Disordered Eating and Health-Related Quality of Life in Overweight and Obese Youth

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Title:
Disordered Eating and Health-Related Quality of Life in Overweight and Obese Youth
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1 online resource (58 p.)
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english
Creator:
Gowey, Marissa A
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University of Florida
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Gainesville, Fla.
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Thesis/Dissertation Information

Degree:
Master's ( M.S.)
Degree Grantor:
University of Florida
Degree Disciplines:
Psychology, Clinical and Health Psychology
Committee Chair:
Janicke, David M
Committee Members:
Mccrae, Christina S
Boggs, Stephen R
Price, Catherine

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Subjects / Keywords:
children -- disordered -- eating -- obesity -- qol
Clinical and Health Psychology -- Dissertations, Academic -- UF
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Psychology thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
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Abstract:
Research suggests that overweight and obese children have significantly lower health-related quality of life (HRQOL). However, the role of demographics in relation to HRQOL remains unclear. Additionally, factors with negative physical and psychosocial outcomes, such as disordered eating, have not been thoroughly investigated in association with HRQOL. The current study examines the relationship between demographic variables, disordered eating attitudes and behaviors, unhealthy weight control behaviors, and HRQOL. Participants were 181 overweight or obese youth ages 7-12 years and their parents in a behavioral weight management program. Prior to treatment, children were measured for height and weight and completed questionnaires regarding disordered eating attitudes and behaviors and HRQOL, while parents completed questionnaires regarding demographics and child HRQOL. Almost 17% of the sample endorsed clinically significant disordered eating attitudes and behaviors, while over two-thirds endorsed unhealthy weight control behaviors. Younger children endorsed more disordered eating and lower HRQOL, while children with higher BMI z-scores reported more unhealthy weight control behaviors and lower HRQOL. No significant relationships were found between gender and other variables. Disordered eating attitudes and behaviors and unhealthy weight control behaviors were negatively associated with HRQOL, although differences were revealed among parent-proxy and child-self report of HRQOL. This study suggests that a subset of overweight and obese children engage in disordered eating attitudes and unhealthy weight control behaviors, which has important implications for assessment and treatment. Furthermore, discrepancies between HRQOL reports underline the utility of multiple informants in research and practice.
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In the series University of Florida Digital Collections.
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Includes vita.
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Includes bibliographical references.
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Description based on online resource; title from PDF title page.
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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 Marissa A Gowey.
Thesis:
Thesis (M.S.)--University of Florida, 2012.
Local:
Adviser: Janicke, David M.
Electronic Access:
RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2014-05-31

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lcc - LD1780 2012
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UFE0044206:00001


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1 DISORDERED EATING AND HEALTHRELATED QUALITY OF LIFE IN OVERWEIGHT AND OBESE YOUTH By MARISSA A. GOWEY A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS F OR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2012

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2 2012 Marissa A. Gowey

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3 To my parents, Kim and Lori Gowey

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4 ACKNOWLEDGMENTS I tha nk David Janicke, Ph.D. for his truly excellent mentoring and dedication to this project. I tha nk Crystal Lim, Ph.D. and the E FLIP team for their hard work which made this project possible. Finally, I thank my parents f or their endless support in pursuing my dreams, which has continued to motivate me to do what I love and complete this study

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS .................................................................................................. 4 LIST OF TABLES ............................................................................................................ 7 ABSTRACT ..................................................................................................................... 8 CHAPTER 1 INTRODUCTION .................................................................................................... 10 Disordered Eating Attitudes and Behaviors ............................................................ 10 Unhealthy Weight Control Behaviors ...................................................................... 14 Health Related Quality of Life (HRQOL) ................................................................. 15 Study Purpose ........................................................................................................ 18 2 METHODS A ND PROCEDURES ........................................................................... 21 Participants ............................................................................................................. 21 Procedures ............................................................................................................. 21 Measures ................................................................................................................ 22 Anthropometric Information .............................................................................. 22 Demographic Information ................................................................................. 23 Health Related Quality of Life (HRQOL) ........................................................... 23 Disordered Eating Attitudes and Behaviors ...................................................... 23 Unhealthy Weight Control Behaviors ................................................................ 24 Statistical Analyses ................................................................................................. 24 3 RESULTS ............................................................................................................... 27 Sample Descriptives ............................................................................................... 27 Disordered Eating Attitudes and Behaviors and HRQOL ........................................ 28 Exploratory Analyses .............................................................................................. 30 4 DISCUSSION ......................................................................................................... 40 Prevalence of Disordered Eating ............................................................................ 41 Demographics in Disordered Eating and HRQOL ................................................... 42 Disordered Eating and HRQOL .............................................................................. 43 Child Self and Parent Proxy Report HRQOL ......................................................... 45 Implications ............................................................................................................. 46 St rengths and Limitations ....................................................................................... 47 Future Directions .................................................................................................... 48 LIST OF REFERENCES ............................................................................................... 50

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6 BIOGRAPHICAL SKETCH ............................................................................................ 58

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7 LIST OF TABLES Table page 3 1 Descriptive sample characteristics ..................................................................... 32 3 2 Descriptive characteristics of key independent and dependent variables ........... 33 3 3 ANOVA results for clinically significant disordered eating attitudes and behaviors and child self and parent proxy report HRQOL ................................. 34 3 4 Hierarchical regression results for total disordered eating attitudes and behaviors and child self report HRQOL .............................................................. 35 3 5 Hierarchical regression results for total disordered eating attitudes and behaviors and parent proxy report HRQOL ........................................................ 36 3 6 ANOVA results for dichotomized unhealthy weight control behaviors and child self and parent proxy report HRQOL ........................................................ 37 3 7 Hierarchical regression results for CLBC total unhealthy weight control behaviors and child self report HRQOL .............................................................. 38 3 8 Hierarchical regression results for CLBC total unhealthy weight control behaviors and parent proxy report HRQOL ........................................................ 39

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8 Abstract of Thesis Presented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science DISORDERED EATING AND HEALTHRELATED QUALITY OF LIFE IN OVERWEIGHT AND OBESE YOUTH By Marissa A. Gowey May 2012 Chair: David Janicke Major: Psycholog y Research suggests that overweight and obese children have significantly lower healthrelated quality of life (HRQOL) However the role of demographics in rel ation to HRQOL remains unclear. Additionally, f actors with negative physical and psychosocial o utcomes such as disordered eating, have not been thoroughly investigated in association with HRQOL. The current study examines the relationship between demographic variables, disordered eating attitudes and behaviors, unhealthy weight control behaviors, and HRQOL Participants were 181 overw eight or obese youth ages 7 1 2 years and their parents in a behavioral weight management program. Prior to treatment, children were measured for height and weight and completed questionnaires regarding disordered eating attitudes and behaviors and HRQOL, while parents completed questionnaires regarding demographics and child HRQOL. Almost 17% of the sample endorsed clinically significant disordered eating attitudes and behaviors, while over twothirds endorsed unhealthy weight control behavior s. Younger children endorsed more disordered eating and lower HRQOL, while children with higher BMI z scores reported more unhealthy weight control behaviors and lower HRQOL. No significant relationships were found between gender and other v ariables. D isordered

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9 eating attitudes and behaviors and unhealthy weight control behaviors were negatively associated with HRQOL, although differences were revealed among parent proxy and child self report of HRQOL. This study suggests that a subset of overweight and obese children engage in disordered eating attitudes and unhealthy weight control behaviors, which has important implications for assessment and treatment Furthermore, discrepancies between HRQOL reports underline the utility of multiple informants in research and practice.

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10 CHAPTER 1 INTRODUCTION It has been well established over the past few decades that pediatric obesity has become a major health concern in the United States as well as other regions of the world (Ebbeling, Pawlak, & Ludwig, 2002). Recent data suggests that although previously increasing levels of childhood overweight appear to be leveling off, approximately 32% of youth in the United States are currently overweight while almost 17% of the nations youth are obese (Og den, Carroll, Kit, & Flegal, 2012). This has significant implications for the physical health of these children and adolescents, as childhood obesity has been associated with various chronic medical conditions such as type II diabetes, metabolic syndrome, sleep apnea, and a number of cardiovascular risk factors such as hyperlipidemia and hypertension (Dietz, 1998; Must & Strauss, 1999). In addition to the physical complications, the psychosocial functioning of children who are overweight is adversely impact ed as well. Relative to nonoverweight peers, overweight and obese children are more likely to experience problems with self esteem and body image (Erermis et al., 2004; Strauss, 2000; Pesa, Syre, & Jones, 2000), depression (Erermis et al., 2004; Erickson, Robinson, Haydel, & Killen, 2000), and peer victimization (Janssen, Craig, Boyce, & Pickett, 2004; Storch et al., 2007). Furthermore, children who are overweight are more likely than nonoverweight children to be overweight or obese in adulthood (Ferraro, Thorpe, & Wilkinson, 2003), highlighting the potential for sustained physical and psychosocial problems in these children. Disordered Eating Attitudes and Behaviors Children who are overweight are at increased risk for engaging in disordered eating attit udes and behaviors (Tanofsky Kraff et al., 2004; Neumark Sztainer &

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11 Hannan, 2000). Disordered eating attitudes are generally conceptualized as excessive concerns about shape and weight, excessive thoughts about food, and strong emotions or beliefs related to these concepts (e.g., feeling guilty after eating), while disordered eating behaviors include unhealthy dieting, binge eating, and a range of other unhealthy methods used to attempt to lose or maintain ones weight. These unhealthy weight control behavi ors are described in greater detail in the following section. A number of studies have linked disordered eating to impaired psychosocial functioning in youth, including depression, anxiety, low self esteem, negative body image, and substance abuse (Abrams, Allen, & Gray, 1993; Lock, Reisel, & Steiner, 2001; Stice, Hayward, Cameron, Killen, & Taylor, 2000). Binge eating and emotional overeating, two types of disordered eating, have been highly studied and documented in the literature. There is evidence to support that these unhealthy behaviors are associated with more perceived barriers to weight loss (Sherwood, Jeffery, & Wing, 1999), underlining the importance of preventing, identifying, and managing disordered eating in at risk individuals, as well as thos e participating in weight management programs, and the effect these behaviors may have on other aspects of functioning. Several attempts have been made to identify distinguishing demographic and anthropometric characteristics among overweight youth who engage in disordered eating. Specifically, trends in age, sex, and weight status related to disordered eating have been clearly established in the adolescent and young adult literature. Although the literature suggests that both nonoverweight and overweight youth engage in disordered eating, weight related concerns and behaviors tend to be more prevalent in overweight youth, particularly those who are obese (Neumark Sztainer, Story, Hannan, Perry, &

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12 Irving, 2002). The prevalence of disordered eating attitudes and behaviors has been consistently higher in females than males (Croll, Neumark Sztainer, Story, & Ireland, 2002; Keel, Fulkerson, & Leon, 1997; Presnell, Bearman, & Stice, 2004). However, this gender difference has not been clearly established in younger populations. Thelen and colleagues (1992) found no gender differences in body image and eating related concerns of second graders in contrast to fourth and sixth graders who displayed greater concern among females. Alternatively, Shapiro and colleagues (1997) studied a sa mple of 810 year old children of which girls were significantly more distressed over becoming fat than boys. Thus, the role of gender in disordered eating in younger children has yet to be fully understood. In general, older children h ave been identified as more likely to engage in disordered eating practices. In particular, puberty has been identified as an at risk time for youth (Killen et al., 1993; Ackard & Peterson, 2001). Accordingly, a significant portion of the literature has been devoted to the adolescent population, as this age group has frequently endorsed higher rates of disordered eating attitudes and unhealthy weight control behaviors compared to younger children (Adams, Katz, Beaucham p C ohen, & Zavis, 1993; Neumark Szt ain er et al., 2002). However, data suggests that many children, as young as 8 years old, have significant shapeand weight related concerns and use/have used unhealthy weight control methods to try to lose weight, including dieting and extreme behaviors such as vomiting and diet pill/laxative use (Killen et al., 1993; Shapiro et al., 1997; Thomas et al., 2000). As children are becoming overweight at alarmingly young ages, it is becoming increasingly important to gather data on these concepts in younger age gr oup s. Furthermore, similar to adolescents,

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13 younger children who are overweight are exposed to messages from the social media regarding the ideal thin body image, struggle with low self esteem and negative body image, which have been linked to disordered eating attitudes and behaviors, and experience the negative psychosocial and physical consequences of being overweight (Burrows & Cooper, 2002; Carney & Louw, 2006). Thus, we might expect younger, preadolescent children who are overweight to be at a similar increased risk for engaging in disordered eating attitudes and behaviors as overweight adolescents and consider this a crucial window for prevention and potentially intervention. Nonetheless, more research is needed to determine the frequency and severit y of disordered eating in younger children who are overweight and the impact it has on their functioning. Although subthreshold and partial eating disorders have not generated as much attention as full syndromal eating disorders in the literature, they ar e more prevalent and associated with functional impairment and distress, medical and psychological problems, progression to full syndromal eating disorders, and can be difficult to distinguish from full syndromal disorders as they appear to have comparable levels of shapeand weight related concerns (Crow, Agras, Halmi, Mitchell, & Kraemer, 2002; Stice, Marti, Shaw, & Jaconis, 2009; Striegel Moore, Seeley, & Lewinsohn, 2003). As most adolescents seeking treatment for disordered eating do not meet the Diagn ostic and Statistical Manual of Mental Disorders ( DSM IV ; APA, 1994) diagnostic criteria for an eating disorder (Fairburn & Harrison, 2003; Herzog, Hopkins, & Burns, 1993), it is imperative that more research is conducted in the area of subclinical disordered eating in this developmental range. The Eating Attitudes Test (EAT; Garner & Garfinkel, 1979) is a disordered eating measure that has been successful in serving as a dual

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14 assessment tool that acts as a screener for eating disorders (i.e., clinically si gnificant disordered eating) with the use of a clinical cutoff score and also measures disordered eating on a continuum. Tools like this provide researchers and clinicians the ability to assess disordered eating in multiple ways, which may be particularly useful for evaluating individuals endorsing subclinical symptoms. Unhealthy Weight Control Behaviors Compared to the broad concept of disordered eating attitudes and behaviors, unhealthy weight control behaviors are one component of dis ordered eating which encompass a number of behaviors that individuals may engage in to attempt to maintain or lose weight. In contrast to healthy weight control behaviors, which include methods such as eating more fruits and vegetables and less high fat foods and exercising, engaging in unhealthy weight control behaviors often involves dieting or skipping meals, as well as more extreme behaviors such as vomiting or using diet pills or laxatives. Research suggests that approximately 20% of boys and 40% of girls who are overw eight engage in some form of unhealthy weight control behavior (Neumark Sztainer, Wall, Story, & Perry, 2003). Moreover, longitudinal research reveals that adolescents who engage in unhealthy weight control behaviors continue to exhibit these behaviors as young adults and may even increase their level of engagement in these harmful behaviors (Neumark Sztainer, Wall, Larson, Eisenberg, & Loth, 2011). Many unhealthy weight control behaviors, particularly those thought to be more extreme or severe, have harmful short and long term consequences. A child who engages in these behaviors has the potential to experience a range of physical consequences such as nutritional insufficiencies, delayed puberty, and more severe complications as a result of bulimic behavior s (Story, Neumark Sztainer, Sherwood, Stang, & Murray, 1998;

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15 Pomeroy & Mitchell, 2002). Beyond physical complications, these children experience psychosocial difficulties similar to those associated with broad disordered eating attitudes and behaviors (Sti ce, Presnell, & Spangler, 2002). Moreover, unhealthy weight control behaviors are predictive of subsequent eating disorder psychopathology (Killen et al., 1996; Patton, Selzer, Coffey, Carlin, & Wolfe, 1999). Notably, these unhealthy behaviors have been as sociated with further weight gain (Field et al., 2003; Neumark Sztainer et al., 2006), complicating an already serious problem for overweight youth and creating additional barriers to treatment. Health Related Quality of Life (HRQOL) As evidence has accum ulated for the harmful physical and psychosocial effects of obesity on children, researchers have begun to focus on how much children are affected by their weight status and factors such as mood and disordered eating attitudes and behaviors. One tool used in measuring the influences of these factors is a concept known as healthrelated quality of life (HRQOL), which assesses subjective physical and mental health and has been widely studied in overweight and obese children in recent years (Pinhas Hamiel et a l., 2006; Zeller & Modi, 2006). The PedsQL (Varni, Seid, & Rode, 1999) is a well validated, general measure of HRQOL that has been widely used to study multiple acute and chronic health conditions in children including obesity (Keating, Moodie, & Swinburn, 2011; Varni, Limbers, Bryant, & Wilson, 2010; Varni, Limbers, & Burwinkle, 2007). While HRQOL generally measures overall physical and psychosocial health, it is also often broken down into several domains. In addition to a total score, the PedsQL yields s cores for Physical, Emotional, Social, and School Functioning domains, all of which have been negatively impacted by childhood overweight or obesity (Keating et al., 2011; Pinhas Hamiel et al., 2006), although the

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16 Physical and Social domains appear to be m ost consistently impacted regardless of degree of overweight. According to the literature, HRQOL in overweight children is significantly lower than their healthy weight peers and comparable to rates of children with cancer (Schwimmer, Burwinkle, & Varni, 2003). In fact, research in overweight youth suggests that as weight status increases, HRQOL decreases (Pinhas Hamiel et al., 2006; Williams, Wake, Hesketh, Maher, & Waters, 2005). Children who are extremely obese, with BMIs greater than or equal to 40, ex perience the most significant impact on HRQOL and report the most physical and psychosocial impairments (Zeller, Roehrig, Modi, Daniels, & Inge, 2006). While research on the relationship between BMI and HRQOL has been largely consistent among children and adolescent samples, the roles of age and gender have been less clear across varying age groups. Although many studies on gender and HRQOL in overweight and obese youth have failed to find a significant association between the two variables (Hughes, Farewel l, Harris, & Reilly, 2007; Pinhas Hamiel et al., 2006; Schwimmer et al., 2003), oth er research has suggested that girls are more likely than boys to report impairments in general health, physical symptoms and limitations, depression, and low self esteem (S wallen, Reither, Haas, & Meier, 2005). Similarly, the literature on g ender and HRQOL in overweight and obese youth has been mixed. Among overweight youth, there is some evidence that adolescents have poorer psychosocial functioning than children (Kaplan & Wadden, 1986). Although other studies conducted on obese youth samples have found agespecific associations with HRQOL, (Schwimmer et al., 2003; Swallen et al., 2005), no patterns have emerged. As

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17 such, further exploration into factors such as age and gend er is needed to properly identify and treat children who may be at risk for or experiencing decreased psychosocial and physical impairments. Lower HRQOL in chronically ill children has been linked to increased healthcare utilization, disease severity and medical complications, higher intensity treatment, behavioral and emotional problems, and decreased self worth (Landolt, Vollrath, Niggli, Gnehm, & Sennhauser, 2006; Marino et al., 2010). Specifically, poorer HRQOL in obese children has been associated wit h depression (Zeller et al., 2006). As suggested by Zeller and colleagues (2006), depression has been identified as a barrier to pediatric weight management programs (Zeller et al., 2004). In addition, HRQOL has been associated with lower perceived social support (Zeller & Modi, 2006), which has been identified as a barrier to healthy eating practices and physical activity in children (ODea, 2003). In line with the previously mentioned factors, researchers have begun to explore disordered eating as another barrier to weight management in relation to HRQOL. To our knowledge, only two studies have been identified in the literature that have investigated this relationship, both of which found a significant relationship between disordered eating and HRQOL. Cons istent with previous disordered eating research, both studies focused on adolescents (Doyle, le Grange, Goldschmidt, & Wilfley, 2007; Herpertz Dahlmann, Wille, Hlling, Vloet, & Ravens Sieberer, 2008). Thus, similar studies are needed with overweight children who are younger in order to elucidate the mechanisms of lower HRQOL in this preadolescent population. This will enable researchers and clinicians to target those factors (e.g., disordered eating) in terms of preventative efforts toward HRQOL in these c hildren.

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18 Study Purpose As the negative impact of childhood overweight on HRQOL has been well studied, a plausible next step is to identify specific factors that contribute to poorer HRQOL in these children. Considering the significant negative impact that disordered eating attitudes and unhealthy weight control behaviors have on the physical and psychosocial health of overweight children, in combination with increased risk to engage in these unhealthy beliefs and activities, we suspect that di sordered eati ng is associated with lower HRQOL in these children. Furthermore, disordered eating has been identified as a barrier to pediatric weight management, emphasizing the at risk status of overweight children for engaging in these unhealthy attitudes and behaviors and the potential harmful consequences. However, few studies have thoroughly investigated the relationship between disordered eating attitudes and behaviors and HRQOL in overweight children. Among existing studies, samples have primarily consisted of adolescents. Thus, it is important to examine these relationships in greater depth including a more extensive analysis of disordered eating and how it relates to HRQOL. Moreover, multiple informant data offers a broadened perspective of childrens daily func tioning. In particular, the child self and parent proxy report used in the current study provides an opportunity to learn about the subjective experience of both the c hild and parent in terms of the relationship between being overweight and overall daily functioning of the child as well as specific physical, emotional, social, and school functioning, which may have important implications for assessment and intervention techniques. The current study has two main purposes: (1) to identify the role that demographic and anthropometric variables play in disordered eating attitudes and

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19 behaviors, unhealthy weight control behaviors, and child healthrelated quality of life in young, overweight children and (2) to examine the relationship between disordered eating and healthrelated quality of life. Within the latter purpose, there are important distinctions to be made: (2a) two measures are used to examine the concept of disordered eating exhaustively: a broad disordered eating attitudes and behaviors questionnaire and an unhealthy weight control behaviors checklist; these are measured in separate analyses against HRQOL; (2b) disordered eating attitudes and behaviors and unhealthy weight control behaviors are used both dichotomously and continuously for analyses; (2c) both child self and parent proxy report of HRQOL are used and examined d separately in their relationships with disordered eating. Based on previous research, it is hypothesized that (1) children who are older female, and have a higher weight st atus will be more likely to engage in (1a) clinically significant disordered eating attitudes and behaviors; (1b) more total disordered eating attitudes and behaviors; (1c) at least one (vs. zero) unhealthy weight control behaviors; (1d) more total unhealt hy weight control behaviors. Based on limited previous research and the link between disordered eating and child physical and psychosocial functioning, it is hypothesized that (2a) clinically significant disordered eating attitudes and behaviors will be si gnificantly associated with both parent and childreport of HRQOL. In addition, (2b) children who engage in more total disordered eating behaviors will have lower child and parent reported HRQOL. Furthermore, we hypothesize that (2c) children who endorse at least one unhealthy weight control behavior (vs. zero) will have lower parent and child reported HRQOL. Lastly, it is hypothesized that (2d) children

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20 who engage in more total unhealthy weight control behaviors will have lower parent and childreported HRQOL.

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21 CHAPTER 2 METHODS AND PROCEDURES Participants The sample included 181 overweight or obese children ages 712 and their parent/legal guardian participating in one of two behavioral weight management programs or an education control condition (Janicke et al., 2010). Although children were required to be 8 or older to participate, a small portion of children in the sample were age 7 at their screening or baseline visits who turned 8 by the time treatment began. This sample contains data from the fir st 2 treatment waves, representing part of the larger sample, as an additional wave of treatment was yet to be completed. Eligibility criteria included: (1) children 812 years of age at the start of treatment, (2) children with a Body Mass Index (BMI) at or above the 85th percentile for age and gender, (3) participating parent or legal guardian 75 years old or less, and (4) living in a rural, medically underserved area. Families were excluded if either the child or parent (1) had dietary or exercise restri ctions, (2) had a medical condition that contraindicated mild energy restriction and moderate physical activity, (3) were on antipsychotic agents, systemic cortiocosteroids, antibiotics for HIV or tuberculosis, chemotherapeutic drugs, or prescription weight loss drugs (4) were participating in another weight management program or (5) display ed conditions or behaviors likely to affect their participation in the study. Procedures The study was approved by the governing Institutional Review Board. Recruitmen t consisted of direct mailings of study advertis e ments, distribution of brochures via local schools and physicians offices, newspaper press releases, and

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22 presentations at community events. A toll free telephone number was provided to interested families t o call to learn more about the study and participate in a brief telephone screening with a trained research team member to determine preliminary eligibility for the study. In person screenings were then scheduled for interested and eligible families at which informed consent/assent procedures, height and weight measurements, medical history, and initial health and psychosocial questionnaires were completed. After final eligibility was established, inperson baseline assessments were completed within three w eeks of intervention commencement, where additional health and psychosocial questionnaires were completed. At the conclusion of the baseline visit, families were informed of the intervention condition to which they were randomized. A total of 182 families completed screening and baseline procedures for the first 2 waves of treatment. One family was excluded due to missing questionnaire data, resulting in a final sample of 181. Measures Anthropometric Information The study nurse or medical technician took double measurements of both child height and weight, and averages were used for statistical analyses. Child height was measured without shoes to the nearest 0.1 centimeter using a Harpendon stadiometer. Child weight was measured with one layer of clothes and without shoes to the nearest 0.1 kilogram using a calibrated digital scale. Child BMI was calculated using the following form ula: BMI = weight(kg) / height( m). BMI was converted to z scores, which were used to represent child weight status in statistic al analyses.

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23 Demographic Information The parent/guardian completed a questionnaire created for this study assessing various background information, such as child and parent sex, age, and race, parent marital status, and family income. Health Related Quali ty of Life (HRQOL) The Pediatric Quality of Life Inventory (PedsQL; Varni, Seid, & Rode, 1999) was used to assess child healthrelated quality of life (HRQOL). Both child self and parent proxy report forms of the PedsQL were obtained and used in separate statistical analyses in this study. The measure consists of 23 items on a 5point Likert scale, which yield a Total Scale Score and four subscale scores, Physical, Emotional, Social, and School Functioning. The PedsQL has been used with healthy children, as well as children with acute and chronic illnesses. The internal consistency, validity, and factors of the measure have been well supported (Varni, Bulwinkle, Seid, & Skarr, 2003; Varni, Seid, & Kurtin, 2001). In the current sample, Cronbachs Alpha was 91 for the parent report version and .87 for the childreport version. Disordered Eating Attitudes and Behaviors The Childrens Eating Attitudes Test ( ChEAT) was used to assess broad disordered eating attitudes and behaviors in children. This child self r eport measure consists of 26 items on a 6point Likert scale. However, item responses are scored as follows: Always = 3, Very Often = 2, Often = 1, Sometimes, Rarely, or Never = 0. A total continuous score was used to assess the range of disordered eating attitudes and behaviors, while the published clinical cutoff score ( Garner, Olmsted, Bohr, & Garfinkel, 1982) was used to identify children who engaged in clinically significant disordered eating, creating a dichotomous variable. The ChEAT has good internal

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24 reliability, concurrent validity, and support for the factors noted above (Maloney, McGuire, & Daniels, 1988; Smolak & Levine, 1994). Cronbachs Alpha for the current sample was .78. Unhealthy Weight Control Behaviors The Child Lifestyle Behavior Checklist (CLBC) is a child report questionnaire adapted from a measure created by Neumark Sztainer and colleagues (Neumark Sztainer, Paxton, Hannan, Haines, & Story, 2006) used to assess healthy and unhealthy weight control behaviors that children have engaged in over the past year. As the healthy behaviors were not relevant to the purpose of this study, the remaining unhealthy behavior items were used for statistical analyses. A total of 10 items were used to assess unhealthy weight control behaviors in a yes/no checklist format. This tool is a more specific measure of disordered eating which assesses specific disordered eating behaviors rather than broad disordered eating attitudes and behaviors. While a total continuous score was used to assess the rang e of unhealthy weight control behaviors, a dichotomous score also was created to identify children who did not report engaging in any unhealthy weight control behaviors versus those who engaged in at least one unhealthy weight control behavior. Statistica l Analyses Participants screening and baseline data was used for analyses. All statistical analyses were conducted using Predictive Analytics SoftWare (PASW Statistics 18.0). Variable normality was assessed via skewness and kurtosis values, as well as standardized residuals where appropriate. Normality was within acceptable limits for all variables except the continuous ChEAT variable. Thus, a square root transformation was conducted, which successfully normalized the data.

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25 Independent samples t tests, Pearson correlation coefficients, Pearson chi square coefficients, and simple linear regressions were used to detect significant relationships between demographic/anthropometric variables (i.e., age, gender, BMI z) and variables of interest (i.e., continuous disordered eating attitudes, dichotomous disordered eating attitudes, continuous unhealthy weight control behaviors, dichotomous unhealthy weight control behaviors, child self and parent proxy report HRQOL, and HRQOL subscales) in an effort to identify necessary covariates in subsequent analyses of covariance and hierarchical regressions. The relationships between disordered eating attitudes and HRQOL were examined using two different statistical procedures. Oneway analyses of covariance, controlling f or variables that differed across IV groups, were used to examine differences in childand parent report of HRQOL between children who endorsed clinically significant disordered eating attitudes and behaviors versus those who did not. Hierarchical multipl e regressions were conducted to determine whether the overall level of disordered eating attitudes and behaviors was significantly related to childand parent report of HRQOL. The first block in each regression analysis contained the covariate(s). The sec ond block included the continuous disordered eating attitudes and behaviors variable. Similarly, one way analyses of variance and hierarchical multiple regressions were used to identify significant relationships between unhealthy weight control behaviors and HRQOL using both continuous and dichotomous unhealthy weight control variables. Oneway ANOVAS were used to examine differences in childand parent report of HRQOL between children who did not endorse any unhealthy weight

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26 control behaviors and those w ho endorsed one or more unhealthy weight control behaviors. Hierarchical multiple regressions were conducted to determine whether the overall level of unhealthy weight control behaviors was significantly related to childand parent report of HRQOL. The fi rst block in each regression analysis contained the covariate(s), followed by the continuous unhealthy weight control behaviors variable in block 2. Separate hierarchical multiple and simple linear regression analyses were conducted to examine whether significant relationships existed between disordered eating attitudes and behaviors and HRQOL subscales (i.e., Physical, Emotional, Social, and School Functioning). The first block in each hierarchical multiple regression analysis contained the covariate(s), f ollowed by the second block consisting of the disordered eating attitudes variable.

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27 CHAPTER 3 RESULTS Sample Descriptives Descriptive statistics are displayed in Table 3 1. Children were 712 years of age ( M = 9.94, SD = 1.45). The majority of the sam ple was obese as approximately 67% of the sample had a BMI z score of 2.00 or greater ( M = 2.15, SD = 0.40). Just over half of the sample was female (54.1%; n = 98). Most of the children in the sample were Caucasian (64.1%); however, a fair number of chil dren were identified as ethnic minorities, including AfricanAmerican (16.6%), Hispanic (12.2%), Other (6.6%), and Asian (0.6%). The median family reported income was $40,000 $59,999. The majority of participating parents and legal guardians were married (63.5%). The average age of adult participants was 40.37 years ( SD = 6.90). Statistically significant relationships were found between age and clinically significant disordered eating attitudes and behaviors [ t (179) = 1.976, p = .05], total disordered eating attitudes and behaviors [ r = .170, p = .022], and child self reported HRQOL [ r = .209, p = .005], suggesting that younger children in this sample engaged in more clinically significant and total disordered eating attitudes and behaviors and endorsed lower HRQOL than older children. In addition, BMI z scores were significantly related to unhealthy weight control behaviors [ r = .204, p = .006] and child[ r = .165, p = .026] and parent reported HRQOL [ r = .197, p = .008]. Thus, children with higher w eight status es endorsed more unhealthy weight control behaviors and lower HRQOL by both self and parent report. Results revealed that gender was not significantly related to disordered eating attitudes and behaviors, unhealthy weight control behaviors, or HRQOL.

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28 Descriptive information related to the individual variables of interest (i.e., disordered eating attitudes, unhealthy weight control behaviors, HRQOL) is presented in Table 3 2. The average total score on the ChEAT indicating the level of disordered eating attitudes and behaviors endorsed by each child was well below clinical cutoff ( M = 12.0, SD = 9.0). However, 16.6% of the sample ( n = 30) endorsed disordered eating attitudes and behaviors in the clinically significant range (total score 20). On average, children endorsed between 1 and 2 unhealthy weight control behaviors ( M = 1.48, SD = 1.44) on the Child Lifestyle Behavior Checklist, and almost 70% of the sample ( n = 121) endorsed at least 1 of these behaviors. Children rated their HRQ OL slightly higher than their parents did (child: M = 75.7, SD = 14.0; parent: M = 73.4, SD = 15.2). Disordered Eating Attitudes and Behaviors and HRQOL The relationships between disordered eating attitudes and behaviors and child self and parent proxy r eport of HRQOL were examined using two different statistical procedures. First, oneway analyses of covariance were conducted with age as a covariate to examine differences in childand parent report of HRQOL between children who endorsed clinically signi ficant disordered eating attitudes and behaviors versus those who did not. Results indicated that children who reported clinically significant levels of disordered eating attitudes and behaviors on the ChEAT had lower self reported HRQOL compared to those who did not report clinically significant levels of disordered attitudes and behaviors [ F (1,178) = 4.30, p = .04 ]. However, parent proxy report of child HRQOL was not significantly different between children who endorsed clinically significant disordered eating and those who did not [ F (1,179) = 2.03, NS]. Results for the corresponding mean, standard deviation, partial n, and R levels of

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29 HRQOL in children who reached or exceeded clinical cutoff of the ChEAT versus those who did not are displayed in Table 33 H ierarchical multiple regression analyses were used to examine the unique effect of total disordered eating attitudes and behaviors on childand parent report of HRQOL. The child report HRQOL model included age and BMI z score as covariates in block 1 and the continuous total score variable on the ChEAT in block 2. The parent report HRQOL model consisted of BMI z score as a covariate in block 1, while block 2 included the continuous total score variable on the ChEAT. Results revealed that while disordered eating attitudes and behaviors were significantly associated with lower parent reported HRQOL [ b = 2.13, B = .182, p = .01; F (2,178) = 6.83, p = .001], their relationship with childreported HRQOL only bordered on statistical significance [ b = 1.54, B = .142, p = .055; F (3,177) = 5.76, p = .001]. Table 3 4 presents hierarchical regression results for the relationship between disordered eating attitudes and behaviors and child self report of HRQOL. Table 3 5 displays regression results for disordered eating and parent proxy report of HRQOL. One way analyses of variance and hierarchical multiple regressions were both used to examine the relationships between unhealthy weight control behaviors on the Child Lifestyle Behavior Checklist and HRQOL. Onewa y ANOVAs were conducted to analyze differences in child self and parent proxy report of HRQOL between children who did not endorse any unhealthy weight control behaviors and those who endorsed one or more unhealthy weight control behaviors. Children endor sing at least one unhealthy weight control behavior had significantly lower self reported HRQOL than those who did not report any [ F (1,179) = 10.54, p = .001]. However, parent report of

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30 child HRQOL did not reveal a significant relationship [ F (1,179) = 0.52, NS]. Means, standard deviations, and ef fect sizes are provided for these ANOVA analyses in Table 3 6. Hierarchical multiple regressions were used to detect whether the total number of unhealthy weight control behaviors was significantly related to childand parent report of HRQOL. The first block of the childreport HRQOL model contained the covariates age and BMI z score, and the second block consisted of the continuous CLBC unhealthy weight control behaviors variable. The parent report HRQOL model inc luded BMI z score as the only covariate in block 1 and the continuous CLBC variable in block 2. According to results, unhealthy weight control behaviors were significantly associated with lower child reported HRQOL [ b = 1.96, B = .200, p = .007; F (3,177) = 7.13, p = .000] but not parent reported HRQOL [ b = 0.023, B = .002, NS; F (2, 178) = 3.61, p = .029].Table 3 7 displays regression results for unhealthy weight control behaviors and ch ild self reported HRQOL, while T able 3 8 includes regression results for unhealthy behaviors and parent reported child HRQOL. Exploratory Analyses Significant relationships found between both measures of disordered eating (i.e., ChEAT and CLBC) and HRQOL supported further analyses to investigate which domains of HRQOL (i. e., Physical, Emotional, Social, and School Functioning) were linked to disordered eating. The broader measure of disordered eating (i.e., ChEAT) was used in these analyses as it assessed both disordered eating attitudes and behaviors rather than behaviors only. Separate hierarchical multiple regressions and simple linear regression analyses were run to examine these relationships. T tests and Pearsons correlations were conducted to identify covariates. Results indicated that BMI

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31 z score was significantly related to child and parent report of Physical (child: r = .23, p = .002; parent: r = .22, p = .004) and Social Functioning (child: r = .18, p = .017; parent: r = .22, p = .002). In addition, significant relationships between age and childreport of Physical ( r = .23, p = .002) and Emotional Functioning ( r = .16, p = .034) were identified. Gender was not significantly related to any of the PedsQL subscales. Thus, BMI z score and age were controlled for accordingly. A significant association was found between disordered eating attitudes and behaviors and emotional functioning by both child self [ b = 3.82, B = .237, p = .001; F (2,178) = 7.69, p proxy report [ b = 2.31, B = .163, p = .029; F (1,179) = 4.86, p report of child school functioning was significantly related to disordered eating [ b = 3.11, B = .216, p = .004; F ( 1,179) = 8.72, p report of their physical [ b = .687, B = .059, NS; F (3,177) = 6.94, p = .000], social [ b = 1.71, B = .110, NS; F (2,178) = 4.04, p = .019], and school functioning [ b = 1.01, B = .075, NS; F (1,179) = 1.01, NS] were not significantly related to disordered eating. No significant relationships were identified between disordered eating and parent proxy report of child physical [ b = 2.14, B = .140, NS; F (2,178) = 6.27, p = .002] and social funct ioning [ b = 1.15, B = .076, NS; F (2, 178) = 5.23, p = .006] although the unique relationship between parent report of child physical functioning and disordered eating border ed significance ( p = .057).

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32 Table 3 1. Descriptive sample characteristics D emographic Characteristic N M SD % Child Age 181 9.94 1.45 Child Gender Female 98 54.1 Male 83 45.9 Child Race/Ethnicity Caucasian 116 64.1 African American 30 16.6 Hispanic 22 12.2 Asian 1 0.6 Other 12 6.6 Parent Age 181 40.37 6.90 Parent Marital Status Married 115 63.5 Not Married 66 36.6 Family Income Below $19,999 33 18.3 $20,000 $39,999 48 26.7 $40,000 $59,999 42 23.3 $60,000 $79,999 26 14.4 Above $80,000 31 17.2

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33 Table 32. Descriptive characteristics of key independent and dependent variables PedsQL = Pediatric Quality of Life Inventory; ChEAT = Childrens Eating Attitudes Test; CLBC = Child Lifestyle Behavior Checklist Measure Mean SD Actual Min Max Poss. Min Max ChEAT 12.0 9.0 0 53 0 69 CLBC Unhealthy 1.48 1.44 0 7 0 10 PedsQL Child 75.7 14.0 30.43 100 0 100 P edsQL Parent 73.4 15.2 32.61 100 0 100

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34 Table 33. ANOVA results for clinically significant disordered eating attitudes and behaviors and child self and parent proxy report HRQOL <20 Mean SD Mean SD p value partial R PedsQLChild 76.80 13.23 70.04 16.91 .040* .024 066 PedsQLParent 74.14 14.82 69.81 17.02 .133 .013 .014 PedsQL = Pediatric Quality of Life Inventory *p<.05, **p<.01

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35 Table 34. Hierarchical regression results for total disordered eating attitudes and behaviors and child self report HRQOL B SE B t p R2 R2 Step 1 Constant Age BMI Z 67.975 2.009 5.700 9.021 .704 2.550 .206** .162* 7.535 2.854 2.236 .000 .005 .027 .070 .070 Step 2 Constant Age BMI Z ChEAT 73.514 1.797 4.997 1.535 9.403 .707 2.556 .796 .185** .142 .142 7.818 2.541 1.955 1 .929 .000 .012 .052 .055 .089 .019 ChEAT = Childrens Eating Attitudes Test B = Unstandardized Beta, = Standardized Beta *p< .05, **p<.01

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36 Table 35. Hierarchical regression results for total disordered eating attitudes and behaviors and parent prox y report HRQOL B SE B t p R2 R2 Step 1 Constant BMI Z 89.638 7.533 6.123 2.798 .197** 14.639 2.692 0 .008 .039 .039 Step 2 Constant BMI Z ChEAT 94.363 6.540 2.133 6.328 2.787 .857 .171* .182* 14.912 2.346 2.488 .000 .020 .014 .071 .032 ChE AT = Childrens Eating Attitudes Test B = Unstandardized Beta, = Standardized Beta *p< .05, **p<.01

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37 Table 36. ANOVA results for dichotomized unhealthy weight control behaviors and child self and parent proxy report HRQOL 0 1 & above Mean SD Me an SD p value partial R PedsQLChild 80.38 12.50 73.35 14.28 .001** .056 .056 PedsQLParent 74.58 14.46 72.85 15.64 .474 .003 .003 PedsQL = Pediatric Quality of Life Inventory *p<.05, **p<.01

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38 Table 3 7. Hierarchical regression results for CLBC tot al unhealthy weight control behaviors and child self report HRQOL B SE B t p R2 R2 Step 1 Constant Age BMI Z 67.975 2.009 5.700 9.021 .704 2.550 .206** .162* 7.535 2.854 2.236 .000 .005 .027 .070 .070 Step 2 Constant Age BMI Z CLBC 65.904 2. 194 4.246 1.957 8.892 .695 2.559 .712 .225** .120 .200** 7.412 3.159 1.659 2.747 .000 .002 .099 .007 .108 .038 CLBC = Child Lifestyle Behavior Checklist B = Unstandardized Beta, = Standardized Beta *p< .05, **p<.01

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39 Table 3 8. Hierarchic al regression results for CLBC total unhealthy weight control behaviors and parent proxy report HRQOL B SE B t p R2 R2 Step 1 Constant BMI Z 89.638 7.533 6.123 2.798 0.197** 14.639 2.692 0 0.008 .039 .039 Step 2 Constant BMI Z CLBC 89.635 7.516 0.02 6.141 2.866 0.795 0.197** 0.002 14.597 2.622 0.029 0 0.009 0.977 .039 .000 CLBC = Child Lifestyle Behavior Checklist B = Unstandardized Beta, = Standardized Beta *p< .05, **p<.01

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40 CHAPTER 4 DISCUSSION The current study set out to ident ify the role of demographics in relation to disordered eating and healthrelated quality of life (HRQOL) in overweight and obese children and examine the relationships between various types and degrees of disordered eating and HRQOL. Our study is unique in that it is one of the few studies to investigate the association between disordered eating and HRQOL in overweight and obese youth. Results from the current study extend the literature by providing prevalence rates of children, rather than adolescents, engaging in clinically significant disordered eating as well as total disordered eating attitudes and unhealthy weight control behaviors. To our knowledge, this is the first study to provide evidence that disordered eating is associated with lower HRQOL in preadolescent overweight and obese children. Furthermore, the current studys results regarding child self and parent proxy report of HRQOL in relation to disordered eating are unique due to the differences noted between child and parent perceptions of HR QOL. Contrary to extant research, younger children in our sample endorsed more disordered eating attitudes and unhealthy weight control behaviors than older children, while gender was not a significant factor. The literature suggests that overweight yout h have significantly lower HRQOL than their nonoverweight peers (Schwimmer et al., 2003), which has been associated with barriers to pediatric weight management and healthy practices, such as depression and lower perceived social support (ODea, 2003; Zel ler et al., 2006). Although disordered eating has also been identified as a significant risk factor in children who are overweight and a barrier to pediatric weight management (Sherwood et al., 1999;

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41 Tanofsky Kraff et al., 2004), little is known about how disordered eating is related to HRQOL in overweight youth, specifically younger children. To our knowledge, there are only two studies that have investigated this relationship, both of which focused on adolescents (Doyle et al., 2007; Herpertz Dahlmann et al. 2008). However, previous research has documented significant disordered eating attitudes and behaviors in younger, overweight/obese children (Killen et al., 1993; Shapiro et al., 1997; Thomas et al., 2000). Thus, the lack of data in this at risk, youn g population is problematic, calling for investigation into these unhealthy practices and their relationship to childrens overall physical and psychosocial functioning. The results of the current study have begun to fill those gaps in the literature. Pre valence of Disordered Eating While the average level of disordered eating endorsed on the ChEAT was well below the clinical cutoff, almost 17% of children in the current sample endorsed clinically significant disordered eating attitudes and behaviors. This is somewhat higher than rates of young children engaging in clinically significant levels of disordered eating found in the literature (Maloney, McGuire, Daniels, & Specker, 1989; Razenhofer et al., 2008). Furthermore, over twothirds of the sample endors ed at least one unhealthy weight control behavior, which is a substantially larger portion of individuals sampled in comparison to other studies, which have indicated approximately 1040% participation in these behaviors (Shapiro et al., 1997; Neumark Szta iner et al., 2003). However, children in the current sample endorsed between one and two unhealthy weight control behaviors on average, which is slightly below the 22.5 average behaviors endorsed in a large adolescent sample (Neumark Sztainer et al., 2003). Nonetheless, the high proportion of obese children in the sample may explain the increase in clinically

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42 significant disordered eating and endorsement of unhealthy behaviors, as increases in weight status are associated with greater psychosocial and phys ical impairments (Pinhas Hamiel et al., 2006; Williams et al., 2005; Zeller et al., 2006). Demographics in Disordered Eating and HRQOL Among the analyses conducted between demographics, disordered eating, and HRQOL, age and gender results were most noteworthy. Compared to older children in the sample, younger children engaged in more clinically significant and overall total disordered eating attitudes and behaviors. These findings are generally inconsistent with the literature, which emphasizes adolescence and puberty as highrisk periods for engaging in disordered eating (Adams et al., 1993; Killen et al., 1993; Neumark Sztainer et al., 2002). Accordingly, younger children in the sample may have had difficulty understanding the abstract concepts of disordered eating, endorsing those items without fully comprehending their meaning. In addition, compared to adolescents, younger children may be less aware of the adverse nature of these concepts and behaviors, making them less susceptible to response bias and m ore likely to provide truthful responses. Furthermore, children who were younger endorsed lower HRQOL. In particular, younger children reported lower HRQOL in Physical and Emotional Functioning domains. These results are in contrast with the limited research in this area, which indicates that older children are more likely to exhibit impairments in HRQOL than younger children (Kaplan & Wadden, 1986). While it is quite possible that additional factors not accounted for here may be responsible for lower HRQO L levels, the inconsistencies and limited amount of research in this area render the validity of these results probable as well. Moreover, contradictory to a large body of research indicating

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43 that disordered eating is more prevalent in females than males ( Croll et al., 2002; Keel et al., 1997; Presnell et al., 2004), gender was not significantly related to disordered eating attitudes or unhealthy weight control behaviors in the current sample. Similarly, gender was not related to total HRQOL or any of the s ubdomains of HRQOL. As disordered eating has been largely studied in adolescent and young adult populations, where gender differences have been apparent, these differences simply may not be relevant in younger populations. One reason may be that younger children may be less aware of the gender disparity among eating disorders ; thus, males may feel less pressure to suppress psychological distress and refrain from reporting disordered eating attitudes and behaviors. Alternatively, additional unidentified fact ors (e.g., family/parental variables, environmental factors, social functioning) may be accountable, as previously stated. As anticipated, children with higher weight status endorsed more unhealthy weight control behaviors, in line with existing literature (Neumark Sztainer et al., 2002). Children with increased weight status es and their parents also reported lower HRQOL, specifically in the areas of Physical and Social Functioning, suggesting that childhood overweight and obesity is associated with HRQOL i n preadolescence and has a distinct link to their physical health and social skills and interactions. Disordered Eating and HRQOL With evidence of the early association between increased weight status and lower healthrelated quality of life, the signif icance of our findings regarding the relationships between disordered eating attitudes, unhealthy weight control behaviors, and HRQOL becomes evident. The degree of both disordered eating attitudes and behaviors and unhealthy weight control behaviors were negatively associated with HRQOL, although differences were revealed among child self and parent proxy report

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44 of child HRQOL. Children who engaged in clinically significant disordered eating attitudes and behaviors reported lower HRQOL than their peers who did not endorse clinically significant levels of disordered eating, although parents did not report significant differences in HRQOL between groups. Additionally, children who endorsed more total disordered eating attitudes and behaviors overall had lower parent reported HRQOL but did not self report significantly lower levels of HRQOL. Thus, children who engage in significant, problematic disordered eating behaviors appear to recognize and report problems in their physical and psychosocial functioning al though their parents do not seem to observe or report similar difficulties. Taking into consideration the nature of some of the behaviors children may be endorsing to reach a clinically significant level of disordered eating, parents may not be aware that their children are engaging in such extreme weight control behaviors. Thus, they may be unaware of the associated emotional, social, physical or school problems their children are experiencing. Interestingly, youth who engage in more total disordered eating attitudes and behaviors do not report significantly more problems with their physical and mental health but their parents report that these children experience more difficulties In this case, children may not feel as much pressure to keep less extreme behaviors to themselves (e.g., dieting), as they may perceive these to be more acceptable forms of weight management. Thus, parents may have increased concern regarding their childrens HRQOL, although their children may not view these behaviors as problem atic or impairing. On the contrary, unhealthy behaviors were significantly associated with lower childreported HRQOL but not parent reported HRQOL. Therefore, children appear to be experiencing lower HRQOL in relation to unhealthy weight control behaviors although their parents do not

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45 seem to observe similar impairments. As the majority of children in the current sample did not endorse a large number of unhealthy weight behaviors, parents may not have been as aware of their childrens participation in these behaviors or may have underestimated the problems associated with their childrens functioning as the quantity of behaviors endorsed was rather low in general. Exploratory analyses were conducted to identify which domains of HRQOL were related to disordered eating attitudes and behaviors, revealing the link between disordered eating and the emotional health and school performance of children. Both children and parents reported significantly more problems in Emotional Functioning in children who engaged in more total disordered eating practices. In addition, parents reported that School Functioning was significantly lower for children who reported more total disordered eating than others, indicating that children may not be as aware of their school performance or how their unhealthy eating habits may be related to their ability to function during the school day and on school related tasks. However, childand parent report of Physical and Social Functioni ng, as well as child report of School Fu nctioning, were not significantly associated with disordered eating. Parents report of childrens Physical Functioning bordered significance, which is consistent with the physical difficulties with which disordered eating is often associated. Child Self and Parent Proxy Report HRQOL The only known study of disordered eating and HRQOL to use both child self and parent proxy report of HRQOL suggests that there is general agreement among child and parent report of HRQOL in overweight children engaging in disor dered eating (Herpertz Dahlmann et al., 2008), while the current studys results indicate that children and parents often have different perceptions of child HRQOL related to these concepts

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46 and behaviors. In the current study, parents ratings were slightly lower than childrens overall ratings of HRQOL, indicating that parents subjectively rated their childrens physical and psychosocial functioning as slightly worse than their children did. As found in other studies, this could have been a slight overestimation of childrens difficulties by parents as a result of their own distress (Canning, Hanser, Shade, & Boyce, 1992; Levi & Drotar, 1999). Otherwise, this may have been due to minor underreporting of problems by the children or a lack of insight into one or mor e domains of functioning on either the child or parents end (e.g., child may not fully understand physical impairments, parent may not be aware of all social problems). Certainly this is an area requiring further investigation as data regarding child and parent perceptions have strong implications for both assessment and treatment. Implications The results of the current study revealed lower HRQOL in children who endorsed clinically significant disordered eating attitudes and behaviors by reaching the clinical cutoff on the ChEAT, as well as those who reported more total disordered eating attitudes on the ChEAT and total unhealthy weight control behaviors on the CLBC. As demonstrated here, there is utility in viewing disordered eating attitudes and behavior s and unhealthy weight control behaviors on a continuum and using cutoffs, particularly for assessment purposes. As previously discussed, child and parent report was incongruent at times, highlighting the importance of multiple informants to obtain a broad description of functioning. As the roles of gender and age in HRQOL remain unclear, continuing to explore these relationships will be essential as identifying risk factors remains an important task. The identification of risk factors in these children aids in treatment referral and provides researchers, clinicians, and other professionals with

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47 guidance in the appropriate distribution of resources and education on disordered eating. Unfortunately, the current sample is not representative of children from low SES backgrounds who are in distress but lacking resources and unable to seek treatment. For this reason, it will be increasingly important for physicians, teachers, and other professionals and paraprofessionals to be aware of the warning signs and indic ators of disordered eating and associated psychological distress. Overweight and obese children should be monitored closely for the development of these behaviors. Regarding treatment, there is certainly a need to improve HRQOL in this population. The cur rent study found that overweight children who engaged in disordered eating had significantly lower HRQOL. Treatment tailored to these groups of children can be developed from research in this area. Components of treatment should include developmentally appropriate materials related to disordered eating attitudes, unhealthy weight control behaviors, and issues often related to these concepts, such as body image, self esteem, and depressive symptoms. These treatment materials could potentially be integrated i nto a pediatric weight management program or given as independent resources at primary care offices, schools, or local community agencies. Strengths and Limitations The current study features a number of strengths. The sample consisted of overweight and o bese children who were in the preadolescent age range, which has been studied less frequently than other age groups in the literature on disordered eating and weight control behaviors. Multiple informants were used in assessing child HRQOL to provide a mor e comprehensive perspective of this concept. The measures used in this study were well validated and widely used with overweight and obese children (i.e., ChEAT, PedsQL). As discussed earlier, there are few studies examining the

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48 relationships between disor dered eating and HRQOL. These findings are generally consistent with those results; however, this study also examines unhealthy weight control behaviors, in addition to conceptualizing disordered eating and unhealthy weight control behaviors dichotomously and continuously, which allowed us to report and apply valuable information toward assessment and treatment. The following limitations should be considered in the context of the current study. Although significant relationships were found between disorder ed eating and HRQOL, the amount of variance accounted for by disordered eating attitudes and unhealthy weight control behaviors was small. This highlights the importance of further research in this area and places emphasis on our implications pertaining to the integration of these components into a weight management or similar multifaceted program. The measures used in the current study were primarily self report, which may be associated with social desirability and inaccuracy. Unfortunately, no comparison group was used in this study, such as a nonoverweight sample. The current sample included treatment seeking children with many from midSES, two parent households, limiting generalizability. Finally, as this was a cross sectional study, no cause and effec t relationships can be drawn from the data. Although relationships were established between disordered eating and HRQOL, the directional nature of these associations is unknown. Thus, we cannot assume that disordered eating leads to lower HRQOL as the opposite is possible. Future Directions Moving forward, longitudinal studies are necessary to determine the directionality and impact of disordered eating attitudes and unhealthy weight control behaviors on HRQOL over time, as cross sectional studies only all ow us to determine an association.

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49 Clearly, the role of demographics needs to be further explored. Particularly, the roles of age, gender, and race/ethnicity in relation to HRQOL are areas for future research. Certainly, more research is needed with younger populations as they appear to be an at risk group. Non treatment seeking youth should be studied through venues such as schools and physicians offices to determine the prevalence of disordered eating in younger overweight/obese children and the impact on HRQOL in this population Using developmentally appropri ate tools to measure cognitions, emotions, and behavior s to decrease misinterpretation and increase validity of responses will be a key factor in working with these younger populations. This might incorporate interviewing techniques, diagrams, and extra instruction, explanation, or resources beyond paper and pencil questionnaires. With existing knowledge of the relationship between unhealthy weight control behaviors and HRQOL and the potentially damaging effects of these behaviors, the impact of extreme unhealthy weight control behaviors (e.g., fasting, vomiting, diet pills) on HRQOL should be explored. We suspect that children will report significantly lower HRQOL when engaging in severe disor dered eating behaviors, as they may experience a greater negative impact in their psychosocial and physical health given the hazardous nature of these behaviors. Now that we have begun to investigate disordered eating more closely, additional factors that may be accounting for variability in HRQOL should be explored, such as SES, medical comorbidities, psychological comorbidities, family functioning, social functioning, and peer victimization.

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50 LIST OF REFERENCES Abrams, K. K., Allen, L. R., & Gray, J. J. (199 3). Disordered eating attitudes and behaviors, psychological adjustment, and ethnic identity: A comparison of black and white female college students. International Journal of Eating Disorders, 14, 49 57. doi:10.1002/1098108X(199307) Ackard, D. M., & Peterson, C. B. (2001). Association between puberty and disordered eating, body image, and other psychological variables. International Journal of Eating Disorders, 29, 187 194. doi: 10.1002/1098108X(200103)29:2<187::AID EAT1008>3.0.CO;2R Adams, P. J., Katz R. C., Beauchamp, K., Cohen, E., & Zavis, D. (1993). Body dissatisfaction, eating disorders, and depression: A developmental perspective. Journal of Child and Family Studies, 2, 37 46. doi: 10.1007/BF01321299 American Psychiatric Association. (1994). Dia gnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Burrows, A., & Cooper, M. (2002). Possible risk factors in the development of eating disorders in overweight preadolescent girls. International Journal of Obesity and R elated Metabolic Disorders, 26, 12681273. doi:10.1038/sj.ijo.0802033 Canning, E. H., Hanser, S. B., Shade, K. A., & Boyce, W. T. (1992). Mental disorders in chronically ill children: Parent child discrepancy and physician identification. Pediatrics, 90, 692 696. Carney, T., & Louw, J. (2006). Eating disordered behaviors and media exposure. Social Psychiatry and Psychiatric Epidemiology, 41, 957966. doi:10.1007/s00127006 01209 Croll, J., Neumark Sztainer, D., Story, M., & Ireland, M. (2002). Prevalence and risk and protective factors related to disordered eating behaviors among adolescents: Relationship to gender and ethnicity. Journal of Adolescent Health, 31, 166 175. doi: 10.1016/S1054139X(02)003683 Crow, S. J., Agras, W. S., Halmi, K., Mitchell, J E., & Kraemer, H. C. (2002). Full syndromal versus subthreshold anorexia nervosa, bulimia nervosa, and binge eating disorder: A multicenter study. International Journal of Eating Disorders, 32(3), 309 318. doi: 10.1002/eat.10088 Dietz, W. H. (1998). Heal th consequences of obesity in youth: Childhood predictors of adult disease. Pediatrics, 101, 518 525. Doyle, A. C., le Grange, D., Goldschmidt, A., & Wilfley, D. E. (2007). Psychosocial and physical impairment in overweight adolescents at high risk for eating disorders. Obesity, 15 (1), 145154. doi:10.1038/oby.2007.515

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53 Lock, J., Reisel, B., & Steiner, H. (2001). Associated health risks of adolescents with disordered eating: How different are they from their peers? Results from a high school survey. Child Psychiatry and Human Development, 31, 249 265. doi: 10.1023/A:1026433506298 Maloney, M. J., McGuire, J. B., & Daniels, S. R. (1988). Reliability testing of the children's version of the Eating Attitudes Test. Journal of American Academy of Child Adolescent Psychiatry, 27, 541 3. doi:10.1097/0000458319880900000004 Marino, B. S., Tomlinson, R. S., Wernovsky, G., Drotar, D., Newburger, J. W., Mahony, L., Shea, J. A. (2010). Validation of the pediatric c ardiac quality of life inventory. Pediatrics, 126(3), 498 508. doi: 10.1542/peds.20092973 Mintz, L. B., & OHalloran, M. S. (2000). The Eating Attitudes Test: Validation with DSM IV eating disorder criteria. Journal of Personality Assessment, 74(3), 489503. doi: 1 0.1207/S15327752JPA7403_11 Must, A., & Strauss, R. S. (1999). Risks and consequences of childhood and adolescent obesity. International Journal of Obesity and Related Metabolic Disorders, 23, S2 S11. doi:10.1038/sj.ijo.0800852 Neumark Sztainer D., Croll, J., Story, M., Hannan, P. J., French, S., & Perry, C. (2002). Ethnic/racial differences in weight related concerns and behaviors among adolescent girls and boys: Findings from Project EAT. Journal of Psychosomatic Research, 53, 963 974. doi:10 .1016/S00223999(02)004865 Neumark Sztainer, D., & Hannan, P. J. (2000). Weight related behaviors among adolescent girls and boys: Results from a national survey. Archives of Pediatric and Adolescent Medicine, 154 569 57 Neumark Sztainer, D., Paxton, S. J., Hannan, P. J., Haines, J., & Story, M. (2006). Does body satisfaction matter? Fiveyear longitudinal associations between body satisfaction and health behaviors in adolescent females and males. Journal of Adolescent Health, 39, 244 251. doi: 10.1016 /j.jadohealth.2005.12.001 Neumark Sztainer, D., Story, M., Hannan, P. J., Perry, C. L., & Irving, L. M. (2002). Weight related concerns and behaviors among overweight and nonoverweight adolescents: Implications for preventing weight related disorders. Arc hives of Pediatric and Adolescent Medicine, 156, 171 178. Neumark Sztainer, D., Wall, M., Guo, J., Story, M., Haines, J., & Eisenberg, M. (2006). Obesity, disordered eating, and eating disorders in a longitudinal study of adolescents: How do dieters fare five years later? Journal of the American Dietetic Association,106, 559 568. doi: 10.1016/j.jada.2006.01.003

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54 Neumark Sztainer, D., Wall, M., Larson, N. I., Eisenberg, M. E., & Loth, K. (2011). Dieting and disordered eating behaviors from adolescence to young adulthood: Findings from a 10year longitudinal study. Journal of the American Dietetic Association, 111, 1004 1011. doi: 10.1016/j.jada.2011.04.012 Neumark Sztainer, D., Wall, M. M., Story, M., & Perry, C. L. (2003). Correlates of unhealthy weight con trol behaviors among adolescents: Implications for prevention programs. Health Psychology, 22, 88 98. doi: 10.1037/02786133.22.1.88 ODea, J. A. (2003). Why do kids eat healthful food? Perceived benefits of and barriers to healthful eating and physical ac tivity among children and adolescents. Journal of the American Dietetic Association, 4, 497 501. doi:10.1053/jada.2003.50064 Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2012). Prevalence of obesity and trends in body mass index among US chi ldren and adolescents, 19992010. Journal of the American Medical Association, 307(5), 483490. doi:10.1001/jama.2012.40 Patton, G. C., Selzer, R., Coffey, C., Carlin, J. B., & Wolfe, R. (1999). Onset of adolescent eating disorders: Population based cohor t study over 3 years. British Medical Journal, 318, 765768. doi:10.1136/bmj.318.7186.765 Pesa, J. A., Sy re, T. R., & Jones, E. (2000). Psychosocial differences associated with body weight among female adolescents: The importance of body image. Journal of Adolescent Health, 26, 330337. doi: 10.1016/S1054139X(99)001184 Pinhas Hamiel, O., Singer, S., Pilpel, N., Fradkin, A., Modan, D., & Reichman, B. (2006). Healthrelated quality of life among children and adolescents: Associations with obesity. Internat ional Journal of Obesity 30, 267 272. doi:10.1038/sj.ijo.0803107 Pomeroy, C., & Mitchell, J. E. (2002). Medical complications of anorexia nervosa and bulimia nervosa. In C. G. Fairburn & K. D. Brownell (Eds.), E ating disorders and obesity: A comprehensiv e handbook 2nd edition (pp 278 285). New York, NY: Guilford Press. Presnell, K., Bearman, S., & Stice, E. (2004). Risk factors for body dissatisfaction in adolescent boys and girls: A prospective study. International Journal of Eating Disorders, 36, 389 401. doi:10.1002/eat.20045 Pugliese, M. T., Lifshitz, F., Grad, G., Fort, P., & Marks Katz, M. (1983). Fear of obesity: A cause of short stature and delayed puberty. New England Journal of Medicine, 309, 513 518. doi: 10.1056/NEJM198309013090901

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55 Ranzenho fer, L. M., Tanofsky Kraff, M., Menzie, C. M., Gustafson, J. K., Rutledge, M. S., Keil, M. F. Yanovski, J. A. (2008). Structure analysis of the Childrens Eating Attitudes Test in overweight and at risk for overweight children and adolescents. Eating Beh avior, 9(2), 218227. doi:10.1016/j.eatbeh.2007.09.004 Schwimmer, J. B., Burwinkle, T. M., & Varni, J. W. (2003) Health related quality of life of severely obese children and adolescents. Journal of the American Medical Association, 289, 1813 1819. doi : 10.1001/jama.289.14.1813 Shapiro, S., Newcomb, M., & Loeb, T. B. (1997). Fear of fat, disregulatedrestrained eating, and body esteem: Prevalence and gender differences among eight to ten year old children. Journal of Clinical Child Psychology, 26, 358 365. doi: 10.1207/s15374424jccp2604_4 Sherwood, N. E., Jeffery, R. W., & Wing, R. R. (1999). Binge status as a predictor of weight loss treatment outcome. International Journal of Obesisty and Related Metabolic Disorders, 23, 485 493. doi: 10.1038/sj.ijo.0 800846 Smolak, L., & Levine, M. P. (1994). Psychometric properties of the Childrens Eating Attitudes Test. International Journal of Eating Disorders, 16, 275 282. doi:10.1002/1098108X(199411)16:3<275::AID EAT2260160308>3.0.CO;2U Stice, E., Hayward, C., Cameron, R. P., Killen, J. D., & Taylor, C. B. (2000). Body image and eating related factors predict onset of depression in female adolescents: A longitudinal study. Journal of Abnormal Psychology, 109, 438 444. doi: 10.1037/0021843X.109.3.438 Stice, E., Marti, N., Shaw, H., & Jaconis, M. (2009). An 8 year longitudinal study of the natural history of threshold, subthreshold, and partial eating disorders from a community sample of adolescents. Journal of Abnormal Psychology, 118(3), 587 597. doi: 10.1037/a 0016481 Stice, E., Presnell, K., & Spangler, D. (2002). Risk factors for binge eating onset in adolescent girls: A 2year prospective investigation. Health Psychology, 21, 131 138. d oi : 10.1037/0278 6133.21.2.131 Storch, E. A., Milsom, V. A., DeBraganza, N., Lewin, A. B., Geffken, G. R., & Silverstein, J. H. (2007). Peer victimization, psychosocial adjustment, and physical activity in overweight and at risk for overweight youth. Journal of Pediatric Psychology, 32, 80 89. doi: 10.1093/jpepsy/jsj113 Story, M., Neumark Sztainer, D., Sherwood, N., Stang, J., & Murray, D. (1998). Dieting status and its relationship to eating and physical activity behaviors i n a representative sample of U. S. adolescents Journal of the American Dietetic Association, 98, 1127 113 5, 1255. doi:10.1016/S00028223(98)002612

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56 Strauss, R. S. (2000). Childhood obesity and self esteem. Pediatrics, 105(1), e15. doi:10.1542/peds.105.1.e15 Striegel Moore, R. H., Seeley, J. R., & Lewinsohn, P. M. (2003). Psychosocial adjustment in young adulthood of women who experience an eating disorder during adolescence. American Academy of Child and Adolescent Psychiatry, 42, 587 593. doi:10.1097/01.CHI. 0000046838.90931.44 Swallen, K. C., Reither, E. N., Haas, S. A., & Meier, A. M. (2005). Overweight, obesity, and healthrelated quality of life among adolescents: The national longitudinal study of adolescent health. Pediatrics, 115(2), 340 347. doi:10.15 42/peds.20040678 Tanofsky Kraff, M., Yanovski, S. Z., Wilfley, D. E., Marmarosh, C., Morgan, C. M., & Yanovski, J. A. (2004). Eating disordered behaviors, body fat, and psychopathology in overweight and normal weight children. Journal of Consulting and C linical Psychology, 72, 53 61. doi:10.1037/0022006X.72.1.53 Thelen, M. H., Powell, A. L., Lawrence, C. & Kuhnert, M. E. (1992). Eating and body image concern among children. Journal of Clinical Child Psychology, 21(1), 41 46. doi:10.1207/s15374424jccp2101_7 Thomas, K., Ricciardelli, L. A., & Williams, R. J. (2000). Gender traits and self concept as indicators of problem eating and body dissatisfaction among children. Sex Roles, 43, 441 458. doi: 10.1023/A:1007163331749 Varni, J. W., Burwinkle, T. M., Sei d, M., & Skarr, D. (2003). The PedsQL 4.0 as a pediatric population health measure: Feasibility, reliability, and validity. Ambulatory Pediatrics, 3, 329 341. doi:10.1016/S15301567(05)602560 Varni, J. W., Limbers, C. A., Bryant, W. P., & Wilson, D. P. (2010). The PedsQL Multidimensional Fatigue Scale in pediatric obesity: Feasibility, reliability, and validity. International Journal of Pediatric Obesity, 5, 3442. doi:10.1186/147775255 43 Varni, J. W., Limbers, C. A., & Burwinkle, T. M. (2007). Impaired healthrelated quality of life in children and adolescents with chronic conditions: A comparative analysis of 10 disease clusters and 33 disease categories/severities utilizing the PedsQL 4.0 Generic Core Scales. Health and Quality of Life Outcomes, 5(43), 1 15. doi:10.1186/147775255 4 3 Varni, J. W., Sei d, M., & Kurtin, P. S. (2001). PedsQL 4.0: Reliability and validity of the Pediatric Quality of Life Inventory Version 4.0 Generic Core Scales in h ealthy and patient populations. Medical Care, 39, 800 812.

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57 Varni, J. W., Seid, M., & R ode, C. A. (1999). The PedsQL : Measurement model for the Pediatric Quality of Life Inventory. Medical Care, 37 126 139. Williams, J., Wake, M., Hesketh, K., Maher, E., & Waters, E. (2005). Health related quality of life of overweight and obese children. Journal of the American Medical Association, 293, 70 76. doi: 10.1001/jama.293.1.70 Zeller, M. H., Kirk, S., Claytor, R., Khoury, P., Grieme, J., Santangelo, M., & Daniels, S. (2004). Predictors of attrition from a pediatric weight management program. Jou rnal of Pediatrics, 144, 466 470. doi:10.1016/j.jpeds.2003.12.031 Zeller, M. H., & Modi, A. C. (2006). Predictors of healthrelated quality of life in obese youth. Obesity, 14, 122 130. doi: 10.1038/oby.2006.15 Zeller, M. H., Roehrig, H. R., Modi, A. C., Daniels, S. R., & Inge, T. H. (2006). Healthrelated quality of life and depressive symptoms in adolescents with extreme obesity presenting for bariatric surgery. Pediatrics, 117, 1155 1161. doi: 10.1542/peds.2005 1141

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58 BIOGRAPHICAL SKETCH Marissa Gowey r eceived a bachelors degree in psychology at the University of Minnesota in 2008. She is currently a graduate student in the Clinical and Health Psychology doctoral prog ram at the University of Florida Marissa received her masters degree in May 2012 and is continuing her doctoral training in clinical psychology at the University of Florida