The factor structure of the ChEAT questionnaire determined by previous analyses was partially supported in a sample of overweight 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 that 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 overweight 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 consistency.
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 Wal & 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, Tweed, & Blackmore, 2004
; Rolland, Farnill, & Griffiths, 1997
), and on other measures of eating pathology (Burrows & Cooper, 2002
; Tanofsky-Kraff, et al., 2004
; Vander Wal & Thelen, 2000
). Similar to previous analyses, ChEAT total scores generated high internal consistency, confirming 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 who’s 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, Ricciardelli, & Clarke, 1999
; Smolak & Levine, 1994
), but not all (Anton, et al., 2006
; Sancho, Asorey, Arija, & Canals, 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, Asorey, Arija, & Canals, 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 appropriately manifest only body/weight concern. Indeed, it is possible that after numerous unsuccessful attempts to restrict food intake, some overweight 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 eating 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 separate constructs.
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 (Tanofsky-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
; Killen et al., 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 speculate 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 understand one or more questions were excluded from the analysis. It should also be noted that participants of the present investigation were 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.