Structure analysis of the Children's Eating Attitudes Test in overweight and at-risk for overweight children and adolescents

Article (PDF Available)inEating Behaviors 9(2):218-27 · May 2008with47 Reads
DOI: 10.1016/j.eatbeh.2007.09.004 · Source: PubMed
Abstract
In school-based samples of children, the Children's Eating Attitudes Test (ChEAT) has a four-factor structure; however, previous studies have not examined its factor structure in samples restricted to overweight youth. The ChEAT was administered to 220 overweight (BMI>or=95th percentile) and 45 at-risk for overweight (BMI 85th-<95th percentile) children and adolescents. Factors were identified by a principal component analysis with varimax rotation. ChEAT factor scores of children with BMI>or=85th percentile were contrasted with those of 152 non-overweight (BMI 5th to <85th percentile) children and adolescents. Factor analysis generated four subscales described as 'body/weight concern,' 'food preoccupation,' 'dieting,' and 'eating concern.' ChEAT total score, body/weight concern, and dieting subscale scores were positively related to BMI-Z and body fat mass (p's<.05). Compared to non-overweight children, overweight and at-risk for overweight children had higher ChEAT total (9.9+/-7.4 vs. 6.6+/-7.8, p<.001), body/weight concern (3.2+/-3.1 vs. 1.3+/-3.0, p<.001), and dieting (1.8+/-2.2 vs. .8+/-2.3, p<.001) subscale scores. The previously elucidated factor structure of the ChEAT was primarily supported in a sample of overweight children. The emergence of separate body/weight concern and dieting subscales may relate to these children's experiences with attempted weight reduction.

Figures

Structure analysis of the Children's Eating Attitudes Test in
overweight and at-risk for overweight children and adolescents
Lisa M. Ranzenhofer
a
, Marian Tanofsky-Kraff
a,b
, Carolyn M. Menzie
a
,
Jennifer K. Gustafson
a
, Margaret S. Rutledge
a
, Margaret F. Keil
a
,
Susan Z. Yanovski
a,c
, Jack A. Yanovski
a,
,1
a
Unit on Growth and Obesity, Developmental Endocrinology Branch, NICHD, National Institutes of Health, DHHS, Hatfield CRC, 10 Center Dr.,
Rm 1-3330 MSC-1103, Bethesda, MD 20892-1103, USA
b
Department of Medical and Clinical Psychology, Uniformed Services University of the Health Sciences, 4301 Jones Bridge Rd,
Bethesda, MD 20814-4712, USA
c
Division of Digestive Diseases and Nutrition, NIDDK, NIH, DHHS, 6707 Democracy Blvd., Rm 675, Bethesda, MD 20892-5450, USA
Received 28 March 2007; received in revised form 7 August 2007; accepted 12 September 2007
Abstract
Background: In school-based samples of children, the Children's Eating Attitudes Test (ChEAT) has a four-factor structure;
however, previous studies have not examined its factor structure in samples restricted to overweight youth.
Methods: The ChEAT was administered to 220 overweight (BMI 95th percentile) and 45 at-risk for overweight (BMI 85thb 95th
percentile) children and adolescents. Factors were identified by a principal component analysis with varimax rotation. ChEAT factor
scores of children with BMI 85th percentile were contrasted with those of 152 non-overweight (BMI 5th to b 85th percentile)
children and adolescents.
Results: Factor analysis generated four subscales described as body/weight concern,’‘food preoccupation,’‘dieting, and eating
concern. ChEAT total score, body/weight concern, and dieting subscale scores were positively related to BMI-Z and body fat mass
( p'sb .05). Compared to non-overweight children, overweight and at-risk for overweight children had higher ChEAT total (9.9±7.4 vs.
6.6 ± 7.8, pb .001), body/weight concern (3.2±3.1 vs. 1.3±3.0, pb .001), and dieting (1.8±2.2 vs. .8±2.3, p b .001) subscale scores.
Conclusions: The previously elucidated factor structure of the ChEAT was primarily supported in a sample of overweight children.
The emergence of separate body/weight concern and dieting subscales may relate to these children's experiences with attempted
weight reduction.
Published by Elsevier Ltd.
Keywords: Obesity; Child; Eating behaviors; Methodology; Eating attitudes
A
vailable online at www.sciencedirect.com
Eating Behaviors 9 (2008) 218 227
Corresponding author. Tel.: +1 301 496 0858; fax: +1 301 402 0574.
E-mail address: jy15i@nih.gov (J.A. Yanovski).
1
J. Yanovski is a commissioned officer in the United States Public Health Service, DHHS.
1471-0153/$ - see front matter. Published by Elsevier Ltd.
doi:10.1016/j.eatbeh.2007.09.004
1. Introduction
Disturbed eating attitudes and behaviors are more common among overweight than healthy weight youth
(Neumark-Sztainer, Story, Hannan, Perry, & Irving, 2002; Tanofsky-Kraff et al., 2004). The increased prevalence of
overweight among youth (Ogden et al., 2006), and findings that disordered eating patterns, including binge eating and
self-reported dieting, prospectively predict excessive weight and fat gain among children and adolescents (Field et al.,
2003; Stice, Cameron, Killen, Hayward, & Taylor, 1999; Stice, Presnell, & Spangler, 2002; Tanofsky-Kraff et al.,
2006), underscore the importance of identifying measures that assess eating pathology in overweight youth.
Although the structured clinical interview is considered the optimal approach for the assessment of individuals with
eating disordered pathology (Bryant-Waugh, Cooper, Taylor, & Lask, 1996; Wilfley, Schwartz, Spurrell, & Fairburn,
1997), questionnaire methodology is often employed because of its brief, economical (Garner, 2002), and easily
administered (Kashubeck-West, Mintz, & Saunders, 2001) format that allows data to be collected from large samples.
Another potential advantage is that questionnaire methodology may be less susceptible to interviewer bias because it
does not require interviewer/participant interaction (Garner, 2002).
A commonly used, brief, self-report questionnaire to assess disordered eating attitudes among children is the
Children's Eating Attitude Test (ChEAT) (Maloney, McGuire, & Daniels, 1988). Examinations of the psychometric
properties of the ChEAT in previous studies have found good internal consistency, with Cronbach's α values in the
range of .71.87 ( Maloney et al., 1988; Sancho, Asorey, Arija, & Canals, 2005; Smol ak & Levine, 1994) and adequate
to good testretest reliability, with reliability correlations ranging between .56 and .81 (Maloney et al., 1988; Sancho
et al., 2005). Concurrent validity has been established in that ChEAT scores have significant, positive correlations with
weight management behavior (r = .36, p b .001), and body dissatisfaction (r = .39, p b .001) (Smolak & Levine, 1994)
and have significant negative correlati ons with subscales from the Body Areas Satisfaction Scale that measure
satisfaction with distinct body areas or aspects (Cash, 1997; Sancho et al., 2005).
Four separate studies of unselected school-aged children have performed exploratory factor analyses of the ChEAT,
each of which reported the emergence of four factors. In a sample of 308 sixth through eighth grade girls, four factors
collectively explained 52.1% of variance (Smolak & Levine, 1994). A Catalan adapted version of the ChEAT in a Spanish
sample of 1336 fifth and sixth grade boys and girls also reported four factors which, taken together, explained 49.4% of
variance (Sancho et al., 2005). In a third study, separate subscales were determined for boys and girls in 228 second
through fourth graders (Kelly, Ricciardelli, & Clarke, 1999). Results of a later factor analysis among 225 fifth through
eighth grade girls generally supported Kelly's findings for girls (Ambrosi-Randic & Pokrajac-Bulian, 2005). A
commonality among previous factor analyses is the emergence of factors related to dieting, food preoccupation,
restricting/purging, and oral control, the latter of which is also referred to as social pressure to eat. In a later study of
second through sixth grade participants, Anton et al. (2006) conducted both exploratory and confirmatory factor analyses
to identify six ChEAT factors, three of which generated sufficient internal consistency using a Cronbach's α cutoff of .70.
Although children within this sample were not overweight, the fact that they elected to participate in a two year obesity
prevention trial may have rendered these children more health conscious and/or having a heightened concern about the
risk of becoming overweight than other children their age. Despite variation in the factor labels, emergent subscales on
each of these factor analyses reflect similar groupings of ChEAT items. Findings from two additional studies using solely
confirmatory factor analysis in school-based samples have generally supported the commonalities noted among previous
factor analyses of the ChEAT (Lynch & Eppers-Reynolds, 2005; Sinton & Birch, 2005).
Research on the relationship betw een total ChEAT scores and BMI among children is inconclusive. Several studies
have found higher ChEAT scores among heavier children (McVey, Tweed, & Blackmore, 2004; Morgan, Tanofsky-
Kraff, Wilfley, & Yanovski, 2002; Rolland, Farnill, & Griffiths, 1997). However, the only prospective study that
examined the relationship between overall ChEAT score and fat gain over time among a sample of children (6
12 years) at risk for adult obesity, found no effect of ChEAT score on subsequent fat gain (Tanofsky-Kraff et al., 2006).
To our knowledge, no study has examined the relationship between potential ChEAT subscale scores and BMI, among
normal weight or overweight children.
Thus, the objectives of the current study were to examine the factor structure of the ChEAT in overweight youth, and
to determine whet her the identified factors were meaningful in terms of their relationships with body weight and fat
mass. We hypothesized that the factor structure elucidated by previous analyses would be upheld in a sample of
overweight and at-risk for overweight participants, and that the factors identified would be positively correlated with
children's body mass index (BMI; kg/m
2
) and total body fat mass.
219L.M. Ranzenhofer et al. / Eating Behaviors 9 (2008) 218227
2. Methods
2.1. Subjects
Children and adolescents, age 618 years, were recruited through newspaper advertisements and mailings to families and
physicians for studies of the physiological, metabolic, and molecular bases of childhood obesity. Participants were recruited as
healthy volunteers (Anon, 1994) for investigations of the natural history of weight gain (Anon, 1996) and for weight reduction trials
involving medication (Anon, 2005a,b). According to the CDC recommendation (Ogden et al., 2002), a BMI between the 5th through
85th percentile is considered normal weight. All but thirteen children in the non-overweight group had a BMI between the 15th and
85th percentile. Children whose BMI percentiles were lower than the 15th percentile did not differ on any demographic variable
from the rest of the non-overweight children, except that there were significantly more girls in this subset (Fisher's exact pb .01);
however inclusion of these children did not alter the analyses. At-risk for overweight children between the BMI 85thb 95th
percentile, and overweight children (BMI 95th percentile) were also studied. Inclusion and exclusion criteria have been previously
described for treatment-seeking (McDuffie et al., 2002) and non-treatment-seeking (Tanofsky-Kraff et al., 2004). These studies were
approved by the National Institute of Child Health and Human Development Institutional Review Board. Each child provided
written assent, and a parent gave written consent, for protocol participation.
2.2. Measures
All measures were completed during an outpatient clinic visit to the NIH. Treatment-seeking participants completed all
questionnaires prior to initiation of any treatment. For all children aged seven and younger, and in cases where children had difficulty
reading or understanding the questions, trained research assistants read the questions aloud and provided simple alternative
definitions for words and statements that were not understood.
The Children's Eating Attitudes Test (ChEAT) is a 26-item measure that examines eating and dieting attitudes and behaviors.
Example questions include, I am terrified of being overweight,”“I eat diet foods, and, I stay away from foods with sugar in them.
Children are asked to rate the frequency of each attitude or behavior on a 6-item Likert scale, with answers to each question ranging
from Never (1) through Always (6). The ChEAT was modified from the original adult Eating Attitudes Test (EAT-26; Garner,
Olmsted, Bohr, & Garfinkel, 1982) that examines adults' and adolescents' eating attitudes and behaviors, with several items adapted
to make the measure more easily understood by children. Validity testing of the ChEAT confirms recoding scores such that the least
three symptomatic answers (never, rarely, sometimes) are recoded as 0, with often = 1, usually = 2, and the most symptomatic score,
always, coded as 3 (Maloney et al., 1988). Thus, the total ChEAT score may range from 0 to 78.
The Three-Factor Eating Questionnaire (TFEQ; Stunkard & Messick, 1985), is a 51-item questionnaire designed to assess three
dimensions of human eating behavior: restraint, disinhibition, and hunger. The TFEQ is a validated measure that has demonstrated
stable testretest reliability (Bond, McDowell, & Wilkinson, 2001). To assess general depressive symptoms, children completed the
Children's Depression Inventory (CDI; Kovacs, 1992), a validated 27-item measure that assesses depressive symptomatology in
children. Internal consistency for the CDI has been demonstrated to fall in the range of .70.86 for the overall measure (Kovacs,
1985). Anxiety was assessed via the State-Trait Anxiety Inventory for Children (STAIC; Spielberger, Edwards, Lushene, Montuori,
& Platzek, 1973), a 40-item self-report measure of immediate and general anxiety. The STAIC was developed for use with
elementary school children, and both forms were shown to have good internal consistency with Cronbach's α values between .78
and .87, for both boys and girls. Children's parents completed the Child Behavior Checklist for ages 418 (CBCL; Achenbach &
Elderbrock, 1991), an empirically derived measure with excellent norms that assesses a range of internalizing and externalizing
behavioral symptoms and which yields age-appropriate T-scores for each of these scales. The CBCL has demonstrated sufficient
reliability and internal consistency.
Children's heights were measured three times to the nearest millimeter by a calibrated electronic stadiometer (Holtain, Crymych,
Wales), and weights were measured to the nearest 0.1 kg by a calibrated digital scale (Scale-Tronix, Wheaton, IL). Body weight and
the average of three heights were used to calculate BMI. BMI standard deviation scores (BMI-Z) were calculated according to the
Centers for Disease Control and Prevention 2000 formula for boys and girls. Body fat mass was measured by dual energy X-ray
absorptiometry (DXA; Hologic QDR2000 or QDR4500A, Bedford, MA), according to the manufacturer's instructions and
procedures as previously described (Ellis, Shypailo, Pratt, & Pond, 1993; Robotham et al., 2006).
2.3. Statistical analysis
All analyses were conducted using SPSS for Windows, 12.0 (SPSS, Inc., Chicago, IL). The first analysis performed was to
determine the factor structure of the ChEAT in the 265 overweight and at-risk for overweight children who completed the
questionnaire. All 26 ChEAT items were subjected to a principal component analysis with a varimax rotation. We used a factor
loading cutoff of .4, consistent with previous studies' use of .3 and .4 as factor loading cutoffs (Kelly et al., 1999; Sancho et al., 2005;
Smolak & Levine, 1994). In addition, a loading cutoff of .4 generated clear subscale themes. Internal consistency was examined for
220 L.M. Ranzenhofer et al. / Eating Behaviors 9 (2008) 218227
emergent subscales as a measure of reliability using itemtotal correlations. Cronbach's α's are reported. Convergent and
discriminant validity were examined by conducting bivariate and partial correlations, controlling for BMI-Z, to compare ChEAT
subscale scores with the TFEQ scales and CDI, STAIC, and CBCL, respectively.
Post-hoc multiple regression analyses were then used to examine relationships between ChEAT total scores and subscale scores
derived from the factor analysis, and both BMI-Z and body fat mass, among the entire sample of overweight and non-overweight
children. Covariates considered in the regression models were sex, race, age, height, socioeconomic status, and treatment-seeking
status. Race was coded as either Caucasian or non-Caucasian; the latter group included African American, Hispanic, and youth of
other race/ethnicity. Insignificant covariates were subsequently removed from the models. Analyses of covariance, accounting for
the contribution of age, sex, and race were used to compare overweight and non-overweight children's ChEAT total and subscale
scores. Associations and differences were considered significant when p values were 0.05.
3. Results
A total of 220 (52.7%) overweight (BMI N 95th percentile), 45 (10.8%) at-risk for overweight (BMI 85thb 95th percentile), and
152 (36.5%) non-overweight (BMI 5th to b 85th percentile) children and adolescents, with average age 10.8± 3.1 years, participated
in the study (Table 1). Twenty-nine percent of the overweight group was seeking weight loss treatment and the rest were participating
in non-intervention studies. Overweight children were slightly older ( p b .001) and, as expected, had significantly higher BMI-Z
( p b .001) and percent body fat ( p b .001). Overweight children also reported significantly higher socioeconomic status scores (2.4 ±
1.4 vs. 2.8± .1.3, p = .01) indicative of lower parental income and education level, and greater ChEAT total scores (6.6 ± 7.8 vs. 9.9 ±
7.4, p b .001), than non-overweight youth. Mean ChEAT score for girls (9.6) was significantly higher than the mean score for boys
(7.5; p = .01).
3.1. Factor analysis among overweight sample
A principal component analysis with varimax rotation was performed using responses to the ChEAT from overweight and at-
risk for overweight (n =265) children and adolescents. Eight components with Eigenvalues N 1.00 collectively accounted for
58.2% of variance. A factor loading cutoff of 0.4 produced 6 constructs that contained at least three items, four of which
demonstrated clear themes. The four subscales were labeled as body/weight concern,’‘food preoccupation,’‘dieting, and eating
concern, which collectively explained 33.3% of variance (Table 2).
The body/weight concern subscale, which explained 9.1% of variance, included items related to body concern and
dissatisfaction, and contained the following individual items: I think a lot about wanting to be thinner,”“I think about burning up
energy (calories) when I exercise,”“I think a lot about having fat on my body, and I am scared about being overweight. The
food preoccupation,
subscale aligned with previously described food preoccupation subscales, identifying excessive thoughts
of food and eating including, I think about food a lot of the time,”“I have gone on eating binges where I feel that I might not be
able to stop, and I give too much time and thought to food. The food preoccupation subscale explained 9.2% of variance. The
dieting subscale (8.0% of variance) identified dieting behaviors including I am aware of the energy content in foods that I eat,
I try to stay away from foods such as breads, potatoes and rice,”“I cut my food into small pieces,”“I eat diet foods, and I have
been dieting. Finally, the present study's eating concern subscale, which explained 7.1% of variance, contained the items
I stay away from eating when I am hungry,”“I feel that others would like me to eat more, and I feel that others pressure me
to eat.
Table 1
Participant demographics
Normal weight (n = 152) Overweight (n = 220) Significance
Age (years) 9.6±3.7 11.6 ±4.5 b .001
Race 30.3% African American 51.3% African American .09
61.8% Caucasian 47.2% Caucasian
2.0% Hispanic 1.1% Hispanic
5.9% other .4% other
Sex 49.3% female 59.6% female .10
Socioeconomic status score 2.4 ± 1.4 2.8 ± 1.3 .01
BMI-Z score .10±.6 2.2±.6 b .001
Percent body fat (%) 23.3± 10.1 38.9± 10.5 b .001
Total ChEAT score 6.6± 7.8 9.9± 7.4 .03
Mean ± SD shown unless otherwise indicated.
221L.M. Ranzenhofer et al. / Eating Behaviors 9 (2008) 218227
3.2. Reliability analysis
Adequate internal consistency was demonstrated for ChEAT total score (Cronbach's α = .78), and the body/weight concern
subscale (Cronbach's α = .74), but the food preoccupation, dieting, and eating concern subscales were less consistent (Cronbach's
α's = .66, .55, and .52, respectively).
3.3. Psychometric properties of the ChEAT among overweight youth
3.3.1. Convergent validity
ChEAT total score was significantly related to the disinhibition ( β = .25, p b .01) and hunger ( β = .28, pb .01) subscales of the
TFEQ. Furthermore, ChEAT subscales were correlated with respective subscales of the TFEQ: the ChEAT dieting subscale was
significantly related to the TFEQ restraint scale ( β = .34, p =b .001), and the food preoccupation subscale was significantly related to
both disinhibition ( β = .30, p = .001) and hunger ( β =.35, p = b .001). Due to lack of respective subscales, body weight concern and
oral control were not analyzed for concurrent validity.
3.3.2. Discriminant validity
ChEAT total score was significantly related to total CDI scores ( β =.33, p b .01), and CBCL internalizing ( β= .20, p = .04), and
externalizing (β =.23, p = .02) T-scores, and trait anxiety β= .38, p b .01). The body weight concern, but not dieting, subscale, was
also associated with depressive symptoms ( β = .28, p b .01) and trait anxiety ( β = .44, p b .01).
3.4. Relationships between ChEAT total and subscale scores and BMI-Z and body fat
Among the entire sample of overweight, at-risk for overweight, and normal weight children and adolescents, multivariate
regression analyses accounting for demographic and anthropometric variables found that the ChEAT total score, and the body/
weight concern and dieting subscales, were significantly related to both BMI-Z ( β's = .28, .34, .27, respectively, all p's b .001), and
total body fat mass ( β's = .31 .35, .31, respectively, all p's b .001) (Fig. 1AD). Children's food preoccupation ( p = .54) and eating
concern ( p = .16) subscale scores were neither related to BMI-Z nor total body fat mass ( p's = .28, .19, respectively). In analyses
restricted to the cohort of overweight and at-risk for overweight children and adolescents, and accounting for demographic and
anthropometric variables that contributed significantly to the models, children's BMI-Z was positively related to the ChEAT total
score (β =.27, p b .001), as well as the body/weight concern ( β= .24, p = .001), dieting ( β = .19, p = .02), and food preoccupation
Table 2
Factor Loadings of the present study
Item Description Loading
Factor 1: Body weight concern
1 I am scared about being overweight. .60
11 I think a lot about wanting to be thinner. .79
12 I think about burning up energy (calories) when I exercise. .68
14 I think a lot about having fat on my body. .73
Factor 2: Food preoccupation
3 I think about food a lot of the time. .72
4 I have gone on eating binges where I feel that I might not be able to stop. .63
21 I give too much time and thought to food. .62
Factor 3: Dieting
5 I cut my food into small pieces. .51
6 I am aware of the energy (calorie) content in foods that I eat. .48
7 I try to stay away from foods such as breads, potatoes, and rice. .70
17 I eat diet foods. .71
23 I have been dieting. .47
Factor 4: Eating concern
2 I stay away from eating when I am hungry. .60
8 I feel that others would like me to eat more. .67
15 I take longer than others to eat my meals. .43
20 I feel that others pressure me to eat. .39
222 L.M. Ranzenhofer et al. / Eating Behaviors 9 (2008) 218227
( β = .16, p = .02) subscales, but were unrelated to the eating concern subscale ( p= .07). For this cohort, ChEAT total score ( β= .29,
p b .01), and the body/weight concern ( β = .29, p b .01) and dieting ( β= .22, p = .03) subscale scores, but neither the food
preoccupation ( p= .7) nor the eating concern ( p = .07) subscales, were significantly related to total body fat mass.
Fig. 1. Associations between body composition and ChEAT subscale scores. A: Body mass index standard deviation score (BMI-Z score) and ChEAT
body/weight concern subscale ( β= .34, p b .001). B: Body fat mass and ChEAT body/weight concern subscale ( β = .35, p b .001). C: BMI-Z score and
food preoccupation subscale ( p = .54). D: Body fat mass and food preoccupation subscale ( p = .28). E: BMI-Z score and dieting subscale ( β= .27,
p b .001). F: Body fat mass and dieting subscale ( β= .31, pb .001). G: BMI-Z score and eating concern subscale (p = .16). H: Body fat mass and eating
concern subscale ( p = .19).
223L.M. Ranzenhofer et al. / Eating Behaviors 9 (2008) 218227
4. Discussion
The factor structure of the ChEAT questionnaire determined by previous analyses was partially supported in a sample
of o verweight and at-risk for overweight children, with similar factors explaining approximately 20% less variance than
prior studies demonstrated. Because our primary interest was to explore ChEAT constructs that are potentially more
meaningful than the total score for overweight children, we focused on the four factors that demonstrated clear themes,
even though this approach limited the total variability explained by the overall measure. In our analysis, both the ChEAT
total score and the body/weight concern subscale demonstrated adequate internal consistency and were related to
children's BMI-Z and total body fat mass within the entire sample of both overweigh t and normal weight children. The
dieting subscale was also significantly related to both BMI-Z and body fat mass, but failed to demonstrate sufficient
internal consistency. Contrary to our expectations, the other ChEAT subscales, food preoccupation and eating concern,
were unrelated to body weight and fat mass, and demonstrated poor internal consistenc y.
Our analysis of the psychometric properties of the ChEAT revealed good convergent validity with the TFEQ and its
subscales. The association of both ChEAT total and subscale scores with various measures of general pathology may
suggest limited discriminant validity of the measure among an overweight sample. However, such findings may be
reflective of an association between general and eating related pathology, as reported in some other studies (Erickson,
Robinson, Haydel, & Killen, 2000; Striegel-Moore, 1995; Vander Wa l & Thelen, 2000).
ChEAT total scores were significantly related to BMI-Z, supporting previous studies that found higher scores among
overweight compared to normal weight children on the ChEAT questionnaire (McVey et al., 2004; Rolland et al.,
1997), and on other measures of eating pathol ogy (Burrows & Cooper, 2002; Tanofsky-Kraff et al., 2004; Vander Wal
& Thelen, 2000). Similar to previous analyses, ChEAT total scores generated high internal consistency, confi rming the
total score as a measure to assess disordered eating attitudes among overweight children.
To elucidate relevant factors for children at high risk for becoming overweight and for children who are overweight,
we restricted our factor analysis to children whose BMI-Z equaled or exceeded the 85th percentile. These data
produced findings that were supportive of, but not identical to, previous studies among unselected samples of school
children. The body/weight concern subscale demonstrated considerable overlap with previously named dieting
subscales, with the primary difference being that the current study's body/weight concern subscale did not encompass
items that assess food restriction, such as, I stay away from foods with sugar in them, that rendered other analyses'
first factor more reminiscent of traditional dieting. Further, unlike some (Kelly et al., 1999; Smolak & Levine, 1994),
but not all (Anton et al., 2006; Sancho et al., 2005), of the previously identified dieting subscales, the current study's
dieting subscale did not include items related to body/weight concern. Rather, in our cohort of overweight and at-risk
for overweight children, we found that body/weight concern and dieting were separable constructs. Two other studies
(Anton et al., 2006; Sancho et al., 2005), including one conducted in children who were heavier, and possibly
predisposed toward gaining excess weight, have found dieting to be a construct distinct from weight concern. We
therefore speculate that weight concern and dieting as separable constructs may be characteristic of overweight youth.
There are several potential reasons for the emergence of weight concern and dieting as separable constructs among
overweight children. First, overweight children who were not trying to restrict their food intake at the time the
questionnaire was completed might appropr iately manifest only body/weight concern. Indeed, it is possible that after
numerous unsuccessful attempts to restrict food intake, some overw eight youth may cease responding to body
dissatisfaction by restricting their food intake, despite experiencing concerns with their body weight and shape.
Whereas successful weight loss may constitute positive reinforcement for dieting in normal weight or underweight
individuals who exhibit disordered eating, it is conceivable that overweight youth, who do not readily lose weight by
restricting intake, develop other manifestations of disordered eating in the place of restriction. Bolstering this
hypothesis are findings that overweight adolescents who report disordered eating behaviors fail to differ from those
who report no such behaviors in terms of their level of dietary restraint, despite having more e ating concern, shape
concern, and weight concern (Glasofer et al., 2007). The distinction between actual dieting and dietary restraint offers
another potential explanation for the emergence of separate subscales for body concern and dieting among overweight
youth. Unlike the Eating Disorder Examination (Fairburn & Cooper, 1993), which assesses both attempted and
successful dietary restraint, the ChEAT asks children to report actual restrictive behaviors, possibly aligning more
closely with genuine dieting than dietary restraint. Thus, unsuccessful dieting, seemingly more common among
overweight youth, would not be captured by the ChEAT's questions, and questions that assess actual dieting among an
overweight sample would not necessarily co-occur with body/weight concern, rendering separa te constructs.
224 L.M. Ranzenhofer et al. / Eating Behaviors 9 (2008) 218227
It is notable that the ChEAT total score and body/weight concern subscale were the only constructs that generated
sufficient internal consistency and that were significantly correlated with BMI-Z and DXA fat mass. Although the
ChEAT total score was not predictive of excessive fat gain in one prospective study (Tanofsk y-Kraff et al., 2006), the
body weight concern subscale has not been examined in longitudinal studies of weight gain. Among samples of
adolescent girls, other measures of weight concern (Killen et al., 1994, 1996) and thin body preoccupation
(McKnight Investigators, 2003) were predictive of the development of full and partial syndrome eating disorders.
Whether or not the ChEAT body/weight concern subscale is similarly useful for predicting eating disorder onset and
excessive weight gain among overweight youth warrants future investigation.
We specula te that the poor internal consistency we found for the dieting subscale may be a reflection of an unclear
concept of dieting among overweight youth. Despite inadequate internal consistency, further exploration of the dieting
subscale is justified, because this subscale was significantly correlated with both BMI-Z and fat mass. Poor internal
consistency and the lack of relationship with body weight were also found for the food preoccupation and eating concern
subscales among overweight youth. These findings may be partially explained by the degree of pathology exemplified
by items on these two subscales. For overweight children, items on the food preoccupation and oral control subscales,
such as I have gone on eating binges where I feel that I might not be able to stop, and I stay away from eating when I
am hungry, may be less common than restricting food intake and/or being concerned with one's body weight.
While data suggest that many overweight children express weight concern and report dieting, few report binge
eating behaviors and even fewer endorse complete food avoidance (e.g., fasting; Tanofsky-Kraff, Faden, Yanovski,
Wilfley, & Yanovski, 2005 ). Furthermore, items on the oral control subscale, such as I feel that others would like me
to eat more, and, I feel that others pressure me to eat, may be more reflective of disordered eating among children
with restrictive eating disorders (e.g., anorexia nervosa) than overweight children.
Strengths of this study include the large and racially diverse sample. However, one concern that arises from the use
of questionnaire methodology in a pediatric sample is that some young children may have had difficulty understanding
particular questions. To address this concern, precautions were taken to ensure that children understood the measure by
having questions read aloud when there was concern regarding comprehension. Data gathered for children who clearly
did not unders tand one or more questions were excluded from the analysis. It should also be noted that participants of
the present investigation wer e not recruited in a population-based fashion. Families in the studied sample chose to
respond to our notices and thus may be more health conscious than the general population, possibly limiting the
external validity of the study.
We conclude that while the subscales generated from school samples are generally supported in overweight children
and adolescents, body/weight concern and dieting appear to be separable constructs, and only the total score and body/
weight concern and dieting subscales appear to be associated with body weight and adiposity. Future prospective
research is required to determine whether or not these newly developed ChEAT subscale scores are predictive of full
syndrome eating disturbance in samples of overweight children and adolescents.
Acknowledgment
This study was supported by the Intramural Research Program of the NIH, grant ZO1 HD-00641 (to JAY) from the
National Institute of Child Health and Human Development, NIH and by a supplement from the National Center on
Minority Health and Health Disparities, NIH.
References
Achenbach, T. M., & Elderbrock, C. (1991). Manual for the child behavior checklist and revised child behavior profile. Burlington, VT: University of
Vermont Department of Psychiatry.
Ambrosi-Randic, N., & Pokrajac-Bulian, A. (2005). Psychometric properties of the eating attitudes test and children's eating attitudes test in Croatia.
Eating and Weight Disorders, 10(4), e76e82.
Anon. (1994). Endocrine Studies of Healthy Children. Retrieved January 4, 2006, from http://www.clinicaltrials.gov/ct/show/NCT00001195
Anon. (1996). Metabolic Differences of Overweight Children and Children of Overweight Parents. Retrieved May 19, 2006, from http://www.
clinicaltrials.gov/ct/show/NCT00001522
Anon. (2005a). Effects of metformin on energy intake, energy expenditure, and body weight in overweight children with insulin resistance. Retrieved
November 7, 2005, from http://clinicalstudies.info.nih.gov/detail/A_2000-CH0134.html
Anon. (2005b). Safety and efficacy of xenical in children and adolescents with obesity-related diseases. Retrieved January 24, 2006, from http://www.
clinicaltrials.gov/ct/show/NCT00001723
225L.M. Ranzenhofer et al. / Eating Behaviors 9 (2008) 218227
Anton, S. D., Han, H., Newton, R. L., Jr., Martin, C. K., York-Crowe, E., Stewart, T. M., et al. (2006). Reformulation of the Children's Eating
Attitudes Test (ChEAT): Factor structure and scoring method in a non-clinical population. Eating and Weight Disorders, 11(4), 201210.
Bond, M. J., McDowell, A. J., & Wilkinson, J. Y. (2001). The measurement of dietary restraint, disinhibition and hunger: An examination of the factor
structure of the Three Factor Eating Questionnaire (TFEQ). International Journal of Obesity and Related Metabolic Disorders, 25(6), 900906.
Bryant-Waugh, R. J., Cooper, P. J., Taylor, C. L., & Lask, B. D. (1996). The use of the eating disorder examination with children: A pilot study.
International Journal of Eating Disorders, 19(4), 391397.
Burrows, A., & Cooper, M. (2002). Possible risk factors in the development of eating disorders in overweight pre-adolescent girls. International
Journal of Obesity and Related Metabolic Disorders, 26(9), 12681273.
Cash, T. F. (1997). The Body Image Workbook: An 8-step program for learning to like your looks. Oakland, CA: New Harbinger Publications.
Ellis, K. J., Shypailo, R. J., Pratt, J. A., & Pond, W. G. (1993). Accuracy of DXA-based body composition measurements for pediatric studies. Basic
Life Sciences, 60, 153156.
Erickson, S. J., Robinson, T. N., Haydel, K. F., & Killen, J. D. (2000). Are overweight children unhappy? Body mass index, depressive symptoms,
and overweight concerns in elementary school children. Archives of Pediatrics and Adolescent Medicine, 154(9), 931935.
Fairburn, C., & Cooper, Z. (1993). The Eating Disorder Examination (12th ed.). In F. CG & W. GT (Eds.), Binge eating, nature, assessment and
treatment (pp. 317360). New York: Guilford.
Field, A. E., Austin, S. B., Taylor, C. B., Malspeis, S., Rosner, B., Rockett, H. R., et al. (2003). Relation between dieting and weight change among
preadolescents and adolescents. Pediatrics, 112(4), 900906.
Garner, D. M. (2002). Measurement of eating disorder psychopathology. In C. G. Fairburn & K.D. Brownell (Eds.), Eating disorders and obesity: A
comprehensive handbook (pp. 141146)., 2nd ed. New York: Guilford Press.
Garner, D. M., Olmsted, M. P., Bohr, Y., & Garfinkel, P. E. (1982). The eating attitudes test: Psychometric features and clinical correlates.
Psychological Medicine, 12(4), 871878.
Glasofer, D. R., Tanofsky-Kraff, M., Eddy, K. T., Yanovski, S. Z., Theim, K. R., Mirch, M. C., et al. (2007). Binge eating in overweight treatment-
seeking adolescents. Journal of Pediatric Psychology, 32(1), 95105.
Kashubeck-West, S., Mintz, L. B., & Saunders, K. J. (2001). Assessment of eating disorders in women. The Counseling Psychologist, 29(5), 662694.
Kelly, C., Ricciardelli, L. A., & Clarke, J. D. (1999). Problem eating attitudes and behaviors in young children. International Journal of Eating
Disorders, 25(3), 281286.
Killen, J. D., Hayward, C., Wilson, D. M., Taylor, C. B., Hammer, L. D., Litt, I., et al. (1994). Factors associated with eating disorder symptoms in a
community sample of 6th and 7th grade girls. International Journal of Eating Disorders, 15(4), 357367.
Killen, J. D., Taylor, C. B., Hayward, C., Haydel, K. F., Wilson, D. M., Hammer, L., et al. (1996). Weight concerns influence the development of
eating disorders: A 4-year prospective study. Journal of Consulting and Clinical Psychology, 64(5), 936940.
Kovacs, M. (1985). The Children's Depression Inventory (CDI). Psychopharmacology Bulletin, 21(4), 995998.
Kovacs, M. (1992). Children's Depression Inventory (CDI) manual (Multi-Health Systems, Inc.
Lynch, W. C., & Eppers-Reynolds, K. (2005). Children's Eating Attitudes Test: Revised factor structure for adolescent girls. Eating and Weight
Disorders, 10(4), 222235.
Maloney, M. J., McGuire, J. B., & Daniels, S. R. (1988). Reliability testing of a children's version of the Eating Attitude Test. Journal of the
American Academy of Child and Adolescent Psychiatry, 27(5), 541543.
McDuffie, J. R., Calis, K. A., Uwaifo, G. I., Sebring, N. G., Fallon, E. M., Hubbard, V. S., et al. (2002). Three-month tolerability of orlistat in
adolescents with obesity-related comorbid conditions. Obesity Research, 10(7), 642650.
McKnight Investigators (2003). Risk factors for the onset of eating disorders in adolescent girls: Results of the McKnight longitudinal risk factor
study. American Journal of Psychiatry, 160(2), 248254.
McVey, G., Tweed, S., & Blackmore, E. (2004). Dieting among preadolescent and young adolescent females. Canadian Medical Association
Journal, 170(10), 15591561.
Morgan, C. M., Tanofsky-Kraff, M., Wilfley, D. E., & Yanovski, J. A. (2002). Childhood obesity. Child and Adolescent Psychiatric Clinics of North
America, 11(2), 257278.
Neumark-Sztainer, D., Story, M., Hannan, P. J., Perry, C. L., & Irving, L. M. (2002). Weight-related concerns and behaviors among overweight and
nonoverweight adolescents: Implications for preventing weight-related disorders. Archives of Pediatrics and Adolescent Medicine, 156(2),
171178.
Ogden, C. L., Carroll, M. D., Curtin, L. R., McDowell, M. A., Tabak, C. J., & Flegal, K. M. (2006). Prevalence of overweight and obesity in the
United States, 19992004. Journal of the American Medical Association, 295(13), 15491555.
Ogden, C. L., Kuczmarski, R. J., Flegal, K. M., Mei, Z., Guo, S., Wei, R., et al. (2002). Centers for Disease Control and Prevention 2000 growth
charts for the United States: Improvements to the 1977 National Center for Health Statistics version. Pediatrics, 109(1), 4560.
Robotham, D. R., Schoeller, D. A., Mercado, A. B., Mirch, M. C., Theim, K. R., Reynolds, J. C., et al. (2006). Estimates of body fat in children by
Hologic QDR-2000 and QDR-4500A dual-energy X-ray absorptiometers compared with deuterium dilution.
Journ al of Ped iatric
Gastroenterology and Nutrition, 42(3), 331335.
Rolland, K., Farnill, D., & Griffiths, R. A. (1997). Body figure perceptions and eating attitudes among Australian schoolchildren aged 8 to 12 years.
International Journal of Eating Disorders, 21(3), 273278.
Sancho, C., Asorey, O., Arija, V., & Canals, J. (2005). Psychometric characteristics of the children's eating attitudes test in a Spanish sample.
European Eating Disorders Review, 13(5), 338343.
Sinton, M. M., & Birch, L. L. (2005). Weight status and psychosocial factors predict the emergence of dieting in preadolescent girls. International
Journal of Eating Disorders, 38(4), 346354.
Smolak, L., & Levine, M. P. (1994). Psychometric properties of the Children's Eating Attitudes Test. International Journal of Eating Disorders, 16
(3), 275282.
226 L.M. Ranzenhofer et al. / Eating Behaviors 9 (2008) 218227
Spielberger, C. D., Edwards, C. D., Lushene, R. E., Montuori, J., & Platzek, D. (1973). STAIC preliminary manual. Palo Alto, CA: Consulting
Psychologist Press.
Stice, E., Cameron, R. P., Killen, J. D., Hayward, C., & Taylor, C. B. (1999). Naturalistic weight-reduction efforts prospectively predict growth in
relative weight and onset of obesity among female adolescents. Journal of Consulting and Clinical Psychology, 67(6), 967974.
Stice, E., Presnell, K., & Spangler, D. (2002). Risk factors for binge eating onset in adolescent girls: A 2-year prospective investigation. Health
Psychology, 21(2), 131138.
Striegel-Moore, R. (1995). Psychological factors in the etiology of binge eating. Addictive Behaviors, 20 (6), 713723.
Stunkard, A. J., & Messick, S. (1985). The three-factor eating questionnaire to measure dietary restraint, disinhibition and hunger. Journal of
Psychosomatic Research, 29(1), 7183.
Tanofsky-Kraff, M., Cohen, M. L., Yanovski, S. Z., Cox, C., Theim, K. R., Keil, M., et al. (2006). A prospective study of psychological predictors of
body fat gain among children at high risk for adult obesity. Pediatrics, 117(4), 12031209.
Tanofsky-Kraff, M., Faden, D., Yanovski, S. Z., Wilfley, D. E., & Yanovski, J. A. (2005). The perceived onset of dieting and loss of control eating
behaviors in overweight children. International Journal of Eating Disorders, 38(2), 112122.
Tanofsky-Kraff, M., Yanovski, S. Z., Wilfley, D. E., Marmarosh, C., Morgan, C. M., & Yanovski, J. A. (2004). Eating-disordered behaviors, body fat,
and psychopathology in overweight and normal-weight children. Journal of Consulting and Clinical Psychology, 72(1), 5361.
Vander Wal, J. S., & Thelen, M. H. (2000). Eating and body image concerns among obese and average-weight children. Addictive Behavior, 25(5),
775778.
Wilfley, D. E., Schwartz, M. B., Spurrell, E. B., & Fairburn, C. G. (1997). Assessing the specific psychopathology of binge eating disorder patients:
Interview or self-report? Behavior Research and Therapy, 35(12), 11511159.
227L.M. Ranzenhofer et al. / Eating Behaviors 9 (2008) 218227
    • "Sin embargo, en los estudios que toman muestras de niños los hallazgos son contradictorios. Algunos autores encuentran que las niñas presentan medias superiores en el ChEAT en comparación con los varones (Ranzenhofer et al., 2008), e identifican una mayor proporción de niñas que de varones con riesgo de trastorno alimentario (Maloney et al., 1988; Nicholls, Lynn, & Viner, 2011). Sin embargo, otros autores no encontraron diferencias por sexo a estas edades (Rolland, Farnill, & Griffiths, 1998). "
    [Show abstract] [Hide abstract] ABSTRACT: El presente estudio se propone evaluar riesgo de trastorno alimentario (TA) y perfeccionismo en niñas y niños escolarizados y analizar si existe asociación entre ambas variables. La muestra estuvo conformada por 337 niños (51% niñas-49% varones) de entre 9 y 13 años. Se realizó un estudio en dos fases. En la primera, los niños completaron los siguientes instrumentos: Cuestionario sociodemográfico, Test de Actitudes Alimentarias para Niños (ChEAT), Cuestionario de Perfeccionismo Infantil y Escala de Siluetas para niños y adolescentes. Fueron pesados y medidos por una nutricionista, según normas de la Sociedad Argentina de Pediatría. En la segunda fase, los niños en riesgo de TA y un grupo control fueron entrevistados con el fin de corroborar o no dicho riesgo. Tras la primera fase se identificó un 30.56% de niños con posible riesgo de TA. Luego de la segunda fase se confirmó el riesgo en un 9.79% de los niños de la muestra total, no existiendo diferencias por sexo en esta variable. Se halló una asociación significativa positiva entre la puntuación total del ChEAT y la puntuación total en la medida de Perfeccionismo. Finalmente, se puede concluir que el perfeccionismo constituye una variable asociada al riesgo de TA en niños.
    Full-text · Article · Dec 2012
    • ". The sociocultural framework of body dissatisfaction and disordered eating development, incorporating adiposity. body dissatisfaction are not confined to girls who are, or who risk being, overweight, although both are more common in this group (Ranzenhofer et al., 2008; Smolak, 2004). Further research with girls during middle-childhood is therefore needed to elucidate the sociocultural and psychological context in which body dissatisfaction and disordered eating attitudes develop and operate (Wertheim, Paxton, & Blaney, 2009). "
    [Show abstract] [Hide abstract] ABSTRACT: We examined the sociocultural model of body dissatisfaction and disordered eating attitude development in young girls for the first time. According to the model, internalizing an unrealistically thin ideal body increases the risk of disordered eating via body dissatisfaction, dietary restraint, and depression. Girls aged 7-11 years (N=127) completed measures of thin-ideal internalization, body dissatisfaction, dieting, depression, and disordered eating attitudes. Participants' height and weight were measured and their body mass index calculated. Thin-ideal internalization predicted disordered eating attitudes indirectly via body dissatisfaction, dietary restraint, and depression; it also predicted disordered eating attitudes directly. Path analyses showed that a revised sociocultural model fit well with the data. These data show that a sociocultural framework for understanding disordered eating and body dissatisfaction in adults is useful, with minor modifications, in understanding the development of related attitudes in young girls.
    Full-text · Article · Nov 2012
    • "Internal reliability was adequate for all three versions, and as well as for the total sample as for each subsample according to gender, age, school level, and weight status. Compared to the studies on the English version (Maloney et al., 1988; Ranzenhofer et al., 2008; Smolak & Levine, 1994a ) we can conclude that the Dutch ChEAT has similar intern reliability. The factor analysis showed a factor structure quite different from the original ChEAT (Maloney et al., 1988). "
    [Show abstract] [Hide abstract] ABSTRACT: Disturbed eating attitudes may be important precursors of pathological eating patterns and, therefore need to be researched adequately. The Children's Eating Attitude Test (ChEAT) is indicated for detecting at-risk attitudes and concerns in youngsters. Method. The present study was designed to provide a preliminary psychometric evaluation of the Dutch version of the ChEAT, by examining reliability and validity in a sample of 166 youngsters. Results. Generally the ChEAT seems to be a reliable instrument. Concurrent validity was demonstrated by positive correlations with measures assessing pathological eating behaviour and with related psychological problems. The discriminant validity was good. Based on ChEAT scores we can distinguish overweight youngsters from the community sample and "dieters" from "non dieters". Divergent validity and factor structure show still shortcomings. Discussion. The Dutch version of the ChEAT seems to be a promising screening- and research instrument. Future prospective research could focus on a cut-off score for identifying at-risk youngsters.
    Full-text · Article · Dec 2010
Show more