Body Image 20 (2017) 49–57

Contents lists available at ScienceDirect

Body Image
journal homepage: www.elsevier.com/locate/bodyimage

Is body shame a significant mediator of the relationship between

mindfulness skills and the quality of life of treatment-seeking
children and adolescents with overweight and obesity?
Helena Moreira ∗ , Maria Cristina Canavarro
Faculty of Psychology and Educational Sciences, University of Coimbra, Coimbra, Portugal

a r t i c l e i n f o a b s t r a c t

Article history: This study aimed to examine (a) whether mindfulness skills were associated with higher quality of
Received 12 May 2016 life through lower body shame for treatment-seeking children/adolescents with overweight and obe-
Received in revised form sity and (b) whether this indirect effect was moderated by children/adolescents’ age and gender. The
15 November 2016
sample included 153 children/adolescents with overweight/obesity followed in individual nutrition con-
Accepted 17 November 2016
sultations. Participants completed self-report measures of mindfulness, body shame, and quality of life.
Moderated mediation analyses showed that higher levels of mindfulness were associated with better
Keywords:
perceived quality of life through lower body shame, but only among girls. For boys, higher levels of body
Mindfulness
Body shame
shame did not translate into a poorer perception of quality of life, and the indirect effect of mindfulness
Quality of life on quality of life via lower body shame was not significant. These results suggest that body shame is an
Pediatric obesity important mechanism to explain why mindfulness may help girls with overweight/obesity perceive a
better quality of life.
© 2016 Elsevier Ltd. All rights reserved.

Introduction
Children and adolescents with overweight and obesity are at an
increased risk of presenting poor psychosocial outcomes, includ-
ing high levels of psychological problems such as internalizing
(e.g., depression, low self-esteem) and externalizing (e.g., conduct
problems) symptomatology (Moreira et al., 2013; Zeller, Saelens,
Roehrig, Kirk, & Daniels, 2004), disordered eating (Goldschmidt,
Wall, Loth, & Neumark-Sztainer, 2015), peer problems (e.g., lone-
liness, weight-related teasing; Hayden-Wade et al., 2005), and
poor quality of life (Moreira et al., 2013; Ottova, Erhart, Rajmil,
Dettenborn-Betz, & Ravens-Sieberer, 2012). An important risk fac-
tor for negative psychosocial outcomes is a negative body image
or the presence of body image concerns, which are very com-
mon among children and adolescents with overweight and obesity
(Gouveia, Frontini, Canavarro, & Moreira, 2014; Neumark-Sztainer,
2011; Pinquart, 2013). For instance, some research has suggested
that children/adolescents with overweight and obesity who are
more dissatisfied with their appearance tend to report lower self-
∗ Corresponding author at: The Cognitive-Behavioural Center for Research and
Intervention, Faculty of Psychology and Educational Sciences, University of Coimbra,
Rua do Colégio Novo, 3000-115 Coimbra, Portugal.
E-mail address: hmoreira@fpce.uc.pt (H. Moreira).
esteem and more depressive and anxious symptoms, stress, and
poor quality of life than children/adolescents with overweight and
obesity who are less dissatisfied (e.g., Allen, Byrne, Blair, & Davis,
2006; Gouveia et al., 2014; Mond, van den Berg, Boutelle, Hannan,
& Neumark-Sztainer, 2011; Pinquart, 2013; Shin & Shin, 2008).
The vast majority of studies conducted among chil-
dren/adolescents, especially among those of higher weight,
have focused on body dissatisfaction. However, some studies (e.g.,
Iannaccone, D’Olimpio, Cella, & Cotrufo, 2016; Mustapic, Marcinko,
& Vargek, 2015), particularly those developed within the objec-
tification theory framework (Fredrickson & Roberts, 1997), have
highlighted the important role of body shame. Body shame is a
self-conscious emotion focused on the body that is experienced
when individuals evaluate themselves or perceive themselves to
be evaluated by others as inferior, flawed, or unattractive (Gilbert,
2002). According to objectification theory (Fredrickson & Roberts,
1997), body shame can result from self-objectification, i.e., from
girls’ and women’s tendency to “view and treat themselves as
objects to be evaluated on the basis of their appearance” (Calogero,
2012, p. 575). Self-objectification may increase levels of body
shame among girls and women because it leads to a continuous
self-monitoring or self-surveillance that increases their perception
of failure to attain an unrealistic ideal body despite their struggle
to do so (Grabe, Hyde, & Lindberg, 2007). Body shame and other
negative subjective consequences of self-objectification (e.g.,

http://dx.doi.org/10.1016/j.bodyim.2016.11.004
1740-1445/© 2016 Elsevier Ltd. All rights reserved.
50 H. Moreira, M.C. Canavarro / Body Image 20 (2017) 49–57
appearance anxiety) can in turn increase the risk of mental health
problems, particularly depression, eating disorders, and sexual
dysfunction (Calogero, 2012; Fredrickson & Roberts, 1997; Grabe
et al., 2007; Noll & Fredrickson, 1998).
The few studies that have explored the role of body shame
in pediatric samples have found this emotion to be an important
mediator of the link between self-esteem and eating disorder risk
among adolescents of various weights (Iannaccone et al., 2016), as
well as between body dissatisfaction and eating behaviors among
adolescent girls of different weights (Mustapic et al., 2015). Consis-
tent with objectification theory, in the current study, we explored
the link between body shame and quality of life, which is a key
indicator of individuals’ well-being and psychosocial functioning
in several domains of life (World Health Organization, 1994).
The poor psychosocial outcomes and high levels of body image
concerns of children and adolescents with overweight and obesity
can be explained by weight stigma, which in the context of pediatric
obesity can be defined as “negative weight-related attitudes and
beliefs that are manifested by stereotypes, bias, rejection, and prej-
udice toward children and adolescents because they are overweight
or obese” (Puhl & Latner, 2007, p. 558). There is extensive evi-
dence that weight-based stigmatization is highly prevalent among
children with overweight and obesity (Griffiths, Wolke, Page, &
Horwood, 2006; Janssen, Craig, Boyce, & Pickett, 2004; McCormack
et al., 2011; Neumark-Sztainer et al., 2002) and that stigmatization
can result from multiple sources, including the peers, educators,
and parents of these children (McCormack et al., 2011; Neumark-
Sztainer, Story, & Harris, 1999; Puhl & Latner, 2007). For instance,
several studies show that children/adolescents with obesity are
often teased and frequently face social exclusion and isolation
(Puhl, Luedicke, & Heuer, 2011), are less likely than their average-
weight peers to be chosen as friends (Latner & Stunkard, 2003), and
are at greater risk of suffering from bullying (Lumeng et al., 2010).
Therefore, it is not surprising that children with overweight and
obesity are at an increased risk for a range of negative psychoso-
cial outcomes, including poor quality of life and high levels of body
shame (Juvonen, Lessard, Schacter, & Suchilt, 2016; Puhl & Latner,
2007).
Considering the strong link between higher weight and the
poorer psychosocial functioning of children/adolescents, it is essen-
tial to explore key modifiable factors that are amenable to change in
the therapeutic context. One factor that has recently been identified
as having beneficial outcomes for youths’ adjustment is mindful-
ness skills (Burke, 2009; Greco & Hayes, 2008). Mindfulness can be
broadly described as a state of attention and awareness to what
is happening in the present moment, with a stance of curiosity,
experiential openness, and acceptance (Baer, Smith, & Allen, 2004;
Bishop et al., 2004; Kabat-Zinn, 2003). Mindfulness reflects an
individual’s natural tendency to be aware of his or her present expe-
rience in an open and nonjudgmental way (Baer, Smith, Hopkins,
Krietemeyer, & Toney, 2006; Brown, Ryan, & Creswell, 2007), and
is considered both a dispositional variable and a skill that can be
developed through the practice of meditation (Baer, 2003; Bishop
et al., 2004).
In the last few years, there has been growing interest in the
study of mindfulness among children and adolescents (Greco &
Hayes, 2008; Zoogman, Goldberg, Hoyt, & Miller, 2015). Despite
this recent interest, to the best of our knowledge, no study
has been conducted among children/adolescents with overweight
and obesity, and no mindfulness-based intervention has been
developed for this population. O’Reilly and Black (2015) argued
that mindfulness-based interventions could be particularly useful
for these children/adolescents because, similar to adult popula-
tions (e.g., Katterman, Kleinman, Hood, Nackers, & Corsica, 2014;
Mantzios & Wilson, 2015; Olson & Emery, 2015; O’Reilly, Cook,
Spruijt-Metz, & Black, 2014), these interventions may help them
regulate obesity-related eating behaviors (e.g., emotional eating,
binge eating) and improve healthful eating behaviors.
Mindfulness skills can also promote the psychosocial adjust-
ment of children/adolescents with overweight and obesity through
the promotion of more positive experiences with their body image.
Although this hypothesis has not been investigated, some stud-
ies of adult populations have shown that mindfulness is positively
associated with body image satisfaction. For instance, Dijkstra and
Barelds (2011) found that higher levels of dispositional mindfulness
were associated with higher levels of body satisfaction and lower
levels of body comparison in a large sample of women. In another
study, Dekeyser, Raes, Leijssen, Leysen, and Dewulf (2008) found
that body satisfaction was positively correlated with all subscales
of the Kentucky Inventory of Mindfulness Skills in a sample mostly
composed of women. Similar results were found among men in a
study that found positive associations between dispositional mind-
fulness and overall appearance evaluation and satisfaction with
body areas, and negative associations between dispositional mind-
fulness and the drive for muscularity (Lavender, Gratz, & Anderson,
2012). However, the role of mindfulness on the body image of
children and adolescents, particularly those with overweight and
obesity, remains to be investigated.
The Current Study
In the current study, we examined whether mindfulness is indi-
rectly associated with the quality of life through body shame among
treatment-seeking children and adolescents with overweight and
obesity. Because girls tend to experience more body image concerns
and body shame than boys and because these concerns and body
shame tend to have a stronger impact on girls’ adjustment (Grabe
et al., 2007; Wertheim, Paxton, & Blaney, 2009), we also examined
whether the indirect effect is moderated by children’s gender. In
addition, because childhood and adolescence are distinct develop-
mental phases characterized by different developmental tasks and
maturational issues, and because body image concerns tend to have
a stronger impact on adolescents’ adjustment (Gouveia et al., 2014),
the moderator role of age in the proposed mediation model was also
explored.
Although the associations between mindfulness, body shame,
and quality of life have never been investigated among children and
adolescents with or without overweight and obesity, the proposed
mediation model and the established hypotheses are supported
by the literature and previous studies. First, a positive associa-
tion was expected between mindfulness and quality of life. The
relationship between mindfulness and several indicators of psy-
chosocial adjustment has received considerable empirical support.
Not only is there solid evidence of the positive link between mind-
fulness and adult well-being and mental health (e.g., Brown & Ryan,
2003; Brown et al., 2007), but recent studies with children and ado-
lescents also suggest that mindfulness skills are associated with
several psychosocial outcomes, such as quality of life and academic
competence (Greco, Baer, & Smith, 2011), and that the development
of mindfulness skills may have a positive impact on a variety of
mental health problems in young people (Ames, Richardson, Payne,
Smith, & Leigh, 2014; Bögels, Hoogstad, Dun, Schutter, & Restifo,
2008; Semple, Reid, & Miller, 2005).
In this study, we further hypothesized that this relationship can
also be indirectly established through body shame. Based on previ-
ous investigations (Dekeyser et al., 2008; Dijkstra & Barelds, 2011;
Lavender et al., 2012), we expect higher levels of mindfulness to be
associated with lower levels of body shame. Because mindfulness
implies an attitude of acceptance and non-judgment of internal
and external experiences (Kabat-Zinn, 2003), children and adoles-
cents with higher levels of mindfulness may be more able to accept
their weight and body shape and not evaluate their body image
 H. Moreira, M.C. Canavarro / Body Image 20 (2017) 49–57
as unattractive or inferior to an unrealistic ideal body. In addi-
tion, because mindfulness also involves the capacity to be aware
of the present moment, children and adolescents with higher lev-
els of mindfulness can pay less attention to the ruminative (Cheung,
Gilbert, & Irons, 2004), self-evaluative, and self-conscious thoughts
and emotions (Woods & Proeve, 2014) that are typically involved in
the experience of shame. Finally, based on the extensive research
evidencing a consistent association between negative body image
and poor psychosocial adjustment of children and adolescents (e.g.,
Allen et al., 2006; Shin & Shin, 2008) as well as strong evidence of the
link between body shame and mental health (Noll & Fredrickson,
1998), a negative association was expected between body shame
and quality of life. Overall, we expect that higher levels of mind-
fulness will be associated with a better perception of quality of life
through lower levels of body shame.
Method
Participants
A total of 153 treatment-seeking Caucasian chil-
dren/adolescents with overweight or obesity participated in
the study. The following inclusion criteria were considered: (a)
age between 8 and 18 years; (b) body mass index (BMI) between
the 85th and the 95th percentile (overweight) or equal or above
the 95th percentile (obesity); (c) ability to understand and answer
the questionnaires; (d) no serious mental illness or developmental
delay; and (e) absence of genetic syndromes for which obesity is a
comorbidity.
Children had a mean age of 13.56 years (SD = 2.66; range: 8–18),
a mean BMI of 28.23 (SD = 4.70; range: 18.27–41.04), and a mean
BMI z-score of 1.83 (SD = 0.42; range: 1.02–2.76). The majority of
participants were aged between 13 and 18 years old (65.4%) and
were girls (62.7%). A small proportion of children/adolescents had
a comorbid condition (24.8%), mainly asthma (39.5%).
Procedure
Children and adolescents were recruited at the nutrition outpa-
tient services of two public pediatric hospitals in the central region
of Portugal. The Ethics Committees and the Board of Directors of
both hospitals approved the study. The children were participating
in a non-structured medical weight management program consist-
ing of individual nutrition consultations in which the nutritionist
provided nutrition and physical activity advice as well as behavior
modification recommendations and prescribed diet and exercise
plans. This non-structured program was tailored according to the
specific needs of each child and was followed until the initially
established weight loss was achieved. Therefore, the specific num-
ber of sessions was not pre-determined. The inclusion criteria for
participation in the nutrition consultations were a clinical diagnosis
of overweight or obesity and age of ≤18 years old. These consul-
tations were aimed at children/adolescents, but parents could be
present whenever necessary. Children were referred to these nutri-
tion consultations by their family doctor or other physician, or the
consultation was requested directly by their parents.
Children were invited to participate in the study if they were
being followed in the nutrition consultation and were overweight
or obese. The duration of participation in the consultation was not
considered an inclusion criterion. Therefore, some children com-
pleted the study measures at the beginning of the treatment, while
others completed the measures months after the beginning of the
treatment. Treatment did not address body shame, mindfulness
skills, or overall quality of life. After the nutrition consultation, a
research assistant explained the study to the children/adolescents
51
and their parents and requested their participation. All parents pro-
vided written informed consent, and all children provided verbal
assent. Children completed the questionnaires in the presence of
a research assistant who was available to assist them whenever
necessary. Participation was voluntary, and no monetary or other
compensation was given to participants.
Measures
Mindfulness. The Child and Adolescent Mindfulness Mea-
sure (CAMM; Cunha, Galhardo, & Pinto-Gouveia, 2013; Greco
et al., 2011) was used to assess children’s mindfulness (i.e.,
children’s present-moment awareness and their nonjudgmental,
nonavoidant responses to their thoughts and feelings). This ques-
tionnaire was developed for the comprehension level of children
over the age of 9 years old, and it has 10 items (e.g., “I keep myself
busy so I don’t notice my thoughts or feelings”; “I get upset with
myself for having certain thoughts”) rated on a 5-point Likert-type
scale ranging from 0 (never true) to 4 (always true). The total score
is the sum of the 10 items and ranges from 0 to 40, with higher
scores indicating higher levels of mindfulness. The original valida-
tion studies of CAMM (Greco et al., 2011) included different samples
of children and adolescents, and scores demonstrated internal
consistency (Cronbach’s ˛ = .80) and validity (convergent and incre-
mental) among children and adolescents aged 10–17 years from
the USA. Scores on the Portuguese version (Cunha et al., 2013) con-
firmed the unidimensional factor structure of the scale and yielded
evidence of internal consistency (Cronbach’s ˛ = .80), temporal sta-
bility (r = .46), and validity (convergent and discriminant) among a
sample of Portuguese adolescents aged 12–18 years. For the present
study, Cronbach’s alpha was .77.
Body shame. The body shame subscale of the Experience of
Shame Scale (ESS; Andrews, Qian, & Valentine, 2002; Rodrigues,
2013) was used to assess the experiential, cognitive, and behav-
ioral components of body shame. This subscale has four items
rated on a 4-point Likert-type scale ranging from 1 (not at all) to
4 (very much) and requires the respondent to select the option that
best expresses the intensity to which he or she experienced each
item in the last 3 months (e.g., “Have you avoided looking at your-
self in the mirror?”; “Have you worried about what other people
think of your appearance?”). Items are summed, and the total score
ranges between 4 and 16, with higher scores indicating higher lev-
els of shame. Although the ESS has been developed for adults, it
has also been used among children (Moreira, Gouveia, Frontini, &
Canavarro, 2015) and adolescents (Rodrigues, 2013). Scores on the
original ESS version evidenced test-retest reliability (r = .83) and
validity (construct and discriminant) among a sample of psychol-
ogy undergraduate students from the UK. The Portuguese version
(Rodrigues, 2013) was validated in a sample of adolescents and its
scores demonstrated internal consistency (Cronbach’s alpha = .87),
temporal stability (r = .80), and validity (convergent and divergent).
In the present study, Cronbach’s alpha was .84.
Quality of life. The children’s quality of life was assessed with
the Portuguese child-report version of the KIDSCREEN-10 index
(Matos, Gaspar, & Simões, 2012; Ravens-Sieberer et al., 2010), a
10-item questionnaire that assesses the general subjective well-
being of children and adolescents (e.g., “Have you felt fit and well?”;
“Have you felt sad?”). This measure is answered using a 5-point
Likert-type scale that ranges from 1 (never; not at all) to 5 (always;
extremely) and provides a global index of quality of life. Standard-
ized scores (0–100) were calculated, with higher scores indicating
better quality of life. The psychometric properties of the origi-
nal version of the KIDSCREEN-10 index (Ravens-Sieberer et al.,
2010) were tested among a large sample of European children and
52 H. Moreira, M.C. Canavarro / Body Image 20 (2017) 49–57
Table 1
Descriptive statistics, comparison analyses, and correlations among the study variables.
Boys (n = 57) Girls (n = 96)
M (SD)
1. Mindfulness 27.46 (6.46) 26.25 (6.92)
2. Body shame 6.84 (2.83) 8.09 (3.17)
3. Quality of life 73.99 (10.50) 71.33 (14.77)
*
p < .01.
adolescents aged 8–18 years. Scores on the child-report version
presented adequate reliability (Cronbach’s ˛ = .82) and temporal
stability (ICC = .70) and demonstrated criterion and construct (con-
vergent, discriminant, and known-groups) validity. The validation
study of the Portuguese version (Matos et al., 2012) confirmed the
original unidimensional structure and showed internal consistency
(Cronbach’s ˛ = .78) among a sample of children and adolescents
aged 10–16 years. In the present study, Cronbach’s alpha was .73.
Anthropometric information. The weight and height of chil-
dren/adolescents were measured by the nutritionist. The weight
condition was classified as overweight or obesity according to
the Centers for Disease Control and Prevention growth charts
that take into account the percentile values of the BMI for chil-
dren/adolescents of the same age and gender, calculated by
weight (kg) and height (cm) according to the following formula:
weight/height2 . The BMI was transformed into z-scores (zBMI).
Data Analyses
The data analyses were conducted using the Statistical Package
for the Social Sciences (SPSS, version 22.0; IBM SPSS, Chicago, IL)
and the PROCESS computation tool for SPSS (Hayes, 2013). Before
conducting the main analyses, the presence of missing values and of
univariate and multivariate outliers, and the normality assumption
were investigated. Besides the identification of univariate outliers
(cases with z scores > 3.29, p < .001), multivariate outliers were
examined through the examination of leverage indices and the
Mahalanobis distance statistic (D2 ) for all participants. Criteria for
multivariate outliers were a leverage score five times greater than
the sample leverage value (Brown, 2006) and a D2 value at p < .001
for the 2 value (Tabachnick & Fidell, 2007). Normality was assessed
through the examination of skewness and kurtosis of each vari-
able. Variables were considered reasonably normally distributed
if skewness and kurtosis values were within the 1 and −1 range
(Meyers, Gamst, & Guarino, 2006).
Descriptive statistics were computed for all sociodemographic,
clinical, and study variables. Differences between boys and girls
in mindfulness skills, body shame and quality of life were exam-
ined through univariate analyses of variance (ANOVAs). Pearson
correlations between study variables were computed. In addition,
correlations between socio-demographic and study variables were
performed to identify possible covariates to introduce into the
moderated mediation model. Cohen’s guidelines (1988) were used
to describe the effect sizes of correlations (i.e., small for correlations
close to .10, medium for those near .30, and large for correlations
at .50 or higher). To examine whether mindfulness was associated
with quality of life through body shame and whether this indirect
effect was moderated by age and gender, a moderated mediation
model was estimated with PROCESS (Hayes, 2013). The moderators
were hypothesized to affect the path linking body shame and qual-
ity of life (Model 16 in Hayes, 2013). Therefore, two interactions
were initially tested in the path linking body shame and quality of
life (body shame × age and body shame × gender). Prior to model
estimation, the variables used in the construction of the products
were mean-centered (Aiken & West, 1991). In the absence of one or
Comparison analyses
1 2 3
F(1, 151) = 1.14, p = .287, 2 = .01 –
F(1, 151) = 6.04, p = .015, 2 = .04 −.41* –
F(1, 151) = 1.42, p = .235, 2 = .01 .31* −.43* –
more significant interactions, the model was re-estimated after the
removal of nonsignificant interactions (Hayes, 2013). A significant
interaction was probed in a simple moderation model by estimat-
ing the conditional effect of body shame on quality of life at each
level of the moderator (simple slope analyses). To graphically visu-
alize the interaction, we used the estimates of quality of life from
the regression model for different values of body shame and the
two values of the moderator generated by PROCESS. The indirect
or mediation effect was assessed using a bootstrapping procedure
with 10,000 resamples. This procedure creates 95% bias-corrected
and accelerated confidence intervals (95% BCaCIs) of the indirect
effects, which are considered significant if zero is not contained
within the lower and upper CIs. The index of moderated mediation
was used as a formal test of moderation of the indirect effect by the
moderator in the model.
Results
Preliminary Analyses
Three outlier cases were detected and, therefore, eliminated
from the sample, which resulted in a final sample of 153 children.
There were no missing data points. The scores of the study vari-
ables were approximately normally distributed, with a skewness
of −0.280, 0.795, and 0.301, and a kurtosis of 0.225, −0.050, and
−0.492 for mindfulness, body shame, and quality of life, respec-
tively. The visual inspection of histograms and normal Q–Q plots
has also shown that variable scores were reasonably normally dis-
tributed.
Comparison Analyses and Correlations
Descriptive statistics and correlations between the study vari-
ables are presented in Table 1. Differences between boys and girls
in mindfulness, body shame, and quality of life were examined. As
presented in Table 1, a significant difference was found only for
body shame, with girls reporting higher levels of shame than boys.
In the full sample, correlations between variables evidenced a
negative and strong correlation between mindfulness and body
shame, a positive and moderate correlation between mindfulness
and quality of life, and a negative and strong correlation between
body shame and quality of life (see Table 1). Correlations were
also computed separately for each gender. Among girls, all correla-
tions were significant (r = −.44, p < .001, for the correlation between
body shame and mindfulness; r = −.51, p < .001, for the correlation
between body shame and quality of life; and r = .39, p < .001, for the
correlation between mindfulness and quality of life). Among boys,
only the correlation between body shame and mindfulness was sig-
nificant (r = −.33, p = .014). The correlations between body shame
and quality of life (r = −.18, p = .184) and between mindfulness and
quality of life (r = .08, p = .551) were not significant.
Moderated Mediation Analyses
A moderated mediation model was estimated to examine
whether mindfulness was associated with quality of life through
 H. Moreira, M.C. Canavarro / Body Image 20 (2017) 49–57 53

Gender Age

Body shame

Quality of
Mindfulness
life

Fig. 1. Conceptual diagram of the proposed moderated mediation model.

body shame and whether this indirect effect was moderated by
age and gender. The conceptual diagram of the moderated medi-
ation model is presented in Fig. 1. Prior to the estimation of the
moderated mediation model, correlations between body shame
and quality of life and children’s age, gender, zBMI, and the pres-
ence of comorbidities were analyzed to identify variables that
should be controlled in the model. A significant association was
found between age and quality of life (r = −.31, p < .001), age and
body shame (r = .19, p = .022), and gender and body shame (r = .20,
p = .015). Because age and gender were introduced as moderators
in the model, no covariate was considered initially.
The moderated mediation analyses revealed that the path from
body shame to quality of life was moderated only by gender.
Specifically, while the interaction between body shame and gen-
der was statistically significant (b = −1.47, SE = 0.67, p = .029), the
interaction between body shame and age was not statistically sig-
nificant (b = −0.00, SE = 0.13, p = .985). Therefore, the model was
re-estimated without introducing age as a moderator. Neverthe-
less, the child’s age was introduced as a covariate in the re-specified
model because it was significantly correlated with body shame and
quality of life.
The statistical re-specified model is presented in Fig. 2, and
the regression coefficients and model summary information for
the re-specified model are presented in Table 2. As presented in
Table 2, the association between body shame and quality of life
seems to be contingent on children’s gender, as evidenced by
the significant interaction between body shame and gender. This
interaction was examined in a simple moderation model by esti-
mating the association between body shame and quality of life
in each gender group. Simple slope analyses demonstrated that
an increase in body shame was associated with a decrease in
quality of life only for girls (b = −2.13, SE = 0.39, t = −5.51, p < .001,
95%IC = −2.89/−1.36). Among boys, this association was not signifi-

19.01%

Body shame

-0.18*** -0.38

28.25%
0.18*
Mindfulness 0.30 Quality of
life

9.68

Gender
-1.47*

-1.13**
Body shame
X Gender

Age

Fig. 2. Statistical diagram of the re-specified moderated mediation model.

Note. Path values represent unstandardized regression coefficients. Standard errors and confidence intervals are presented in Table 2. Age was introduced as a covariate in
the model. Percentage values in body shame and quality of life represent the percentage of variance contributed by the predictors. The link between body shame and quality
of life was significant for girls but not for boys (the visual representation of this moderation effect is depicted in Fig. 2). *p < .05; **p < .01; ***p < .001.
54 H. Moreira, M.C. Canavarro / Body Image 20 (2017) 49–57

Table 2
Regression coefficients and model summary information for the re-specified moderated mediation model in Fig. 2.

Body shame Quality of life

b SE p 95%CIs (LLCI/ULCI) b SE p 95%CIs (LLCI/ULCI)

Mindfulness −.18 .03 <.001 −.248/−.115 .30 .15 .053 −.004/.596

Age .18 .09 .038 .010/.350 −1.13 .36 .002 −1.841/−.415
Gender – – – – 9.68 5.21 .065 −.616/19.968
Body shame – – – – −.38 .56 .500 −1.475/.723
Body shame × gender – – – – −1.47 .66 .029 −2.777/−.156
2 2
R = .190; F(2, 150) = 17.61, p < .001 R = .283; F(5, 147) = 11.58, p < .001

100

80
b = -0.60, p = .281
Quality of life

b = -2.13, p < .001

60

Girls
40
Boys

20

0
Low Medium High
Body shame

Fig. 3. The moderation role of gender on the association between body shame and quality of life.

cant (b = −0.60, SE = 0.55, t = −1.08, p = .281, 95%IC = −1.68/0.49; see
Fig. 3).
With regard to the analysis of individual paths, as presented
in Fig. 2 and Table 2, a significant and negative association
was found between mindfulness and body shame, in contrast to
the association between mindfulness and quality of life, which
was not significant. Because the significant interaction between
body shame and gender involves a component of the indirect
effect, the indirect effect was also moderated by children’s gender
(index of moderated mediation = .27, SE = 0.11, 95%IC = 0.08/0.52).
Specifically, the indirect effect of mindfulness on quality of
life through body shame was significant for girls (point esti-
mate = 0.33, SE = 0.09, 95%BCaCI = 0.19/0.54) but not for boys (point
estimate = 0.07, SE = 0.07, 95%BCaCI = −0.07/0.23).
Discussion
Our results demonstrated that children/adolescents with over-
weight and obesity who have higher levels of mindfulness
experienced lower levels of body shame, which in turn was asso-
ciated with a better quality of life. Although mindfulness was
significantly correlated with quality of life, the proposed mediation
model showed that the link between these variables was not direct
but was explained by body shame. However, this indirect effect was
only significant for girls. For boys, higher levels of body shame did
not seem to translate into a poorer perception of quality of life, and
the indirect effect of mindfulness on quality of life via body shame
was not significant. In addition, we found that age was not a sig-
nificant moderator in the mediation model, a finding that suggests
that mindfulness, body shame, and quality of life demonstrated the
same pattern of relationships, regardless of the children’s age.
With regard to the specific link between mindfulness and body
shame, corroborating previous studies conducted among adults
(Dekeyser et al., 2008; Dijkstra & Barelds, 2011), this association
was significant and negative. Mindfulness involves an attitude of
acceptance and non-judgment of the current internal and exter-
nal experiences (Bishop et al., 2004; Kabat-Zinn, 2003). Therefore,
children/adolescents with overweight and obesity who have higher
levels of mindfulness may be more able to accept their weight and
body image without experiencing shame in this domain. Addition-
ally, we may suppose that children/adolescents with higher levels
of mindfulness, similar to adults (Baer et al., 2006; Brown et al.,
2007; Kabat-Zinn, 2003), tend to have an increased capacity to be
in the present moment and, therefore, to direct their attentional
resources to their current experiences. This increased focus on the
present moment may lead them to have fewer attentional resources
available to focus on self-evaluative and self-conscious thoughts
and emotions, such as those involved in body shame. In fact, body
shame has been conceptualized as a self-conscious emotion, as well
as guilt and pride (Castonguay, Brunet, Ferguson, & Sabiston, 2012),
that arises when the individual perceives or fears a loss of social
status or a failure to achieve internalized social standards (Lewis,
1971). According to Woods and Proeve (2014), the intense, nega-
tive, and self-evaluative focus on the self that is characteristic of the
experience of shame is inversely related with the present-centered
attention and the compassionate and non-judgmental attitude of a
mindful orientation.
It is also important to consider that shame, whether focused
on the body or on another feature of the self, is frequently asso-
ciated with ruminative and self-critical thoughts (Cheung et al.,
2004). Mindfulness skills allow individuals to decenter from their
inner experiences and to view them as transitory events that are
not a defining feature of the self. Therefore, children/adolescents
with higher levels of mindfulness may be more able to disentan-
gle from self-ruminative thoughts about their weight and body
image, which may lead them to feel less ashamed by their appear-
ance and, consequently, at least among girls, to experience a better
quality of life. Nevertheless, we should note that due to the cross-
 H. Moreira, M.C. Canavarro / Body Image 20 (2017) 49–57 55

sectional design of the study, the link between mindfulness and promoted and developed in children through mindfulness-based
body shame may be bidirectional. For instance, it is possible that interventions (Greco et al., 2011; Greco & Hayes, 2008), our study
children and adolescents with overweight and obesity who have suggests that these interventions may be particularly useful for
higher levels of body shame have an increased difficulty being children/adolescents with overweight and obesity, particularly for
aware of the present moment because of the frequent ruminative girls who struggle with body shame. Such interventions should
and self-critical thoughts about their weight and appearance that devote particular attention to body-related thoughts and emotions
divert their attention from the present moment. to help children and adolescents, particularly girls, relate to their
As expected, we found a negative association between body weight and body image in a more accepting and nonjudgmental
shame and quality of life. Although this association and, conse- way.
quently, the indirect effect were not moderated by age, this link
and the indirect effect were moderated by gender. Specifically, the
Conclusions
association was significant only for girls, which suggests that body-
related thoughts and emotions and, specifically, body shame are
It is crucial to expand treatments for childhood obesity beyond
particularly important for the well-being of girls. This finding cor-
traditional education and diet-based programs. Although these
roborates the results of previous studies showing that the way
programs are very important, it is also necessary to consider
girls relate to their body image is strongly associated with their
the psychosocial adjustment of children/adolescents. Some stud-
psychosocial adjustment (Allen et al., 2006; Mond et al., 2011;
ies developed in adult samples suggest that certain psychosocial
Pinquart, 2013; Shin & Shin, 2008), including their quality of life
variables, including body image and quality of life, are important
(Gouveia et al., 2014). Although this study has a cross-sectional
predictors of health related outcomes, including weight loss, in obe-
design and does not allow causal inferences, these results are con-
sity treatment (e.g., Teixeira et al., 2002, 2004). Therefore, we can
sistent with objectification theory (Fredrickson & Roberts, 1997),
hypothesize that a child who experiences higher levels of body
according to which the experience of body shame can have impor-
shame and perceives a poor quality of life will most likely strug-
tant consequences for women’s mental health (Calogero, 2012). The
gle more regulate eating than a child who is better adjusted. In fact,
premise that body shame is more relevant for the emotional health
this situation may create a vicious circle in which being overweight
of women than for the emotional health of men has not only been
leads a child (particularly girls) to experience higher body shame
theorized (Fredrickson & Roberts, 1997) but has also been demon-
and lower well-being or quality of life (Gouveia et al., 2014; Moreira
strated in several studies. For instance, Daniel and Bridges (2010)
et al., 2013; Ottova et al., 2012; Puhl & Latner, 2007), which may in
examined whether the link between internalization of media ide-
turn lead the child to engage in unhealthy eating or weight control
als and the drive for muscularity in men was mediated by variables
behaviors as emotion regulation strategies (O’Reilly & Black, 2015)
of objectification theory (i.e., self-objectification, body surveillance,
and, consequently, to gain or maintain the weight. Mindfulness-
and body shame) and found that although some associations were
based interventions may be useful in this context, but future studies
significant in the path model, variables of objectification theory,
should be developed to further explore this possibility.
including body shame, were not significantly associated with the
drive for muscularity. In contrast, the link between body shame
and mental health has been strongly supported among women Conflicts of Interest
(e.g., Grabe & Jackson, 2009; Moradi & Huang, 2008; Szymanski
& Henning, 2007). The authors declare that they have no conflicts of interest.
This study has some limitations that should be mentioned. First,
the cross-sectional design impedes the examination of causal rela-
Acknowledgements
tionships between study variables and the determination of causal
mechanisms. The validity of conducting mediation analyses with
This work was supported by the Portuguese Foundation for Sci-
cross-sectional data may be questioned since it has been sug-
ence and Technology [grant SFRH/BPD/70063/2010]. FCT had no
gested that a cross-sectional design to test a mediation model can
role in the study design, collection, analysis or interpretation of the
produce biased estimates in the model and can over- or under-
data, writing the manuscript, or the decision to submit the paper
estimate longitudinal effects (Maxwell & Cole, 2007). Therefore,
for publication.
future studies should employ a longitudinal design to ascertain
The authors wish to thank the nutritionists at the Coimbra Pedi-
the direction of associations between variables. Second, our sam-
atric Hospital, and at the Pediatric Department of the Leiria Hospital
ple included a higher number of girls than boys. Ideally, a similar
for providing the conditions for data collection. The authors would
number of boys and girls should have been included. Third, chil-
also like to acknowledge Ana Filipa Simões, Daniela Fernandes,
dren/adolescents were recruited at only two hospitals in the central
Maria João Gouveia, and Roberta Frontini, who collected data for
region of Portugal, which compromises the representativeness of
this study, as well as the children and adolescents who participated
the sample. Additionally, the participants were attending nutri-
in the study.
tion appointments with the purpose of losing weight; therefore,
the results cannot be generalized to the entire population of chil-
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