Perceived body image and eating behavior in young adults with cystic fibrosis and their healthy peers

Disordered eating behaviors in pediatric patients with inflammatory bowel disease in remission or mild-moderate disease activity

BACKGROUND

Inflammatory bowel disease (IBD) is a chronic, autoimmune disorder that affects the gastrointestinal tract. Disordered eating describes irregular eating behaviors that may be a precursor to an eating disorder diagnosis. Higher rates of disordered eating have been described in chronic diseases. Screening for disordered eating is not performed in pediatric patients with IBD. The goal of this longitudinal study was to use the Eating Attitudes Test (EAT-26) to screen pediatric patients with IBD for disordered eating, estimate our population's prevalence, identify potential risk factors, and correlate positive EAT-26 screen results with evaluation in adolescent medicine clinic.

METHODS

Eighty patients with IBD between 10 and 21 years completed the EAT-26 questionnaire during gastroenterology clinic visit. Disease activity was measured using Pediatric Ulcerative Colitis Activity Index (PUCAI) and Pediatric Crohn's Disease Activity Index (PCDAI). Patients also rated their own disease activity on a numerical scale.

RESULTS

Five patients had a positive EAT-26 screen and were evaluated in the adolescent medicine clinic. One hundred percent of those who screened positive were diagnosed with a concomitant eating disorder once evaluated. Only 20% of those who screened positive had active IBD. Higher weight, body mass index, and patient perception of disease activity were associated with increased EAT-26 score.

CONCLUSION

Pediatric patients with IBD are at risk for disordered eating, with a prevalence of 6% in our population, which is twice the prevalence of disordered eating in the general population. The EAT-26 questionnaire is a feasible tool to screen pediatric IBD patients for disordered eating.

Dietary intake and quality among adults with cystic fibrosis: A systematic review

AIMS

This systematic review aims to describe the dietary quality, dietary intake and related behaviours of adults diagnosed with cystic fibrosis.

METHODS

A comprehensive literature search was conducted in four databases (Medline, CINAHL, EMBASE, CENTRAL); studies were included if they addressed dietary intake, diet quality or eating behaviours among adults (≥15 years) living with cystic fibrosis and were published from January 2000 to November 2022. The Mixed Methods Appraisal Tool was used to assess the risk of bias and quality of included studies. Findings were synthesised narratively.

RESULTS

Nineteen observational studies (n = 2236) were included and considered high to moderate quality. Most (13/19) studies reported that individuals with cystic fibrosis were consuming high-energy diets; where studies reported energy intake as a proportion of requirements met, energy intake was high, even when using individualised or cystic fibrosis-specific referents. In addition, fat intakes as a proportion of energy appeared high (29%-39% of total energy), particularly as current guidelines recommend macronutrient profile similar to the general population (<30% of total energy). There was considerable variation in the reporting of fatty acid profiles and other nutrients. Five studies reported on concerns regarding diet and eating in this population.

CONCLUSION

Findings from the current review suggest dietary intakes of adults with cystic fibrosis appear to be less than optimal and concerns about diet, weight and food may be emerging in this population. Future research utilising consistent measures of dietary assessment and reporting, reporting of medical therapies, and exploring potential concerns about diet and eating is warranted.

Nutritional management of people living with cystic fibrosis throughout life and disease continuum: Changing times, new challenges

Cystic fibrosis (CF) is a genetic disease caused by mutations in the gene encoding for the ion channel cystic fibrosis transmembrane conductance regulator (CFTR). The management of CF disease has evolved in recent decades from treating downstream disease manifestations affecting the airways, the lungs and the gastrointestinal system to addressing the CFTR gene defect. The advent of CFTR modulators, which correct the functionality of the defective CFTR, contributes to reshaping the landscape of CF demographics, prognosis and therapies, including nutritional management. A spectrum of clinical manifestations is emerging within the same patient population where undernutrition and nutritional deficiencies coexist with excessive weight gain and metabolic derangements. Such contrasting presentations challenge current practices, require adjustments to traditional approaches, and involve more individualised interventions. This narrative review examines the current state of knowledge on the nutritional management of people living with cystic fibrosis from early life to adulthood in the era of CFTR modulation.

Nutritional considerations for a new era: A CF foundation position paper

OBJECTIVE

To provide interim advice and considerations to the CF Community around CF nutrition in the current era.

METHODS

The Cystic Fibrosis (CF) Foundation organized a multidisciplinary committee to develop a Nutrition Position Paper based on the rapidly changing nutrition landscape in CF, due in part to widespread use of cystic fibrosis transmembrane regulator highly effective modulator therapy (HEMT). Four workgroups were formed: Weight Management, Eating Behavior/Food Insecurity, Salt Homeostasis and Pancreatic Enzyme use. Each workgroup conducted their own focused review of the literature.

RESULTS

The committee summarized current understanding of issues pertaining to the four workgroup topics and provided 6 key take-aways around CF Nutrition in the new era.

CONCLUSION

People with CF (pwCF) are living longer, particularly with the advent of HEMT. The traditional high fat, high calorie CF diet may have negative nutritional and cardiovascular consequences as pwCF age. Individuals with CF may have poor diet quality, food insecurity, distorted body image, and an higher incidence of eating disorders. An increase in overweight and obesity may lead to new considerations for nutritional management, given potential effects of overnutrition on pulmonary and cardiometabolic parameters.

Psychometric properties of the Cystic Fibrosis Eating Attitudes and Behaviours scale (CFEAB) in an adult population

OBJECTIVES

Individuals with Cystic Fibrosis (CF) may be at an increased risk of developing a range of eating difficulties. Scales designed to measure disordered eating in the general population do not cover CF-specific behaviours resulting in a knowledge gap. The CFEAB was developed as a CF-specific measure assessing eating behaviours and attitudes however little evidence exists regarding its psychometric quality. The aim of this cross-sectional study was to provide a robust assessment of its internal consistency, structural validity, and criterion validity.

METHODS

One-hundred and thirty-two people with CF completed self-report scales pertaining to mental health, eating disorders, and the Cystic Fibrosis Eating Attitudes and Behaviours (CFEAB).

RESULTS

Results of exploratory structural equation modelling indicated that a three-factor structure produced good fit with the 24-item CFEAB but a purified 12-item CFEAB displayed superior fit and internal consistency. Also, the 12-item scale predicted significant amounts of variance for anxiety, depression, and eating disorders showing enhanced relevance for clinical use. Conclusions These findings add emphasis to the importance of the validation and development of CF-specific measures and the possible inclusion at clinics to help improve CF patient care.

Eating disorders in adolescents and young adults with cystic fibrosis

INTRODUCTION

There is evidence for increased risk of eating disorders in individuals with diet-treated chronic illnesses, however, data in patients with cystic fibrosis (CF) is less clear. No studies have evaluated avoidant/restrictive food intake disorder (ARFID) in the CF population. We investigated the prevalence of eating disorders, including ARFID, in adolescents and young adults with CF.

METHODS

Patients with CF aged 14-35 years were recruited to complete three validated surveys: (1) Eating Disorder Examination Questionnaire (EDE-Q), (2) Nine-Item Avoidant/Restrictive Food Intake Disorder Scale (NIAS), and (3) Cystic Fibrosis Questionnaire-Revised (CFQ-R). Univariate linear regression analysis identified baseline risk factors associated with these survey scores. Variables with univariate p &lt; 0.20 were considered for inclusion in a multivariable linear regression model. Backwards stepwise linear regression was used to identify the final model.

RESULTS

A total of 52 patients enrolled. The prevalence of a positive screen on the EDE-Q was 9.6%, and on the NIAS was 13.5%. The CFQ-R eating and weight subscales were associated with scores on the EDE-Q, and CFQ-R eating subscale and being dF508 homozygous were correlated with the NIAS total score.

DISCUSSION

A clinically significant number of participants screened positive for eating disorders on the EDE-Q and NIAS. Scores on the eating and weight scales of the CFQ-R were associated with the scores on these surveys. Further work is needed to better understand the optimal way to use such tools to screen and treat for eating disorders in individuals with CF.

Eating Disorders and Disordered Eating Behaviors in Cystic Fibrosis: A Neglected Issue

As with the majority of chronic diseases having specific nutrition recommendations, in cystic fibrosis (CF), the emphasis placed on patients regarding their diet and ideal body weight status often increases the risk of developing disordered eating behaviors and by inference, eating disorders (EDs). Body weight appears to be an important concern for patients with CF, with many patients struggling to lose weight. Between sexes, women appear more preoccupied with dieting compared to men, but exhibit a better body image, mainly due to their preference for a lower weight. Several comorbidities appear to change these dynamics, and visibly apparent factors, including scars, ports, and tubes, and the need for supplementary oxygen supply, may also influence body image perception. Disordered eating is usually initiated during a bout of pulmonary infection, with the patient feeling unwell to eat. Regarding the prevalence of EDs, research appears conflicting on whether it is higher among individuals with a CF diagnosis or not. As for comorbidities, anxiety and depression consist of the most common psychiatric diagnoses in CF, also greatly prevalent in EDs. Despite the plethora of studies, non-specific CF tools, small samples, and lack of data regarding important outcomes, including lung health, indicate the need for more research.

Just breathe: a review of sex and gender in chronic lung disease

Chronic lung diseases are the third leading cause of death worldwide and are increasing in prevalence over time. Although much of our traditional understanding of health and disease is derived from study of the male of the species - be it animal or human - there is increasing evidence that sex and gender contribute to differences in disease risk, prevalence, presentation, severity, treatment approach, response and outcomes. Chronic obstructive pulmonary disease, asthma and bronchiectasis represent the most prevalent and studied chronic lung diseases and have key sex- and gender-based differences which are critical to consider and incorporate into clinical and research approaches. Mechanistic differences present opportunities for therapeutic development whereas behavioural and clinical differences on the part of patients and providers present opportunities for greater education and understanding at multiple levels. In this review, we seek to summarise the sex- and gender-based differences in key chronic lung diseases and outline the clinical and research implications for stakeholders.

Perception, experience and relationship with food and eating in adults with cystic fibrosis

BACKGROUND

Cystic fibrosis (CF) is a multisystem disorder that primarily affects the respiratory and gastrointestinal systems. Dietetic therapy is a prominent aspect of CF management, with patients receiving nutritional surveillance and advice throughout their lifetime. The present study aimed to explore the perception, experience and relationship with food and eating in adults with CF.

METHODS

Semi-structured telephone interviews were conducted with nine adults with CF. Interviews were audio-recorded, transcribed verbatim and analysed thematically following a previously described six-phase procedure.

RESULTS

Six themes were identified: 'Sustained influence of eating experience in childhood', 'Eating for health: weight gain to prevent infection', 'Balancing health and body image', 'I'm different,' 'Strategies for managing food intake' and 'Support from family, friends and the CF Team'. Participants talked about the range of strategies they employ, with a focus on eating well and choosing high calorie foods being an important part of their health management strategy. This is driven by the belief that a good weight ensures better health and perceiving eating as a treatment.

CONCLUSIONS

This group felt able to cope well and had developed strategies to manage their dietary needs. Food experience was variable throughout their lifetime, with childhood experience having a sustained effect on adult eating behaviour. Weight gain, body image and dietary health implications are considerable concerns for patients. New CF transmembrane modulator treatments (CFTR modulators) are changing the dietary needs of this population. It is important that these issues are explored during dietetic consultations to identify barriers to dietary change.

Eating disorders and body image in cystic fibrosis

Eating disorders and disturbed body image have been reported in individuals with cystic fibrosis (CF) and may contribute to poor weight gain, reduced lung function and increased mortality. CF individuals often look and feel different from their peers and bear the additional burden of body-altering side effects of treatment. As a result, the impact of disorders such as binge eating, anorexia nervosa, and bulimia nervosa may adversely affect the social, emotional, and physical development of those with CF.

Multiple risk factors may contribute to the development of an eating disorder in CF. Growth failure is affected by the physical impairments of CF, including pancreatic insufficiency, high energy demands, respiratory infections, and delayed and stunted growth and puberty. Psychological factors, such as CF associated depression and anxiety, intense focus on BMI, lack of control in a chronic disease, and preoccupation with morbidity and mortality, likely further contribute. Exercise inefficiency, secondary to poor lung function, low BMI and pulmonary exacerbations, and the potential for medication manipulation are also additional risk factors.

The intense scrutiny around BMI may lead to a poor relationship with food, including disordered eating habits, abnormal mealtime behaviors, and stressful caregiver-patient interactions regarding meals. This further contributes to a discrepancy between ideal CF nutritional standards and the reality of the challenges of appropriate daily energy intake for an individual with CF.

It is imperative that CF providers are equipped to identify potential eating disorders and disturbed body image in their CF patients. Improved screening and monitoring practices should be developed and implemented, with multidisciplinary support from all CF care team members, including dietitians, mental health professionals, and social workers, to best support holistic care and optimize outcomes. Increased attention to these concerns may help reduce CF related morbidity and mortality.

Challenges Faced by Women with Cystic Fibrosis

Women with cystic fibrosis (CF) face several unaddressed concerns related to their health. These areas of concern include explanations and guidance on a sex disparity in outcomes, timing of puberty, effects of contraception, prevalence of infertility and impact of pregnancy, and prevention of urinary incontinence and osteoporosis. These understudied topics leave women with numerous unanswered questions about how to manage sexual and reproductive health in the setting of CF. Because people with CF are living longer and healthier lives, there is an increasing awareness of these important aspects of care and multiple ongoing studies to address these understudied topics.

Accuracy of Body Size Estimation in Youth with Cystic Fibrosis and Association with Health-Related Quality of Life

Accuracy of body size estimation may impact motivation to adhere to treatment recommendations and health-related quality of life (HRQOL) in youth with cystic fibrosis (CF), but this has not yet been investigated. Thus, the goal of the current study was to examine accuracy of body size estimation in youth with CF, and associations with HRQOL, lung functioning, and dietary intake. Fifty-four youth diagnosed with CF (M = 13.61 years) completed the Figure Rating Scale, the Cystic Fibrosis Questionnaire-Revised, and a 24-h diet recall interview. Cohen's Weighted Kappa Coefficient evaluated agreement between body size estimation and BMI percentile. Binary logistic regression analyses examined associations between body size accuracy and HRQOL, lung functioning, and dietary intake. A less than adequate agreement was found between youth body size estimation and BMI percentile. Most participants overestimated body size (69.8%). Body Image HRQOL, but neither lung functioning nor dietary intake, was significantly associated with body size estimation accuracy. Working with patients to improve perceptions of body size may also improve HRQOL scores and allow for discussion about treatment goals related to body size.

Health-related quality of life of teen/adult patients with cystic fibrosis in the Republic of North Macedonia

The present study investigates the Health-related quality of life of teen/adults patients with cystic fibrosis in the Republic of N. Macedonia for the first time. The main objective was to describe the health-related quality of life status of these patients with cystic fibrosis and the second objective was to investigate the connection of the current medical treatment with the analysed parameters. The survey was conducted on 31 patients by using the Cystic Fibrosis Questionnaire Revised for Health-related quality of live measurement and questions for current medical treatment. All patients scored their digestive condition with the highest score, while the lower score was reported for social activity. The gender, the nationality and the educational level of the patients with Cystic Fibrosis had no significant impact on their perception of Health-Related Quality of Live. The highest score for digestive condition was in positive correlation with the fact that all patients continuously used enzyme therapy. Patients who practiced physical therapy and physical activities reported high scores for physical conditions and body images. This finding point out that patient with Cystic Fibrosis should be encouraged to practice physical activity more often. The lowest scores for life activities and treatment burden shows that this medical condition has a negative impact on the patients’ self-perception and in the execution of their daily activities. Keywords: cystic fibrosis, Health-Related Quality of Live, digest, daily activities

Admitted for an Eating Disorder: Challenges Clinical Psychologists Face in Working with Patients and Their Families on a Consultation-Liaison Service in a Tertiary Pediatric Hospital

Eating disorders are one of the most common causes of pediatric hospitalizations due to primary mental health diagnoses. The purpose of this article is to discuss the challenges clinical psychologists face in working with patients with eating disorders and their families during medical admissions. Using the Psychiatry Consultation Service at a tertiary pediatric academic medical center in the Northeast as a framework, authors present the responsibilities of clinical psychologists on this service and their role within the larger, interdisciplinary team. Topics addressed also include systemic challenges, medical and psychiatric comorbidities, and differential psychiatric diagnoses. Case examples are provided to highlight various challenges as well as potential solutions and approaches. Clinical implications, limitations, and directions for future research are also discussed.

A Survey Identifying Nutritional Needs in a Contemporary Adult Cystic Fibrosis Cohort

Background

Cystic fibrosis (CF) is a disease in which nutritional barriers are diverse and common, with malnutrition greatly influencing pulmonary trajectory and overall outcomes. Despite this, the most effective methods to optimize CF nutrition are unknown, and literature describing patients’ perspectives on their specific nutritional needs is lacking, particularly in the modern era of CF care. This study aimed to identify the most important nutritional needs and desired health-improvement resources in a contemporary adult CF cohort.

Methods

A 14-question investigator-designed survey addressing nutrition concerns, preferred health-improvement resources, and dietary/exercise routines was administered to CF adults. Clinical characteristics and survey responses are presented with descriptive statistics, and responses compared by body mass index (BMI) category (< 18.5 kg/m²; 18.5–24.99 kg/m²; 25–29.99 kg/m²; ≥30 kg/m²), gender, and socioeconomic status using Chi square or Fisher’s Exact testing.

Results

Of 66 total patients, nine (13.6%) were underweight (BMI < 18.5 kg/m²), while 19 (28.8%) were overweight or obese (BMI ≥ 25 kg/m²). In the overall cohort, the most common primary concern was preventing weight loss [in 20/66 patients (30.3%)], but there were significant differences by BMI (p < 0.001), with the most common concern in the overweight subgroup being preventing weight gain. Fifteen (46.9%) men (BMI mean 20.7, range 16.4–29.2 kg/m²) listed preventing weight loss as the primary concern, compared to only 5 (14.7%) women (BMI mean 18.4, range 16.2–19.9 kg/m²), representing a trend toward a difference in primary concerns by gender (p = 0.066).

The most commonly desired health-improvement resource was online CF nutrition and fitness information, found in 26 patients (39.4%) in the overall cohort, without significant differences by BMI (p = 0.814) or gender (p = 0.199). Financial assistance was the preferred resource in 17 (26.2%), without differences by socioeconomic status (p = 0.367).

Conclusions

We identified a wide variety of nutritional needs in CF adults, including a high prevalence of overweight status, many patients desiring weight loss, and many seeking financial resources. Our findings support the individualization of modern-day CF nutrition programs and development of online resources, in an effort to address the heterogeneous barriers that exist in the contemporary CF population and improve outcomes in patients with the disease.

Electronic supplementary material

The online version of this article (10.1186/s40795-018-0266-3) contains supplementary material, which is available to authorized users.

Patient and Provider Perspectives on Communication About Body Image With Adolescents and Young Adults With Cystic Fibrosis

Objective

This mixed-methods study examined perspectives of adolescents and young adults (AYAs) with cystic fibrosis (CF) and health care providers on body image communication.

Methods

Interviews and questionnaires were completed by 20 AYAs and 28 providers.

Results

Although 85% of patients reported they had never had a body image conversation with a health care provider, 74% of providers reported discussing this topic with patients. Patients and providers described body image as an important issue, which should be discussed comfortably and supportively. However, patients often preferred to discuss body image as a distinct topic, separate from physical health, whereas providers preferred integrating body image conversations within weight- and health-based discussions.

Conclusions

Body image is an important topic for AYAs with CF that often goes unaddressed or addressed in ways that are less preferred by patients. Providers should reduce barriers to effective communication about this important topic, particularly through increased awareness of AYA preferences.

Caring for Children With Cystic Fibrosis: A Collaborative Clinical and School Approach

Earlier diagnosis and more effective treatments have improved both morbidity and mortality associated with cystic fibrosis, making regular school attendance a reality. School nurses have a unique opportunity to assist students with cystic fibrosis successfully manage their disease. Medical treatment for cystic fibrosis can be complex, leaving students and families in need of health consultation and support. The clinic and school nurse each brings a unique perspective to cystic fibrosis care management. Working to understanding perspectives across settings and looking for ways to collaborate through mutual planning and goal setting is an ideal way to support families and promote achievement of optimal health status for students.

[A pilot study on the specificity of body image disturbance in anorexia nervosa]

OBJECTIVE

Body image disturbance (BID) is a central feature of anorexia nervosa (AN), but evidence for bodily-related disorders also exists for patients with cystic fibrosis (CF), who are frequently underweight. A comparison of BID in patients with AN, CF and controls serves to clarify the specificity of BID for AN.

METHOD

22 patients with AN, 10 patients with CF, and 23 controls were tested with regard to perceptual and cognitive-affective components of BID. Further data concerning eating-disorder-related psychopathology were assessed.

RESULTS

BID occurred in all patients with AN. Patients with CF perceived themselves as thinner than the controls did, and three of them exhibited BID. Patients with AN and CF did not differ regarding body satisfaction, and only controls showed higher satisfaction than patients with CF. Patients with AN and CF differed on desire for thinness, dissatisfaction with their body, and interoceptive awareness, with higher scores occurring in patients with AN.

CONCLUSIONS

Our pilot study reveals no severe psychopathology concerning body image in patients with CF. However, we did observe a general body dissatisfaction among these patients, probably associated with their being underweight. BID still seems to be a central diagnostic criterion for AN and should be carefully considered during therapeutic interventions.

Self-esteem and its relationship to mental health and quality of life in adults with cystic fibrosis

Research from the general population indicates an important role for self-esteem in mental health, but limited research in this area exists in the cystic fibrosis (CF) literature. This study aimed to explore the predictive value of self-esteem and health-related quality of life (HRQoL) in mental health symptoms in adults with CF. Seventy-four participants, recruited online, completed the Clinical Outcomes in Routine Evaluation-Outcome Measure 34 (CORE-OM), Rosenberg Self-esteem Scale and Cystic Fibrosis Questionnaire-Revised (CFQ-R). Comparably high levels of self-esteem were found, but HRQoL was lower than previous research. Thirty percent of participants scored within the clinical range for mental health difficulty. Hierarchical regression, controlling for gender, explored the value of four CFQ-R subscales (physical, social, emotional and role functioning) and self-esteem in predicting CORE-OM total score. Gender accounted for 8.2% of the variance in mental health scores while the five independent variables accounted for a further 73.0% of variance. Of the five variables, CFQ-R emotional functioning and self-esteem were significant predictors of mental health symptoms. Results are discussed in relation to clinical implications and potential uses for internet technologies to promote socialisation.

Chronic illness and disordered eating: a discussion of the literature

This paper describes the prevalence of eating disorders and disordered eating behaviors, the reasons why these practices are endorsed, and the potential consequences in youths and young adults with selected diet-related chronic health conditions (DRCHCs) and provides recommendations for eating disorder prevention interventions and research efforts. Although it remains unclear whether the prevalence of eating disorders is higher in those with DRCHCs compared with the general population, overall findings suggest that young people with DRCHCs may be at risk of endorsing disordered eating behaviors that may lead to diagnosis of an eating disorder and other health problems over the course of their treatment. Thus, health care providers should be aware that young people with DRCHCs may be at risk of eating disorders and carefully monitor psychological changes and the use of unhealthy weight control methods. It is also important to develop and evaluate theory-based interventions and disease-specific eating disorder risk screening tools that are effective in halting the progression of eating disorders and negative health outcomes in young people with chronic health conditions.

Do patient-reported outcomes have a role in the management of patients with cystic fibrosis?

BACKGROUND

Health-related quality of life (HRQoL) is a rapidly growing area of expertise and the most commonly used patient-reported outcome (PRO). The impact of cystic fibrosis (CF) on HRQoL is liable to be great, making CF patients ideal candidates for the application of HRQoL instruments. The aims of this study were to assess the affect of CF on HRQoL, to ascertain the reliability and validity of the United Kingdom Sickness Impact Profile (UKSIP) and the Cystic Fibrosis Quality of Life Questionnaire (CFQoL) in the adult CF population, and to examine their role in the management of patients.

METHODS

Seventy participants were recruited from the All Wales Adult Cystic Fibrosis Centre at Llandough Hospital, UK. There were two stages to the study: self-report of the UKSIP and CFQoL; and completion of the same two questionnaires 7-10 days later.

RESULTS

The areas of HRQoL most impaired by CF were employment and concerns regarding the future. The UKSIP and CFQoL showed high internal consistency (rα = 0.89-0.93) and test-retest reliability (r(s) = 0.57-0.94, p < 0.005) in the CF population. Validity was variable with the UKSIP showing discrimination across socio-demographic factors, whilst the CFQoL showed increased sensitivity to clinical variables. Many parameters influenced patient-reported HRQoL, with the greatest correlations seen with the Borg score (p < 0.005). The use of a HRQoL instrument in CF annual reviews is recommended to provide holistic patient care. The results of this study underpin the value of HRQoL as a patient-reported outcome measure in the management of adult CF.

Body image and cystic fibrosis: a critical review

A slight frame and poor appetite are common among patients with cystic fibrosis (CF) yet healthy body weight has been related to a better prognosis. A review of studies exploring body image (BI) among adults and adolescents with CF was conducted. Seven electronic databases were searched for potential papers. They located 128 references, of which 24 were read in full and 12 included in the review. Accepted papers suggested females with CF had a better BI compared to males, but this could compromise survival, given their preference for a low body weight. Males may be more motivated to adhere to nutritional advice because they favor a larger form. Practitioners should broach the topic of BI at clinic appointments to ensure this does not have a detrimental impact on self-management, although more research is required to guide professionals in this task.

Body satisfaction, nutritional adherence, and quality of life in youth with cystic fibrosis

Children with cystic fibrosis (CF) typically have similar nutritional intake as healthy peers, despite recommendations to consume more calories and fat. Body satisfaction may play a role in nutritional intake: females may be content with their smaller size despite recommendations for weight gain, while males may desire to be larger and more muscular, which is more congruent with medical advice. Females are especially at risk, given their propensity to desire a smaller body size, tendency for lower HRQOL, steeper trajectory of health decline and shorter life expectancy than males. This study evaluated body satisfaction in relation to nutritional adherence and HRQOL in youth with CF. Fifty-four individuals with CF (age 9-17) completed the Cystic Fibrosis Questionnaire-Revised (CFQ-R), the Figure Rating Scale, and a 24-hr diet recall interview with their caregiver. Twenty-four percent of youth were non-adherent with caloric goals, and 40.7% did not obtain the minimum recommendation for fat intake. Youth were classified as inconsistent with treatment goals (TI) if they desired a smaller body size or were content with their current size despite a BMI less than the 50th percentile; 44.8% of females were classified as TI, compared to only 8% of males. Statistical analyses were performed to evaluate the impact of gender and body satisfaction on HRQOL in youth with CF. Linear multiple regression models were fit; TI females had Emotional HRQOL scores 23 points lower than males. Results suggest that improving body satisfaction, especially for females, may help to improve overall quality of life and potentially impact nutritional adherence.

Effects of gender and age at diagnosis on disease progression in long-term survivors of cystic fibrosis

RATIONALE

Long-term survivors of cystic fibrosis (CF) (age > 40 yr) are a growing population comprising both patients diagnosed with classic manifestations in childhood, and nonclassic phenotypes typically diagnosed as adults. Little is known concerning disease progression and outcomes in these cohorts.

OBJECTIVES

Examine effects of age at diagnosis and gender on disease progression, setting of care, response to treatment, and mortality in long-term survivors of CF.

METHODS

Retrospective analysis of the Colorado CF Database (1992-2008), CF Foundation Registry (1992-2007), and Multiple Cause of Death Index (1992-2005).

MEASUREMENTS AND MAIN RESULTS

Patients with CF diagnosed in childhood and who survive to age 40 years have more severe CFTR genotypes and phenotypes compared with adult-diagnosed patients. However, past the age of 40 years the rate of FEV(1) decline and death from respiratory complications were not different between these cohorts. Compared with males, childhood-diagnosed females were less likely to reach age 40 years, experienced faster FEV(1) declines, and no survival advantage. Females comprised the majority of adult-diagnosed patients, and demonstrated equal FEV(1) decline and longer survival than males, despite a later age at diagnosis. Most adult-diagnosed patients were not followed at CF centers, and with increasing age a smaller percentage of CF deaths appeared in the Cystic Fibrosis Foundation Registry. However, newly diagnosed adults demonstrated sustained FEV(1) improvement in response to CF center care.

CONCLUSIONS

For patients with CF older than 40 years, the adult diagnosis correlates with delayed but equally severe pulmonary disease. A gender-associated disadvantage remains for females diagnosed in childhood, but is not present for adult-diagnosed females.

Symposium 6: Young people, artificial nutrition and transitional care The nutritional challenges of the young adult with cystic fibrosis: transition

Cystic fibrosis (CF) is a complex multisystem disorder affecting mainly the gastrointestinal tract and respiratory system. Intestinal malabsorption occurs in approximately 90% of patients. In the past, malnutrition was an inevitable consequence of disease progression, leading to poor growth, impaired respiratory muscle function, decreased exercise tolerance and immunological impairment. A positive association between body weight and height and survival has been widely reported. The energy requirements of patients with CF vary widely and generally increase with age and disease severity. For many young adults requirements will be 120–150% of the age-related estimated average requirement. To meet these energy needs patients are encouraged to eat a high-fat high-energy diet with appropriate pancreatic enzyme supplements. Many patients are unable to achieve an adequate intake as a result of a variety of factors including chronic poor appetite, infection-related anorexia, gastro-oesophageal reflux and abdominal pain. Oral energy supplements and enteral tube feeding are widely used. Nutritional support has been shown to improve nutritional status and stabilise or slow the rate of decline in lung function. With such emphasis on nutritional intake and nutritional status throughout life, poor adherence to therapies and issues relating to body image are emerging. The median survival of patients with CF is increasing. CF is now considered a life-limiting disease of adulthood rather than a terminal childhood illness. With increased longevity new challenges are emerging that include the transition of young adults with CF to adult services, CF-related diabetes, disordered eating, osteoporosis, liver disease and transplantation.

Associations of psychosocial factors with health outcomes among youth with cystic fibrosis

PURPOSE

The purpose of this study was to examine the relationship of strains, resources, feelings, and behaviors about treatment adherence reported by youth with cystic fibrosis (CF) with repeated clinic measures of their pulmonary function and nutritional status.

METHODS

Linear mixed models, stratified by gender, adjusting for age, were used to examine the effects of strains, resources, and adherence behaviors on repeated pulmonary function and nutritional status measures. All 10-21 years old with CF at the Minnesota Cystic Fibrosis Center were invited by mail to participate. Of these 177 youth, 51% (43 boys, 47 girls) returned surveys. Forced expiratory volume in 1 sec and predicted weight-for-height were extracted from participants' clinic records for the 18 months following receipt of the survey.

RESULTS

Females showed significantly greater variability in repeated measures of pulmonary function and nutritional status compared to males. Parent-youth strains, physical strains, activity limitations, and cough suppression had significant effects on the 18-month mean of pulmonary function measures for females, but only physical strains had a significant effect for males.

CONCLUSION

Compared to males, females experienced more strains and poorer treatment adherence, which may be factors associated with declines in pulmonary function observed among females with CF during the adolescent years.

Gender differences in treatment adherence among youth with cystic fibrosis: Development of a new questionnaire

BACKGROUND

Some prior studies have reported that girls with cystic fibrosis (CF) experience higher morbidity and mortality compared to boys. In this study, the authors compared boys' and girls' perceptions of disease-related strains and resources associated with living with CF, and the relationship of these factors to CF treatment feelings and behaviors.

METHODS

All 10-21 year olds with CF at the Minnesota Cystic Fibrosis Center were invited by mail to complete a new self-report survey (Living with CF Questionnaire--LCFQ). Of these 177 youth, 58% (49 boys and 54 girls) returned surveys.

RESULTS

Exploratory and confirmatory factor analyses revealed nine factors in the LCFQ. Partial support was found for hypothesized gender differences in these factors. Compared to boys, girls reported significantly more illness-related strains and worries, including emotional strains, greater treatment discouragement, lower self-esteem, and lower adherence to some aspects of the CF treatment regimen (coughing, eating high-fat foods, taking meds/pills).

CONCLUSIONS

Living with CF appears to have a greater emotional impact on adolescent girls compared to boys. These gender differences may contribute to the poorer pulmonary function observed among girls with cystic fibrosis during the adolescent years.

Nutritional status, perceived body image and eating behaviours in adults with cystic fibrosis

BACKGROUND & AIMS

Achieving and maintaining an ideal nutritional status is the primary aim of the nutritional management of cystic fibrosis (CF). It is unclear how nutritional interventions impact on patients' perceptions and behaviours concerning body image and eating. This work aimed to provide a psychosocial profile and compare CF patients receiving (a) enteral tube feeding, (b) nutritional supplements, (c) no nutritional interventions, and (d) healthy controls.

METHODS

A cross-sectional questionnaire design was employed. Age, gender, lung function, and body mass index were recorded. Subjects completed measures of eating attitudes, perceived and desired body shape, body image, self-esteem and quality of life (QoL).

RESULTS

A minority of CF patients reported disordered eating. Those receiving nutritional interventions engaged in less dieting behaviour. All CF groups, especially intervention groups, received more pressure from others to eat. For females, control groups desired to be slimmer whereas intervention groups desired to be heavier. Healthy males were content with their body whereas CF males wished to be heavier. Patients receiving enteral tube feeding were less satisfied with their body image, reported lower self-esteem and poorer QoL.

CONCLUSION

Body image and eating behaviours are important considerations of nutritional interventions for maintaining QoL.

Gender differences in health-related quality of life of adolescents with cystic fibrosis

Background

Female patients with cystic fibrosis (CF) have consistently poorer survival rates than males across all ages. To determine if gender differences exist in health-related quality of life (HRQOL) of adolescent patients with CF, we performed a cross-section analysis of CF patients recruited from 2 medical centers in 2 cities during 1997–2001.

Methods

We used the 87-item child self-report form of the Child Health Questionnaire to measure 12 health domains. Data was also collected on age and forced expiratory volume in 1 second (FEV₁). We analyzed data from 98 subjects and performed univariate analyses and linear regression or ordinal logistic regression for multivariable analyses.

Results

The mean (SD) age was 14.6 (2.5) years; 50 (51.0%) were female; and mean FEV₁ was 71.6% (25.6%) of predicted. There were no statistically significant gender differences in age or FEV₁. In univariate analyses, females reported significantly poorer HRQOL in 5 of the 12 domains. In multivariable analyses controlling for FEV₁ and age, we found that female gender was associated with significantly lower global health (p < 0.05), mental health (p < 0.01), and general health perceptions (p < 0.05) scores.

Conclusion

Further research will need to focus on the causes of these differences in HRQOL and on potential interventions to improve HRQOL of adolescent patients with CF.

Associations between clinical variables and quality of life in adults with cystic fibrosis

BACKGROUND

The disease progression of cystic fibrosis (CF) is marked by an increase in clinical conditions and therapeutic interventions, which have the potential to affect health-related quality of life (HRQoL). This cross-sectional study explored associations between clinical variables and HRQoL.

METHODS

HRQoL was measured using the Cystic Fibrosis Quality of Life (CFQoL) questionnaire, which consists of nine domains: physical, social, treatment, chest symptoms, emotional functioning, concerns for the future, relationships, body image, and career concerns. The CFQoL was completed by 223 adults with CF. Clinical and demographic data collected were: age, gender, FEV1% predicted, BMI, Burkholderia cepacia status, lung transplant status, diabetic status, level of nutritional intervention, and presence of an intravenous access device. Multiple regression using forward selection was used to construct models relating these variables to each HRQoL domain.

RESULTS

Despite many of the variables being inter-related, some variables were associated with CFQoL domains even in the presence of other important clinical factors. FEV1% predicted was weakly positively associated with all nine domains. Strong evidence emerged that patients who had received a lung transplant reported a higher HRQoL in physical and social functioning, chest symptoms, and treatment issues. Females tended to report a lower quality of life for chest symptoms and career issues, but higher values for body image. Patients with an access device expressed more career concerns. There was no evidence of an association between B. cepacia and any of the nine CFQoL domains. The model for the body image domain explained a high percentage of the variance (R2=30%): negative body image was associated with lower BMI, having an access device, diabetes, and enteral feeding.

CONCLUSIONS

While important associations were identified, much of the variance in HRQoL remains unexplained. Other clinical and psychosocial variables merit investigation. A longitudinal study is required to investigate how the disease trajectory and associated treatments affect an individual's quality of life.

Quality of life in cystic fibrosis: the impact of gender, general health perceptions and disease severity

BACKGROUND

Disease progression in cystic fibrosis (CF) is marked by deterioration across a number of physiological systems. In addition, there is evidence that females have a worse prognosis than males. The current work assesses the impact of both these factors on health related quality of life (HRQoL).

METHODS

Two hundred and twenty-three adolescents and adults completed the cystic fibrosis quality of life (CFQoL) questionnaire with a further 185 approached and not responding by non-completion of the questionnaire. The CFQoL is divided into nine domains: physical, social, treatment, chest symptoms, emotional functioning, concerns for the future, relationships, body image, and career. Measurement of objective clinical status included, body mass index (BMI), and percentage of predicted forced expiratory volume in one second (FEV1). General health perceptions (GHP) were also measured.

RESULTS

Patients were sub-divided by gender and disease severity (mild > 70% FEV1, moderate 40-69% and severe < 40%). Factorial analysis of variance indicated significant main effects for FEV1 (F = 587.98, P < or = 0.001) and BMI (F = 17.29, P < or = 0.001) as a function of disease severity. Post hoc tests revealed significant two-group differences for FEV1 and BMI between disease severity groups. No differences were observed for gender across FEV1 or BMI. Differences emerged across most CFQoL domains for disease severity, with the exception of concerns for the future, which was consistently low throughout. Gender differences emerged for chest symptoms, emotional functioning, concerns for the future, body image and career. With the exception of body image, females exhibited poorer HRQoL. Pearson correlations indicated that females' perception of health was more closely related to clinical status than males.

CONCLUSIONS

Disease severity has an impact on HRQoL in adolescents and adults with CF. Some differences emerged between males and females, with females generally reporting poorer HRQoL. Evidence indicated that males and females perceived their health status differently, with females having a more accurate perception of objective clinical health status.

Quality of life in children and adolescents with cystic fibrosis: implications for optimizing treatments and clinical trial design

Health related quality of life (QOL) as an outcome measure in clinical trials is becoming increasingly important. Trials should not only be able to demonstrate the pharmacologic activity of a therapy, but of equal importance, they should demonstrate clinical effectiveness that is of significant benefit to the patient. QOL measurement provides a way of incorporating the child/parent's perspective of how cystic fibrosis (CF) and its therapies impact on their lives. Several validated generic instruments have been employed to measure QOL in adolescents and adults. QOL assessment is more difficult in children and, therefore, has been employed less often in children with CF. Difficulties arise with the issue of whether children can report their own experiences directly, or whether a parent or clinician should report on behalf of the child. A child-centered approach is imperative since the literature indicates that children are able to report on their own QOL. An additional complication has been the use of adult measures with children. These are often inappropriate in their complexity, use of language, response scales, and time frame. The evaluation of pharmacologic therapies can profit from QOL measurement. The effectiveness of a drug and any adverse effects that impact on daily life can be assessed from the child/parent's viewpoint. Home therapy versus hospital therapy and drug delivery systems, are additional areas where QOL as an outcome measure is valuable. There have been relatively few appropriately powered trials in CF, and only a minority of these have evaluated QOL as an outcome measure. This review highlights areas where QOL measurement is appropriate. It focuses on the pharmacologic trials that have employed QOL assessment for antibiotic, mucociliary clearance, anti-inflammatory, and nutritional therapies. Methodological issues of incorporating QOL assessment into trials center on cross-cultural and data interpretation issues. QOL measurement in CF has been patchy and largely unreliable. The notion that improved symptoms equate with improved QOL is erroneous. Measurement of how symptoms impact on QOL is essential. Currently, the development and validation of CF specific measures (across the CF age range) provides optimism for appropriate QOL measurement in clinical trials, and for future meta-analysis and systematic reviews.

Body image in cystic fibrosis--development of a brief diagnostic scale

For a number of reasons, body image is an important concept in behavioral medicine. First, it is known to be related to clinical phenomena such as poor self-esteem, depression, and anxiety. Second, body image has the potential to influence the patients' self-management and compliance motivation. Finally, body image can be improved through psychological and educative interventions. This study presents the development and validation of a brief, 8-item scale assessing attitudinal body image in patients with cystic fibrosis. A principal component analysis supported three domains represented by the items: evaluation/satisfaction, importance, and trust in physical functioning/health. The test-retest correlations ranged from 0.83 to 0.88, internal consistencies were above 0.70, except for the domain "importance" (alpha = 0.44). The scale scores differentiated between patients with mild and severe symptoms of the disease. Regression analyses identified body image as an important predictor of the patients' health-related quality of life. In summary, our results provide preliminary evidence for the reliability and construct, concurrent, and clinical validity of the instrument.

Body image of adolescents in a multi-ethnic Caribbean population

OBJECTIVE

To examine the perceptions of body size among adolescents in Trinidad and to determine whether there were ethnic differences.

DESIGN

Cross-sectional survey.

SETTING

Secondary schools in Trinidad.

SUBJECTS

A stratified random sample of 1139 adolescents, aged 14-17 y.

MEASUREMENTS

Silhouettes of different body sizes were used to determine perceptions of body size, while weights and heights were measured to determine actual body size.

RESULTS

A total of 1090 students (96% response rate) participated, comprising 578 (53%) females. The main ethnic groups were South Asian (49%), African (25%) and persons of mixed ethnicity (23%). The calculated body mass index (BMI) indicated that 14% were thin, 73% normal and 13% overweight; however there was a preponderance of thinness among South Asian males (28%). Whereas 68% of students correctly identified their body size, South Asian males were also more likely to overestimate their body size than the other adolescents, ie they were thinner than they thought. Overall, 64% of the sample was satisfied with their current size, but thin South Asians were more likely to be satisfied with their size than other thin adolescents (P=0.04), while overweight Africans were more likely to be satisfied than other overweight persons (P=0.03). The majority of the sample associated the normal body size with good health, but the majority also associated the overweight and obese silhouettes with wealth. In addition, 40% of them associated the male overweight and obese silhouettes with happiness.

CONCLUSION

Although the prevalence of overweight/obesity was not high, the perception of the Trinidadian adolescent that obesity was associated with wealth, and to a lesser extent happiness, and the satisfaction of the overweight African females with their size, were all causes for concern.

Body image and dieting behavior in cystic fibrosis

OBJECTIVE

To examine the relationship between pulmonary function, nutritional status, body image, and eating attitudes in children with cystic fibrosis (CF) compared with healthy controls.

METHOD

Seventy-six children with CF (39 girls) and 153 healthy control children (82 girls) were recruited. All children were between 7 and 12 years of age. After being weighed and measured, participants undertook a structured 1-to-1 interview. Four measures were used to assess body image: body size (perception and satisfaction) were ascertained using the Children's Body Image Scale (CBIS), which uses photographs of children of various body mass index (BMI) representative of the range of BMI percentiles for children 7 to 12 years of age. Body size satisfaction was measured by the response to the questions, "Do you think your body is 1) much too thin, 2) too thin, 3) just right, 4) too fat, and 5) much too fat?" Body weight satisfaction was measured by the question, "Would you like your body to be 1) much thinner, 2) a little bit thinner, 3) stay the same, 4) a little bit fatter, and 5) much fatter?" Global self-esteem was measured using the children's version of the Rosenberg Self-Esteem Scale and Body Esteem Scale using a 24-item scale. Dieting behavior was measured by asking directly about previous weight control behaviors, use of the Dutch Eating Behavior-Restraint Scale (DEBQ-R), and, in children who acknowledged previous dieting behavior, the Children's Eating Attitude Test (ChEAT) was additionally administered. Results. Both girls and boys with CF had significantly reduced BMI percentiles compared with control children. Boys with CF did not have a significantly different BMI compared with girls with CF. There were significant positive correlations between forced expiratory volume in 1 second (FEV(1)) (% of predicted) and BMI percentile in girls (r =.35) and boys (r =.50) with CF. Body image perceptions in boys and girls with CF were examined in relation to the healthy control group using 2 (CF and control groups) by 2 (male and female) analysis of variance. The interaction effect was examined to explore the prediction that girls compared with boys with CF would have greater acceptance of their body shape and less desire to become larger. There were no differences between groups or sex in body esteem. On the CBIS body dissatisfaction score, children with CF were significantly more likely to perceive their ideal body size as a little larger than their current size while control children desired a smaller body size than their current size. CF children had a significantly lower mean score for body size satisfaction (an item assessing perception being too thin) and a significantly higher mean score on body weight satisfaction. There was a significant main effect of gender for only 1 measure, difference between the CBIS body dissatisfaction score, with girls being more likely to nominate a smaller ideal than their current figure. There were no significant interaction effects. Of children with CF and a low BMI (</=10th percentile), 25% of girls and 38% of boys thought they were too thin. Fewer girls (19%) than boys (38%) would have liked to be fatter. The CF group had significantly lower mean scores on the DEBQ-R scale compared with controls. Of the children with CF completing the ChEAT (n = 13), none obtained a score of clinical significance compared with 6 (4%) for controls. To examine predictors of BMI a multiple regression analysis was conducted separately for boys and girls with CF and control boys and girls in which the dependent variable was BMI and the independent variables were FEV(1) (% of predicted) (in CF children only), body esteem, self-esteem, and body dissatisfaction score. In the case of boys with CF, the regression equation was significant (Adjusted R(2) = 0.30). In the case of girls with CF, the regression equation was significant (Adjusted R(2) = 0.25) with body dissatisfaction making a significant independent contribution. For control boys the regression equation was significant (Adjusted R(2) = 0.18). Variables making a significant contribution to the equation were body esteem and body dissatisfaction. Finally, for control girls the regression equation was significant (Adjusted R(2) = 0.13). The only variable to make a significant contribution to the equation was body dissatisfaction.

DISCUSSION

Children with CF had very similar body esteem and general self-esteem as controls. A consideration of body image constructs does reveal group differences between perception and satisfaction with body size between groups. Children with CF were more likely to perceive their body size as larger than it actually was and have greater satisfaction with their current body size in contrast to control children. The girls and boys with CF with a higher BMI frequently selected a smaller body size as their ideal. (ABSTRACT TRUNCATED)