The purpose of the current study was to examine the diagnostic significance of overvaluation of shape and weight among overweight children and adolescents with loss of control eating disturbances. Approximately half of participants with loss of control eating reported at least moderate levels of overvaluation (i.e., indicating that shape and weight are a main aspect of one’s scheme for self-evaluation). These individuals were characterized by lower self-esteem than overweight controls with minimal or absent overvaluation, and greater behavioral problems than overweight controls regardless of overvaluation status, but did not differ from youth with loss of control eating reporting minimal or absent overvaluation across these domains. Thus, in contrast to findings in adults with BED (Goldschmidt, et al., 2010
; Grilo, et al., 2009
; Grilo, et al., 2008
; Grilo, et al., 2010
; Hrabosky, et al., 2007
; Masheb & Grilo, 2008
; Mond, et al., 2007
), overvaluation of shape and weight does not seem to demarcate meaningful subtypes among youth with loss of control eating.
However, before overvaluation of shape and weight is abandoned as a meaningful construct in children, several considerations are warranted. It has previously been argued that certain cognitive features of eating disorders are inappropriate for children as endorsement of these features demands capacities for abstract reasoning that are not yet fully developed (Bravender et al., 2007
). The concept of self-worth is in itself abstract, and arranging aspects of self-worth according to magnitude demands compound abstract reasoning. It may be that further qualitative exploratory work into the nature of overvaluation of shape and weight in children is needed. Moreover, despite the fact that overvaluation did not distinguish subtypes of youth with loss of control eating, interventions targeting this behavior may benefit from a focus on overvaluation and other shape- and weight-related constructs to prevent or minimize chronicity (Fairburn, et al., 1993
; Fairburn, et al., 2003
), especially as this construct is related to poorer treatment outcome in adults (Masheb & Grilo, 2008
Interestingly, a substantial proportion of overweight controls reported relatively high levels of overvaluation. Indeed, their mean overvaluation score (M
=4.9±0.7) was similar to that reported by LOC-Mod participants (M
=5.0±0.7). This could explain the results of the discriminant function analysis, in which clinically significant overvaluation did only a modest job of classifying participants as LOC vs. CON. It may be indicated for health care providers to inquire about the importance of shape and weight among their overweight patients, given that this is often considered a core feature of eating disorders (Fairburn, 2008b
) and hence may reflect increased risk for the development of pathological eating disturbances. Although existing pediatric weight control treatments often address shape and weight concerns (Follansbee-Junger, Janicke, & Sallinen, 2010
), for youth exhibiting extreme concerns, a more overt or prolonged focus on the role of shape and weight in one’s self-evaluative scheme may be necessary.
Although we could not examine the relation between overvaluation and treatment-seeking status given that the vast majority of participants were presenting for eating- or weight-disorders treatment (n
=476/526), motivation for treatment should be further studied in relation to overvaluation of shape and weight among youth with loss of control eating. It is possible that eating-related distress is enough to impel youth with loss of control eating disturbances to seek treatment; however, modest levels of body dissatisfaction have been shown motivate youth to improve eating and physical activity behaviors (Heinberg, Thompson, & Matzon, 2001
). For youth with loss of control eating who report low levels of overvaluation, identifying other factors that could potentially facilitate engagement in treatment should be a priority.
The only measure on which loss of control participants differed by overvaluation status was global severity of eating-related symptoms. This finding may be due to assessment issues, in that participants were reporting on similar symptoms within a similar timeframe; thus, those reporting high levels of overvaluation may have been more likely to report high levels of other eating-related concerns. However, it is also possible that higher levels of shape and weight overvaluation are associated with a more severe profile of eating disorder symptomatology, as other research has suggested (Hilbert & Czaja, 2009
). As such, overvaluation may signal a need for more rapid identification and treatment of loss of control eating; indeed, future research should investigate whether overvaluation moderates treatment response among youth with loss of control eating. Because of the cross-sectional nature of our data, it is impossible to deduce whether overvaluation precedes loss of control eating, or vice versa; however, some studies have found that appearance overvaluation is a risk factor for binge eating onset in adolescents (Stice, et al., 2002
). Thus, prevention programs targeting youth at high risk for developing loss of control eating should address overvaluation of shape and weight, perhaps through helping youth identify other valued aspects of their identity. Furthermore, interventions addressing overvaluation among youth with loss of control eating may help improve both overt eating behavior and the more covert cognitive features with which it is associated (Jones, et al., 2008
Our results stand in contrast to studies of adults, which have found that overvaluation of shape and weight is a useful diagnostic specifier in discriminating a more generally impaired subset of individuals with BED (Goldschmidt, et al., 2010
; Grilo, et al., 2008
). Given that loss of control eating tends to persist over time, and is associated with conversion to partial- or full-syndrome eating disorders (Tanofsky-Kraff et al., 2010
), overvaluation of shape and weight may become more clinically meaningful as youth progress through development and eating-related concerns become a more salient aspect of one’s identity. Indeed, longitudinal data suggest that persistent loss of control eating is related to worsening of eating-related attitudes (Tanofsky-Kraff, et al., 2010
); research is needed to further disentangle directionality with respect to these two constructs in order to inform prevention and intervention efforts. Conversely, the divergence of our findings from the adult literature may be related to children and adolescents’ different cognitive developmental level and understanding of the meaning of loss of control and/or overvaluation of shape and weight as compared to adults. Although we did not find gender differences, this may be especially pronounced in boys, who may not readily admit to experiencing eating- and weight-related concerns given that they are generally considered to belong in the female domain.
Limitations to the current study include the cross-sectional nature of the data, which precludes speculation about the timing of loss of control eating onset relative to the onset of shape and weight overvaluation. Our sample included only overweight youth, thus results are not generalizable to normal-weight individuals. It was not possible to stratify the sample by age group, limiting our ability to detect differences in the clinical significance of overvaluation of shape and weight during different developmental periods. Hence, future studies should seek to replicate our findings in children and adolescents separately. Some participants completed the adult EDE, and some the ChEDE, which could have led to small alterations in ratings of shape and weight overvaluation given the ChEDE’s addition of a card-sort task to score participants on this construct; these small alterations may have in turn affected overvaluation group membership. However, only a small minority (n=23) of participants completed the adult EDE, and when our analyses were re-run excluding these participants from the dataset, the pattern of results was the same. Finally, our measurement of psychological distress was limited to self-esteem and general behavioral problems; future studies should examine other psychological variables, such as depression and anxiety, in relation to overvaluation in loss of control eating. Strengths include the large sample, which included both treatment-seeking and non-treatment seeking individuals. Further, we included well-validated measures delivered to both parents and children. In particular, the use of a semi-structured interview to assess loss of control eating, overvaluation of shape and weight, and other eating-related attitudes enhances the validity of our findings.
In summary, overvaluation of shape and weight appears to be prevalent among overweight children and adolescents with and without loss of control eating problems. However, its diagnostic significance among those with loss of control is questionable, as the presence of clinically significant overvaluation did not seem to demarcate a more severely impaired subset within the loss of control sample. Research suggests that this construct is diagnostically meaningful in adults with full-syndrome BED; hence, future studies should determine its trajectory over time in youth with loss of control eating disturbances, as this group is at high risk for the development of a full-syndrome eating disorder. Further research should also examine whether addressing overvaluation of shape and weight improves psychosocial outcomes within the context of pediatric loss of control eating and/or obesity treatment.