Citation
Predictors of Healthy and Unhealthy Weight Control Behaviors among a Pediatric Primary Care Sample

Material Information

Title:
Predictors of Healthy and Unhealthy Weight Control Behaviors among a Pediatric Primary Care Sample
Creator:
Carmody, Julia K
Place of Publication:
[Gainesville, Fla.]
Florida
Publisher:
University of Florida
Publication Date:
Language:
english
Physical Description:
1 online resource (71 p.)

Thesis/Dissertation Information

Degree:
Master's ( M.S.)
Degree Grantor:
University of Florida
Degree Disciplines:
Psychology
Clinical and Health Psychology
Committee Chair:
JANICKE,DAVID
Committee Co-Chair:
BOGGS,STEPHEN R
Committee Members:
PERLSTEIN,WILLIAM MICHAEL
MCCRAE,CHRISTINA SMITH
Graduation Date:
5/3/2014

Subjects

Subjects / Keywords:
Adolescents ( jstor )
Caregivers ( jstor )
Encouragement ( jstor )
Obesity ( jstor )
Overweight ( jstor )
Parents ( jstor )
Siblings ( jstor )
Weight control ( jstor )
Weight loss ( jstor )
Weight loss diets ( jstor )
Clinical and Health Psychology -- Dissertations, Academic -- UF
adolscents -- children -- dieting -- obesity -- overweight -- parents -- peers -- siblings
Genre:
bibliography ( marcgt )
theses ( marcgt )
government publication (state, provincial, terriorial, dependent) ( marcgt )
born-digital ( sobekcm )
Electronic Thesis or Dissertation
Psychology thesis, M.S.

Notes

Abstract:
Youth engage in a variety of weight control behaviors (WCBs) that may be categorized as healthy or unhealthy. Unhealthy weight control behaviors (UWCBs) are associated with weight gain, eating disorders, and poor psychological well being. In order to inform clinical assessment and interventions, it is important to gain a better understanding of socioenvironmental factors associated with youth engagement in WCBs. Therefore, the current study aims to identify the healthy and unhealthy WCBs that are most prevalent among youth, how often youth engage in each WCB, how aware parents of child engagement in WCBs, and whether supporter groups (parents, siblings, and peers) engaging in WCBs or encouraging youth to engage in WCBs influence how frequently youth engage in WCBs. Participants were 216 youth, ages 10 to 17 years, and their caregivers recruited from a pediatric clinic. Results indicated that overweight and obese youth were more likely to engage in both healthy and unhealthy WCBs. Caregivers reported youth engaged in fewer healthy and unhealthy WCBs than youth themselves reported. Parent engagement in both healthy and unhealthy WCBs significantly predicted youth healthy and unhealthy WCB frequency, respectively. Parents encouraging youth to engage in HWCBs significantly predicted youth HWCB frequency, however, this association was not significant for UWCBs. Results indicate parents play a significant role in influencing child engagement in WCBs, particularly for healthy WCBs, through behaviors and encouragement; this has important implications for parent involvement in healthy lifestyle interventions for pediatric obesity. ( en )
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, 2014.
Local:
Adviser: JANICKE,DAVID.
Local:
Co-adviser: BOGGS,STEPHEN R.
Electronic Access:
RESTRICTED TO UF STUDENTS, STAFF, FACULTY, AND ON-CAMPUS USE UNTIL 2015-05-31
Statement of Responsibility:
by Julia K Carmody.

Record Information

Source Institution:
UFRGP
Rights Management:
Applicable rights reserved.
Embargo Date:
5/31/2015
Classification:
LD1780 2014 ( lcc )

Downloads

This item has the following downloads:


Full Text

PAGE 1

PREDICTORS OF HEALTHY AND UNHEALTHY WEIGHT CONTROL BEHAVIORS AMONG A PEDIATRIC PRIMARY CARE SAMPLE By JULIA K. CARMODY A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2014

PAGE 2

2014 Julia K. Carmody

PAGE 3

To m y parents, Matt and Jen Carmody

PAGE 4

4 ACKNOWLEDGMENTS I would like to express my deepest appreciation to my mentor, Dr. David Janicke, for his unwavering sup port and exceptional mentoring. I thank Page Klitzman and the project possible. Finally, I thank my parents, whose loyalty to my best interests and willing sacrifices have been such great factors in moti vating me to pursue an education and life of much value.

PAGE 5

5 TABLE OF CONTENTS page ACKNOWLEDGMENTS ................................ ................................ ................................ .. 4 LIST OF TABLES ................................ ................................ ................................ ............ 7 ABSTRACT ................................ ................................ ................................ ..................... 8 CHAPTER 1 INTRODUCTI ON ................................ ................................ ................................ .... 10 Health y and Unhealthy Weight Control Behaviors ................................ .................. 10 Parent Influence ................................ ................................ ................................ ...... 13 Sibling & Pe er Influence ................................ ................................ .......................... 15 Study Purpose ................................ ................................ ................................ ........ 16 Aims and Hypotheses ................................ ................................ ............................. 18 Prevalence and Frequency of Youth Healthy and Unhealthy Weight Control Behaviors ................................ ................................ ................................ ...... 18 Psychosocial Predictors of Youth WCB Frequency ................................ .......... 18 2 METHODS ................................ ................................ ................................ .............. 20 Participants ................................ ................................ ................................ ............. 20 Measures ................................ ................................ ................................ ................ 20 Anthropometric Information ................................ ................................ .............. 20 Weight Control Behaviors Questionnaire: Youth Report ................................ .. 21 Youth Perception of Parent, Peer, and Sibling Modeling and Encouragement ................................ ................................ ............................. 22 Weight Control Behaviors Questionnaire: Caregiver Report ............................ 22 Demographic Information ................................ ................................ ................. 23 Statistical Analyses ................................ ................................ ................................ 23 3 RESULTS ................................ ................................ ................................ ............... 26 Sample Descriptive Statistics ................................ ................................ .................. 26 Aim 1 ................................ ................................ ................................ ....................... 27 Aim 2 ................................ ................................ ................................ ....................... 30 Aim 3 ................................ ................................ ................................ ....................... 31 Aim 4 ................................ ................................ ................................ ....................... 32 4 DISCUSSION ................................ ................................ ................................ ......... 51 Prevalence of Weight Control Behaviors ................................ ................................ 51 Weight Control Behavior Frequency ................................ ................................ ....... 55 Psychosocial Predictors of Youth Weight Control Behavior Frequency .................. 57

PAGE 6

6 Strengths and Limitations ................................ ................................ ....................... 60 Implications ................................ ................................ ................................ ............. 62 Future Direction s ................................ ................................ ................................ .... 64 LIST OF REFERENCES ................................ ................................ ............................... 66 BIOGRAPHICAL SKETCH ................................ ................................ ............................ 71

PAGE 7

7 LIST OF TABLES Table page 3 1 Youth Demographic Characteristics ................................ ................................ ... 34 3 2 Youth Weight Status ................................ ................................ ........................... 35 3 3 Parent Demographic Characteristics ................................ ................................ .. 36 3 4 Pearson correlations among demographics and variables of interest HWCB .. 37 3 5 Pearson correlations among demographics and variables of interest UWCB .. 38 3 6 Youth Report of HWCB Ever in Past Year ................................ .......................... 39 3 7 Caregiver Report of Youth HWCB Ever in Past Year ................................ ......... 40 3 8 Descriptive statistics of youth behavior frequency ................................ .............. 41 3 9 Youth Report of UWCB Ever in Past Year ................................ .......................... 42 3 10 Caregiver Report of Youth Engagement in UWCB Ever in Past Year ................ 43 3 11 Mean Number of Unique Healthy and Unhealthy Weight Control Behaviors Used in Past Year by Weight Status ................................ ................................ ... 44 3 12 ... 45 3 13 Number of yo ... 46 3 14 Youth perceived engagement in WCBs by parents, siblings, peers ................... 47 3 15 How perceived engagement by supp orter groups predicts youth WCB frequency ................................ ................................ ................................ ............ 48 3 16 Youth perceived encouragement by parents, siblings, peers ............................. 49 3 17 How perceived encouragement by supporter groups predicts youth WCB frequency ................................ ................................ ................................ ............ 50

PAGE 8

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 PREDICTORS OF HEALTHY AND UNHEALTHY WEIGHT CONTROL BEHAVIORS AMONG A PEDIATRIC PRIMARY CARE SAMPLE By Julia K. Carmody May 2014 Chair: David Janicke Major: Psychology Youth engage in a varie ty of weight control behaviors ( WCBs ) that may be categorized as healthy or unhealthy. Unhealthy weight control behaviors (UWCBs) are associated with weight gain, eating disorders, and poor psychological well being. In order to inform clinical assessment and interventions it is important to gain a better understanding of socioenvironmental factors associated with y outh engagement in WCBs Therefore, the current study aims to identify the healthy and unhealthy WCBs that are most prevalent among youth, how often youth engage in each WCB, how WCBs and whether supporter grou ps (parents, siblings, and peers) engaging in WCBs or encouraging youth to engage in WCBs influence how frequently youth engage in WCBs. Participants were 216 youth, ages 10 17 years, and their caregivers recruited from a pediatric clinic Results indicate d that overweight and obese youth were more likely to engage in both healthy and unhealthy WCBs Caregivers reported youth engaged in fewer healthy and unhealthy WCBs than youth themselves reported. Parent engagement in both healthy and unhealthy WCBs significantly predicted youth healthy and unhealthy WCB frequency, respectively. Parents encouraging youth to engage in HWCBs significantly

PAGE 9

9 predicted youth HWCB frequency, however, this association was not significant fo r UWCBs. Results indicate parents play a significant role in influencing child engagement in WCBs, particularly for healthy WCBs, through behaviors and encouragement; this has important implications for parent involvement in healthy lifestyle interventions for pediatric obesity.

PAGE 10

10 CHAPTER 1 INTRODUCTION The extent and negative health consequences of the pediatric obesity epidemic are well documented. Nearly a third of children and adolescents aged 6 to 19 in the United Sta tes are overweight or obese ( Ogden, Carroll, Kit, & Flegal, 2012 ) Obesity in children and adolescents is associated with increased risk for health problems such as hypertension, type II diabetes, joint and bone problems, and obesity in adulthood ( Freedman, Khan, Dietz, Srinivasan, & Berens on, 2001 ; Raj, 2012 ) Overweight and obese (OV/OB) youth are more likely to report psychosocial problems such as depression, low self esteem, and body image dissatisfaction ( Strauss & Pollack, 2003 ; Wardle & Cooke, 2005 ) In addition, overweight in adolescence has been shown to predict lower levels of socioeconomic attainment in adulthood ( Gortmaker, Must, Perrin, Sobol, & Dietz, 1993 ) Given the negative health and psychosocial ou tcomes associated with pediatric obesity, the development of obesity prevention and treatment programs as well as learning more about factors that impact weight gain and weight loss, remain public health priorit ies Healthy and Unhealthy Weight Control Behaviors According to the Youth Risk Behavior Survey, a national survey of health risk behaviors among high school students, 59.3% of females and 30.5% of males reported they were trying to lose weight ( Eaton et al., 2010 ) A large school based study found that 46% of girls and 31% of boys reported dieting in the past year ( Dianne Neumark Sztainer et al., 2012 ) OV/OB youth are ofte n encouraged to lose weight by their pediatricians, parents, and peers ( Barlow, Trowbridge, Klish, & Dietz, 2002 ; M. McCabe & Ricciardelli, 2001 ; Wertheim, Mee, & Paxton, 1999 ) Children and adolescents

PAGE 11

11 attempting to lose weight or ma intain their current weight may adopt a variety of weight management strategies, often without clinical guidance. Some of these behaviors are considered healthy weight control behaviors (HWCBs) such as engaging in recommended levels of physical activity, decreasing fat and sugar intake, eating more fruits and vegetables, and limiting portion sizes. However, a number of strategies are considered unhealthy Unhealthy weight control behaviors (UWCBs ) include strategies such as skipping meals, using laxatives or diet pills, fasting, or vomiting. Both healthy and unhealthy weight control behaviors are prevalent among youth. In one school based survey, 85% of girls and 70% boys reported engaging in at l east one HWCB while 57% of girls and 33% of boys reported they had engaged in at least one UWCB in the past year ( Dianne Neumark Sztainer, Story, Hannan, Perr y, & Irving, 2002 ) OV/OB youth are more likely to engage in UWCBs than healthy weight youth ( K. Boutelle, Neumark Sztainer, Story, & Resnick, 2002 ; Eisenberg, Neumark Sztainer, Story, & Perry, 2005 ) and girls are more likely to report engaging in UWCBs than boys (Neumark Stzainer et. al, 2007). Longitudinal studies indicate UWCBs are largely ineffective for maintaining weight loss ( Field et al., 2003 ; Haines & Neumark Sztainer, 2006 ) and may even lead to future weight gain ( D. R. Neumark Sztainer et al., 2007 ) In addit ion, youth who engage in unhealthy weight loss methods are less likely to consume nutritious foods and are more likely to engage in other health risk behaviors such as substance use, eating disorders, and unsafe sexual practices ( Dianne Neumark Sztainer, Story, & French, 1996 ; Story, Neumark Sztainer, Sherwood, Stang, & Murray, 1998 ) Moreover, youth who engage in UWCB are more likely to continue engaging in UWCBs into adulthood and are more likely to adapt future disordered eating attitudes

PAGE 12

12 and behaviors, such as binging and purging ( Dianne Neumark Sztainer, Wall, Larson, Eisenberg, & Loth, 2011 ; D. R. Neumark Sztainer et al., 2007 ) Given the potentially serious consequences of UWCBs, researchers have begun to identify psychosocial factors related to youth engagement in UWCBs. Understanding these factors will help to better inform interventions aimed at providing skills for healthful weight man agement and decreasing instances of UWCB among youth. HWCBs, the frequency with which children and adolescents engage in them, and their subsequent effects have not received the same amount of attention in the literature as UWCBs. This is somewhat surpris ing, given that HWCBs such as exercising and decreasing fat intake are associated with positive weight loss and maintenance outcomes ( Klem, 2000 ) One retrosp ective study found adolescents who success fully lost weight were more likely to report they had engaged in HWCBs than adolescents who did not achieve or maintain weight loss ( K. N. Boutelle, Libbey, Neumark Sztainer, & Story, 2009 ) Despite the potential benefits for weight loss, hea lthy weight youth tend to report engaging in regular physical activity and healthy eating patterns more often than their OV/OB peers ( K. Boutelle et al., 2002 ) In addition, girls are more likely to engage in HWCBs than boys among healthy weight and overweight groups ( Quick, Loth, MacLehose, Linde, & Neumark Sztainer, 2013 ) While researchers have begun to characterize those who engage in HWCBs, little is understood about how often youth engage in these behaviors or which psychosocial factors are relate d to youth engagement in HWCBs While researchers have documented the prevalence of healthy and unhealthy weight control behaviors among youth, much less is known about how often youth

PAGE 13

13 engage in individual weight control behaviors Paxton and colleagues fo und that y outh who engage d in severe dieting, characterized by frequent use of weight control methods such as food restriction, were more likely to develop an eating disorder than those who did not diet or diet ed at a moderate level ( Patton, Selzer, Coffey, Carlin, & Wolfe, 1999 ) In addition, research has shown that how often one engages in certain HWCBs, such as physical activity, is a better indicator of healthier weight status than simply endorsing one has engaged in that behavior at all ( K. Boutelle et al., 2002 ; Veloso, Matos, Carvalho, & Diniz, 2012 ) Given our limited understanding of how frequently youth are engaging in both healthy and unhealthy weight control behaviors the present study aims to assess how often youth engage in each healthy and unhealthy weight control behaviors Par ent Influence Researchers have begun to examine specific psychosocial factors related to youth engagement in healthy and unhealthy weight control behaviors Among these factors, parent dieting and pare ntal encouragement to diet are two of the most well doc umented predictors of youth dieting and use of weight control behaviors Parents may influence adolescent eating attitudes and behaviors through their own eating behaviors, which they model, or by explicitly encouraging their child ren to diet ( Fulkerson et al., 2002 ) Parent dieting, as reported by parents and perceived by youth, has been shown to predict both healthy and unhealthy weight control behaviors in children ( Helene Keery, Marla E Eisenberg, Kerri Boutelle, Dianne Neumark Sztainer, & M ary Story, 2006 ; D. R. Neumark Sztainer et al., 2007 ; Wertheim et al., 1999 ) It is important to distinguish here that the majority of the literature on parent dieting assessed only whether or not parents dieted, rather than parent engageme nt in unique

PAGE 14

14 healthy and unhealthy weight control behaviors The limited research examining how parent engagement in specific weight control behaviors relates to youth weight control behaviors is equivocal. Benedikt and colleagues ( 1998 ) found adolescent daughters were more likely to engage in fasting and skipping meals if their mothers also reported engaging in those same behaviors. In contrast, Cromley and colleagues ( 2010 ) found that parent engagement in at least one UWCB did not significantly predict youth engagement in UWCBs, however, parent engagement in other dietary changes such as Atkins or South Beach Diet was significantly associated with adolescent engagement in one or more UWCB. particular attitudes or expectations about weight loss and weight related behaviors to their children. Both parent weight concern (i.e. parents expressing concern about their weight status) as well as parental encouragement to diet (i.e. parents directly encouraging/instructing their child to temporarily change their eating habits for the purpose of weight loss) have been found to predict UWCBs among youth ( Armstrong & Ja nicke, 2012 ; Linde, Wall, Haines, & Neumark Sztainer, 2009 ) However, to our knowledge, the impact of parents telling their children to engage in specific weight control behaviors rather than broadly te lling their children to diet, has not been studied. Given our limited understanding of how parent engagement in specific behaviors as well as parent encouragement to engage in specific behaviors impacts youth behaviors, the present study aims to examine wh ether youth engagement in healthy or UWCBs is associated with youth perception of 1) parents engaging in various healthy and

PAGE 15

15 unhealthy weight control behaviors and 2) parents instructing youth to engage in health and/or unhealthy weight control behaviors Sibling and Peer Influence Research examining relationships between family variables and weight related behaviors has extended to incorporate sibling attitudes and behaviors. The present literature pertaining to the relationship between sibling dieting a nd youth engagement in UWCBs is somewhat mixed. In a study of sister pairs, sisters were correlated on bulimic be haviors and dietary restriction ( Coomber & King, 2008 ) In contrast, on e of the few studies examining sibling influence as perceived by boys found that sibling comme nts about eating or body shape patterns in order to lose weight ( Ricciardelli, McCabe, & Banfield, 2000 ) Therefore, sibling influence via encour agement or modeling of UWCBs may vary based on the are positively associated with youth HWCBs Sallis and colleagues ( 2000 ) found that male physical activity was significantly related to sibling physical activity. Increasing healthy food intake and decreasing unhealthy food intake by siblings was associated with improved nutritional intake among youth ( Cislak, Safron, Pratt, Gaspar, & Luszczynska, 2012 ; van der Horst et al., 2007 ) Taken together, the literature suggests that siblings may positively impact youth weight control behaviors by engaging in healthy behaviors themselves; however, siblings may not have a significant influence on youth UWCBs. The present study will examine whether youth perception of siblings engaging in healthy and unhealthy weight contr ol behaviors impacts their own behaviors. In addition, sibling influence on youth weight control behaviors via direct encouragement to engage in various weight control behaviors will be examined.

PAGE 16

16 Peers appear to be an important sociocultural determinant in the development of body image concerns and eating behaviors among youth. Adolescent perceptions about related attitudes and behaviors predict ed dieting and UWCBs among youth ( M. P. McCabe & Ricciardelli, 2005 ) The relationship between peer weight related talk and dieting behaviors in girl s is particularly well established, perhaps because girls are more likely to report discussing weight loss and thinness with peers than boys ( Dianne Neumark Sztainer, Story, Falkner, Be uhring, & Resnick, 1999 ) Both peer teasing about weight status and peer encouragement to diet have been shown to significantly predict dieting in girls ( Lieberman, Gauvin, Bukowski, & White, 2001 ) Vincent and McCabe ( Vincent & McCabe, 2000 ) found peer discussion about weight loss significantly predicted bulimi c tendencies, extreme weight loss, and binge eating among boys. To our knowledge, no studies have assessed whether peers encourage youth to engage in specific weight control strategies, and if they do, how this type of encouragement impacts youth behavior. Youth perception of which behaviors their peers engage may also be an important predictor of youth weight control behaviors The present study will examine how youth perception of peers engaging in various weight control behaviors is related to their own engagement in weight control behaviors In addition, we will examine whether youth are more likely to engage in weight control behaviors if their peers encou rage them to do so. Study Purpose Research has established that UWCBs are prevalent among youth, an d these behaviors have been linked to adverse physical and mental health outcomes. Alternatively, HWCBs have been shown to predict weight loss and have been associated with improved health and psychosocial well being ( K. N. Boutelle et al.,

PAGE 17

17 2009 ) The present study aims to address some of the current gaps in this body of literature. First, while past research has largely reported on youth engagement in UWCB, the present study will examine the prevalence of a number of unique HWCBs, in addition to UWCBs. Second, little is kn own about how often youth engage in various weight control strategies (both healthy and unhealthy). Therefore, a plausible next step is to examine how often youth engage in these specific weight loss behaviors Third, caregiver reports are often not obtain ed, particularly among school based samples which make up the majority of the literature on youth weight control behaviors However, as parents play an influential role in helping youth make lifestyle changes, it is important to assess their awareness of t study will include caregiver reports in addition to youth reports. Finally, researchers have identified various psychosocial factors that influence youth weight related attitudes and behaviors. In particul ar, youth perception of their parents and friends dieting has been shown to significantly predict youth dieting. However, little research has focused on whether youth perception of various supporter groups (parents, siblings, and peers) engaging in specifi c weight control strategies predicts how frequently youth engage in weight control behaviors In addition, encouragement to diet by supporter groups has been shown to significantly predict youth dieting; however, little is known about whether supporter groups encouraging youth to engage in specific weight control behaviors predicts youth WCB frequency. The current study will assess which unique behaviors youth perceive their parents, siblings, and peers engaging in as well as which unique behaviors these supporter groups are encouraging them to engage predict youth WCB frequency.

PAGE 18

18 Aims and Hypotheses Prevalence and Frequency of Youth Healthy and Unhealthy Weight Control Behaviors Aim 1: Identify what percentage of youth in the sample engage d i n each WCB in the past year in order to lose weight as well as the mean number of unique healthy and unhealthy weight control behaviors youth engaged in in the past year, according to youth self report and caregiver report. Examine item level and mean differences ac ross sex and weight status groups. Examine differences between youth and caregiver reports. Hypothesis 1.1: Girls and OV/OB youth will be more likely to engage in healthy and unhealthy weight control behaviors, according to youth and caregiver report. Hypo thesis 1.2: Youth will report engaging in a greater number of UWCBs than caregivers report. Aim 2: Identify how often youth engage in each individual WCB over the past year. Hypothesis 2.1: Youth will report they engaged in HWCBs more often (i.e. every da y or a few times per week) than UWCB. Psychosocial Predictors of Youth WCB Frequency Aim 3: Identify whether youth perception of caregiver, sibling, and peer engagement in healthy and unhealthy weight control behaviors predicts how frequently youth engage in weight control behaviors. Hypothesis 3.1: Youth perceived caregiver and sibling engagement in HWCBs, but not peer engagement, will be positively associated with youth HWCB frequency. Hypothesis 3.2: Youth perceived caregiver engagement and peer engage ment in UWCBs, but not sibling engagement, will by positively associated with youth UWCB frequency.

PAGE 19

19 Aim 4: Identify whether youth perceived encouragement from caregivers, siblings, and peers to engage in weight control behaviors is associated with youth W CB frequency. Hypothesis 4.1: Youth perceived caregiver and peer encouragement to engage in HWCBs will be positively associated with youth HWCB frequency. Hypothesis 4.2: Youth perceived caregiver and peer encouragement to engage in UWCBs will be positive ly associated with youth UWCB frequency.

PAGE 20

20 CHAPTER 2 METHODS Participants Participants were 219 youth ages 10 17 years old and their caregivers attending an outpatient pediatric medical clinic for a well check or an acute care appointment. Eligible yout h and their caregivers were approached and asked to participate in a study examining weight control behaviors in youth. Informed consent was obtained from interested parents and assent from interested youth. Questionnaires were completed by caregivers and youth participants and families were compensated with a $5 gift card for their participation. Youth were eligible if they were between 10 and 17 years of age, were fluent in English, and were accompanied to an appointment at the pediatric clinic by an Engl ish speaking parent or legal guardian. Exclusion criteria included having been diagnosed with short stature, having been diagnosed as intellectually disables or with a psychotic disorder. Data were collected between January 2011 and May 2013. Procedures fo llowed were in accordance with the University of Florida Institutional Review Board. Measures Anthropometric Information Youth height and weight were obtained by medical staff during their routine medical exam. Height and weight were copied from the medica l record or were communicated to the research study team by a member of the medical staff. BMI z score was calculated using the norms provided by the Centers for Disease Control and Prevention ( Kuc zmarski et al., 2000 ) Caregiver BMI was calculated from caregiver reported height and weight.

PAGE 21

21 Weight Control Behaviors Questionnaire: Youth Report The questionnaire assesses eight HWCBs (e.g. exercising, drinking more water, eating fewer high fat foods) and 10 UWCBs (e.g. fasting, taking diet pills, taking laxatives). The questionnaire was modified for the present study from a measure developed by Neumark Sztainer and co lleagues and used in Project Eating and Activity in Teens (Project EAT) (2002). Youth indicated whether or not they had engaged in for both healthy and unhealthy weight control behaviors to obtain the total score for each category. Similar scales have been used to assess weight control behaviors in ( H. Keery, M. E. Eisenberg, K. Boutelle, D. Neumark Sztainer, & M. Story, 2006 ) Internal consistency in the current sample was a healthy weight control behaviors. While previous versions of the weight control behaviors questionnaire assessed only whether or not youth engaged in each behavior in the past year, we added a follow up question to each item to assess how frequently participants engaged in the asked to indicate how often they engaged in th at behavior by choosing one of the following responses from a 5 point Likert scale: One time, a few times per year, a few times per month, a few times per week, or every day. Internal consistency in the current H WCBs UWCBs Two scores, one for overall HWCB frequency and the other for UWCB frequency, were calculated for each youth participant by summing responses on the

PAGE 22

22 frequency measure for healthy and unhealthy weight control behaviors. Higher scores represented more frequent engagement in weight control behaviors Youth Perception of Parent, Peer, and Sibling Engagement and Encouragement On a separate measure, for each of the 18 weight control behaviors assessed in the first measure li response with regard to parents, siblings, and friends. Responses were summed to create six separate v ariables: (1) youth perception of parent use of HWCBs (2) youth perception of parent use of UWCBs (3) youth perception of sibling use of HWCBs (4) youth perception of sibling use of UWCBs (5) youth perception of peer use of HWCBs and (6) youth percept ion of peer use of UWCBs them to engage in any specific weight control behaviors? Once again, participants were asked to provide a separate response with regard to parents, siblings, and friends for each behavior Responses were summed to create six separate variables: (1) parent encouragement of youth HWCBs (2) parent encouragement of youth UWCBs (3) sibling encouragement of youth HWCBs (4) sibling encouragement of youth UWCBs (5) peer encouragement of youth HWCBs and (6) peer encouragement of youth UWCBs Weight Control Behaviors Questionnaire: Caregiver Report Caregivers reporte d whether or not youth had engaged in each of the 18 weight unhealthy weight control behaviors to obtain the total score for each category. Internal

PAGE 23

23 consistency was strong for HWCBs (C = .90) and low for UWCBs =.67 ) Demographic Information Caregivers provided demographic information including youth race, annual household income, caregiver race, occupation, level of education, marital status, and the number of adults and youth in the home. Statistical Analyses Analyses were conducted with SPSS, version 16.0. Descriptive statistics were used to describe sample characteristics. For Aim 1, i ndependent samples t tests were used to examine significant d ifferences between the mean number of healthy and unhealthy weight control behaviors endorsed across sex and weight status groups (e.g. obese vs healthy weight youth) for both youth and caregiver reports. Pearson product moment correlations were used to ex amine the relationships between youth age and the mean number of healthy and unhealthy WCBs endorsed as well as the relationships between youth race and the mean number of healthy and unhealthy weight control behaviors endorsed. Lastly, i ndependent samples t tests were used to compare significant differences between the mean number of weight control behaviors reported by youth versus caregivers for healthy and unhealthy behaviors. For Aim 2, each individual weight control behavior item frequency statistic s were generated to examine how many youth endorsed each response value on the 5 point Likert scale For Aim 3, a series of hierarchical linear regressions were conducted to examine roduct moment correlation

PAGE 24

24 coefficients were generated to examine associations between youth weight control behavior frequency and demographic variables (youth sex, age, race, and BMI z score). Demographic variables significantly related to outcome variable s were enter ed in Block 1 as covariates in subsequent regressions. A hierarchical linear regression was conducted to examine whether youth perception of parent, sibling, and peer engagement in HWCBs was associated with youth self reported frequency of HWC Bs Variables were entered into blocks to assess the contribution of successive predictors after controlling for previously entered variables. Covariates were entered into Block 1 and youth perception of parent, sibling and peer engagement in HWCBs were si multaneously entered into B lock 2. The outcome was youth reported frequency of HWCBs Next, a hierarchical multiple linear regression was conducted to examine whether youth perception of parent, sibling, and peer engagement in UWCBs predicted youth self reported frequency of UWCBs Covariates entered into Block 1, while youth perception of parent, sibling and peer engagement in UWCBs were simultaneously entered into Bl ock 2 For Aim 4, a hierarchical multiple linear regression was conducted to examine whether youth perception of parent, sibling, and peer encouragement to engage in HWCBs was associated with youth self reported frequency of HWCBs Any qualifying demographic control variables were entered into B lock 1 and youth perception of paren t, sibling, and peer engagement in HWCBs were entered simultaneously into B lock 2.

PAGE 25

25 Finally, a regre ssion was conducted to examine whether youth perception of parent, sibling, and peer encouragement to engage in UWCBs predicted youth self reported UWCB fr equency Covariates were entered into Block 1 and encouragement to engage in UWCBs by parents, siblings, and peers were entered into Block 2

PAGE 26

26 CHAPTER 3 RESULTS Sample Descriptive Statistics Descriptive statistics are displayed in Table 3 1. Participants were 219 youth caregiver dyads. Youth were 10 17 years old (M=13.00, SD=2.08) and slightly more than half the youth participants were female (52.1%, n=114). Over half (55%) of participants were African American and about a third (32%) were Caucasian. Based on BMI z score, about 6% (n=12) of youth participants were underweight, roughly half (48%, n=106) were healthy weight 15% (n=33) were overweight (>+1SD) and nearly a third (31%, n=68) were obese (>+2SD) (Table 3 2). Parent descriptive st atistics are provided in Table 3 3. The majority of caregivers who participated were mothers (81%). The median household income reported was less than $19,000 (42%) and the preponderance of caregivers (79%) reported an annual household income of less than $40,000. associations between youth weight control behavior frequency and demographic variables (youth sex, age, race, and BMI z score) (Tables 3 4 and 3 5) A statistically signi ficant relationship was found between youth sex and youth HWCB frequency [r=.168, p=.018], such that female youth engaged in more HWCBs over the past year than males (Table 3 4). Demographic variables did not significantly correlate with youth UWCB frequen cy (Table 3 5). examine associations between youth age and the average number of healthy and unhealthy weight control behaviors endorsed. No significant correlations were detected

PAGE 27

27 Aim 1 Aim 1: Identify what percentage of youth in the sample engaged in each healthy and UWCB according to youth and caregiver reports and examine differences across sex and weight status. Compare differences between youth and caregiver reports. 79% of girls (n=90) and 67.6% (n=71) of boys reported they had engaged in at least one HWCB in the past year. According to caregiver report, 62.3% ( n= 71) of girls and 49.5% ( n= 52) of boys engaged in one or more HWCB s in the past year. Overall, fewer youth endors ed engaging in one or more UWCB s at least once in the past year (43.9% girls, n=51; 39.1% boys, n=41) compared to the number of youth who endorsed engaging in one or more HWCBs Caregivers reported 44.7% (n=51) of girls and 27.6% (n=29) of boys engaged in one or more UWCB in the past year. The numbers and percentages of youth who endorsed engaging in each unique HWCB at least once in the past year in order to lose weight are reported in Table 3 6. While a higher percentage of females than males reported en gaging in each of the HWCBs the difference only reached statistical significance for the following behaviors: exercised [X 2 (1, N = 219) = 7.89, p=.005], ate more fruits and veggies [X 2 (1, N = 219) = 4.64, p=.041], drank more water [X 2 (1, N = 219) = 4.8 3, p=.028], and ate less high fat foods [X 2 (1, N = 219) = 6.03, p=.014]. Females reported they engaged in a greater number of total HWCBs in the past year, on average, compared to the average number reported by males, and this difference r eached significa nce [M=3.48 (2.5) vs M= 2.56 (2.5); p<.001]. Table 3 7 shows the numbers and percentages of caregivers who reported youth engaged in each HWCB at least once in the past year in order to lose weight. Caregivers reported that females were more likely to eng age in each of the various

PAGE 28

28 HWCBs compared to males. However, the difference only reached significance for the following behaviors: ate more fruits and veggies [X 2 (1, N = 219) = 7.15, p=.008], drank less soda or sugar sweetened beverages [X 2 (1, N = 219) = 8.81, p=.028], ate less high fat foods [X 2 (1, N = 219) = 9.47, p=.002],and cut out carbs [X 2 (1, N = 219) = 4.27, p=.039]. Similar to the youth report, caregivers reported that, on average, females engaged in a greater number of total HWCBs at least once in the past year than the overall average they reported about males [M=2.42 (2.5) vs M=1.71(2.4); p=0.32]. The mean numbers of healthy and unhealthy weight control behaviors youth engaged in at least once in the past year, as reported by youth and by the ir caregivers, are shown in Table 3 8. Comparing the average number of HWCBs reported by youth and the average reported by caregivers, youth reported they engaged in significantly more HWCBs than caregivers reported about their youth [M=2.98 (2.59) vs M=2. 37 (2.81), p<.005]. The numbers and percentages of youth who endorsed engaging in each UWCB at least once in the past year in order to lose weight are reported in Table 3 9. According to youth report, females were more likely to endorse each UWCB compared females on individual items did not reach significance. Similarly, the difference between the average number of total unique UWCB females reported they engaged in at lea st once during the past year in order to lose weight compared to the average number reported by males did not reach significance [

PAGE 29

29 Table 3 10 depicts the numbers and percentages of caregivers who reported youth engaged in each UWCB at least once in the past year in order to lose weight. X 2 (1, N = 219 ) = 15.81, p<.005]; however, differences between males and females according to caregiver report did not reach significance on any other individual item. Caregivers reported females overall engaged in a significantly greater number of HWCBs in the past yea r compared to males [M=2.42 (2.5) vs M=1.71(2.4); p=.032]. Consistent with youth report, caregivers also reported youth engaged in significantly fewer unique UWCBs, on average, compared to HWCBs [M=.80 (1.41) vs M=2.37 (2.81); p<.05] (Table 3 8 ). Compari ng youth versus caregiver report of UWCB, while youth did report they engaged in more UWCBs than caregivers reported about youth, the difference between the means of youth and caregiver reports was not significant [ M=.97 (1.44) vs. M=.80 (1.41), p>.05 ] (Ta ble 3 8 ). Table 3 11 depicts the mea n numbers of total healthy and unhealthy weight control behaviors youth engaged in at least once in the past year, according to youth and caregiver report, for underweight, healthy weight, over weight, and obese youth Th ere was a significant difference between the mean number of HWCBs endorsed by overweight youth compared to healthy weight youth [M=3.52 (2.37) vs M=1.78 (2.09); p<.001]; and a significant difference between the mean number of HWCBs endorsed by obese youth compared to healthy weight youth [M=3.52 (2.37) vs M=4.88 (2.32);

PAGE 30

30 p=<.001]. The difference between the number of HWCBS endorsed by obese youth versus overweight youth was not significant [M=4.88(2.32) vs M=3.52(2.37); p>.05]. For UWCBs, there were signific ant differences between the mean number of UWCBs reported by obese youth compared to healthy weight youth [M=1.81(1.64) vs M=.42(1.03); p<.001] and for obese youth compared to overweight youth [M=1.81(1.64) vs M=.91(1.35); p=.008]. According to caregivers, the difference between the mean number of HWCBs endorsed by overweight youth compared to healthy weight youth was not significant [M=2.21 (2.7) vs M=1.36 (2.26); p >.05]; however, the difference between the mean number of HWCBs reported by obese youth comp ared to healthy weight youth was significant [M=4.23(2.78) vs M=1.36(2.26); p = .0 01 ]. C aregivers reported obese youth engaged in a significantly greater number of HWCBs in the past year compared to overweight youth [M= 4.22(2.78) vs M=2.21(2.74); p = .001]. T urning to UWCBs caregivers did not report overweight youth engaged in significantly more UWCBs compared to healthy weight youth [M=.73(1.31) vs M=.48(1.14); p < .05]. Caregivers did report obese youth engaged in significantly more UWCBs compared to healthy weight youth [M=1.38(1.63) vs M=.47(1.14); p <.001 ] and compared to overweight youth [ M=1.38(1.63) vs M=.73(1.31); p<.05 ]. Aim 2 Aim 2: Identify how often youth engaged in each healthy and unhealthy WCB in the past year. Youth who reported they had engaged in a behavior in order to lose weight in the past year were asked to report how frequently they had engaged in that behavior on a 5

PAGE 31

31 num bers and percentages of youth who endorsed each response are depicted in Tables 3 12 (HWCB) and 3 13 (UWCB). Based on visual inspection of responses, youth were in order to lose weight compared to UWCBs. The following items had the highest every day in ord er to lose weight during the past year; (2) 30% of youth reported ing the past year. For UWCBs, 10% of youth reported they skipped ose weight during the past year, reported they engag ed in this behavior every day in order to lose weight. Of all the UWCBs assessed, smoking cigarettes, vomiting, and using diuretics were least prevalent; and youth who did endorse these behaviors only reported they had engaged during the past year in order to lose weight. Aim 3 Aim 3: Identify whether youth perception of caregiver, sibling, and peer engagement in healthy and unhealthy weight control behaviors predicts youth weight control behavior frequency. Table 3 14 provides descriptive statistics for youth perception of pa rent, sibling and peer engagement in weight control behaviors. Table 3 15 shows how youth perceived engagement in weight control behaviors by parents, siblings, and peers predicts youth WCB frequency for bo th healthy and unhealthy behaviors. In Model 1

PAGE 32

32 (HWCBs), child sex was entered into Block 1 of the regression and youth perception of parent, sibling, and peer engagement in HWCBs were entered into Block 2. Model 1 was significant (F=15.084, p=<.001, R 2 =. 236). Parent engagement in healthy weight control behaviors significantly predicted the frequency with which youth engaged in HWCBs [B=1.39, p=.001). In Model 2 (UWCBs), child sex and child age were entered into Block 1 of the regression and youth percept ion of parent, sibling, and peer engagement in UWCB were entered into Block 2. Model 2 was significant (F=5.79, p<.001, R 2 =.123); only parent engagement in UWCBs significantly predicted the frequency with which youth engaged in UWCBs (B=.772, p=.023). Aim 4 Aim 4: Identify whether youth perceived encouragement from caregivers, siblings, and peers to engage in weight control behaviors is associated with WCB frequency in youth. Table 3 16 describes how many behaviors youth reported parents, siblings, or peer s encouraged them to engage in Their responses for each supporter group (parents, siblings, and peers) were summed separately across all HWCBs (range of 0 8) and all UWCBs (range 0 10). Table 3 17 describes how perceived encouragement from parents, siblin gs, and peers to engage in weight control behaviors predicts youth frequency of weight control behaviors both healthy and unhealthy. In Model 3 (HWCBs), child sex was entered in Block 1, and youth perceived parent, sibling, and peer encouragement to enga ge in HWCBs were entered into Block 2. Model 3 was significant [F=7.025, p<.001, R 2 =.405) and p arent encouragement of HWCB significantly predicted youth HWCB frequency (B=2.357, p=.001). In Model 4, child sex

PAGE 33

33 and age were entered into Block 1 and parent, sibling, and peer encouragement to engage in UWCBs were entered into Block 2. The overall model was significant [F=3.95, p=.002, R 2 =.088); however, only child gender significantly predicted youth UWCB frequency (B=1.229, p<.05), such that girls were more likely to report engaging in UWCB more frequently. Perceived encouragement to engage in UWCBs by parents, siblings, and peers were not significant predictors of youth UWCB frequency.

PAGE 34

34 Table 3 1. Youth Demographic Characteristics N M SD % Youth Age 219 13.00 2.08 Youth Gender Female 114 52.1 Male 105 47.9 Youth Race/Ethnicity African American 120 54.8 Caucasian 71 32.4 Hispanic 8 3.7 Asian 1 .5 Bi racial 10 4.6 Other 7 3.2 Missing 2 0.9

PAGE 35

35 Table 3 2 Youth Weight Status N % N % N % Weight Status Female Male Total Underweight 4 3.5 8 7.6 12 5.5 Healthy weight 52 45.6 54 51.4 106 48.4 Overweight 21 18.4 12 11.4 33 15.0 Obese 37 32.5 31 29.3 68 31.1

PAGE 36

36 Table 3 3 Parent Demographic Characteristics N % Total 223 Relationship to Youth Mother 178 81.3 Father 18 6.4 Step mother 1 0.5 Step father 4 1.8 Grandparent 9 4.1 Other legal guardian 13 5.9 Weight Status Underweight or healthy weight 25 11.4 Overweight 51 23.3 Obese 54 54.3 Family Income 24 89.0 Below $19,999 92 42.0 $20,000 $39,999 81 37.0 $40,000 $59,999 28 12.8 $60,000 $79,999 7 3.1 Above $80,000 5 2.2 Missing 6 2.7

PAGE 37

37 Table 3 4 Pearson correlations among demographics and variables of interest HWCB Variables Youth HWCB frequency Parent engagement Sibling engagement Peer engagement Parent encourage Sibling encourage Peer encourage Youth Age .011 .014 .063 .149* .030 .033 .072 Youth Sex .168* .188 .065 .075 .204 .123 .018 Youth Race .027 .007 .029 .058 .018 .040 .115 Youth BMI z score .127 .029 .018 .006 .101 .020 .092 Correlation is significant at the .05 level (2 tailed)

PAGE 38

38 Table 3 5 Pearson correlations among demographics and variables of interest UWCB Variables Youth UWCB frequency Parent engagement Sibling engagement Peer engagement Parent encourage Sibling encourage Peer encourage Youth Age .054 .007 .169* .187** .018 .040 .119 Youth Sex .117 .079 .065 .144* .030 .054 .043 Youth Race .024 .049 .015 .045 .030 .068 .016 Youth BMI z score .116 .112 .115 .032 .082 .056 .050 Correlation is significant at the .05 level (2 tailed) **Correlation is significant at the .01 level (2 tailed)

PAGE 39

39 Table 3 6 Youth Report of HWCB Ever in Past Year N % N % Girls N=114 Boys N=105 Exercised 81 71.1% 55 52.4% a Ate more fruits and veggies 59 51.8% 40 38.1% a Drank less soda or SSB 52 45.6% 32 30.5% Ate fewer sweets 51 44.7% 33 31.4% Drank more water 50 43.9% 32 30.5% a Ate less high fat food 47 41.2% 36 34.3% a Drank more low fat milk 41 36.0% 33 31.4% Cut out carbs 16 14.0% 8 7.6% Mean # HWCB M(SD) 3.48 (2.50) 2.56 (2.50) d a Chi square test, difference is significant at the .05 level b Chi square test, difference is significant at the .005 level c Independent samples t test, difference is significant at the .05 level d Independent samples t test, difference is significant at the .005 level

PAGE 40

40 Table 3 7 Caregiver Report of Youth HWCB Ever in Past Year N % N % Girls N=114 Boys N=105 Exercised Ate more fruits and veggies a Ate fewer sweets Drank more water Drank less soda or SSB a Drank more low fat milk Ate less high fat foods b Cut out carbs a Mean # HWCB endorsed c a = Chi square test, difference is significant at the .05 level b = Chi square test, difference is significant at the .005 level c = Independent samples t test, difference is significant at the .05 level

PAGE 41

41 Table 3 8 Descriptive statistics of youth behavior frequency Variable Mean SD Actual Min Max Poss. Min Max Healthy WCB # Items endorsed youth report 3.04 2.59 0 8 0 8 # Items endorsed caregiver report 2.37 2.81 0 8 0 8 Unhealthy WCB # Items endorsed youth report 0.97 1.44 0 7 0 10 # Items endorsed caregiver report 0.80 1.41 0 7 0 10

PAGE 42

42 Table 3 9 Youth Report of UWCB Ever in Past Year N % N % Girls N=114 Boys N=105 Ate very little food 28.1% 19 18.1%

PAGE 43

43 Table 3 10 Caregiver Report of Youth Engagement in UWCB Ever in Past Year N % N % Ate very little food a c a = Chi square test, p<.05 b = Chi square test, p<.005 c = Independent samples t test, p<.05 d =Ind ependent samples t test, p<.005

PAGE 44

44 Table 3 11 Mean Number of Unique Healthy and Unhealthy Weight Control Behaviors Used in Past Year by Weight Status 12 5.5% 106 49.7% 33 15.3% 68 31.5% 1.33 (2.50) 1.37 (2.26) 2.21 (.48) 4.23 (2.78)** .67 (1.72) .47 (1.14) .73 (1.31) (1.63)* *Independent samples t test with healthy weight as reference group, difference significant at the .05 level (2 tailed) ** Independent samples t test with healthy weight as reference group, difference significant at the .005 level (2 tailed

PAGE 45

45 Table 3 12 Never One time A few time s per year A few times per month A few times per week Every day N % N % N % N % N % N % Exercised 90 41.1 4 1.8 10 4.6 28 12.8 57 26.0 30 13.7 Ate more fruits and vegetables 126 57.5 5 2.3 6 2.7 10 4.6 41 18.7 31 14.2 Drank more water 142 64.8 3 1.4 3 1.4 5 2.3 15 6.8 51 23.3 Ate fewer sweets 136 62.1 5 2.3 7 3.2 15 6.8 38 17.4 18 8.2 Drank more low fat milk 148 67.6 6 2.7 0 0.0 10 4.6 15 6.8 40 18.3 Ate less high fat foods 137 62.6 5 2.3 8 3.7 17 7.8 45 20.5 7 3.2 Drank less soda or SSB 148 67.6 4 1.8 6 2.7 15 6.8 28 12.8 18 8.2 Cut out carbohydrates 196 89.5 3 1.4 1 0.5 9 4.1 7 3.2 3 1.4

PAGE 46

46 Table 3 13 Never One time A few times per year A few times per month A few times per week Every day N % N % N % N % N % N % Ate very little food 160 73.1 10 4.6 4 1.8 11 5.0 24 11.0 10 4.6 Skipped meals 169 77.2 11 5.0 7 3.2 13 5.9 11 5.0 8 3.7 Skipped breakfast 178 81.3 6 2.7 4 1.8 9 4.1 8 3.7 14 6.4 Used food substitute 199 90.9 6 2.7 3 1.4 2 0.9 4 1.8 5 2.3 Fasted 200 91.3 8 3.7 3 1.4 2 0.9 4 1.8 2 0.9 Used a laxative 211 96.3 2 0.9 1 0.5 2 0.9 0 0.0 3 1.4 Took diet pills 213 97.3 3 1.4 1 0.5 1 0.5 1 0.5 1 0.5 Smoked cigarettes 218 99.5 1 0.5 0 0.0 0 0.0 0 0.0 0 0.0 Vomited 216 98.6 3 1.4 0 0.0 0 0.0 0 0.0 0 0.0 Used diuretics 218 99.5 1 0.5 0 0.0 0 0.0 0 0.0 0 0.0

PAGE 47

47 Table 3 14 Youth perceived engagement in WCBs by parents, siblings, peers Variable Mean SD Actual Min Max Poss. Min Max N (%) Youth endorsed at least one Parent engagement HWCB 3.12 2.76 0 8 0 8 154 (70.6%) Sibling engagement HWCB 1.65 2.29 0 8 0 8 103 (47.2%) Peer engagement HWCB 1.90 2.34 0 8 0 8 121 (55.5%) Parent engagement UWCB .86 1.65 0 10 0 10 79 (36.2%) Sibling engagement UWCB .49 1.14 0 10 0 10 53 (24.3%) Peer engagement UWCB 1.31 2.33 0 10 0 10 83 (38.1%)

PAGE 48

48 Table 3 15 How perceived engagement by supporter groups predicts youth WCB frequency *= p<.05 **=p<.01 B SE p R 2 p F Model 1 Predictors of HWCB .236 .000** 15.084 Child sex 1.872 .000 .171 Parent engagement in HWCB 1.391 .000 .001** Sibling engagement in HWCB .681 .003 .093 Peer engagement in HWCB .406 .001 .224 Model 2 Predictors of UWCB .123 .000* 5.79 0 Child sex .985 .037 .090 Child age .115 .009 .472 Parent engagement in UWCB .772 .032 .023* Sibling engagement in UWCB .528 .016 .069 Peer engagement in UWCB .020 .007 .899

PAGE 49

49 Table 3 16 Youth perceived encouragement by parents, siblings, peers Variable Mean SD Actual Min Max Poss. Min Max N(%) Youth endorsed one or more Parent encouragement HWCB 2.08 2.71 0 8 0 8 101 (46.3%) Sibling encouragement HWCB .78 1.73 0 8 0 8 56 (25.7%) Peer encouragement HWCB .90 1.80 0 8 0 8 65 (29.8%) Parent encouragement UWCB .39 1.32 0 10 0 10 34 (15.6%) Sibling encouragement UWCB .25 .99 0 10 0 10 28 (12.8%) Peer encouragement UWCB .54 1.66 0 10 0 10 40 (18.3%)

PAGE 50

50 Table 3 17 How perceived encouragement by supporter groups predicts youth WCB frequency B SE p R 2 p F Model 3 Predictors of HWCB .405 .000** 7.025 Child sex 1.069 1.216 .381 Parent encourage HWCB 2.357 .262 .001** Sibling encourage HWCB .285 .532 .581 Peer encourage HWCB .740 .410 .074 Model 4 Predictors of UWCB .088 .002** 3.95 Child age .103 .143 291 Child sex 1.229 .590 .043* Parent encourage UWCB .621 .629 .267 Sibling encourage UWCB .274 .825 .729 Peer encourage UWCB .470 .324 .126 *= p<.05 **=p<.01

PAGE 51

51 CHAPTER 4 DISCUSSION This study is unique in that it reported on weight control behavior prevalence for unhealthy and healthy weight control behaviors based on both youth and caregiver reports. In addition, this is one of the only studies to assess how often youth engaged in each individual weight control behavior over the past year. Furthermore, this s tudy is novel in that it assesses how youth perception of supporter groups engaging in distinct healthy and unhealthy behaviors and encouraging youth to engage in distinct behaviors impacts youth weight control behavior frequency. Prevalence of Weight C ontrol Behaviors Overall, 7 9 % of girls and 67% of boys in the current sample reported they had engaged in at least one HWCB in the pas t year in order to lose weight. Caregivers reported 62% of girls and 50% of boys engaged in at least one HWCB in the past year in order to lose weight. These figures are s lightly lower than percentages of youth who endorsed at least one HWCB among population based youth report samples from 1999 (83% of girls and 75% of boys) and 2010 (87% of girls and 83% of boys) ( Dianne Neumark Sztainer et al., 2012 ) Differences in HWCB prevalence might be explained by the racial composition of the current sample. Previous research found that Caucasian girls were significantly more likely to endorse HWCBs than African American girls, and, similarly, Caucasian boys were significantly more likely to endorse they engaged in almost every HWCB (except exercised) in the past year compared to African American boys ( Dianne Neumark Sztainer, Croll, et al., 2002 ) Given that the current sample was comprised of 55% African Americans and less than 33% Caucasians, this may explain

PAGE 52

52 why the current sample reported lower HWCB prevalence compared to previous samples. With regard to UWCBs, p reviou s research from the Project EAT study found 58% of girls and 40% of boys engaged in at least one UWCB in the past year ( Croll, Neumark Sztainer, Story, & Ireland, 2002 ) A lower percentage of girls (44%) in the current study reported they had engaged in one or more UWCBs in the past year, while the percentage of males (39%) who endorsed engaging in one or more UWCB in the past year was comparable to findings from Project EAT Caregivers reported 45 % of girls and 28 % of boys engaged in at l east one UWCB in the past year. While UWCB prevalence rates in the current study are lower compared to original findings from the Project EAT study, it is possible that the current findings support a broader trend of significant decreases in UWCB prevalenc e, particularly among girls. Project EAT recently repeated their survey with 2,793 middle and high school participants and found 50% of girls had engaged in at least one UWCB in the past year, compared to 59% in 1999 ( Croll et al., 2002 ; Dianne Neumark Sztain er, Story, et al., 2002 ) Similarly, the 2011 Youth Risk Behavior Survey (YRBS) revealed significant decreases since 1991 in UWCB prevalence, particularly among girls, although fewer weight control behaviors were assessed compared to the present study ( Centers for Disease Control and Prevention, 2011 ) A decrease in UWCB prevalence has positive implications for reductions in disordered eating and pediatric obesity. Girls engaged in significantly more HWCBs in the past year than boys, according to both youth and caregiver report. This finding extends previous knowledge about youth engagement in HWCBs since previous research compared HWCB differences by

PAGE 53

53 weight status, but not sex ( K. Boutelle et al., 2002 ) According t o caregiver report, girls in the present study engaged in a significantly greater number of unique HWCBs at least once in the past year than boys. Turning to UWCB, according to youth report, the difference between the average number of unique UWCBs girls reported they engaged in at least once in the past year compared to the average number of unique UWCBs that boys engaged in at least once in the past year was not significant. Similarly, the percentage of girls who engaged in at least one UWCB in the past year (44%) was not significantly different from the percentage of males (39%) who engaged in at least one UWCB [ (1, N = 219) = .384, p >.05]. This finding contrasts previous research, which found significantly more girls reported they engaged in one or more UWCBs than boys ( Dianne Neumark Sztainer et al., 1999 ; Vander Wal, 2012 ) Differences between the current findings and previous research may be considered, again, in the context of the racial composition of the current sample. Previous research found that African American boys were more likely to report they had engaged in every UWCB assessed, except for smoked cigarettes and used laxatives, compared to Caucasian boys. In contrast, there were no significant d ifferences between the percentage African American versus Caucasian girls who endorsed each UWCB, except on one item, eating very little food, which was endorsed by a greater percentage of African American girls ( Dianne Neumark Sztainer, Croll, et al., 2002 ) Therefore, the higher prevalence of African Americans in the current sample may help explain why the difference between the number of UWCBs endorsed by girls ve rsus boys was not significant. Overweight and obese youth reported they engaged in a significantly greater number of HWCBs at least once in the past year c ompared to healthy weight youth.

PAGE 54

54 Caregivers reported that only obese youth engaged in significantly more HWCBs compared to healthy weight youth. These findings are consistent with past research that examined differen ces in weight control behavior prevalence among adolescents by weight status ( Dianne Neumark Sztainer, Story, et al., 2002 ) However, these findings were inconsistent with another study by Boutelle and colleagues ( K. Boutelle et al., 2002 ) which demonstrated OV/OB youth were less likely to engage in healthy behaviors such as exercising and eating more fruits and vegetables than healthy weight peers Turning to UWCB, both caregivers and youth reported o bese youth had engaged in more UWCBs than healthy weight youth; these findings are consistent with previous r esearch ( K. Boutelle et al., 2002 ; French, Perry, Leon, & Fulkerson, 1995 ; D. Neumark Sztainer et al., 19 97 ) However, according to both youth and caregi ver reports, overwe ight youth in the present study did not report they had engaged in a significantly greater average number of UWCBs compared to healthy weight peers, and these findings are in contrast with existing research which demonstrated overweight youth differed significantly from healthy weight peers on UWCB engagement ( Dianne Neumark Sztainer, Story, et al., 2002 ) Overall, the current finding demonstrating obese youth engaged in more unique healthy and unhealthy weight control behaviors at least once in the past year compared to their healthy weight peers is not surprising, given that obese youth are more likely to be told they need to lose weight by pediatricians, par ents, and peers ( Barlow et al., 2002 ; M. P. McCabe & Ricciardelli, 2005 ) are more likely to report dieting ( K. Boutelle et al., 2002 ) and therefore may try a greater variety and number of weight loss strategies in order to accomplish that goal.

PAGE 55

55 Compared to other youth weight control behavior prevalence studies, this study was unique in that it included both caregiver and youth reports of youth behaviors. Caregivers reported youth were engaging in fewer healthy and unhealthy weight control behaviors compared to youth report. One reason for this discrepancy may be that youth over reported their own use of HWCBs in order to seem more soci ally desirable. In addition, youth (as well as caregivers) may have difficulty recalling all their behaviors and how often they engaged in those behaviors over the past year. Future studies should assess either a shorter period of time or utilize daily tra cking measures in order to gain a more accurate understanding of behavior frequency among youth. Alternatively, parents may have under reported youth engagement in weight control behaviors if they were ill dieting goals and strategies Caregivers who did not live with their child full time as well as caregivers of older adolescents, who are more likely to eat meals away from their family or engage in e inaccuracies in reporting. This finding has important implications for assessment and intervention. Clinicians and other medical professionals may gain valuable information by asking parents about the behaviors their child has engaged in In addition, i nterventions should focus on increasing communication between children and their parents about weight loss strategies. Weight Control Behavior Frequency The current study assessed how often youth engaged i n each weight control behavior and findings for H WCB frequency were somewhat positive, as youth indicated they engaged in a number of HWCBs on a regular basis. Close to 40% of youth reported exercising at least a few times per week in order to lose or maintain weight.

PAGE 56

56 These findings are promising, given that increased exercise levels have been associated with successful weight loss and maintenance among adolescents ( K. N. Boutelle et al., 2009 ) In addition, youth reported engaging in the following dietary habits at least a few times per week in order to control their weig ht: 33% of youth reported they ate more fruits and vegetables, about 30% drank more water, 25% ate fewer sweets, and 23% reported they ate fewer high fat foods. Certain dietary changes among youth have been associated with positive outcomes in past researc h; decreasing high fat food consumption was associated with successful weight loss among adolescents ( K. N. Boutelle et al., 2009 ) and youth who reported eating at least one fruit or vegetable every day were more likely to engage in physical activity and were less likely to engage in self induced vomiting or diet pill use ( Story et al., 1998 ) One consideration regarding the interpretation of these results is that youth were asked to report how often they engaged in a behavior in order to l ose or maintain weight; therefore, youth may have engaged in behaviors for reasons other than weight loss (e.g. exercising with a sports team) and it is possible that some youth failed to endorse these behavior items due to this qualifier. Turning to UWC B frequency, nearly a third of youth endorsed skipping meals at least a few times per month and one in five reported they ate very little food at least a few times per day month in order to lose weight. These findings are concerning, given that cycles of r estrictive eating occurring at least once a week have been associated with future increase in zBMi score and episodes of binge eating among OV/OB youth ( Field et al., 2003 ) In addition, ten percent of youth reported skipping breakfast at least a few times a week in order to lose or maintain weight. Given that decreased breakfast

PAGE 57

57 consumption has been associated with increased BMI from adolescence to adulthood ( Niemeier, Raynor, Lloyd Richardson, Rogers, & Wing, 2006 ) the current findings indicate an area where brief intervention may be helpful. Finally, three participants endorsed using laxatives every day and two participants endorsed using diet pills at le ast a few times per week. While most youth did not engage in these behaviors at all, a small number engaged in them at potentially dangerous frequencies, and therefore asking youth about how often they engage in these behaviors is crucial. Psychosocial Pr edictors of Youth Weight Control Behavior Frequency Youth perception of parent engagement in healthy and unhealthy weight control behaviors were examined as predictors of youth weight control behavior frequency. Parent engagement in both healthy and unheal thy weight control behaviors significantly predicted weight control behavior frequency in youth, and the association between parent engagement in HWCBs and youth HWCB frequency was particularly strong (B=1.391). These findings are not entirely surprising, given that they support the notion that parents play a significant role in establishing eating and healthy lifestyle habits in their children ( Davis et al., 2007 ) Specifically, m aternal dieting has been shown to significantly predict self induced vomiting, using laxatives, taking diet pills, and using diuretics among youth ( Haines & Neumark Sztainer, 2006 ; D. R. Neumark Sztainer et al., 2007 ) In addition, parent engagement in unhealthy weight loss behaviors such as fasting and skipping meals were found to predict those same behaviors among adolescent daug hters ( Benedikt et al., 1998 ) However, research on the influence of parent behaviors on you th behaviors is not uniform. Cromley and colleagues ( 2010 ) did not find that parent engagement in HWCBs or UWCBs significantly predicted youth weight control

PAGE 58

58 behaviors. There are two reasons why the present study may have found different results compared to Cromley and colleagues. F irst, the presen t study assessed youth perception of parent behaviors, instead of parent report Previous research found youth perception of parent behavior is a greater predictor of youth behavior, above parent report of their own behaviors ( Francis, Hofer, & Birch, 2001 ) ; therefore, the current study may have been able to better detect youth perceptions which impacted their own behaviors. S econd, yout h were asked about whether or not their parents engaged in a greater number of HWCBs than were assessed by Cromley and colleagues (the current study assessed eight HWCBs while past research assessed four) Therefore, it is possible that by asking about a g reater number of behaviors, the current study was able to detect youth perceived parent behaviors that were more salient in predicting youth behavior. Parent encouragement to engage in HWCBs significantly predicted youth HWCB frequency, however, parent e ncouragement to engage in UWCB did not significantly predict youth UWCB frequency. This finding contrasts past research by Benedikt and colleagues ( 1998 ) which found parental encouragement to diet significantly predicted unhealthy dieting behaviors in girls. It should be noted, however, that previous literature asked youth participants whether or not their parents encouraged them to diet. The present stud y is novel in that it assessed whether or not parents encouraged their children to engage in each unique weight control behavior rather than assess one overarching question about dieting and therefore findings regarding parental encouragement to diet may not be comparable to current findings. By assessing the specific behaviors parents encouraged, we were able to discern that encouraging

PAGE 59

59 different types of weight control strategies had differ ing effects on youth behavior, as parent encouragement to engage in HWCBs predicted youth HWCB frequency, whereas parent encouragement to engage in UWCBs did not significantly predict youth WCB frequency. To summarize parent influence, parent engagement in HWCBs and encouragement of youth to engage in HWCBs both appea r to play an important role in youth engagement in HWCBs. While past literature focused primarily on demonstrating the negative impact parent behaviors and parent diet related talk may have on youth behaviors, the present study extends our knowledge about parent influence, demonstrating parent behaviors and parent encouragement have a substantial impact on youth engagement in HWCBs. Therefore, the current findings support the development of interventions that empower parents to make positive changes to supp loss goals and improve lifestyle habits by teaching parents to model healthy weight loss strategies and discuss ways to achieve healthy lifestyle changes with their children. Youth perceived sibling engagement in weight control behaviors did not significantly impact youth weight control behavior frequency. Similarly, youth perception of siblings encouraging them to engage in weight control behaviors did not impact how frequently they engaged in weight control behaviors. Given t hat youth reported their siblings engaged in and encouraged lower numbers of behaviors compared to peer and parent groups, this finding is not surprising. Future research should address correlates of individual weight control behaviors among siblings, as s hared behaviors may become more apparent in a sample of only sibling pairs. Similar models examining sibling pairs

PAGE 60

60 have been used to study bulimic behaviors ( Coomber & King, 2008 ) how ever, correlates of individual weight control behaviors among sibling pairs have not been examined. Peer engagement in weight control behaviors, as perceived by youth, did not significantly predict youth WCB frequency for healthy or unhealthy behaviors. This finding is somewhat surprising, given that peers are thought to play a signifi cant role in shaping each other a nd eating ( Paxton, Schutz, Wertheim, & Muir, 1999 ) In one study, peer dieting, as assessed by the was found to predict the use of UWCBs among youth ( D. R. Neumark Sztainer et al., 2007 ) However, these differences in find ings may be due to the fact that the present study assessed the specific weight control behaviors youth perceived their peers engaged in, but did not ask about dieting in general It is possible that other behaviors peers engage in, such as weight related teasing, may be more salient predictors of youth dieting behavior ( Lieberman et al., 2001 ; Vincent & McCabe, 2000 ) Similarly, youth perception of p eers encouraging them to engage in various weight control behaviors did not significantly predict youth weight control behavior frequency for healthy or unhealthy behaviors. Other factors not considered in the present models may explain the relationship be tween peer influence and youth dieting behaviors; for example, future analyses should examine whether youth with lower self esteem are more likely to be influenced by peers encouraging them to engage in various weight control behaviors Strengths and Limit ations The current study features several strengths. The sample served to expand upon the existing WCB literature by including both caregiver and youth reports of individual

PAGE 61

61 youth weight control behaviors. In addition, the present study added a measure of how often youth engaged in each behavior in the past year. Turning to the analyses, t he information gathered pertaining to how often youth engaged in each behavior was used to create interval scales of healthy and unhealthy weight control behavior freq uency as outcome variables in regression analyses. In contrast to dichotomized outcome variables used in previous research (i.e. yes/no engaged in any healthy or unhealthy WCB) ( Cromley et al., 2010 ; We rtheim et al., 1999 ) interval scale analysis allows for all participants to contribute to the detection of relationships and improves model power ( Royston, Altman, & Sauerbrei, 2006 ) The following limitations should be considered in the context of the current study. As discussed previously, the self report ed nature of these data are a limitation, as ad olescents may have over reported their engagement in HWCBs and underreported their engagement in UWCBs in order to appear more desirable. Second, coefficient alpha (which takes into account variance attributable to subjects and interaction between subjects differences between individual items, rather than general and group factors ( Cortina, 1993 ) The low coefficient alpha is likely due to more than one underlying factor structure, and this may be remedied in future analyses by breaking the UWCB scale into two groups: extreme UWCB (smoking, usin g diet pills, taking laxatives, and vomiting) and all other UWCBs; similar adjustments were made by other researchers ( Cromley et al., 2010 ; Dianne Neumark Sztainer, Croll, et al., 2002 ) A third limitation relates to the measure used to assess parent, sibling, and peer engagement in weight

PAGE 62

62 control behaviors. This measure relied on youth perception of the behaviors of those around them, and youth may not have been aware of or recalled every behavior their parents, siblings, or peers engage d in. Furthermore, this measure d id not assess how often supporter groups engaged in weight control behaviors or encouraged youth to engage in weight control behaviors and undetected frequencies of modeling or encouragement may have impact ed youth behavior frequency. Lastly, the cross se ctional nature of this study is a limitation. Longitudinal data are needed to examine the direction of potential effects of supporter group behaviors and encouragement over time; however, the present findings can inform further research and interventions. Implications Given the pervasiveness of UWCBs among youth and their associated negative outcomes, it is important for clinicians to screen for these behaviors. However, health care professionals face time constraints and therefore a comprehensive screening may not be p ossible. One implication from the current findings is that clinicians should be aware that OV/OB youth and females are more likely to engage in UWCB, therefore asking these groups about engagement in UWCBs is particularly important. In addition, the findin gs provide information about which individual behaviors may be more or less prevalent among youth and therefore might help the clinician choose a few key behaviors to ask about. The following items on the WCB questionnaire were rarely or never endorsed: ma de myself vomit (n=0), smoked cigarettes (n=1), and used diuretics (n=0). While it is important for clinicians to ask youth if they are engaging in these behaviors, since they are associated with harmful health consequences, clinicians should also take the time to ask about those UWCBs that are more prevalent among youth, such as eating very little, skipping meals, and fasting. In addition, considering the

PAGE 63

63 low agreement between youth and caregiver report detected in this study, clinicians should seek caregi ver report of youth engagement in various weight control behaviors in addition to youth report. The current findings serve to extend the existing knowledge of factors associated with youth engagement in weight control behaviors that may serve as targets f or integrated interventions. The present study identified parent engagement in both UWCBs and HWCBs as predictors of increased weight control behavior frequency among youth. Parent involvement is one important component of family based behavioral treatment programs for pediatric obesity ( Whitlock, O'Connor, Williams, Beil, & Lutz, 2010 ) efforts through communicating positive health behavior messages a nd controlling the environme nt in order increase exposure to healthy foods and create opportunities for physical activity ( Gruber & Haldeman, 2009 ) Consistent with this theory, interventions such as the Positive Parenting Program ( West, Sanders, Cleghorn, & Davies, 2010 ) Parents are taught behavior management skills that include modeling healthy eating behaviors su ch as trying new fruits and vegetables in front of their children and decreasing their own unhealthy behaviors, such as skipping breakfast. Triple P was a success in that the intervention was associated with significant reductions in child BMI z score as w ell as increased parent confidence and more consistent parenting practices. In order to increase HWCBs according to the current findings, interventions should aim to teach parents how to emphasize healthy behaviors via engaging in these

PAGE 64

64 behaviors themselv es and encourage youth to engage in healthy behaviors through discussions about healthy lifestyle choices Future Directions In the future, longitudinal research is necessary to examine whether supporter groups modeling particular weight control behaviors or encouraging youth to engage in weight control behaviors are salient predictors of youth WCB frequency. Future research would benefit from gathering peer and sibling reports of their own behavior in order to better understand how supporter groups might influence youth behavior. Second, other s ocio environmental factors that may predict youth UWCB frequency should be explored, given that the present models did not explain much of the variance in youth UWCB frequency One factor that has not yet been cons idered in the literature that may be related to youth engagement in weight control behaviors is how safe youth perceive various behaviors to be for weight loss. Third, future analyses should aim to compare parent child agreement about youth engagement in s pecific behaviors, as this may serve to identify which behaviors youth engage in that their parents may be less aware of. Lastly, future analyses should examine specific sample characteristics related to how often youth engage in individual behaviors. In p articular, while the current study are as likely to regularly (e.g. every day or a few times per week) engage in various weight loss behaviors compared to healthy weight peers. In summary, the current study expanded our current understand of factors related to youth engagement in healthy and unhealthy weight control behaviors. Girls as well as OV/OB youth were more likely to engage in both health and unhealthy weight

PAGE 65

65 control behaviors, according to youth and caregiver reports. Caregivers reported youth engaged in fewer healthy and unhealthy behaviors compared to youth report, in dicating both the need for clinicians to gather caregiver report in addition to youth report as well as the need for interventions aimed at increasing parent child communication about weight loss behaviors. Parent engagement in both healthy and unhealthy w eight control behaviors significantly predicted youth healthy and unhealthy weight control behavior frequency, respectively, however, peers and sibling engagement did not significantly predict youth behavior frequency. Parents encouraging youth to engage i n HWCBs significantly predicted youth HWCB frequency, however, parents encouraging youth to engage in UWCBs did not significantly predict youth UWCB frequency. Neither sibling nor peer encouragement to engage in weight control behaviors significantly predi cted youth WCB frequency. Taken together, parents play a significant role in influencing child engagement in weight control behaviors, particularly for healthy WCBs; this has important implications for parent involvement in healthy lifestyle interventions for pediatric obesity.

PAGE 66

66 LIST OF REFERENCES Armstrong, B., & Janicke, D. M. (2012). Differentiating the effects of maternal and peer encouragement to diet on child weight control attitudes and behaviors. Appetite Barlow, S. E., Trowbridge, F. L., Klish, W. J., & Dietz, W. H. (2002). Treatment of child and adolescent obesity: reports from pediatricians, pediatric nurse practitioners, and registered dietitians. Pediatrics, 110 (Supplement 1), 229 235. Benedikt, R., W ertheim, E. H., & Love, A. (1998). Eating attitudes and weight loss attempts in female adolescents and their mothers. Journal of Youth and Adolescence, 27 (1), 43 57. Boutelle, K., Neumark Sztainer, D., Story, M., & Resnick, M. (2002). Weight control behav iors among obese, overweight, and nonoverweight adolescents. [Comparative Study]. J Pediatr Psychol, 27 (6), 531 540. Boutelle, K. N., Libbey, H., Neumark Sztainer, D., & Story, M. (2009). Weight control strategies of overweight adolescents who successfull y lost weight. J Am Diet Assoc, 109 (12), 2029 2035. Centers for Disease Control and Prevention, C. (2011). 1991 2011 High School Youth Risk Behavior Survey Data Retrieved January 26, 2014, from http://apps.nccd.cdc.gov/youthonline Cislak, A., Safron, M. Pratt, M., Gaspar, T., & Luszczynska, A. (2012). Family related predictors of body weight and weight related behaviours among children and adolescents: a systematic umbrella review. Child: Care, Health and Development, 38 (3), 321 331. Coomber, K., & Kin g, R. M. (2008). The role of sisters in body image dissatisfaction and disordered eating. Sex Roles, 59 (1 2), 81 93. Cortina, J. M. (1993). What is coefficient alpha? An examination of theory and applications. Journal of applied psychology, 78 (1), 98. Cr oll, 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 (2), 166 175. Cromle y, T., Neumark Sztainer, D., Story, M., & Boutelle, K. N. (2010). Parent and family associations with weight related behaviors and cognitions among overweight adolescents. Journal of Adolescent Health, 47 (3), 263 269. Davis, M. M., Gance Cleveland, B., Ha ssink, S., Johnson, R., Paradis, G., & Resnicow, K. (2007). Recommendations for prevention of childhood obesity. Pediatrics, 120 (Supplement 4), S229 S253.

PAGE 67

67 Eaton, D. K., Kann, L., Kinchen, S., Shanklin, S., Ross, J., Hawkins, J., . Chyen, D. (2010). Yo uth risk behavior surveillance United States, 2009. MMWR Surveill Summ, 59 (5), 1 142. Eisenberg, M. E., Neumark Sztainer, D., Story, M., & Perry, C. (2005). The role of social control behaviors among adole scent girls. Social Science & Medicine, 60 (6), 1165 1173. Field, A. E., Austin, S., Taylor, C., Malspeis, S., Rosner, B., Rockett, H. R., . Colditz, G. A. (2003). Relation between dieting and weight change among preadolescents and adolescents. Pediatr ics, 112 (4), 900 906. Francis, L. A., Hofer, S. M., & Birch, L. L. (2001). Predictors of maternal child feeding style: maternal and child characteristics. Appetite, 37 (3), 231 243. Freedman, D. S., Khan, L. K., Dietz, W. H., Srinivasan, S. R., & Berenson G. S. (2001). Relationship of childhood obesity to coronary heart disease risk factors in adulthood: the Bogalusa Heart Study. Pediatrics, 108 (3), 712 718. French, S. A., Perry, C. L., Leon, G. R., & Fulkerson, J. A. (1995). Dieting behaviors and weight change history in female adolescents. [Research Support, U.S. Gov't, P.H.S.]. Health Psychol, 14 (6), 548 555. Fulkerson, J., McGuire, M., Neumark Sztainer, D., Story, M., French, S., & Perry, C. (2002 ). Weight related attitudes and behaviors of adolescent boys and girls who are encouraged to diet by their mothers. International Journal of Obesity; International Journal of Obesity Gortmaker, S. L., Must, A., Perrin, J. M., Sobol, A. M., & Dietz, W. H. (1993). Social and economic consequences of overweight in adolescence and young adulthood. New England journal of medicine, 329 (14), 1008 1012. Gruber, K. J., & Haldeman, L. A. (2009). Using the family to combat childhood and adult obesity. Prev Chronic Dis, 6 (3), A106. Haines, J., & Neumark Sztainer, D. (2006). Prevention of obesity and eating disorders: a consideration of shared risk factors. Health Education Research, 21 (6), 770 782. Keery, H., Eisenberg, M. E., Boutelle, K., Neumark Sztainer, D., & Story, M. (2006). Relationships between maternal and adolescent weight related behaviors and concerns: The role of perception. Journal of psychosomatic research, 61 (1), 105 111. Klem, M. L. (2000). Successful losers. The habits of individuals who have ma intained long term weight loss. Minnesota medicine, 83 (11), 43 45.

PAGE 68

68 Kuczmarski, R. J., Ogden, C. L., Grummer Strawn, L. M., Flegal, K. M., Guo, S. S., Wei, R., . Johnson, C. L. (2000). CDC growth charts: United States. Adv Data (314), 1. Lieberman, M., Gauvin, L., Bukowski, W. M., & White, D. R. (2001). Interpersonal influence and disordered eating behaviors in adolescent girls: The role of peer modeling, social reinforcement, and body related teasing. Eating behaviors, 2 (3), 215 236. Linde, J. A., Wal l, M. M., Haines, J., & Neumark Sztainer, D. (2009). Predictors of initiation and persistence of unhealthy weight control behaviours in adolescents. International Journal of Behavioral Nutrition and Physical Activity, 6 (1), 72. McCabe, M., & Ricciardelli, L. (2001). Parent, peer and media influences on body image and strategies to both increase and decrease body size among adolescent boys and girls. Adolescence, 36 (142), 225 240. McCabe, M. P., & Ricciardelli, L. A. (2005). A prospective study of pressure s from parents, peers, and the media on extreme weight change behaviors among adolescent boys and girls. Behaviour research and therapy, 43 (5), 653 668. Neumark Sztainer, D., Croll, J., Story, M., Hannan, P. J., French, S. A., & Perry, C. (2002). Ethnic/r acial differences in weight related concerns and behaviors among adolescent girls and boys: findings from Project EAT. Journal of psychosomatic research, 53 (5), 963 974. Neumark Sztainer, D., Story, M., Falkner, N. H., Beuhring, T., & Resnick, M. D. (1999 ). Sociodemographic and personal characteristics of adolescents engaged in weight loss and weight/muscle gain behaviors: who is doing what? Preventive medicine, 28 (1), 40 50. Neumark Sztainer, D., Story, M., & French, S. A. (1996). Covariations of unhealt hy weight loss behaviors and other high risk behaviors among adolescents. Archives of pediatrics & adolescent medicine, 150 (3), 304. Neumark Sztainer, D., Story, M., French, S. A., Hannan, P. J., Resnick, M. D., & Blum, R. W. (1997). Psychosocial concerns and health compromising behaviors among overweight and nonoverweight adolescents. [Comparative Study]. Obes Res, 5 (3), 237 249. Neumark Sztainer, D., Story, M., Hannan, P. J., Perry, C. L., & Irving, L. M. (2002). Weight related concerns and behaviors am ong overweight and nonoverweight adolescents: implications for preventing weight related disorders. Archives of pediatrics & adolescent medicine, 156 (2), 171. 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 10 year longitudinal study. J Am Diet Assoc, 111 (7), 1004 1011.

PAGE 69

69 Neumark Sztainer, D., Wall, M. M., Larson, N., Story, M., Fulkerson, J. A., Eisenberg, M. E., & Hannan, P. J. (2012). Secular trends in weight status and weight related attitudes and behaviors in adolescents from 1999 to 2010. Preventive medicine, 54 (1), 77 81. Neumark Sztainer, D. R., Wall, M. M., Haines, J. I., Story, M. T., Sherwood, N. E., & van den Berg, P. A. (2007). Shared risk and protective factors for overweight and disordered eating in adolescents. American journal of preventive medicine, 33 (5), 359 369. e353. Niemeier, H. M., Raynor, H. A., Lloyd Richardson, E. E., Rogers, M. L., & Wing, R. R. (2006). Fast food consumption and breakfast skipping: predictors of weight gain from adolescence to adulthood in a nationally representative sample. Journal of Adolescent Health, 39 (6), 842 849. Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2012). Prevalence of obesity and trends in body mass index among US children and adolescents, 1999 2010. JAMA: the journal of the American Medical Association, 307 (5), 483 490. Patton, G., Selzer, R., Coffey, C., Carlin, J., & Wolfe, R. (1 999). Onset of adolescent eating disorders: population based cohort study over 3 years. BMJ: British Medical Journal, 318 (7186), 765. Paxton, S. J., Schutz, H. K., Wertheim, E. H., & Muir, S. L. (1999). Friendship clique and peer influences on body image concerns, dietary restraint, extreme weight loss behaviors, and binge eating in adolescent girls. Journal of abnormal psychology, 108 (2), 255. Quick, V., Loth, K., MacLehose, R., Linde, J. A., & Neumark Sztainer, D. (2013). Prevalence of Adolescents' Self Weighing Behaviors and Associations With Weight Related Behaviors and Psychological Well Being. Journal of Adolescent Health Raj, M. (2012). Obesity and cardiovascular risk in children and adolescents. Indian journal of endocrinology and metabolism, 16 ( 1), 13. Ricciardelli, L. A., McCabe, M. P., & Banfield, S. (2000). Body image and body change methods in adolescent boys: Role of parents, friends and the media. Journal of psychosomatic research, 49 (3), 189 197. Royston, P., Altman, D. G., & Sauerbrei, W. (2006). Dichotomizing continuous predictors in multiple regression: a bad idea. Statistics in medicine, 25 (1), 127 141. Sallis, J. F., Prochaska, J. J., & Taylor, W. C. (2000). A review of correlates of physical activity of children and adolescents. Me dicine and science in sports and exercise, 32 (5), 963 975.

PAGE 70

70 Story, M., Neumark Sztainer, D., Sherwood, N., Stang, J., & Murray, D. (1998). Dieting status and its relationship to eating and physical activity behaviors in a representative sample of US adoles cents. J Am Diet Assoc, 98 (10), 1127 1135. Strauss, R. S., & Pollack, H. A. (2003). Social marginalization of overweight children. Archives of pediatrics & adolescent medicine, 157 (8), 746. van der Horst, K., Oenema, A., Ferreira, I., Wendel Vos, W., Gis kes, K., Van Lenthe, F., & Brug, J. (2007). A systematic review of environmental correlates of obesity related dietary behaviors in youth. Health Education Research, 22 (2), 203 226. Vander Wal, J. S. (2012). Unhealthy weight control behaviors among adoles cents. Journal of health psychology, 17 (1), 110 120. Veloso, S. M., Matos, M. G., Carvalho, M., & Diniz, J. A. (2012). Psychosocial Factors of Different Health Behaviour Patterns in Adolescents: Association with Overweight and Weight Control Behaviours. Journal of obesity, 2012 Vincent, M. A., & McCabe, M. P. (2000). Gender differences among adolescents in family, and peer influences on body dissatisfaction, weight loss, and binge eating behaviors. Journal of Youth and Adolescence, 29 (2), 205 221. Ward le, J., & Cooke, L. (2005). The impact of obesity on psychological well being. Best Practice & Research Clinical Endocrinology & Metabolism, 19 (3), 421 440. Wertheim, E. H., Mee, V., & Paxton, S. J. (1999). Relationships among adolescent girls' eating beh aviors and their parents' weight related attitudes and behaviors. Sex Roles, 41 (3 4), 169 187. West, F., Sanders, M. R., Cleghorn, G. J., & Davies, P. S. (2010). Randomised clinical trial of a family based lifestyle intervention for childhood obesity invo lving parents as the exclusive agents of change. Behaviour research and therapy, 48 (12), 1170 1179. Whitlock, E. P., O'Connor, E. A., Williams, S. B., Beil, T. L., & Lutz, K. W. (2010). Effectiveness of weight management interventions in children: a targe ted systematic review for the USPSTF. Pediatrics, 125 (2), e396 e418.

PAGE 71

71 BIOGRAPHICAL SKETCH College in 2009. She is currently a second year graduate student in the Clinical and Health Psychology doctoral program at the University of Florida, with a concentration in pediatri c psychology. Julia on May 2 and is continuing her doctoral training in clinical psychology at the University of Florida.


xml version 1.0 encoding UTF-8
REPORT xmlns http:www.fcla.edudlsmddaitss xmlns:xsi http:www.w3.org2001XMLSchema-instance xsi:schemaLocation http:www.fcla.edudlsmddaitssdaitssReport.xsd
INGEST IEID EWQM7S8QM_G0DS5Q INGEST_TIME 2014-10-03T21:48:19Z PACKAGE UFE0046764_00001
AGREEMENT_INFO ACCOUNT UF PROJECT UFDC
FILES