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Nutritional Adherence, Body Satisfaction, and Quality of Life in Youth with Cystic Fibrosis

Permanent Link: http://ufdc.ufl.edu/UFE0022028/00001

Material Information

Title: Nutritional Adherence, Body Satisfaction, and Quality of Life in Youth with Cystic Fibrosis
Physical Description: 1 online resource (42 p.)
Language: english
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: adherence, adolescents, body, cystic, fibrosis, gender, life, mediator, moderator, nutrition, of, quality, satisfaction
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Cystic Fibrosis (CF) is a chronic, life-shortening, genetic disorder requiring a complex daily treatment regimen including airway clearance, inhaled and oral medications, nutritional supplements, and a high calorie diet. Adherence to this regimen is problematic, with rates of adherence to dietary aspects of the regimen especially low. Adolescents are particularly at risk, as this developmental stage is a critical period for growth, as well as a time of typically lower adherence compared to other age groups. Furthermore, patient body mass index (BMI) is directly related to lung functioning and health status. Identifying factors that could improve nutritional adherence as well as overall quality of life (QOL) in adolescents has the potential to inform clinical practice such that targeted interventions can be developed to address these factors. The aims of the current study were twofold: (a) to evaluate nutritional adherence as a mediating variable between the predictor of body satisfaction and the psychosocial outcome of quality of life, as well as (b) to evaluate gender as a moderator in the relationship between body satisfaction and quality of life in youth with CF. Participants included 54 patients (ages 9 to 17) with CF recruited from two pediatric pulmonary centers, one in Florida and the other in Maryland. When examining data for the overall sample, health status varied, but was on average good for a CF population. Youth reported a high degree of adherence to their dietary regimen, including a high caloric intake with an adequate percentage of calories from fat. Consistent with health care recommendations for many CF patients, most participants desired to gain weight (53.7%), or were content with their current size (29.6%), while only a small percentage wished to lose weight (16.7%). Correlation analyses showed a negative correlation between body satisfaction and caloric intake, with youth who wished to lose weight taking in fewer calories (r = -0.34, p < .05). Youth ratings of QOL were negatively correlated with body satisfaction (r = -0.36, p < .01), such that youth who desired a smaller body image endorsed lower scores on the QOL measure. Regression analyses revealed that the hypothesized mediator model was not supported. However, moderator analyses found that the relationship between body satisfaction and quality of life was moderated by youth gender (beta = 0.36, p < .05). Specifically, females who wished to lose weight had lower quality of life than those who wished to gain, while this relationship was not seen in males. These results have implications for clinical practice such that improving body satisfaction, especially for females, may help to improve adolescent's overall quality of life and potentially impact treatment adherence. Future research is warranted in order to further elucidate gender differences in the relationships of body satisfaction, quality of life, and nutritional adherence, as well as to design interventions specific to youth targeting these factors.
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.
Thesis: Thesis (M.S.)--University of Florida, 2008.
Local: Adviser: Adams, Christina D.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-05-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022028:00001

Permanent Link: http://ufdc.ufl.edu/UFE0022028/00001

Material Information

Title: Nutritional Adherence, Body Satisfaction, and Quality of Life in Youth with Cystic Fibrosis
Physical Description: 1 online resource (42 p.)
Language: english
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2008

Subjects

Subjects / Keywords: adherence, adolescents, body, cystic, fibrosis, gender, life, mediator, moderator, nutrition, of, quality, satisfaction
Clinical and Health Psychology -- Dissertations, Academic -- UF
Genre: Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Cystic Fibrosis (CF) is a chronic, life-shortening, genetic disorder requiring a complex daily treatment regimen including airway clearance, inhaled and oral medications, nutritional supplements, and a high calorie diet. Adherence to this regimen is problematic, with rates of adherence to dietary aspects of the regimen especially low. Adolescents are particularly at risk, as this developmental stage is a critical period for growth, as well as a time of typically lower adherence compared to other age groups. Furthermore, patient body mass index (BMI) is directly related to lung functioning and health status. Identifying factors that could improve nutritional adherence as well as overall quality of life (QOL) in adolescents has the potential to inform clinical practice such that targeted interventions can be developed to address these factors. The aims of the current study were twofold: (a) to evaluate nutritional adherence as a mediating variable between the predictor of body satisfaction and the psychosocial outcome of quality of life, as well as (b) to evaluate gender as a moderator in the relationship between body satisfaction and quality of life in youth with CF. Participants included 54 patients (ages 9 to 17) with CF recruited from two pediatric pulmonary centers, one in Florida and the other in Maryland. When examining data for the overall sample, health status varied, but was on average good for a CF population. Youth reported a high degree of adherence to their dietary regimen, including a high caloric intake with an adequate percentage of calories from fat. Consistent with health care recommendations for many CF patients, most participants desired to gain weight (53.7%), or were content with their current size (29.6%), while only a small percentage wished to lose weight (16.7%). Correlation analyses showed a negative correlation between body satisfaction and caloric intake, with youth who wished to lose weight taking in fewer calories (r = -0.34, p < .05). Youth ratings of QOL were negatively correlated with body satisfaction (r = -0.36, p < .01), such that youth who desired a smaller body image endorsed lower scores on the QOL measure. Regression analyses revealed that the hypothesized mediator model was not supported. However, moderator analyses found that the relationship between body satisfaction and quality of life was moderated by youth gender (beta = 0.36, p < .05). Specifically, females who wished to lose weight had lower quality of life than those who wished to gain, while this relationship was not seen in males. These results have implications for clinical practice such that improving body satisfaction, especially for females, may help to improve adolescent's overall quality of life and potentially impact treatment adherence. Future research is warranted in order to further elucidate gender differences in the relationships of body satisfaction, quality of life, and nutritional adherence, as well as to design interventions specific to youth targeting these factors.
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.
Thesis: Thesis (M.S.)--University of Florida, 2008.
Local: Adviser: Adams, Christina D.
Electronic Access: RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2010-05-31

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2008
System ID: UFE0022028:00001


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1 NUTRITIONAL ADHERENCE, BODY SATISFA CTION, AND QUALITY OF LIFE IN YOUTH WITH CYSTIC FIBROSIS By STACEY LYNN SIMON A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2008

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2 2008 Stacey L. Simon

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3 ACKNOWLEDGMENTS I would like to thank m y mentor, Christina Ad ams, for her generous time, encouragement, and support. I would like to thank Kr istin Reikert for her help with this project. I w ould also like to thank my family for their love and support. Funding for this project was provided by a minigrant from the Center for Pediatric Psychology and Family Studies at the University of Florida.

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4 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................3LIST OF TABLES................................................................................................................. ..........5LIST OF FIGURES.........................................................................................................................6ABSTRACT.....................................................................................................................................7CHAPTER 1 INTRODUCTION....................................................................................................................9Nutritional Adherence.......................................................................................................... ..10Factors Related to Nutritional Non-Adherence...................................................................... 11Quality of Life as a Related Outcome.................................................................................... 15Interventions to Improve Nutritional Adherence....................................................................16Study Aims.............................................................................................................................162 METHOD......................................................................................................................... ......18Procedure................................................................................................................................18Participants.............................................................................................................................18Measures.................................................................................................................................19Statistical Analyses........................................................................................................... ......213 RESULTS...............................................................................................................................25Descriptive Statistics......................................................................................................... .....25Regression Analyses............................................................................................................ ...26Mediation.........................................................................................................................26Moderation......................................................................................................................264 DISCUSSION.........................................................................................................................32LIST OF REFERENCES...............................................................................................................38BIOGRAPHICAL SKETCH.........................................................................................................42

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5 LIST OF TABLES Table page 3-1 Correlational analyses..................................................................................................... ...283-2 Summary of regression analyses for tes ting the mediation and moderation models.........29

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6 LIST OF FIGURES Figure page 2-1 Representation of the mediation mode l: nu tritional adherence mediating the relationship between body satisfa ction and quality of life................................................. 232-2 Representation of the moderation model: gender moderating the relationship between body satisfaction and quality of life...................................................................................243-1 Results of the mediation analysis for body satisfaction, quality of life, and nutritional adherence...........................................................................................................................303-2 Graph of the relationship between body sa tisfaction and quality of life for males and females...............................................................................................................................31

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7 Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science NUTRITIONAL ADHERENCE, BODY SATISFA CTION, AND QUALITY OF LIFE IN YOUTH WITH CYSTIC FIBROSIS By Stacey Lynn Simon May 2008 Chair: Christina D. Adams Major: Psychology--Clinical and Health Psychology Cystic Fibrosis (CF) is a ch ronic, life-shortening, genetic disorder requiring a complex daily treatment regimen including airway clearance, inhaled and oral medications, nutritional supplements, and a high calorie diet. Adherence to this regimen is problematic, with rates of adherence to dietary aspects of th e regimen especially low. Adoles cents are particularly at risk, as this developmental stage is a critical period for growth, as well as a time of typically lower adherence compared to other ag e groups. Furthermore, patient body mass index (BMI) is directly related to lung functioning and h ealth status. Identifying factors that could improve nutritional adherence as well as overall qual ity of life (QOL) in adolescents has the potential to inform clinical practice such that targeted interventions can be developed to address these factors. The aims of the current study were twofold: (a) to evaluate nutri tional adherence as a mediating variable between the predictor of body satis faction and the psychosocial outcome of quality of life, as well as (b) to evaluate gender as a moderator in the relationship between body satisfaction and quality of life in youth with CF. Participants included 54 patients (ages 9 to 17) with CF recruited from two pediatric pulmona ry centers, one in Flor ida and the other in Maryland.

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8 When examining data for the overall sample, h ealth status varied, but was on average good for a CF population. Youth reported a high degree of adherence to their dietary regimen, including a high caloric intake with an adequate percentage of calor ies from fat. Consistent with health care recommendations for many CF patients, most participants desired to gain weight (53.7%), or were content with th eir current size (29.6%), while only a small per centage wished to lose weight (16.7%). Correlation analyses showed a negative corr elation between body satisfaction and caloric intake, with youth who wished to lose weight taking in fewer calories ( r = -0.34, p < .05). Youth ratings of QOL were negatively correlated with body satisfaction ( r = -0.36, p < .01), such that youth who desired a smaller body image endorsed lo wer scores on the QOL measure. Regression analyses revealed that the hypot hesized mediator model was not supported. However, moderator analyses found that the relationship between bod y satisfaction and quality of life was moderated by youth gender ( = 0.36, p < .05). Specifically, females who wi shed to lose weight had lower quality of life than those who wished to gain, wh ile this relationship was not seen in males. These results have implications for clinical practice such that improving body satisfaction, especially for females, may help to improve a dolescents overall quality of life and potentially impact treatment adherence. Future research is warranted in order to further elucidate gender differences in the relationships of body satisfacti on, quality of life, and nut ritional adherence, as well as to design interventions specific to youth targeting these factors.

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9 CHAPTER 1 INTRODUCTION Cystic Fib rosis (CF) is a genetic disorder transmitted through a recessive trait and affects pulmonary and pancreatic functioning (B eers & Berkow, 2006). Though the disease is progressive and terminal in nature, medical a dvances have significantly increased the life expectancy of CF patients to a median of approximately 36 years (Cystic Fibrosis Foundation, 2006). With these advances, however, comes a significant treatment burden: a complex and timeconsuming daily regimen consisting of airway clearance, inhaled and oral medications, nutritional supplements, and a high calorie diet. Approximately 85-90% of CF pa tients have pancreatic insuffi ciency (PI) that contributes to the malabsorption of nutrients, particular ly fat (Borowitz, Baker, & Stallings, 2002). As a result, malnutrition, shortened stature, and delayed puberty may occur. These negative health outcomes may be ameliorated through the use of pancreatic enzyme replacement therapy, as well as consumption of a high fat, high calorie diet Specifically, enzymes should be taken directly prior to or during all meals and snacks. Guidelines suggest that children with CF should achieve 120-150% of the recommended daily energy intake of healthy children, with 35-40% of those calories coming from fat (Borowitz et al.; Dodge & Turck, 2006). Adherence to any long-term chronic treatment regimen is challenging, and the CF regimen is no exception. Rates of adherence vary depend ing on the specific trea tment component, but have typically been found to be higher for medi cations, and lower for airway clearance therapy and vitamins (Abbott & Gee, 1998; Ant hony, Paxton, Catto-Smith, & Phelan, 1999). Compounding the difficulty of an already dema nding treatment regimen is the period of adolescence. Studies have shown that adolescent s are typically less adhe rent to their regimen than younger age groups (Anthony et al.; Hobbs et al ., 2003). This discrepancy could be due to a

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10 variety of factors, such as youth taking more personal responsibility for their regimen and a subsequent decrease in parental involvemen t. Non-adherence to a CF regimen has many implications, including more frequent respiratory infections, more rapid disease progression, additional inpatient and outpatien t medical visits, and more school absences (Abbott & Gee). Nutritional Adherence Of particular concern for adolescents with CF is nutrition. A dolescence is considered a critical period for growth and adequate nutriti on. In addition to the extra nutrient and energy required for accelerated growth a nd pubertal development, the high levels of physical activity and more frequent pulmonary symptoms typical of teens increase their nutritional requirements (Borowitz et al., 2002; Lai et al., 1998). The effects of malnutriti on are particularly detrimental and, in addition to delayed growth and onset of puberty, include a diminished immune response thereby increasing propensity to infection and impaired respiratory performance (Anthony et al., 1999). Additionally, there is an established posi tive association between nutritional status and pulmonary functioning, and in turn, an inverse relation to morbidity and mortality (Bentur, Kalnins, Levison, Corey, & Durie, 1996). In spite of this, adherence to the nutritional regimen is of ten low. Dietary adherence is especially problematic, as this treatment component requires significant problem-solving abilities and is more obtrusive to daily life than other aspects of the CF regimen (Anthony et al., 1999). While few studies have examined nutritional adherence in adolescen ts or adults, several studies have been conducted with younger children. Results show that children with CF typically consume similar nutritional amounts as their hea lthy peers, thus not ac hieving the recommended fat and caloric intake (Stark & Powers, 2006). In a study of 75 children with CF age 6 to 9 yearsold, 61% did not reach the caloric intake and 72% did not meet the fat intake recommended for patients with CF (Tomezsko, Stallings, & Scanlin, 1992). Additionally, only 29% of these

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11 children had good adherence to enzymes (i.e., t ook enzymes appropriately 80% of the time or more). Similarly, only 16% of 7 to 12-year-old s reached their goal of 120% or more of the recommended caloric intake of healthy same-age peers, with a simila r proportion of specific nutrients compared to healthy children, rather than a higher proportion of fat (Anthony, Bines, Phelan, & Paxton, 1998; Anthony et al., 1999). Factors Related to Nutritional Non-Adherence Beyond its interference in daily life, there are a variety of potential reasons why the nutritional com ponent of treatmen t is typically so low. Schools and the media heavily promote a healthy diet (i.e., low fat and low calorie) in direct contrast to the diet appropriate for children with CF (Schall, Bentley, & Stallings, 2006; Stark & Powers, 2006). In fact, interviews with children with CF and their parents found that many caregivers were wary of allowing their child to eat a high fat diet, as it c onflicted with their beliefs about h ealthy eating, and these children felt a conflict between the advice of their doctors and what they l earned about nutrition at school (Savage & Callery, 2005). Furthe rmore, because of the potentia l for adverse physical effects associated with eating high fat foods (i.e., stomach ache, nausea), children with CF are prone to develop aversions to these foods (Schall et al .; Stark & Powers), and in fact, many children indicate that they decide what foods to eat based on taste rather than energy or fat content (Savage & Callery). Mealtime behavior problems may promot e non-adherence to the dietary regimen as well. Stark and Powers (2006) found that parents often perceive more problem behaviors such as whining and refusing meals than parents of healthy children, and that these parents engage in behaviors aimed at encouraging their child with CF to eat, such as demanding and coaxing. Finally, a lack of nutrition-specific knowledge ma y influence adherence: mean scores on one CF nutrition knowledge questionnaire were 63% for children age 6 to 11, and 85%

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12 for parents, with specific knowledge deficits for caloric needs, fat content in foods, and salt requirements (Stapleton, Gurrin, Zubric k, Silburn, Sherriff, & Sly, 2000). Peer and social concerns also have the potential of exacerbating the demands of a CF nutritional regimen in adolescents. Specifically, adolescence is a ti me when peer acceptance is particularly important, and the dietary aspect of CF regimen particul arly may be seen as conflicting with teenage norms. Teens are especi ally preoccupied with how they appear to others. The idea of an imaginary audience evaluating adolescents appearance has been described in the litera ture (Elkind, 1967). In adolescence, body image is beginning to be of increased importance, with teen girls often desi ring a slender body shap e, and male teenagers wishing to be more muscular (Cohn et al., 1987; Frisen, 2007). This incr eased awareness of body image has significant implications for youth with CF, as the disease has many physical effects such as short stature, low we ight, and clubbing of the fingertips (Wenninger, Weiss, Wahn, & Staab, 2003). Studies consistently show th at adult women with CF tend to underestimate their own body size, while males with CF have a more accurate perception of their current shape (Abbott et al., 2000; 2007). A misperception of ones own body size is especially concerning for those patients who see themselves as being of normal weight but are in fact significan tly underweight, as these patients may not be motivated to gain weight. In fact, one study found that adults with CF who perceived themselves to be overweight were less likely to engage in weight enhancing behaviors (Walters, 2000). Examining the degree and direction of body sa tisfaction, a study of 223 teen and adult patients from an adult CF center in the United Kingdom found that males had less body satisfaction than females, which the authors hypot hesized may reflect cultural stereotypes, such

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13 that men desire heavier and more muscular bodies, which male patients with CF do not tend to have (Gee, Abbott, Conway, Etherington, & Webb, 2003). In contrast, studies by Abbott and colleagues (2000, 2007) found that British adult females with CF describe poorer body image than males with CF, with females desiring to be thinner, and males wishing to be heavier. It should be noted, however, that th ese body satisfaction levels were consistent with a healthy comparison group, also suggesting that these patie nts may be subscribing to cultural norms regarding body size. A study of children age 7 to 12 years found no difference in body size perception between children with CF and heal thy children, or between boys and girls (Truby & Paxton, 2001), while another study of adolescents w ith CF found that females were more likely to accurately perceive their body weight, and te enage males more often underestimated their weight (Bentur, Kalnins, Levison, Corey, & Durie, 1996). However, the children with CF were more likely to desire a larger body size while the healthy children wished for a smaller shape. Additionally, girls were more likely than boys to want a smaller shape than they currently had. Taken together, these studies show that patients with CF tend to be dissatisfied by their bodies, with males wishing to gain weight and females desiring a slimmer shape, though this dissatisfaction may be congruent with the healthy population. Body satisfaction has the potential to impact eating behaviors in adolescents. Indeed, a relationship has been shown between body image and dieting or disordered eating in the healthy population. A large study of healthy adolescents found that lowe r body satisfaction in both males and females was tied to more dieting and unhealthy weight control behaviors, such as fasting or skipping meals, abuse of laxatives, and purging (Neumark-Sztainer, Paxton, Hannan, Haines, & Story, 2006). Similarly, for adult female with CF lower body satisfaction was associated with more self-reported dieting behavi ors (Abbott et al., 2000). Especially worrisome is the finding by

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14 Abbott and colleagues (2007) regarding a small group of adult females with CF who were prescribed nutritional interven tions, yet still engaged in dys functional eating behaviors (e.g., excessive dieting, preoccupation with food). In the single study examining this issue in children, few children with CF reported attempts to lose weight, and most described trying to gain weight; additionally, no children (ages 712) with CF had clinically si gnificant scores on a measure of eating attitudes and behaviors (Truby & Paxt on, 2001). One study exploring this issue with adolescents with CF found that 5% of participants in their study used compensatory behaviors to avoid weight gain, including excessive exercise and misuse of enzymes (Shearer & Bryon, 2004). Similar findings have been seen in research done with adolescents w ith Type I diabetes, a population similar to CF as the treatment regi men also includes a significant nutritional component. These studies report that teens ha ve been found to mani pulate their treatment regimen in order to control their weight. Specifically, 37% of female adolescents with diabetes reported under-using or omitting insulin for weight control (Fairburn, Peveler, Davies, Mann, & Mayou, 1991), and it is estimated that this behavi or may occur in 12-15% of all teenagers with diabetes (Aslander-van Vliet, Smart, & Waldron, 2007). The relationship between nutriti onal intake and body satisfaction is different for males and females. Gender may play a pivotal role in the relationship between body dissatisfaction and nutritional behaviors in adoles cents with CF. A theory of gendered embodiment has been proposed for teens with CF, such that these youth id entify first as male or female and second as patients with CF (Willis, Miller, & Wyn, 2001). Becau se of this, they embrace the cultural norms attributed to their respective gende r, and may alter their treatment regimen in order to adhere to these gender roles. As females in general are typically less sati sfied with their body than males, and strive for a thinner body shape, females with CF who subscribe to this typical view may be

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15 less adherent to their dietary regimen. In inte rviews with 40 Australian teenagers with CF, females reported they did not eat as much or as often as males with CF, often skipped meals, and took less enjoyment from food (Willis et al.). Th e authors hypothesized that female adolescents with CF must go against societal norms about women and food to eat a large quantity of food high in calories and fat. Add itionally, males may have an adva ntage in achieving adequate nutritional status, as the typical male desire to be heavier a nd have a muscular body shape may enhance their adherence to th e CF nutritional regimen (Abbo tt et al., 2000). This gender difference in nutritional status due to body satisfaction has particular relevance as it has been documented that survival is poorer for females with CF as compared to males (Anthony et al., 1999), though this discrepancy is narrowing as medical advances continue to proliferate (Verma, Bush, & Buchdahl, 2005). Quality of Life as a Related Outcome Quality of life is defined as the psychol ogical functioning[that] encompasses clinical, social and psychological aspects of a person s health (Abbott & Gee, 1998). In healthy populations, body image has been found to be relate d to quality of life, especially for women, and this has been found to be true in a sample of adults with CF, where body image, along with perception of general health, was the strongest predictor of a patie nts quality of life (Wenninger, Weiss, Wahn, & Staab, 2003). Taken together, th e disease itself, its treatment, and an individuals body satisfaction may influence the quality of life in adolescents with CF. As treatment regimens have led to longer life expectancy for patients it is important to understand the effect that CF and its trea tment have on the patients life. Previous studies have found that quality of life of CF patients is approximate to that of healthy control participants; however, this finding may be due to a response shift, such that patients with CF have a different definition of healthy than healthy peers (Wahl et al., 2005 ; Britto et al., 2004). Addi tionally, a consistent

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16 relationship has been found between health status and quality of lif e, such that CF patients with poorer health report lower quality of life than pa tients with better lung functioning (Gee, Abbott, Conway, Etherington, & Webb, 200 3; Koscik, Douglas, Zaremba, Rock, Splaingard, Laxova, & Farrell, 2005; Wahl et al.). These findings suggest that it is possi ble for those livi ng with CF to have a good quality of life, and emphasize the importance of bette r physical functioning, especially through proper nut ritional adherence. Interventions to Improve Nutritional Adherence Researchers have proposed several interventions to help increase nut ritional intake in patien ts with CF. Reviews of the literature have found that behavioral interventions for families of young children with CF are successful, and pr oduce results comparable to more invasive medical interventions (Jelalian, Stark, Reynolds, & Seifer, 1998; Mackner, McGrath, & Stark, 2001). These interventions typically involve nu tritional education, goal setting, teaching child behavior management strategies to parents, as well as positive reinforcement and differential attention. Studies have shown that these interventions are effective at increasing calories and fat, as well as child weight in child ren age 4 to 12 (Stark & Powers, 2006). It is noteworthy that the literature, however, consists primarily of intervention studi es focused on young children and their parents, with little to no attention given to adolescents. Study Aims Because res earch findings with younger ch ildren with CF may not generalize to adolescents with CF, it is important to examine f actors that influence nutri tional adherence in CF with older youth. For instance, by identifying variables that play a role in dietary adherence in adolescence, researchers could design interventions specific to this age group. Consequently, the principal aim of the current study is to examin e a conceptual model hypot hesized to explain the role of nutritional adherence in relation to body image satisfaction and quality of life. This

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17 mediation model hypothesizes that body image satisfac tion is related to adol escent quality of life through adherence to the dietary regimen. A secondary goal of this study is to evaluate gender as a moderator in the relationship between body image satisfaction and quality of life in adolescents with CF.

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18 CHAPTER 2 METHOD Procedure This m ulti-site research study utilized an observational cross-sectional design. Families with a child between the ages of 9 to 17 with cystic fibrosis were recruited at their regular clinic appointment from two academic medical centers one in rural Florida and the other in a metropolitan area of Maryland. After giving inform ed consent, participating caregivers and youth each completed questionnaires and took part in a joint interview to obtain dietary information for the previous 24-hour time pe riod. After completing study related measures, families received $20 compensation for their time. Participants A total of 38 families were contacted in the Florida clinic, of which 32 agreed to participate. Of the families that declined part icipation, reasons cited included no interest in research ( n = 4) and lack of time ( n = 2). At the site in Maryland, per institutional procedures, a mailing was sent to 124 families informing them of the study. Of these, 58 families were contacted either by telephone or in clinic, and 23 participated in the study. The families that did not participate either were unabl e to be reached after an initial telephone call by research staff ( n = 20), cancelled their clinic appointment ( n = 7), were not able to schedule an appointment prior to the end of the study ( n = 6), or were not interested in research ( n = 2). Overall, a total of 55 families (57.23%) agreed to participate. One family was excluded from the study due to incomplete study measures. Across both sites, the 54 families that comp leted the study included primarily mothers (77.8%), with a mean patient age of 13.61 years ( SD = 2.32). Of these children, 46.3% were male, and, as is most common in CF populations, a majority were Caucasian (90.7%). Our

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19 participant sample was primarily of moderate so cioeconomic status (median annual income level of $50k-60k). Independent samples t-tests and Chi-square analyses were performed for continuous and categorical data, respectively, to determine if th ere were any site differences. Participants did not diffe r by site significantly ( p > .05) on any of the above stated demographic variables except with re gards to youth gender ( 2 (1) = 4.05, p < .05), with fewer boys recruited from the site in Maryland. Measures Patient Info rmation Form. The Patient Information Form was designed specifically for the purpose of this study and was completed by caregivers. The form elicited relevant demographic (e.g., family structure and parent education) and medical information (e.g., presence of liver disease in the patient). Cystic Fibrosis Questionnaire Revised (CFQ-R; Quittner, Buu, Messer, Modi, & Watrous, 2005). This measure consists of questionnaires for parents, adol escents age 14 years and older, and children 12 to 14, as well as an interview form for child ren 11 years of age and younger. The youth informant versions of the ques tionnaire were used for the current study. The CFQ-R assesses the impact of CF and its treatment on the childs quality of life and health status along a variety of subscales. This measure has demonstrated reliability with Cronbachs alpha coefficients ranging from .67 to .94 across subscales, as well as sa tisfactory test-r etest stability (Modi & Quittner, 2003; Quittner, Buu, Messer, Modi, & Watrous). For the purpose of the current study, the following subscales were averaged to create a general quality of life measure: physical, emotional and social. Figure Rating Scale (FRS; Stunkard, Sorenson, & Schulsinger, 1983). To assess body satisfaction, the FRS was administered to all pa tients participating in the study. The FRS is a

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20 two-item self-report measure depicting a series of 9 male or 9 female black-and-white figures ranging from very thin to very heavy in appearan ce. Participants selected the figure that matched how they currently believed they lo oked at the time of the assessm ent, as well as the figure that matched their ideal body image. This measure ha s demonstrated good test-retest reliability as well as validity for a variety of age ranges (Cohn et al., 1987; Thompson & Altabe, 1990). Based on these responses, youth were then ca tegorized into one of three groups: those desiring a thinner image (i.e., wish to lose weight), those desiri ng a heavy image (i.e., wish to gain weight), or those satisfied with their body. For the purpose of this study and consistent with standard weight management advice delivered to CF patients, those yout h who wished to gain weight and those who were satisfied with their weight were combined into one group and then compared to those who desired to lose weight. 24-hour diet recall. The youths dietary intake for the previous 24-hour period was obtained through a joint interview with the adolescent and the car egiver. A joint interview was used because it was felt that a more comprehens ive evaluation of the patients food intake would be obtained, given that parents often prepare food for meals at home, but children also eat many foods outside of their parents presence (e.g., at school). The interview was conducted based on the multiple-pass method developed by the United States Department of Agriculture (described in: Raper, Perloff, Ingwersen, Steinfeldt, & Anand, 2004). The 24-hour diet recall is the most commonly used method of dietary in take in the United States (Buz zard, 1998), and this particular technique has been shown to be accurate in es timating nutrient intake (Blanton, Moshfegh, Baer, & Kretsch, 2006). Families were informed that the interviewer wished to know about everything the child ate and drank from the time they woke up yesterday morning, to the time they woke up this

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21 morning (i.e., the previous 24-hour period). Four passes were obtained during the interview: first, a quick listing of all foods and drinks c onsumed during the period; a review of the foods and drinks listed and obtaini ng any forgotten items for the second pass; the third pass goes through each meal and snack asking for additio ns (e.g., condiments) and portion sizes using visual measurement estimation aids (i.e., measur ing cups and spoons); finally, the fourth pass reviews and confirms all items. Additionally, fami lies were also asked for information regarding enzymes, vitamins, and nutritional supplemen ts taken throughout the 24-hour period. Each item from the diet recall was entered into the Food and Nutrient Database for Dietary Studies 1.0 (United States Department of Agri culture, 2004), an online computerized nutrition database to obtain nutrition anal ysis data (calories and grams of fat). Based on the treatment plans in the participants medical record, three adherence scores were then calculated: overall percentage of enzyme adherence, percentage of da ily calories consumed from fat, and number of calories consumed per kilogram of the childs body weight. Medical chart review The patients medical chart was reviewed to obtain information regarding anthropomorphic data and pulmonary functi on test results from that days clinic visit, as well as physician recommendations for treatment regimen from the previous clinic appointment. Specific values obtained include the childs body mass i ndex (BMI) percentile, which is a measure of body mass based on height, weight, age, and gender, and percent forced expiratory volume (FEV1%-predicted), which is a measure of pulmonary functioning indicating the percentage of the volume of air exhaled in one second expected for an individual of a given age, height, ethnicity and sex. Statistical Analyses Data were analyzed using SPSS soft ware (Version 14.0, SPSS Inc., Chicago, 2005). Consistent with mediator and moderator analysis instructions in Holmbeck (1997), a series of

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22 linear regression analyses were performed. Thes e analyses employed the following variables of interest: body satisfaction, genera l quality of life, and nutritiona l adherence (calories consumed per kilogram of body weight). The mediation model hypothesized that adherenc e to the nutritional regimen mediates the relationship between adolescent sa tisfaction with their body and their quality of life (see Figure 2-1). The model was tested using a series of regression analyses: a) the outcome variable regressed onto the predictor vari able, b) the mediator variable regressed onto the predictor variable, c) the outcome variable regressed onto the mediator variable, and lastly, d) the outcome variable regressed onto both the predictor variable and the mediator variable. According to Baron and Kenny (1986), mediation occurs if there is no relationship between the predictor and outcome variables after controlli ng for the mediating variable (p art d above). Partial mediation may occur if this relationship only partly reduces Subsequently, a Sobel test is performed to determine if the mediation effect is statistically significant. Secondary analyses were conducted utiliz ing gender as a moderator between the relationship of body satisfaction and nutritional adherence (see Figur e 2-2). First, the variables were centered in order to reduce multi-collinearit y. Then, regression analyses were conducted for each model using body satisfaction, child gender, a nd the interaction of these two variables to predict the outcome of quality of life. Moderation is said to occur when there is a significant effect for the interaction term when controlling for the main effects.

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23 Figure 2-1. Representation of the mediation model: nutritional adherence mediating the relationship between body satisfa ction and quality of life. Nutritional Adherence Quality of Life Body Satisfaction

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24 Figure 2-2. Representation of the moderation mode l: gender moderating th e relationship between body satisfaction and quality of life. Ge n der Body Satisfaction Quality of Life

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25 CHAPTER 3 RESULTS Descriptive Statistics The health status of patie nts in this study varied subs tantially, but youth, on average, were healthy for a CF population. The average FEV1 %-predicted was 83.28% ( SD = 23.62), suggesting a mild to moderate severity of pul monary disease. Similarly, participants BMI ranged from the 1st to 99th percentile, with a mean of 44.67 ( SD = 29.48). For youth with CF, current guidelines for BMI define below the 10th percentile as nutritional failure, with children below the 25th percentile at risk for nutriti onal failure (Dodge & Turck, 2006). Results from the diet recall suggest that youth ate a large nu mber of calories ( M = 3951.14, SD = 1747.22), with approximately 35% of these calories coming from fat. These results are on par with the recommended intake of 35-40% of calories from fat sources. Percent adherence to enzymes was cal culated to be on average 77.1 0% for all participants ( SD = 30.96). Patients generally reported high scores on th e quality of life measure: out of a maximum of 100, the mean score for general quality of life was 81.34 ( SD = 12.26). These scores are congruent with those CFQ scores reported for youth of similar age and disease severity in the extant literature (Modi & Quittner, 2003; Qu ittner, Buu, Messer, Modi, & Watrous, 2005). On the measure of body satisfaction, most youth descri bed themselves as wishing to gain weight, (53.7%). Only a small percentage reported de siring a smaller body shape (16.7%), with the remainder indicating feel ing content with their current size (29.6%). Exploratory correlation analyses revealed a significant positi ve correlation between youth BMI percentile and FEV1 %-predicted ( r = 0.48, p < .01), indicating that youth with a higher BMI percentile had better lung functioning. BMI percentile was also correlated significantly and negatively with the childs rati ng on the FRS. For those who desired to lose weight, BMI

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26 percentile was higher ( r = 0.29, p < .05). A negative correlation was found between body satisfaction and caloric intake, such that those youth who wish ed for a smaller body size took in fewer calories ( r = -0.34, p < .05). The youths ratings of QOL were negatively correlated with body satisfaction ( r = -0.36, p < .01); in particular, youth who wished to lose weight endorsed lower scores on the QOL of measure. Yout h age was not significantly related to body satisfaction, QOL, or caloric inta ke, and thus was not controlled for in subsequent analyses. Regression Analyses Mediation The regression analyses testing the m ediati on model that nutritiona l adherence (kcal/kg) acts as a mediator between the relationship of body satisfaction (FRS) and quality of life (QOL) revealed that a) the predictor variable (FRS) was significantly related to the outcome variable (QOL), = -0.36, p < .05, b) the mediator variable (kca l/kg) was significantly related to the predictor variable (FRS), = -0.34, p < .05, c) the mediator variable (kcal/kg) was not significantly related to the outcome variable (QOL), = 0.11, p > .05, and d) the relationship between the predictor variable (FRS) and the outcome variable (QOL) remained significant ( = -0.36, p < .05) even while controlling for the medi ator (kcal/kg), while the relationship between the mediator (kcal/kg) and the outcome variable (QOL) when controlling for the predictor variable (FRS) remained non-significant. Thus the results do not support the hypothesis that nutritional adherence mediates the relationship between body satisfaction a nd quality of life for youth with CF. Moderation The overall regression analysis testing the hypothesis that bo dy satisfaction and quality of life would be m oderated by youth gender was found to be statistically significant, F(3, 49) = 4.01, p < .05. Furthermore, the interaction term (g ender x FRS) was found to be statistically

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27 significant, = 0.36, p < .05 while controlling for the main effects of body satisfaction (FRS) and gender. A graph of the inte raction (Figure 3-1) between body satisfaction and gender showed that girls who wished to lose we ight had lower quality of life than those who wished to gain or were happy with their current size, while for boys, those who wanted a larger body or were happy with their current weight had lower quality of life than those who wi shed to lose weight. Taken together, the results support the hypothesis that gender influen ces the strength or direction of the relationship between body sa tisfaction and quality of life for those who desire a smaller body shape compared to those who wish to gain or are content with their current weight.

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28 Table 3-1. Correlational analyses. Gender Child age FEV1% BMI %-ileKcal/kgFRS QOL Gender --0.16 0.14 0.07 0.32* -0.32* 0.13 Child age -----0.26 -0.11 -0.19 -0.03 -0.13 FEV1% ------0.48** -0.12 0.03 0.19 BMI %-ile --------NR 0.29* -0.03 Kcal/kg -----------0.34* 0.11 FRS -------------0.36** QOL --------------* p < .05, ** p < .01; NR = Not reported due to the confound of weight in both variables

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29 Table 3-2. Summary of regression analyses for testing the mediation and moderation models. Outcome Variable Predictor Variable F R2 p Mediation Model QOL Step (a) FRS 7.47 0.11 0.01 -0.36** Body Satisfaction Step (b) Kcal/kg 6.67 0.10 0.01 -0.34** QOL Step (c) Kcal/kg 0.66 0.01 0.42 0.11 QOL Step (d) FRS 3.66 0.10 0.03 -0.36* Kcal/kg -0.01 Moderation model QOL FRS 4.01 0.15 0.01 -0.09 Gender 0.11 FRS x gender 0.36* *p < .05, **p < .01

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30 = -0.34, p < .05 = 0.11, p > .05 = -0.36, p < .05 ( = -0.36, p < .05) Figure 3-1. Results of the mediation analysis fo r body satisfaction, quality of life, and nutritional adherence. Nutritional Adherence Quality of Life Body Satisfaction

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31 0 10 20 30 40 50 60 70 80 90 100 Boys Girls Lose Gain/Content Figure 3-2. Graph of the relations hip between body satisfaction and quality of life for males and females.

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32 CHAPTER 4 DISCUSSION Treatm ent for cystic fibrosis involves a si gnificant dietary com ponent including a high caloric intake with a large percen tage of fat, as well as pancrea tic enzymes taken with all snacks and meals. Adequate intake is especially important for adolescents, as their nutritional requirements are increased due to rapid phys ical development and worsening pulmonary symptoms. Despite this, adherence to the nutriti onal regimen has been found to be problematic for youth with CF. With healthy girls typically desiring a smaller figur e, and healthy boys wishing to be more muscular, body image becomes more salient in adolescence, which may impact eating behaviors and quality of life. However, few studies have explored the relationships surrounding body satisfaction, nutritional adherence and quality of life in adolescents with CF. Thus, the purpose of the current study was twofold: to test the mediating effects of nutritional adherence on the relationship between body satisf action and quality of lif e, and to investigate gender as a moderator in the same relationship. Correlation results in the current study supported previous research relating lung functioning to BMI. As lung functioning is a signi ficant indicator of dis ease progression, this relationship underscores the importance of dietar y recommendations to increase growth in our youth with CF. Highlighting this relationship, Peterson and colle agues (2003) found that children with CF who weighed more and those who consistently gained weight had better pulmonary function test results. Nonetheless, analysis of the National CF Patient Registry (Lai, 1998) revealed that 33% of children and adolescents we re below the 10th percentile for height and weight, indicating that proper gr owth and nutritional status is a significant challenge in many children with CF.

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33 In addition to being associated with health status, our results reveal ed that BMI was also correlated with body satisfaction. As BMI increa sed, patients body satisfaction ratings went down, indicating they preferred a smaller body si ze and were unhappy with their current shape. This is concerning, as it indicates that the adolescents desires for their body are contrary to that of their health care providers, and these desires ma y be damaging to their health. If teens are not accepting of the message that they should desire to gain weight or maintain a healthy weight to improve their CF health status, they may not fully engage in their treatment regimen. This concern could be more salient for females with CF who seem to be subscribing to the cultural ideal of preferring a thin body shape. In fact, results from this study show that gender does play a role in reported body satisfaction. Analyses supported the moderation hypothesis, finding that gender moderated the relationship between body satisfa ction and quality of life. Sp ecifically, lower body satisfaction was associated with lower QOL for females, wh ile this relationship was not found for males. This finding is supported by the extant literature in healthy adolescents, which states that, in Western culture, men typically prefer a larger, muscular body size, while females wish to be slim (Cohn et al., 1987; Frisen, 2007). Additionally, body im age has been linked to quality of life in healthy adolescents, such that a negative body image is associated with poorer quality of life (Frisen). In the CF population, this finding has many pot ential clinical implications. Encouraging children with CF to gain weight could be in direct conflict of the desire of female patients to be thin. In turn, these patients may be willing to sacrif ice their health in order to obtain their desired body image. In fact, body satisfactio n was found to be associated significantly with nutritional adherence in the current study. Specifically adolescents with CF who endorsed a smaller body

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34 shape took in significantly fewer calories than those who were happy with their weight or wished to gain weight. This finding is particularly troubling, as CF patients are most susceptible for health complications associated with low BMI; s o, it is especially important that they improve their nutritional status. Yet, these patients may be at risk for non-adherence to their nutritional regimen. Indeed, while the current literature show s that patients with CF are no more likely to have eating disorders than their healthy peers, a small percentage do enga ge in distorted eating practices (Raymond et al., 2000). A study by Shear er and Bryon (2004) found that 16% of the adolescents in their study were currently attemp ting to lose or maintain their weight, including 5% who were already significantly underweight Conversely, those pa tients with better body satisfaction took in more calories, suggesting that a way to improve nutritional adherence may be to improve adolescent conten tment with their body. However, contrary to the stated hypothesi s, this study did not find that nutritional adherence had a mediating effect on the relati onship between body satisfa ction and quality of life. This is surprising, given th e expectation th at teens may alter their eating behaviors based upon their desired body shape, and that quality of life is so closely tied to body image. Based on the findings of the current study regarding the moderating effect gender has on the relationship between body satisfaction and qual ity of life, future research conceptualizing a more complex moderated-mediation model (hypo thesizing that the mediating relationship of nutritional adherence on body satisfaction and quality of life will only exist for one gender but not the other) may yield more informative results. Moreove r, the way this study measured nutritional adherence may have impacted the findings of the current model. For the purposes of this study, only caloric intake was considered for the mediation model. However, nutritional adherence is a multidimensional concept, encompassing caloric in take, fat intake, as well as adherence to

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35 enzyme replacement therapy. Additionally, in our sample, self-reported adherence to the dietary regimen was quite high for all components (calories, fat and enzymes), so ceiling effects may have played a role in limiting the statistical power of our analyses. Potentially confounding the study results, the di etary recall was obtaine d at the patients clinic appointment just subse quent to the physicians and nutri tionists examination of the patient. Thus, youth had just been asked about en zymes and their typical dietary intake, and the message about weight gain was particularly sa lient. This may have had an effect on their response to the study measures, specifically the diet recall. Furthermor e, although interviewing parents and youth together was intended to enhance the accuracy of the recall, this approach also may have led to socially desirable responding, pa rticularly on the part of the youth who may want to please his or her parent. While the diet recall is a simple and common method of obtaining nutritional intake info rmation, studies have shown that both adults (Jonnalagadda et al., 2000) and children (Baxter et al., 2003) te nd to underestimate their food consumption. For children with CF, this tendency may be reversed, such that patients over-report their nutrient intake due to both the saliency of the nutritioni sts message of increased intake and social desirability. This study was subject to several other limiti ng factors. The sample size was relatively small, especially for the analyses performed. Wh ile the literature suggests that a large sample size is required for acceptable power in medi ation analyses (Fritz & MacKinnon, 2007), the current study is consistent with other research utilizing mediation and moderation analysis in the pediatric psychology literature, where the samp le sizes tend to be small (Holmbeck, 1997). While the CF population is generally limited at most sites, future resear ch with a larger, multisite sample may yield different results. Additi onally, our findings may have been limited by the

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36 distribution of males and females across body satisfac tion categories (i.e., de sire to gain, desire to lose, content). Specifically, the small size of our overall sample coupled with a generally low base rate, the number of males w ho wished to lose weight was quite small compared to those who wanted to gain or were happy with thei r weight. Again, a much larger sample is recommended in order to further examine the differences between these groups. Finally, while participants in this study demons trated a wide range of health status (BMI percentile and lung functioning), it was nonetheless a sa mple of convenience. The patients who opted to participate were the ones who attended their regularly scheduled cl inic appointment, and were in a state of health such that they were able to be seen on an outpatient basis. Home visits may be superior in terms of ensuring unbiased results; however, as many patients live a sign ificant distance away from the clinic, the tertiary care setting was most amenable to study recruitment. Despite these limitations, this study is one of the first to examine nut ritional adherence, body satisfaction, and quality of life in an adoles cent CF sample, while measuring these variables through reliable and valid tools and with well-controlled methodology. As such, it offers valuable and possible implications for clinical practice and future research. Regular assessment of body satisfaction as part of routine CF care is recommended in order to detect patients who may have poor body image. Rather than fruitles sly encouraging the adol escent to increase their dietary intake, health care pr oviders can instead focus on increasing body satisfaction. In addition to improving adherence, targeting body image may also improve overall quality of life, which is important for all aspects of a patients li fe. More research is needed as to interventions specific to teenagers concentrating on these fact ors. Additionally, further research to parse out the specific gender differences in these rela tionships is warranted. Specifically, our study examined those who wanted to lose weight in co mparison to those who wished to gain or were

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37 content with their weight. Howeve r, males may desire to gain weight, which is consistent with CF treatment goals, yet be highly dissatisfied with their body due to their underweight status. As this consideration was outside the scope of our study, it is an area amenable to further study. Similarly, investigating the specific eating patterns of females with CF who wish to lose weight may identify further areas for intervention. Overall, this study found th at body satisfaction is an impor tant concern for adolescents with CF. The relationship between body satisfaction and quality of life was found to be moderated by gender. Specifically for female s, these youth may not be internalizing the nutritional treatment recommendati ons designed to improve their health status due to their conflicting desire for a smaller body shape. Clinic ians should be aware of their patients body image, as well as the potential for youth with CF to engage in distorted ea ting practices related to their dissatisfaction with their body. By focusing on improvi ng body satisfaction, especially for females, health care providers and researchers may help to impr ove youths overall quality of life and potentially have an impact on trea tment adherence and health outcome.

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38 LIST OF REFERENCES Abbott, J., Conway, S., Etherington, C., Fitzjohn, J., Gee, L., Morton, A., Musson, H., & W ebb, A.K. (2000). Perceived body image and eating behavior in young adults with cystic fibrosis and their healthy peers. Journal of Behavioral Medicine, 23, 501-517. Abbott, J., & Gee, L. (1998). Contemporary psychos ocial issues in cystic fibrosis: Treatment adherence and quality of life. Disability and Rehabilitation, 20, 262-271. Abbott, J., Morton, A.M., Musson, H., Conway, S.P., Etherington, C., Gee, L., Fitzjohn, J., & Webb, A.K. (2007). Nutritional status, perc eived body image and eating behaviors in adults with cystic fibrosis. Clinical Nutrition, 26, 91-99. Anthony, H., Bines, J., Phelan, P., & Paxton, S. (1998). Relation between dietary intake and nutritional status in cystic fibrosis. Archives of Disease in Childhood, 78, 443-447. Anthony, H., Paxton, S., Catto-Smith, A., & Phela n, P. (1999). Physiological and psychosocial contributors to malnutrition in children with cystic fibrosis: A review. Clinical Nutrition, 18, 327-335. Aslander-van Vliet, E., Smart, C., & Waldron, S. (2007). Nutritional management in childhood and adolescent diabetes. Pediatric Diabetes, 8, 323-339. Baron, R.M., & Kenny, D.A. (1986). The moderator-m ediator variable dis tinction in social psychological research: Conceptual, stra tegic and statistical considerations. Journal of Personality and Social Psychology, 51, 1173-1182. Baxter, S.D., Thompson, W.O., Litaker, M.S., Guinn, C.H., Frye, F.H.A., Baglio, M.L., & Shaffer, N.M. (2003). Accuracy of fourth-grade rs dietary recalls of school breakfast and school lunch validated with observations: In-person versus telephone interviews. Journal of Nutrition Education and Behavior, 35, 124-134. Beers, M.H., & Berkow, R. (2007). Cystic fibrosis (section 19, chapter 278). In The Merck Manuals Online Medical Library. Retrieved December 15, 2007, from www.merck.com/mmpe/sec19/ch278/ch0278a.html Bentur, L., Kalnins, D., Levison H., Corey, M., & Durie, P.R. (1996). Dietary intakes of young children with cystic fibros is: Is the re a difference? Journal of Pediatri c Gastroenterology and Nutrition, 22, 254-258. Blanton, C.A., Moshfegh, A.J., Baer, D.J., & Kr etsch, M.J. (2006). The USDA automated multiple-pass method accurately estimates group total energy and nutrient intake. Journal of Nutrition, 136, 2594-2599. Borowitz, D., Baker, R.D., & Stallings, V. ( 2002). Consensus report on nutrition for pediatric patients with cystic fibrosis. Journal of Pediatric Gastro enterology and Nutrition, 35, 246-259.

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39 Britto, M.T., Kotagal, U.R., Chenier, T., Tsevat J., Atherton, H.D., & Wilmott, R.W. (2004). Differences between adolescents and parents reports of health-relate d quality of life in cystic fibrosis. Pediatric Pulmonology, 37, 165-171. Buzzard, M. (1998). 24-hour dietary recall and fo od record methods. In W. Willett (Ed.), Nutritional epidemiology (2nd ed., pp. 50-73). New York, NY: Oxford University Press. Cohn, L.D., Adler, N.E., Irwin, C.E., Millstein, S. G., Kegeles, S.M., & Stone, G. (1987). Bodyfigure preferences in male and female adolescents. Journal of Abnormal Psychology, 96, 276-279. Cystic Fibrosis Foundation. (2006). Patient registry 2006 annual report Bethesda, MD: Cystic Fibrosis Foundation. Dodge, J.A., & Turck, D. (2006). Cystic fibrosis : Nutritional consequences and management. Best Practice & Research Clinical Gastroenterology, 20, 531-546. Elkind, D. (1967). Egocentrism in adolescence. Child Development, 38, 1025-1034. Fairburn, C., Peveler, R., Davies, B., Mann, J ., & Mayou, R. (1991). Eating disorders in young adults with insulin dependent diabetes mellitus: A controlled study. British Medical Journal, 303, 17-20 Frisen, A. (2007). Measuring health-rel ated quality of life in adolescence. Acta Paediatrica, 96, 963-968. Fritz, M.S., & MacKinnon, D.P. (2007). Required sa mple size to detect the mediated effect. Psychological Science, 18, 233-239. Gee, L., Abbott, J., Conway, S.P., Etherington, C., & Webb, A.K. (2003). Quality of life in cystic fibrosis: The impact of gender, gene ral health perceptions and disease severity. Journal of Cystic Fibrosis, 2, 206-213. Hobbs, S.A., Schweitzer, J.B., Cohen, L.L., Haye s, A.L., Schoell, C., & Crain, B.K. (2003). Maternal attributions related to compliance with cystic fibrosis treatment. Journal of Clinical Psychology in Medical Settings, 10, 273-277. Holmbeck, G.N. (1997). Toward terminological, concep tual, and statistical cl arity in the study of mediators and moderators: Examples from the child-clinical and pediatric psychology literatures. Journal of Consulting an d Clinical Psychology, 65, 599-610. Jelalian, E., Stark, L., Reynolds, L., & Seifer, R. (1998). Nutrition inte rvention for weight gain in cystic fibrosis: A meta analysis. Journal of Pediatrics, 132, 486-492. Jonnalagadda, S.S., Mitchell, D.C., Smicikla s-Wright, H., Meaker, K.B., Van Heel, N.,

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40 Karmally, W., Ershow, A.G., & Kris-Ethert on, P.M. (2000). Accuracy of energy intake data estimated by a multiple-pass, 24-hour dietary recall technique. Journal of the American Dietetic Association, 100, 303-308. Koscik, R.L., Douglas, J.A., Zaremba, K., Rock, M.J., Splaingard, M.L., Laxova, A., & Farrell, P.M. (2005). Quality of life of children with cystic fibrosis. Journal of Pediatrics, 147, S64-S68. Lai, H.-C., Kosorok, M.R., Sondel, S.A., Chen, S. -T., FitzSimmons, S.C., Green, C.G., Shen, G., Walker, S., & Farrell, P.M. (1998). Growth status in children with cystic fibrosis based on the National Cystic Fibrosis Patient Registry data: Evaluation of vari ous criteria used to identify malnutrition. Journal of Pediatrics, 132, 478-485. Mackner, L. M., McGrath, A. M., & Stark. L.J. (2001). Dietary recommenda tions to prevent and manage chronic pediatric health conditions: Ad herence, intervention, and future directions. Journal of Developmental and Behavioral Pediatrics, 22, 130-143. Modi, A.C., & Quittner, A.L. (2003). Validation of a disease-specific measure of health-related quality of life for children with cystic fibrosis. Journal of Pediatric Psychology, 28, 535546. Neumark-Sztainer, D., Paxton, S.J., Hannan, P.J ., Haines, J., & Story, M. (2006). Does body satisfaction matter? Five-year longitudinal associations between body satisfaction and health behaviors in adolescent females and males. Journal of Adolescent Health, 39, 244251. Peterson, M.L., Jacobs, D.R., & Milla, C.E. (2003) Longitudinal changes in growth parameters are correlated with changes in pulmonary function in children with cystic fibrosis. Pediatrics, 112, 588-592. Quittner, A.L., Buu, A., Messer, M.A., Modi, A. C., & Watrous, M. (2005). Development and validation of the cystic fibros is questionnaire in the United States: A health-related qualityof-life measure for cystic fibrosis. Chest, 128, 2347-2354. Raper, N., Perloff, B., Ingwersen, L.A., Steinfel dt, L., & Anand, J. (2004). An overview of the USDAs Dietary Intake Data System. Journal of Food Composition Analysis, 17, 545-555. Raymond, N.C., Chang, P.-N., Crow, S.J., Mitchell, J.E., Dieperink, B.S., Beck, M.M., Crosby, R.D., Clawson, C.C., & Warwick, W.J. (2000). Eating disorders in patients with cystic fibrosis. Journal of Adolescence, 23, 359-363. Savage, E., & Callery, P. (2005). Weight and ener gy: parents and childrens perspectives on managing cystic fibrosis diet. Archives of Disease in Childhood, 90, 249-252. Schall, J.I., Bentley, T., & Stallings V.A. (2006). Meal patterns, diet ary fat intake and pancreatic enzyme use in preadolescent children with cystic fibrosis. Journal of Pediatric Gastroenterology and Nutrition, 43, 651-659.

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BIOGRAPHICAL SKETCH Stacey Sim on grew up in Okemos, Michigan, an d received Bachelor of Arts degrees in psychology and music performance from Case We stern Reserve University. After college, she obtained research experience in the Division of Child Psychiatry at th e Cincinnati Childrens Hospital Medical Center, Cincinna ti, Ohio. She is currently purs uing her doctorate in clinical psychology at the University of Florida, with a specialty in pediatric psychology. Research and clinical interests include chr onic health conditions and treatment adherence in children and adolescents.