The BPI group consisted of parent-only contact with two trained group leaders. Each week,

the basic session format began with parents meeting with the group leaders to review the

previous week's goals and any barriers that occurred. A brief interactive didactic lesson followed

and then the group leaders worked with parents to set behavioral goals for the parents and their

children for the upcoming week. At home, parents were encouraged to serve as their child's

interventionist and review the week's materials with their child and set weekly goals for dietary

and physical activity changes.









Wait-List Control (WLC) Group

The WLC group received the BFI intervention (described above) after the six-month

follow-up visit, or ten-months from the beginning of the initial intervention programs in each

respective county. Participants in this condition completed assessments on the same schedule as

families participating in the BFI and BPI.

Measures

Criterion Measure

Harter self-perception profile for children

The Self-Perception Profile for Children (SPPC; Harter, 1985) is a self-report assessment

of the child's perception of his or her global self-worth and competence in six specific domains:

scholastic competence, social acceptance, athletic competence, physical appearance, behavioral

conduct, and global self-worth. Given gender differences in self-esteem, normative data for the

measure is presented separately for boys and girls. Based on research identifying the scales most

relevant to pediatric weight management programs (Jelalian & Mehlenbeck, 2002; Braet et al.,

2003; Brehm et al., 2003; Walker et al., 2003; Braet et al., 2004; Braet et al., 2006; Jelalian et

al., 2006), only the social acceptance, athletic competence, physical appearance, and global self-

1 1,i th subscales will be examined in this study. For each item, the child was asked to choose

between two statements to indicate which statement is most like him or her. The child was then

asked to choose whether that statement was "sort of true for me" or "really true for me." The

SPPC was developed specifically for children and has good internal consistencies ranging from

.74 to .92 for the individual subscales. This measure has been shown to be sensitive to detect

change in self-esteem over time (Strauss, 2000) in weight management programs with children

(Gately et al., 2005; Walker et al., 2003). Internal consistency for the SPPC in this study for the

social subscale was a = 0.785 (pre-treatment) and a = 0.801 (post-treatment). Internal









consistency for the athletic subscale was a = 0.842 (pre-treatment) and a = 0.850 (post-

treatment). Internal consistency for the physical subscale was a = 0.833 (pre-treatment) and a =

0.877 (post-treatment). Internal consistency for the global subscale was a = 0.790 (pre-treatment)

and a = 0.838 (post-treatment).

Predictor Measures

Demographic questionnaire

Parents completed a demographic questionnaire that provided a variety of information

including parent and child dates of birth, parent and child ethnicity and gender, family income,

parent occupations, and family composition. A copy of this questionnaire is provided in

Appendix A.

Body height and weight

Study administrators assessed parent and child height and weight. Height without shoes

was measured to the nearest 0.1 centimeter using a Harpendon stadiometer. Weight was

measured with one layer of clothes on, without shoes, and with pockets emptied on a standard

body weight scale. Height and weight were used to calculate BMI, which was then used to

calculate pre-treatment and post-treatment z-scores. Pre-treatment z-score was then subtracted

from post-treatment z-score to calculate a "z-score change" to reflect change in child weight

status. Z-scores were selected as units of measurement in this study based on data that BMI z-

score previously has been indicated to be an adequate measure of adiposity change over time

(Hunt, Ford, Sabin, Crowne, & Shiel, 2007).

Daily habit log

A self-report food and activity form, the Daily Habit Log, was provided weekly to each

participant so that they could monitor their food intake and daily steps. Each log had columns for

foods consumed, the time the food was consumed, the amount of food consumed, and whether









the food was a green, yellow, or red food. Each Daily Habit Log also included a space for total

daily steps as measured by the participant's pedometer. Participants were instructed how to

complete the form during the first session of the intervention. The Daily Habit Log was

completed by the parent and child; however, only the child's form was used for the purposes of

this study. Children were encouraged to complete their logs with their parents' help and

supervision. Although participants were encouraged to categorize food consumption into the

"green, yellow, and red" categories, for the purposes of these analyses a trained interventionist

reviewed each log with families at session check-in and reviewed the categorization and number

of red foods consumed by each child. A copy of the Daily Habit Log is provided in Appendix B.

Group leader check in sheet

During "check-in," at the beginning of each session, an interventionist reviewed Daily

Habit Logs individually with the family, focusing on the number of days that a child ate equal to

or less than the previously agreed upon red food goal. This number was entered as the "Number

of Days Met Red Food Goal" on the Check In Sheet. The same procedure was calculated for step

data. For families that tracked fruit and vegetable goals, these data were included on the Check

In Sheet as well. However, since not all families consistently tracked fruit and vegetable goal

data, only red food and step goal attainment data were examined in this study. The number of

days possible to meet red food and step goals each week was capped at six to exclude the day of

the session. The final equation used to calculate goal achievement was: (# of days red food goals

met + # of days step goals met) / (# of days possible to achieve red food goals + # of days

possible to achieve step goals). A copy of the Check in Sheet is provided in Appendix C.

Self-efficacy questionnaire for healthy lifestyle behavior choices

A questionnaire to measure child self-efficacy for making various health lifestyle behavior

choices was created for this study. Items included "(1) I feel confident that I can eat healthy









foods more often. (2) I feel confident that I can eat more fruits and vegetables more often. (3) I

feel confident in that I can change habits to eat fewer junk foods. (4) I feel confident that I can

change my habits to be more physically active. This means running, playing outside, or just

getting up and moving around more often." These items were selected to assess for confidence in

a variety of weight-related behaviors including dietary and physical activity behaviors. The

questionnaire was scored on a four-point Likert scale (really not true for me, sort of not true for

me, sort of true for me, or really true for me). Internal consistency for the self-efficacy

questionnaire in this study was a = 0.660 (pre-treatment) and a = 0.801 (post-treatment). A copy

of this measure is provided in Appendix D.

Modified weight locus of control scale

The original Weight Locus of Control (WLOC; Saltzer, 1982) is a four item weight-

specific locus of control scale designed for adults. Original items include "(1) Whether I gain,

lose or maintain my weight is entirely up to me. (2) Being the right weight is largely a matter of

good fortune. (3) No matter what I intend to do, if I gain or lose weight, or stay the same in the

near future, it is just going to happen. (4) If I eat right and get enough exercise and rest, I can

control my weight in the way that I desire." Original items are scored on a six-point Likert scale

(strongly disagree to strongly agree), with scores ranging from four to 24. Lower scores indicated

internality and higher scores indicated externality. Saltzer (1982) found test-retest reliability

coefficients ofr = 0.67 over a 24-day interval and internal validity coefficients of a = 0.58 and a

= 0.56 for the two administrations. This scale has been shown to be sensitive to detect change in

weight management programs with adults (Bryan & Tiggemann, 2001).

For the purposes of this study, the scale was modified for use with children. The resulting

items were "(1) Whether I gain or lose weight is up to me. (2) Being the right weight is mostly

due to good luck. (3) No matter what I try to do to lose weight, it doesn't change anything. (4) If









I eat right and get enough exercise, I can control my weight." Additionally, items were scored

on a four-point Likert scale (really not true for me, sort of not true for me, sort of true for me, or

really true for me) to provide consistency with other child measures included in this study. These

modifications resulted from consultation between the author, chair, and other doctoral-level

graduate students. In order to further examine the reading level of these modifications, the scale

was given to doctoral-level graduate students and doctoral level psychologists for their

qualitative feedback as well. Internal consistency for the WLOC in this study was a = 0.360 (pre-

treatment) and a = 0.553 (post-treatment). A copy of this measure was provided in Appendix E.

Schwartz peer victimization scale

The Schwartz Peer Victimization Scale (SPVS; Schwartz, Farver, Change, & Lee-Shin,

2002) is a five-item self-report measure that assesses peer victimization experiences over the past

two weeks. Items assess both overt and relational victimization. The scale has been shown to

have good internal consistency, and correlates well with teacher and peer reports of victimization

and loneliness. Participants were asked to answer each question regarding the frequency of

victimization experiences by selecting one of four multiple choice items: never, sometimes,

often, or almost every day. Internal consistency for the SPVS in this study was a = 0.925 (pre-

treatment) and a = 0.910 (post-treatment). A copy of this measure was provided in Appendix F.

Children's body image scale

The Children's Body Image Scale (CBIS; Truby & Paxton, 2002) is a measure of body

size perception that has been shown to have adequate psychometric properties for use in boys

and girls eight years and older. Previous research has indicated that it is a good measure of body

dissatisfaction (Truby & Paxton, 2002) and reflects change in body size dissatisfaction across an

intervention. The scale consists of seven pictures of a child ranging from thinnest to heaviest as

reference points, with a separate set of pictures for boys and girls. The scale was administered by









giving the child a gender-matched pictorial scale and asking the child to circle the body shape

that is most like his or her own (perceived figure). The child was then given another gender-

matched pictorial scale and asked to circle the body shape that he or she would most like to have

(ideal figure). The difference between the perceived and ideal figures was used as a measure of

body size dissatisfaction.











Figure 2-1. Screening, assessment and intervention participation in Project STORY.


Screened for Eligibility via Phone
(N= 154)


Met Initial Eligibility Criteria.
Scheduled for In-Person Screening
(N= 133)


Completed In-Person Screening
(N= 111)


Scheduled for Pre-Start Assessment
(N= 109)


No-Show at In-Person Screening:

(N= 22)


Do Not Meet Eligibility Criteria
at In-Person Screening:
BMI Below 85% (N= 2)


No-Show at Pre-Start Assessment (8)



Did Not Start Treatment:

- Excluded: BMI below 85% (5)
- Did Not Accept Randomization (3):
-Waitlist (2)
-Family (1)


Accepted Randomization and Started

Treatment (N= 93)


Family Intervention

(N = 33)



Family Intervention:

Completed Post-Tx

Assessment (N= 31)


Parent-Only Interve

(N = 34)


nationn Waitlist Control Condition

(N = 26)


I


Parent-Only Intervention:

Completed Post-Tx

Assessment (N = 29)


Waitlist Control:

Completed Post-Tx

Assessment (N = 21)


Completed Pre-Start Assessment (101) No




1


-----


- I









Table 2.1. Mean baseline characteristics of participants who completed pre-treatment and post-treatment assessment.
All Conditions BFI BPI WLC
Characteristic Total Girls Boys Total Girls Boys Total Girls Boys Total Girls Boys
(N=81) (n=50) (n 31) (n 31) (n 20) (n 11) (n 29) (n 14) (n 15) (n 21) (n 16) (n 5)
Age (yrs) 11.07 11.23 10.81 11.03 10.90 11.26 11.15 11.50 10.82 11.02 11.40 9.80
(1.58) (1.6) (1.6) (1.6) (1.7) (1.4) (1.4) (1.3) (1.5) (1.81) (1.7) (1.9)
Grade 5.65 5.70 5.58 5.45 5.25 5.81 5.93 6.14 5.73 5.57 5.88 4.60
(1.70) (1.7) (1.7) (1.7) (1.9) (1.3) (1.5) (1.4) (1.75) (1.9) (1.7) (2.2)
BMI z-score 2.15 2.13 2.20 2.20 2.22 2.15 2.21 2.20 2.22 2.02 1.96 2.20
(0.41) (0.44) (0.35) (0.43) (0.45) (0.40) (0.33) (0.40) (0.26) (0.46) (0.43) (0.54)
Note. Values enclosed in parentheses represent standard deviations.









Table 2.2. Frequency (and percentage) of participants who completed pre-treatment and post-treatment assessment.
Frequency All Conditions BFI BPI WLC
Gender:
Male 31 (38%) 11 (35.5%) 15 (51.7%) 5 (23.8%)
Female 50 (62%) 20 (64.5%) 14 (48.3%) 16 (76.2%)
Ethnicity:
Caucasian 64 (79%) 23 (74.2%) 24 (82.8%) 17 (81%)
African American 7 (8.6%) 3 (9.7%) 1 (3.4%) 3 (14.3%)
Hispanic 6 (7.4%) 4 (12.9%) 1 (3.4%) 1 (4.8%)
Asian 2 (2.5%) 1 (3.2%) 1 (3.4%) 0 (0%)
Bi-racial 2 (2.5%) 0 (0%) 2 (6.9%) 0 (0%)
Other 0 (0%) 0 (0%) 0 (0%) 0 (0%)
Income Range *:
> $9,999 5 (6.3%) 2 (6.9%) 2 (6.9%) 1 (4.8%)
$10,000 $19,999 10 (12.7%) 3 (10.3%) 4 (13.8%) 3 (14.3%)
$20,000 $39,999 24 (30.4%) 14 (48.3%) 5 (17.2%) 5 (23.8%)
$40,000 $59,999 19(24.1%) 2 (6.9%) 9 (31%) 8 (38.1%)
$60,000 $79,999 8 (10.1%) 2 (6.9%) 5 (17.2%) 1 (4.8%)
> $80,000 13 (16.5%) 6 (20.7%) 4 (13.8%) 3 (14.3%)
Parent Marital Status:
Currently Married 62 (76.5%) 23 (74.2%) 25 (86.2%) 14 (66.7%)
Single, divorced 8 (9.9%) 3 (9.7%) 0 (0%) 5 (23.8%)
Single, never married 5 (6.2%) 2 (6.5%) 2 (6.9%) 1 (4.8%)
Single, co-habitating 1 (1.2%) 1 (3.2%) 0 (0%) 0 (0%)
Single, widowed 5 (6.2%) 2 (6.5%) 2 (6.9%) 1 (4.8%)
Parent Age** 41.85 (9.06) 40.23 (9.50) 41.75 (7.638) 44.18 (9.974)
*Note. Income range data missing for two participants.
**Note. Parent Age is listed by Mean (Standard Deviation). Parent age missing data for one participant.









CHAPTER 3
RESULTS

Analyses and Statistical Significance

Given the number of analyses performed, thep value for significance for analyses related

to the primary aims was kept atp < 0.05, while thep value for significance for secondary aims

was set atp < .01 to prevent committing a Type I error (rejecting the null hypothesis when it is

really true) (Grimm & Yamold, 1995). Analyses included mixed model Repeated Measures

ANOVA to assess for the impact of the treatment and gender on variables of interest (Aim 1, 5,

6, and 7). If appropriate, post hoc analyses including paired t-tests were conducted to examine

main effect for time, and pairwise comparisons were conducted to examine significant main

effects for treatment and gender.

Multiple regression analyses were utilized to examine the association between criterion

and predictor variables (Aim 2, 3, 4, 5, 6, and 7). As cross sectional research has provided some

evidence for gender differences in self-esteem, we included a moderator analysis to assess for

differential impact of self-esteem among boys and girls (Mendelson & White, 1985; Pesa et al.,

2000; Israel & Ivanova, 2002). The effect of the predictor variable on the criterion variable, and

gender differences in those associations, were assessed by testing for moderating effects of

gender via multiple regression, based on protocol recommended by Frazier and colleagues

(Frazier, Tix, & Barron, 2004). Based on this approach, the predictor variable of interest was

transformed into a z-score and tested against the criterion variable in block one to analyze for

direct effects of the predictor variable on the variable of interest. Main effects for the predictor

were indicated if the predictor was a significant contributor to the model. In order to examine

potential moderation of gender, the variable for gender was dummy coded as either "1" or "-1."

Then a product (interaction term) was created by multiplying the z-score of the predictor variable









by the dummy coded variable for gender. The z-score for the predictor variable and the dummy

coded gender variables were entered into block two. Then the product of the z-score predictor

variable and dummy coded gender variable was entered into block three. Moderation was

indicated if the unstandardized beta weight for the interaction between the predictor and gender

was a significant contributor to the model.

Primary Aims

Significance values for primary aims were set atp < 0.05.

Aim 1: To Examine the Impact of the Intervention Groups on Self-Esteem

Four 2 x 3 x 2 mixed model ANOVAs were conducted to evaluate the within subjects

change in social, athletic, physical, and global self-esteem from pre- to post-treatment

examining the between subjects effects of treatment condition and gender. All self-esteem pre-

and post-treatment means for girls and boys in each treatment condition are listed in Table 3-1.

Analysis of the model for global self-esteem indicated a significant main effect of time (F

[1, 75] = 9.029,p = 0.004, r2 = 0.107). The main effect of time was explored using post-hoc

paired samples t-tests which indicated a significant improvement in global self-esteem from pre-

to post-treatment for participants in the BPI condition (t = -2.157, df= 28, p = 0.040) and WLC

condition (t = -2.823, df= 20, p = 0.011), but no significant change in global self-esteem over

time for participants in the BFI condition (t = 01.003, df= 30, p = 0.324). The model indicated a

non-significant main effect of gender (F [1, 75] = 0.070, p = 0.793, r2 = 0.001), a non-significant

main effect of treatment condition (F [2, 75] = 0.056, p = 0.945, r2 = 0.001), a non-significant

time by gender interaction effect (F [1, 75] = 2.414, p = 0.124, r2 = 0.031), a non-significant

time by treatment interaction (F [2, 75] = 0.974, p = 0.382, r2 = 0.025), a non-significant

treatment by gender interaction effect (F [2, 75] = 0.956, p = 0.389, T2 = 0.025), and a non-









significant time by treatment by gender effect (F [2, 75] = 0.277, p = 0.759, rl2 = 0.007). Please

refer to Figure 3-1 for a graph of mean change in global self-esteem by treatment condition.

Analysis of the model for social self-esteem indicated a significant main effect of time (F

[1, 74] = 6.530,p = 0.013, r2 = 0.081). The main effect of time was explored using post-hoc

paired samples t-tests which indicated a significant improvement in social self-esteem from pre-

to post-treatment for participants in the BPI condition (t = -2.587, df= 28, p = 0.015), but no

significant change in social self-esteem over time for participants in the BFI (t = -0.163, df= 30,

p = 0.872) or WLC (t = -1.573, df = 19, p = 0.132) conditions. The model indicated a non-

significant main effect of gender (F [1, 74] = 0.037, p = 0.847, r12 = 0.001), a non-significant

main effect of treatment condition (F [2, 74] = 0.930, p = 0.399, rl2 = 0.025), a non-significant

time by gender interaction effect (F [1, 74] = 1.333, p = 0.252, r2 = 0.018), a non-significant

time by treatment interaction (F [2, 74] = 0.954, p = 0.390, r2 = 0.025), a non-significant

treatment by gender interaction effect (F [2, 74] = 0.493,p = 0.613, r2 = 0.013), and a non-

significant time by treatment by gender effect (F [2, 74] = 0.248, p = 0.781, r12 = 0.007). Please

refer to Figure 3-2 for a graph of mean change in social self-esteem by treatment condition.

Analysis of the model for athletic self-esteem indicated a significant main effect of time (F

[1, 75] = 6.268,p = 0.014, r2 = 0.077). The main effect of time was explored using post-hoc

paired samples t-tests which indicated a significant improvement in athletic self-esteem from pre-

to post-treatment for participants in the BFI condition (t = -2.623, df= 30, p = 0.014), but no

significant change in athletic self-esteem over time for participants in the BPI (t = -1.166, df=

28, p = 0.254) or WLC (t = -0.314, df= 20, p = 0.757) conditions. The model indicated a non-

significant main effect of gender (F [1, 75] = 2.119, p = 0.150, r2 = 0.027), anon-significant

main effect of treatment condition (F [2, 75] = 0.140, p = 0.869, r2 = 0.004), a non-significant









time by gender interaction effect (F [1, 75] = 0.104, p = 0.748, r12 = 0.001), a non-significant

time by treatment interaction (F [2, 75] = 1.011, p = 0.369, r2 = 0.026), a non-significant

treatment by gender interaction effect (F [2, 75] = 0.295, p = 0.746, rl2 = 0.008), and a non-

significant time by treatment by gender effect (F [2 ,75] = 0.892, p = 0.414, r2 = 0.023). Please

refer to Figure 3-3 for a graph of mean change in athletic self-esteem by treatment condition.

Analysis of the model for physical self-esteem indicated a significant main effect of gender

(F [1, 75] = 4.643,p = 0.034, r2 = 0.058). Specifically, boys' mean physical self-esteem (M=

2.480, SE = 0.143) was higher than girls' mean physical self-esteem (M= 2.101, SE = 0.102).

The model indicated a non-significant main effect of time (F [1, 75] = 2.743, p = 0.102, 2 =

0.035), a non-significant main effect of treatment condition (F [2, 75] = 0.707, p = 0.497, 2 =

0.018), a non-significant time by gender interaction effect (F [1, 75] = 2.740, p = 0.102, 2 =

0.035), a non-significant time by treatment interaction (F [2, 75] = 1.158, p = 0.320, r2 = 0.030),

a non-significant treatment by gender interaction effect (F [2, 75] = 0.186, p = 0.831, r12 =

0.005), and a non-significant time by treatment by gender effect (F [2, 75] = 1.846, p = 0.165, r2

=0.047).

In summary, participants in the BPI condition experienced significant social self-esteem

and global self-esteem improvements over time. Participants in the BFI condition experienced

significant improvements in athletic self-esteem over time. Participants in the WLC condition

experienced significant improvements in global self-esteem over time. No treatment condition

was significantly different than another group with regard to impact on self-esteem change over

time. Gender differences were present in that boys had significantly higher mean physical self-

esteem than girls; however, boys and girls did not differ in self-esteem improvements over time









or due to treatment. Self-esteem changes did not differ when examined by age, ethnicity, or

county of treatment.

Aim 2: To Determine the Impact of Weight Status Change on Self-Esteem

All impact variable pre- and post-treatment means for girls and boys in each treatment

condition are listed in Table 3-2. The average percent decrease in BMI z-score for child

participants across conditions was 0.0417, SD = 0.11 (BFI: M= 0.0365 [SD = 0.09]; BPI: M=

0.0734 [SD = 0.12]; WLC: M= 0.0057 [SD = 0.09]). Multiple regressions based on procedures

recommended by Frazier and colleagues (Frazier et al., 2004) were conducted to evaluate the

association between weight status change and change in social, athletic, physical, and global

self-esteem.

Block one of the regression analysis showed a non-significant direct effect for weight

status change on globalself-esteem (R2 = 0.038, F [1, 80] = 3.096, = 0.194, t = 1.759, p=

0.082), indicating that change in global self-esteem was not associated with change in weight

status. Block two showed a significant direct effect for gender (f = 0.218, t = 2.011,p = 0.048),

indicating that gender was significantly associated with change in global self-esteem. However,

the unstandardized beta weight for the product of weight status and gender in block three was not

significant (/ = 0.200, t = 1.772, p = 0.080). Thus, gender was not a moderator of the association

between weight status change and change in global self-esteem

Block one of the regression analysis showed a non-significant direct effect for weight

status change on social self-esteem (R2 = -0.012, F [1, 79] = 0.079, = 0.032, t = 0.281,p =

0.779), indicating that change in social self-esteem was not associated with change in weight

status. Block two showed a non-significant direct effect for gender (f = -0.167, t = -1.482, p =

0.142). The unstandardized beta weight for the product of weight status and gender in block









three was not significant (f = 0.108, t = 0.925,p = 0.358). Thus, gender was not a moderator of

the association between weight status change and change in social self-esteem.

Block one of the regression analysis showed a non-significant direct effect for weight

status change on athletic self-esteem (R2 < 0.001, F [1, 80] < 0.001, f = -0.002, t = -0.022, p=

0.983), indicating that change in athletic self-esteem was not associated with change in weight

status. Block two showed a non-significant direct effect for gender on athletic self-esteem (f =

0.006, t = 0.054, p = 0.957). The unstandardized beta weight for the product of weight status and

gender in block three was not significant (f = 0.084, t = 0.699, p = 0.487). Thus, gender was not

a moderator of the association between weight status change and change in athletic self-esteem.

Block one of the regression analysis showed a non-significant direct effect for weight

status change on physical self-esteem (R2 = 0.038, F [1, 80] = 3.091, = 0.194, t = 1.758,p =

0.083), indicating that change in physical self-esteem was not associated with change in weight

status. Block two showed a non-significant direct effect for gender on physical self-esteem (/ =

0.207, t = 1.904, p = 0.061). The unstandardized beta weight for the product of weight status and

gender in block three was not significant (f = 0.184, t = 1.620, p = 0.109). Thus, gender was not

a moderator of the association between weight status change and change in physical self-esteem.

In summary, change in weight status was not associated with improvements in social,

athletic, physical, and global self-esteem. Furthermore, no gender differences were observed.

Secondary Aims

Significance values for secondary aims were set atp < 0.01.

Aim 3: To Examine the Impact of Behavioral Goal Attainment on Self-Esteem

Multiple regressions were conducted to evaluate the association between goal attainment

and improvements in social, athletic, physical, and global self-esteem. Data only from children

in the BPI and BFI were used in these analyses, as families in the WLC did not complete weekly









habit logs or set goals. Mean goal attainment for the participants was approximately 40%, SD =

0.26 (BFI: M= 35% [SD = 0.27]; BPI: M= 44% [SD = 0.26]).

Block one of the regression analysis showed a non-significant direct effect for behavioral

goal attainment on change in global self-esteem (R2 = 0.006, F [1, 59] = 0.340, f = -0.076, t = -

0.583,p = 0.562), indicating that change in global self-esteem was not associated with behavioral

goal attainment. Block two showed a non-significant direct effect for gender on global self-

esteem (f = 0.199, t = 1.507, p = 0.137). The unstandardized beta weight for the product of

behavioral goal attainment and gender in block three was not significant (f = -0.039, t = -0.292,

p = 0.772). Thus, gender was not a moderator of the association between behavioral goal

attainment and change in global self-esteem.

Block one of the regression analysis showed a non-significant direct effect for behavioral

goal attainment on change in social self-esteem (R2 = 0.003, F [1, 59] = 0.162, f = -0.053, t = -

0.403, p = 0.689), indicating that change in social self-esteem was not associated with behavioral

goal attainment. Block two showed a non-significant direct effect for gender on social self-

esteem (f = -0.243, t = -1.855, p = 0.069). The unstandardized beta weight for the product of

behavioral goal attainment and gender in block three was not significant (f = -0.039, t = -0.292,

p = 0.771). Thus, gender was not a moderator of the association between behavioral goal

attainment and change in social self-esteem.

Block one of the regression analysis showed a non-significant direct effect for behavioral

goal attainment on change in athletic self-esteem (R2 = 0.007, F [1, 59] = 0.393, f = -0.082, t = -

0.627, p = 0.533), indicating that change in athletic self-esteem was not associated with

behavioral goal attainment. Block two showed a non-significant direct effect for gender on

athletic self-esteem (f = 0.100, t = 0.747, p = 0.458). The unstandardized beta weight for the









product of behavioral goal attainment and gender in block three was not significant (f = -0.036, t

= -0.268, p = 0.790). Thus, gender was not a moderator of the association between behavioral

goal attainment and change in athletic self-esteem.

Block one of the regression analysis showed a non-significant direct effect for behavioral

goal attainment on change in physical self-esteem (R2 = 0.001, F [1, 59] = 0.035, = 0.024, t =

0.186, p = 0.853), indicating that change in physical self-esteem was not associated with

behavioral goal attainment. Block two showed a significant direct effect for gender on physical

self-esteem (f = 0.351, t = 2.766, p = 0.008), indicating that gender was significantly associated

with change in physical self-esteem. The unstandardized beta weight for the product of

behavioral goal attainment and gender in block three was not significant (f = -0.203, t = -1.627,

p = 0.109). Thus, gender was not a moderator of the association between behavioral goal

attainment and change in physical self-esteem.

Attainment of red food goals and step goals was examined separately to identify if

attainment of a particular type of goal (red food goal attainment and step goal attainment) was

associated with self-esteem improvement, but these associations also were not significant. In

summary, goal attainment was not associated with self-esteem improvement. Furthermore,

gender was not a significant moderator of associations.

Aim 4: To Determine the Impact of Self-Efficacy on Weight Status and Self-Esteem

Multiple regressions were conducted to evaluate the association between pre-treatment

self-efficacy for making healthy lifestyle choices and changes in weight status. Block one of the

regression analysis showed a non-significant direct effect for pre-treatment self-efficacy on

weight status change (R2 = 0.008, F [1, 80] = 0.604, f = 0.087, t = 0.777, p = 0.439), indicating

that pre-treatment self-efficacy was not associated with change in weight status. Block two

showed a non-significant direct effect for gender on change in weight status (f = -0.087, t = -









0.768, p = 0.445). The unstandardized beta weight for the product of pre-treatment self-efficacy

and gender in block three was not significant (f = -0.063, t = -0.488, p = 0.627). Thus, gender

was not a moderator of the relationship between pre-treatment self-efficacy and weight status

change.

Multiple regressions were conducted to evaluate the association between pre-treatment

self-efficacy for making healthy lifestyle choices and change in social, athletic, physical, and

global self-esteem. Block one of the regression analysis showed a non-significant direct effect for

pre-treatment self-efficacy on change in global self-esteem (R2 = 0.017, F [1, 80] = 1.348, f =

0.130, t = 1.161,p = 0.249), indicating that change in global self-esteem was not associated with

pre-treatment self-efficacy. Block two showed a non-significant direct effect for gender on

global self-esteem (f = 0.188, t = 1.692, p = 0.095). The unstandardized beta weight for the

product of pre-treatment self-efficacy and gender in block three was not significant (f = 0.155, t

= 1.235, p = 0.221). Thus, gender was not a moderator of the association between pre-treatment

self-efficacy and change in global self-esteem.

Block one of the regression analysis showed a non-significant direct effect for pre-

treatment self-efficacy on change in social self-esteem (R2 = 0.008, F [1, 79] = 0.595, f = 0.087, t

= 0.772, p = 0.443), indicating that change in social self-esteem was not associated with pre-

treatment self-efficacy. Block two showed a non-significant direct effect for gender on social

self-esteem (f = -0.184, t = -1.629, p = 0.107). The unstandardized beta weight for the product of

pre-treatment self-efficacy and gender in block three was not significant (f = 0.200, t = 1.589, p

= 0.116). Thus, gender was not a moderator of the association between pre-treatment self-

efficacy and change in social self-esteem.









Block one of the regression analysis showed a non-significant direct effect for pre-

treatment self-efficacy on change in athletic self-esteem (R2 = 0.006, F [1, 80] = 0.472, f =

0.077, t = 0.687, p = 0.494), indicating that change in athletic self-esteem was not associated

with pre-treatment self-efficacy. Block two showed a non-significant direct effect for gender on

athletic self-esteem (f = -0.005, t = -0.041, p = 0.967). The unstandardized beta weight for the

product of pre-treatment self-efficacy and gender in block three was not significant (f = 0.169, t

= 1.322, p = 0.190). Thus, gender was not a moderator of the association between pre-treatment

self-efficacy and change in athletic self-esteem.

Block one of the regression analysis showed a non-significant direct effect for pre-

treatment self-efficacy on change inphysical self-esteem (R2 = 0.007, F [1, 80] = 0.587, f =

0.086, t = 0.766, p = 0.446), indicating that change in physical self-esteem was not associated

with pre-treatment self-efficacy. Block two showed a non-significant direct effect for gender on

physical self-esteem (f = 0.184, t = 1.638, p = 0.105). The unstandardized beta weight for the

product of pre-treatment self-efficacy and gender in block three was not significant (f = 0.052, t

= 0.413, p = 0.681). Thus, gender was not a moderator of the association between pre-treatment

self-efficacy and change in physical self-esteem.

Multiple regressions were conducted to evaluate the association between change in self-

efficacy for making healthy lifestyle choices and change in social, athletic, physical, and global

self-esteem. Block one of the regression analysis showed a non-significant direct effect for

change in self-efficacy on change in global self-esteem (R2 = 0.001, F [1, 80] = 0.094, = -

0.034, t = -0.306, p = 0.760), indicating that change in global self-esteem was not associated with

change in self-efficacy. Block two showed a non-significant direct effect for gender on global

self-esteem change (f = -0.202, t = 1.805, p = 0.075). The unstandardized beta weight for the









product of change in self-efficacy and gender in block three was not significant (f = 0.026, t =

0.222, p = 0.825). Thus, gender was not a moderator of the association between change in self-

efficacy and change in global self-esteem.

Block one of the regression analysis showed a non-significant direct effect for change in

self-efficacy on social self-esteem (R2 < 0.001, F [1, 79] = 0.008, f = 0.010, t = 0.088, p =

0.930), indicating that change in social self-esteem was not associated with change in self-

efficacy. Block two showed a non-significant direct effect for gender on social self-esteem

change (f = -0.170, t = -1.497, p = 0.138). The unstandardized beta weight for the product of

change in self-efficacy and gender in block three was not significant (f = -0.058, t = -0.488, p =

0.627). Thus, gender was not a moderator of the association between change in self-efficacy and

change in social self-esteem.

Block one of the regression analysis showed a non-significant direct effect for change in

self-efficacy on athletic self-esteem (R2 = 0.038, F [1, 80] = 3.113, = 0.195, t = 1.764, p =

0.082), indicating that change in athletic self-esteem was not associated with change in self-

efficacy. Block two showed a non-significant direct effect for gender on athletic self-esteem

change (f = 0.036, t = 0.320, p = 0.750). The unstandardized beta weight for the product of

change in self-efficacy and gender in block three was not significant (f = -0.114, t = -0.965, p =

0.338). Thus, gender was not a moderator of the association between change in self-efficacy and

change in athletic self-esteem.

Block one of the regression analysis showed a non-significant direct effect for change in

self-efficacy on physical self-esteem (R2 = 0.001, F [1, 80] = 0.094, f = 0.034, t = 0.306,p =

0.760), indicating that change in physical self-esteem was not associated with change in self-

efficacy. Block two showed a non-significant direct effect for gender on physical self-esteem









change (f = 0.202, t = 1.797, p = 0.076). The unstandardized beta weight for the product of

change in self-efficacy and gender in block three was not significant (f = -0.079, t = -0.666, p =

0.508). Thus, gender was not a moderator of the association between change in self-efficacy and

change in physical self-esteem.

In summary, self-efficacy for healthy lifestyle behaviors was not associated with change in

weight status or self-esteem change for participants at any stage of the study. Furthermore, no

gender differences were observed.

Aim 5: To Determine the Impact of and Association Between Weight-Specific Locus of
Control, Weight Status, and Self-Esteem in Overweight Children

Multiple regressions were conducted to evaluate the association between pre-treatment

weight-specific locus of control and pre-treatment social, athletic, physical, and global self-

esteem. Block one of the regression analysis showed a non-significant direct effect for pre-

treatment locus of control on global self-esteem (R2 < 0.001, F [1, 80] < 0.001, f = -0.001, t= -

0.009, p = 0.993), indicating that pre-treatment global self-esteem was not associated with pre-

treatment locus of control. Block two showed a non-significant direct effect for gender on global

self-esteem (f = 0.208, t = 1.852, p = 0.068). The unstandardized beta weight for the product of

pre-treatment locus of control and gender in block three was not significant (f = 0.140, t = 1.221,

p = 0.226). Thus, gender was not a moderator of the association between pre-treatment locus of

control and pre-treatment global self-esteem.

Block one of the regression analysis showed a non-significant direct effect for pre-

treatment locus of control on social self-esteem (R2 = 0.005, F [1, 79] = 0.420, f = 0.073, t =

0.648, p = 0.519), indicating that pre-treatment social self-esteem was not associated with pre-

treatment locus of control. Block two showed a non-significant direct effect for gender on social

self-esteem (f = -0.161, t = -1.416, p = 0.519). The unstandardized beta weight for the product of









pre-treatment locus of control and gender in block three was not significant (f = 0.091, t = 0.778,

p = 0.439). Thus, gender was not a moderator of the association between pre-treatment locus of

control and pre-treatment social self-esteem.

Block one of the regression analysis showed a non-significant direct effect for pre-

treatment locus of control on athletic self-esteem (R2 = 0.003, F [1, 80] = 0.198, / = 0.050, t =

0.445, p = 0.657), indicating that pre-treatment athletic self-esteem was not associated with pre-

treatment locus of control. Block two showed a non-significant direct effect for gender on

athletic self-esteem (f = 0.014, t = 0.123, p = 0.902). The unstandardized beta weight for the

product of pre-treatment locus of control and gender in block three was not significant (/ =

0.088, t = 0.746, p = 0.458). Thus, gender was not a moderator of the association between pre-

treatment locus of control and pre-treatment athletic self-esteem.

Block one of the regression analysis showed a non-significant direct effect for pre-

treatment locus of control on physical self-esteem (R2 < 0.001, F [1, 80] < 0.001, f = -0.001, t= -

0.012, p = 0.991), indicating that pre-treatment physical self-esteem was not associated with pre-

treatment locus of control. Block two showed a non-significant direct effect for gender on

physical self-esteem (f = 0.196, t = 1.746, p = 0.085). The unstandardized beta weight for the

product of pre-treatment locus of control and gender in block three was not significant (/ =

0.179, t = 1.562, p = 0.122). Thus, gender was not a moderator of the association between pre-

treatment locus of control and pre-treatment physical self-esteem.

A 2 x 3 x 2 mixed model ANOVA was performed to examine change in weight-specific

locus of control from pre- to post-treatment, examining the between subjects effects of treatment

condition and gender. Examination of the model indicated a non-significant direct effect of time

(F [1, 75] = 3.316,p = 0.073, r2 = 0.042), a non-significant direct effect of gender (F [1, 75] =









1.302, p = 0.257, r2 = 0.017), a non-significant direct effect of treatment condition (F [2, 75] =

0.896, p = 0.413, r2 = 0.023), a non-significant time by gender interaction effect (F [1, 75] =

0.028, p = 0.868, r12 < 0.001), a non-significant time by treatment interaction (F [2, 75] = 0.833,

p = 0.439, r2 = 0.022), a non-significant treatment by gender interaction effect (F [2, 75] =

0.793,p = 0.456, r2 = 0.021), and a non-significant time by treatment by gender effect (F [2, 75]

= 0.513,p = 0.601, r2 = 0.013). In summary, weight-specific locus of control did not change

over time or due to treatment, and no gender differences were present in the sample.

Multiple regressions were conducted to evaluate the association between post-treatment

weight-specific locus of control and weight status on post-treatment social, athletic, physical,

and global self-esteem. In the sample, post-treatment locus of control was significantly

associated with post-treatment global self-esteem (R2 = 0.116, F [1, 80] = 10.322, p = 0.002),

social self-esteem (R2 = 0.121, F [1, 80] = 10.848, p = 0.001), athletic self-esteem (R2 = 0.103, F

[1, 80] = 9.074, p = 0.003), and physical self-esteem (R2 = 0.157, F [1, 80] = 14.669, p < 0.001).

However, weight status change was only a statistically significant predictor of post-treatment

athletic self-esteem (R2 = 0.097, F [1, 80] = 8.474, p = 0.005), and not statistically associated

with post-treatment social self-esteem (R2 = 0.017, F [1, 80] = 1.368, p = 0.246), physical self-

esteem (R2 = 0.033, F [1, 80] = 2.728, p = 0.103), or global self-esteem (R2 = 0.054, F [1, 80] =

4.472, p = 0.038). Moderator effects were not indicated because the effect of the interaction

(between weight-specific locus of control and weight status change) was not significant when the

simple effects of the independent variables (weight-specific locus of control and weight status

change) were controlled (interaction f = 0.562, t = 0.686, p = 0.495). No gender differences were

observed when examining the interaction between post-treatment weight-specific locus of









control and change in weight status on post-treatment self-esteem (interaction f = 0.071, t =

0.550,p = 0.584).

In summary, weight-specific locus of control was not associated with participants' self-

esteem. Weight-specific locus of control did not change over time or as a result of treatment for

the participants. The interaction between weight status change and self-esteem change was not

significant. Furthermore, no gender differences existed in the relationship.

Aim 6: To Examine the Impact of Peer Victimization on Self-Esteem

Multiple regressions were conducted to evaluate the association between pre-treatment

peer victimization and pre-treatment social, athletic, physical, and global self-esteem. Block

one of the regression analysis showed a significant direct effect for pre-treatment peer

victimization on pre-treatment global self-esteem (R2 = 0.135, F [1, 80] = 12.340, f = -0.368, t =

-3.513, p = 0.001), indicating that pre-treatment global self-esteem was associated with pre-

treatment peer victimization such that greater peer victimization was associated with poorer

global self-esteem. Block two showed a non-significant direct effect for gender on global self-

esteem (f = -0.103, t = -0.980, p = 0.330). The unstandardized beta weight for the product of pre-

treatment peer victimization and gender in block three was not significant (f = 0.122, t = 1.125, p

= 0.264). Thus, gender was not a moderator of the association between pre-treatment peer

victimization and pre-treatment global self-esteem.

Block one of the regression analysis showed a significant direct effect for pre-treatment

peer victimization on pre-treatment social self-esteem (R2 = 0.209, F [1, 79] = 20.582, f = -

0.457, t = -4.537, p < 0.001), indicating that pre-treatment social self-esteem was associated with

pre-treatment peer victimization such that greater peer victimization was associated with poorer

social self-esteem. Block two showed a non-significant direct effect for gender on social self-

esteem (f = 0.141, t = 1.409, p = 0.163). The unstandardized beta weight for the product of pre-









treatment peer victimization and gender in block three was not significant (f = 0.031, t = 0.294, p

= 0.770). Thus, gender was not a moderator of the association between pre-treatment peer

victimization and pre-treatment social self-esteem.

Block one of the regression analysis showed a significant direct effect for pre-treatment

peer victimization on pre-treatment athletic self-esteem (R2 = 0.110, F [1, 80] = 9.806, = -

0.332, t = -3.132, p = 0.002), indicating that pre-treatment athletic self-esteem was associated

with pre-treatment peer victimization such that greater peer victimization was associated with

poorer athletic self-esteem. Block two showed a non-significant direct effect for gender on

athletic self-esteem (/ = -0.147, t = -1.396, p = 0.167). The unstandardized beta weight for the

product of pre-treatment peer victimization and gender in block three was not significant (f = -

0.108, t = -0.993, p = 0.324). Thus, gender was not a moderator of the association between pre-

treatment peer victimization and pre-treatment athletic self-esteem.

Block one of the regression analysis showed a non-significant direct effect for pre-

treatment peer victimization on pre-treatment physical self-esteem (R2 = 0.064, F [1, 80] = 5.441,

f = -0.254, t = 02.333, p = 0.022), indicating that pre-treatment physical self-esteem was not

associated with pre-treatment peer victimization. Block two showed a significant direct effect for

gender on physical self-esteem (f = -0.326, t = -3.153, p = 0.002), indicating that gender was

associated with pre-treatment physical self-esteem, such that boys had higher pre-treatment

physical self-esteem. The unstandardized beta weight for the product of pre-treatment peer

victimization and gender in block three was not significant (f = 0.125, t = 1.173, p = 0.244).

Thus, gender was not a moderator of the association between pre-treatment peer victimization

and pre-treatment physical self-esteem.









Multiple regressions were conducted to evaluate the association between change in peer

victimization and change in social, athletic, physical, and global self-esteem. Block one of the

regression analysis showed a non-significant direct effect for change in peer victimization on

change in global self-esteem (R2 = 0.011, F [1, 80] = 0.910, = -0.107, t = -0.954, p = 0.343),

indicating that change in global self-esteem was not associated with change in peer victimization.

Block two showed a non-significant direct effect for gender on change in global self-esteem (f =

0.190, t = 1.690, p = 0.095). The unstandardized beta weight for the product of change in peer

victimization and gender in block three was not significant (f = -0.163, t = -1.414, p = 0.161).

Thus, gender was not a moderator of the association between change in peer victimization and

change in global self-esteem.

Block one of the regression analysis showed a significant direct effect for change in peer

victimization on change in social self-esteem (R2 = 0.083, F [1, 79] = 7.085, f = -0.289, t = -

2.662, p = 0.009), indicating that change in social self-esteem was associated with change in peer

victimization, such that reductions in peer victimization were associated with improvements in

social self-esteem. Block two showed a non-significant direct effect for gender on change in

social self-esteem (f = -0.228, t = -2.110, p = 0.038). The unstandardized beta weight for the

product of change in peer victimization and gender in block three was not significant (f = -0.033,

t = -0.299, p = 0.766). Thus, gender was not a moderator of the association between change in

peer victimization and change in social self-esteem.

Block one of the regression analysis showed a non-significant direct effect for change in

peer victimization on change in athletic self-esteem (R2 = 0.031, F [1, 80] = 2.489, f = -0.175, t =

-1.578, p = 0.119), indicating that change in athletic self-esteem was not associated with change

in peer victimization. Block two showed a non-significant direct effect for gender on change in









athletic self-esteem (f = -0.026, t= -0.228, p = 0.820). The unstandardized beta weight for the

product of change in peer victimization and gender in block three was not significant (f = -0.168,

t = -1.447, p = 0.152). Thus, gender was not a moderator of the association between change in

peer victimization and change in athletic self-esteem.

Block one of the regression analysis showed a significant direct effect for change in peer

victimization on change inphysical self-esteem (R2 = 0.105, F [1, 80] = 9.302, f = -0.325, t = -

3.050, p = 0.003), indicating that change in physical self-esteem was associated with change in

peer victimization, such that reductions in peer victimization were associated with improvements

in physical self-esteem. Block two showed a non-significant direct effect for gender on change in

physical self-esteem (f = 0.138, t = 1.283, p = 0.203). The unstandardized beta weight for the

product of change in peer victimization and gender in block three was not significant (f = -0.037,

t = -0.327, p = 0.744). Thus, gender was not a moderator of the association between change in

peer victimization and change in physical self-esteem.

Multiple regressions were conducted to evaluate the association between post-treatment

peer victimization and post-treatment social, athletic, physical, and global self-esteem. Block

one of the regression analysis showed a significant direct effect for post-treatment peer

victimization on post-treatment global self-esteem (R2 = 0.162, F [1, 80] = 15.253, f = -0.402, t =

-3.905, p < 0.001), indicating that post-treatment global self-esteem was associated with post-

treatment peer victimization, such that lower post-treatment peer victimization was associated

with higher post-treatment global self-esteem. Block two showed a non-significant direct effect

for gender on post-treatment global self-esteem (f = -0.002, t = -0.020, p = 0.984). The

unstandardized beta weight for the product of post-treatment peer victimization and gender in

block three was not significant (f = -0.060, t = -0.563, p = 0.575). Thus, gender was not a









moderator of the association between post-treatment peer victimization and post-treatment global

self-esteem.

Block one of the regression analysis showed a significant direct effect for post-treatment

peer victimization on post-treatment social self-esteem (R2 = 0.213, F [1, 80] = 21.433, f = -

0.462, t = -4.630, p < 0.001), indicating that post-treatment social self-esteem was associated

with post-treatment peer victimization, such that lower post-treatment peer victimization was

associated with higher post-treatment social self-esteem. Block two showed a non-significant

direct effect for gender on post-treatment social self-esteem (f = -0.033, t = -0.328, p = 0.744).

The unstandardized beta weight for the product of post-treatment peer victimization and gender

in block three was not significant (f = -0.28, t = -0.274, p = 0.785). Thus, gender was not a

moderator of the association between post-treatment peer victimization and post-treatment social

self-esteem.

Block one of the regression analysis showed a non-significant direct effect for post-

treatment peer victimization on post-treatment athletic self-esteem (R2 = 0.033, F [1, 80] = 2.690,

f = -0.181, t = -1.640, p = 0.105), indicating that post-treatment athletic self-esteem was not

associated with post-treatment peer victimization. Block two showed a non-significant direct

effect for gender on post-treatment athletic self-esteem (f = 0.175, t = -1.589, p = 0.116). The

unstandardized beta weight for the product of post-treatment peer victimization and gender in

block three was not significant (f = -0.035, t = -0.308, p = 0.759). Thus, gender was not a

moderator of the association between post-treatment peer victimization and post-treatment

athletic self-esteem.

Block one of the regression analysis showed a significant direct effect for post-treatment

peer victimization on post-treatment physical self-esteem (R2 = 0.113, F [1, 80] = 10.036, f = -









0.336, t = -3.168, p = 0.002), indicating that post-treatment physical self-esteem was associated

with post-treatment peer victimization, such that lower post-treatment peer victimization was

associated with higher post-treatment physical self-esteem. Block two showed a non-significant

direct effect for gender on post-treatment physical self-esteem (f = -0.298, t = -1.898, p = 0.061).

The unstandardized beta weight for the product of post-treatment peer victimization and gender

in block three was not significant (f = 0.040, t = 0.372, p = 0.711). Thus, gender was not a

moderator of the association between post-treatment peer victimization and post-treatment

physical self-esteem.

In summary, pre- and post-treatment peer victimization ratings were significantly

associated with many domains of pre- and post-treatment self-esteem for girls and boys.

Analyses indicated that reductions in peer victimization ratings were associated with

improvements in social self-esteem and physical self-esteem. All associations between peer

victimization and self-esteem were such that more peer victimization was associated with poorer

self-esteem. Gender differences were not observed.

Aim 7: To Examine the Impact of Body Image on Self-Esteem

Multiple regressions were conducted to evaluate the association between pre-treatment

body dissatisfaction ratings and pre-treatment social, athletic, physical, and global self-esteem.

Block one of the regression analysis showed a significant direct effect for pre-treatment body

dissatisfaction ratings on pre-treatment global self-esteem (R2 = 0.172, F [1, 80] = 16.372, f = -

0.414, t = -4.046, p < 0.001), indicating that poorer pre-treatment global self-esteem was

associated with greater pre-treatment body dissatisfaction. Block two showed a non-significant

direct effect for gender on pre-treatment global self-esteem (f = -0.062, t = -0.601, p = 0.550).

The unstandardized beta weight for the product of pre-treatment body dissatisfaction and gender

in block three was not significant (f = -0.099, t = -0.905, p = 0.368). Thus, gender was not a









moderator of the association between pre-treatment body dissatisfaction and pre-treatment global

self-esteem.

Block one of the regression analysis showed a non-significant direct effect for pre-

treatment body dissatisfaction ratings on pre-treatment social self-esteem (R2 = -.036, F [1, 79] =

2.876, = -0.189, t= -1.696, p = 0.094), indicating that pre-treatment social self-esteem was not

associated with pre-treatment body dissatisfaction. Block two showed a non-significant direct

effect for gender on pre-treatment social self-esteem (f = 0.150, t = 1.337, p = 0.185). The

unstandardized beta weight for the product of pre-treatment body dissatisfaction and gender in

block three was not significant (f = 0.066, t = 0.556, p = 0.580). Thus, gender was not a

moderator of the association between pre-treatment body dissatisfaction and pre-treatment social

self-esteem.

Block one of the regression analysis showed a non-significant direct effect for pre-

treatment body dissatisfaction ratings on pre-treatment athletic self-esteem (R2 = 0.056, F [1, 80]

= 4.691, f = -0.237, t = -2.166, p = 0.033), indicating that pre-treatment athletic self-esteem was

not associated with pre-treatment body dissatisfaction. Block two showed a non-significant direct

effect for gender on pre-treatment athletic self-esteem (f = -0.132, t = -1.203, p = 0.233). The

unstandardized beta weight for the product of pre-treatment body dissatisfaction and gender in

block three was not significant (f = -0.079, t = -0.680, p = 0.499). Thus, gender was not a

moderator of the association between pre-treatment body dissatisfaction and pre-treatment

athletic self-esteem.

Block one of the regression analysis showed a significant direct effect for pre-treatment

body dissatisfaction ratings on pre-treatment physical self-esteem (R2 = 0.100, F [1, 80] = 8.785,

f = -0.316, t = -2.964, p = 0.004), indicating that poorer pre-treatment physical self-esteem was









associated with greater pre-treatment body dissatisfaction. Block two showed a significant direct

effect for gender on pre-treatment physical self-esteem (f = -0.298, t = -2.889, p = 0.005),

indicating that gender was significantly associated with pre-treatment physical self-esteem, such

that boys experienced higher pre-treatment physical self-esteem. The unstandardized beta weight

for the product of pre-treatment body dissatisfaction and gender in block three was not

significant (f = -0.076, t = -0.700, p = 0.486). Thus, gender was not a moderator of the

association between pre-treatment body dissatisfaction and pre-treatment physical self-esteem.

A 2 x 3 x 2 mixed model ANOVA was performed to examine change in body

dissatisfaction ratings from pre- to post-treatment examining the between subjects effects of

treatment condition and gender. Examination of the model indicated a significant main effect of

time (F [1, 74] = 12.254,p = 0.001, r2 = 0.142). The main effect of time was examined using

paired samples t-tests which indicated a significant improvement in body dissatisfaction from

pre- to post-treatment for participants in the BFI condition (t = 3.412, df= 30, p = 0.002) and

participants in the BPI condition (t = 2.826, df= 27, p = 0.009), but no significant difference in

body dissatisfaction over time for participants in the WLC (t = 0.170, df= 20, p = 0.867)

condition. The model also indicated a non-significant direct effect of gender (F [1, 74] = 0.929, p

= 0.338, r2 = 0.012), a non-significant direct effect of treatment condition (F [2, 74] = 0.333, p =

0.718, r2 = 0.009), a non-significant time by gender interaction effect (F [1, 74] = 0.333,p =

0.566, r2 = 0.004), and a non-significant time by treatment interaction (F [2, 74] = 2.316, p =

0.106, r2 = 0.059), a non-significant treatment by gender interaction effect (F [2, 74] = 3.180, p

= 0.047, r2 = 0.079), and a non-significant time by treatment by gender effect (F [2, 74] = 2.451,

p = 0.093, r2 = 0.062). In summary, body dissatisfaction ratings improved over time for









participants in the BFI and BPI conditions. Please refer to Figure 3-4 for a graph of mean change

in body dissatisfaction by treatment condition.

Multiple regressions were conducted to evaluate the association between change in body

dissatisfaction ratings and change in social, athletic, physical, and global self-esteem. Block one

of the regression analysis showed a non-significant direct effect for change in body

dissatisfaction ratings on change in global self-esteem (R2 = 0.010, F [1, 79] = 0.751, = -0.098,

t = -0.867, p = 0.389), indicating that change in global self-esteem was not associated with

change in body dissatisfaction. Block two showed a non-significant direct effect for gender on

change in global self-esteem (f = 0.207, t = 1.869, p = 0.065). The unstandardized beta weight

for the product of change in body dissatisfaction and gender in block three was not significant (f

= 0.070, t = 0.626, p = 0.533). Thus, gender was not a moderator of the association between

change in body dissatisfaction and change in global self-esteem.

Block one of the regression analysis showed a non-significant direct effect for change in

body dissatisfaction ratings on change in social self-esteem (R2 = 0.071, F [1, 78] = 5.882, f = -

0.266, t = -2.425, p = 0.018), indicating that change in social self-esteem was not associated with

change in body dissatisfaction. Block two showed a non-significant direct effect for gender on

change in social self-esteem (/ = -0.165, t= -1.515,p = 0.134). The unstandardized beta weight

for the product of change in body dissatisfaction and gender in block three was not significant (f

= -0.064, t = -0.581, p = 0.563). Thus, gender was not a moderator of the association between

change in body dissatisfaction and change in social self-esteem.

Block one of the regression analysis showed a non-significant direct effect for change in

body dissatisfaction ratings on change in athletic self-esteem (R2 = 0.004, F [1, 79] = 0.310, f = -

0.063, t = -0.557, p = 0.579), indicating that change in athletic self-esteem was not associated









with change in body dissatisfaction. Block two showed a non-significant direct effect for gender

on change in athletic self-esteem (f = 0.011, t = 0.098, p = 0.922). The unstandardized beta

weight for the product of change in body dissatisfaction and gender in block three was not

significant (f = 0.066, t = 0.580, p = 0.564). Thus, gender was not a moderator of the association

between change in body dissatisfaction and change in athletic self-esteem.

Block one of the regression analysis showed a non-significant direct effect for change in

body dissatisfaction ratings on change in physical self-esteem (R2 = 0.011, F [1, 79] = 0.847, =

0.104, t = 0.921, p = 0.360), indicating that change in physical self-esteem was not associated

with change in body dissatisfaction. Block two showed a non-significant direct effect for gender

on change in physical self-esteem (f = 0.192, t= 1.727, p = 0.088). However, the unstandardized

beta weight for the product of change in body dissatisfaction and gender in block three was

significant (f = 0.301, t = 2.831, p = 0.006). Follow-up analyses were performed to further

examine the interaction. These analyses indicated that change in body dissatisfaction ratings

were not significantly associated with change in physical self-esteem for boys (f = -0.245, t= -

1.363, p = 0.183), yet were approaching significance for girls (/ = 0.359, t = 2.637, p = 0.011).

Furthermore, improvements in girls' body satisfaction accounted for approximately 13% of the

variance in change in physical self-esteem (R2 = .129). Thus, gender was a moderator of the

association between change in body dissatisfaction and change in physical self-esteem.

Multiple regressions were conducted to evaluate the association between post-treatment

body dissatisfaction ratings and post-treatment social, athletic, physical, and global self-esteem.

Block one of the regression analysis showed a significant direct effect for post-treatment body

dissatisfaction ratings on post-treatment global self-esteem (R = 0.108, F [1, 79] = 9.415, / = -

0.328, t = -3.068, p = 0.003), indicating that poorer post-treatment global self-esteem was









associated with greater post-treatment body dissatisfaction. Block two showed a non-significant

direct effect for gender on post-treatment global self-esteem (f = 0.059, t = 0.549, p = 0.584).

The unstandardized beta weight for the product of post-treatment body dissatisfaction and gender

in block three was not significant (f = 0.085, t = 0.790, p = 0.432). Thus, gender was not a

moderator of the association between post-treatment body dissatisfaction and post-treatment

global self-esteem.

Block one of the regression analysis showed a non-significant direct effect for post-

treatment body dissatisfaction ratings on post-treatment social self-esteem (R2 = 0.069, F [1, 79]

= 5.759, f = -0.262, t = -2.400, p = 0.019), indicating that post-treatment social self-esteem was

not associated with post-treatment body dissatisfaction. Block two showed a non-significant

direct effect for gender on post-treatment social self-esteem (/ = 0.038, t = 0.345, p = 0.731).

The unstandardized beta weight for the product of post-treatment body dissatisfaction and gender

in block three was not significant (f = -0.095, t = -0.856, p = 0.395). Thus, gender was not a

moderator of the association between post-treatment body dissatisfaction and post-treatment

social self-esteem.

Block one of the regression analysis showed a non-significant direct effect for post-

treatment body dissatisfaction ratings on post-treatment athletic self-esteem (R2 = 0.036, F [1,

79] = 2.938, f = -0.191, t = -1.714, p = 0.091), indicating that post-treatment athletic self-esteem

was not associated with post-treatment body dissatisfaction. Block two showed a non-significant

direct effect for gender on post-treatment athletic self-esteem (f = -0.139, t = -1.250, p = 0.215).

The unstandardized beta weight for the product of post-treatment body dissatisfaction and gender

in block three was not significant (f = -0.076, t = -0.682, p = 0.497). Thus, gender was not a









moderator of the association between post-treatment body dissatisfaction and post-treatment

athletic self-esteem.

Block one of the regression analysis showed a significant direct effect for post-treatment

body dissatisfaction ratings on post-treatment physical self-esteem (R2 = 0.257, F [1, 79] =

27.015, f = -0.507, t= -5.198, p < .001), indicating that poorer post-treatment physical self-

esteem was associated with greater post-treatment body dissatisfaction. Block two showed a non-

significant direct effect for gender on post-treatment physical self-esteem (/ = -0.118, t = -1.208,

p = 0.231). The unstandardized beta weight for the product of post-treatment body dissatisfaction

and gender in block three was not significant (f = -0.056, t = -0.568, p = 0.572). Thus, gender

was not a moderator of the association between post-treatment body dissatisfaction and post-

treatment physical self-esteem.

In summary, body dissatisfaction was associated with physical and global self-esteem at

multiple time points. All associations between body dissatisfaction and self-esteem were such

that more body dissatisfaction was associated with poorer self-esteem. Gender moderated the

association between improvements in physical self-esteem and change in body dissatisfaction

such that reductions in body dissatisfaction were approaching significance for association with

change in girls' physical self-esteem, but were not significantly associated with change in boys'

physical self-esteem. Participants in the BFI and BPI conditions experienced significant

reductions in body dissatisfaction over time. No treatment condition was significantly different

than another group with regard to the impact on body dissatisfaction.






























Figure 3-1. Global self-esteem change by treatment condition.


Social Self-Esteem Change

3.1

2.9 --
^ 2.8 _
2.7 BPI
r 2.7
| 2.6 WLC
S2.5
2.4
Pre-Treatment Post-Treatment

Time


Figure 3-2. Social self-esteem change by treatment condition.


Global Self-Esteem Change


3.2
3.1
3 BFI
2.9 BPI
2.8 WLC
2.7
2.6
Pre-Treatment Post-Treatment

Time










Athletic Self-Esteem Change

2.9
2.8
S2.7 -
2.6 BFI
2 ./ BPI
C 2.5 -
WLC
o 2.4
2.3
2.2
Pre-Treatment Post-Treatment
Time


Figure 3-3. Athletic self-esteem change by treatment condition.


Body Dissatisfaction Change


S3
2.5
2 BFI
1.5 BPI
o 1 WLC
S0.5
IC 0
Pre- Treatment Post-Treatment

Time


Figure 3-4. Body dissatisfaction change by treatment condition.









Table 3-1. Mean scores (standard deviations) of SPPC scores for children who completed pre-
treatment and post-treatment assessment.


Pre-treatment Post-treatment
value value
Total Sample
Girls (n = 50)
Social Self-Esteem 2.87 (0.79) 2.96 (0.78)
Athletic Self-Esteem 2.43 (0.88) 2.63 (0.85)
Physical Self-Esteem 1.98 (0.75) 2.22 (0.81)
Global Self-Esteem 2.77 (0.73) 3.05 (0.72)
Boys (n = 31)
Social Self-Esteem 2.69 (0.71) 2.95 (0.68)
Athletic Self-Esteem 2.70 (0.60) 2.89 (0.66)
Physical Self-Esteem 2.52 (0.72) 2.51 (0.80)
Global Self-Esteem 2.95 (0.70) 3.01 (0.67)

BFI
Girls (n =20)
Social Self-Esteem 3.00 (0.61) 2.92 (0.70)
Athletic Self-Esteem 2.29 (0.94) 2.72 (0.79)
Physical Self-Esteem 1.99 (0.73) 2.30 (0.66)
Global Self-Esteem 2.73 (0.82) 2.88 (0.70)
Boys (n 11)
Social Self-Esteem 2.93 (0.79) 3.14 (0.76)
Athletic Self-Esteem 2.80 (0.73) 3.08 (0.75)
Physical Self-Esteem 2.62 (0.85) 2.70 (0.90)
Global Self-Esteem 3.15 (0.73) 3.15 (0.79)

BPI
Girls (n = 14)
Social Self-Esteem 2.79 (1.03) 2.96 (0.90)
Athletic Self-Esteem 2.46 (0.97) 2.62 (1.00)
Physical Self-Esteem 1.92 (0.72) 2.46 (1.04)
Global Self-Esteem 2.80 (0.67) 3.18(0.79)
Boys (n = 15)
Social Self-Esteem 2.46 (0.67) 2.78 (0.65)
Athletic Self-Esteem 2.67 (0.56) 2.74 (0.61)
Physical Self-Esteem 2.52 (0.69) 2.40 (0.82)
Global Self-Esteem 2.88 (0.76) 2.92 (0.66)

WLC
Girls (n = 16)
Social Self-Esteem 2.78 (0.77) 2.99 (0.81)
Athletic Self-Esteem 2.58 (0.74) 2.53 (0.81)









Physical Self-Esteem 2.02 (0.85) 1.92 (0.70)
Global Self-Esteem 2.80 (0.71) 3.15(0.68)
Boys (n 5)
Social Self-Esteem 2.83 (0.50) 3.07 (0.55)
Athletic Self-Esteem 2.57 (0.51) 2.90 (0.58)
Physical Self-Esteem 2.30 (0.58) 2.30 (0.55)
Global Self-Esteem 2.73 (0.35) 2.97 (0.49)


Table 3-2. Mean scores (and standard deviations) of impact variables for children who completed
pre-treatment and post-treatment assessments.
Pre-treatment Post-treatment
value value
Total Sample
Girls (n =50)
BMI Z score 2.13 (0.44) 2.07(0.51)
Self-Efficacy Score 13.76 (2.13) 13.38 (2.50)
WLOC Score 12.48 (2.13) 13.02 (2.58)
Peer Victimization Score 8.97 (4.00) 8.36 (3.11)
Body Dissatisfaction 2.76 (1.30) 2.14 (1.30)
Boys (n = 31)
BMI Z score 2.19 (0.35) 2.09 (0.44)
Self-Efficacy Score 13.19 (1.62) 13.58 (2.35)
WLOC Score 13.13 (2.06) 13.58 (1.78)
Peer Victimization Score 8.55 (3.96) 8.94 (4.80)
Body Dissatisfaction 2.39 (1.17) 1.84 (1.51)

BFI
Girls (n =20)
BMI Z score 2.22 (0.45) 2.20 (0.48)
Self-Efficacy Score 13.60 (2.28) 13.75 (2.49)
WLOC Score 12.30 (1.66) 12.60 (2.60)
Peer Victimization Score 8.75 (3.74) 7.75 (3.11)
Body Dissatisfaction 3.10(1.52) 2.45(1.15)
Boys (n 11)
BMI Z score 2.15 (0.40) 2.00 (0.56)
Self-Efficacy Score 13.73 (1.49) 13.09 (2.47)
WLOC Score 13.36 (1.57) 13.45 (1.81)
Peer Victimization Score 9.18 (5.36) 8.18 (4.94)
Body Dissatisfaction 2.27 (1.01) 1.09 (1.38)

BPI
Girls (n = 14)
BMI Z score 2.20 (0.40) 2.02 (0.59)
Self-Efficacy Score 14.14 (1.70) 13.71 (1.98)
WLOC Score 12.86 (2.32) 14.29 (1.64)









Peer Victimization Score 9.07 (4.70) 8.86 (2.77)
Body Dissatisfaction 2.57 (1.16) 1.31 (1.38)
Boys (n = 15)
BMI Z score 2.22 (0.26) 2.11 (0.32)
Self-Efficacy Score 12.93 (1.67) 13.67 (2.38)
WLOC Score 13.07 (2.34) 13.67 (1.99)
Peer Victimization Score 8.93 (3.15) 10.00 (5.26)
Body Dissatisfaction 2.47 (1.41) 2.20 (1.42)

WLC
Girls (n = 16)
BMI Z score 1.96 (0.43) 1.94 (0.46)
Self-Efficacy Score 13.63 (2.36) 12.63 (2.87)
WLOC Score 12.38 (2.55) 12.44 (2.94)
Peer Victimization Score 9.13 (3.95) 8.69 (3.44)
Body Dissatisfaction 2.50 (1.10) 2.44 (1.21)
Boys (n 5)
BMI Z score 2.20 (0.35) 2.09 (0.44)
Self-Efficacy Score 12.80 (1.79) 14.40 (2.19)
WLOC Score 12.80 (2.49) 13.60 (1.34)
Peer Victimization Score 6.00 (1.00) 7.40 (2.51)
Body Dissatisfaction 2.40 (0.89) 2.40 (1.67)









CHAPTER 4
DISCUSSION

Findings Regarding Self-Esteem Change

This study adds to the mixed and methodologically limited research on the effects of

weight management programs on pediatric self-esteem and mechanisms of change responsible

for self-esteem change. Improvements in self-esteem over time were observed for several

domains of self-esteem. However, behavioral intervention did not lead to significantly greater

improvements in self-esteem relative to children in the no-treatment control group. These

findings are similar to findings from three other studies that have found no change in self-esteem

due to treatment for pediatric participants in a weight management program (Rohrbacher, 1973;

Thomas-Dobersen et al., 1993; Huang, Norman, Zabinski, Calfas, & Patrick, 2007). However, a

number of other studies have reported positive improvements in self-esteem for participants in

pediatric weight management programs (Stoner & Fiorillo, 1976; Foster et al., 1985; Mellin et

al., 1987; Wadden et al., 1990; Sherman et al., 1992; Sahota et al., 2001; Jelalian & Mehlenbeck,

2002; Braet et al., 2003; Brehm et al., 2003; Walker et al., 2003; Barton et al., 2004; Braet et al.,

2004 [2-year follow-up: Braet, 2006]; Edwards et al., 2005; Gately et al., 2005; Sacher et al.,

2005; Savoye et al., 2005; Jelalian et al., 2006). There are a number of methodological and

sample considerations that may account for the difference between these studies and the current

study.

A major difference between this study and much of the previous research in this area is the

use of a control group. Of the studies that reported no change in self-esteem due to treatment,

Thomas-Dobersen and colleagues' (1993) and Huang and colleagues' (2007) studies included

control groups and were able to determine that self-esteem did not change due to treatment,

despite changes in self-esteem that occurred over time. However, many of the studies that have









reported positive improvement in self-esteem over time did not utilize a control group for

comparison (Wadden et al., 1990; Sherman et al., 1992; Sahota et al., 2001; Jelalian &

Mehlenbeck, 2002; Brehm et al., 2003; Braet et al., 2004; Edwards et al., 2005; Sacher et al.,

2005; Savoye et al., 2005; Jelalian et al., 2006). This makes it difficult to determine if the

positive improvements seen in those studies were due to an effect of time or the intervention,

particularly since we found change in self-esteem over time in 3 of the 4 domains of self-esteem

examined. Other studies have utilized a control group, and have reported positive improvements

in self-esteem, including social, physical, athletic, and/or global domains of self-esteem, from

pre- to post-treatment with higher improvements in the treatment group relative to the control

group (Stoner & Fiorillo, 1976; Foster et al., 1985; Mellin et al, 1987; Braet et al., 2003; Walker

et al., 2003; Gately et al., 2005). However, the type of control groups utilized in these studies

included both overweight and/or non-overweight children, who may not have been actively

seeking treatment at the time.

In contrast, our control group was a group of treatment-seeking overweight children asked

to delay treatment for several months, instead of a control group of individuals selected from a

sample of convenience in the community who were not seeking treatment (Foster et al., 1985;

Gately et al., 2005). Furthermore, all families in this program self-initiated contact with the study

investigators to increase healthy lifestyle behaviors, and were not a sample of individuals

referred for treatment by a healthcare provider that may have never directly indicated a desire for

treatment (Cameron, 1999). Even though parents were likely largely responsible for initiating

contact and participation in the study, all participating family members took part in screenings,

assessments, and consented in person to the program. General treatment literature has indicated

that the largest gains in treatment tend to occur early in treatment, and it is possible that the mere









act of initiating participation in treatment may have resulted in behavioral or emotional changes

in participants and their families in all conditions. Indeed, application of the Transtheoretical

Model (Prochaska & DiClemente, 1983; Prochaska, DiClemente, & Norcross, 1992; Prochaska

& Velicer, 1997) with our study would indicate that all participants, even individuals in the

control group, were in the 'Action' stage. According to the model, the Action stage is where

change occurs and perhaps even the participants in our control group were ready, or possibly had

already started, to make changes in their lifestyle habits. The fact that all participating family

members (including participants in the control group) had contact with the investigators and

agreed to the extensive terms of participation to be included in this intervention is evidence of

some level of readiness for change. Therefore, the use of a treatment-seeking control group in

this study had significant implications in the way in which we interpreted our data and makes

this study distinctly different than other weight management programs that have examined

pediatric self-esteem. However, it is only one of a number of factors to consider when

interpreting our results.

Another factor that may have impacted our ability to detect more significant changes over

time was that in this study, participants' baseline self-esteem scores were similar to the published

normative data (Harter, 1985). The average norms for social, athletic, physical, and global self-

esteem for girls and boys based on the Harter manual (1985) is presented in Table 4-1. Although

we might have expected the self-esteem of the overweight children in this study to be lower than

that of published norms, this was not the case. Furthermore, baseline self-esteem scores for our

participants were closer to the post-treatment scores (rather than pre-treatment) for other weight

management programs that have utilized the same self-esteem measure and published raw self-









esteem data (Brehm et al., 2003; Braet et al., 2004). Thus, it is possible that overweight children

in this study had less room for improvement in self-esteem.

Given that many of the participants presented with relatively high or normative levels of

self-esteem at baseline, follow-up analyses were utilized to examine the effects of the

intervention on only participants who exhibited self-esteem ratings below the mean gender-

specific normative level presented by Harter (1985). These analyses were conducted against our

sample separately for girls and boys, due to the gender-specific nature of the normative data. The

number of girls that presented with self-esteem below normative values and the number of girls

that experienced improvements, no change, and decreases in self-esteem across time are

presented in Table 4-2. Findings from analyses examining only girls that presented with lower

than normative self-esteem at baseline paralleled the findings from the larger sample of girls in

the study. Girls in this subsample experienced significant improvements in physical and global

self-esteem over time, but again; the change was not due to the intervention as girls in all

conditions experienced the improvements.

The number of boys that presented with self-esteem below normative values and the

number of boys that experienced improvements, no change, and decreases in self-esteem across

time are presented in Table 4-3. Findings were similar to the larger study such that boys that

presented with lower than normative baseline self-esteem scores in this sample experienced a

significant increase in social self-esteem over time (F [1, 12] = 11.176, p = 0.006), but

improvements were not due to the intervention.

Another reason for the lack of significant intervention effects on domains of self-esteem

(social, athletic, physical, global) may be the brief period of assessment. It is possible that

changes in self-esteem for the intervention participants compared to the control group may not









become apparent until after more extensive opportunities for extended use and benefit from the

self-esteem enhancing techniques taught in intervention. Furthermore, the intervention period

may not have provided sufficient time for the effect of weight status or behavioral change to

impact self-esteem. This would be consistent with a previous study which indicated that children

in the intervention continued to experience gains in self-esteem during the follow-up period after

the end of the active intervention compared to the control group (Mellin et al., 1987). However,

another study reported improvements in the control group as well (Foster, Wadden, & Brownell,

1985). Follow-up data are not available at the time of this study, but examination of the follow-

up data on self-esteem for the participants in this study will be critical to evaluate changes in

self-esteem, or if self-esteem remains largely preserved at current rates.

Finally, examination of normative developmental changes in self-esteem are worthy of

consideration. Indeed, results indicated that the behavioral interventions did not lead to greater

changes in self-esteem than the control group, but a change across time was seen in global,

social, and athletic self-esteem. This finding would seem to be contradictory to research

indicating that normative self-esteem development includes a drop in self-esteem around

adolescence, or more specifically around the onset of puberty (Harter, 1999; Strauss, 2000). This

finding is also contradictory to the concerns of some researchers that weight management

programs may have adverse psychosocial effects for pediatric participants (O'Dea, 2005).

However, it is also possible that social desirability effects were present, due to the self-report

nature of self-esteem assessment. Thus, improvements in self-esteem could be inflated across

conditions due to reporting bias.









Self-Esteem in the Rural Population

Most of the previous research with rural populations suggests that rural children have

lower self-esteem than their metropolitan peers (Roscigno & Crowley, 2001). However, our

study found that self-esteem ratings for the participants were largely equivalent to normative

means for self-esteem. Our data also are consistent with a recently published study of rural

children who presented with self-esteem rates similar to normative means in the general

population (Yang & Fetsch, 2007).

One reason that the participants' self-esteem ratings in this study were similar to normative

levels may be that previous research has primarily focused on individuals in these communities

who are "at-risk" due to factors such as limited financial resources, minority ethnicity status, or a

lower educational attainment. However, our study (and Yang and Fetsch's study [2007]) was not

comprised primarily of an economically, ethnically, or educationally "at-risk" sample. The

similarity of our sample to national and statewide norms based on the 2000 U.S. Census Data

(U.S. Census Bureau, 2007) supports that our sample is not "at-risk" because national means are

higher than those of economically, ethnically, and educationally "at-risk" samples. For ethnicity,

the U.S. sample was 80% Caucasian, while our final dataset consisted of 79% Caucasian

children. The U.S. median household income in 2004 was estimated at $44,334, and the median

income range for participants in this study was $40,000 $59,999. However, it should be noted

that the modal income range for participants in this study was the $20,000 $39,999 range.

National estimates of persons over the age of 25 years with a bachelor's degree or higher was

24.4%, and the frequency of parents with a bachelor's degree or higher in our sample was 21%.

Estimates for the state of Florida were also similar to that of our sample and the national

averages.









These findings have significant implications given that overweight individuals in rural

communities are at increased risk for overweight status, and may be susceptible to greater

medical complications of overweight due to limited healthcare resources. Therefore, it is

important to establish whether or not they are also at risk for greater psychosocial complications,

such as poorer self-esteem compared to non-overweight children. However, given the self-

selection method of participation in our study, it should be noted that the families who

participated in our program may have had more resources to devote the necessary time and effort

to participate, and therefore may not be fully representative of the rural communities in which

they live. These findings suggest that it may be important to consider demographic

characteristics rather than viewing all children and families from rural areas as homogeneous.

Mechanisms of Self-Esteem Change

Impact of Weight Status Change

Although we expected to see significant associations between weight status change and

self-esteem change, this was not the case. Perhaps the degree of weight change in our

participants (Mean z-score change = 0.0417, SD = 0.11), was not large enough during the short

time frame of assessment to be meaningful to the pediatric participants' self-esteem. Other

programs have reported significant associations between weight status change and change in

self-esteem (Cameron, 1999; Walker et al., 2003; Jelalian et al., 2006). Alternatively, three

studies found no statistically significant relationship between self-esteem change and weight

status change (Rohrbacher, 1973; Stoner & Fiorillio, 1976; Wadden et al., 1990). Moreover,

three additional studies reported significant improvements in self-esteem, despite lack of

significant weight loss, although the relationship was not examined statistically (Sherman,

Alexander, Gomez, Kim, & Marole, 1992; Sahota et al., 2001; Brehm, Rourke, Cassell, &

Sethurman, 2003). A common theme among the programs that did not find significant









association between weight status change and self-esteem and our program was that self-esteem

was targeted directly during the intervention in each of these studies. Perhaps targeting self-

esteem directly in the context of these programs reduces the impact of weight change on self-

esteem. It will be interesting to examine the impact of weight status change on self-esteem

change at 6-month follow-up in order to determine if the impact is significant, particularly if

larger improvements in weight status are experienced by the participants.

Impact of Goal Attainment and Self-Efficacy for Healthy Lifestyle Behaviors

The lack of significant associations between goal attainment and self-esteem are especially

noteworthy as the program attempted to de-emphasize the importance of weight and increase the

emphasis on behavior, behavioral goals, and confidence in achieving these goals. Many other

programs have also attempted to de-emphasize weight status change, and focus on behaviors as

well, but this is the first study to examine the effects of behavioral goal attainment and self-

efficacy for healthy behaviors on pediatric self-esteem. However, despite the program emphasis

on behavior, attainment of goals and self-efficacy were not associated with self-esteem. It is

possible that the positive reinforcement for children in the BPI condition was not enough to lead

to self-esteem change, given that these children did not participate in the group directly and have

interaction with the group leaders. It should be noted that the method of assessing goal

attainment and the self-efficacy questionnaire used in this study were created specifically for this

study, and therefore the reliability and validity of these measures are unknown. Clearly more

research is needed to examine what factors are meaningful to children who participate in these

programs and impact self-esteem.









Impact of Weight-Specific Locus of Control

Research in adult and pediatric samples would have supported associations between

weight-specific locus of control and self-esteem change, given that previous research has

reported such associations, particularly in the adult literature. Furthermore, adult literature has

also indicated that internal locus of control may be associated with more positive psychosocial

outcomes, such as more adaptive coping (Hilton, 1989). It is noteworthy that our findings seem

to contrast with those of Cameron (1999), who had suggested that self-esteem deficits could

occur because of increased internalization of locus of control due to weight management

program participation. Our participants not only did not experience statistically significant

changes in locus of control, but changes were not associated with self-esteem changes in boys or

girls. However, it should be noted that the WLOC measure in this study had poor internal

consistency, and thus findings regarding weight-specific locus of control with this population

should be interpreted with caution. Finally, the locus of control measure utilized was created

specifically for this study, and thus has not been validated previously; therefore the reliability

and validity of the data obtained from this measure is unknown.

Impact of Peer Victimization

Peer victimization ratings at baseline and final assessment in this study were associated

with poorer self-esteem scores for the entire sample. These findings are consistent with past

research that has repeatedly indicated that higher levels of peer victimization are associated with

poorer self-esteem in overweight youth (Young-Hyman et al., 2003; Hayden-Wade et al., 2005;

Sweeting, Wright, & Minnis, 2005; Stern et al., 2006; Thompson et al., 2007). These findings

further highlight the potentially deleterious impact that negative peer interactions can have on

psychosocial functioning and self-esteem.









In this study, no significant change in peer victimization over time or due to the treatment

was observed. This was not surprising, given that the treatment did not aim to change peer

victimization experiences that occurred outside of the group setting. Our findings in this area

also may have been hampered by measurement emphasis on peer victimization and not social

support. Although the program did aim to enhance participants' ability to cope with these

experiences, the measure used in this study did not capture changes in coping with peer

victimization or changes in positive peer interactions or support, both of which have been

associated with self-esteem in overweight children (Strauss & Pollack, 2003; Dishman et al., 2006).

Furthermore, social support in rural youth typically has included extended family and

community members, although other research has indicated that these support systems have

changed in recent years (MacTavish & Salamon, 2003). Therefore, social support could have

been an especially significant influence on self-esteem in our participants, but unfortunately, it

was not assessed.

However, for participants who did experience reductions in peer victimization ratings,

these reductions were associated with improvements in social self-esteem and physical self-

esteem. This is not surprising as this teasing from peers would affect a child's perception of

worth in social interactions, and thus impact social self-esteem. Furthermore, previous research

has indicated that overweight children experience teasing that is more focused on appearance

than other characteristics (Hayden-Wade et al., 2005; Thompson et al., 2007). Rationale for why

these children felt that they were experiencing less peer victimization would have been an

interesting concept to explore, but unfortunately was not assessed in this study. These findings

support the need for continued assessment of peer interactions and the emotional consequences

of negative interactions on child self-esteem, particularly for overweight children.









Impact of Body Dissatisfaction

Moderator analyses were conducted in this study to assess for gender differences based on

past research that has demonstrated differences in boys' and girls' self-esteem (Harter, 1985).

However, the only gender difference found in this study was the impact of reductions in body

dissatisfaction on improvement in physical self-esteem for girls. Follow-up analysis indicated

that this variable accounted for 13% of the variance in girls' physical self-esteem change. There

was no significant association for boys. We also found that participants in the BFI and BPI

conditions experienced significant reductions in body dissatisfaction ratings over time, but were

not significantly different that the WLC condition. One possibility for this finding may be similar

to the reasons hypothesized for changes in participants' self-esteem regarding readiness for

change.

Findings regarding the association of body satisfaction to self-esteem change are supported

by previous studies. Past research has demonstrated that girls' self esteem is more affected by

overweight status and thus girls may experience more change in self-esteem when body

satisfaction is improved compared to boys (Mendelson & White, 1985; Pesa et al., 2000; Israel &

Ivanova, 2002). Girls may be more vulnerable to the effects of body dissatisfaction due to larger

societal and media messages that emphasize appearance as a significant contributor to female

perceptions of self-worth. Research has supported that girls of increasingly younger ages are

influenced by these messages, also known as the "thin ideal" (Tiggemann, 2001; Sands &

Wardle, 2003). Although this study did not examine the influence of the media or cultural

stereotypes on our population, the fact that only girls' physical and global self-esteem were

below normative data may serve to support that overweight status was negatively influential on

these domains of girls' self-esteem, perhaps due to cultural and media stereotypes. Furthermore,

other researchers have suggested that girls in rural communities also experience lower rates of









physical self-esteem and that these lower rates may be reflective of the media's emphasis on

sexualization and appearance of girls and women (Yang & Fetsch, 2007).

Previous research has suggested that the impact of weight status change on self-esteem

may be accounted for by changes in body dissatisfaction (Lowry et al., 2007). However,

examination of the mediating effects of body dissatisfaction change on the association between

weight status change and physical self-esteem improvement in this sample did not support body

dissatisfaction as a mediator. Furthermore, weight status and body dissatisfaction were not

significantly associated with each other at any assessment point, and interestingly, weight status

at baseline was not predictive of body dissatisfaction for the girls in the sample (R2 = 0.06, F [1,

49] = 3.096,p = 0.085).

Although it may be natural to assume that weight status would be related to body

dissatisfaction, current research indicates that girls' levels of body dissatisfaction may be

independent of weight status (Davison & Birch, 2001). In other words, girls' perceptions of their

bodies may not be based solely on the size of their bodies, but also may be due to their

perception of their body size in comparison to 'role models' in the larger society, who have

become increasingly thinner and less representative of the general population. Research supports

this assertion such that girls who demonstrate body dissatisfaction rates that are not associated

with their weight status tend to be more influenced by the media, societal pressure for thinness,

and cultural stereotypes regarding the importance of body size on global self-worth. Although we

did not assess the impact of the media on our sample, it is possible that these associations would

apply to our female participants given the similarity in our findings regarding body

dissatisfaction, self-esteem, and weight status. However, all participants in this study were

overweight, which makes it more difficult to find significant associations with limited weight









status variability. Perhaps it was overweight status and not degree of overweight that was most

influential on self-esteem.

Although body dissatisfaction change was associated with physical self-esteem change in

girls, it only comprised a small portion of the total variance for change. Furthermore, other

impact variables examined in this study (weight status change, goal attainment, self-efficacy, or

locus of control) were not significantly associated with girls' physical self-esteem change. It is

possible that self-esteem change was also impacted by changes in social support or changes in

the home environment such as more supportive parenting techniques or more attentive parenting

resulting from parents who initiated participation in a weight management program, even if they

were not currently attending the program at that time (which may have been the case for the

WLC condition). However, these variables were not assessed by this study and their impact on

self-esteem is purely theoretical.

Strengths of this Study

This study includes several unique components that address limitations in the literature

examining the effects of weight management programs on pediatric self-esteem. First, to our

knowledge, this is the only study to statistically examine the impact of variables on self-esteem

change that have previously only been speculated to impact self-esteem in overweight children

(including goal attainment, self-efficacy, and locus of control). Second, we believe this is the

only research to examine the moderating impact of gender on self-esteem change in children

participating in a family-based weight management program. Third, another major strength is

that this study compared intervention changes to a waitlist control group comprised of

overweight children. Without this control group, it is possible that we could have reached a

different conclusion as to the impact of the intervention on self-esteem change. Fourth, we used

statistical techniques to appropriately assess for intervention differences by treatment condition









and gender, and did not merely conduct analyses on the active treatment conditions or boys and

girls separately. These analyses allowed us to use statistical analyses to assess for the interaction

of variables of interest and determine if those differences were significant and meaningful,

instead of only noting that they were different, as has been presented in other studies with similar

findings (Huang et al., 2007). Fifth, a unique aspect of this study is that it was conducted

exclusively with children from rural settings. Historically, there has been limited research

examining psychosocial functioning of children in rural settings. Children living in rural

communities are at increased risk for overweight in childhood and obesity in adulthood

(McMurray et al., 1999) yet may have fewer healthcare resources available to them to address

the complications associated with overweight. Research examining the psychosocial effects of

health promotion programs in these communities fills an important need in the current treatment

outcome literature.

Considerations and Limitations

Standard significance test values (p < 0.05) were used to assess for significance for the

primary aims of this study (self esteem change due to treatment and the impact of weight status

change on self-esteem change). However, a conservative p value (p < .01) was adopted for the

secondary aims of this study. Although we feel that this more conservative approach was

necessary, in order to find a balance between prevention of Type I and Type II errors, it

nonetheless affected our interpretation of the data.

Several limitations may impact the interpretation of the current findings. First, the

participants in this study largely did not experience change in self-esteem which limited the

variance in self-esteem and thus made it more difficult to find an association between predictor

variables and self-esteem change. Second, several components of the study limited the

generalizability of our findings including a) that our sample consisted primarily of Caucasian









participants and b) that we utilized a specific treatment seeking population and rural setting.

Third, this study included a limited time frame of assessment with lack of follow-up data. Fourth,

measurement issues also may have impacted our findings. Several of the questionnaires were

created specifically for this study and had not been previously examined to determine and ensure

that they had adequate psychometric properties and would therefore be valid measurements of

the intended constructs in this study. In fact, the WLOC had poor internal consistency.

Furthermore, the peer victimization scale did not measure social support and therefore neglected

to assess the potential buffering impact of positive social support or increases in social support

that may have occurred due to participation in a program of similar peers. Moreover, although

the Harter SPPC has been validated for children as young as eight years of age, some participants

had difficulty understanding some of the concepts and how to complete the measure, even with

assistance from an examiner.

Implications for Clinical Intervention and Research

Researchers have cautioned interventionists to be mindful when conducting this weight

management program for children to ensure that they "do no harm" (O'Dea, 2005). There also

has been debate at to whether pediatric weight management interventions may negatively impact

self-esteem (Golan et al., 1998). Although this study indicates that self-esteem was not improved

as a result of the treatment, it also indicates that participant self-esteem was not adversely

affected. The importance of these findings are further amplified as our participants presented

with self-esteem rates similar to normative, non-overweight samples, unlike the findings of other

studies that have reported self-esteem rates for overweight children that are lower than their non-

overweight peers. If lower self-esteem is more common for overweight children, then we might

have expected to see a 'regression to the mean.' Instead, the children in our study were able to

preserve their self-esteem. These findings do not remove the need for clinicians to be sensitive









when conducting this type of research, but they do suggest that carefully designed programs that

are sensitive to self-esteem and body image, and respectful of participants do not result in

adverse psychosocial effects for participants. We recommend that future interventionists

continue to be mindful of these potential effects and to assess for positive, negative, and lack of

changes in participants' psychosocial functioning during treatment.

This study specifically targeted self-esteem during the intervention. Although we cannot

assess the impact that this component of the treatment may have provided to preserving our

population's relatively high baseline self-esteem scores (i.e., we did not have a comparison

intervention that did not target self-esteem), other research has suggested that targeting self-

esteem and the use of a group format during the intervention is associated with more positive

self-esteem outcomes (Lowry et al., 2007), and previous studies that found no association

between weight status change and self-esteem change reported targeting self-esteem in the

context of this group format during the intervention (Rohrbacher, 1973; Sherman et al., 1992;

Jelalian et al., 2006). Participation in a group intervention of similar peers may provide an

opportunity for social bonding, perceived support, group activities, and group problem solving.

Perhaps the key to de-emphasizing the importance of weight status is not emphasizing behavioral

goals, but rather promoting positive peer contact and support and providing positive self-esteem

building exercises. Therefore, we recommend that future interventions address self-esteem

directly and promote positive peer interactions during the intervention. Certainly further research

on how to best address self-esteem change is needed. Given the associations found in this study

between peer victimization and body satisfaction and self-esteem, we also recommend that

clinicians provide children and families with coping skills to help them manage negative

emotions or negative messages from their environment with non-food related techniques.









A number of implications for future research are suggested by these results. Additional

research with rural populations will be necessary to better understand psychosocial

complications for overweight status in this population, and the effects of weight management

programs on psychosocial functioning. Given the importance of self-esteem on child functioning

and possible long term effects of child self-esteem (Harter, 1999), we recommend that future

research programs continue to examine self-esteem change and the variables that may lead to

change in the context of weight management programs, particularly the impact of peer

interactions and positive social support. Although this study found limited gender differences in

self-esteem, future research should continue to examine self-esteem by gender given the strong

gender differences in self-esteem found in other studies (Harter, 1985). Finally, future studies

should include a no-treatment and/or waitlist control group of overweight and non-overweight

youth for comparison so as to better understand normative changes in self-esteem.

Summary

In summary, we found that the intervention did not impact any domain of self-esteem,

although a significant improvement in self-esteem across time was observed for social, athletic,

and global self-esteem. Potential explanations for the results include the presence of a control

group to assess for time effects and relatively high baseline ratings of self-esteem in our

participants. Gender differences were observed in self-esteem changes such that change in girls'

physical self-esteem was predicted by improvements in body satisfaction. Reduction in peer

victimization was associated with improvements in social and physical self-esteem. Weight

status change, goal attainment, self-efficacy for healthy lifestyle behaviors, and locus of control

did not appear to be associated with self-esteem in this study, although measurement limitations

may have complicated these findings. These findings are significant as this study indicates that

participation in a weight management program does not adversely affect pediatric self-esteem.









Table 4-1. Harter normative mean scores and current study baseline mean scores for self-esteem by gender.
Social Athletic Physical Global
Harter norms
Girls 2.87 2.61 2.68 2.98
Boys 2.94 3.08 2.97 3.07
Current study
Girls 2.87 2.43 1.98 2.77
Boys 2.69 2.70 2.52 2.95
Note. Mean scores are averaged from mean scores provided by grade in the manual for the SPPC (Harter, 1985).

Table 4-2. Frequency of girls (total N = 50) with self-esteem ratings below normative values and the number of girls that experienced
improvements, no change, and decreases in self-esteem across time.
Social* Athletic Physical Global
Baseline value below 25 22 40 27
normative mean
S Improvement 17 14 27 19
No change 2 6 6 4
Decrease 6 2 7 4
Note. Pre-treatment social self-esteem total N = 49 because score could not be calculated for one participant due to missing data.

Table 4-3. Frequency of boys (total N = 31) with self-esteem ratings below normative values and the number of boys that experienced
improvements, no change, and decreases in self-esteem across time.
Social Athletic Physical Global
Baseline value below 15 21 22 19
normative mean
Improvement 11 14 12 12
No change 3 4 2 3
Decrease 1 3 8 4









APPENDIX A
DEMOGRAPHIC QUESTIONNAIRE

Information about your Family


Child's Name:

Child's gender (please circle): Boy

Child's race (please circle)

Caucasian African American
Other


/ Girl


Hispanic


Asian Bi-racial


Child's age: Child's Date of Birth: / / Child's grade in school:

Your Name:

Your Gender (please circle): Male / Female

Your race (please circle):

Caucasian African American Hispanic Asian Bi-racial
Other

You are the child's (please check one):
Mother Father
Step-Mother Step-Father
Grandparent Other Legal Guardian

Your (parent/guardian's) age:

Please indicate your current marital status (please check one):
Married Single

Including yourself, how many adults live in your home:

Including your child, how many children live in your home:

What is the highest level (grade) of school you completed?
Middle school Some college
Some high school Graduated college
Graduated high school Post-Graduate school









What is your current occupation?


Estimated Family Income per Year (please check one).
Below $9,999 $40,000 $59,999
$10,000 $19,999 $60,000 $79,000
$20,000 $39,999 Over $80,000









APPENDIX B
MODIFIED WEIGHT LOCUS OF CONTROL

Instructions: We want to learn more about how you feel about changing when
you eat and drink. Read each sentence carefully. Place a check
below 1 of the 4 boxes on the right side of the page that shows how
true each state is for you.
Really Sort of Sort of Really
Not True Not True True for True for
for Me for Me Me Me



1. Whether I gain or lose weight is up to me.


2. Being the right weight is mostly due to good
luck.


3. No matter what I try to do to lose weight, it
doesn't change anything.


4. If I eat right and get enough exercise, I can
control my weight.










APPENDIX C
DAILY HABIT LOG


Food or Drink


Amount R-Y-G
Calories


SSBreakfast Total:

Morning Snacks






Snlack Tolal:
Lincl















Lunch Total:
.Aferniooni Snacks


Time


Breiakrast


I I I I













Snack Total:
Time Food or Drink Amount R-Y-G
Calories

Dinner


Dinner Total:
Evening Snacks


Snack Total:


Daily Total Red Foods

Daily Total Calories

Daily Total of Fruits & Vegetables

Total Daily Steps

OTHER "OFF-FEET" ACTIVITIES
Activity How Many Minutes








Bicycling
Swimming
Skate boarding or Roller Blading
Other:
Other:
TOTAL DAILY MINUTES









APPENDIX D
GROUP LEADER CHECK IN SHEET















Participan
t Session Food Intake Info Steps TV
# # # # Wee
Days Past Days New Avg Past Days New Past Days New Base Past kly New
Com Wks Met Wks Met Total Wks Total
plete Base Avg Red Red Red Red F&V F&V F&V Base Wks Avg Met Step Hrs. TV Hrs. TV
Food Step Step
Week Att Logs Cal Cal Goal Goal Goal s Goal Goal Goal s Goal s Goal Goal TV Goal TV Goal

Week #1
01/09/07

Week #2
01/16/07

Week #3
01/23/07

Week #4
01/30/07

Week #5
02/06/07

Week #6
02/13/07

Week #7
02/20/07

Week #8
02/27/07

Week #9
03/06/07

Week #10
03/13/07

Week #11
03/20/07

Week #12
03/27/07

Notes









APPENDIX E
SELF-EFFICACY QUESTIONNAIRE

Instructions: We want to learn more about how you feel about changing when
you eat and drink. Read each sentence carefully. Place a check
below 1 of the 4 boxes on the right side of the page that shows how
true each state is for you.


Really Sort of Sort of Really
Not True Not True True for True for
for Me for Me Me Me



1. I feel confident that I can eat healthy foods
more often.


2. I feel confident that I can eat more fruits and
vegetables more often.


3. I feel confident in that I can change habits to
eat fewer junk foods.


4. I feel confident that I can my habits to be
more physically active. This means
running, playing outside, or just getting up
and moving around more often.









APPENDIX F
SCHWARTZ PEER VICTIMIZATION SCALE


For each question, please circle the best answer.


1. How often do other kids tease or make fun of you?
A. Never

B. Sometimes
C. Often
D. Almost every day


2. How often do other kids bully or pick on you?
A. Never
B. Sometimes
C. Often

D. Almost every day


3. How often do other kids hit or push you?
A. Never
B. Sometimes

C. Often
D. Almost every day


4. How often do other kids gossip or say mean things about you?
A. Never
B. Sometimes
C. Often
D. Almost every day











5. How often do other kids hurt your feelings by excluding you?

A. Never
B. Sometimes

C. Often
D. Almost every day









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BIOGRAPHICAL SKETCH

A native of West Virginia, I received my Bachelor of Arts in Psychology from West

Virginia University, summa cum laude in 2002. I received my master of science degree in

clinical psychology from the University of Florida in Gainesville, FL in 2004. I completed my

pre-doctoral internship at Children's Memorial Hospital in Chicago, IL in 2007.





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1 MECHANISMS OF SELF-ESTEEM CH ANGE IN OVERWEIGHT CHILDREN PARTICIPATING IN A FAMILY-BAS ED WEIGHT MANAGEMENT PROGRAM By KELLY WALKER A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2007

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2 2007 Kelly Walker

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3 To my father and mother, Arnold and Cheryl Wa lker; and my husband Paul for all their support through the years.

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4 ACKNOWLEDGMENTS I would like to thank my chair, David M. Janicke, Ph.D., for all of his support and supervision. His mentorship has been extremely valu able to me and I am greatly appreciative of the time that he has devoted. I would also like to acknowledge the other members of my committee, Michael Perri, Ph.D., Brenda Wiens, Ph.D., and Linda Bobroff, Ph.D., RD, LD/N, for their assistance and feedback in preparing this dissertation. The larger study from which this dissertation data collected was supported by a grant from the National Institute for Diabetes and Di gestive and Kidney Diseases R34 DK071555-01. Additional supplemental funding fo r the preliminary pilot work for this study was supplied by the Institute for Child and Adolescent Research a nd Evaluation at the University of Florida. Finally, I am deeply grateful to all of my family and friend s who have supported me in my pursuit of higher education throughout the years. It has been a pl easure to have them join me along this journey.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........8 LIST OF FIGURES................................................................................................................ .........9 ABSTRACT....................................................................................................................... ............10 CHAPTER 1 INTRODUCTION..................................................................................................................12 Medical Complications.......................................................................................................... .13 Psychosocial Complications...................................................................................................14 A Brief Overview of Self-Esteem...........................................................................................14 Self Esteem in Overweight Children......................................................................................15 Childhood Overweight and Wei ght Management Programs..................................................17 Pediatric Weight Management Programs and Self-Esteem....................................................20 Factors That May Impact Self-Esteem During Weight Management Programs....................21 Impact of Changes in Weight Status...............................................................................22 Impact of Behavioral Goal Achievement........................................................................23 Impact of Self-Efficacy for Healthy Lifestyle Behaviors................................................24 Impact of Locus of Control.............................................................................................25 Impact of Peer Victimization...........................................................................................26 Impact of Body Satisfaction............................................................................................27 Summary........................................................................................................................ .........28 Current Aims and Hypotheses................................................................................................29 Primary Aims...................................................................................................................29 Aim 1: To examine the impact of th e intervention groups on self-esteem..............29 Aim 2: To determine the impact of weight status change on self-esteem................29 Secondary Aims...............................................................................................................29 Aim 3: To examine the impact of beha vioral goal attainment on self-esteem.........29 Aim 4: To determine the impact of se lf-efficacy on weight status and selfesteem...................................................................................................................29 Aim 5: To determine the impact of a nd association between weight-specific locus of control, weight status, a nd self-esteem in overweight children..............30 Aim 6: To examine the impact of peer victimization on self-esteem......................30 Aim 7: To examine the impact of body satisfaction on self-esteem........................31 2 METHODS........................................................................................................................ .....32 Participants................................................................................................................... ..........32 Inclusion Criteria.............................................................................................................33 Exclusion Criteria............................................................................................................34

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6 Procedure...................................................................................................................... ..........34 Location of Intervention..................................................................................................34 Recruitment.................................................................................................................... .35 Initial In-Person Screening..............................................................................................35 Schedule for Assessment.................................................................................................36 Interventionists............................................................................................................... .37 Basic Intervention Program.............................................................................................37 Behavioral-Family Intervention (BFI) Group.................................................................39 Behavioral-Parent Intervention (BPI) Group..................................................................39 Wait-List Control (WLC) Group.....................................................................................40 Measures....................................................................................................................... ..........40 Criterion Measure............................................................................................................40 Harter self-perception profile for children...............................................................40 Predictor Measures..........................................................................................................41 Demographic questionnaire......................................................................................41 Body height and weight............................................................................................41 Daily habit log..........................................................................................................41 Group leader check in sheet.....................................................................................42 Self-efficacy questionnaire for heal thy lifestyle behavior choices..........................42 Modified weight locu s of control scale....................................................................43 Schwartz peer victimization scale............................................................................44 Childrens body image scale....................................................................................44 3 RESULTS........................................................................................................................ .......49 Analyses and Statistical Significance.....................................................................................49 Primary Aims................................................................................................................... .......50 Aim 1: To Examine the Impact of the Intervention Groups on Self-Esteem..................50 Aim 2: To Determine the Impact of We ight Status Change on Self-Esteem..................53 Secondary Aims................................................................................................................. .....54 Aim 3: To Examine the Impact of Behavioral Goal Attainment on Self-Esteem...........54 Aim 4: To Determine the Impact of Se lf-Efficacy on Weight Status and SelfEsteem......................................................................................................................... .56 Aim 5: To Determine the Impact of a nd Association Between Weight-Specific Locus of Control, Weight Status, and Self-Esteem in Overweight Children..............60 Aim 6: To Examine the Impact of Peer Victimization on Self-Esteem..........................63 Aim 7: To Examine the Impact of Body Image on Self-Esteem.....................................68 4 DISCUSSION..................................................................................................................... ....80 Findings Regarding Self-Esteem Change...............................................................................80 Self-Esteem in the Rural Population.......................................................................................85 Mechanisms of Self-Esteem Change......................................................................................86 Impact of Weight Status Change.....................................................................................86 Impact of Weight-Specific Locus of Control..................................................................88 Impact of Peer Victimization...........................................................................................88 Impact of Body Dissatisfaction.......................................................................................90

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7 Strengths of this Study........................................................................................................ ....92 Considerations and Limitations..............................................................................................93 Implications for Clinical Intervention and Research..............................................................94 Summary........................................................................................................................ .........96 APPENDIX A DEMOGRAPHIC QUESTIONNAIRE..................................................................................98 B MODIFIED WEIGHT LOCUS OF CONTROL..................................................................100 C DAILY HABIT LOG...........................................................................................................101 D GROUP LEADER CHECK IN SHEET...............................................................................104 E SELF EFFICACY QUESTIONNAIRE...............................................................................106 F SCHWARTZ PEER VICTIMIZATION SCALE................................................................107 LIST OF REFERENCES.............................................................................................................109 BIOGRAPHICAL SKETCH.......................................................................................................120

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8 LIST OF TABLES Table page 2.1. Mean baseline characteristics of particip ants who completed pr e-treatment and posttreatment a ssessment..........................................................................................................47 2.2. Frequency (and percentage) of participan ts who completed pretreatment and posttreatment a ssessment..........................................................................................................48 3-1. Mean scores (standard deviations) of SPPC scores for children who completed pretreatment and post-treatment assessment...........................................................................77 3-2. Mean scores (and standard deviations) of impact variables for children who completed pre-treatment and post-treatment assessments...................................................................78 4-1. Harter normative mean scores and current study baseline mean scores for self-esteem by gender...................................................................................................................... ......97 4-2. Frequency of girls (total N = 50) with self-esteem ratings below normative values and the number of girls that experienced improve ments, no change, and decreases in selfesteem across time.............................................................................................................97 4-3. Frequency of boys (total N = 31) with se lf-esteem ratings below normative values and the number of boys that experienced impr ovements, no change, and decreases in self-esteem across time......................................................................................................97

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9 LIST OF FIGURES Figure page 2-1. Screening, assessment and interventi on participation in Project STORY..............................46 3-1. Global self-esteem cha nge by treatment condition.................................................................75 3-2. Social self-esteem change by treatment condition.................................................................75 3-3. Athletic self-esteem ch ange by treatment condition...............................................................76 3-4. Body dissatisfaction change by treatment condition..............................................................76

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10 Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy MECHANISMS OF SELF-ESTEEM CH ANGE IN OVERWEIGHT CHILDREN PARTICIPATING IN A FAMILY-BAS ED WEIGHT MANAGEMENT PROGRAM By Kelly Walker August 2007 Chair: David M. Janicke Major: Psychology Overweight in children and adolescents is a national epidemic with significant medical and psychosocial consequences. Weight mana gement programs are strongly recommended for children and adolescents to reduce complicat ions of overweight, but few programs have examined the effects of these programs on psychoso cial outcomes, particularly self-esteem. The aims of this study were to examine self-esteem and determine which factors impact self-esteem in the context of a weight management program. Data for this study was gathered as part of a larger study comparing the effects of a parent-on ly family-based pediatric weight management program, a parent-plus-child family-based pe diatric weight management program, and a wait list control group targeting rural ch ildren aged 8 -14 years of age. We found that the behavioral interventions, relative to control groups, did not impact self-esteem, although a significant improvement in global self-esteem across time wa s observed for social, at hletic, and global selfesteem. Gender differences were observed in self -esteem changes such th at change in girls physical self-esteem was predicted by improveme nts in body satisfaction. Reduction in peer victimization was associated w ith improvements in social an d physical self-esteem. Weight status change, goal attainment, se lf-efficacy for healthy lifestyle behaviors, and locus of control did not appear to be associated with self-esteem in this study, although measurement limitations

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11 may have complicated these fi ndings. Despite some researcher s concerns that weight management programs may have a negative impact on children and adolescents psychosocial functioning, these findings suggest that participation in a pediat ric weight management program does not adversely affect pediatric self-esteem.

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12 CHAPTER 1 INTRODUCTION Overweight in children and adolescents is a national epidemic. Recent estimates indicate that over 33% of children and a dolescents are either at-risk for overweight or overweight (Ogden et al., 2006). Although adult overweight and obesity are defined by body mass index (BMI) cutoffs, childhood obesity and overweight are defined according to a childs BMI percentile based on revised Centers of Disease Control and Prevention (CDC) growth charts. Specifically, children are classified as overw eight if their BMI is at or above the 95th percentile and considered at-risk for overweight if their BMI is between the 85th and 95th percentile for gender and age (U.S. Department of Health and Human Services, 2001). Obesity poses a particular concern in rura l areas. Research examining rates of adult obesity across levels of urbaniza tion finds obesity rates to be higher in rural areas (Patterson, Moore, Probst, & Shinogle, 2004). A comparison of childhood overweight rates in urban and rural areas by McMurray and co lleagues (1999) reports that child ren in rural areas have a 54.7% increased risk of overweight compared to urba n children. One reason for these differences may be that individuals from rural locations, particularly those in the southeastern United States, traditionally consume high fat and high calorie diets. Increased rates of sedentary behavior also reduce the potential for activity levels to offset increased caloric consumption (Pearson & Lewis, 1998). Rural obesity is further complicated becau se individuals living in rural areas may be medically underserved due to 1) limited health promotion programs, 2) higher rates of poverty (Economic Research Services, 1993), 3) higher pe rcentages of patients w ithout health insurance (Frenzen, 1993), and 4) lower numbers of hea lth care providers. Thus, research targeting overweight children in rural areas of the United Stat es is a significant priority and an objective of

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13 Healthy People 2010 (U.S. Department of Hea lth and Human Services, 2000) and the U.S. Surgeon General (U.S. Department of Health and Human Services, 2001). Medical Complications Children and adolescents who are overweight ar e at increased risk for significant medical complications including increased risk of endocri ne, pulmonary, orthopedic gastroenterological, and neurological concerns (American Academ y of Pediatrics, 2003; Deckelbaum & Williams, 2001). Sixty percent of overweight children have at least one risk factor for cardiovascular disease and 25% of overweight ch ildren have at least two ri sk factors including hypertension, hyperlipidemia, and hyperinsulinemia (Strauss 1999). Once considered adult-onset diabetes, type 2 diabetes is another significant medical complication for overweight children and adolescents (Goran, Ball, & Cruz, 2003) and acco unts for 8-45% of all new cases of diabetes (Dietz, 2004). The prevalence of me tabolic syndrome also increases with the severity of obesity. Metabolic syndrome is described as the link between insulin resistance and hypertension, dyslipidemia, type 2 diabetes, and other meta bolic abnormalities (Reaven, 1988) and cited by some medical professionals to be a precursor of diabetes (Dietz, 2004) Metabolic syndrome is also associated with an increased risk of cardi ovascular disease in adu lts. Rates of metabolic syndrome reach up to 50% in severely overweigh t children and increases in BMI have been associated with increased risk of metabolic s yndrome (Weiss et al., 2004 ). Child and adolescent overweight status is associated with more severe obesity in a dulthood and studies have suggested that up to 80% of overweight adolescents become obe se adults. This risk is especially prevalent for girls (Dietz, 2004). Additionally, societal co sts associated with child and adolescent overweight have tripled in the last 20 years a nd annual overweight-related hospital costs for 6-17 year olds reach up to $127 million per year (Goran et al., 2003).

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14 Psychosocial Complications Psychosocial complications for overwei ght children and youth include social stigmatization, peer victimization, depressi on, psychosocial maladjustment, and poorer body image compared to their non-overweight peers (Sjoberg, Nilsson, & Leppert, 2005; Zametkin, Zoon, Klein, & Munson, 2004; Zeller, Saelens, Roehrig, Kirk, & Daniels, 2004). The link between poor self-esteem and pedi atric overweight has received si gnificant attention. Broadly defined, self-esteem refers to the extent to which one values oneself as a person (Harter & Whitesell, 2003). Poor self-esteem is a notable complication of pediatric overweight because research links poorer self-esteem with negative consequences such as behavioral disorders, negative or depressed mood, and other emotiona l concerns (Harter, 1993). Conversely, higher self-esteem is associated with positive consequences (Shirk, Bu rwell, & Harter, 2003) and selfesteem improvements also are associated with improvements in other areas of functioning, such as a decrease in externalizing disorders (Haney & Durlak, 1998). Advers e effects of overweight on self-esteem in childhood and adolescence have potential long-term implications given that adolescent self-esteem may remain stable into adulthood (Harter & Whitesell, 2003). A Brief Overview of Self-Esteem A leading theory of self-esteem developmen t by Harter (1985) combines James theory (1892) that self-esteem is the ra tio of successes to aspirations a nd Cooleys theory (1902) that self-esteem is the product of self-comparison against others (the looking-glass model). However, Harter extends James theory by assert ing that the ratio of successes to aspirations contributes to self-esteem only if competence in that domain is important to the individual. Harter also theorizes that each individual has mu ltiple types of self-esteem for specific areas of functioning, such as academic comp etence, social competence, athl etic competence, and so forth. Global self-esteem, or overall self -worth, is not necessa rily a summation of these different types

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15 of self-esteem, but rather an overall perception including only t hose types of esteem in which success is important to the individual. An exampl e illustrating Harters th eory is an individual who perceives herself to have poor academic performance compared against her peers performance. This would damage her self-esteem only if she perceives academic competence as important, and have no effect on her self-esteem if she does not value academic competence. Normative self-esteem development provide s support for this theory. Self-esteem development begins with the emergence of a sense of self as different from others (also known as self awareness) in early ch ildhood at approximately age one. Around pre-school age, children begin to develop self-perception, which is largel y positive and general at this point. School entry then provides expanded opportuni ties for mastery and comparison experiences, consistent with Cooleys looking-glass model of self-esteem. This is the poi nt during which variability in selfesteem begins to emerge along a positive and negative continuum. Self-esteem continues along this pathway until the onset of puberty and a dolescence, when most children experience a normative dip in self-esteem as peer comparisons and fitting in become more important. Most individuals then experience a rebound in self-est eem as they enter late adolescence and early adulthood, when individualization increases and the importance of the beliefs of others diminishes. Many researchers believe that this level of self-esteem then remains stable through adulthood (Harter, 1999). Self Esteem in Overweight Children Over ten years ago, French and colleagues (1995) reported that ove rweight in children was inversely associated with self-esteem and body-esteem, but noted th at the association was modest and that lower scores often still fell with in normal ranges. A number of studies since that time suggest that overweight children and adolesce nts report moderately lower levels of selfesteem compared to non-overweight adolescent s and children (Manus & Killeen, 1995; Pesa,

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16 Syre, & Jones, 2000; Stradmeijer, Bosch, & Koops, 2000; Strauss, 2000). However, these findings are not universal, as a number of other studies have not found an association between self-esteem and weight status (Gortmaker, Must, Perrin, Sobol, & Dietz, 1993; Renman, Engstrom, Silfverdal, & Aman, 1999; Rumpel & Harris, 1994; Swallen, Reither, Haas, & Meier, 2005). While a clear answer to this question may not exist, these findings point to the importance of examining factors that may lead some childre n who are overweight to be at greater risk for low self-esteem. Although the data regarding the association between self-esteem a nd overweight is still mixed, a group of factors appear to place overweight children at-risk for the development of poor self-esteem. A review by Lowry, Sallinen, and Janicke (2007) examined potential moderating factors to help clarify this association. The development of self-esteem in overweight children compared to normative self-esteem developmen t may differ in significant ways. Research suggests that overweight children, particularly girls experience larger dips in self-esteem in adolescence than non-overweight children, perhaps due to th e increasing importance of body shape and size as a component of many adolescent s global self-esteem ra tings. In addition to gender and developmental differences ethnicity also may interact w ith age and gender to impact the association between overwei ght and self-esteem. Research has consistently found that overweight White children experi ence poorer self-esteem than overweight African American children (Kaplan & Wadden, 1986; Wilson, Sargent, & Dias, 1994; Brown et al., 1998; Strauss, 2000; Young-Hyman, Herman, Scott, & Schl undt, 2000; Young-Hyman, Schlundt, HermanWenderoth, & Bozylinski, 2003; Kelly, Wall, Eisenberg, Story, & Neumark-Sztainer, 2005), perhaps due to the fact that larger body sizes may be more culturally acceptable among some African Americans (Wilson, Sargent, & Dias, 19 94) and that African American parents may

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17 misperceive their childs weight. Researchers also suggest that negative attitudes about weight may not be communicated to overweight Afri can-American children (Young-Hyman, Herman, Scott, & Schlundt, 2000), which may lead to a more positive body image, (Kelly, Wall, Eisenberg, Story & Neumark-Sztainer, 2005) and ultimately contribute to higher self-esteem. Reports of self-esteem in overweight Hispanic ch ildren is mixed (Brewis, 2003; Mirza, Davis, & Yanovski, 2005), and differences in this population a ppear to be linked to identification with majority cultural standards of body shape (Lowry et al., 2007). Other factors that may place overweight childr en at-risk for poorer self-esteem include a high incidence of teasing and peer victimiza tion (Strauss & Pollack, 2003; Young-Hyman et al., 2003; Hayden-Wade et al., 2005; Sweeting, Wri ght, & Minnis, 2005; Stern et al., 2006; Thompson et al., 2007) and internal attributions about weight status (Pierce & Wardle, 1997). Additionally, positive social support may shield overweight children from decreases in selfesteem (Strauss & Pollack, 2003; Dishman et al., 2006). While the data are still mixed as to the association between global self-esteem and weight status, there is more evidence to support that specific domains of self-esteem, such as physical, social and athletic self-esteem are more likely to be associated with overweight status. Given the influence of these f actors on self-esteem in cross-sectional studies and the implications for future ps ychosocial functioning, these data highlight the need to examine self-esteem in the context of weight management programs. Childhood Overweight and Weight Management Programs Due to potentially severe medical comp lications, Expert Committee Recommendations suggest that children with a BMI at or above the 95th percentile undergo treatment for overweight (Barlow & Dietz, 1998). The committee also reco mmends that children and adolescents whose BMI is within the 85th to 95th percentile for their height and weight undergo additional screening for secondary complications including; 1) a family history of cardi ovascular disorders,

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18 hypercholesterolemia, or diabetes mellitus, 2) pare ntal obesity, 3) high blood pressure, elevated total cholesterol, a large recent increase in BMI, and/or 4) child-adoles cent concerns regarding weight status (Faith et al., 2001) Children or adolescents who pres ent with one or more of the previous complications are recommended to undergo treatment, while children without secondary complications should be monitore d annually. According to Expert Committee Recommendations (Barlow & Dietz, 1998), treatment should include primary behavioral goals of healthy eating and activity. Medica l goals are also recommended if secondary complications are present. Gradual, permanent weight goals and behavioral changes are recommended based on the childs current weight status. Pa rent involvement is stressed as an essential component through parent training techniques incl uding praise, use of non-food reward s, daily family meals, and maintaining a healthy, non-tempting home e nvironment for the child. Support for these recommendations are found in a review of empiri cally supported treatments in pediatric obesity by Jelalian & Saelens (1999) which indicates that the essential components of childhood weight management programs include behavioral modifi cation, parent training, he althy dietary habits, and increases in physical activity. Two studies utilizing treatment de signs and components relevant to this disser tation are reviewed below. One program designated as a well-established treatment (Jelalian & Saelens, 1999) is Epsteins Stop-Light Program (E pstein, Wing, & Valoski, 1985). Th is program combines dietary reductions (changes in eating beha viors and food intake) along w ith lifestyle activity. The StopLight Program is a simplified, chil d-friendly program that classifi es foods into three categories: green, yellow, and red. Green foods have less than 2 grams of fa t per serving, yellow foods have between 2.0 and 4.9 grams of fat per se rving, and red foods ha ve 5.0 or more grams of fat per ser ving (Epstein, Roemmich, & Ra ynor, 2001). Epstein and co lleagues (2001) also

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19 recommend increasing fruit and vegeta ble intake as this has been s hown to be an effective way to not only increase consumption of these foods, but also to decrease high fat and high calorie food consumption. During Epsteins programs, parents and children work with group leaders to set goals to reduce children and parents red food consumption, to reduce daily caloric consumption, and to increase their physical activity level. Physic al activity changes are based on lifestyle activities (such as walking), because th e combination of lifestyle activities in weight management programs with dietary interventions is shown to be more effective than dietary interventions alone (Epstein & Goldfield, 1999). Data from Epst eins programs indicate that up to 30% of children treated across four treatmen t interventions had reac hed non-obese status at ten-year follow-up (Epstein, Va loski, Wing, & McCurley, 1994). An essential component of this program is parent involvement. Interestingly, parents who attended the program demonstrated a 12% decrease in their own overweight status at fi ve year follow-up and a 15% decrease in their overweight status at ten year follow up (Epstein et al., 1994). An alternative intervention model is presen ted by Golan and colleagues (Golan, Fainaru, & Wizman, 1998; Golan, 2006). Golan suggests that the home environment is the most important setting to shape childre ns dietary and activity behavi ors and that parents are key figures in making and maintaining changes in th at environment. Golan and Crow (2004) suggest that if parents are the main agents of change then parents should be targeted in weight management programs to change the home enviro nment rather than targeting the child. Her program does not target specific redu ctions in caloric intake and sh e considers her approach to be health centered rather than weight centered. Golans research has examined the effectiveness of her program by comparing a par ent-only approach to a childonly or a parent-plus-child intervention. Her research demonstrates positive results in both child and parent weight status

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20 with the parent-only approach compared to the two other interventi ons (Golan, 2006). Golan suggests that targeting the pare nt exclusively is more cost-e ffective and may buffer the child from potential negative psychosocial consequences that may occur due to participation in a weight management program. Pediatric Weight Management Programs and Self-Esteem Many studies have reported positive success in reducing weight status, reducing percent overweight, and reducing medi cal complications such as risk fa ctors for cardiovascular disease. However, much less attention has been focused on the impact of these interventions on psychosocial functioning, and in particular, pediatri c self-esteem. This is a particularly important question as researchers express concern regardin g the impact of interventions for pediatric overweight on self-esteem and whether or not we ight management programs may do more harm than good (ODea, 2005). Unfortunately, minimal or no outcome data on self-esteem for intervention participants has been reported by many of the empiri cally supported treatments for pediatric overweight. Although Epstein and Golan have reported su ccess in establishi ng long-term healthy body weights in children, incomplete data are av ailable related to psyc hosocial functioning of children and parents involved in the programs. To our knowledge, Epstein and colleagues have not published data on self-esteem values or self-esteem change for children who participate in their intervention programs. Although Golan em phasizes the importance of self-esteem and protecting children against poten tial adverse effects from par ticipation, she only has reported data concerning rates of disordered eating and not self-esteem changes for the children who participate in her interventions. While these two research groups have not reported the impact of their intervention programs on child self-esteem, a recent review found that 20 published studies have reported

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21 preand post-treatment self-esteem data in th e context of a pediatri c weight management intervention program (Lowry et al., 2007). Of these, 17 studies report evidence of increases in global self-esteem or components of self-esteem from preto pos t-treatment (Stoner & Fiorillo, 1976; Foster, Wadden, & Brownell, 1985; Mellin et al., 1987; Wadden, Stunkard, Rich, Rubin, Sweidel, & McKinney, 1990; Sherma n et al., 1992; Sahota et al., 2001; Jelalian & Mehlenbeck, 2002; Braet et al., 2003; Brehm, Rourke, Cassell, & Seth uraman, 2003; Walker, Gately, Bewick, & Hill, 2003; Bart on et al., 2004; Braet et al ., 2004 [2-year follow-up: Braet, 2006]; Edwards et al., 2005; Gately et al., 2005 ; Sacher et al., 2005; Savoye et al., 2005; Jelalian, Mehlenbeck, Lloyd, Richardson, Birm aher, & Wing, 2006). Two studies report no change in self-esteem or components of se lf-esteem (Rohrbacher, 1973; Thomas-Dobersen, Butler-Simon, Fleshner, 1993) and only one stud y reports decreases in self-esteem (Cameron, 1999). However, this review is limited in that the number of pediatri c weight management programs that examine self-esteem at baseline an d post-treatment is minimal compared to the number of published pediatric weight management programs. A dditionally, these 20 studies are widely variable with respect to methodology, statis tical examination of re sults, and inconsistent reporting of demographic and outcome data, whic h makes drawing firm conclusions from these studies difficult. Factors That May Impact Self-Esteem During Weight Management Programs This study sought to explain the differen ces in self-esteem changes by examining a number of factors that theoretica lly may impact self-esteem in th e context of a pediatric weight management program. Cross-sectional research ha s indicated that gender differences exist in self-esteem rates (Mendelson & White, 1985; Pesa et al., 2000; Israel & Ivanova, 2002), and it is likely that self-esteem will change in girls and boys differentl y. However, no study has examined gender differences in self-esteem within wei ght management interventions. Based on cross-

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22 sectional research, differences ba sed on age and ethnicity also exis t, but, changes in self-esteem are not fully explained by devel opmental and ethnicity differences alone. Other factors that may influence self-esteem during a weight manageme nt intervention worthy of examination, with particular relevance to this diss ertation, include the impact of we ight status change, behavioral goal achievement, self-efficacy for healthy lifestyle behavior s, locus of control, peer victimization, and body satisfaction. Impact of Changes in Weight Status Three studies provide support for an associa tion between self-esteem change and weight status change (Cameron, 1999; Walker et al., 2003; Jelalian et al ., 2006). In these studies weight status change was associated w ith athletic, physical, and global self-esteem. In the only study to report a decrease in self-esteem from preto po st-treatment, the pediatri c participants did not experience a statistically significant change in wei ght status and reported feelings of failure due to their lack of success in m eeting weight loss goals (Cameron, 1999). However, three older studies reported no stat istically significant association betw een self-esteem change and weight status change (Rohrbacher, 1973; Stoner & Fiorillio, 1976; Wadden et al., 1990). Despite findings of differences in self-e steem in overweight girls and boys cross sectionally, no study has examined the impact of changes in weight status on self-esteem by gender for participants in a weight management program. This mixed pattern of results makes it difficult to draw definitive conclusions about the role of wei ght loss in self-esteem change s ubsequent to treatment, or the direction of potential effect. Rega rdless of the direction or effect of weight status change on selfesteem, it appears to be only one of a number of factors that may impact self-esteem in pediatric weight management programs (Lowry et al., 2007).

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23 Impact of Behavioral Goal Achievement Goal achievement has been suggested to be another factor that ma y impact self-esteem (Lowry et al., 2007). Research with children ( not in the area of weight management) has demonstrated that achieving short-term goals is a ssociated with enhanced self-learning, increased intrinsic interest in the subject at hand, a gr eater sense of mastery, and more personal selfefficacy, whereas achieving long-te rm goals demonstrates no such associations (Bandura & Schunk, 1981). In the context of weight management programs, behavioral goals to decrease the consumption of high fat, high calorie foods or to increase physical activity may be seen as shortterm goals, whereas weight change may seen as a non-behavioral, long-term goal. The association between short-term behavioral goal a ttainment (such as weekly dietary and physical activity goals) and long-term outcome s (such as weight loss) has b een clearly examined in adult weight management programs (Bandura & Si mon, 1977; Israel & Saccone, 1979). In fact, researchers have recommended that future program s consider setting specific behavioral goals for participants due to the increased success fo r participants who set and achieve behavioral goals (Linde, Rothman, Baldwin, & Jeffery, 2006). Minimal research has examined goal setti ng for pediatric participants in weight management programs. Given the positive a ssociation between self-esteem and mastery experiences in children, it is likely that goal settin g may contribute to self-esteem as reaching intervention goals may be perceived as a mast ery experience. These short term successes may also buffer potential disappointment if long-term weight status change goals are set and not achieved. Support for this association may be fou nd in the only study to report that pediatric participants experienced a decrea se in self-esteem preto post -treatment. In the study, children reported feelings of failure due to their lack of success in meeting weight loss goals (Cameron, 1999), although this association was not examined st atistically. These findi ngs highlight the need

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24 for programs to set directly achievable short-te rm goals, such as dietary and physical activity changes, rather than indirect longterm goals, such as weight loss. They also highlight the need to examine the impact of self-efficacy for healthy lifestyle behaviors on self-esteem change for children participating in a we ight management program. Impact of Self-Efficacy for Healthy Lifestyle Behaviors Self-efficacy is an individuals perception of how well he or she can achieve a behavior and is considered to be a cri tical component of beha vior change (from Social Learning Theory; Bandura, 1977). Self-efficacy in children has been associated with academic functioning (Bandura, Barbaranelli, Caprara, & Pastorel li, 1996), depressive symptoms (Bandura, Barbaranelli, Caprara, & Pastor elli, 1999), and perceived occupational self-efficacy (Bandura, Barbaranelli, Caprara, & Pastor elli, 2001). Research examining self-efficacy in overweight children has indicated that overweight children are less confident of their ability to overcome barriers to physical act ivity than non-overweight peers (Trost, Kerr, Ward, & Pate, 2001) and that self-efficacy is a very important determin ant of physical activity change in children (Reynolds et al., 1990; Sallis et al., 1992; Tr ost, Pate, Ward, Saunders, & Riner, 1999). Research examining self-efficacy for healthy lif estyle behaviors in the context of weight management interventions is mixed. Substantial ev idence exists in the adult literature outlining the predictive association between high baseline self-efficacy and weight loss at post-treatment (Forster & Jeffery, 1986; Strecher, DeVellis, Becker, & Rosenstock, 1986; Edell, Edington, Herd, OBrien, & Witkin, 1987; Stotland & Zu roff, 1991; Dennis & Goldberg, 1996; Linde, Rothman, Baldwin, & Jeffery, 2006) and during six-week (Berni er & Avard, 1986), one-year, and two-year follow-up (Jeffery et al., 1984). Howe ver, the evidence is very limited in pediatric samples and only one study has reported that self-e fficacy was an important factor in weight loss

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25 efforts in a school-based program (Perry et al., 1990). No study in adult or pediatric populations has examined the association betwee n self-efficacy and self-esteem. It is likely that as an individuals confidence or beliefs in his or her ability to perform a behavior successfully increases, so may self-esteem. Success in short-term goal attainment may lead to improvements in an individuals conf idence, or self-efficacy. Although the path through which self-efficacy impacts self -esteem may be via goal attain ment and mastery experiences, self-efficacy may also directly impact self-esteem by promoting more positive feelings towards the self and the individuals abilities. This hi ghlights the need to determine if increased selfefficacy adds to the prediction of self-esteem above and beyond weight status and goal achievement. However, no research exists exam ining the association between self-efficacy and self-esteem for overweight ch ildren participating in we ight management programs. Impact of Locus of Control An individuals sense of control of their weight, or locus of control, also has been linked to pediatric self-esteem (Pierce & Waddle, 1997). Locus of control is defined as a persons perceived responsibility for outcome s. Individuals with an internal locus of control believe that their behaviors have an impact on their outcomes while those with an external locus of control believe that external factors are responsible for their outcomes (Ro tter, 1966). In a crosssectional study, Pierce and Wardle (1997) reported that overweight 9 to 11 year old children who believed that they were responsible for their weight status had lowe r rates of self-esteem compared to children who did not believe that th ey were responsible for their weight status. Data from the adult literature have suggested that an internal locus of control at baseline is associated with increased weight loss for obese adults participa ting in weight management programs (Balch & Ross, 1975; Wallston, Wallston, Kaplan, & Maides, 1976), but that adults with more internal attributions regarding their overweight status may experience lower self-

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26 esteem during participation in wei ght management programs (Bryan & Tiggemann, 2001). In one of the few studies examining locus of contro l change across a weight management program, Tobias and MacDonald (1977) found that adult locus of control be came more internalized during their participation in a weight control program, which is understan dable as most programs target individual control over weight-r elated behaviors such as food in take and exercise. However, the researchers did not examine the impact of th is increasing internalization on self-esteem. Research on locus of control in pediatric wei ght management is limited. It is possible that some of these same mechanisms regarding locu s of control in adult populations may generalize to pediatric populations includi ng; 1) associations between in ternal locus of control and increased weight loss during interv ention participation, 2) a trend for participants to experience more internal locus of control during intervention participation, and 3) a possible association between internal weight-specific locus of control and decreased self-esteem across the intervention, particularly with limited wei ght loss success. The only weight management intervention that reported decrease s in self-esteem sugge sted that changes towards more internal attributions regarding weight status may have contributed to self-esteem changes (Cameron, 1999). Specifically, Cameron suggests that overwei ght children may mainta in self-worth by deemphasizing the value of weight status on their ov erall self-worth, and th at placing a child in a weight management program directly opposes a nd weakens those coping strategies. However, this theory was not tested statistically in he r treatment program, and non e of the associations from adult weight management literature ha s been examined in pediatric populations. Impact of Peer Victimization Cross-sectional studies have repeatedly described the de leterious impact of peer victimization on self-esteem in overweight childr en. In a sample of 2,127 middle school children, degree of overweight was associat ed with depressed mood, low self -esteem, and greater levels of

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27 peer victimization (Sweeting, Wright, & Minn is, 2005). Weight-based teasing was negatively associated with self-esteem in a sample of 117 African-American overweight youth (YoungHyman, Schlundt, Herman-Wenderoth, & Bozylinski, 2003), and this pattern has been found in both Caucasian and African American samples (S tern et al., 2006). Researchers also have reported that overweight childre n experience victimization that is focused on appearance and body weight more than other charac teristics. Furthermore, overweight children appear to be more influenced by peers negative comments and attributions about thei r appearance than nonoverweight youth (Hayden-Wade et al., 2005; Thompson et al., 2007). Despite the well-documented association of peer victimization on self-esteem, no study has examined how rates of peer victimization or changes in peer victimiz ation may affect selfesteem during participation in a weight manageme nt program. This is esp ecially surprising given that positive social support th rough sport and club participati on has been suggested to be associated with higher self-esteem independent of weight status (S trauss & Pollack, 2003; Dishman et al., 2006) and that many weight mana gement programs may utilize the group format to buffer or diminish the negative effects of victimization and enhance self-esteem. Impact of Body Satisfaction Body satisfaction, also commonly referred to as body image, also has been linked to selfesteem in overweight children. Body image is fre quently associated with physical self-esteem, particularly in Western cultures, but the two te rms do represent different constructs (Lau, Lee, Ransdell, Yu, & Sung, 2004). Body satisfaction differs from physical self-esteem in that in the weight management literature body satisfaction mo st frequently refers to the discrepancy between actual and ideal body size whereas physi cal self-esteem refers to an individuals perceived judgment of physical appearance, which may be inclusive of more than just body size. French and colleagues (1995) hypothesized that body image may influence a significant portion

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28 of global self-esteem for overweight youth. However, this association has rarely been examined statistically, despite mounting evidence that body image changes may account for and/or impact self-esteem changes in cross-s ectional samples (Pesa et al., 2000), or that changes in body satisfaction may precede changes in global self-esteem. In studies examining self-esteem change, improvements are frequently noted in body satis faction (Rohrbacher, 1973 ; Stoner & Fiorillo, 1976; Thomas-Dobersen et al., 1993 ; Jelalian & Mehlenbeck, 2002; Br aet et al., 2003; Walker et al., 2003; Braet et al., 2004). This suggests th at improvements in body satisfaction may be another factor that could impact domains of se lf-esteem. However, this association has rarely been examined in the context of pediatric we ight management programs. Furthermore, gender differences in the association between body satisf action and self-esteem in weight management programs has not been examined, despite the evid ence that body satisfaction may have a greater impact on the self-esteem of girls when compared to boys (Pesa et al., 2000). Summary In summary, childhood overweight is a significant public heal th concern, associated with multiple medical and psychosocial consequences, particularly in rural areas (American Academy of Pediatrics, 2003; Deckelbaum & Williams, 2001; Zametkin et al., 2004). Overweight children are at greater risk for self-esteem deficits as compared to normal weight children (ODea & Abraham, 1999; Stradmeijer, Bosch, & Koops, 2000; Strauss, 2000), and self-esteem deficits appear to occur via the influe nce of several moderating factor s (Lowry et al., 2007). Research suggests that gender differences exist in self-est eem rates and self-esteem change for overweight children. The impact of weight management pr ograms on pediatric self-esteem has primarily focused on the impact of weight change. Cross-se ctional research examining the effects of goal acquisition, self-efficacy, locus of control, peer victimization, and body satisfaction support the need to examine how these factors may impact se lf-esteem for girls and boys participating in a

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29 weight management program. The specific purpose of this study is to examine the effects of a pediatric weight management program on self-e steem and possible mechanisms of change in self-esteem, based on the factors highlighted previously. The ai ms and hypotheses are listed below. Current Aims and Hypotheses Primary Aims Aim 1: To examine the impact of the intervention groups on self-esteem Hypothesis 1.1. We hypothesized that pa rticipants in the intervention groups (Behavioral Family Intervention [BFI] and Behavioral Parent Intervention [BPI]) wo uld experience greater self-esteem improvements from pre-treatment to pos t-treatment relative to participants in the control group (Wait Li st Control [WLC]). Aim 2: To determine the impact of we ight status change on self-esteem Hypothesis 2.1. We hypothesized that improvements in child weight status would be positively associated with greater self-esteem improvements from preto post-treatment. Secondary Aims Aim 3: To examine the impact of behavi oral goal attainment on self-esteem Hypothesis 3.1. We hypothesized that gr eater short term behavioral goal achievement (for dietary and physical activity ch anges) would be associated with greater self-esteem improvements from preto post-treatment. Aim 4: To determine the impact of self-e fficacy on weight status and self-esteem Hypothesis 4.1. We hypothesized that gr eater pre-treatment child self-efficacy would be positively related to improvements in child weig ht status from preto post-treatment. Hypothesis 4.2. We hypothesized that gr eater pre-treatment child self-efficacy would be positively related to greater self-esteem improvements from pre to post-treatment.

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30 Hypothesis 4.3. We hypothesized that improvements in child self-efficacy from preto post-treatment would be positively related to gr eater self-esteem improvements from preto post-treatment. Aim 5: To determine the impact of and association between weight-specific locus of control, weight status, and self-esteem in overweight children Hypothesis 5.1. We hypothesized that gr eater pre-treatment internal weight-specific locus of control would be associated with poorer pre-treatment self-esteem. Hypothesis 5.2. We hypothesized that pa rticipants in the intervention groups (BFI and BPI) would experience changes toward more internal weight-specific locus of control from preto post-treatment relative to participants in the control group (WLC). Hypothesis 5.3. We hypothesized that th e childs post-treatment weight-specific locus of control would interact with change in child weight status such th at 1) internal weight-specific locus of control with reduction in weight status during the weight management program would be associated with greater self-esteem at post-trea tment but that, 2) intern al weight-specific locus of control without a reduction in weight stat us during the weight management program would be associated with lower self-esteem at post-treatment. Aim 6: To examine the impact of peer victimization on self-esteem Hypothesis 6.1. We hypothesized that gr eater pre-treatment child-rated peer victimization experiences would be associated with lower pre-treatment self-esteem. Hypothesis 6.2. We hypothesized that reductions in child-rated peer victimization experiences would be associated with greater self-esteem improvement. Hypothesis 6.3. We hypothesized that greater po st-treatment peer victimization experiences would be associated wi th lower post-treatment self-esteem.

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31 Aim 7: To examine the impact of body satisfaction on self-esteem Hypothesis 7.1. We hypothesized that greate r pre-treatment child-rated body dissatisfaction would be associated w ith lower pre-treatment self-esteem. Hypothesis 7.2. We hypothesized that pa rticipants in the intervention groups (BFI and BPI) would experience greater reductions in rati ngs of body dissatisfaction from preto posttreatment relative to participants in the control group (WLC). Hypothesis 7.3. We hypothesized that reductions in child-rated body dissatisfaction would be associated with greater self-esteem improvement. Hypothesis 7.4. We hypothesized that greater post-treatment body dissatisfaction would be associated with lower post-treatment self-esteem

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32 CHAPTER 2 METHODS Data for this study were collected as part of a larger intervention study, Sensible Treatment for Overweight Rural Youth (Project STORY), which compared the impact of a Behavioral Family-Based Intervention (BFI) and a Behavioral Parent-Based Intervention (BPI) on weight status in overweight children in underserved rural settings. A Wait List Control (WLC) group was used to compare the eff ects of the two interventions. The intervention utilized a modified Stop-Light Diet (Epstein et al ., 1985) and emphasized behavior al goals including reducing high fat foods and high sugar beverages (i.e., red foods ), increasing fruit and vegetable consumption, and increasing physical activity ra ther than focusing primarily on weight loss. Parent and child self-esteem and body satisfaction issues were ad dressed during the inte rvention with special sessions focusing specifically on these concerns. For a full description of the design and methods of the larger Project STORY, please refer to the methodology paper by Janicke and colleagues (2007). Participants The 81 study participants who complete d both pre-treatment and post-treatment assessments were overweight child ren between 8 and 14 years old ( M =11.05, SD =1.6 years) and their parent(s) or caretaker who volunteered to participate in a wei ght management program designed to help children and pare nts adopt healthier lifestyle hab its (dietary intake and physical activity) and to improve their weight status. Fi gure 2-1 provides a flowchart outlining the process by which participants were enrolled. Enrollment is described in more detail in the Recruitment section under Procedures. T-test s were conducted to assess for differences at baseline between participants who did ( n = 81) and did not ( n = 12) complete post-treatment assessments. The participants who did not comple te post-treatment assessment were comprised of significantly

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33 more girls (75% female vs. 62% female; t = 2.597, df = 15, p = 0.020), were younger ( M = 9.73 [ SD = 1.74] vs. M = 11.07 [ SD = 1.58]; t = 2.701, df = 91, p = 0.008), in a lower grade ( M = 4.08 [ SD = 1.88] vs. M = 5.65 [ SD = 1.70]; t = 2.953, df = 91, p = 0.004), and heavier (z-score M = 2.48 [ SD = .24] vs. M = 2.15 [ SD = .41]; t = -2.708, df = 91, p = 0.008) than participants who did complete post-treatment assessments. The two groups did not differ in ethnicity, parent marital status, parent highest education, or family income. Furthermore, no significant differences existed between baseline self-esteem ratings in any domain, or baseline ratings of weightspecific locus of control, peer victimization, body dissatisfaction, or self-efficacy. Given that no significant differences existed at baseline for self-esteem scores, only data from the 81 participants completing both assessment points were used in the analyses. The resulting sample was primarily female ( 50 girls; 31 boys). The sample was moderately diverse with 64 Caucasians (79 %), seven African Americans (8.6 %), six Hispanics (7.4%), two Asian Americans (2.5%), and two Bi-racial partic ipants (2.5%). The majority of families had currently married parents (76%), and two adults in the home (69%). Many of the parents had some college education (43%). The modal family income was between $20,000 39,999. All child-parent dyads were randomized to one of three four-month behavioral weight management interventions (family-based, parent-based, or waitlist control). Participants were recruited from four medically underserved rural counties, with enrollments of 22-27 participants per county. Tables 2-1 and 2-2 provide further base line characteristics of participants. Inclusion Criteria Child criteria for participation in cluded a BMI at or above the 85th percentile for sex and age. Parent criteria for particip ation included being a parent or legal guardian living in the same house as the child, 75 years old or younger, child and parent must live in the designated rural

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34 area, and that the participating parent was primarily or equall y responsible for food purchasing and meal preparation. Exclusion Criteria Child and parent exclusion cr iteria included the presence of a medical condition that contraindicated mild energy restriction or moderate physical activ ity, pregnancy in the participant(s), or if the child or parent was pa rticipating in another we ight control program. Another exclusion criterion wa s medication use including: antip sychotic medication, systemic corticosteroids, prescription weight-loss medicati ons, insulin, or other medications for diabetes. Additional exclusion criteria includ ed conditions or behaviors likely to affect the conduct of the intervention such as: 1) parent or legal guardian unable to read English at the 5th grade level, 2) unwilling to accept randomization, 3) unable to tr avel to Extension office for intervention sessions, 4) likely to move out of the county within the next 18 months, 5) child or parent with major psychiatric disorder, 6) child with major cognitive or developmental delay, or 7) or any other condition/situation which in the opinion of staff would a dversely affect participation in the intervention. Procedure Location of Intervention All interventions were provided at Cooperative Extension offices in north central Florida. Cooperative Extension is a partnership among stat e, federal, and county governments with the goal of providing scientific knowledge and e xpertise to the greater public. The Florida Cooperative Extension Service is funded by th e University of Flor ida and Florida A & M University. Cooperative Extension o ffices were selected as the se tting in which to provide the interventions in order to enhance delivery of this program to the rural populations of interest by

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35 providing the intervention in a trusted and esta blished center directly in the participants communities. Recruitment Recruitment occurred during the three months prior to the intervention phase in each county. A variety of recruitment methods were us ed including direct solicitation through mailers to all families in counties with at least one ch ild 8-13 years old. Additional recruitment efforts included flyers provided to loca l physicians and pediatricians, pr esentations and flyers provided to youth and community groups (e.g., church a nd youth groups), and flye rs provided to public health departments and school nurses for dist ribution. Each mailer, presentation, and flyer provided potential participants with a toll-free telephone number that the family could call to learn more about the study. A total of 154 familie s initially called to le arn more about the study. A trained recruiter then made follow-up phone ca lls to describe the study and perform a brief phone screen to determine participant eligibility. Overall, 133 families met this first phase of eligibility criteria. Families that expressed intere st and met initial eligibility requirements were scheduled for an in-per son screening visit. Initial In-Person Screening Those families who met initial criteria a nd expressed interest during the initial phone screen were scheduled for an initial in-pers on assessment approximately two to three months prior to the beginning of the intervention in each county. During this visit, the study was described in detail and informed consent for pa rticipation was obtained. All parents completed a demographic and medical questionnaire for themse lves and their child. E ligible families also were measured for height and weight. Two P hysician Approval Forms were given to each interested family for their physician to complete. Families were required to return these approval forms to the study investigator in order to clear the parent a nd child to participate in the

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36 intervention. An examination by a licensed physicia n was provided free of charge if needed for families with limited financial or healthcare resources. Of the 133 families scheduled for an in-pers on screening visit, 111 families completed the initial in-person screening. Of these, two fam ilies were excluded because they did not meet eligibility criteria as the target childs body mass index (BMI) was below the 85th percentile for height and weight according to age and gende r normative data published by the Centers for Disease Control and Prevention (CDC). See Figur e 2.1 for participant fl ow through recruitment and assessments. Schedule for Assessment Each parent/child dyad completed three assessme nt visits over the course of the study. The first assessment occurred one to tw o weeks prior to the beginning of the intervention and served as the pre-treatment assessment. A total of 109 families were scheduled for pre-treatment assessment. Of these 101 families completed the pre-start assessment. Five families were excluded due to child BMI below the 85th percentile for gender and age. Within each county families were randomly assigned to treatment condition. Three families did not accept randomization (WLC n = 2; BFI n = 1). Thus, a total of 93 families accepted randomization and started treatment; Behavioral-Family Intervention (BFI; n = 33), Behavioral Pa rent Intervention (BPI; n = 34), or Wait List Control (WLC; n = 26) group. Post-treatment assessment occurred at the completion of the fou r-month intervention and served as the post-treatment assessment. A total of 81 families completed preand posttreatment assessment (BFI n = 31; BPI n = 29; WLC n = 21). A final assessment visit occurred at six-months follow up to the intervention, or at 10-months following the beginning of the intervention in each county. Participants in th e BFI or BPI group participated in a four-month intervention. The WLC group received the BFI in tervention after post-treatment and six-month

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37 follow-up. For the purposes of this study, only data from the pre-treatment and posttreatment assessments were used. The six-m onth follow-up assessment point will not be described in more detail. All asse ssment visits occurred at the lo cal Cooperative Extension office in participating counties. Interventionists Interventionists included Cooperative Extension agents and a trained doctoral level psychologist(s), doctoral level graduate studen t, or a licensed and registered nutritionist. Cooperative Extension agents were included as interventionists with the philosophy that these agents could be trained in the program and then provide the program to the community again in the future in a cost-effective partnership. Cooperative extension agents have experience and training delivering programs to children and fa milies, as well as experience in nutrition education. Every interventionist attended extensiv e training provided by the primary investigator and consultants regarding the pr ogram philosophy, behavioral cha nge techniques, group therapy techniques, and goal setting. Each interventionist attended weekly supervision with the primary investigator throughout each wave of treatment. Basic Intervention Program The intervention utilized a m odified Stop-Light Diet (Epste in et al., 1985) and emphasized behavioral goals including; reducing high fat f oods and high sugar beverages (i.e., red foods), increasing fruit and vegetable cons umption, and increasing physical activity rather than focusing primarily on weight loss. Each intervention followed a manualized treatment program to provide participants with didactic information about he althy lifestyle habits, to provide information on behavior change, and to maintain reliability across interventionists. During the program parents and children worked with group leaders to set goals to reduce their consumption of high-fat foods and increase fruit and vegetable intake.

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38 Physical activity goals were targeted via a walking-based pr ogram. Parents and children were given pedometers and worked with group l eaders to increase their daily steps. A study by Tudor-Locke and colleagues (2004) demonstr ated that overweight children average approximately 3,000 steps less per day than their normal weight peers. Thus, the goal of the program was to increase steps for children a nd parents by approximately 3,000 steps per day above their baseline level. The program also addressed self-esteem and bod y image. At the time of this intervention, little published research existed suggesting that previous chil dhood obesity interventions have directly addressed strategies to increase self-esteem in children participating in weightmanagement programs. In the current program two sessions targeted self-esteem and body image concerns for overweight children direct ly through child sessions (if applicable) and indirectly through parent sessions. These sessions examined the impact of self-esteem and body image on parents and children and helped the pa rticipants to increase their self-esteem and body image through interactive activit ies during the session. Examples of these activ ities included sessions on how to handle teasing, focusing on beha viors (i.e., red food consumption or physical activity) instead of weight cha nge, using positive self talk to build self-esteem, and parent modeling of positive self-esteem and body image. Behavioral strategies were incorporated throughout all aspe cts of the program to achieve intervention goals and promote parent and child behavior change. Behavi oral techniques have been shown to be effective methods to promot e individual change, part icularly in weight management settings (Jelalian & Saelens, 1999). Strategies used in this program included selfmonitoring, goal setting, shaping, stimulus control, behavioral contracting, contingent attention, positive reinforcement, modeling, role playing, in centives, and portion size control (Janicke et

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39 al., 2007). Group leaders worked carefully with e ach family to help them reach their goals through 1) gradual reductions in red foods and in creases in physical act ivity, 2) behavioral contracting with children to reach food goals, ac tivity goals, and family meal times, and 3) additional parent management strategies for reaching behavioral goa ls and managing child behavior. Behavioral-Family Intervention (BFI) Group The BFI groups consisted of concurrent parent and child sessions led by two trained group leaders each in the child and parent group, for a to tal of four group leaders. Parents and children participated in separate, but simultaneous groups based on the superior findings of separating the parents and children into different groups (Brownell, Kelman, & Stunkard, 1983). Each week, the basic session format included parent s and children meeting individually with the group leaders to review the previous weeks goals and problem solve any barriers that occurred. A brief interactive didactic lesson then reviewed the cu rrent weeks materials. In the child group this lesson was followed by an active game or activity to reinforce the weeks lesson. Finally, at the conclusion of the session, the parents and childre n joined together with group leaders to set behavioral goals for the upcoming week. Behavioral-Parent Intervention (BPI) Group The BPI group consisted of parent-only contact with two trained group leaders. Each week, the basic session format began with parents meeting with the group l eaders to review the previous weeks goals and any barriers that o ccurred. A brief interactive didactic lesson followed and then the group leaders worked with parents to set behavioral goals for the parents and their children for the upcoming week. At home, parents were encouraged to serve as their childs interventionist and review the weeks materials w ith their child and set weekly goals for dietary and physical activity changes.

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40 Wait-List Control (WLC) Group The WLC group received the BFI intervention (described above) after the six-month follow-up visit, or ten-months from the beginni ng of the initial intervention programs in each respective county. Participants in this condition completed assessments on the same schedule as families participating in the BFI and BPI. Measures Criterion Measure Harter self-perception profile for children The Self-Perception Profile for Children (SPPC ; Harter, 1985) is a self-report assessment of the childs perception of his or her global self-worth and competence in six specific domains: scholastic competence, social accep tance, athletic competence, phys ical appearance, behavioral conduct, and global self-worth. Given gender diff erences in self-esteem, normative data for the measure is presented separately for boys and girl s. Based on research identifying the scales most relevant to pediatric weight management progr ams (Jelalian & Mehlenbeck, 2002; Braet et al., 2003; Brehm et al., 2003; Walker et al., 2003; Braet et al., 2004; Braet et al., 2006; Jelalian et al., 2006), only the social acceptance, athletic competence, physical appearance and global selfworth subscales will be examined in this study. Fo r each item, the child was asked to choose between two statements to indicate which statemen t is most like him or her. The child was then asked to choose whether that statement was sort of true for me or really true for me. The SPPC was developed specifically for children an d has good internal consistencies ranging from .74 to .92 for the individual subscales. This meas ure has been shown to be sensitive to detect change in self-esteem over time (Strauss, 2000) in weight management programs with children (Gately et al., 2005; Walker et al ., 2003). Internal consistency for the SPPC in this study for the social subscale was = 0.785 (pre-treatment) and = 0.801 (post-treatment). Internal

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41 consistency for the athletic subscale was = 0.842 (pre-treatment) and = 0.850 (posttreatment). Internal consistenc y for the physical subscale was = 0.833 (pre-treatment) and = 0.877 (post-treatment). Internal cons istency for the global subscale was = 0.790 (pre-treatment) and = 0.838 (post-treatment). Predictor Measures Demographic questionnaire Parents completed a demographic questionnaire that provided a variety of information including parent and child dates of birth, parent and child ethnicity and gender, family income, parent occupations, and family composition. A copy of this questionnaire is provided in Appendix A. Body height and weight Study administrators assessed parent and child height and weight. Height without shoes was measured to the nearest 0.1 centimeter using a Harpendon stadiometer. Weight was measured with one layer of clothes on, without shoes, and with pockets emptied on a standard body weight scale. Height and weight were used to calculate BMI, which was then used to calculate pre-treatment and post-treatment z-scor es. Pre-treatment z-score was then subtracted from post-treatment z-score to calculate a z-sco re change to reflect change in child weight status. Z-scores were selected as units of measurement in this study based on data that BMI zscore previously has been indicated to be an ad equate measure of adiposity change over time (Hunt, Ford, Sabin, Crowne, & Shiel, 2007). Daily habit log A self-report food and activity form, the Daily Habit Log, was provided weekly to each participant so that they could m onitor their food intake and daily steps. Each log had columns for foods consumed, the time the food was consumed, the amount of food consumed, and whether

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42 the food was a green, yellow, or red food. Each Da ily Habit Log also included a space for total daily steps as measured by the participants pedo meter. Participants were instructed how to complete the form during the first session of the intervention. The Daily Habit Log was completed by the parent and child; however, only th e childs form was used for the purposes of this study. Children were encouraged to complete their logs with thei r parents help and supervision. Although participants were encourag ed to categorize food consumption into the green, yellow, and red categories, for the purpo ses of these analyses a trained interventionist reviewed each log with families at session check-in and reviewed the categorization and number of red foods consumed by each child. A copy of the Daily Habit Log is provided in Appendix B. Group leader check in sheet During check-in, at the beginning of each session, an interventionist reviewed Daily Habit Logs individually with the family, focusing on the number of days that a child ate equal to or less than the previously agr eed upon red food goal. This number was entered as the Number of Days Met Red Food Goal on the Check In Sheet The same procedure was calculated for step data. For families that tracked fruit and vegetable goals, these data were included on the Check In Sheet as well. However, since not all familie s consistently tracked fruit and vegetable goal data, only red food and step goal attainment data were examined in this study. The number of days possible to meet red food and step goals each week was capped at six to exclude the day of the session. The final equation used to calculate goal achievement was: (# of days red food goals met + # of days step goals met) / (# of days possible to achieve red food goals + # of days possible to achieve step goals). A copy of th e Check in Sheet is provided in Appendix C. Self-efficacy questionnaire for heal thy lifestyle behavior choices A questionnaire to measure child self-efficacy for making various health lifestyle behavior choices was created for this study. Items included (1) I feel confident that I can eat healthy

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43 foods more often. (2) I feel confid ent that I can eat more fruits and vegetables more often. (3) I feel confident in that I can cha nge habits to eat fewer junk foods. (4) I feel confident that I can change my habits to be more physically activ e. This means running, playing outside, or just getting up and moving around more of ten. These items were selected to assess for confidence in a variety of weight-related beha viors including dietary and phys ical activity behaviors. The questionnaire was scored on a fourpoint Likert scale (rea lly not true for me, sort of not true for me, sort of true for me, or really true for me). Internal consistency for the self-efficacy questionnaire in this study was = 0.660 (pre-treatment) and = 0.801 (post-treatment). A copy of this measure is provided in Appendix D. Modified weight locus of control scale The original Weight Locus of Control (WLOC; Saltzer, 1982) is a four item weightspecific locus of control scale designed for adu lts. Original items include (1) Whether I gain, lose or maintain my weight is entirely up to me (2) Being the right weight is largely a matter of good fortune. (3) No matter what I intend to do, if I ga in or lose weight, or stay the same in the near future, it is just going to happen. (4) If I eat right and ge t enough exercise and rest, I can control my weight in the way that I desire. Original items are sc ored on a six-po int Likert scale (strongly disagree to strongly agre e), with scores ranging from four to 24. Lower scores indicated internality and higher scores indi cated externality. Saltzer (19 82) found test-retest reliability coefficients of r = 0.67 over a 24-day interval and internal validity coefficients of = 0.58 and = 0.56 for the two administrations. This scale has been shown to be sensitive to detect change in weight management programs with adults (Bryan & Tiggemann, 2001). For the purposes of this study, the scale was modified for use with children. The resulting items were (1) Whether I gain or lose weight is up to me. (2) Being the right weight is mostly due to good luck. (3) No matter what I try to do to lose weight, it doesnt change anything. (4) If

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44 I eat right and get enough exercise, I can control my weight. Additionally, items were scored on a four-point Likert scale (really not true for me, sort of not true for me, sort of true for me, or really true for me) to provide consistency with other child measures incl uded in this study. These modifications resulted from consultation betwee n the author, chair, and other doctoral-level graduate students. In order to further examine th e reading level of these modifications, the scale was given to doctoral-level graduate student s and doctoral level ps ychologists for their qualitative feedback as well. Internal c onsistency for the WLOC in this study was = 0.360 (pretreatment) and = 0.553 (post-treatment). A copy of this measure was provided in Appendix E Schwartz peer victimization scale The Schwartz Peer Victimization Scale (SPV S; Schwartz, Farver, Change, & Lee-Shin, 2002) is a five-item self-report measure that assesse s peer victimization experiences over the past two weeks. Items assess both overt and relationa l victimization. The scale has been shown to have good internal consistency, and correlates well wi th teacher and peer reports of victimization and loneliness. Participants were asked to an swer each question regarding the frequency of victimization experiences by selecting one of four multiple choice items: never, sometimes, often, or almost every day. Internal cons istency for the SPVS in this study was = 0.925 (pretreatment) and = 0.910 (post-treatment). A copy of this measure was provided in Appendix F Childrens body image scale The Childrens Body Image Scale (CBIS; Truby & Paxton, 2002) is a measure of body size perception that has been shown to have adequate psyc hometric properties for use in boys and girls eight years and older. Previous research has indicated that it is a good measure of body dissatisfaction (Truby & Paxton, 2002) and reflects change in body size dissatisfaction across an intervention. The scale consists of seven pictures of a child ranging from thinnest to heaviest as reference points, with a separate set of pictures for boys and girl s. The scale was administered by

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45 giving the child a gender-matched pictorial scale and asking the child to circle the body shape that is most like his or her own (perceived figure). The child was th en given another gendermatched pictorial scale and asked to circle the body shape that he or she would most like to have (ideal figure). The difference between the perceive d and ideal figures was used as a measure of body size dissatisfaction.

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46 Figure 2-1. Screening, assessment and interven tion participation in Project STORY. Scheduled for Pre-Start Assessment (N= 109) Met Initial Eligibility Criteria. Scheduled for In-Person Screening ( N= 133 ) Screened for Eligibility via Phone (N= 154) Completed In-Person Screening (N= 111) Accepted Randomization and Started Treatment (N= 93) Do Not Meet Eligibility Criteria at In-Person Screening: BMI Below 85% (N= 2) No-Show at Pre-Start Assessment (8) Family Intervention ( N = 33 ) Waitlist Control Condition ( N = 26 ) Parent-Only Intervention ( N = 34 ) Waitlist Control: Completed Post-Tx Assessment (N = 21) Parent-Only Intervention: Completed Post-Tx Assessment (N = 29) Family Intervention: Completed Post-Tx Assessment (N = 31) Completed Pre-Start Assessment (101) Did Not Start Treatment: Excluded: BMI below 85% (5) Did Not Accept Randomization (3): -Waitlist (2) -Family (1) No-Show at In-Person Screening: (N= 22)

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47Table 2.1. Mean baseline characteristics of participants who completed pre-tr eatment and post-treatment assessment. All Conditions BFI BPI WLC Characteristic Total (N=81) Girls (n=50) Boys (n=31) Total (n=31) Girls (n=20) Boys (n=11) Total (n=29) Girls (n=14) Boys (n=15) Total (n=21) Girls (n=16) Boys (n=5) Age (yrs) 11.07 (1.58) 11.23 (1.6) 10.81 (1.6) 11.03 (1.6) 10.90 (1.7) 11.26 (1.4) 11.15 (1.4) 11.50 (1.3) 10.82 (1.5) 11.02 (1.81) 11.40 (1.7) 9.80 (1.9) Grade 5.65 (1.70) 5.70 (1.7) 5.58 (1.7) 5.45 (1.7) 5.25 (1.9) 5.81 (1.3) 5.93 (1.5) 6.14 (1.4) 5.73 (1.75) 5.57 (1.9) 5.88 (1.7) 4.60 (2.2) BMI z-score 2.15 (0.41) 2.13 (0.44) 2.20 (0.35) 2.20 (0.43) 2.22 (0.45) 2.15 (0.40) 2.21 (0.33) 2.20 (0.40) 2.22 (0.26) 2.02 (0.46) 1.96 (0.43) 2.20 (0.54) Note. Values enclosed in parenthe ses represent standard deviations.

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48Table 2.2. Frequency (and percen tage) of participants who completed pre-treatment and post-treatment assessment. Frequency All Conditions BFI BPI WLC Gender: Male 31 (38%) 11 (35.5%) 15 (51.7%) 5 (23.8%) Female 50 (62%) 20 (64.5%) 14 (48.3%) 16 (76.2%) Ethnicity: Caucasian 64 (79%) 23 (74.2%) 24 (82.8%) 17 (81%) African American 7 (8.6%) 3 (9.7%) 1 (3.4%) 3 (14.3%) Hispanic 6 (7.4%) 4 (12.9%) 1 (3.4%) 1 (4.8%) Asian 2 (2.5%) 1 (3.2%) 1 (3.4%) 0 (0%) Bi-racial 2 (2.5%) 0 (0%) 2 (6.9%) 0 (0%) Other 0 (0%) 0 (0%) 0 (0%) 0 (0%) Income Range*: > $9,999 5 (6.3%) 2 (6.9%) 2 (6.9%) 1 (4.8%) $10,000 $19,999 10 (12.7%) 3 (10.3%) 4 (13.8%) 3 (14.3%) $20,000 $39,999 24 (30.4%) 14 (48.3%) 5 (17.2%) 5 (23.8%) $40,000 $59,999 19 (24.1%) 2 (6.9%) 9 (31%) 8 (38.1%) $60,000 $79,999 8 (10.1%) 2 (6.9%) 5 (17.2%) 1 (4.8%) > $80,000 13 (16.5%) 6 (20.7%) 4 (13.8%) 3 (14.3%) Parent Marital Status: Currently Married 62 (76.5%) 23 (74.2%) 25 (86.2%) 14 (66.7%) Single, divorced 8 (9.9%) 3 (9.7%) 0 (0%) 5 (23.8%) Single, never married 5 (6.2%) 2 (6.5%) 2 (6.9%) 1 (4.8%) Single, co-habitating 1 (1.2%) 1 (3.2%) 0 (0%) 0 (0%) Single, widowed 5 (6.2%) 2 (6.5%) 2 (6.9%) 1 (4.8%) Parent Age** 41.85 (9.06) 40.23 (9.50) 41.75 (7.638) 44.18 (9.974) *Note. Income range data missing for two participants. **Note. Parent Age is listed by Me an (Standard Deviation). Parent ag e missing data for one participant.

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49 CHAPTER 3 RESULTS Analyses and Statistical Significance Given the number of analyses performed, the p value for significance for analyses related to the primary aims was kept at p < 0.05, while the p value for significance for secondary aims was set at p < .01 to prevent committing a Type I erro r (rejecting the null hypothesis when it is really true) (Grimm & Yarnold, 1995). Analyses included mixed model Repeated Measures ANOVA to assess for the impact of the treatment and gender on variables of interest (Aim 1, 5, 6, and 7). If appropriate, post hoc analyses incl uding paired t-tests we re conducted to examine main effect for time, and pairwise comparisons were conducted to examine significant main effects for treatment and gender. Multiple regression analyses were utilized to examine the association between criterion and predictor variables (Aim 2, 3, 4, 5, 6, and 7). As cross sectional research has provided some evidence for gender differences in self-esteem, we included a moderator analysis to assess for differential impact of self-esteem among boys a nd girls (Mendelson & White, 1985; Pesa et al., 2000; Israel & Ivanova, 2002). The e ffect of the predicto r variable on the crit erion variable, and gender differences in those associations, were assessed by testing for moderating effects of gender via multiple regression, based on protoc ol recommended by Frazier and colleagues (Frazier, Tix, & Barron, 2004). Based on this appro ach, the predictor variab le of interest was transformed into a z-score and tested against the criterion variable in block one to analyze for direct effects of the predictor va riable on the variable of interest. Main effects for the predictor were indicated if the predictor was a significant contributor to the model. In order to examine potential moderation of gender, the variable for gender was dummy coded as either or -1. Then a product (interaction term) was created by mu ltiplying the z-score of the predictor variable

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50 by the dummy coded variable for gender. The z-sc ore for the predictor va riable and the dummy coded gender variables were ente red into block two. Then the pr oduct of the z-score predictor variable and dummy coded gender variable wa s entered into block three. Moderation was indicated if the unstandardized beta weight for the interaction between the predictor and gender was a significant contributor to the model. Primary Aims Significance values for primary aims were set at p < 0.05. Aim 1: To Examine the Impact of the Intervention Groups on Self-Esteem Four 2 x 3 x 2 mixed model ANOVAs were cond ucted to evaluate the within subjects change in social, athletic, physical, and global self-esteem from preto post-treatment examining the between subjects effects of trea tment condition and gender. All self-esteem preand post-treatment means for girls and boys in each treatment condition are listed in Table 3-1. Analysis of the model for global self-esteem indicated a significant main effect of time ( F [1, 75] = 9.029, p = 0.004, 2 = 0.107). The main effect of tim e was explored using post-hoc paired samples t-tests which indicated a significant improvement in global self-esteem from preto post-treatment for participants in the BPI condition ( t = -2.157, df = 28, p = 0.040) and WLC condition ( t = -2.823, df = 20, p = 0.011), but no significant change in global self-esteem over time for participants in the BFI condition ( t = 01.003, df = 30, p = 0.324). The model indicated a non-significant main effect of gender ( F [1, 75] = 0.070, p = 0.793, 2 = 0.001), a non-significant main effect of treatment condition ( F [2, 75] = 0.056, p = 0.945, 2 = 0.001), a non-significant time by gender interaction effect ( F [1, 75] = 2.414, p = 0.124, 2 = 0.031), a non-significant time by treatment interaction ( F [2, 75] = 0.974, p = 0.382, 2 = 0.025), a non-significant treatment by gender in teraction effect ( F [2, 75] = 0.956, p = 0.389, 2 = 0.025), and a non-

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51 significant time by treatment by gender effect ( F [2, 75] = 0.277, p = 0.759, 2 = 0.007). Please refer to Figure 3-1 for a graph of mean cha nge in global self-esteem by treatment condition. Analysis of the model for social self-esteem indicated a significant main effect of time ( F [1, 74] = 6.530, p = 0.013, 2 = 0.081). The main effect of tim e was explored using post-hoc paired samples t-tests which indicated a significant improvement in social self-esteem from preto post-treatment for participants in the BPI condition ( t = -2.587, df = 28, p = 0.015), but no significant change in social self-esteem over time for participants in the BFI ( t = -0.163, df = 30, p = 0.872) or WLC ( t = -1.573, df = 19, p = 0.132) conditions. The model indicated a nonsignificant main effect of gender ( F [1, 74] = 0.037, p = 0.847, 2 = 0.001), a non-significant main effect of treatment condition ( F [2, 74] = 0.930, p = 0.399, 2 = 0.025), a non-significant time by gender interaction effect ( F [1, 74] = 1.333, p = 0.252, 2 = 0.018), a non-significant time by treatment interaction ( F [2, 74] = 0.954, p = 0.390, 2 = 0.025), a non-significant treatment by gender in teraction effect ( F [2, 74] = 0.493, p = 0.613, 2 = 0.013), and a nonsignificant time by treatment by gender effect ( F [2, 74] = 0.248, p = 0.781, 2 = 0.007). Please refer to Figure 3-2 for a graph of mean cha nge in social self-esteem by treatment condition. Analysis of the model for athletic self-esteem indicated a significant main effect of time ( F [1, 75] = 6.268, p = 0.014, 2 = 0.077). The main effect of tim e was explored using post-hoc paired samples t-tests which indicated a significant improvement in athletic self-esteem from preto post-treatment for participants in the BFI condition ( t = -2.623, df = 30, p = 0.014), but no significant change in athletic self-esteem over time for participants in the BPI ( t = -1.166, df = 28, p = 0.254) or WLC ( t = -0.314, df = 20, p = 0.757) conditions. The model indicated a nonsignificant main effect of gender ( F [1, 75] = 2.119, p = 0.150, 2 = 0.027), a non-significant main effect of treatment condition ( F [2, 75] = 0.140, p = 0.869, 2 = 0.004), a non-significant

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52 time by gender interaction effect ( F [1, 75] = 0.104, p = 0.748, 2 = 0.001), a non-significant time by treatment interaction ( F [2, 75] = 1.011, p = 0.369, 2 = 0.026), a non-significant treatment by gender in teraction effect ( F [2, 75] = 0.295, p = 0.746, 2 = 0.008), and a nonsignificant time by treatment by gender effect ( F [2 ,75] = 0.892, p = 0.414, 2 = 0.023). Please refer to Figure 3-3 for a graph of mean change in athletic self-esteem by treatment condition. Analysis of the model for physical self-esteem indicated a significant main effect of gender ( F [1, 75] = 4.643, p = 0.034, 2 = 0.058). Specifically, boys mean physical self-esteem ( M = 2.480, SE = 0.143) was higher than girls mean physical self-esteem ( M = 2.101, SE = 0.102). The model indicated a non-significant main effect of time ( F [1, 75] = 2.743, p = 0.102, 2 = 0.035), a non-significant main eff ect of treatment condition ( F [2, 75] = 0.707, p = 0.497, 2 = 0.018), a non-significant time by ge nder interaction effect ( F [1, 75] = 2.740, p = 0.102, 2 = 0.035), a non-significant time by treatment interaction ( F [2, 75] = 1.158, p = 0.320, 2 = 0.030), a non-significant treatment by gender interaction effect ( F [2, 75] = 0.186, p = 0.831, 2 = 0.005), and a non-significant time by treatment by gender effect ( F [2, 75] = 1.846, p = 0.165, 2 = 0.047). In summary, participants in the BPI condition experienced significant social self-esteem and global self-esteem improvements over time. Participants in the BFI condition experienced significant improvements in athletic self-esteem over time. Participants in the WLC condition experienced significant improvements in global self-esteem over time. No treatment condition was significantly different than another group with regard to impact on self-esteem change over time. Gender differences were present in that boys had significantly higher mean physical selfesteem than girls; however, boys a nd girls did not differ in self -esteem improvements over time

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53 or due to treatment. Self-esteem changes did not differ when examined by age, ethnicity, or county of treatment. Aim 2: To Determine the Impact of We ight Status Change on Self-Esteem All impact variable prea nd post-treatment means for girl s and boys in each treatment condition are listed in Table 3-2. The average percent decrease in BMI z-score for child participants across conditions was 0.0417, SD = 0.11 (BFI: M = 0.0365 [ SD = 0.09]; BPI: M = 0.0734 [ SD = 0.12]; WLC: M = 0.0057 [ SD = 0.09]). Multiple regressions based on procedures recommended by Frazier and colleagues (Frazier et al., 2004) were conduc ted to evaluate the association between weight status change and change in social, athletic, physical and global self-esteem Block one of the regression analysis showed a non-significant direct effect for weight status change on global self-esteem ( R2 = 0.038, F [1, 80] = 3.096, = 0.194, t = 1.759, p = 0.082), indicating that change in gl obal self-esteem was not associ ated with change in weight status. Block two showed a signifi cant direct effect for gender ( = 0.218, t = 2.011, p = 0.048), indicating that gender was significa ntly associated with change in global self-esteem. However, the unstandardized beta weight for the product of we ight status and gender in block three was not significant ( = 0.200, t = 1.772, p = 0.080). Thus, gender was not a moderator of the association between weight status change and change in global self-esteem Block one of the regression analysis showed a non-significant direct effect for weight status change on social self-esteem ( R2 = -0.012, F [1, 79] = 0.079, = 0.032, t = 0.281, p = 0.779), indicating that change in so cial self-esteem was not associ ated with change in weight status. Block two showed a non-signif icant direct effect for gender ( = -0.167, t = -1.482, p = 0.142). The unstandardized beta weight for the pr oduct of weight status and gender in block

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54 three was not significant ( = 0.108, t = 0.925, p = 0.358). Thus, gender was not a moderator of the association between weight status ch ange and change in social self-esteem. Block one of the regression analysis showed a non-significant direct effect for weight status change on athl etic self-esteem ( R2 < 0.001, F [1, 80] < 0.001, = -0.002, t = -0.022, p = 0.983), indicating that change in at hletic self-esteem was not associ ated with change in weight status. Block two showed a non-significant direct effect for gender on athletic self-esteem ( = 0.006, t = 0.054, p = 0.957). The unstandardized beta weight for the product of weight status and gender in block three was not significant ( = 0.084, t = 0.699, p = 0.487). Thus, gender was not a moderator of the association betw een weight status change and ch ange in athletic self-esteem. Block one of the regression analysis showed a non-significant direct effect for weight status change on physical self-esteem ( R2 = 0.038, F [1, 80] = 3.091, = 0.194, t = 1.758, p = 0.083), indicating that change in phys ical self-esteem was not associ ated with change in weight status. Block two showed a non-significant direct effect for gender on physical self-esteem ( = 0.207, t = 1.904, p = 0.061). The unstandardized beta weight for the product of weight status and gender in block three was not significant ( = 0.184, t = 1.620, p = 0.109). Thus, gender was not a moderator of the association be tween weight status change and change in physical self-esteem. In summary, change in weight status was not associated with improvements in social, athletic, physical, and global se lf-esteem. Furthermore, no gender differences were observed. Secondary Aims Significance values for secondary aims were set at p < 0.01. Aim 3: To Examine the Impact of Behavi oral Goal Attainme nt on Self-Esteem Multiple regressions were conducted to evalua te the association between goal attainment and improvements in social, athletic, physical, and global self-esteem Data only from children in the BPI and BFI were used in these analyses, as families in the WLC did not complete weekly

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55 habit logs or set goals. Mean goal attainment for the partic ipants was approximately 40%, SD = 0.26 (BFI: M = 35% [ SD = 0.27]; BPI: M = 44% [ SD = 0.26]). Block one of the regression anal ysis showed a non-significant di rect effect for behavioral goal attainment on change in global self-esteem ( R2 = 0.006, F [1, 59] = 0.340, = -0.076, t = 0.583, p = 0.562), indicating that change in global self -esteem was not associated with behavioral goal attainment. Block two showed a non-signifi cant direct effect for gender on global selfesteem ( = 0.199, t = 1.507, p = 0.137). The unstandardized beta weight for the product of behavioral goal attainment and gende r in block three was not significant ( = -0.039, t = -0.292, p = 0.772). Thus, gender was not a moderator of the association betw een behavioral goal attainment and change in global self-esteem. Block one of the regression anal ysis showed a non-significant di rect effect for behavioral goal attainment on change in social self-esteem ( R2 = 0.003, F [1, 59] = 0.162, = -0.053, t = 0.403, p = 0.689), indicating that change in social self -esteem was not associat ed with behavioral goal attainment. Block two showed a non-signifi cant direct effect for gender on social selfesteem ( = -0.243, t = -1.855, p = 0.069). The unstandardized beta weight for the product of behavioral goal attainment and gende r in block three was not significant ( = -0.039, t = -0.292, p = 0.771). Thus, gender was not a moderator of the association betw een behavioral goal attainment and change in social self-esteem. Block one of the regression anal ysis showed a non-significant di rect effect for behavioral goal attainment on change in athletic self-esteem ( R2 = 0.007, F [1, 59] = 0.393, = -0.082, t = 0.627, p = 0.533), indicating that change in athlet ic self-esteem was not associated with behavioral goal attainment. Block two showed a non-significant direct effect for gender on athletic self-esteem ( = 0.100, t = 0.747, p = 0.458). The unstandardized beta weight for the

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56 product of behavioral goal attainment and gender in block three was not significant ( = -0.036, t = -0.268, p = 0.790). Thus, gender was not a moderator of the association between behavioral goal attainment and change in athletic self-esteem. Block one of the regression anal ysis showed a non-significant di rect effect for behavioral goal attainment on change in physical self-esteem ( R2 = 0.001, F [1, 59] = 0.035, = 0.024, t = 0.186, p = 0.853), indicating that change in physical self-esteem was not associated with behavioral goal attainment. Block two showed a significant direct effect for gender on physical self-esteem ( = 0.351, t = 2.766, p = 0.008), indicating that gender was significantly associated with change in physical self-esteem. The uns tandardized beta wei ght for the product of behavioral goal attainment and gende r in block three was not significant ( = -0.203, t = -1.627, p = 0.109). Thus, gender was not a moderator of the association betw een behavioral goal attainment and change in physical self-esteem. Attainment of red food goals and step goals was examined separately to identify if attainment of a particular type of goal (red f ood goal attainment and step goal attainment) was associated with self-esteem improvement, but thes e associations also were not significant. In summary, goal attainment was not associated with self-esteem improvement. Furthermore, gender was not a significant m oderator of associations. Aim 4: To Determine the Impact of Self-E fficacy on Weight Status and Self-Esteem Multiple regressions were conducted to evaluate the association between pre-treatment self-efficacy for making healthy lifestyle choices a nd changes in weight status. Block one of the regression analysis showed a nonsignificant direct effect for pre-treatment self-efficacy on weight status change ( R2 = 0.008, F [1, 80] = 0.604, = 0.087, t = 0.777, p = 0.439), indicating that pre-treatment self-efficacy was not associat ed with change in weight status. Block two showed a non-significant direct effect fo r gender on change in weight status ( = -0.087, t = -

PAGE 57

57 0.768, p = 0.445). The unstandardized beta weight for the product of pre-treatment self-efficacy and gender in block thre e was not significant ( = -0.063, t = -0.488, p = 0.627). Thus, gender was not a moderator of the relationship between pre-treatment self-efficac y and weight status change. Multiple regressions were conducted to evaluate the association between pre-treatment self-efficacy for making healthy lifestyle choices and change in social, athletic, physical, and global self-esteem Block one of the regression analysis sh owed a non-significant direct effect for pre-treatment self-efficacy on change in global self-esteem ( R2 = 0.017, F [1, 80] = 1.348, = 0.130, t = 1.161, p = 0.249), indicating that change in globa l self-esteem was not associated with pre-treatment self-efficacy. Block two showed a non-significant direct effect for gender on global self-esteem ( = 0.188, t = 1.692, p = 0.095). The unstandardized beta weight for the product of pre-treatment self-efficacy and ge nder in block three was not significant ( = 0.155, t = 1.235, p = 0.221). Thus, gender was not a moderator of the association between pre-treatment self-efficacy and change in global self-esteem. Block one of the regression analysis show ed a non-significant direct effect for pretreatment self-efficacy on change in social self-esteem ( R2 = 0.008, F [1, 79] = 0.595, = 0.087, t = 0.772, p = 0.443), indicating that change in social self-esteem was not associated with pretreatment self-efficacy. Block two showed a non-si gnificant direct effect for gender on social self-esteem ( = -0.184, t = -1.629, p = 0.107). The unstandardized beta weight for the product of pre-treatment self-efficacy and gender in block three was not significant ( = 0.200, t = 1.589, p = 0.116). Thus, gender was not a moderator of th e association between pre-treatment selfefficacy and change in social self-esteem.

PAGE 58

58 Block one of the regression analysis show ed a non-significant direct effect for pretreatment self-efficacy on change in athletic self-esteem ( R2 = 0.006, F [1, 80] = 0.472, = 0.077, t = 0.687, p = 0.494), indicating that change in athl etic self-esteem was not associated with pre-treatment self-efficacy. Block two show ed a non-significant direct effect for gender on athletic self-esteem ( = -0.005, t = -0.041, p = 0.967). The unstandardized beta weight for the product of pre-treatment self-efficacy and ge nder in block three was not significant ( = 0.169, t = 1.322, p = 0.190). Thus, gender was not a moderator of the association between pre-treatment self-efficacy and change in athletic self-esteem. Block one of the regression analysis show ed a non-significant direct effect for pretreatment self-efficacy on change in physical self-esteem ( R2 = 0.007, F [1, 80] = 0.587, = 0.086, t = 0.766, p = 0.446), indicating that change in phys ical self-esteem was not associated with pre-treatment self-efficacy. Block two show ed a non-significant direct effect for gender on physical self-esteem ( = 0.184, t = 1.638, p = 0.105). The unstandardized beta weight for the product of pre-treatment self-efficacy and ge nder in block three was not significant ( = 0.052, t = 0.413, p = 0.681). Thus, gender was not a moderator of the association between pre-treatment self-efficacy and change in physical self-esteem. Multiple regressions were conducted to evaluate the association between change in selfefficacy for making healthy lifestyle choices and change in social, athletic, physical, and global self-esteem Block one of the regressi on analysis showed a non-signi ficant direct effect for change in self-efficacy on change in global self-esteem ( R2 = 0.001, F [1, 80] = 0.094, = 0.034, t = -0.306, p = 0.760), indicating that change in global self-esteem was not associated with change in self-efficacy. Block two showed a non-significant direct e ffect for gender on global self-esteem change ( = -0.202, t = 1.805, p = 0.075). The unstandardized beta weight for the

PAGE 59

59 product of change in self-efficacy and gende r in block three was not significant ( = 0.026, t = 0.222, p = 0.825). Thus, gender was not a moderator of the association betwee n change in selfefficacy and change in global self-esteem. Block one of the regression anal ysis showed a non-significant di rect effect for change in self-efficacy on social self-esteem ( R2 < 0.001, F [1, 79] = 0.008, = 0.010, t = 0.088, p = 0.930), indicating that change in social self-esteem was not asso ciated with change in selfefficacy. Block two showed a non-significant dir ect effect for gender on social self-esteem change ( = -0.170, t = -1.497, p = 0.138). The unstandardized beta weight for the product of change in self-efficacy and gender in block three was not significant ( = -0.058, t = -0.488, p = 0.627). Thus, gender was not a moderator of the asso ciation between change in self-efficacy and change in social self-esteem. Block one of the regression anal ysis showed a non-significant di rect effect for change in self-efficacy on athletic self-esteem ( R2 = 0.038, F [1, 80] = 3.113, = 0.195, t = 1.764, p = 0.082), indicating that change in at hletic self-esteem was not asso ciated with change in selfefficacy. Block two showed a non-significant direct effect for gender on athletic self-esteem change ( = 0.036, t = 0.320, p = 0.750). The unstandardized beta weight for the product of change in self-efficacy and gender in block three was not significant ( = -0.114, t = -0.965, p = 0.338). Thus, gender was not a moderator of the asso ciation between change in self-efficacy and change in athletic self-esteem. Block one of the regression anal ysis showed a non-significant di rect effect for change in self-efficacy on physical self-esteem ( R2 = 0.001, F [1, 80] = 0.094, = 0.034, t = 0.306, p = 0.760), indicating that change in physical self-esteem was not asso ciated with change in selfefficacy. Block two showed a non-significant direct effect for gender on physical self-esteem

PAGE 60

60 change ( = 0.202, t = 1.797, p = 0.076). The unstandardized beta weight for the product of change in self-efficacy and gender in block three was not significant ( = -0.079, t = -0.666, p = 0.508). Thus, gender was not a moderator of the asso ciation between change in self-efficacy and change in physical self-esteem. In summary, self-efficacy for healthy lifestyle behaviors was not associated with change in weight status or self-esteem change for particip ants at any stage of th e study. Furthermore, no gender differences were observed. Aim 5: To Determine the Impact of and A ssociation Between Weight-Specific Locus of Control, Weight Status, and Se lf-Esteem in Overweight Children Multiple regressions were conducted to evaluate the association between pre-treatment weight-specific locus of control and pre-treatment social, athletic, physical and global selfesteem Block one of the regression analysis show ed a non-significant direct effect for pretreatment locus of control on global self-esteem ( R2 < 0.001, F [1, 80] < 0.001, = -0.001, t = 0.009, p = 0.993), indicating that pre-treatment global self-esteem was not associated with pretreatment locus of control. Block two showed a non-significant direct eff ect for gender on global self-esteem ( = 0.208, t = 1.852, p = 0.068). The unstandardized beta weight for the product of pre-treatment locus of cont rol and gender in block th ree was not significant ( = 0.140, t = 1.221, p = 0.226). Thus, gender was not a moderator of th e association between pr e-treatment locus of control and pre-treatment global self-esteem. Block one of the regression analysis show ed a non-significant direct effect for pretreatment locus of control on social self-esteem ( R2 = 0.005, F [1, 79] = 0.420, = 0.073, t = 0.648, p = 0.519), indicating that pre-treatment social self-esteem was not associated with pretreatment locus of control. Block two showed a nonsignificant direct effect for gender on social self-esteem ( = -0.161, t = -1.416, p = 0.519). The unstandardized beta weight for the product of

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61 pre-treatment locus of cont rol and gender in block th ree was not significant ( = 0.091, t = 0.778, p = 0.439). Thus, gender was not a moderator of th e association between pr e-treatment locus of control and pre-treatment social self-esteem. Block one of the regression analysis show ed a non-significant direct effect for pretreatment locus of control on athletic self-esteem ( R2 = 0.003, F [1, 80] = 0.198, = 0.050, t = 0.445, p = 0.657), indicating that pre-tr eatment athletic self-esteem was not associated with pretreatment locus of control. Block two showed a non-significant direct effect for gender on athletic self-esteem ( = 0.014, t = 0.123, p = 0.902). The unstandardized beta weight for the product of pre-treatment locus of control and gender in block three was not significant ( = 0.088, t = 0.746, p = 0.458). Thus, gender was not a moderator of the association between pretreatment locus of control and pretreatment athletic self-esteem. Block one of the regression analysis show ed a non-significant direct effect for pretreatment locus of control on physical self-esteem ( R2 < 0.001, F [1, 80] < 0.001, = -0.001, t = 0.012, p = 0.991), indicating that pre-treatment physical self-esteem was not associated with pretreatment locus of control. Block two showed a non-significant direct effect for gender on physical self-esteem ( = 0.196, t = 1.746, p = 0.085). The unstandardized beta weight for the product of pre-treatment locus of control and gender in block three was not significant ( = 0.179, t = 1.562, p = 0.122). Thus, gender was not a moderator of the association between pretreatment locus of control and pr e-treatment physical self-esteem. A 2 x 3 x 2 mixed model ANOVA was performed to examine change in weight-specific locus of control from preto post-treatment, ex amining the between subjec ts effects of treatment condition and gender. Examination of the model indi cated a non-significant direct effect of time ( F [1, 75] = 3.316, p = 0.073, 2 = 0.042), a non-significant direct effect of gender ( F [1, 75] =

PAGE 62

62 1.302, p = 0.257, 2 = 0.017), a non-significant direct effect of treatment condition ( F [2, 75] = 0.896, p = 0.413, 2 = 0.023), a non-significant time by gender interaction effect ( F [1, 75] = 0.028, p = 0.868, 2 < 0.001), a non-significant time by treatment interaction ( F [2, 75] = 0.833, p = 0.439, 2 = 0.022), a non-significant treatment by gender interaction effect ( F [2, 75] = 0.793, p = 0.456, 2 = 0.021), and a non-significant time by treatment by gender effect ( F [2, 75] = 0.513, p = 0.601, 2 = 0.013). In summary, weight-specific locus of control did not change over time or due to treatment, and no gender differences were present in the sample. Multiple regressions were conducted to evaluate the association between post-treatment weight-specific locus of control and weight status on post-treatment social, athletic, physical and global self-esteem In the sample, post-treatment lo cus of control was significantly associated with post-treatment global self-esteem ( R2 = 0.116, F [1, 80] = 10.322, p = 0.002), social self-esteem ( R2 = 0.121, F [1, 80] = 10.848, p = 0.001), athletic self-esteem ( R2 = 0.103, F [1, 80] = 9.074, p = 0.003), and physical self-esteem ( R2 = 0.157, F [1, 80] = 14.669, p < 0.001). However, weight status change was only a statistically signifi cant predictor of post-treatment athletic self-esteem ( R2 = 0.097, F [1, 80] = 8.474, p = 0.005), and not statistically associated with post-treatment social self-esteem ( R2 = 0.017, F [1, 80] = 1.368, p = 0.246), physical selfesteem ( R2 = 0.033, F [1, 80] = 2.728, p = 0.103), or global self-esteem ( R2 = 0.054, F [1, 80] = 4.472, p = 0.038). Moderator effects were not indicated because the effect of the interaction (between weight-specific locus of control and wei ght status change) was not significant when the simple effects of the independent variables (wei ght-specific locus of cont rol and weight status change) were controlled (interaction = 0.562, t = 0.686, p = 0.495). No gender differences were observed when examining the interaction betw een post-treatment weight-specific locus of

PAGE 63

63 control and change in weight status on post-treatment self-esteem (interaction = 0.071, t = 0.550, p = 0.584). In summary, weight-specific lo cus of control was not associat ed with participants selfesteem. Weight-specific locus of control did not change over time or as a result of treatment for the participants. The interaction between weight status change and self-esteem change was not significant Furthermore, no gender differences existed in the relationship. Aim 6: To Examine the Impact of Peer Victimization on Self-Esteem Multiple regressions were conducted to evaluate the association between pre-treatment peer victimization and pre-treatment social, athletic, physical, and global self-esteem Block one of the regression analysis showed a signi ficant direct effect for pre-treatment peer victimization on pre-treatment global self-esteem ( R2 = 0.135, F [1, 80] = 12.340, = -0.368, t = -3.513, p = 0.001), indicating that pretreatment global self-esteem was associated with pretreatment peer victimization such that greater peer victimizatio n was associated with poorer global self-esteem. Block two show ed a non-significant direct eff ect for gender on global selfesteem ( = -0.103, t = -0.980, p = 0.330). The unstandardized beta weight for the product of pretreatment peer victimization and gender in block three was not significant ( = 0.122, t = 1.125, p = 0.264). Thus, gender was not a moderator of th e association between pre-treatment peer victimization and pre-treatment global self-esteem. Block one of the regression anal ysis showed a significant dir ect effect for pre-treatment peer victimization on pre-treatment social self-esteem ( R2 = 0.209, F [1, 79] = 20.582, = 0.457, t = -4.537, p < 0.001), indicating that pre-treatment so cial self-esteem was associated with pre-treatment peer victimization such that greater peer victimi zation was associated with poorer social self-esteem. Block two showed a non-signif icant direct effect for gender on social selfesteem ( = 0.141, t = 1.409, p = 0.163). The unstandardized beta weight for the product of pre-

PAGE 64

64 treatment peer victimization and gender in block three was not significant ( = 0.031, t = 0.294, p = 0.770). Thus, gender was not a moderator of th e association between pre-treatment peer victimization and pre-treatment social self-esteem. Block one of the regression anal ysis showed a significant dir ect effect for pre-treatment peer victimization on pre-treatment athletic self-esteem ( R2 = 0.110, F [1, 80] = 9.806, = 0.332, t = -3.132, p = 0.002), indicating that pre-treatment athletic self-esteem was associated with pre-treatment peer victimization such that greater peer victimization was associated with poorer athletic self-esteem. Block two showed a non-significant direct effect for gender on athletic self-esteem ( = -0.147, t = -1.396, p = 0.167). The unstandardized beta weight for the product of pre-treatment peer victimization a nd gender in block three was not significant ( = 0.108, t = -0.993, p = 0.324). Thus, gender was not a moderator of the association between pretreatment peer victimization and pr e-treatment athletic self-esteem. Block one of the regression analysis show ed a non-significant direct effect for pretreatment peer victimi zation on pre-treatment physical self-esteem ( R2 = 0.064, F [1, 80] = 5.441, = -0.254, t = 02.333, p = 0.022), indicating that pre-treatm ent physical self-esteem was not associated with pre-treatment peer victimization. Block two showed a significant direct effect for gender on physical self-esteem ( = -0.326, t = -3.153, p = 0.002), indicating that gender was associated with pre-treatment physical self-est eem, such that boys had higher pre-treatment physical self-esteem. The unstandardized beta weight for the product of pre-treatment peer victimization and gender in bl ock three was not significant ( = 0.125, t = 1.173, p = 0.244). Thus, gender was not a moderator of the associa tion between pre-treatmen t peer victimization and pre-treatment physical self-esteem.

PAGE 65

65 Multiple regressions were conducted to evaluate the association between change in peer victimization and change in social, athletic, physical, and global self-esteem Block one of the regression analysis showed a nonsignificant direct effect for ch ange in peer victimization on change in global self-esteem ( R2 = 0.011, F [1, 80] = 0.910, = -0.107, t = -0.954, p = 0.343), indicating that change in global se lf-esteem was not associated with change in peer victimization. Block two showed a non-significant direct effect for gender on ch ange in global self-esteem ( = 0.190, t = 1.690, p = 0.095). The unstandardized beta weight for the product of change in peer victimization and gender in bl ock three was not significant ( = -0.163, t = -1.414, p = 0.161). Thus, gender was not a moderator of the associa tion between change in peer victimization and change in global self-esteem. Block one of the regression analysis showed a significant direct effect for change in peer victimization on change in social self-esteem ( R2 = 0.083, F [1, 79] = 7.085, = -0.289, t = 2.662, p = 0.009), indicating that change in social self -esteem was associated with change in peer victimization, such that reductions in peer vict imization were associated with improvements in social self-esteem. Block two showed a non-signif icant direct effect for gender on change in social self-esteem ( = -0.228, t = -2.110, p = 0.038). The unstandardized beta weight for the product of change in peer victimization a nd gender in block three was not significant ( = -0.033, t = -0.299, p = 0.766). Thus, gender was not a moderator of the association between change in peer victimization and change in social self-esteem. Block one of the regression anal ysis showed a non-significant di rect effect for change in peer victimization on change in athletic self-esteem ( R2 = 0.031, F [1, 80] = 2.489, = -0.175, t = -1.578, p = 0.119), indicating that change in athletic self-esteem was not associated with change in peer victimization. Block two showed a non-si gnificant direct effect for gender on change in

PAGE 66

66 athletic self-esteem ( = -0.026, t = -0.228, p = 0.820). The unstandardized beta weight for the product of change in peer victimization a nd gender in block three was not significant ( = -0.168, t = -1.447, p = 0.152). Thus, gender was not a moderator of the association between change in peer victimization and change in athletic self-esteem. Block one of the regression analysis showed a significant direct effect for change in peer victimization on change in physical self-esteem ( R2 = 0.105, F [1, 80] = 9.302, = -0.325, t = 3.050, p = 0.003), indicating that change in physical se lf-esteem was associated with change in peer victimization, such that re ductions in peer victimization we re associated with improvements in physical self-esteem. Block two showed a non-significant direct e ffect for gender on change in physical self-esteem ( = 0.138, t = 1.283, p = 0.203). The unstandardized beta weight for the product of change in peer victimization a nd gender in block three was not significant ( = -0.037, t = -0.327, p = 0.744). Thus, gender was not a moderator of the association between change in peer victimization and change in physical self-esteem. Multiple regressions were conducted to evaluate the association between post-treatment peer victimization and post-treatment social, athletic, physical, and global self-esteem. Block one of the regression analysis showed a signi ficant direct effect for post-treatment peer victimization on post-treatment global self-esteem ( R2 = 0.162, F [1, 80] = 15.253, = -0.402, t = -3.905, p < 0.001), indicating that post -treatment global self-esteem was associated with posttreatment peer victimization, such that lower post-treatment peer victimization was associated with higher post-treatment global self-esteem. Block two showed a non-significant direct effect for gender on post-treatment global self-esteem ( = -0.002, t = -0.020, p = 0.984). The unstandardized beta weight for the product of post-treatment peer victimization and gender in block three was not significant ( = -0.060, t = -0.563, p = 0.575). Thus, gender was not a

PAGE 67

67 moderator of the association be tween post-treatment peer victim ization and post-treatment global self-esteem. Block one of the regression anal ysis showed a significant dir ect effect for post-treatment peer victimization on post-treatment social self-esteem ( R2 = 0.213, F [1, 80] = 21.433, = 0.462, t = -4.630, p < 0.001), indicating that post-treatment social self-esteem was associated with post-treatment peer victimization, such th at lower post-treatment peer victimization was associated with higher post-treatment social self-esteem. Block two showed a non-significant direct effect for gender on posttreatment social self-esteem ( = -0.033, t = -0.328, p = 0.744). The unstandardized beta weight for the product of post-treatment peer victimization and gender in block three was not significant ( = -0.28, t = -0.274, p = 0.785). Thus, gender was not a moderator of the association betw een post-treatment peer victimi zation and post-treatment social self-esteem. Block one of the regression analysis show ed a non-significant direct effect for posttreatment peer victimization on post-treatment athletic self-esteem ( R2 = 0.033, F [1, 80] = 2.690, = -0.181, t = -1.640, p = 0.105), indicating that post-treatm ent athletic self-esteem was not associated with post-treatment peer victimiza tion. Block two showed a non-significant direct effect for gender on post-treatment athletic self-esteem ( = 0.175, t = -1.589, p = 0.116). The unstandardized beta weight for the product of post-treatment peer victimization and gender in block three was not significant ( = -0.035, t = -0.308, p = 0.759). Thus, gender was not a moderator of the association between post-treatment peer vi ctimization and post-treatment athletic self-esteem. Block one of the regression anal ysis showed a significant dir ect effect for post-treatment peer victimization on post-treatment physical self-esteem ( R2 = 0.113, F [1, 80] = 10.036, = -

PAGE 68

68 0.336, t = -3.168, p = 0.002), indicating that post-treatment physical self-esteem was associated with post-treatment peer victimization, such th at lower post-treatment peer victimization was associated with higher post-treatment physical self-esteem. Block two showed a non-significant direct effect for gender on posttreatment physical self-esteem ( = -0.298, t = -1.898, p = 0.061). The unstandardized beta weight for the product of post-treatment peer victimization and gender in block three was not significant ( = 0.040, t = 0.372, p = 0.711). Thus, gender was not a moderator of the association between post-treatment peer vi ctimization and post-treatment physical self-esteem. In summary, preand post-treatment peer victimization rating s were significantly associated with many domains of preand pos t-treatment self-esteem for girls and boys. Analyses indicated that reductions in peer victimization ratings were associated with improvements in social self-esteem and physical self-esteem All associations between peer victimization and self-esteem were such that more peer victimization was associated with poorer self-esteem. Gender differences were not observed. Aim 7: To Examine the Impact of Body Image on Self-Esteem Multiple regressions were conducted to evaluate the association between pre-treatment body dissatisfaction ratings and pre-treatment social, athletic, physical, and global self-esteem Block one of the regression analysis showed a significant direct effect for pre-treatment body dissatisfaction ratings on pre-treatment global self-esteem ( R2 = 0.172, F [1, 80] = 16.372, = 0.414, t = -4.046, p < 0.001), indicating that poorer pretreatment global self-esteem was associated with greater pre-treatment body dissa tisfaction. Block two showed a non-significant direct effect for gender on pr e-treatment global self-esteem ( = -0.062, t = -0.601, p = 0.550). The unstandardized beta weight for the product of pre-treatment body diss atisfaction and gender in block three was not significant ( = -0.099, t = -0.905, p = 0.368). Thus, gender was not a

PAGE 69

69 moderator of the association be tween pre-treatment body dissatisfa ction and pre-treatment global self-esteem. Block one of the regression analysis show ed a non-significant direct effect for pretreatment body dissatisfaction ratings on pre-treatment social self-esteem ( R2 = -.036, F [1, 79] = 2.876, = -0.189, t = -1.696, p = 0.094), indicating that pre-treatme nt social self-esteem was not associated with pre-treatment body dissatisfactio n. Block two showed a non-significant direct effect for gender on pre-trea tment social self-esteem ( = 0.150, t = 1.337, p = 0.185). The unstandardized beta weight fo r the product of pre-treatment body dissatisfaction and gender in block three was not significant ( = 0.066, t = 0.556, p = 0.580). Thus, gender was not a moderator of the association be tween pre-treatment body dissatisfa ction and pre-treatment social self-esteem. Block one of the regression analysis show ed a non-significant direct effect for pretreatment body dissatisfaction ratings on pre-treatment athletic self-esteem ( R2 = 0.056, F [1, 80] = 4.691, = -0.237, t = -2.166, p = 0.033), indicating that pre-trea tment athletic self-esteem was not associated with pre-treatme nt body dissatisfaction. Block two s howed a non-significant direct effect for gender on pre-treatm ent athletic self-esteem ( = -0.132, t = -1.203, p = 0.233). The unstandardized beta weight fo r the product of pre-treatment body dissatisfaction and gender in block three was not significant ( = -0.079, t = -0.680, p = 0.499). Thus, gender was not a moderator of the association between pre-treatment body dissa tisfaction and pre-treatment athletic self-esteem. Block one of the regression anal ysis showed a significant dir ect effect for pre-treatment body dissatisfaction ratings on pre-treatment physical self-esteem ( R2 = 0.100, F [1, 80] = 8.785, = -0.316, t = -2.964, p = 0.004), indicating that poorer pretreatment physical self-esteem was

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70 associated with greater pre-treatment body dissatis faction. Block two showed a significant direct effect for gender on pre-treatment physical self-esteem ( = -0.298, t = -2.889, p = 0.005), indicating that gender was significa ntly associated with pre-treat ment physical self-esteem, such that boys experienced higher pre-treatment physical self-esteem. The unsta ndardized beta weight for the product of pre-treatment body dissatisf action and gender in block three was not significant ( = -0.076, t = -0.700, p = 0.486). Thus, gender was not a moderator of the association between pre-treatment body dissatisfac tion and pre-treatment physical self-esteem. A 2 x 3 x 2 mixed model ANOVA was performed to examine change in body dissatisfaction ratings from preto post-treatme nt examining the between subjects effects of treatment condition and gender. Examination of the model indicated a significant main effect of time ( F [1, 74] = 12.254, p = 0.001, 2 = 0.142). The main effect of time was examined using paired samples t-tests which indicated a sign ificant improvement in body dissatisfaction from preto post-treatment for part icipants in the BFI condition ( t = 3.412, df = 30, p = 0.002) and participants in the BPI condition ( t = 2.826, df = 27, p = 0.009), but no significant difference in body dissatisfaction over time for participants in the WLC ( t = 0.170, df = 20, p = 0.867) condition. The model also indicated a non-si gnificant direct effect of gender ( F [1, 74] = 0.929, p = 0.338, 2 = 0.012), a non-significant direct effect of treatment condition ( F [2, 74] = 0.333, p = 0.718, 2 = 0.009), a non-significant time by gender interaction effect ( F [1, 74] = 0.333, p = 0.566, 2 = 0.004), and a non-significant time by treatment interaction ( F [2, 74] = 2.316, p = 0.106, 2 = 0.059), a non-significant treatmen t by gender interaction effect ( F [2, 74] = 3.180, p = 0.047, 2 = 0.079), and a non-signif icant time by treatment by gender effect ( F [2, 74] = 2.451, p = 0.093, 2 = 0.062). In summary, body dissatisfacti on ratings improved over time for

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71 participants in the BFI and BPI conditions. Please refer to Figure 3-4 for a graph of mean change in body dissatisfaction by treatment condition. Multiple regressions were conducted to evaluate the association between change in body dissatisfaction ratings and change in social, athletic, physical, and global self-esteem Block one of the regression analysis showed a non-signi ficant direct effect for change in body dissatisfaction ratings on change in global self-esteem ( R2 = 0.010, F [1, 79] = 0.751, = -0.098, t = -0.867, p = 0.389), indicating that change in globa l self-esteem was not associated with change in body dissatisfaction. Block two showed a non-significant direct effect for gender on change in global self-esteem ( = 0.207, t = 1.869, p = 0.065). The unstandardized beta weight for the product of change in body dissatisfaction and gender in block thre e was not significant ( = 0.070, t = 0.626, p = 0.533). Thus, gender was not a mode rator of the association between change in body dissatisfaction and change in global self-esteem. Block one of the regression anal ysis showed a non-significant di rect effect for change in body dissatisfaction ratings on change in social self-esteem ( R2 = 0.071, F [1, 78] = 5.882, = 0.266, t = -2.425, p = 0.018), indicating that change in social self-esteem was not associated with change in body dissatisfaction. Block two showed a non-significant direct effect for gender on change in social self-esteem ( = -0.165, t = -1.515, p = 0.134). The unstandardized beta weight for the product of change in body dissatisfaction and gender in block thre e was not significant ( = -0.064, t = -0.581, p = 0.563). Thus, gender was not a mode rator of the association between change in body dissatisfaction and change in social self-esteem. Block one of the regression anal ysis showed a non-significant di rect effect for change in body dissatisfaction ratings on change in athletic self-esteem ( R2 = 0.004, F [1, 79] = 0.310, = 0.063, t = -0.557, p = 0.579), indicating that change in athl etic self-esteem was not associated

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72 with change in body dissatisfac tion. Block two showed a non-signifi cant direct effect for gender on change in athletic self-esteem ( = 0.011, t = 0.098, p = 0.922). The unstandardized beta weight for the product of change in body dissa tisfaction and gender in block three was not significant ( = 0.066, t = 0.580, p = 0.564). Thus, gender was not a moderator of the association between change in body dissatisfaction a nd change in athletic self-esteem. Block one of the regression anal ysis showed a non-significant di rect effect for change in body dissatisfaction ratings on change in physical self-esteem ( R2 = 0.011, F [1, 79] = 0.847, = 0.104, t = 0.921, p = 0.360), indicating that change in phys ical self-esteem was not associated with change in body dissatisfac tion. Block two showed a non-signifi cant direct effect for gender on change in physical self-esteem ( = 0.192, t = 1.727, p = 0.088). However, the unstandardized beta weight for the product of change in body dissatisfaction and gende r in block three was significant ( = 0.301, t = 2.831, p = 0.006). Follow-up analyses were performed to further examine the interaction. These analyses indicat ed that change in body dissatisfaction ratings were not significantly associated with change in physical self-esteem for boys ( = -0.245, t = 1.363, p = 0.183), yet were approachi ng significance for girls ( = 0.359, t = 2.637, p = 0.011). Furthermore, improvements in girls body satisfa ction accounted for approximately 13% of the variance in change in physical self-esteem ( R2 = .129). Thus, gender was a moderator of the association between change in body dissatisf action and change in physical self-esteem. Multiple regressions were conducted to evaluate the association between post-treatment body dissatisfaction ratings and post-treatment social, athletic, physical, and global self-esteem. Block one of the regression analysis showed a significant direct effect for post-treatment body dissatisfaction ratings on post-treatment global self-esteem ( R2 = 0.108, F [1, 79] = 9.415, = 0.328, t = -3.068, p = 0.003), indicating that poorer posttreatment global self-esteem was

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73 associated with greater post-treatment body di ssatisfaction. Block two showed a non-significant direct effect for gender on pos t-treatment global self-esteem ( = 0.059, t = 0.549, p = 0.584). The unstandardized beta weight for the product of post-treatment body dissatisfaction and gender in block three was not significant ( = 0.085, t = 0.790, p = 0.432). Thus, gender was not a moderator of the association between post-treatment body dissa tisfaction and post-treatment global self-esteem. Block one of the regression analysis show ed a non-significant direct effect for posttreatment body dissatisfaction ratings on post-treatment social self-esteem ( R2 = 0.069, F [1, 79] = 5.759, = -0.262, t = -2.400, p = 0.019), indicating that post-trea tment social self-esteem was not associated with post-treatment body dissati sfaction. Block two showed a non-significant direct effect for gender on posttreatment social self-esteem ( = 0.038, t = 0.345, p = 0.731). The unstandardized beta weight for the product of post-treatment body dissatisfaction and gender in block three was not significant ( = -0.095, t = -0.856, p = 0.395). Thus, gender was not a moderator of the association between post-treatment body dissa tisfaction and post-treatment social self-esteem. Block one of the regression analysis show ed a non-significant direct effect for posttreatment body dissatisfaction ratings on post-treatment athletic self-esteem ( R2 = 0.036, F [1, 79] = 2.938, = -0.191, t = -1.714, p = 0.091), indicating that post-tr eatment athletic self-esteem was not associated with post-treatment body diss atisfaction. Block two showed a non-significant direct effect for gender on posttreatment athletic self-esteem ( = -0.139, t = -1.250, p = 0.215). The unstandardized beta weight for the product of post-treatment body dissatisfaction and gender in block three was not significant ( = -0.076, t = -0.682, p = 0.497). Thus, gender was not a

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74 moderator of the association between post-treatment body dissa tisfaction and post-treatment athletic self-esteem. Block one of the regression anal ysis showed a significant dir ect effect for post-treatment body dissatisfaction ratings on post-treatment physical self-esteem ( R2 = 0.257, F [1, 79] = 27.015, = -0.507, t = -5.198, p < .001), indicating that poorer post-treatment physical selfesteem was associated with greater post-tre atment body dissatisfaction. Block two showed a nonsignificant direct effect for gender on post-treatment physi cal self-esteem ( = -0.118, t = -1.208, p = 0.231). The unstandardized beta weight for the product of pos t-treatment body dissatisfaction and gender in block thre e was not significant ( = -0.056, t = -0.568, p = 0.572). Thus, gender was not a moderator of the association betw een post-treatment body di ssatisfaction and posttreatment physical self-esteem. In summary, body dissatisfaction was associated with physical and global self-esteem at multiple time points. All associations between body dissatisfaction and self-esteem were such that more body dissatisfaction was associated wi th poorer self-esteem. Gender moderated the association between improvements in physical self-esteem and change in body dissatisfaction such that reductions in body dissatisfaction were approaching significance for association with change in girls physical self-esteem, but were not significantly associated with change in boys physical self-esteem. Participants in the BFI and BPI conditions experienced significant reductions in body dissatisfaction over time. No treatment condition was significantly different than another group with regard to the impact on body dissatisfaction.

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75 Global Self-Esteem Change 2.6 2.7 2.8 2.9 3 3.1 3.2 Pre-Treatment Post-Treatment TimeMean Self-Estee m BFI BPI WLC Figure 3-1. Global self-esteem change by treatment condition. Social Self-Esteem Change 2.4 2.5 2.6 2.7 2.8 2.9 3 3.1 Pre-Treatment Post-Treatment TimeMean Self-Estee m BFI BPI WLC Figure 3-2. Social self-esteem change by treatment condition.

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76 Athletic Self-Esteem Change 2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 Pre-Treatment Post-Treatment TimeMean Self-Estee m BFI BPI WLC Figure 3-3. Athletic self-esteem change by treatment condition. Body Dissatisfaction Change 0 0.5 1 1.5 2 2.5 3 Pre-Treatment Post-Treatment TimeMean Body Dissatisfactio n BFI BPI WLC Figure 3-4. Body dissatisfaction change by treatment condition.

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77 Table 3-1. Mean scores (standard deviations) of SPPC scores for children who completed pretreatment and post-treatment assessment. Pre-treatment value Post-treatment value Total Sample Girls (n = 50) Social Self-Esteem 2.87 (0.79) 2.96 (0.78) Athletic Self-Esteem 2.43 (0.88) 2.63 (0.85) Physical Self-Esteem 1.98 (0.75) 2.22 (0.81) Global Self-Esteem 2.77 (0.73) 3.05 (0.72) Boys (n = 31) Social Self-Esteem 2.69 (0.71) 2.95 (0.68) Athletic Self-Esteem 2.70 (0.60) 2.89 (0.66) Physical Self-Esteem 2.52 (0.72) 2.51 (0.80) Global Self-Esteem 2.95 (0.70) 3.01 (0.67) BFI Girls (n = 20) Social Self-Esteem 3.00 (0.61) 2.92 (0.70) Athletic Self-Esteem 2.29 (0.94) 2.72 (0.79) Physical Self-Esteem 1.99 (0.73) 2.30 (0.66) Global Self-Esteem 2.73 (0.82) 2.88 (0.70) Boys (n = 11) Social Self-Esteem 2.93 (0.79) 3.14 (0.76) Athletic Self-Esteem 2.80 (0.73) 3.08 (0.75) Physical Self-Esteem 2.62 (0.85) 2.70 (0.90) Global Self-Esteem 3.15 (0.73) 3.15 (0.79) BPI Girls (n = 14) Social Self-Esteem 2.79 (1.03) 2.96 (0.90) Athletic Self-Esteem 2.46 (0.97) 2.62 (1.00) Physical Self-Esteem 1.92 (0.72) 2.46 (1.04) Global Self-Esteem 2.80 (0.67) 3.18 (0.79) Boys (n = 15) Social Self-Esteem 2.46 (0.67) 2.78 (0.65) Athletic Self-Esteem 2.67 (0.56) 2.74 (0.61) Physical Self-Esteem 2.52 (0.69) 2.40 (0.82) Global Self-Esteem 2.88 (0.76) 2.92 (0.66) WLC Girls (n = 16) Social Self-Esteem 2.78 (0.77) 2.99 (0.81) Athletic Self-Esteem 2.58 (0.74) 2.53 (0.81)

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78 Physical Self-Esteem 2.02 (0.85) 1.92 (0.70) Global Self-Esteem 2.80 (0.71) 3.15 (0.68) Boys (n = 5) Social Self-Esteem 2.83 (0.50) 3.07 (0.55) Athletic Self-Esteem 2.57 (0.51) 2.90 (0.58) Physical Self-Esteem 2.30 (0.58) 2.30 (0.55) Global Self-Esteem 2.73 (0.35) 2.97 (0.49) Table 3-2. Mean scores (and standa rd deviations) of impact vari ables for children who completed pre-treatment and post-treatment assessments. Pre-treatment value Post-treatment value Total Sample Girls (n = 50) BMI Z score 2.13 (0.44) 2.07 (0.51) Self-Efficacy Score 13.76 (2.13) 13.38 (2.50) WLOC Score 12.48 (2.13) 13.02 (2.58) Peer Victimization Score 8.97 (4.00) 8.36 (3.11) Body Dissatisfaction 2.76 (1.30) 2.14 (1.30) Boys (n = 31) BMI Z score 2.19 (0.35) 2.09 (0.44) Self-Efficacy Score 13.19 (1.62) 13.58 (2.35) WLOC Score 13.13 (2.06) 13.58 (1.78) Peer Victimization Score 8.55 (3.96) 8.94 (4.80) Body Dissatisfaction 2.39 (1.17) 1.84 (1.51) BFI Girls (n = 20) BMI Z score 2.22 (0.45) 2.20 (0.48) Self-Efficacy Score 13.60 (2.28) 13.75 (2.49) WLOC Score 12.30 (1.66) 12.60 (2.60) Peer Victimization Score 8.75 (3.74) 7.75 (3.11) Body Dissatisfaction 3.10 (1.52) 2.45 (1.15) Boys (n = 11) BMI Z score 2.15 (0.40) 2.00 (0.56) Self-Efficacy Score 13.73 (1.49) 13.09 (2.47) WLOC Score 13.36 (1.57) 13.45 (1.81) Peer Victimization Score 9.18 (5.36) 8.18 (4.94) Body Dissatisfaction 2.27 (1.01) 1.09 (1.38) BPI Girls (n = 14) BMI Z score 2.20 (0.40) 2.02 (0.59) Self-Efficacy Score 14.14 (1.70) 13.71 (1.98) WLOC Score 12.86 (2.32) 14.29 (1.64)

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79 Peer Victimization Score 9.07 (4.70) 8.86 (2.77) Body Dissatisfaction 2.57 (1.16) 1.31 (1.38) Boys (n = 15) BMI Z score 2.22 (0.26) 2.11 (0.32) Self-Efficacy Score 12.93 (1.67) 13.67 (2.38) WLOC Score 13.07 (2.34) 13.67 (1.99) Peer Victimization Score 8.93 (3.15) 10.00 (5.26) Body Dissatisfaction 2.47 (1.41) 2.20 (1.42) WLC Girls (n = 16) BMI Z score 1.96 (0.43) 1.94 (0.46) Self-Efficacy Score 13.63 (2.36) 12.63 (2.87) WLOC Score 12.38 (2.55) 12.44 (2.94) Peer Victimization Score 9.13 (3.95) 8.69 (3.44) Body Dissatisfaction 2.50 (1.10) 2.44 (1.21) Boys (n = 5) BMI Z score 2.20 (0.35) 2.09 (0.44) Self-Efficacy Score 12.80 (1.79) 14.40 (2.19) WLOC Score 12.80 (2.49) 13.60 (1.34) Peer Victimization Score 6.00 (1.00) 7.40 (2.51) Body Dissatisfaction 2.40 (0.89) 2.40 (1.67)

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80 CHAPTER 4 DISCUSSION Findings Regarding Self-Esteem Change This study adds to the mixed and methodol ogically limited research on the effects of weight management programs on pediatric self-e steem and mechanisms of change responsible for self-esteem change. Improvements in self -esteem over time were observed for several domains of self-esteem. However, behavioral in tervention did not lead to significantly greater improvements in self-esteem relative to chil dren in the no-treatment control group. These findings are similar to findings from three other studies that have found no change in self-esteem due to treatment for pediatric participants in a weight management program (Rohrbacher, 1973; Thomas-Dobersen et al., 1993; Huang, Norman, Zabinski, Calfas, & Patrick, 2007). However, a number of other studies have reported positive imp rovements in self-esteem for participants in pediatric weight management programs (Stoner & Fiorillo, 1976; Foster et al., 1985; Mellin et al., 1987; Wadden et al., 1990; Sherman et al., 1992; Sahota et al., 2001; Je lalian & Mehlenbeck, 2002; Braet et al., 2003; Brehm et al., 2003; Walker et al., 2003; Ba rton et al., 2004; Braet et al., 2004 [2-year follow-up: Braet, 2006]; Edwards et al ., 2005; Gately et al., 2005; Sacher et al., 2005; Savoye et al., 2005; Jelalian et al., 2006) There are a number of methodological and sample considerations that may account for the difference between these studies and the current study. A major difference between this study and much of the previous research in this area is the use of a control group. Of the studies that reporte d no change in self-esteem due to treatment, Thomas-Dobersen and colleagues (1993) and Hu ang and colleagues (2007) studies included control groups and were able to determine that self-esteem did not change due to treatment, despite changes in self-esteem th at occurred over time. However, many of the studies that have

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81 reported positive improvement in self-esteem over time did not utilize a control group for comparison (Wadden et al., 1990; Sherman et al., 1992; Sahota et al., 2001; Jelalian & Mehlenbeck, 2002; Brehm et al., 2003; Braet et al., 2004; Edward s et al., 2005; Sacher et al., 2005; Savoye et al., 2005; Jelalian et al., 2006). This makes it difficult to determine if the positive improvements seen in those studies were due to an effect of time or the intervention, particularly since we found change in self-esteem over time in 3 of the 4 domains of self-esteem examined. Other studies have utilized a cont rol group, and have reported positive improvements in self-esteem, including social physical, athletic, and/ or global domains of self-esteem, from preto post-treatment with higher improvement s in the treatment group relative to the control group (Stoner & Fiorillo, 1976; Foster et al., 1985; Mellin et al, 1987; Braet et al., 2003; Walker et al., 2003; Gately et al., 2005). However, the type of control gr oups utilized in these studies included both overweight and/or non-overweight children who may not have been actively seeking treatment at the time. In contrast, our control group was a group of treatment-seeking overweight children asked to delay treatment for several months, instead of a control group of indivi duals selected from a sample of convenience in the community who were not seeking treatment (Foster et al., 1985; Gately et al., 2005). Furthermore, all families in this program self-initiat ed contact with the study investigators to increase healthy lifestyle beha viors, and were not a sample of individuals referred for treatment by a healthcare provider that may have never directly indicated a desire for treatment (Cameron, 1999). Even though parents we re likely largely resp onsible for initiating contact and participation in the study, all participating family me mbers took part in screenings, assessments, and consented in person to the pr ogram. General treatment literature has indicated that the largest gains in treatment tend to occur early in treatment, and it is possible that the mere

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82 act of initiating participation in treatment may ha ve resulted in behavior al or emotional changes in participants and their families in all conditi ons. Indeed, application of the Transtheoretical Model (Prochaska & DiClemente, 1983; Prochask a, DiClemente, & Norcross, 1992; Prochaska & Velicer, 1997) with our study w ould indicate that all particip ants, even individuals in the control group, were in the Actio n stage. According to the m odel, the Action stage is where change occurs and perhaps even the participants in our control group were ready, or possibly had already started, to make changes in their lifestyle habits. The fact that all participating family members (including participants in the control group) had contact with the investigators and agreed to the extensive terms of participation to be included in this intervention is evidence of some level of readiness for change. Therefore, the use of a treatmentseeking control group in this study had significant implications in the wa y in which we interpreted our data and makes this study distinctly different than other wei ght management programs that have examined pediatric self-esteem. However, it is only one of a number of factor s to consider when interpreting our results. Another factor that may have impacted our ab ility to detect more significant changes over time was that in this study, participants baseline self-esteem scores were similar to the published normative data (Harter, 1985). The average norms fo r social, athletic, physi cal, and global selfesteem for girls and boys based on the Harter ma nual (1985) is presented in Table 4-1. Although we might have expected the self-e steem of the overweight children in this study to be lower than that of published norms, this was not the case. Fu rthermore, baseline self-esteem scores for our participants were closer to the post -treatment scores (rather than pre-treatment) for other weight management programs that have utilized the sa me self-esteem measure and published raw self-

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83 esteem data (Brehm et al., 2003; Braet et al., 2004). Thus, it is po ssible that overweight children in this study had less room for improvement in self-esteem. Given that many of the participants presented with relatively high or normative levels of self-esteem at baseline, follow-up analyses we re utilized to examine the effects of the intervention on only participants who exhibited self-esteem ratings below the mean genderspecific normative level presente d by Harter (1985). These anal yses were conducted against our sample separately for girls and boys, due to the gender-specific nature of the normative data. The number of girls that presented with self-esteem below normative values and the number of girls that experienced improvements, no change, a nd decreases in self-esteem across time are presented in Table 4-2. Findings from analyses examining only girls that presented with lower than normative self-esteem at baseline paralleled the findings from the larger sample of girls in the study. Girls in this subsam ple experienced significant impr ovements in physical and global self-esteem over time, but again; the change wa s not due to the intervention as girls in all conditions experienced the improvements. The number of boys that presented with self-esteem below normative values and the number of boys that experien ced improvements, no change, and decreases in self-esteem across time are presented in Table 4-3. Findings were sim ilar to the larger study such that boys that presented with lower than normative baseline self -esteem scores in this sample experienced a significant increase in social self-esteem over time ( F [1, 12] = 11.176, p = 0.006), but improvements were not due to the intervention. Another reason for the lack of significant in tervention effects on domains of self-esteem (social, athletic, physical, global) may be the br ief period of assessment. It is possible that changes in self-esteem for the intervention partic ipants compared to th e control group may not

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84 become apparent until after more extensive oppo rtunities for extended use and benefit from the self-esteem enhancing techniques taught in intervention. Furtherm ore, the intervention period may not have provided sufficient time for the effect of weight status or behavioral change to impact self-esteem. This would be consistent with a previous study which indicated that children in the intervention continued to experience gains in self-estee m during the follow-up period after the end of the active inte rvention compared to the control gr oup (Mellin et al., 1987). However, another study reported improvements in the cont rol group as well (Foster, Wadden, & Brownell, 1985). Follow-up data are not availa ble at the time of this stu dy, but examination of the followup data on self-esteem for the partic ipants in this study will be cr itical to evaluate changes in self-esteem, or if self-esteem remains largely preserved at current rates. Finally, examination of normative developmen tal changes in self-esteem are worthy of consideration. Indeed, results indi cated that the behavioral interv entions did not lead to greater changes in self-esteem than the control group, but a change across time was seen in global, social, and athletic self-esteem. This finding w ould seem to be contradictory to research indicating that normative self -esteem development includes a drop in self-esteem around adolescence, or more specifically around the onset of puberty (Harter, 1999; Strauss, 2000). This finding is also contradictory to the concerns of some resear chers that weight management programs may have adverse psyc hosocial effects for pediatri c participants (ODea, 2005). However, it is also possible that social desirab ility effects were present, due to the self-report nature of self-esteem assessment. Thus, improve ments in self-esteem could be inflated across conditions due to reporting bias.

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85 Self-Esteem in the Rural Population Most of the previous research with rural populations suggests that rural children have lower self-esteem than their metropolitan peers (Roscigno & Crowley, 2001). However, our study found that self-esteem ratings for the partic ipants were largely equivalent to normative means for self-esteem. Our data also are cons istent with a recently published study of rural children who presented with se lf-esteem rates similar to normative means in the general population (Yang & Fetsch, 2007). One reason that the participants self-esteem ra tings in this study were similar to normative levels may be that previous research has prim arily focused on individuals in these communities who are at-risk due to factors such as limited financial resources minority ethnicity status, or a lower educational attainment. However, our st udy (and Yang and Fetschs study [2007]) was not comprised primarily of an economically, ethnica lly, or educationally at-risk sample. The similarity of our sample to national and stat ewide norms based on the 2000 U.S. Census Data (U.S. Census Bureau, 2007) supports that our sample is not at-r isk because national means are higher than those of economicall y, ethnically, and educationally a t-risk samples. For ethnicity, the U.S. sample was 80% Caucasian, while our final dataset consisted of 79% Caucasian children. The U.S. median household income in 2004 was estimated at $44,334, and the median income range for participants in this st udy was $40,000 $59,999. However, it should be noted that the modal income range for particip ants in this study was the $20,000 $39,999 range. National estimates of persons over the age of 25 years with a bachelors degree or higher was 24.4%, and the frequency of parents with a bachel ors degree or higher in our sample was 21%. Estimates for the state of Florida were also si milar to that of our sample and the national averages.

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86 These findings have significant implications given that overweight individuals in rural communities are at increased risk for overweight status, and may be susceptible to greater medical complications of overweight due to lim ited healthcare resources. Therefore, it is important to establish whether or not they are al so at risk for greater psychosocial complications, such as poorer self-esteem compared to non-ove rweight children. Howe ver, given the selfselection method of participation in our st udy, it should be noted that the families who participated in our program may have had more re sources to devote the nece ssary time and effort to participate, and therefore may not be fully representative of the rural communities in which they live. These findings sugge st that it may be important to consider demographic characteristics rather than viewing all children and families from rural areas as homogeneous. Mechanisms of Self-Esteem Change Impact of Weight Status Change Although we expected to see si gnificant associati ons between weight status change and self-esteem change, this was not the case. Pe rhaps the degree of weight change in our participants ( Mean z-score change = 0.0417, SD = 0.11), was not large enough during the short time frame of assessment to be meaningful to the pediatric participan ts self-esteem. Other programs have reported significant associations between weight st atus change and change in self-esteem (Cameron, 1999; Walker et al., 2003 ; Jelalian et al., 2006). Alternatively, three studies found no statistically si gnificant relationship between se lf-esteem change and weight status change (Rohrbacher, 1973; Stoner & Fi orillio, 1976; Wadden et al., 1990). Moreover, three additional studies reporte d significant improvements in self-esteem, despite lack of significant weight loss, although the relationship was not examin ed statistically (Sherman, Alexander, Gomez, Kim, & Ma role, 1992; Sahota et al., 2001; Brehm, Rourke, Cassell, & Sethurman, 2003). A common theme among the pr ograms that did not find significant

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87 association between weight status change and se lf-esteem and our program was that self-esteem was targeted directly during the intervention in each of these studies. Perhaps targeting selfesteem directly in the context of these program s reduces the impact of weight change on selfesteem. It will be interesting to examine the im pact of weight status change on self-esteem change at 6-month follow-up in order to determine if the impact is significant, particularly if larger improvements in weight status are experienced by the participants. Impact of Goal Attainment and Self-E fficacy for Healthy Lifestyle Behaviors The lack of significant associa tions between goal attainment a nd self-esteem are especially noteworthy as the program attempted to de-empha size the importance of weight and increase the emphasis on behavior, behavioral goals, and c onfidence in achieving these goals. Many other programs have also attempted to de-emphasize we ight status change, and focus on behaviors as well, but this is the first study to examine the effects of behavioral goa l attainment and selfefficacy for healthy behaviors on pediatric self -esteem. However, despite the program emphasis on behavior, attainment of goals and self-efficacy were not associated with self-esteem. It is possible that the positive reinforcement for child ren in the BPI condition was not enough to lead to self-esteem change, given that these children did not participate in th e group directly and have interaction with the group leaders. It should be noted that the met hod of assessing goal attainment and the self-efficacy ques tionnaire used in this study were created specifically for this study, and therefore the reliability and validity of these measures are unknown. Clearly more research is needed to examine what factors are meaningful to children w ho participate in these programs and impact self-esteem.

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88 Impact of Weight-Specific Locus of Control Research in adult and pediatric samples would have supported a ssociations between weight-specific locus of contro l and self-esteem change, given that previous research has reported such associations, particul arly in the adult literature. Fu rthermore, adult literature has also indicated that internal locus of control may be associated with more positive psychosocial outcomes, such as more adaptive coping (Hilton, 1989). It is noteworthy th at our findings seem to contrast with those of Cameron (1999), who had suggested that self-esteem deficits could occur because of increased inte rnalization of locus of contro l due to weight management program participation. Our part icipants not only did not expe rience statistically significant changes in locus of control, but changes were not associated with self-esteem changes in boys or girls. However, it should be noted that the WLOC measure in this study had poor internal consistency, and thus findings regarding weight-specific locus of control with this population should be interpreted with caution. Finally, the lo cus of control measure utilized was created specifically for this study, and thus has not been validated previously; therefore the reliability and validity of the data obtained from this measure is unknown. Impact of Peer Victimization Peer victimization ratings at baseline and final assessment in this study were associated with poorer self-esteem scores fo r the entire sample. These findi ngs are consistent with past research that has repeatedly indicated that higher levels of peer victimizat ion are associated with poorer self-esteem in overwei ght youth (Young-Hyman et al., 2003; Hayden-Wade et al., 2005; Sweeting, Wright, & Minnis, 2005; Stern et al., 2006; Thompson et al., 2007). These findings further highlight the potentially de leterious impact that negative peer interactions can have on psychosocial functioning and self-esteem.

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89 In this study, no significant cha nge in peer victimization over time or due to the treatment was observed. This was not surprising, given that the treatment did not aim to change peer victimization experiences that occurred outside of the group sett ing. Our findings in this area also may have been hampered by measurement emphasis on peer victimization and not social support. Although the program did aim to enhance participants ability to cope with these experiences, the measure used in this study di d not capture changes in coping with peer victimization or changes in posit ive peer interactions or supp ort, both of which have been associated with self-esteem in overwei ght children (Strauss & Pollack, 2003; Dishman et al., 2006). Furthermore, social support in rural youth typically has included extended family and community members, although other research ha s indicated that these support systems have changed in recent years (MacTavish & Salamon, 2003). Therefore, social support could have been an especially significant influence on self -esteem in our participan ts, but unfortunately, it was not assessed. However, for participants who did experien ce reductions in peer victimization ratings, these reductions were associated with improvements in so cial self-esteem and physical selfesteem. This is not surprising as this teasing from peers would affect a childs perception of worth in social interactions, and thus impact social self-esteem. Furthermore, previous research has indicated that overweight ch ildren experience teasing that is more focused on appearance than other characteristics (Ha yden-Wade et al., 2005; Thompson et al., 2007). Rationale for why these children felt that they were experiencing less peer victimization would have been an interesting concept to explore, but unfortunate ly was not assessed in this study. These findings support the need for continued asse ssment of peer interactions and the emotional consequences of negative interactions on child self-estee m, particularly for overweight children.

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90 Impact of Body Dissatisfaction Moderator analyses were conducted in this st udy to assess for gender differences based on past research that has demonstr ated differences in boys and gi rls self-esteem (Harter, 1985). However, the only gender difference found in th is study was the impact of reductions in body dissatisfaction on improvement in physical self-e steem for girls. Follow-up analysis indicated that this variable accounted for 13% of the variance in girls p hysical self-esteem change. There was no significant association for boys. We also found that part icipants in the BFI and BPI conditions experienced significan t reductions in body dissatisfacti on ratings over time, but were not significantly different that the WLC condition. One possibility for this finding may be similar to the reasons hypothesized for changes in part icipants self-esteem regarding readiness for change. Findings regarding the association of body satisfa ction to self-esteem change are supported by previous studies. Past research has demonstrated that girls se lf esteem is more affected by overweight status and thus girls may experi ence more change in self-esteem when body satisfaction is improved compared to boys (Mende lson & White, 1985; Pesa et al., 2000; Israel & Ivanova, 2002). Girls may be more vulnerable to the effects of body dissatis faction due to larger societal and media messages th at emphasize appearance as a si gnificant contribu tor to female perceptions of self-worth. Res earch has supported that girls of increasingly younger ages are influenced by these messages, also known as the thin ideal (Tiggemann, 2001; Sands & Wardle, 2003). Although this study did not exam ine the influence of the media or cultural stereotypes on our population, the f act that only girls physical and global self-esteem were below normative data may serve to support that ov erweight status was negatively influential on these domains of girls self-esteem, perhaps due to cultural and media ster eotypes. Furthermore, other researchers have suggested that girls in rural communities also experience lower rates of

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91 physical self-esteem and that these lower rates may be reflective of the medias emphasis on sexualization and appearance of girl s and women (Yang & Fetsch, 2007). Previous research has suggested that the imp act of weight status change on self-esteem may be accounted for by changes in body dissatis faction (Lowry et al., 2007). However, examination of the mediating effects of body di ssatisfaction change on th e association between weight status change and physical self-esteem improvement in this sample did not support body dissatisfaction as a mediator. Furthermore, we ight status and body di ssatisfaction were not significantly associated with each other at any as sessment point, and interestingly, weight status at baseline was not predictive of body dissa tisfaction for the girl s in the sample ( R2 = 0.06, F [1, 49] = 3.096, p = 0.085). Although it may be natural to assume that weight status would be related to body dissatisfaction, current research indicates that girls levels of body dissatisfaction may be independent of weight status (Davison & Birch, 2 001). In other words, girl s perceptions of their bodies may not be based solely on the size of their bodies, but also may be due to their perception of their body size in co mparison to role models in the larger society, who have become increasingly thinner and less representa tive of the general population. Research supports this assertion such that girls who demonstrate body dissatisfaction rates that are not associated with their weight status tend to be more influenc ed by the media, societal pressure for thinness, and cultural stereotypes regarding the importa nce of body size on global self-worth. Although we did not assess the impact of the media on our samp le, it is possible that these associations would apply to our female participants given th e similarity in our findings regarding body dissatisfaction, self-esteem, and we ight status. However, all part icipants in this study were overweight, which makes it more difficult to find significant associations with limited weight

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92 status variability. Perhaps it was overweight status and not degree of overweight that was most influential on self-esteem. Although body dissatisfaction change was associat ed with physical self -esteem change in girls, it only comprised a sma ll portion of the total variance fo r change. Furthermore, other impact variables examined in this study (weight status change, goal attain ment, self-efficacy, or locus of control) were not significantly associated with girls physical self-esteem change. It is possible that self-esteem change was also impacted by changes in social support or changes in the home environment such as more supportive pare nting techniques or more attentive parenting resulting from parents who initia ted participation in a weight ma nagement program, even if they were not currently attending the program at that time (which may have been the case for the WLC condition). However, these variables were not assessed by this study and their impact on self-esteem is purely theoretical. Strengths of this Study This study includes several uni que components that address li mitations in the literature examining the effects of weight management pr ograms on pediatric self-esteem. First, to our knowledge, this is the only study to statistically examine the impact of variables on self-esteem change that have previously only been speculate d to impact self-esteem in overweight children (including goal attainment, self-efficacy, and locu s of control). Second, we believe this is the only research to examine the moderating impact of gender on self-estee m change in children participating in a family-based weight manage ment program. Third, another major strength is that this study compared intervention cha nges to a waitlist control group comprised of overweight children. Without this control group, it is possible th at we could have reached a different conclusion as to the impact of the in tervention on self-esteem change. Fourth, we used statistical techniques to appropr iately assess for intervention di fferences by treatment condition

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93 and gender, and did not merely conduct analyses on the active treatment conditions or boys and girls separately. These analyses allowed us to use statistical analyses to assess for the interaction of variables of interest and de termine if those differences were significant and meaningful, instead of only noting that they we re different, as has been presente d in other studies with similar findings (Huang et al., 2007). Fifth, a unique as pect of this study is that it was conducted exclusively with children from rural settings. Historically, there has been limited research examining psychosocial functioning of children in rural settings. Children living in rural communities are at increased risk for overwei ght in childhood and obesity in adulthood (McMurray et al., 1999) yet may ha ve fewer healthcare resources available to them to address the complications associated with overweight. Research examining the psychosocial effects of health promotion programs in these communities f ills an important need in the current treatment outcome literature. Considerations and Limitations Standard significance test values ( p < 0.05) were used to assess for significance for the primary aims of this study (self esteem change due to treatment and the impact of weight status change on self-esteem change). However, a conservative p value ( p < .01) was adopted for the secondary aims of this study. Although we feel that this more conservative approach was necessary, in order to find a balance between prevention of Type I and Type II errors, it nonetheless affected our inte rpretation of the data. Several limitations may impact the interpre tation of the current findings. First, the participants in this study la rgely did not experience change in self-esteem which limited the variance in self-esteem and thus made it more di fficult to find an association between predictor variables and self-esteem ch ange. Second, several components of the study limited the generalizability of our findings including a) that our sample consisted primarily of Caucasian

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94 participants and b) that we utilized a speci fic treatment seeking popul ation and rural setting. Third, this study included a limited time frame of a ssessment with lack of follow-up data. Fourth, measurement issues also may have impacted our findings. Several of the questionnaires were created specifically for this st udy and had not been previously ex amined to determine and ensure that they had adequate psychometric properties and would therefore be valid measurements of the intended constructs in this study. In f act, the WLOC had poor internal consistency. Furthermore, the peer victimization scale did not measure social support and therefore neglected to assess the potential buffering impact of positiv e social support or increases in social support that may have occurred due to participation in a program of similar peers. Moreover, although the Harter SPPC has been validated for children as young as eight years of age, some participants had difficulty understanding some of the concepts and how to complete the measure, even with assistance from an examiner. Implications for Clinical Intervention and Research Researchers have cautioned interventionists to be mindful when conducting this weight management program for children to ensure th at they do no harm (ODea, 2005). There also has been debate at to whether pediatric weight management interventions may negatively impact self-esteem (Golan et al., 1998) Although this study i ndicates that self-est eem was not improved as a result of the treatment, it also indicates that participant self-esteem was not adversely affected. The importance of these findings are fu rther amplified as our participants presented with self-esteem rates similar to normative, non-ove rweight samples, unlike the findings of other studies that have reported self -esteem rates for overweight child ren that are lower than their nonoverweight peers. If lower self-esteem is more common for overweight ch ildren, then we might have expected to see a regression to the mean. Instead, the children in our study were able to preserve their self-esteem. These findings do not re move the need for clinicians to be sensitive

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95 when conducting this type of res earch, but they do suggest that carefully designed programs that are sensitive to self-esteem and body image, and respectful of participan ts do not result in adverse psychosocial effects for participants. We recommend that future interventionists continue to be mindful of these potential effects and to assess for positive, negative, and lack of changes in participants psychosoc ial functioning during treatment. This study specifically targeted self-esteem during the interven tion. Although we cannot assess the impact that this component of the treatment may have provided to preserving our populations relatively high baseli ne self-esteem scores (i.e., we did not have a comparison intervention that did not target self-esteem), ot her research has suggested that targeting selfesteem and the use of a group format during the intervention is associated with more positive self-esteem outcomes (Lowry et al., 2007), and previous studies that found no association between weight status change and self-esteem change reported targeting self-esteem in the context of this group format during the inte rvention (Rohrbacher, 1973; Sherman et al., 1992; Jelalian et al., 2006). Participat ion in a group intervention of similar peers may provide an opportunity for social bonding, perceived support, group activities, and group problem solving. Perhaps the key to de-emphasizing the importance of weight status is not emphasizing behavioral goals, but rather promoting positive peer contact and support and providing positive self-esteem building exercises. Therefore, we recommend that future interventions address self-esteem directly and promote positive peer interactions du ring the intervention. Certainly further research on how to best address self-esteem change is n eeded. Given the associations found in this study between peer victimization and body satisfaction and self-esteem, we also recommend that clinicians provide children and families with coping skills to help them manage negative emotions or negative messages from their e nvironment with non-food related techniques.

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96 A number of implications for future resear ch are suggested by these results. Additional research with rural populations will be n ecessary to better understand psychosocial complications for overweight status in this popu lation, and the effects of weight management programs on psychosocial functioning. Given the importance of self-esteem on child functioning and possible long term effects of child self-est eem (Harter, 1999), we recommend that future research programs continue to examine self-esteem change and the variables that may lead to change in the context of weight management programs, particularly the impact of peer interactions and positive social support. Although this study f ound limited gender differences in self-esteem, future research s hould continue to examine self-e steem by gender given the strong gender differences in self-esteem found in othe r studies (Harter, 1985). Finally, future studies should include a no-treatment and/or waitlist control group of overwei ght and non-overweight youth for comparison so as to better unde rstand normative changes in self-esteem. Summary In summary, we found that the intervention did not impact any domain of self-esteem, although a significant improvement in self-esteem across time was observed for social, athletic, and global self-esteem. Potential ex planations for the results include the presence of a control group to assess for time effects and relatively hi gh baseline ratings of self-esteem in our participants. Gender differences we re observed in self-esteem change s such that change in girls physical self-esteem was predicted by improveme nts in body satisfaction. Reduction in peer victimization was associated w ith improvements in social an d physical self-esteem. Weight status change, goal attainment, se lf-efficacy for healthy lifestyle behaviors, and locus of control did not appear to be associated with self-esteem in this study, although measurement limitations may have complicated these findi ngs. These findings are significant as this study indicates that participation in a weight management program does not adversely affect pediatric self-esteem.

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97Table 4-1. Harter normative mean scores and current st udy baseline mean scores for self-esteem by gender. Social Athletic Physical Global Harter norms Girls 2.87 2.61 2.68 2.98 Boys 2.94 3.08 2.97 3.07 Current study Girls 2.87 2.43 1.98 2.77 Boys 2.69 2.70 2.52 2.95 Note. Mean scores are averaged from mean scores pr ovided by grade in the manual for the SPPC (Harter, 1985). Table 4-2. Frequency of girls (tot al N = 50) with self-esteem ratings below norma tive values and the numbe r of girls that exper ienced improvements, no change, and decreases in self-esteem across time. Social* Athletic Physical Global Baseline value below normative mean 25 22 40 27 Improvement 17 14 27 19 No change 2 6 6 4 Decrease 6 2 7 4 Note. Pre-treatment social self-esteem tota l N = 49 because score could not be calculated for one participant due to missing da ta. Table 4-3. Frequency of boys (tot al N = 31) with self-esteem ra tings below normative values and the number of boys that experie nced improvements, no change, and decreases in self-esteem across time. Social Athletic Physical Global Baseline value below normative mean 15 21 22 19 Improvement 11 14 12 12 No change 3 4 2 3 Decrease 1 3 8 4

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98 APPENDIX A DEMOGRAPHIC QUESTIONNAIRE Information about your Family Childs Name: _________________________________________ Childs gender (please circle): Boy / Girl Childs race (please circle) Caucasian African Ameri can Hispanic Asian Bi-racial Other Childs age: Childs Date of Birth: ___/___/___ Chil ds grade in school: Your Name: __________________________________________________ Your Gender (please circle): Male / Female Your race (please circle): Caucasian African American Hispanic Asian Bi-racial Other You are the childs (please check one): Mother _____ Father _____ Step-Mother _____ Step-Father _____ Grandparent _____ Other Legal Guardian _____ Your (parent/guardians) age: Please indicate your current mar ital status (please check one): Married _____ Single _____ Including yourself, how many adu lts live in your home: ________________ Including your child, how many ch ildren live in your home: ______________ What is the highest level (g rade) of school you completed? Middle school _____ Some college _____ Some high school _____ Graduated college _____ Graduated high school _____ Post-Graduate school _____

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99 What is your current occupation? ___________________________________________________________ Estimated Family Income per Year (please check one). Below $9,999 _____ $40,000 $59,999 _____ $10,000 $19,999 _____ $60,000 $79,000 _____ $20,000 $39,999 _____ Over $80,000 _____

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100 APPENDIX B MODIFIED WEIGHT LOCUS OF CONTROL Instructions : We want to learn more about how you feel about changing when you eat and drink. Read each senten ce carefully. Place a check below 1 of the 4 boxes on the right side of the page that shows how true each state is for you. Really Not True for Me Sort of Not True for Me Sort of True for Me Really True for Me 1. Whether I gain or lose weight is up to me. 2. Being the right weight is mostly due to good luck. 3. No matter what I try to do to lose weight, it doesnt change anything. 4. If I eat right and get enough exercise, I can control my weight.

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101 APPENDIX C DAILY HABIT LOG Time Food or Drink Amount Calories R-Y-G Breakfast Breakfast Total: Morning Snacks Snack Total: Lunch Lunch Total: Afternoon Snacks

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102 Snack Total: Time Food or Drink Amount Calories R-Y-G Dinner Dinner Total: Evening Snacks Snack Total: Daily Total Red Foods Daily Total Calories Daily Total of Fruits & Vegetables Total Daily Steps OTHER OFF-FEET ACTIVITIES Activity How Many Minutes

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103 Bicycling Swimming Skate boarding or Roller Blading Other: ________________________ Other: ________________________ TOTAL DAILY MINUTES ______________________

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104 APPENDIX D GROUP LEADER CHECK IN SHEET

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105 Participan t Session Food Intake Info Steps TV # Days Past # Days New Avg Past # Days New Past # Days New Base Past Wee kly New Com plete Base Avg Wks Red Met Red Red Red Wks F&V Met F&V F&V Base Wks Avg Met Step Total Hrs. Wks TV Total Hrs. TV Week Att Logs Cal Cal Goal Goal Goal Food s Goal Goal Goal Step s Goal Step s Goal Goal TV Goal TV Goal Week #1 01/09/07 Week #2 01/16/07 Week #3 01/23/07 Week #4 01/30/07 Week #5 02/06/07 Week #6 02/13/07 Week #7 02/20/07 Week #8 02/27/07 Week #9 03/06/07 Week #10 03/13/07 Week #11 03/20/07 Week #12 03/27/07 Notes

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106 APPENDIX E SELF-EFFICACY QUESTIONNAIRE Instructions : We want to learn more about how you feel about changing when you eat and drink. Read each senten ce carefully. Place a check below 1 of the 4 boxes on the right side of the page that shows how true each state is for you. Really Not True for Me Sort of Not True for Me Sort of True for Me Really True for Me 1. I feel confident that I can eat healthy foods more often. 2. I feel confident that I can eat more fruits and vegetables more often. 3. I feel confident in that I can change habits to eat fewer junk foods. 4. I feel confident that I can my habits to be more physically active. This means running, playing outside, or just getting up and moving around more often.

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107 APPENDIX F SCHWARTZ PEER VICTIMIZATION SCALE For each question, please circle the best answer. 1. How often do other kids t ease or make fun of you? A. Never B. Sometimes C. Often D. Almost every day 2. How often do other kids bully or pick on you? A. Never B. Sometimes C. Often D. Almost every day 3. How often do other kids hit or push you? A. Never B. Sometimes C. Often D. Almost every day 4. How often do other kids gossip or say mean things about you? A. Never B. Sometimes C. Often D. Almost every day

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108 5. How often do other kids hurt your feelings by excluding you? A. Never B. Sometimes C. Often D. Almost every day

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109 LIST OF REFERENCES American Academy of Pediatrics. (2003). Policy statement: Prevention of pediatric overweight and obesity. Pediatrics, 112 424-430. Balch, P., & Ross, A. (1975). Predicting success in weight reduction as a function of locus of control: A unidimensional and multidimensional approach. Journal of Consulting & Clinical Psychology, 43 119. Bandura, A. (1977). Social learning theory. Englewood Cliffs, N.J.: Prentice-Hall. Bandura, A. (1981). Self-referent thought: A developmental analysis of self-efficacy. In J.H. Flavell & L.Ross (Eds.), Social cognitive development: Frontiers and possible futures. Cambridge, England: Cambridge University Press, 1981. Bandura, A., Barbaranelli, C., Caprara, G.V., & Pastorelli, C. (1996). Mu ltifaceted impact of self-efficacy beliefs on academic functioning. Child Development, 67, 1206-1222. Bandura, A., Barbaranelli, C., Caprara, G.V., & Pastorelli, C. (1999). Se lf-efficacy pathways to childhood depression. Journal of Personality and Social Psychology, 76, 258-269. Bandura, A., Barbaranelli, C., Caprara, G.V., & Pastorelli, C. (2001). Self-efficacy beliefs as shapers of childrens aspira tions and career trajectories. Child Development, 72, 187-206. Bandura, A., & Schunk, D.H. (1981). Cultivating comp etence, self-efficacy, and intrinsic interest through proximal self-motivation. Journal of Personality and Social Psychology, 41, 586 -598. Bandura, A., & Simon, K.M. (1977). The role of proximal intentions in self-regulation of refractory behavior. Cognitive Therapy and Research, 1, 177-193. Barlow, S.E., & Dietz, W.H. (1998). Obesity Evaluation and Treatment: Expert committee recommendations. Pediatrics, 102 e29. Barton, S., Walker, L., & Lambert, G. (2004). Cognitive change in obese adolescents losing weight. Obesity Research, 12 313-319. Bernier, M., & Avard, J. (1986). Self-efficacy, ou tcome, and attrition in a weight-reduction program. Cognitive Therapy and Research, 10, 319-338. Braet, C. (2006). Patient characteristics as predicto rs of weight loss after an obesity treatment for children. Obesity, 14 148-155. Braet, C., Tanghe, A., Bode, P.D., Franckx, H., & Winckel, M.V. (2003). Inpatient treatment of obese children: A multicomponent programme without stringent calorie restriction. European Journal of Pediatrics, 162, 391-396.

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110 Braet, C., Tanghe, A., Decaluwe, V., Moens, E., & Rosseel, Y. (2004). Inpatient treatment for children with obesity: Weight loss, ps ychological well-being, and eating behavior. Journal of Pediatric Psychology, 29 519-529. Brehm, B., Rourke, K., Cassell, C., & Sethuraman, G. (2003). Psyc hosocial outcomes of a pilot program for weight management. American Journal of Health Behavior, 27 348-354. Brewis, A. (2003). Biocultural aspects of obesity in young Mexican schoolchildren. American Journal of Human Biology, 15, 446-460. Brown, K., McMahon, R., Biro, F., Cr awford, P., Schreiber, G., et al (1998). Changes in self esteem in Black and White girls between ages 9 and 14 years. Journal of Adolescent Health, 23 7-19. Brownell, K.D., Kelman, J.H., & Stunkard, A.J. (1983). Treatment of obese children with and without their mothers: changes in weight and blood pressure. Pediatrics, 12 89-96. Bryan, J., & Tiggemann, M. (2001). The effect of weight-loss di eting on cognitive performance and psychological well-bei ng in overweight women. Appetite, 36 147-156. Cameron, J.W. (1999). Self-esteem changes in children enrolled in weight management programs. Issues in Comprehensive Pediatric Nursing, 22 75-85. Cooley, C.H. (1902). Human nature and the social order New York: Charles Scribners Sons. Davison, K.K., & Birch, L.L. ( 2001). Weight status, parent reac tion, and self-concept in 5-year old girls. Pediatrics, 107, 46-53. Deckelbaum. R.J., & Williams, C.L. (2001). Childhood obesity: The health issue. Obesity Research, 9 S239-S243. Dennis, K.E., & Goldberg, A.P. (1996). Weight c ontrol self-efficacy types and transitions affect weight-loss outcomes in obese women. Addictive Behaviors, 21, 103-116. Dietz, W. H. (2004). Overweight in childhood and adolescence. New England Journal of Medicine, 350 855-857. Dishman, R., Hales, D., Pfeiffer, K., Felton, G., Sauders, R., Wa rd, D., et al. (2006). Physical self-concept and self-esteem mediate crosssectional relations of physical activity and sport participation with depressi on symptoms among adolescent girls. Health Psychology, 25 396-407. Economic Research Services. (1993). Rural conditions and trends (Vol. 4). Washington, D.C.: U.S. Department of Agriculture.

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120 BIOGRAPHICAL SKETCH A native of West Virginia, I r eceived my Bachelor of Arts in Psychology from West Virginia University, summa cum laude in 2002. I received my master of science degree in clinical psychology from the Univer sity of Florida in Gainesvill e, FL in 2004. I completed my pre-doctoral internship at Childrens Me morial Hospital in Chicago, IL in 2007.