Body Image and Dieting Behavior in Cystic Fibrosis

Helen Truby, PhD, APD*, and Susan J. Paxton, PhD

ABSTRACT. Objective. To examine the relationship
between pulmonary function, nutritional status, body
image, and eating attitudes in children with cystic fibrosis (CF) compared with healthy controls.
Method. Seventy-six children with CF (39 girls) and
153 healthy control children (82 girls) were recruited. All
children were between 7 and 12 years of age. After being
weighed and measured, participants undertook a structured 1-to-1 interview. Four measures were used to assess
body image: body size (perception and satisfaction) were
ascertained using the Childrens Body Image Scale
(CBIS), which uses photographs of children of various
body mass index (BMI) representative of the range of
BMI percentiles for children 7 to 12 years of age. Body
size satisfaction was measured by the response to the
questions, Do you think your body is 1) much too thin,
2) too thin, 3) just right, 4) too fat, and 5) much too fat?
Body weight satisfaction was measured by the question,
Would you like your body to be 1) much thinner, 2) a
little bit thinner, 3) stay the same, 4) a little bit fatter, and
5) much fatter? Global self-esteem was measured using
the childrens version of the Rosenberg Self-Esteem
Scale and Body Esteem Scale using a 24-item scale. Dieting behavior was measured by asking directly about
previous weight control behaviors, use of the Dutch Eating BehaviorRestraint Scale (DEBQR), and, in children
who acknowledged previous dieting behavior, the Childrens Eating Attitude Test (ChEAT) was additionally
administered.
Results. Both girls and boys with CF had significantly reduced BMI percentiles compared with control
children. Boys with CF did not have a significantly different BMI compared with girls with CF. There were
significant positive correlations between forced expiratory volume in 1 second (FEV1) (% of predicted) and BMI
percentile in girls (r .35) and boys (r .50) with CF.
Body image perceptions in boys and girls with CF were
examined in relation to the healthy control group using 2
(CF and control groups) by 2 (male and female) analysis
of variance. The interaction effect was examined to explore the prediction that girls compared with boys with
CF would have greater acceptance of their body shape
and less desire to become larger. There were no differences between groups or sex in body esteem. On the
CBIS body dissatisfaction score, children with CF were
significantly more likely to perceive their ideal body size
as a little larger than their current size while control
children desired a smaller body size than their current
size. CF children had a significantly lower mean score for
From the *School of Biomedical and Life Sciences, University of Surrey,
Surrey, United Kingdom; and Department of Psychology, University of
Melbourne, Victoria, Australia.
Received for publication Jul 3, 2000; accepted Jan 24, 2001.
Reprint requests to (H.T.) School of Biomedical and Life Sciences, University of Surrey, Guildford, Surrey, GU2 7XH, United Kingdom. E-mail:
h.truby@surrey.ac.uk
PEDIATRICS (ISSN 0031 4005). Copyright 2001 by the American Academy of Pediatrics.

body size satisfaction (an item assessing perception being too thin) and a significantly higher mean score on
body weight satisfaction. There was a significant main
effect of gender for only 1 measure, difference between
the CBIS body dissatisfaction score, with girls being
more likely to nominate a smaller ideal than their current
figure. There were no significant interaction effects.
Of children with CF and a low BMI (<10th percentile),
25% of girls and 38% of boys thought they were too thin.
Fewer girls (19%) than boys (38%) would have liked to be
fatter.
The CF group had significantly lower mean scores on
the DEBQR scale compared with controls. Of the children with CF completing the ChEAT (n 13), none
obtained a score of clinical significance compared with 6
(4%) for controls.
To examine predictors of BMI a multiple regression
analysis was conducted separately for boys and girls
with CF and control boys and girls in which the dependent variable was BMI and the independent variables
were FEV1 (% of predicted) (in CF children only), body
esteem, self-esteem, and body dissatisfaction score. In
the case of boys with CF, the regression equation was
significant (Adjusted R2 0.30). In the case of girls with
CF, the regression equation was significant (Adjusted R2
0.25) with body dissatisfaction making a significant
independent contribution. For control boys the regression equation was significant (Adjusted R2 0.18). Variables making a significant contribution to the equation
were body esteem and body dissatisfaction. Finally, for
control girls the regression equation was significant (Adjusted R2 0.13). The only variable to make a significant
contribution to the equation was body dissatisfaction.
Discussion. Children with CF had very similar body
esteem and general self-esteem as controls. A consideration of body image constructs does reveal group differences between perception and satisfaction with body size
between groups. Children with CF were more likely to
perceive their body size as larger than it actually was and
have greater satisfaction with their current body size in
contrast to control children. The girls and boys with CF
with a higher BMI frequently selected a smaller body
size as their ideal. Control children displayed a large
degree of body dissatisfaction, selecting an ideal figure
smaller than their own and the desire to be thinner.
Given the likely positive health consequences of being
larger, it is encouraging that children with CF are not
adopting the desire to be thinner, widely held by their
healthy peers. However, this may be attributable to the
fact that CF children are thinner than average and so fit
the prevailing body shape ideal. These analyses do not
support the prediction that more girls with CF would be
satisfied with their body size compared with boys but do
provide information of clinical importance as it indicates
that some children with CF, although perceiving themselves to be thin, do not necessarily wish to be any fatter
and they may not be motivated to eat the high-energy
diet recommended. Clinicians need to be aware of the

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possibility that medical targets for growth for individuals may not be in concordance with their desires and
determining the childs point of view may be helpful in
identifying an appropriate individual intervention. The
finding that body dissatisfaction is an independent predictor of nutritional status (BMI) in controls and girls
with CF suggests childrens own concepts of their body
size is important. Encouraging positive body and selfesteem and focusing attention away from weight gain
and more toward achieving optimum growth may be a
useful strategy for clinicians working with this population. Pediatrics 2001;107(6). URL: http://www.pediatrics.
org/cgi/content/full/107/6/e92; cystic fibrosis, nutrition,
body image, dieting.
ABBREVIATIONS. CF, cystic fibrosis; RCH, Royal Childrens
Hospital; SD, standard deviation; FEV1, forced expiratory volume
in 1 second; BMI, body mass index; CBIS, Childrens Body Image
Scale; DEBQ-R, Dutch Eating Behavior Questionnaire-Restraint
Scale; ChEAT, Childrens Eating Attitudes Test.

ife expectancy is improving in individuals with

cystic fibrosis (CF).1,2 This improvement is attributed to enhanced clinical interventions, one
of which is a greater emphasis on adequate nutritional status.3,4 Although health outcomes have improved, there is a marked discrepancy between life
expectancy in males and females.57 The reason for
this is unknown, but physiological risk factors explored to date do not adequately explain this discrepancy.6,8 Gender differences in body image and
related dietary restraint, explored in the present
study, may contribute psychological differences affecting clinical outcome.
In healthy females there is strong social pressure to
be thin,9 which is reflected in widespread dietary
restraint, high body dissatisfaction, and high frequency of disordered eating in adults and in adolescents.10 13 Pressure to conform to this aesthetic ideal
is supported by public health messages encouraging
the prevention of obesity.14 16 Body image concerns
and potentially unhealthy weight loss behaviors are
increasingly being observed in younger children, especially girls,1720 and the cultural preference for the
thin body build is internalized in childhood.21 Female children with CF are likely to be exposed to the
same social pressures to desire a thin body size and
to fear becoming fat. This may conflict with the need
of children with CF to consume a high-energy and
high-fat diet. Previous research indicates that there is
a significant negative correlation between a CF
childs weight and whether his or her mother was
successfully dieting, suggesting the possibility that a
mothers weight concerns may be reflected in the
food consumption of her child.22 To assist in the
nutritional management of children with CF, it
would, therefore, be valuable to understand the attitudes, of girls particularly, to body size and dietary
restraint, and the frequency of disordered eating.
Few studies have examined body image or disturbed eating in children with CF. Behavioral eating
problems during childhood and adolescents have
been reported.2326 One recent study indicated the
potentially important contribution of body image
concerns to inadequate nutritional status in girls.27
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This study compared body esteem, eating attitudes,

and daily caloric intake of 15 females with CF (8 15
years of age) and 15 age-matched healthy controls.
Although on average CF girls in this sample wanted
to weigh slightly more than they did (in contrast to
the control participants), the heavier CF girls did
desire to lose weight and had decreased caloric intake, potentially compromising their health.
More recently, Abbott et al28 reported that healthy
females and female CF patients perceived their body
size as less than it actually was and desired to be
slimmer, whereas male CF participants desired to be
heavier. These data do suggest the need for more
comprehensive research in this area in children with
CF and influences on body perception, satisfaction,
and issues with eating.
Somewhat more research into eating attitudes has
been conducted in groups including adolescents and
adults with CF. Pearson et al29 found that 16.4% of
children 8 to 15 years of age were in the symptomatic
range for disordered eating on the Eating Attitudes
Test.30 However, eating disorder symptoms may
have been confounded with gastrointestinal CF
symptoms and this was not clarified by interview.
Pumariega et al31 (1986) observed that 12% of their
12- to 21-year-old CF patients had atypical eating
patterns. Boyle et al32 observed that their entire sample of 27 adolescent and adult CF patients reported
dissatisfaction with their bodies. These studies do
indicate that for some adolescents and adults, body
image concerns and disturbed eating are issues,
which could influence nutritional status.
In summary, this study aims to examine the relationship between pulmonary function, nutritional
status, body image, and eating attitudes in male and
female children with CF between 7 and 12 years of
age. In addition, it aims to compare attitudes of
children with CF with a healthy control group.
METHODS
Participants
Children With CF
Approval was initially gained to conduct this study from the
Royal Childrens Hospital (RCH) Human Research Ethics Committee. All children with CF between 7 and 12 years of age were
identified from the RCH CF database. The RCH provides a clinical
service to all children with CF in the State of Victoria, Australia,
regardless of insurance status. Exclusion criteria were: severe liver
disease, CF-related diabetes, and/or the presence of gastrostomy
tube. A total of 102 children with CF were identified as eligible to
enter the study. Of these, 19 were not seen at RCH during the
6-month study, and 5 were transferred to other centers. All potential participants were invited to participate when they attended
their routine clinic appointment and active informed consent was
obtained from parents and children. Although all parents agreed
to participate, 2 children did not. Therefore, 76 children with CF,
97% of those available, completed the interview, which was conducted by the first author or a trained interviewer during their
routine clinic visit. The sample consisted of 39 girls (mean age: 9.8
years; standard deviation [SD]: 1.7) and 37 boys (mean age: 9.9
years: SD: 1.6). Girls and boys did not differ significantly on mean
forced expiratory volume in 1 second (FEV1; % of predicted)
(girls FEV1 [% of predicted] 84.9%; SD: 3.5; boys mean FEV1
[% of predicted] 78.9%; SD: 22.6; t 0.13, not significant).

Controls
Control children were recruited from 2 metropolitan primary
schools, 1 from a low-medium and the other from a medium-high

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socioeconomic area. All children in Grades 2 to 6 who attended the

schools were invited by letter to participate in the study. Written
informed consent was obtained from a parent/guardian before
the study took place. All children for whom consent was available
and who were present on the days of the study were interviewed
(n 159; 45% from low-medium school and 55% from mediumhigh school). Four children were excluded because, on interview,
they reported being on a special diet (eg, diabetic or allergy) and
2 were excluded because of comprehension difficulties. The total
control group consisted of 153 children, 82 girls (mean age: 9.2
years; SD: 1.8) and 71 boys (mean age: 9.3 years; SD: 1.7).

Procedures
The assessment instruments described below were administered by interview by dietitians trained in 1 to 1 interviewing. The
interview was conducted in a quiet interview room during school
hours, each interview taking 25 minutes. Care was taken to
ensure the child that their answers would be known only to the
interviewer, this was not a test, there were no right or wrong
answers, and that we were only interested in their honest responses. The interviewer also checked that the child understood
the question if there seemed to be doubt or hesitation. This was
particularly important in the assessment of eating behaviors,
where, for example, some eating behaviors may have occurred
because of illness rather than weight preoccupations.

Assessment Instruments
Pulmonary Function in Children With CF
FEV1 (% of predicted) was used as an indication of pulmonary
function and measured at the time of interview during their
routine clinic visit by a trained technician using Quanjers method.33

naire-Restraint Scale (DEBQ-R).39 This is a 10-item scale that assesses a persons degree of involvement in weight control and
dieting behaviors on a 5-point Likert scale and has previously
been successfully used in children.17 A high score indicates more
restraint in eating. Cronbachs for this sample was 0.89. Participants who responded positively to the first question regarding a
previous weight loss attempt or responded positively to dieting
items on the DEBQ-R were also given the Childrens Eating Attitudes Test (ChEAT). This 26-item test assesses disordered eating
symptoms and has been found to be a valid and reliable measure
in children.40,41 The ChEAT is not a diagnostic instrument, a
higher score indicates more behaviors associated with dieting and
a score above 20 is suggestive of anorexic symptomatology. Cronbachs for the 58 participants given the ChEAT in this sample
was 0.77.

Self-Esteem
Global self-esteem was measured using a validated 5-item childrens version of the Rosenberg Self-Esteem Scale.35 First, it assesses general over arching feelings toward themselves by asking
a series of general questions. Everybody has some things about
them that are good and bad. Are more things said about you that
are good, bad, or both about the same? A reply of good scores 0,
both about the same scores 1, and bad scores 2. Specific qualities
are then investigated such as feelings of being good at things.
Respondents are asked the question, Do you ever feel youre not
much good at things? A negative reply scores 0 and a positive
reply scores 1. Respondents are then asked how often they feel
that way: some of the time (2), most of the time (3), or all of the
time (4), thereby rating responses according to the degree of
feelings. The scores are then summed. A low score indicates that
the person considers himself or herself to be a person of worth,
and a high score would indicate some degree of self-rejection or
dissatisfaction. Cronbachs for this sample was an adequate 0.67.

Body Mass Index (BMI)

All children were weighed and measured in private with the
child in light clothing but without shoes. Height was measured
using a portable stadiometer (accurate to 0.1 cm) in the school
setting and in the hospital using a Holtain wall-mounted stadiometer (accurate to 0.1cm). Weight, using digital scales (accurate
to 0.01 kg), was recorded at the same time. BMI (weight in kg/
height in m2) was calculated and converted to percentiles using
standards of the National Center for Health Statistics.34

Body Size Perception and Body Satisfaction

Four measures were used to assess body image. The first was
the 24-item Body Esteem Scale, which is reliable in children as
young as 7 years old.35 Cronbachs for the present sample was
0.84. The second measure was the Childrens Body Image Scale
(CBIS) developed by the authors. This scale was based on body
silhouette scales used previously to assess body image in children
and found to have strong psychometric properties36 in which a
child is presented with a series of body figures ranging from very
thin to obese and asked to identify which body size is most like
their own and which they would most like to be.37 The discrepancy between these 2 images provides an indication of body
dissatisfaction (CBIS body dissatisfaction). The CBIS differs
from other scales of this type in that the body figures are based on
photographs of prepubescent children of known BMI. The photographs have been digitally altered to standardize facial and other
distinguishing features, but being based on photographic images,
they are more realistic.38 (Additional information regarding this
measure and its scale properties is available from the first author.)
Body size satisfaction was measured by the response to the questions, Do you think your body is: 1) much too thin, 2) too thin, 3)
just right, 4) too fat, or 5) much too fat? Body weight satisfaction
was measured by the response to the question, Would you like
your body to be: 1) much thinner, 2) a little bit thinner, 3) stay the
same, 4) a little bit fatter, or 5) much fatter?

Dieting Behaviors
Dieting behaviors were assessed in a 3-step process. First, children were asked, Have you ever tried to lose or gain weight? If
the answer was that they had tried to lose weight, they were asked
why they had done so and how they had attempted to lose weight.
Second, children were given the Dutch Eating Behavior Question-

Statistical Analysis
Data were analyzed using SPSS, Version 10 software (SPSS,
Chicago, IL). Cronbachs was used to provide details on the
reliability of each scale and the internal consistency for this particular sample. BMI percentile was achieved by assigning the
individual to the closest BMI percentile using growth standards of
the National Center for Health Statistics and the median value is
presented to express central tendencies. Where BMI percentile
group has been used as interval data, the Mann-Whitney U statistic has been used to compare differences in ranks. Two-way
analysis of variance has been used to explore relationships between continuous variables in the normally distributed data. Because nutritional status is an important outcome measure in CF,
multiple regression analysis was used to predict BMI using a
range of factors previously identified in the literature as contributing to nutritional outcome in CF. Significance was defined as
P .05.

RESULTS
BMI and Pulmonary Function in Children With CF

The median BMI for the CF group (n 76) was 25

(range: 590). The median BMI percentile for the
control group (n 153) was 50 (range: 5105). To
explore gender differences in BMI percentiles a
Mann-Whitney U test was used. This showed that
both girls (Z 4.19; P .01) and boys (Z 5.83;
P .01) with CF had significantly reduced BMI
percentiles compared with control children. Boys
with CF did not have a significantly different BMI
compared with girls with CF (Z 1.80; P .07).
This supported previous findings.42 To confirm previous observations in children with CF, the relationship between FEV1 (% of predicted) and body size
was examined. As anticipated, there were significant
positive correlations between FEV1 (% of predicted)
and BMI percentile in girls (r 0.35; P .016) and
boys (r 0.50; P .006) with CF.

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Body Image

Body image perceptions in boys and girls with CF

were examined in relation to the healthy control
group using 2 (CF and control groups) by 2 (male
and female) analysis of variance. The interaction effect was examined to explore the prediction that girls
compared with boys with CF would have greater
acceptance of their body shape and less desire to
become larger. As can be seen in Table 1, there were
no differences between groups or sex in body esteem. On the CBIS body dissatisfaction score, children with CF were significantly more likely to perceive their ideal body size as a little larger than their
current size, whereas control children desired a
smaller body size than their current size. CF children
had a significantly lower mean score for body size
satisfaction (an item assessing perception being too
thin) and a significantly higher mean score on body
weight satisfaction. There was a significant main effect of gender for only 1 measure, difference between
the CBIS body dissatisfaction score, with girls
being more likely to nominate a smaller ideal than
their current figure. There were no significant interaction effects.
Body Size Perception

Because children with CF have an elevated health

risk associated with small body size, aspects of body
size perception in relation to actual body size are
important to assess. Of the girls with CF who were at
or below the 50th BMI percentile, 50% selected an
ideal CBIS body size of equal or thinner than their
own, 46% reported believing themselves to be just
right or too fat, and 54% would like to stay the same
or be thinner. Twenty-five percent of the girls with a
low BMI (at or below the 10th percentile) thought
that they were too thin and 19% would have liked to
be fatter. Of boys at or below the 50th BMI percentile,
52% selected an ideal body size the same as or thinner than their own, 49% reporting that they were too
thin or just right, and 54% stated that they would like
to be thinner or stay the same size. Thirty-eight percent of boys with a low BMI (at or below the 10th
percentile) acknowledged that they were too thin
and 32% wished to be fatter.
Dieting and Disordered Eating

As indicated in Table 1, a 2 (groups) by 2 (gender)

analysis of variance indicated that there was a significant main effect of group on the DEBQ-R measure

of dietary restraint, with CF children having significantly lower scores. There was no main effect of
gender or interaction effect.
Of CF children, only 1 (3%) girl and 3 (8%) boys
said that they had ever tried to lose weight, whereas
66% of girls and 81% of boys with CF reported ever
having tried to gain weight. Of control participants,
20% of girls and 15% of boys reported ever having
tried to lose weight, whereas 11% of girls and 13% of
boys reported ever having tried to gain weight. The
ChEAT was only given to these children and those
who described some weight loss concerns on the
DEBQ-R (CF, n 13; control, n 45). Of those
children with CF given the ChEAT, none obtained a
score of 20 (range: 0 14), the cutoff for clinical
significance in children. Of control children given the
ChEAT, 6 obtained scores above the cutoff (range:
133; 4.0% of total control sample), 5 girls (6% of
girls) and 1 boy (1%).
Predictors of BMI

To examine predictors of BMI, a multiple regression analysis was conducted separately for boys and
girls with CF and control boys and girls in which the
dependent variable was BMI and the independent
variables were FEV1 (% of predicted; in CF children
only), body esteem, self-esteem, and body dissatisfaction score. In the case of boys with CF, the regression equation was significant (F 4.26; df 4,30; P
.0008; R2 0.38; Adjusted R2 0.30). None of the
variables made a significant independent contribution to the equation (body esteem, P .106; FEV1,
P .132; body dissatisfaction, P .194; self-esteem,
P .106). In the case of girls with CF, the regression
equation was significant (F 4.08; df 4,25; P
.008; R2 0.33; Adjusted R2 0.25). The variable
making a significant contribution to the equation
was body dissatisfaction (B 5.8; standard error
2.01; 0.31; t 2.84; P .006). In the case of
control boys, the regression equation was significant
(F 6.23; df 3,65; P .001; R2 0.22; Adjusted
R2 0.18). Variables making a significant contribution to the equation were body esteem (B 2.10;
standard error 0.91; 0.34; t 2.29; P
.025) and body dissatisfaction (B 5.7; standard
error 2.02; 0.321; t 2.82; P .006). Finally, for
control girls the regression equation was significant
(F 4.84; df 3,78; P .004, R2 0.16; Adjusted R2
0.13). The only variable to make a significant contribution to the equation was body dissatisfaction

TABLE 1.
Means and SDs (in Brackets) for Body Esteem, Body Satisfaction and Dissatisfaction, Dieting, and Self-Esteem Measures for
Girls and Boys With CF and the Healthy Control Group, and F Values for Group, Sex, and Group Sex Interaction From Analyses of
Variance

Body esteem
CBIS: body dissatisfaction
Body size satisfaction
Body weight satisfaction
DEBQ-R
Self-esteem

CF
Girls

Group
Boys

Control
Girls

Group
Boys

F
Group

F
Sex

F
Group
Sex

17.50 (0.72)
0.13 (0.23)
2.76 (0.11)
3.20 (0.66)
1.38 (0.13)
3.5 (0.46)

18.49 (0.73)
0.53 (0.24)
2.54 (0.11)
3.30 (0.62)
1.27 (0.13)
3.14 (0.47)

17.93 (0.49)
0.79 (0.16)
3.10 (0.07)
2.56 (0.69)
2.02 (0.08)
3.12 (0.32)

19.24 (0.53)
0.33 (0.17)
2.96 (0.08)
2.79 (0.65)
1.92 (0.09)
2.76 (0.34)

0.34
19.40**
15.40**
36.82**
34.15**
0.87

0.07
4.53*
2.89
3.21
0.94
0.81

0.79
0.87
0.48
0.41
0.00
0.00

* P .05; ** P .001.

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(B 0.58; standard error 2.01; 0.316; t 2.84;

P .006).
DISCUSSION

In confirmation of previous studies, these data

indicate that children with CF tend to be nutritionally compromised compared with healthy control
children. Girls with CF were not more nutritionally
compromised than boys, suggesting that at this age
at least, a difference in nutritional status does not
account for the poorer long-term survival of girls
with CF. It has been documented that gender differences in nutritional deficits are observed during the
adolescent years and do occur more frequently in
females.43 Because this study examines children from
7 to 12 years of age, it may be reasonable to assume
that differentiating paths of nutritional status occur
after the age of 12 years. These data provide additional support for the contention that good nutrition
and growth are important to health in children with
CF, BMI percentile being positively correlated with
FEV1 (% of predicted) in both girls and boys with CF.
Although correlational data of this kind cannot be
assumed to denote cause, this consistently observed
relationship does suggest that every effort should be
made to encourage a high-energy intake from an
early age. Certainly, a low BMI has a significant
negative influence on outcome after transplantation
and achieving and maintaining a good nutritional
status is worthy of much endeavor.44
The CF group in this study, despite their chronic
illness, had very similar body esteem and general
self-esteem to their healthy counterparts. It is notable
that the children with CF were not suffering from
acute illness at the time of the study and sick children
may feel differently, but this finding is very positive
in light of the difficulties many of them endure because of physical ill health. It is likely that positive
self-attitudes are adaptive, enabling children to get
on with life. As age increases, children with CF may
become more aware that they are in a different position from other children, but starting with a positive view of themselves and their bodies is likely to
reduce adverse psychological effects later.
Body image is widely thought to consist of 2 interacting constructs: perception and satisfaction with
body size. A consideration of body image does reveal
group differences between perception and satisfaction with body size between groups. Children with
CF were more likely to perceive their body size as
larger than it actually was and to have greater satisfaction with their current body size in contrast to
control children. The girls and boys with CF with a
higher BMI frequently selected a smaller body size as
their ideal. This is consistent with the findings in
adolescent girls27 and adults with CF.28 Control children displayed a large degree of body dissatisfaction,
selecting an ideal figure smaller than their own and
desiring to be thinner. Given the likely positive
health consequences of being larger, it is encouraging that, on average, children with CF are not adopting the desire to be thinner, widely held by their
healthy peers. Although it is possible that this is in
part attributable to being responsive to the advice of

family and health professionals encouraging a larger

body size in children with CF, this is not the most
probable explanation. It is more likely that this is
attributable to the fact that CF children are thinner
than average and so fit the prevailing body shape
ideal. These analyses do not support the prediction
that more girls with CF would be satisfied with their
body size but do provide information of clinical importance because it indicates that some children with
CF, although perceiving themselves to be thin, do
not necessarily wish to be any fatter. However, more
boys than girls in the lower BMI percentiles wished
to gain weight and would have chosen to be fatter,
which is a helpful attitude. Identifying these individuals for more intensive nutritional counseling may
prove an effective use of resources and, in particular,
dietetic time.
The finding that an important minority of children
with CF selected an ideal body size smaller than their
own or were content to stay the same size has clinical
implications. These children may not be motivated to
eat the high-energy diet recommended. Clinicians
need to be aware of the possibility that medical targets for growth for individuals may not be in concordance with their desires and determining the
childs point of view may be helpful in identifying an
appropriate intervention for the individual. The finding that body dissatisfaction is an independent predictor of nutritional status in controls and in girls
with CF suggests that childrens own concepts of
their body size is important. Encouraging positive
body esteem and self-esteem and focusing attention
away from weight gain and more toward achieving
optimum growth may be a useful strategy for clinicians working with this population.
In this study, there was a significant gender effect
in the difference between perceived and ideal body
size with the mean difference being greater in girls
(ie, the ideal being thinner than the perceived) than
in boys; however, there was no significant interaction, girls and boys with CF not differing significantly on this measure. In the 2 items assessing body
size and weight satisfaction, there were no gender or
group by gender interactions. Therefore, along with
the failure to find a BMI percentile difference, there
was no indication in this study that a greater desire
to be thinner in girls than in boys with CF is contributing to poorer health outcomes.
No children with CF had eating disorder symptoms as indicated by ChEAT. Again, the fact that
these children tend to be thin may contribute to this.
Previous studies in children and adolescents with CF
have reported the presence of eating disorder symptoms.29,31 The discrepancy in findings may be attributable to the data collection methods used. In this
study, the measure of eating disorder symptoms was
delivered in an interview format, which allowed the
clarification of CF-related symptoms compared with
intentional eating disorder/weight control behaviors. For example, one question on the ChEAT asks
the number of occasions that vomiting after eating
occurs. Children and adolescents may not be able to
make a clear distinction between these in a written
questionnaire and there is potential for confusion.

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Disordered eating is observed in younger children

but less frequently than in adolescents. It may be that
some girls with CF may develop frank eating disorder in later years.
It is notable that 6% and 1% of control girls and
boys, respectively, scored above the ChEAT cutoff
for disordered eating symptomatology. This is consistent with previous studies and demonstrates that
we can no longer assume that disordered eating is an
adolescent problem.17,18 Rather, clinicians seeing
children must be alert to the possibility that these
problems may develop in childhood.
This study is one of the first to examine body
image and eating issues in children with CF.
Strengths of the study are the relatively large sample
size of children with CF and the use of interview
presentation of questionnaires, which reduces misinterpretation. However, there are a number of methodological limitations. Self-report has been used and
it was not possible to obtain supporting observer
ratings. Consequently, children may have been giving socially desirable responses. It is also unclear,
without replication, the extent to which data from
this sample may be generalized to other samples.
However, in light of these cautions, this study does
indicate that in children with CF without acute disease, body esteem is comparable with healthy control
children. There is no support for the hypothesis that
girls with CF in this age group will have lower BMI
percentiles than will boys with CF, or that they will
have a greater desire to be thinner than they are.
However, the data do indicate that some children
with CF desire a thinner body size or are content to
stay the same size, which could undermine motivation to comply with a high-energy diet. Clinicians
working with nutritional issues in children with CF
need to be aware of this possibility.

9.
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25.

ACKNOWLEDGMENTS
This work was supported by Australian Research Council and
Royal Childrens Hospital project grants. H.T. was supported by a
National Health and Medical Research Council Scholarship.
We thank dietitians Joanne Boehme, Jodie Bond, Alexia
OCallaghan, and Anna Redshaw for their assistance with interviewing the children; Drs P. Phelan and A. Catto-Smith for critical
review of the study proposal; and Drs Lyndal Bond and Roger
Howland for statistical advice.

26.

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Body Image and Dieting Behavior in Cystic Fibrosis

Helen Truby and Susan J. Paxton
Pediatrics 2001;107;e92
DOI: 10.1542/peds.107.6.e92
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright 2001 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Body Image and Dieting Behavior in Cystic Fibrosis

Helen Truby and Susan J. Paxton
Pediatrics 2001;107;e92
DOI: 10.1542/peds.107.6.e92

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
/content/107/6/e92.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

publication, it has been published continuously since 1948. PEDIATRICS is owned,
published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point
Boulevard, Elk Grove Village, Illinois, 60007. Copyright 2001 by the American Academy
of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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