The enigma of male eating disorders: A critical review and synthesis

Updates in the treatment of eating disorders in 2021: a year in review in Eating Disorders: The Journal of Treatment & Prevention

An array of novel and important studies advancing the treatment of eating disorders (EDs) were published in Eating Disorders: The Journal of Treatment & Prevention in 2021. In an unprecedented year of challenges to the delivery of ED treatment, and the volume of patients requiring it, this review summarizes the recent contributions to the literature on the treatment of EDs. Notably, an emphasis on assessing and addressing barriers to collaborative care offers much promise in augmenting treatment delivery and patient outcomes. In keeping with recent data illustrating an elevated risk for increased symptom severity during the COVID-19 pandemic, a focus on further disseminating treatments to higher level of care settings will be critical as the field meets the challenge presented by COVID-19. In addition, we review recent findings relating to the broader assessment and treatment of comorbidities which exacerbate ED symptom severity-which offer critical insights into the development of novel treatments. These recent contributions pave the way for more nuanced approaches to treating EDs across the diagnostic spectrum.

Compulsive exercise among college students: 5-year time trends in prevalence and demographic, substance use, and mental health correlates

PURPOSE

To provide 5-year time trends in prevalence and demographic, substance use, and mental health correlates of compulsive exercise among a national sample of college men and women.

METHODS

We analyzed 4 academic survey years (2016-2020; N = 8251) of the national (USA) Healthy Minds Study. Compulsive exercise was measured by self-report of any occurrence of "compulsive" exercise in the past 4 weeks. Unadjusted prevalence of compulsive exercise in the past 4 weeks was estimated across the 4 survey years by sex. Multiple logistic regression analyses were conducted among the pooled sample and stratified by sex to estimate the associations between compulsive exercise in the past 4 weeks and demographic, substance use, and mental health correlates.

RESULTS

Among the pooled sample, 11% (95% confidence interval [CI] 9.60-12.42%) of men and 17% (95% CI 15.86-18.24%) of women reported compulsive exercise in the past 4 weeks. Prevalence across the 4 survey years remained stable among men and women. Higher body mass index was associated with greater odds of any compulsive exercise in the past 4 weeks among men, while any sports participation was associated with greater odds of any compulsive exercise in the past 4 weeks among women. Compulsive exercise in the past 4 weeks was associated with greater odds of all mental health symptoms and illicit drug use among men and women, and higher odds of alcohol use among women.

CONCLUSION

Compulsive exercise is relatively common among college men and women and is associated with substance use behaviors and poor mental health symptoms.

LEVEL OF EVIDENCE

V, cross-sectional descriptive study.

Muscle-building behaviors from adolescence to emerging adulthood: a prospective cohort study

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Muscle-building behaviors in adolescence to emerging adulthood were studied.

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Starting muscle-building behaviors is common from adolescence to emerging adulthood.

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Prevalence of any protein powder/shakes use was 55.1% in males and 33.0% in females.

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Prevalence of any steroids use was 6.7% in males and 5.4% in females.

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Protein powder consumption was associated with future use of steroids.

This study aimed to identify patterns of change in muscle-building behaviors from adolescence to emerging adulthood and determine what adolescent factors predict new-onset muscle-building behavior in emerging adulthood. Prospective cohort data from a diverse sample of 1,535 participants followed from adolescence (baseline, M_age = 14.4 ± 2.0 years) to emerging adulthood (follow-up, M_age = 22.1 ± 2.0 years) from the population-based EAT 2010–2018 (Eating and Activity over Time) study were analyzed. Changes in muscle-building behavior were identified (starting, stopping, persistent use, or never use). Log-binomial regression models examined adolescent predictors of starting (i.e., new-onset) muscle-building behaviors in emerging adulthood. Prevalence of any use in adolescence (EAT 2010) and/or emerging adulthood (EAT 2018) was 55.1% (males) and 33.0% (females) for protein powder/shakes, 6.7% (males) and 5.4% (females) for steroids, and 19.4% (males) and 6.5% (females) for other muscle-building substances (e.g., creatine, amino acids). In particular, 22.6% (males) and 13.7% (females) started protein powder/shakes, 2.2% (males) and 1.0% (females) started steroid use, and 9.0% (males) and 2.0% (females) started other muscle-building substances during emerging adulthood. Adolescent protein powder/shake consumption was associated with starting steroids/other muscle-building substances use in emerging adulthood in males (adjusted risk ratio [ARR] 2.09, 95% confidence interval [CI] 1.29–3.39) and females (ARR 4.81, 95% CI 2.01–11.48). Adolescent use of protein powders/shakes may lead to a two- to five-fold higher risk of new use of steroids and other muscle-building products in emerging adulthood. Clinicians, parents, and coaches should assess for use of muscle-building behaviors in adolescents and emerging adults and discourage use of harmful products.

Long-term outcome in males with anorexia nervosa: A prospective, sex-matched study

OBJECTIVE

The objective of this study is to report on the 5.5-years outcome of anorexia nervosa (AN) in male adolescent inpatients and compare it to the outcome of female adolescent inpatients with AN.

METHOD

Diagnostic eating disorder outcome was assessed by the Structured Inventory of Anorexic and Bulimic Syndromes (DSM-IV) in 20 males and 20 females matched for AN diagnosis, age at treatment, and length of follow-up. For documentation, follow-up scores of the Eating Disorder Inventory and the Brief Symptom Inventory are reported.

RESULTS

Diagnostic outcome did not differ between sexes. Four male and six female participants had AN at follow-up. One male and four females had crossed to bulimia nervosa, and five males and three females to eating disorder not otherwise specified. Remission was found in 10 males and 7 females. Effect sizes were mostly small. At follow-up females had higher scores than males with large effect sizes for drive for thinness (Cohen's d = 0.86) and body dissatisfaction (d = 1.07).

DISCUSSION

Few significant sex differences were found. Additional research involving larger samples of males and a broader range of assessed outcomes (e.g., drive for muscularity) in both sexes is urgently needed.

Demographic predictors of objectification theory and tripartite influence model constructs: The U.S. Body Project I

We examined how demographic factors (gender, sexual orientation, racial group, age, body mass) were linked to measures of sociocultural appearance concerns derived from objectification theory and the tripartite influence model (McKinley & Hyde, 1996; Schaefer et al., 2015) among 11,620 adults. Men were less likely than women to report high body surveillance, thin-ideal internalization, appearance-related media pressures, and family pressures; did not differ in peer pressures; and reported greater muscle/athletic internalization. Both men and women expressed greater desire for their bodies to look "very lean" than to look "very thin". Compared to gay men, heterosexual men reported lower body surveillance, thin-ideal internalization, peer pressures, and media pressures. Black women reported lower thin-ideal internalization than White, Hispanic, and Asian women, whereas Asian women reported greater family pressures. Being younger and having higher BMIs were associated with greater sociocultural appearance concerns across most measures. The variation in prevalence of sociocultural appearance concerns across these demographic groups highlights the need for interventions.

Digital technology use and muscle-building behaviors in young adults

OBJECTIVE

Digital technology use and muscle-building behaviors reflect a wide range of behaviors with associated health risks. However, links between digital technology use and muscle-building behaviors remain unknown and this study aimed to address this gap.

METHOD

Data were collected from a diverse sample of 1,483 young adults (mean age 22.2 ± 2.0 years) participating in the population-based Eating and Activity over Time 2018 study. Gender-stratified-modified Poisson regression models were used to determine cross-sectional associations between three types of digital technology use (screen time, social media, weight-related self-monitoring apps) and five types of muscle-building behaviors (changing eating, exercise, protein powders/shakes, pre-workout drinks, steroids/growth hormone/creatine/amino acids) in young adulthood, adjusted for sociodemographic characteristics and body mass index.

RESULTS

Screen time and social media were either not found to be associated with muscle-building behaviors or in a few instances, associated with less use of these behaviors (e.g., screen time and pre-workout drinks in men). In contrast, the use of weight-related self-monitoring apps was positively associated with all muscle-building behaviors, including steroids/growth hormone/creatine/amino acids in men (prevalence ratio [PR] = 1.83; 95% confidence interval [CI]: 1.13-2.97) and women (PR = 4.43; 95% CI: 1.68-11.68).

DISCUSSION

While most recreational screen time may represent sedentary behaviors not related to muscle-building behaviors, weight-related self-monitoring apps are highly associated with more muscle-building behaviors and could be a future target for interventions to discourage the use of steroids and other harmful muscle-building substances.

Night Eating Syndrome in Patients With Obesity and Binge Eating Disorder: A Systematic Review

Night eating syndrome (NES) is currently classified as an Other Specified Feeding or Eating Disorder (OSFED) under the Diagnostic Statistical Manual-5 (DSM-5). This systematic review aims to consolidate the studies that describe the sociodemographic, clinical and psychological features of NES in a population of patients with eating disorders (ED), obesity, or those undergoing bariatric surgery, and were published after the publication of the DSM-5. A further aim was to compare, where possible, NES with BED on the aforementioned variables. Lastly, we aimed to appraise the quality of the studies being included in the review. We conducted a systematic search on three databases (MEDLINE, PubMed and Embase) which resulted in the selection of 22 studies for the review. We included the articles that studied patients with NES and their sociodemographic, clinical and psychological features in a clinical (i.e., ED, obese or bariatric surgery) population, through a quantitative study design. Articles were excluded if the NES patients included in the study had a comorbid psychological disorder, and/or the sample was collected from a university/non-clinical population, and/or the study design was qualitative, and/or NES features were compared with any other disorder, except BED. Our study found that no conclusions about the link between any sociodemographic feature (such as, age, gender, income, etc.) and an NES diagnosis could be made. Further, NES patients presented with elevated ED pathology (including emotional eating and loss of control eating) and higher occurrence of depressive symptoms than controls. Contrary to the literature suggesting that NES and Binge Eating Disorder (BED; an ED subtype which is also comorbid with obesity) patients often report overlapping features, questioning the validity of NES as an ED diagnosis, we found that BED can be differentiated from NES by the higher occurrence of emotional eating, body related concerns and abnormal eating episodes. The review also suggested an overlap between NES and Sleep-Related Eating Disorder. We recommend that it is essential to study NES as an independent disorder to further develop its diagnostic criteria and treatment options, thereby, increasing the quality of life of the patients suffering from this syndrome.

A Plea for Diversity in Eating Disorders Research

Eating disorders (EDs) are often stereotyped as affecting the SWAG, that is, as affecting mostly skinny, White, affluent girls. Over the last decade, however, significant progress has been made toward increasing diversity in ED research. There is consensus that EDs affect individuals of all genders, ages, sexual orientations, ethnic, and socio-economic backgrounds, with recent studies exploring social determinants of ED etiology, ED presentation, and developing diversity-affirming ED assessments. This article provides a brief summary of current developments related to diversity as a research theme, and proposes different perspectives toward further improving diversity in ED research. Specifically, we argue for exploring the role of diversity in ED treatment settings and outcomes, for pursuing diversity-oriented research pro-actively rather than as a reaction to issues of under-representation, and for integrating diversity across different areas of medical education and trainings in psychotherapy. Limitations with respect to the paucity of research, and the link between diversity as a research theme and ED-related workforce diversity are discussed.

Implications for Psychological Practice with Sexual Minority Men around Body Image Issues: An Addendum to the APA's Guidelines for Psychological Practice with Boys and Men

In 2018, the American Psychological Association published Guidelines for Psychological Practice with Boys and Men, in which there was only one mention of issues related to body image. This commentary explores the effects of body image concerns on men, with a particular focus on the experiences of sexual minority men. Using minority stress theory as a framework, this article aims to highlight the myriad negative mental and physical health outcomes related to body image concerns and eating disorder symptomatology in sexual minority men. Recommendations are provided to guide psychological practice related to body image concerns in sexual minority men.

Eating Disorder Symptomatology Among Adolescents Presenting for Bariatric Surgery Candidacy: Examining Differences by Sex and Racial Minority Status

BACKGROUND

Research on adolescent bariatric surgery candidates is limited by insufficient inclusion of ethnic minorities and males, and lack of consideration of the full spectrum of disordered eating behaviors (i.e., restriction, compensatory behaviors [e.g., purging], overeating/binge eating behaviors).

OBJECTIVES

The current study investigated differences in the full range of disordered eating behaviors across sex and ethnicity among adolescents seeking bariatric surgery.

SETTING

Teaching hospital, United States.

METHODS

Data were collected using retrospective chart review of 79 adolescent bariatric surgery candidates (59% female, 46.8% Hispanic, MBMI = 50.2, SDBMI = 10.0, Mage = 17.3, SDage = 2.02) who had completed the self-reported Eating Disorder Diagnostic Scale for DSM-5 at intake.

RESULTS

Approximately 33% of study participants met self-reported criteria for an eating disorder, with 35% endorsing binge eating behaviors and 50% endorsing compensatory behaviors. Few differences in behavior frequencies were observed across sex or racial/ethnic status.

CONCLUSIONS

Findings underscore the importance of assessing the full spectrum of disordered eating behaviors among adolescent bariatric surgery candidates.

Bidirectional relationships between intuitive eating and shape and weight overvaluation, dissatisfaction, preoccupation, and fear of weight gain: A prospective study

Using a prospective design, we investigated possible bi-directional relationships between intuitive eating and four empirically distinct components of negative body image: overvaluation (judgements of self-worth contingent upon weight/shape), dissatisfaction (general discontent with weight/shape), preoccupation (ruminative thinking about weight/shape), and fear of weight gain. We assessed adult women at baseline (T1) and four-month follow-up (T2), as prior work has demonstrated that this time lag is sufficient to detect change in intuitive eating scores. After adjusting for T1 intuitive eating scores and demographic confounds, higher T1 dissatisfaction was the only body image component to significantly predict lower T2 intuitive eating scores in both univariate and multivariate models. Higher T1 intuitive eating scores also significantly predicted lower scores on each of the four negative body image components at T2. Findings suggest that general body discontent may be one of the more important body image variables that lead to decreases in intuitive eating principles. Present findings also add to a growing body of evidence demonstrating the potentially adaptive role of intuitive eating on psychological health indices.

Persistence: A key factor in understanding the circumstances under which dietary restraint predicts restriction of caloric intake

Dietary restraint refers to the intention to restrict caloric intake, whereas dietary restriction refers to the actual intentional and sustained restriction of caloric intake for weight-control purposes. Findings regarding the relation between dietary restraint and restriction to date are inconsistent. Our study sought to clarify this complex relationship using a novel laboratory task. Participants (N = 103; 56.3% female) completed a Paced Visual Serial Addition Task (PVSAT). Participants were provided a choice between ending each of eight PVSAT rounds at any time and drinking a high-calorie Kool-Aid® mixture or correctly completing 10 consecutive computations to access to a zero-calorie mixture for each round. We measured participants' dietary restraint using the Three-Factor Eating Questionnaire - Restraint Subscale and measured persistence and dietary restriction using the PVSAT. Results indicated a positive association between persistence and restriction. Female participants demonstrated higher eating disorder psychopathology, dietary restraint, and dietary restriction compared to male participants. Restraint was positively associated with restriction the more individuals persisted, indicating that persistence is a potentially important modifier of the relation between dietary restraint and restriction. Our findings highlight the complexity of the relation between dietary restraint and restriction; that is, measures of dietary restraint alone may not reliably predict short-term dietary restriction during laboratory consumption tasks; however, other factors, such as persistence, may play critical roles.

Using an app to count calories: Motives, perceptions, and connections to thinness- and muscularity-oriented disordered eating

The number of people counting calories through apps is increasing, yet concerns have been raised that this could trigger symptoms of eating disorders. Although associations between calorie tracking and eating disorder symptomatology have been identified, further research is needed to understand motives for, and the perceived impact of, using a calorie tracking app. This study addressed these gaps with data collected from 1357 adults. A high percentage of participants (n = 964; 71%) had used a calorie tracking app; 531 participants (39%) reported currently using a calorie tracking app. Prior users reported higher levels of thinness- and muscularity-oriented disordered eating than non-users. Those using a calorie tracking app for weight-control/shape reasons were more likely to report that the app had contributed to several eating disorder symptoms (i.e., food preoccupation, all-or-none thinking around food, food anxiety, purging behaviours) than those using an app for health/disease prevention reasons. Engaging in a calorie tracking app for weight/shape reasons was associated with higher perceived helpfulness of calorie tracking app ratings and higher symptom severity. Findings suggest that underlying motives may be important to consider in research investigating the use of calorie tracking apps, as well as for health professionals working with clients engaging in these dietary monitoring tools.

Development and validation of a multicultural Spanish-language version of the Muscularity-Oriented Eating Test (MOET) in Argentina

The utility of traditional eating disorder measures in the assessment of muscularity-oriented disordered eating has been questioned. To address this limitation, the Muscularity-Oriented Eating Test (MOET) was recently developed and validated in a sample of U.S. college men. We aimed to develop a multicultural Spanish-language version of the MOET for use in Latin American samples and validate its use in a sample of Argentinian college men. Combined translation procedures were used to develop a version suitable for different Spanish-speaking populations. A total of 235 students (M_age = 23.47, SD = 5.61) participated in this study by completing a survey including the MOET. A sub-sample (n = 121) completed the MOET again after 1 week. A confirmatory factor analysis of a re-specified model of the original single-factor MOET, allowing for residual correlation between items associated to dietary rules (items 4-12), resulted in an adequate fit (χ²/df = 2.10, CFI = 0.94, TLI = 0.93, RMSEA 0.05 [90% CI = 0.04, 0.06] SRMR = 0.08). Further, the multicultural Spanish-language version of the MOET yielded evidence of internal consistency (omega = 0.83, 95% CI [0.79, 0.88], Cronbach's α = 0.83), a 1-week Intraclass Correlation Coefficient was considered for test-retest reliability (ICC = 0.82), item analysis, convergent validity with measures of eating disorder psychopathology, body dissatisfaction and weight-related behaviors, as well as for divergent validity with an unrelated construct. The availability of a multicultural Spanish-language version of the MOET may have utility in both clinical and research efforts related to muscularity-oriented disordered eating among Latino men.

The Muscularity-Oriented Eating Test, Drive for Muscularity Scale, and Muscle Dysmorphic Disorder Inventory among Chinese Men: Confirmatory Factor Analyses

Research on eating disorders (EDs) and body image disturbances has focused mostly on females from Western countries, and little is known about EDs in male populations in China, which is partially due to the lack of validated assessment measures. The current work aims to translate the Muscularity-Oriented Eating Test (MOET), Drive for Muscularity Scale (DMS) and Muscle Dysmorphic Disorder Inventory (MDDI) into Chinese and examine their psychometric properties. The factor structures, reliability and validity of the translated scales were examined with two samples: male university students (n = 295, M_age = 18.92 years) and general adult men (n = 406, M_age = 28.53 years). With confirmatory factor analyses, the original factor structures are replicated for the MOET, DMS and MDDI. The results also support the adequate internal consistency for both samples. Strong evidence of convergent and incremental validity for the three measures is also found in both samples. Overall, the three measures prove to be good instruments for use among Chinese male university students and general adult men.

Positive body image, intuitive eating, and self-compassion protect against the onset of the core symptoms of eating disorders: A prospective study

OBJECTIVE

Establishing factors that protect against the onset of eating disorder symptoms is needed to identify critical intervention targets to inform the design of more potent prevention programs. Knowledge of robust protective factors is lacking, which might account for the limited effectiveness of existing prevention programs. As positive body image, intuitive eating, and self-compassion show protective potential, the present study tested whether these factors protect against the onset of a range of different eating disorder symptoms.

METHOD

Data were analyzed from 1,270 women who completed study measures at baseline and 8 months. Logistic regressions tested whether, among initially asymptomatic women, baseline and changes in positive body image components (body appreciation, body image flexibility, and functionality appreciation), intuitive eating, and self-compassion predicted the continued absence versus onset of seven core eating disorder symptoms at follow-up.

RESULTS

Each of the five factors at baseline was associated with a lower odds of symptom onset for each outcome in univariate analyses. Baseline body appreciation and intuitive eating scores remained consistent, unique predictors of a lower odds of experiencing symptom onset in multivariate models. Greater increases in intuitive eating and body appreciation over time were the two factors consistently associated with a lower odds of symptom onset across several outcomes.

DISCUSSION

This study provides strong evidence for the protective influence of positive body image components, intuitive eating, and self-compassion against several eating disorder symptoms. Building these factors within established prevention programs may, in the longer term, help reduce the incidence of eating disorder syndromes and symptoms.

Factor structure and psychometric properties of the Muscularity-Oriented Eating Test in university women in Australia

OBJECTIVE

Toned muscularity continues to emerge as a salient aspect of women's body image. However, there is a dearth of research investigating the potentially maladaptive eating practices and related cognitions that accompany the drive for muscularity in women. This may be attributable to the limited empirical and clinical attention previously given to muscularity-oriented disordered eating and, accordingly, the lack of validated measures assessing these concerns. To address this knowledge gap, our study aimed to provide a preliminary evaluation of the factor structure and core psychometric properties of a recently developed measure of muscularity-oriented disordered eating, the Muscularity-Oriented Eating Test (MOET), in university women in Australia.

METHOD

Participants included 419 university women who completed the 15-item MOET and other self-report measures for validity evaluation as part of an online survey. Data from split-half samples were used to undertake an exploratory factor analysis and subsequent confirmatory factor analysis.

RESULTS

Factor analytic results supported a briefer (12-item), one-factor scale in this sample of university women. The internal consistency reliability and validity (convergent and discriminant) of this 12-item unidimensional MOET was supported.

DISCUSSION

Our study provides preliminary support for this modified MOET as a psychometrically sound self-report measure of muscularity-oriented disordered eating in university women in Australia, providing a useful tool for understanding maladaptive eating behaviors and cognitions concomitant to the pursuit of muscularity in this population.

A systematic review of instruments for the assessment of eating disorders among adults

PURPOSE OF REVIEW

The availability of psychometrically sound assessment instruments for assessing eating disorder symptomatology is crucial for both clinical practice and research. The purpose of the current review is to provide the reader with a list of psychometrically validated assessments for adults that are available within the field of eating disorders. Eating disorder interviews and self-report questionnaires were identified using online literature searches, reviewing previous review articles, and via research and/or clinical experience of the authors. The focus of the review was on (1) standard assessments that were frequently used in eating disorder research (such as the Eating Disorder Examination and Eating Attitudes Test), and (2) newer assessments that were developed over the past 5 years. Information compiled on each instrument included the purpose of the assessment, scores that can be derived, psychometric information, translations in other languages, and availability for use in research and clinical settings.

RECENT FINDINGS

Several recent trends in assessment instruments were identified including updates based upon Diagnostic and Statistical Manual criteria, briefer assessments, assessments for specific populations, and assessment of specific clinical features observed in people with eating disorders.

SUMMARY

The current review provides eating disorder clinicians and researchers a guide for making informed decisions about the selection of eating disorder assessments.

Implicit Attitudes Towards Weight, One’s Own Body and its Relation to Food in Women with Overweight and Obesity

Background

Theoretical models emphasize the importance of implicit self-related weight attitudes for the maintenance of body dissatisfaction. Even though body dissatisfaction is increased in obesity, only general implicit weight-related attitudes have been investigated so far. Therefore, the present study assessed self-related and general implicit weight attitudes and their relation to food.

Methods

Women with overweight and obesity (OW; n = 71) and women with normal weight (NW; n = 44) completed three implicit tasks to (1) assess attitudes towards persons with normal weight and overweight in general, (2) attitudes towards one’s own body, and (3) the association between one’s own body and food.

Results

While both groups showed an implicit preference towards persons with normal weight relative to persons with overweight, only women with OW showed a significantly stronger negative implicit attitude towards their own body and a stronger association between food and one’s own body. Additionally, self-related and not general implicit weight attitudes correlated significantly with body dissatisfaction and eating pathology.

Conclusions

The results highlight the importance of self-related implicit attitudes and their relation to body dissatisfaction and eating pathology in women with overweight and obesity. Targeting these self-related implicit weight attitudes might help to improve obesity treatments.

Race bias and gender bias in the diagnosis of psychological disorders

Bias is said to occur when validity is better for one group than another (e.g., when diagnoses are more valid for male or female clients). This article provides (a) a methodological critique of studies on race bias and gender bias in diagnosis and (b) a narrative review of results from studies with good internal validity. The results suggest that race bias occurs for the diagnosis of conduct disorder, antisocial personality disorder, comorbid substance abuse and mood disorders, eating disorders, posttraumatic stress disorder, and the differential diagnosis of schizophrenia and psychotic affective disorders. Other results suggest that gender bias occurs for the diagnosis of autism spectrum disorder, attention deficit hyperactivity disorder, conduct disorder, and antisocial and histrionic personality disorders. The way that symptoms are expressed (e.g., Black cultural expressions of depression) appears to have a significant effect on diagnoses. It may be possible to decrease bias by expanding the use of (a) mental health screening, (b) self-report measures including some psychological tests, (c) structured interviews, and (d) statistical prediction rules. Finally, evidence exists that (a) the diagnosis of personality disorders should be made using dimensional ratings and (b) training in cultural diversity and debiasing strategies should be provided to mental health professionals.

Performance- and image-enhancing drug use in the community: use prevalence, user demographics and the potential role of wastewater-based epidemiology

Performance- and image-enhancing drug (PIED) misuse is a significant public health issue. Currently, seizure data, surveys, anti-doping testing, and needle service provider data are used to estimate PIED use in populations. These methods are time consuming, single point-in-time measurements that often consist of small sample sizes and do not truly capture PIED prevalence. Wastewater-based epidemiology (WBE) has been used globally to assess and monitor licit and illicit drug consumption within the general community. This method can objectively cover large populations as well as specific subpopulations (gyms, music festivals, prisons), and has potential as a complementary monitoring method for PIED use. Information obtained through WBE could be used to aid public health authorities in developing targeted prevention and education programmes. Research on PIED analysis in wastewater is limited and presents a significant gap in the literature. The focus is on anabolic steroids, and one steroid alternative currently growing in popularity; selective androgenic receptor modulators. This encompasses medical uses, addiction, prevalence, user typology, and associated public health implications. An overview of WBE is described including its benefits, limitations and potential as a monitoring method for PIED use. A summary of previous work in this field is presented. Finally, we summarise gaps in the literature, future perspectives, and recommendations for monitoring PIEDs in wastewater.

Prevalence and correlates of weight gain attempts across five countries

OBJECTIVE

To determine the prevalence and correlates of weight gain attempts in a pooled sample of adults aged 18 and older from Canada, Australia, the United Kingdom, the United States, and Mexico.

METHOD

Data collected during 2 years (2018 and 2019) of the International Food Policy Study (N = 42,108) were analyzed. Unadjusted 12-month prevalence of weight gain attempts was estimated based on body mass index (BMI; kg/m² ), weight perception, country, survey year, and sex. Logistic regression analyses were estimated to determine the sociodemographic correlates (age, race/ethnicity, education, BMI, weight perception, weight perception accuracy, and self-rated mental health) of weight gain attempts among the pooled sample stratified by sex.

RESULTS

Men (10.4%) were significantly more likely than women (5.4%) to report weight gain attempts (p < .001). Nearly one in five (17.1%) men with a BMI in the "normal" range (≥18.5 to <25.0) reported weight gain attempts. Among both men and women, minority group identity was associated with higher odds, while older age and higher BMI category were associated with lower odds, of reporting weight gain attempts. Country differences over the two survey years showed the prevalence of weight gain attempts in 2019 (vs. 2018) was higher among women in Australia (p < .05) and men in the United States (p < .01).

DISCUSSION

Weight gain attempts are more common among men, compared to women, across five countries, potentially reflecting the global salience of the pursuit of a muscular body.

The Course of Weight/Shape Concerns and Disordered Eating Symptoms Among Adolescent and Young Adult Males

PURPOSE

Male weight concerns tend to focus on shape and muscularity as opposed to a desire for thinness and remain underdetected by conventional eating disorder assessments. We aimed to describe the longitudinal course of weight concerns and disordered eating behaviors among males across adolescence and young adulthood.

METHODS

We used prospective assessments of 4,489 U S. males, aged 11 to 18 years at baseline of analyses, in the Growing Up Today Study. We assigned mutually exclusive classifications of behaviors consistent with bulimia nervosa (BN), binge eating disorder (BED), purging disorder (PD); high levels of concern with thinness and/or muscularity; and use of muscle-enhancing products. We estimated the probability of maintenance, resolution, or transition to different weight concerns and/or disordered eating behaviors across consecutive survey waves.

RESULTS

Less than 1% of participants met full or partial criteria for BN, PD, or BED at baseline. One-quarter (25.4%, n = 1,137) of males reported high weight concerns during follow-up; nearly all these cases (93.7%, n = 1,065) had high muscularity concerns. The most common transition in concerns or behaviors involved the addition of muscularity concerns to a preoccupation with thinness. Eleven percent of participants used muscle-building products during follow-up. Multi-year product use (23.0% [standard deviation 1.0%] of males who used products) was more common than maintenance of bulimic behaviors (3.0% [.7%] of BN/PD, 10.5% [1.2%] of BED cases).

CONCLUSIONS

Integrating muscularity concerns and product use into health promotion and screening tools may improve prevention and early detection of harmful body image and weight control among adolescent and young adult males.

Validity and Reliability of the Muscularity Oriented Eating Test (MOET) in Turkish

Objectives: In this study, we determine the validity and reliability of the Muscularity Oriented Eating Test (MOET) among Turkish university students, thereby creating the MOET-TR. Methods: First, the MOET was translated by using the translation-back translation method for cultural equivalence. Then, the validity and reliability analyses were performed on 460 university students. To analyze the stability of the scale over time, the MOET-TR was applied to approximately 20% of the sample number for a second time after 2-4 weeks. Results: The one-factor structure of the MOET-TR demonstrated a good agreement with the fix index values. Cronbach's for the MOET-TR was 0.88, and the ICC value was 0.84. In addition, we found a positive statistically significant relationship between the total scores obtained from the DMS, EAT-40, REZZY, and IPAQ-Short forms used to evaluate the convergent divergent validity of the MOET-TR (p < .05). Conclusions: The MOET-TR is suitable for the Turkish culture and can be used to identify individuals who have muscularity oriented eating disorders, who are uncomfortable with their body shape, and who turn their body shapes into a social phobia.

The role of weight- and appearance-related discrimination on eating disorder symptoms among adolescents and emerging adults

BACKGROUND

Eating disorder symptoms (EDs) have been discussed as a prominent problem among late adolescent girls with serious health risks and long-term consequences. However, there is a lack of population-based evidence on EDs comprising the age range from early adolescence to emerging adulthood as well as considering both females and males equally. Additionally, the differential role of a comprehensive set of several relevant risk factors and particularly weight- and appearance-related discrimination warrants further attention. Thus, we aimed to contribute to a better understanding of sex- and age-related differences in associations between discrimination experience and other relevant personal risk factors (body image, social media use, self-efficacy, social support) with EDs. Furthermore, we were interested in the exploration of underlying mechanisms enhancing the risk of EDs by taking discrimination experience into account.

METHODS

Based on a logistic regression model, we investigated associations between weight- and appearance-related discrimination and EDs while controlling for other relevant personal risk factors in a subsample of N = 8504 adolescents and emerging adults (54.4% female, mean age = 20.71 years, SD = 4.32 years) drawn from a German representative health survey (KiGGS Wave 2). In a second step, we investigated the mediating role of discrimination experience between the other risk factors and EDs with the help of a path model.

RESULTS

While controlling for other relevant personal risk factors, weight- and appearance-related discrimination was significantly related to EDs. Whereas the risk of EDs was significantly enhanced in males and emerging adults frequently experiencing weight-related discrimination, adolescents showed a higher risk of EDs when experiencing appearance-related discrimination. Moreover, discrimination experience partly explained the associations between body image dissatisfaction, low self-efficacy, high media use and ED symptoms.

CONCLUSIONS

The results highlight weight- and appearance-related discrimination as one central factor to be considered in the pathogeneses of EDs and underpin the need for discrimination prevention as well as the promotion of adaptive coping with discrimination experience to reduce the risk of developing ED symptoms. Males and emerging adults need particular attention when facing weight-related discrimination whereas risk constellations and EDs particularly affecting females need further investigation.

Self-Reported Lifetime History of Eating Disorders and Mortality in the General Population: A Canadian Population Survey with Record Linkage

Eating disorders (EDs) are often reported to have the highest mortality of any mental health disorder. However, this assertion is based on clinical samples, which may provide an inaccurate view of the actual risks in the population. Hence, in the current retrospective cohort study, mortality of self-reported lifetime history of EDs in the general population was explored. The data source was the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2), linked to a national mortality database. The survey sample was representative of the Canadian household population (mean age = 43.95 years, 50.9% female). The survey inquired about the history of professionally diagnosed chronic conditions, including EDs. Subsequently, the survey dataset was linked to the national mortality dataset (for the date of death) up to 2017. Cox proportional hazards models were used to explore the effect of EDs on mortality. The unadjusted-hazard ratio (HR) for the lifetime history of an ED was 1.35 (95% CI 0.70-2.58). However, the age/sex-adjusted HR increased to 4.5 (95% CI 2.33-8.84), which was over two times higher than age/sex-adjusted HRs for other mental disorders (schizophrenia/psychosis, mood-disorders, and post-traumatic stress disorder). In conclusion, all-cause mortality of self-reported lifetime history of EDs in the household population was markedly elevated and considerably higher than that of other self-reported disorders. This finding replicates prior findings in a population-representative sample and provides a definitive quantification of increased risk of mortality in EDs, which was previously lacking. Furthermore, it highlights the seriousness of EDs and an urgent need for strategies that may help to improve long-term outcomes.

Dialectical Behaviour Therapy Improves Emotion Dysregulation Mainly in Binge Eating Disorder and Bulimia Nervosa: A Systematic Review and Meta-Analysis

Emotion dysregulation is a transdiagnostic phenomenon in Eating Disorders (ED), and Dialectical Behaviour Therapy (DBT) (which was developed for reducing dysregulated emotions in personality disorders) has been employed in patients with ED. This systematic review and meta-analysis investigated whether the effect of DBT was stronger on emotion dysregulation, general psychopathology, and Body Mass Index (BMI) in participants with ED, when compared to a control group (active therapy and waitlist). Eleven studies were identified in a systematic search in accordance with PRISMA guidelines. Most studies included participants with Binge Eating Disorder (BED) (n = 8), some with Bulimia Nervosa (BN) (n = 3), and only one with Anorexia Nervosa (AN). The pooled effect of DBT indicated a greater improvement in Emotion Regulation (ER) (g = −0.69, p = 0.01), depressive symptoms (g = −0.33, p < 0.00001), ED psychopathology (MD = −0.90, p = 0.005), Objective Binge Episodes (OBE) (MD = −0.27, p = 0.003), and BMI (MD = −1.93, p = 0.01) compared to the control group. No improvement was detected in eating ER following DBT (p = 0.41). DBT demonstrated greater efficacy compared with the control group in improving emotion dysregulation, ED psychopathology, and BMI in ED. The limitations included the small number of studies and high variability.

Gender differences in symptom presentation and treatment outcome in children and youths with eating disorders

BACKGROUND

To address the gaps in the literature examining eating disorders among males and gender minority youths, a prospective study was designed to assess gender differences in eating disorder symptom presentation and outcomes. Muscularity concerns may be particularly relevant for male youths with eating disorders, and were included in assessment of eating disorder symptom presentation.

METHODS

All cisgender male youths who presented for specialized eating disorder treatment at one of two sites were invited to participate, along with a group of matched cisgender females, and all youths who did not identify with the sex assigned to them at birth. Youths completed measures of eating disorder symptoms, including muscularity concerns, and other psychiatric symptoms at baseline and end of treatment.

RESULTS

A total of 27 males, 28 females and 6 trans youths took part in the study. At baseline, Kruskal-Wallis tests demonstrated that trans youths reported higher scores than cisgender male and female youths on measures of eating pathology (Eating disorder examination-questionnaire (EDE-Q) and the body fat subscale of the male body attitudes scale (MBAS)). These analyses demonstrated that there were no differences between cisgender male and female youths on eating disorder symptoms at baseline. However, repeated measures ANOVA demonstrated that males had greater decreases in eating pathology at discharge than did females, based on self-reported scores on the EDE-Q, MBAS, and Body Change Inventory.

CONCLUSIONS

Gender differences in eating pathology appeared at baseline, with trans youths reporting higher levels of eating pathology than cisgender youths, though no differences between cisgender males and females emerged at baseline for eating disorder symptom presentation. Contrary to expectations, there were no gender differences in measures of muscularity concerns. Males demonstrated greater eating disorder symptom improvements than females, suggesting that male adolescents may have better treatment outcomes than females in some domains.

Excess mortality associated with eating disorders: population-based cohort study

BACKGROUND

Individuals with eating disorders have a high mortality risk. Few population-based studies have estimated this risk in eating disorders other than anorexia nervosa.

AIMS

To investigate all-cause mortality in a population-based cohort of individuals who received hospital-based care for an eating disorder (anorexia nervosa, bulimia nervosa or eating disorder not otherwise specified) in Ontario, Canada.

METHOD

We conducted a retrospective cohort study of 19 041 individuals with an eating disorder from 1 January 1990 to 31 December 2013 using administrative healthcare data. The outcome of interest was death. Excess mortality was assessed using standardised mortality ratios (SMRs) and potential years of life lost (PYLL). Cox proportional hazards regression models were used to examine sociodemographic and medical comorbidities associated with greater mortality risk.

RESULTS

The cohort had 17 108 females (89.9%) and 1933 males (10.1%). The all-cause mortality for the entire cohort was five times higher than expected compared with the Ontario population (SMR = 5.06; 95% CI 4.82-5.30). SMRs were higher for males (SMR = 7.24; 95% CI 6.58-7.96) relative to females (SMR = 4.59; 95% CI 4.34-4.85) overall, and in all age groups in the cohort. For both genders, the cohort PYLL was more than six times higher than the expected PYLL in the Ontario population.

CONCLUSIONS

Patients with eating disorders diagnosed in hospital settings experience five to seven times higher mortality rates compared with the overall population. There is an urgent need to understand the mortality risk factors to improve health outcomes among individuals with eating disorders.

Internalization of body shape ideals and body dissatisfaction: A systematic review and meta-analysis

OBJECTIVE

The present meta-analysis summarizes existing evidence on the relationship between the internalization of body shape ideals (IBSI) and body dissatisfaction.

METHOD

Pooled effect sizes (r) were computed using a random-effects model. The robustness of the results was examined using influence analyses. Potential predictors of effect heterogeneity were examined using subgroup analysis and univariable/multivariable meta-regressions. Publication bias was examined using the three-parameter selection model (3PSM).

RESULTS

A total of 141 effect-sizes from 78 studies (N = 39,491) were retrieved. Results revealed medium (r = .25; muscular/athletic-ideal internalization) to very large (r = .43, general attractiveness-ideal internalization; and r = .45, thin-ideal internalization) relationships, all these being largely similar in male and female individuals.

DISCUSSION

IBSI and body dissatisfaction were strongly linked: (a) in younger individuals (general attractiveness-ideal internalization); (b) when IBSI was operationalized in terms of endorsement rather than mere awareness of appearance ideals; (c) in studies of lower methodological quality (muscular/athletic-ideal internalization); and (d) when IBSI was assessed using instruments involving social comparisons. Given the largely cross-sectional nature of data included in this meta-analysis, further testing in prospective and experimental studies is needed to confirm hypotheses about causality of observed associations. Such findings would have impact for prevention and intervention studies.

Comorbid obsessive-compulsive disorder in individuals with eating disorders: An epidemiological meta-analysis

The present study aimed to provide a precise, meta-analytic estimate of the prevalence of obsessive-compulsive disorder (OCD) amongst those with a current primary eating disorder (ED) diagnosis, and to isolate its predictors. An online search of PubMed and PsycINFO was conducted with a Boolean search phrase incorporating keywords related to OCD, EDs, comorbidity, prevalence, and epidemiology, complemented by references coded from related review articles and contact with experts in the field. Articles were included if they (a) reported an observational study examining current ED diagnoses, (b) used a semi-structured or structured diagnostic interview for OCD and ED diagnosis, (c) applied DSM or ICD criteria, (d) included adolescent or adult samples (age > 12), (e) included patient or community samples, and (f) reported lifetime or current OCD comorbidity. From the 846 articles identified, 35 lifetime and 42 current estimates were calculated. OCD prevalence was extracted from each study for each ED diagnostic category, along with eleven additional potential moderators. Analyses revealed an aggregate lifetime OCD prevalence of 13.9% CI_95% [10.4 to 18.1] and current OCD prevalence of 8.7% CI_95% [5.8 to 11.8] across EDs. Moderator analyses revealed the prevalence of and risk for OCD in EDs to be greatest in anorexia nervosa binge-eating purging type (ANBP). Further, OCD is most prevalent amongst patient samples than samples recruited from the community.

3D visualisation of psychometric estimates for the ideal male body

Psychological concerns are frequently indexed by psychometric questionnaires but the mental representations that they seek to quantify are difficult to visualise. We used a set of questionnaires designed to measure men's concept of their bodies including: the Drive for Muscularity Scale (DMS; McCreary & Sasse, 2000), the Perceived Sociocultural Pressures Scale (PSPS; Stice, Nemeroff, & Shaw, 1996a), the Body Appreciation Scale (BAS-2; Tylka & Wood-Barcalow, 2015), and the Sociocultural Attitudes Towards Appearance Questionnaire-3 (SATAQ-3; Thompson, van den Berg, Roehrig, Guarda, & Heinberg, 2004). We combined their use with an interactive 3D modelling programme to allow men to create computer-generated representations of their ideal bodies. We used a principal component analysis to extract those shape components of our participants' CGI ideal bodies that were predicted by the questionnaires and reconstructed the body shapes that these questionnaires were capturing. Moving from the lowest to the highest score on both the DMS and SATAQ corresponded with changes in muscularity, particularly muscle mass and definition. This approach allows us to demonstrate the actual body features that are being captured by a particular questionnaire.

Psychometric evaluation of the Muscle Dysmorphic Disorder Inventory (MDDI) among cisgender gay men and cisgender lesbian women

Despite increasing empirical interest in muscle dysmorphia (MD), a dearth of research has assessed this construct in sexual minority populations. In particular, the psychometric properties of one of the most widely used measures of MD symptoms-the Muscle Dysmorphic Disorder Inventory (MDDI)-have not been evaluated in sexual minority populations despite emerging evidence suggesting differential risk for MD symptoms across sexual orientation groups. In this study, we assessed the psychometric properties of the MDDI in a sample of 715 cisgender gay men and 404 cisgender lesbian women ages 18-50 years who participated in a large-scale national longitudinal cohort study of sexual and gender minority adults. The factor structure of the MDDI was examined in each sample using a two-step, split-sample exploratory and confirmatory factor analytic approach. Exploratory factor analysis supported a three-factor structure in both samples, which were confirmed by confirmatory factor analysis. Moreover, results supported the internal consistency reliability and convergent validity of the MDDI subscales in both samples. Cumulatively, these findings suggest that the MDDI is an appropriate measure of MD symptoms among cisgender gay men and cisgender lesbian women.

Predicting probable eating disorder case-status in men using the Clinical Impairment Assessment: Evidence for a gender-specific threshold

The Clinical Impairment Assessment (CIA) is a widely used self-report measure of the psychosocial impairment associated with eating-disorder symptoms. Past studies recommended a global CIA score of 16 to identify clinically significant impairment associated with a probable eating disorder (ED). However, to date, research on the properties of the CIA has been conducted in majority-women samples. Preliminary research on gender differences in CIA scores suggested men with EDs report less impairment on the CIA relative to women with EDs. Thus, the purpose of this study was to test if a different impairment threshold is needed to identify cases of men with EDs. We hypothesized that a lower CIA threshold, relative to that identified in majority-women samples, would most accurately identify men with EDs. Participants (N = 162) were men from our university-based and general community-based ED participant registry who completed the CIA and Eating Disorder Diagnostic Scale. Both precision-recall and receiver operating characteristic curves assessed what CIA global score threshold most accurately identified men with EDs. Both analytic approaches indicated that a CIA global score of 13 best predicted ED case-status in men. Consistent with past research, men with a clinically significant ED appear to report lower impairment on the CIA. Results have implications for screening and assessing for substantial ED-related impairment in men. Additionally, past research using the CIA to identify men with EDs may have under-identified men with clinically significant symptoms.

Associations between weight/shape overvaluation, sociodemographic features and BMI: 10-year time trends

PURPOSE

To investigate the prevalence of overvaluation across sociodemographic features and weight status over time.

METHODS

The data included sequential cross-sectional surveys with representative samples of the adolescent and adult (15 years or older) population in South Australia. Five surveys that assessed overvaluation were conducted in the years 2005 (n = 3047), 2008 (n = 3034), 2009 (n = 3007), 2015 (n = 3005) and 2016 (n = 3047). Overvaluation was assessed by structured interview based on the Eating Disorder Examination. To examine unique effects of demographic variables on the likelihood to report overvaluation, and also to examine whether this varied as a function of time, a multivariate binary logistic regression was computed.

RESULTS

Across survey years, participants who were more likely to endorse overvaluation were female (2005: OR 2.85, CI 2.04-3.99; 2008/9: OR 1.74, CI 1.50-2.01; 2015/6: OR 1.54, CI 1.34-1.76), had a BMI > 30 (2005: OR 3.93, CI 1.49-10.34; 2008/9: OR 2.22, CI 1.31-3.78; 2015/6: OR 2.09, CI 1.19-3.67), had left school (2015/6: OR 1.36, CI 1.14-1.63), and lived in the country (2015/6: OR 1.95, CI 1.69-2.24). Being in the oldest age group was protective against endorsing overvaluation in each survey year. There was also a main effect of survey year, with participants in the 2015/6 survey more likely to endorse overvaluation (p < 0.001).

CONCLUSIONS

Female, young and obese people were more likely to endorse overvaluation; however, the prevalence of overvaluation increased significantly in all sociodemographic and BMI groups in since 2005-2016.

EVIDENCE-BASED MEDICINE

Level IV, evidence obtained from multiple time series with or without the intervention, such as case studies.

Body checking behaviors and eating disorder pathology among nonbinary individuals with androgynous appearance ideals

BACKGROUND

Internalized sociocultural standards of attractiveness are a risk factor repeatedly linked to eating disorders; however, many nonbinary individuals do not conform to these standards.

PURPOSE

This study investigated the body checking behaviors and eating disorder pathology among nonbinary individuals with androgynous appearance ideals.

METHODS

Participants (n = 194) completed an online survey assessing body checking behaviors, body appreciation, gender congruence, and eating disorder pathology RESULTS: Body checking predicted eating disorder pathology, and body image significantly improved the model. Gender congruence did not additional variance in predicting eating pathology CONCLUSION: Though gender congruence was not a significant predictor of eating pathology, content analysis revealed unique body behaviors specific to nonbinary individuals' gender identity and gender expression. Clinical implications include expanding perceptions of eating disorder presentation when working with nonbinary individuals with androgynous appearance ideals.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Validation of the factor structure of the Eating Pathology Symptoms Inventory in an international sample of sexual minority men

Sexual minority individuals are at greater risk for the development of eating-disorder (ED) psychopathology. Despite the importance of understanding ED symptoms in sexual minority men, most ED measures were developed and validated in heterosexual, young adult, white women. The psychometric properties of ED measures in diverse populations remain largely unknown. The purpose of this study was to test: 1) whether the eight-factor structure of the Eating Pathology Symptoms Inventory (EPSI) replicated in sexual minority men and 2) group-level mean differences between gay and bisexual men on the eight EPSI scales. International participants (N = 722 sexual minority men from 20 countries) were recruited via the Grindr smartphone application. Confirmatory factor analysis (CFA) was completed using a weighted least square mean and variance adjusted estimator. Group differences in eating pathology between gay and bisexual men were tested using independent samples t-tests. The CFA model fit was good on all fit indices (CFI/TLI > 0.90, RMSEA < 0.06). Gay and bisexual men only differed on the EPSI Binge Eating scale. The results of this investigation suggest that the EPSI may be a useful tool for understanding eating pathology in this population. Using psychometrically sound assessment tools for sexual minority men is a vital piece of treatment planning and clinical decision making. The current study fills an important gap in the clinical and research literature by testing the validity and psychometric properties of a commonly used ED measure in sexual minority men.

Differential item functioning analysis for the Eating Disorder Examination Questionnaire among heterosexual and sexual minority men

PURPOSE

Sexual minority (SM) men are at a higher risk for eating disorders and related issues, relative to heterosexual men. However, it is currently unknown whether commonly used measures of eating pathology are appropriate to use among diverse groups of men. Determining the unique functioning of existing assessments may help better and more accurately understand eating disorder pathology within this population. The present study examined differences in item endorsement between sexual orientation in the Eating Disorder Examination Questionnaire (EDE-Q) through differential item functioning (DIF).

METHODS

Heterosexual and SM men (N = 703) completed the EDE-Q and a demographic questionnaire. EDE-Q scores were examined for clinically significant DIF based on participants' self-reported sexual orientation (e.g., heterosexual men vs SM men).

RESULTS

SM men reported higher EDE-Q symptom composite scores than heterosexual men. DIF was observed for all EDE-Q items relative to the global score; however, only one item met clinical significance (EDE-Q #19; ∆R² ≥ 0.13).

CONCLUSION

Results suggest that SM men experience greater levels of ED pathology than heterosexual men. While the EDE-Q is a commonly used measure of eating pathology, findings suggest that sexual orientation bias may impact many items on the EDE-Q. However, results from this study indicated that only one item introduces bias that has clinical implications. Additional research is needed to further explore and replicate this finding among more diverse samples of SM and heterosexual men.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Parental experiences with their child's eating disorder treatment journey

BACKGROUND

Parents are integral in the treatment of pediatric eating disorders. The current study was conducted to further understand the barriers and facilitators that parents experience in accessing specialized, tertiary level eating disorder treatment for children and adolescents. The goals of the study were to understand the processes leading to diagnosis and treatment, perceived barriers and facilitators to accessing care, and parents' experiences over the course of their child's eating disorder treatment.

METHODS

Ten parents whose children were admitted to a Canadian tertiary level specialized pediatric eating disorders program took part in an exit interview upon their child's completion of treatment in the program. In-depth semi-structured interviews were combined with a visual timeline. Interpretive induction was performed to generate high-level concepts that emerged from the interviews.

RESULTS

Five high-level concepts were identified: (1) delays in identifying eating disorder symptoms, (2) challenges in accessing eating disorder services, (3) the right treatment at the right time, (4) emotional impact on parents, and (5) parental expertise and involvement.

CONCLUSIONS

Several barriers were identified by parents that interfered with treatment, including system-related challenges when accessing specialized eating disorder treatment, concerns about a lack of appropriate mental health support for their child, and difficulties with transitioning between community and tertiary level care. Negative emotions, including guilt and self-blame, were common early in the treatment journey. Themes of parental involvement throughout treatment, and parents taking charge of their child's recovery, emerged across interviews. The results of this study suggest the importance of early identification of eating disorder symptoms, facilitating smoother transitions between levels of care (e.g., community services and hospital-based eating disorder care), and improving clinical decision-making to ensure children and adolescents with eating disorders receive the most appropriate treatment based on their clinical presentation.

Prevalence and demographic, substance use, and mental health correlates of fasting among U.S. college students

BACKGROUND

Fasting is an unhealthy behavior that has been frequently used as part of weight loss attempts. To date, little research has been conducted to determine the prevalence and substance use and mental health correlates of fasting among college students. Therefore, the aim of this study was to estimate the prevalence and associations between any (≥ 1 time) and regular (≥ 13 times) occurrences of fasting in the past 4 weeks and substance use and mental health correlates among a large sample of college students from 2016 to 2020.

METHODS

Data from four academic survey years (2016-2020; N = 8255) of the national (USA) Healthy Minds Study were analyzed. Unadjusted prevalence of any and regular fasting by survey year and gender was estimated. Multiple logistic regression analyses were conducted to estimate the associations between any and regular fasting and the demographic (age, body mass index, race/ethnicity, sexual orientation, highest parental education), substance use (cigarette use, marijuana use, other illicit drug use, alcohol use), and mental health (depression, anxiety, eating disorder symptoms, suicidal ideation, non-suicidal self-injury) correlates.

RESULTS

Any fasting in the past 4 weeks was common among both men (14.77%) and women (18.12%) and significantly increased from 2016 (10.30%) to 2020 (19.81%) only among men. Regular fasting significantly increased among both men and women from 2016 (men: 1.46%; women: 1.79%) to 2020 (men: 3.53%; women: 6.19%). Among men and women, both any and regular fasting in the past 4 weeks were associated with higher odds of all mental health symptoms, including a positive depression, anxiety, and eating disorder screen, suicidal ideation, and non-suicidal self-injury. Among women, but not men, any and regular fasting in the past 4 weeks were associated with higher odds of marijuana use and other illicit drug use (e.g., cocaine, ecstasy).

CONCLUSIONS

The results from this study underscore both the high and increasing prevalence of fasting among a national sample of college students, as well as the substance use and mental health symptoms associated with this behavior. Healthcare professionals both on and off campus should consider screening for fasting behaviors among college students and provide appropriate intervention when needed.

Changing your body changes your eating attitudes: embodiment of a slim virtual avatar induces avoidance of high-calorie food

The virtual-reality full-body illusion paradigm has been suggested to not only trigger the illusory ownership of the avatar's body but also the attitudinal and behavioral components stereotypically associated to that kind of virtual body. In the present study, we investigated whether this was true for stereotypes related to body size: body satisfaction and eating control behavior. Healthy participants underwent the full-body illusion paradigm with an avatar having either a larger or a slimmer body than their own, and were assessed for implicit attitudes towards body image and food calorie content at baseline and after each full-body illusion session. Results showed that the illusion emerged regardless of the avatar's body size, whereas the perceived dimension of the own body size changed according to the avatar's body size (i.e., participants felt to be slimmer after embodying their slim avatar and larger after embodying their large avatar). Crucially, we found that implicit attitudes towards food, but not those towards one's own body, were modulated by the size of the virtual body. Compared to baseline, ownership of a slimmer avatar increased the avoidance of high-calorie food, whereas ownership of a larger avatar did not induce changes. Our findings suggest that the illusory feeling of being slimmer drives also the food-related stereotypes associated with that body size, increasing the regulation of eating behaviors.

The Association Between Autistic Traits and Disordered Eating is Moderated by Sex/Gender and Independent of Anxiety and Depression

Previous studies have reported positive correlations between autistic traits and disordered eating, though it is unclear whether the association is moderated by sex/gender or whether it is independent of anxiety or depression. We present the findings of an online survey of 691 participants who completed the Autism Spectrum Quotient (AQ), Hospital Anxiety and Depression Scale (HADS), and Eating Attitudes Test-26 (EAT-26). Following a pre-registered analysis plan, we observed positive correlations between AQ and EAT-26 in males and females, with the association being significantly stronger in females. AQ also remained a significant predictor of EAT-26 when anxiety and depression were controlled for statistically. These findings may be relevant when considering therapeutic interventions in disordered eating populations that exhibit autistic traits.

Diabetes technologies in people with type 1 diabetes mellitus and disordered eating: A systematic review on continuous subcutaneous insulin infusion, continuous glucose monitoring and automated insulin delivery

AIMS

In this systematic review, we aimed (1) to identify and describe research investigating the use of advanced diabetes technologies (continuous subcutaneous insulin infusion, CSII; continuous glucose monitoring, CGM; automated insulin delivery, AID) in people with type 1 diabetes (T1DM) and disordered eating and (2) to discuss potential (dis)advantages of diabetes technology use in this population, derived from previous research.

METHODS

We conducted a systematic literature search in two electronic databases for English articles published between 2000 and 2020 addressing eating disorders and/or dysfunctional eating behaviours and diabetes technology use in children, adolescents and adults with T1DM (PROSPERO ID CRD42020160244).

RESULTS

Of 70 publications initially identified, 17 were included. Overall, evidence on the use of diabetes technologies in people with T1DM and disordered eating is scarce. The majority of the studies reports findings on CSII in people with T1DM and dysfunctional eating behaviours or eating disorders. Findings predominantly stem from observational data and are, in most cases, secondary findings of the respective studies. Providing the greatest flexibility in diabetes management, CSII may have benefits in disordered eating. CGM data may complement the diagnostic process of disordered eating with a physiological indicator of insulin restriction (i.e. time spent in hyperglycaemia).

CONCLUSIONS

Results on possible (dis)advantages of diabetes technology use in people with T1DM and disordered eating are based on observational data, small pilot trials and anecdotical evidence from case reports. Prospective data from larger samples are needed to reliably determine potential effects of diabetes technology on disordered eating in T1DM.

The Male Athlete Triad-A Consensus Statement From the Female and Male Athlete Triad Coalition Part 1: Definition and Scientific Basis

ABSTRACT

The Male Athlete Triad is a syndrome of 3 interrelated conditions most common in adolescent and young adult male endurance and weight-class athletes and includes the clinically relevant outcomes of (1) energy deficiency/low energy availability (EA) with or without disordered eating/eating disorders, (2) functional hypothalamic hypogonadism, and (3) osteoporosis or low bone mineral density with or without bone stress injury (BSI). The causal role of low EA in the modulation of reproductive function and skeletal health in the male athlete reinforces the notion that skeletal health and reproductive outcomes are the primary clinical concerns. At present, the specific intermediate subclinical outcomes are less clearly defined in male athletes than those in female athletes and are represented as subtle alterations in the hypothalamic-pituitary-gonadal axis and increased risk for BSI. The degree of energy deficiency/low EA associated with such alterations remains unclear. However, available data suggest a more severe energy deficiency/low EA state is needed to affect reproductive and skeletal health in the Male Athlete Triad than in the Female Athlete Triad. Additional research is needed to further clarify and quantify this association. The Female and Male Athlete Triad Coalition Consensus Statements include evidence statements developed after a roundtable of experts held in conjunction with the American College of Sports Medicine 64th Annual Meeting in Denver, Colorado, in 2017 and are in 2 parts-Part I: Definition and Scientific Basis and Part 2: The Male Athlete Triad: Diagnosis, Treatment, and Return-to-Play. In this first article, we discuss the scientific evidence to support the Male Athlete Triad model.

Role of parental confirmation in body dissatisfaction and body change behaviors among college men

To examine how the components of confirmation (i.e., acceptance and challenge) from mother and father have an indirect effect on college men's body dissatisfaction through self-concept, and if body dissatisfaction, in turn, is related to body change behaviors. Participants: College men (N = 237) aged 18-25 from two large universities completed an online survey. Methods: Structural equation modeling was conducted to test hypothesized mediation model. Results: Maternal acceptance had negative indirect effects on body dissatisfaction through self-concept, and body dissatisfaction, in turn, was positively related to body change behaviors. Mother challenge emerged as a near-significant direct and positive predictor of muscularity enhancement behaviors. None of the paternal variables significantly contributed to the model. Conclusions: Mother acceptance may contribute to sons' positive view of self and their appearance, potentially reducing the likelihood of their engagement in body change behaviors. Intervention can target parent-child communication and enhancement of college men's self-concept.

Last word: A call to develop specific medical treatment guidelines for adolescent males with eating disorders

Males with eating disorders are underdiagnosed and undertreated, which may be a result of inadequate guidance and training to assess and treat eating disorders for medical professionals. This may be particularly problematic for adolescent males given the focus of eating disorders research and treatment on adolescent females. Furthermore, there is a paucity of research to guide screening, medical treatment, and training of health professions in adolescent males with eating disorders. The development of eating disorders education and training for medical professionals are included in the 21st Century Cures Act, which further emphasizes the opportunity to develop treatment guidelines individualized to male patients. This last word calls for the development of specific medical treatment guidelines for adolescent males with eating disorders.

Associations Between Defence-Style, Eating Disorder Symptoms, and Quality of Life in Community Sample of Women: A Longitudinal Exploratory Study

Background and Aim: Eating Disorders (EDs) impact an estimated 15% of the global population and are linked to maladaptive defence-styles (coping strategies) and poorer mental health outcomes. Defence-styles have been grouped into immature, neurotic, and mature behaviours. Studies have yet to examine all three defence-styles in ED symptomatic individuals over an extended period of time. The current study aimed to investigate using converse analysis the relationships between defence-style and ED outcomes over a 5-years period. Methods: Participants (n = 216, mean age 33 years) were recruited through the Women's Eating and Health Literacy study, with the current study examining a 5-years period of two waves (year-4 and year-9). The current study tested associations over time between eating pathology (EDE-Q), psychological distress (K10), mental and physical health related quality of life (M/PHRQoL, SF-12), and defence-style (DSQ-40). Results: Mature, immature and neurotic defence-styles did not significantly change over 5 years. Over the same period, only PHRQoL significantly predicted mature defence-styles having positive effect. Both MHRQoL and PHRQoL significantly predicted immature defence-styles having positive and negative effects, respectively. Psychological distress, PHRQoL and weight concern significantly predicted neurotic defence-styles having positive effects except for psychological distress. PHRQoL, MHRQoL, restraint and eating concern significantly predicted overall eating pathology having positive effects except for PHRQoL and MHRQoL. Conversely, among the defence-style variables, over 5 years, both immature and neurotic defence-styles significantly predicted psychological distress having positive effects, immature and mature defence-styles significantly predicted MHRQoL having negative and positive effects, respectively, while only immature defence-styles significantly predicted overall eating pathology having positive effect. Conclusions: The results of the current study suggest that immaturity and neuroticism but not maturity were the defence-style variables predicting psychological distress over a 5-years period while conversely psychological distress predicted only neurotic defence styles. The findings of the current study may suggest that without intervention, mature, immature and neurotic defence-styles may largely remain immutable to significant shifts over time. Limitations in the current study included limited demographic representation. The current study is anticipated to generate considerations into treatments that could strengthen defence-styles in individuals with increased eating pathology.

Eating-related pathology at the intersection of gender identity and expression, sexual orientation, and weight status: An intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) of the Growing Up Today Study cohorts

The objective of this study was to investigate how gender identity, the overwhelmingly prioritized dimension of social identity/position in eating-related pathology research, intersects with gender expression, sexual orientation, and weight status to structure the social patterning of eating disorders and disordered eating behaviors among young people in the U.S. Data were drawn from the 2010/2011 Growing Up Today Study (GUTS; N = 11,090-13,307). We conducted an intersectional Multilevel Analysis of Individual Heterogeneity and Discriminatory Accuracy (MAIHDA) by nesting participants within social strata defined by intersecting gender identity, gender expression, sexual orientation, and weight status categories in a series of multilevel logistic models for four outcomes (past-year purging, overeating, and binge eating; lifetime eating disorder diagnosis). To illustrate the advantages of intersectional MAIHDA, we compared the results to those from unitary and conventional intersectional analyses. The intersectional MAIHDA revealed a complex social patterning of eating-related pathology characterized by heterogeneity and outcome-specificity. Several multiply marginalized strata (e.g., those including gender nonconforming, sexual minority, and/or larger-bodied girls/women) had disproportionately elevated prevalence, although all estimates were driven by additive effects. Notably, these patterns were obscured within the unitary and conventional intersectional analyses. Future epidemiologic research on eating-related pathology should continue to adopt an intersectional approach through the use of appropriate methodologies.