Journal of Pediatric Psychology Advance Access originally published online on March 3, 2005
Journal of Pediatric Psychology 2005 30(6):522-531; doi:10.1093/jpepsy/jsi077
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Predictors of Body Dissatisfaction in Boys and Girls with Asthma
1 National Jewish Medical and Research Center, University of Colorado and Health Sciences Center, 2 University of California at Los Angeles, and 3 The Children’s Hospital, National Jewish Medical and Research Center, University of Colorado and Health Sciences Center
All correspondence concerning this article should be addressed to Kim Kelsay, National Jewish Medical and Research Center, 1400 Jackson St. Suite A206, Denver, Colorado 80206. E-mail: kelsayk{at}njc.org.
Received May 31, 2004; revisions received October 6, 2004 and November 11, 2004; accepted November 30, 2004
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Abstract |
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Background Body satisfaction is an important issue for youth. Youth with more severe asthma may have experiences and emotions associated with less body satisfaction; however, this has not been studied. Objective To identify correlates of body dissatisfaction in youth with asthma. Methods Sixty-three females and 60 males, ages 8–18 years with asthma, completed measures of body dissatisfaction, anxiety, depression, asthma symptoms, and behaviors. Parents completed measures of asthma limitations; clinicians rated asthma severity. Results Anxiety, depression, and body mass index (BMI) accounted for 21 and 15% of the variance in body dissatisfaction for females and males, respectively. Physical activity added 13% variance to the above model for females. Asthma symptoms added 14% for males. Of note, neither parent ratings of asthma limitations nor clinician ratings of asthma severity contributed additional variance. Conclusion This study increases our understanding of youth with asthma and provides future research directions.
Key words: asthma; adolescent; body image.
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Predictors of Body Image in Boys and Girls with Asthma |
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Body image and body satisfaction have been used interchangeably in the literature and comprise both the perception of one’s body and the thought processes and feelings associated with one’s body (Cash & Pruzinsky, 1990
). Body image is a salient issue for youth, both as conceptualized by experts in the study of quality of life and as demonstrated in several studies. For example, during the development of a new health-related quality-of-life measure for children and adolescents, Kidscreen, 24 experts participated in a Delphi process to arrive at eight dimensions of quality of life, one of which was body image (Herdman et al., 2002).
Studies with youth suggest the importance of body image; body satisfaction has been found to be associated with emotional well being, and conversely, poorer body satisfaction has been associated with greater emotional distress. A large survey study of youth attending middle and high school examined the emotional well being of over 1,600 youth with a chronic illness, and a similar number without a chronic illness (Wolman, Resnick, Harris, & Blum, 1994). A regression analysis for both children with and without a chronic illness found that body image was the strongest predictor of emotional well being, explaining 18% of the variance. When the two groups were examined separately, body satisfaction remained the most salient variable explaining emotional well being for youth with a chronic illness and was the second most salient variable for youth without a chronic illness. Conversely, studies of children (McCabe & Ricciardelli, 2003a) and both male (McCabe & Ricciardelli, 2003b) and female adolescents (Ohring, Graber, & Brooks-Gunn, 2002; Rierdan & Koff, 1997) found that greater body dissatisfaction was associated with increased negative affect. In addition, a factor analysis of depressive symptoms in school-age children yielded a factor related to body image as one of the principal factors (Poli, Sbrana, Marcheschi, & Masi, 2003).
In western culture, body ideal, communicated through mass media; thin for women, and muscular and fit for men, impacts youth (Ricciardelli & McCabe, 2001). These sex differences in the ideal body may in part explain the finding that there are also sex differences with respect to body satisfaction, with females reporting less body satisfaction (Hausenblas, Symons Downs, Fleming, & Connaughton, 2002; McCabe & Ricciardelli, 2001) and a stronger relationship between media influences and body image than males (McCabe & Ricciardelli, 2001). Not surprisingly, a relationship between lower body satisfaction and increased body mass index (BMI) has been found in many cross-sectional studies for both males and females and across several different age groups including children as young as 8 (McCabe & Ricciardelli, 2003a), through middle school (Hausenblas et al., 2002; Sands & Wardle, 2003), and into adolescence (McCabe & Ricciardelli, 2001). Similarly, increased percentage of body fat was related to poorer body image (Duncan, Woodfield, O’Neill, & Al-Nakeeb, 2002) and a prospective study found a greater increase in BMI over the course of a year was associated with a negative change in body image (Kolody & Sallis, 1995). There is some evidence that physical activity or fitness may be somewhat protective. The fitness of middle-school children as rated by a 1-mi walk or run was negatively related to body dissatisfaction (Hausenblas et al., 2002). Adolescents who reported more regular endurance exercise reported a more favorable self-image (Kirkcaldy, Shephard, & Siefen, 2002).
There are many risk factors associated with asthma that may impact body image. For youth with more severe, or more difficult to control asthma, these include the experience of repeated difficulty breathing and functional limitations including decreased physical exercise. Oral steroids are used to treat more severe asthma as well as asthma exacerbations and can lead to weight gain, especially in the face and trunk (National Heart, Lung, and Blood Institute, 2002). Another risk factor may be the relationship between increased BMI and asthma. This relationship is complex; there may be a causal relationship between obesity and asthma, as well as shared risk factors between obesity and asthma such as decreased physical activity and increased inflammation, that may lead to the two conditions occurring together (Tantisira & Weiss, 2001). The evidence for a causal relationship largely rests on the repeated findings from several large prospective studies. In a study of over 3,700 children, a BMI greater than the 85th percentile increased the risk of developing new asthma (Gilliland et al., 2003), and likewise in a study of 9,800 children and adolescents, increased BMI over time increased the risk of developing asthma (Gold, Damokosh, Dockery, & Berkey, 2003). Youth with asthma therefore may have potential risk factors for greater body dissatisfaction and the risk factors may increase with severity.
Although there are theoretical reasons to suggest greater asthma symptoms or severity may be associated with increased body dissatisfaction, there is no research regarding asthma severity and body dissatisfaction. The literature regarding body image and body satisfaction in children and adolescents with asthma is limited to studies that have included youth with asthma as part of a larger group of youth with chronic illness. Several large studies found that youth with a chronic illness reported greater body dissatisfaction (Neumark-Sztainer, Story, Resnick, Garwick, & Blum, 1995) and poorer body image (Wolman et al., 1994) than youth without a chronic illness or condition. Of note, the design of the latter study enabled a comparison between youth with a "visible" chronic condition and youth with an "invisible" chronic condition. There was no difference in body image between the two groups (Wolman et al., 1994).
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Goals of the Study |
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The goal of this study was to examine body satisfaction in children and adolescents with asthma. In the above review, investigators found the strongest evidence for a relationship between BMI and body dissatisfaction and as well as between negative emotions and body dissatisfaction. We hypothesized that as in the above literature, negative emotions (either anxiety or depression) and BMI would contribute significantly to body dissatisfaction for children and adolescents with asthma. We hypothesized that measures of asthma severity and symptoms would contribute to body dissatisfaction after accounting for the contribution of negative affect and BMI.
There is limited evidence with respect to a relationship between physical activity and body dissatisfaction and between media influence and body dissatisfaction. In separate exploratory models, we tested also whether physical activity and exposure to media (television viewing) contribute to body dissatisfaction after accounting for the contribution of negative affect and BMI.
Based on the literature, we predicted models would be different for males and females.
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Methods |
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Participants and Recruitment
Participants were recruited as part of a larger National Heart, Lung, and Blood Institute (NHLBI) funded study assessing asthma symptom perception. Inclusion criteria for the larger study were documented asthma that was actively treated for at least the previous 6 months and the absence of other major chronic medical illnesses. Parents and participants underwent informed consent or assent in accordance with the Institutional Review Board and guidelines of the American Psychological Association. This study was started several months after the larger study and all subjects approached chose to participate in this study. Subjects who were not asked to participate in the study (n = 27) did not differ from those who did complete the study by age, asthma severity, BMI, anxiety, or depression. The percentage of males in the group who did not participate was higher than in the recruited sample (60 vs. 48%).
There were 63 females and 60 males, age 8–18 (M = 12, SD = 2.45) recruited from the greater Denver community. The sample was racially mixed, with 60% White non-Hispanic, 8% White Hispanic, 19% African American, and 12% other, including multiracial. All participants were English speaking. Over half (55%) of the parents of subjects were married, and their education level was high, with 68% of mothers and 64% of fathers having some education beyond high school. Mean Hollingshead occupational codes ranged from 0 to 9 for fathers (M = 4.71, SD = 2.63) and mothers (M = 4.16, SD = 2.88). Table I contains additional descriptive statistics for the sample.
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Procedure and Measures
Visits lasted approximately 4 h, during which time-informed consent or assent was obtained, the accompanying parent and child or adolescent completed questionnaire measures, participant’s height and weight were measured, psychometric testing was performed, and several pulmonary function tests were administered. Research assistants administered questionnaires to participants, and as part of the protocol, stated that they were available to help read any questions that the child or adolescent could not read or found confusing.
Body Perception
The Color-a-Person Body Dissatisfaction Test, Children’s Version (CAPT-C; Breitenoder-Wehrung et al., 1998) was derived from the original adult test (Wooley & Roll, 1991) and consists of a frontal and side view outline of either a male or female figure with sexual body parts represented. Children or adolescents are given five colors and told each color corresponds to very happy, happy, neutral or okay, unhappy, and very unhappy. They are asked to color in the figure based on how they feel about their body. The result is scored by using an overlapping template which divides the body into 60 areas. Each area is assigned a score from 1 to 5 based on the color. An overall body dissatisfaction score is calculated as the mean of all 60 areas, resulting in a range of 1–5. A score of 1 indicates the greatest satisfaction and increasing scores indicate dissatisfaction. A differentiation score is arrived at by counting the number of differently colored areas on both figures. A higher score indicates greater differentiation of feelings toward more body parts. In this study, the CAPT-C was coded by a student and 10% of the sample was double coded by the primary author. Inter-rater reliability was .98.
Psychological Status
The Multidimensional Anxiety Scale for Children (MASC; March, Parker, Sullivan, Stallings, & Conners, 1997) is a self-report questionnaire for children and adolescents developed to assess a wide range of common anxiety symptoms. The questionnaire contains 39 items rated on a 4-point scale from 1 ("never true about me") to 4 ("often true about me"). The MASC has excellent internal reliability and good convergent and divergent validity and has been used with children and adolescents ages 8–19 (March et al., 1997). Established t scores were used in all analyses.
The Children’s Depression Inventory (CDI; Kovacs, 1985) is a self-report measure for children and adolescents ages 8–16 and is comprised of 27 items. Participants pick the one sentence out of three that best describes them over the past 2 weeks. The CDI assesses affective, behavioral, social, attitudinal, and vegetative symptoms of depression. Test–retest reliability at 3 weeks was found to be .74–.77 and internal consistency estimated by coefficient alpha to be .84 (Smucker, Craighead, Craighead, & Green, 1986). The measure has norms for both clinical and nonclinical populations, and established t scores were used for all analyses.
Asthma Status
Two pediatric pulmonologists and one pediatric allergist rated asthma severity based on the then current NHLBI guidelines (Sheffer & Taggart, 1993). The team utilized all available clinical information, including pulmonary function results, medication history, and symptom ratings to create consensus ratings of asthma severity as mild intermittent, mild persistent, moderate, or severe.
A modified version of the Children’s Asthma Symptom Checklist (CASCL; Fritz & Overholser, 1989) was used to evaluate children’s experiences during an asthma attack. The measure included 46 items measured on a 5-point frequency scale (1, "never," 5, "always") compared with 47 items measured on a 4-point scale on the original CASCL ("Breathes quickly" was the item not included). Three subscales, general physical symptoms, panic or fear, and hyperventilation or irritability were calculated according to the factors derived from the children’s reports in Fritz and Overholser (1989). Analyses used the subscales because they allowed for the differentiation of experiences during asthma attacks.
The Functional Severity Scale (FSS; Rosier et al., 1994) is a parent report measure of the frequency of events related to the child’s asthma. The items address increased wheezing, nighttime awakening with asthma symptoms, morning wheezing, severe asthma attacks, and effect of asthma on play and physical activity over the last 12 months. The FSS has been shown to be associated with increased medical service utilization, medication usage, and reduced lung function and to have item reliability of .89 (Rosier et al., 1994). One parent completed the FSS at baseline and every 2 months for a year thereafter. Mothers completed 112 of the FSS ratings, fathers 5, grandparents 4, other 2. All analyses used the mean score from the 7-time points of the FSS.
Health Assessment
Participants answered selected questions from the adolescent health questionnaire developed by Jessor, Turbin, and Costa (1998). Physical activity was assessed on a 4-point scale ranging from none to 4 or more hours per week. Television viewing was assessed on a 4-point scale ranging from 1 h or less to 4 h or more per day.
BMI percentiles were calculated with respect to children’s height, weight, age, and sex using a SAS program provided by the Centers for Disease Control and Prevention (CDC) (Centers for Disease Control and Prevention, 2000b). The calculated scores correspond to the percentiles shown on the 2000 CDC growth charts (Centers for Disease Control and Prevention, 2000a). The CDC has defined the following risk criteria, children below the 5th percentile are underweight, children from the 85th to 95th percentile are at risk for being overweight, and children at or above the 95th percentile are overweight.
Data Analysis
All data were assessed for normality and missing observations. Differentiation and the BMI percentiles were found to be positively skewed and underwent logarithmic transformations before inclusion in analyses. Physical activity in males was excluded from analyses because of a lack of variance (75% of participants endorsed the highest level possible). Most of the participants in the study had either mild persistent (59%) or moderate persistent asthma (25%; Table I). Researchers examined asthma severity as an ordinal variable. Because of the low frequency of mild intermittent and severe persistent asthma when only a single gender was examined, severity ratings were also dichotomized by combining mild intermittent and mild persistent asthma to form a low severity group and moderate and severe persistent to form a higher severity group. Each analysis used all cases for which complete data was available.
Hypotheses were tested for each gender by using a set of hierarchical multiple regressions. In the first step of each regression, depression (CDI), anxiety (MASC), and BMI percentiles were the independent variables entered as a group to explain body dissatisfaction (the dependent variable). The results of the first step tested the first hypothesis. In the second step of each regression, researchers entered a single asthma-related variable, or other variable (television viewing or physical activity) for which a trend (p < .10) toward a significant correlation with body dissatisfaction was observed. This was done to maximize the power available to test the secondary hypotheses given the high rate of intercorrelation among health and asthma-related variables. Bonferroni corrections were used within each regression to minimize the impact of multiple comparisons.
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Results |
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Gender Differences
As shown in Table I, females had significantly higher body differentiation scores. Males had significantly lower scores on the CASCL and each of its subscales. Males reported that they were more physically active and had less depressive symptoms on the CDI. There were no significant gender differences in the distribution of BMI categories shown in Table I,
2(2, N = 116) = 2.91, p = .23.
Females
Table II summarizes intercorrelations between study variables for females. Body differentiation was associated with body dissatisfaction, r = 0.38, p < .01. Greater body dissatisfaction was associated with greater functional severity (FSS), anxiety (MASC), depression (CDI), and BMI and lower physical activity.
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A t test showed females with high asthma severity did not differ with respect to body dissatisfaction from females with low asthma severity, t(60) = –1.96, p > .05.
Table III summarizes change in R2, 
R2, noncentral 95% confidence intervals for R2 (Smithson, 2001), effect sizes (f2; Cohen, 1977), and standardized parameter estimates for each regression. The regression in Step 1 included body image as the dependent variable, and the CDI, MASC, and BMI percentiles together in Step 1, as the independent variable. The model was significant, F(3, 54) = 4.72, p < .01, R2 = 0.21, adjusted R2 = 0.16, f2 = 0.26. FSS, physical activity, and television viewing were each then entered as a second step in individual regression as they were associated with body dissatisfaction with a p value of .1 or lower. Physical activity added significantly to the prediction of body dissatisfaction for females, R2 = 0.14, f2 = 0.21, bs = –0.41, p < .01. None of the other variables made a significant contribution above that made by the CDI, MASC, and BMI.
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Males
Table IV summarizes intercorrelations between study variables for males. Body differentiation was associated with body dissatisfaction, r = 0.49, p < .01. Neither body differentiation nor dissatisfaction was related to asthma severity ratings. Body dissatisfaction was associated with each of the CASCL subscales, anxiety, and depression. A t test comparing males with moderate–severe asthma to those with mild asthma found no difference in body dissatisfaction, t(57) = 0.86, p = .39.
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As per females, Table V summarizes change in R2, R2, noncentral 95% confidence intervals for R2 (Smithson, 2001), effect sizes (f2; Cohen, 1977), and standardized parameter estimates for each regression for males. The regression in Step 1 included body image as the dependent variable, and the CDI, MASC, and BMI percentiles together in Step 1, as the independent variable. Depression (CDI), anxiety (MASC), and BMI significantly predicted body dissatisfaction when entered in the first step of a regression, F(3, 53) = 3.23, p < .05, R2 = 0.15, adjusted R2 = 0.11, f2 = 0.18. Each subscale from the CASCL was then entered as a second step in individual regressions. The panic or fear subscale of the CASCL added significant variance to the model for body dissatisfaction, R2 = 0.15, f2 = 0.21, bs = 0.56, p < .01.
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Discussion |
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TopAbstractPredictors of Body Image...Goals of the StudyMethodsResultsDiscussionAcknowledgmentsReferences |
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To date, our knowledge regarding body satisfaction in youth with asthma has been limited to studies where youth with asthma were included in larger groups of youth with chronic illness. This is the first study to examine body satisfaction of children and adolescents with asthma. In addition to self-report measures, this study included clinicians’ assessment of asthma severity, laboratory measure of height and weight, and caregivers’ reports of functional limitation of asthma over the course of 1 year.
Measures used in other studies regarding body dissatisfaction vary from questionnaires, interviews, and drawings. The method used in this study involved coloring in frontal and side figures with five colors corresponding to different levels of satisfaction, very happy, happy, neutral or okay, unhappy, and very unhappy. Subjects were asked to color in the figure based on how they felt about their body. Within this study, the method was easy for children and adolescents to understand, they were able to complete the task within several minutes and answered with enough variability to allow further analysis. Furthermore, we were able to obtain excellent reliability in coding between an undergraduate coder and the primary investigator.
The finding that anxiety, depression, and BMI account for significant variance in body dissatisfaction replicates studies from children without chronic illness (Hausenblas et al., 2002; McCabe & Ricciardelli, 2001, 2003a, 2003b; Ohring et al., 2002; Rierdan & Koff, 1997; Sands & Wardle, 2003). In addition, as in other studies, researchers also found gender differences. The pattern of intercorrelations was different for males and females as were the variables that contributed to body dissatisfaction after accounting for the contribution of negative affect and BMI. For females, physical activity contributed to body dissatisfaction after accounting for anxiety, depression, and BMI; for males, only the panic or fear subscale of the CASCL contributed.
It is interesting that in this sample of youth with asthma, the more objective ratings of asthma, that is, clinicians’ ratings of asthma severity, were not related to body dissatisfaction. However, self and parent ratings with respect to asthma were related to body dissatisfaction. For example, parent’s ratings of functional severity averaged over the course of a year were related to females’ ratings of body dissatisfaction. Parent’s ratings of functional severity were also strongly related to anxiety, depression, and BMI for females, and this may account for the lack of contribution to body dissatisfaction after accounting for anxiety, depression, and BMI. For males, all subscales of the CASCL were related to body dissatisfaction. Despite strong correlations between anxiety, depression, BMI, and the CASCL, the panic or fear subscale of the CASCL contributed to body dissatisfaction after accounting for anxiety, depression, and BMI. This suggests that the panic or fear subscale of the CASCL measures anxiety about asthma that is not captured by more general measure of anxiety, such as the MASC.
In this study, children and adolescents completed rating scales of anxiety and depression. Although higher ratings can identify children at risk for anxiety and depressive disorders, higher ratings do not establish a clinical diagnosis. As with most studies in the literature, the relationships in this study are associations and thus researchers can only speculate about the direction of these relationships. For example, more negative feelings toward one’s body (greater body dissatisfaction) might lead immediately or in the future, to more negative thoughts and feelings in general and about oneself, and thus higher ratings of anxiety and depression. There is some support for this in the literature. In a longitudinal study of over 500 girls in middle school, negative body image in the fall was predictive of the persistence of depression from the fall to the spring (Rierdan, Koff, & Stubbs, 1989). A longitudinal study of 120 adolescent girls found a similar relationship, in that body dissatisfaction in both early adolescence and mid-adolescence was associated with elevated depressive symptoms in early adulthood (Ohring et al., 2002). The converse is also possible, that negative feelings and thoughts as reflected in the MASC and CDI generalize to include negative feelings and thoughts about one’s body and eventually lead to greater dissatisfaction with one’s body. To fully explore these relationships, longitudinal studies are needed.
BMI was related to body dissatisfaction in this sample of youth with asthma, replicating studies of youth without a chronic illness. Some youth with asthma may be at particular risk for increased BMI, through decreased physical activity, steroid use, and the association between the onset of asthma and increased BMI. In addition, youth with greater BMI may also be at risk for more severe and difficult to control asthma [for review see (Tantisira & Weiss, 2001)]. Understanding more about the emotions of youth with asthma, for example, understanding more about body dissatisfaction may be particularly important for youth with increased BMI to help them engage in losing weight and thereby improve asthma symptoms and severity (Tantisira & Weiss, 2001).
There is evidence that increased physical activity can improve fitness for youth with asthma (Ram, Robinson, & Black, 2000) and decrease BMI in adults, although for children, the evidence is mixed (Summerbell et al., 2003). Although, this study does not reveal both the direction of influence, the finding that decreased physical activity was related to greater body dissatisfaction even after controlling for BMI, and negative affect for females suggests that increased physical activity may be an important intervention point. It is possible that increasing physical activity might improve body satisfaction for youth who are not satisfied with their bodies. Lowering BMI may be a possible additional benefit, but may not be required to improve body satisfaction. Further longitudinal studies are needed to examine the relationships between these variables and whether intervention might be indicated.
In this study, males reported that they were very physically active, with 75% reporting that they were active in activities like basketball, or riding a bike, and so on, 4 or more hours per week. The lack of variance in the reply limited our ability to examine this variable in males. In addition, the reporting of high levels of physical activity in a sample with a mean BMI percentile of 68%, and where 45% have a BMI in the 85 percentile or greater, suggests that the self-assessment of physical activity may be influenced by a prosocial response and is an over report of the amount of time spent in cardiovascular activity. To assess this more accurately, future studies should include more objective methods of measuring physical activity, such as methods that measure activity and acceleration along two or more axes (Livingstone, Robson, Wallace, & McKinley, 2003).
This study revealed no relationship between time spent watching television and body dissatisfaction for this sample of youth with asthma. This finding does not preclude the possibility of a relationship between influence from the media and body dissatisfaction in youth with asthma, but may indicate that our method for ascertaining this was too broad. Future studies interested in examining this issue should consider questions that specifically ask about media influence on body image (McCabe & Ricciardelli, 2003b).
This study was limited by its sample size which precluded us from more complex data analysis such as analysis of mediation effects or analysis of patterns between body dissatisfaction, asthma, and emotional variables by age. In addition, the sample size may have led to type II error, thus missing weak but potentially important relationships between variables. For example in females, the relationship between clinician’s ratings of asthma severity and body dissatisfaction approached significance.
This study is the first to examine body dissatisfaction in a sample of youth with asthma. The relationships identified in this study should be confirmed in future studies. In addition, longitudinal studies and the inclusion of children without a chronic illness might further clarify our understanding of body satisfaction in youth with asthma. Other areas of future investigation include examining whether body satisfaction is related to adherence with medical and behavior recommendations for asthma. At this time, clinicians working with youth with asthma might keep in mind the relationships found in this study and inquire about body image, particularly in youth with increased BMI, negative affect, and decreased physical activity. For males, clinicians may also inquire about anxiety related to asthma symptoms, as this somewhat differentiated from the anxiety measure in more general anxiety questionnaires. Further studies may help determine whether understanding more the relationships between body dissatisfaction, emotional variables, BMI, and asthma-related variables may engage youth with more at risk asthma in the management of their health.
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Acknowledgments |
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This study was supported in part by grants 2RO1 HL45157, K08MH01486, and M01-RR00051. The authors thank Crystal Spindler for her assistance. Work from this study was presented in a poster at the 49th annual meeting of the American Academy of Child and Adolescent Psychiatry, San Francisco, 2003.
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