Cross-cultural validity of the Eating Disorder Inventory: a study of Chinese patients with eating disorders in Hong Kong

Translation and validation of a Chinese version of the body talk scale for women and men

Body talk has received increasing research attention in recent years, with accumulating evidence supporting the link between body talk and eating and body image disturbances. However, research on body talk in China is still relatively scarce and generally focused on fat talk, especially in women, and much remains unknown about muscle talk and positive body talk for both Chinese women and men. To promote a better understanding of body talk in the Chinese context, the present study adapted the Body Talk Scale (BTS) into Chinese Mandarin (i.e., C-BTS) and evaluated the factor structure and psychometric properties of the C-BTS in Chinese adult women and men. The English version of the BTS was translated into Chinese Mandarin with standard procedures. With 300 Chinese women (Mage = 29.48 years, SD = 7.26) and 300 men (Mage = 29.36 years, SD = 6.81), we examined the factor structure and gender invariance of the C-BTS, as well as internal consistency reliability, test-retest reliability, and construct validity, including convergent, concurrent, and incremental validity of the C-BTS. The results indicated that, consistent with the development study of the BTS, the C-BTS had three subscales (i.e., Negative Fat Talk, Negative Muscle Talk, and Positive Body Talk) and good reliability and validity. The findings demonstrate that the C-BTS can be a useful measure of body talk in both Chinese women and men.

The Chinese version of the Functionality Appreciation Scale: Psychometric properties and measurement invariance across gender and age

BACKGROUND

Functionality appreciation, as an important aspect of positive image, is associated with fewer body image disturbances, fewer disordered eating behaviors, and improved psychological well-being. However, it has been under-researched in Asian countries. The current work aimed to examine the psychometric properties of the Functionality Appreciation Scale (FAS) among four Chinese samples of different ages, and further examine measurement invariance and differences of the FAS across gender and age groups.

METHODS

Exploratory and confirmatory factor analyses (EFA and CFA) were conducted to examine the factorial structure of the FAS among four Chinese samples of different ages, including middle school adolescents (n = 894, M_age = 12.17 years), high school adolescents (n = 1347, M_age = 15.07 years), young adults (n = 473, M_age = 21.95 years), and older adults (n = 313, M_age = 67.90 years). The measurement invariance of the FAS across gender and age was examined. Internal consistency reliability and construct validity were evaluated.

RESULTS

The FAS had a unidimensional structure and was invariant across gender and age groups. The FAS presented sound psychometric properties in all age groups by gender, with good internal consistency reliability [e.g., high Cronbach's α values (.91 ~ .97)] and good construct validity (e.g., significant associations with body appreciation, body dissatisfaction, and disordered eating). Moreover, group comparisons showed minimal gender differences in functionality appreciation. However, significant age differences were found in functionality appreciation, with older ages generally associated with higher functionality appreciation.

CONCLUSION

Overall, findings suggest that the FAS is a sound instrument to be used in the Chinese context. Furthermore, functionality appreciation was found to be higher in older adults than adolescents or young adults, suggesting the potential important role of aging in functionality appreciation.

Adolescents at risk of eating disorders: The mediating role of emotional distress in the relationship between differentiation of self and eating disorders

Introduction

Adolescents may feel dissatisfied with their bodies, which may lead to a risk of eating disorders (EDs) due to several factors, with emotional distress being one of the most important. Evidence suggests that family might be one of the most significant factors that may increase or decrease emotional distress. An important family pattern found to contribute to mental and physical health is the differentiation of self (DoS). The primary purpose of the current study was to map the complex relationships between DoS, emotional distress, and EDs among adolescents. We hypothesized that emotional distress would mediate the relationship between DoS and the risk of EDs among adolescents. Moreover, based on findings indicating a higher risk of EDs among females, we expected sex differences in the research indices and the mediation model.

Methods

The sample included 194 non-clinical adolescents (mean age 15.15; mean BMI 21.66). Preliminary analyses examined differences between males and females using t-tests. In addition, Pearson correlations were run to assess the association between background variables and the study metrics among males and females. To examine the mediation effect, we ran SEM.

Results

Due to a sex moderation effect, two mediation models were run (SEM), one for females and one for males. Results indicated that emotional distress partially mediated the relationships between DoS and the risk of EDs. In addition, sex differences were found in the mediated indices, showing that among female adolescents, perfectionism is the only dimension of EDs that was associated with DoS through the mediation of emotional distress. While the relationship between emotional distress and the risk of EDs is well documented.

Conclusions

It is concluded that high DoS may reduce emotional distress, which may, in turn, decrease the risk of EDs. In addition, the results enable an in-depth understanding of specific risk factors of EDs that characterize each sex.

Common Predictive Factors of Social Media Addiction and Eating Disorder Symptoms in Female College Students: State Anxiety and the Mediating Role of Cognitive Flexibility/Sustained Attention

This study aimed to investigate the common predictive factors between social media addiction (SMA) and eating disorder symptoms (EDS), in a group of Chinese female college students. A total of 216 students completed the behavioral assessments of cognitive flexibility and sustained attention, as well as the questionnaires on anxiety, social media dependence, and eating disorders. The results indicate that SMA is significantly correlated with EDS. Structural equation modeling was used to test the model in which state anxiety, cognitive flexibility, and sustained attention predicted social gain and EDS. Additionally, the results confirmed the mediating role of cognitive flexibility and sustained attention between state anxiety and SMA/EDS in the participants. The findings revealed that in the sample group, state anxiety was related to SMA and EDS through cognitive flexibility and sustained attention. These proposals reflect the significance of improving cognitive flexibility/sustained attention and reducing state anxiety to prevent EDS and SMA in female college students.

Increased plasma asprosin levels in patients with drug-naive anorexia nervosa

PURPOSE

Asprosin is a centrally acting appetite-promoting hormone and promotes glucose production in the liver. This study is the first to investigate the difference in asprosin in the plasma between anorexia nervosa (AN) and healthy controls, and to explore the relationship between asprosin changes and plasma glucose levels and AN symptoms.

METHODS

Plasma asprosin and glucose concentrations were detected in AN patients (n = 46) and healthy control subjects (n = 47). Eating Disorder Inventory-2 (EDI-2) was used to assess subjects' eating disorder symptoms and related personality traits. The patient's concomitant levels of depression and anxiety were also measured using the beck depression inventory and beck anxiety inventory, respectively.

RESULTS

Results indicate that AN patients had a higher asprosin concentration in their plasma compared to healthy controls (p = 0.033). Among AN patients, plasma asprosin levels correlated positively with EDI-2 interoceptive awareness subscale score (p = 0.030) and negatively with duration of illness (p = 0.036). Multiple linear regression analyses showed that increases in asprosin levels (p = 0.029), glucose levels (p = 0.024) and body mass index (p = 0.003) were associated with an increase of the score of EDI-2 bulimia subscale.

CONCLUSIONS

Our findings suggest that the increase in plasma asprosin concentration in patients with AN may be a compensation for the body's energy shortage, and asprosin may be involved in the development of bulimia and lack of interoceptive awareness in AN patients.

LEVEL OF EVIDENCE

Level III, case-control analytic study.

Validation of the Chinese Version of the Body Image Concern Inventory

The Body Image Concern Inventory (BICI) was developed to assess dysmorphic appearance concern and has been found to be a reliable and valid instrument in Western societies. To examine the psychometric properties of a new Chinese BICI, the BICI was administered to 1,231 Chinese young adults (Study 1) and 47 female patients with eating disorders and 56 matched controls (ED; Study 2). In study 1, Cronbach's alpha of .92 and test-retest reliability of .73 over a 6-month interval was observed for the total scale. Confirmatory factor analysis supported a 3-factor model for the BICI: avoidant behaviors (AB), safety behaviors against perceived flaws (SB), and negative appearance evaluation (NE). In study 2, ED patients scored significantly higher on the BICI total and three subscale scores than controls. In addition, AB best differentiated ED patients and matched controls (Cohen's d = 1.52); SB best differentiated between the non-clinical female and male groups (Cohen's d = 0.75); NE was most closely associated with level of negative affect and subjective well-being (inverse relationship) in both clinical and non-clinical groups. In conclusion, the Chinese BICI is a reliable and valid tool for evaluating dysmorphic appearance concern among Chinese speakers.

Classifying and characterizing Chinese young adults reporting picky eating: A latent profile analysis

OBJECTIVE

Picky eating (PE) is common across the lifespan and related to psychosocial impairment and limited dietary variety. However, research about PE in non-Western countries is limited. Because eating behaviors may differ by culture, operationalizing PE in non-Western countries (e.g., China) is needed. The present study aimed to replicate two previous studies identifying PE profiles in Western countries by using latent profile analysis (LPA) to classify and characterize adults reporting picky eating in a Chinese sample.

METHOD

A sample of 1,068 Chinese young adults completed a battery of questionnaires including the adult eating behavior questionnaire (AEBQ). LPA was utilized to identify eating profiles. The three-step approach was used to examine predictors of latent memberships and profile differences on various self-reported measures.

RESULTS

The best fit was a four-profile solution, with two picky eating profiles emerging: picky eating and severe picky eating. Compared to those in the other two profiles, participants in the picky eating profile (19.4%) and severe picky eating profile (3.3%) had significantly higher scores on self-reported eating disorder symptoms and psychological distress, and lower scores on self-reported food-related life satisfaction. Relative to the picky eating profile, participants in the severe picky eating profile reported significantly greater self-reported eating disorder symptoms, psychological distress, and food-related dissatisfaction.

DISCUSSION

Characterizing PE profiles is an important step toward understanding eating behaviors among Chinese young adults. Identifying various eating profiles has implications for future research related to PE, including the development of diagnostic tools and interventions to address PE in a Chinese context.

Development and validity of a very short form of the Eating Disorder Inventory

INTRODUCTION

The main objective of the present series of studies was to develop and validate a 16-item very short form of the Eating Disorder Inventory (EDI-VS) for use as a short assessment tool in large-scale comprehensive or longitudinal studies, as well as in-depth idiographic studies.

METHOD

The EDI-VS was developed, and validated, through a series of five studies based on independent community samples including a total of 1372 French adolescents.

RESULTS

The results supported the reliability, content validity, factor validity, convergent validity, and criterion-related validity of the EDI-VS.

CONCLUSIONS

The EDI-VS comprises 16 items assessing the eight original dimensions of the conceptual model for the EDI. Recommendations for future practice and research on the EDI-VS are outlined.

The myth of Chinese Barbies: eating disorders in China including Hong Kong

Much of the literature on eating disorders deals with Western subjects. Although the majority of those seen in clinical settings are Caucasians, reports from Asia suggest that anorexia nervosa and bulimia nervosa do occur in the Chinese, sparking debate as to whether or not it is the result of Westernization. This project begins with a review of the current literature on eating disorders in Chinese populations and the role of culture as a mediating factor. A psychodynamic conceptualization and the potential role of traumatic experiences are explored in the emergence of pathological eating habits. Research suggests that applying Western models for Chinese subjects with eating disorders may not always be appropriate.

A five-item screening version of the Eating Disorder Inventory (EDI-3)

OBJECTIVE

The Eating Disorder Inventory (EDI) is used worldwide in research and treatment of eating disorders (EDs). Using the latest version (EDI-3: 91 items), we extracted the best screening items for a diagnosis of anorexia (AN) and bulimia (BN) nervosa.

METHOD

A patient sample of 561 women was recruited from an ED treatment centre in Denmark, and a comparison group of 878 women was randomly selected from the general population. An ED diagnosis was determined according to the Eating Disorder Examination Interview, yielding 84 AN and 202 BN patients.

RESULTS

Only two EDI items (Cronbach's α = .79) were needed to achieve a superior screening capability of BN (sensitivity = .94, specificity = .94). An adequate screening of AN was possible by using three items (α = .71; sensitivity = .91, specificity = .86).

DISCUSSION

The present study provides an even more economical and reliable screening of AN and BN compared with existing screening instruments. Implications for DSM-5 are also discussed.

The relationship between Internet addiction and bulimia in a sample of Chinese college students: depression as partial mediator between Internet addiction and bulimia

BACKGROUND

It has been reported that Internet addiction is associated with substance dependence. Eating disorders have high rates of co-morbidity with substance use disorders. The relationship between Internet addiction and eating disorders was reported in a previous study.

AIMS

To examine the hypothesis that Internet addiction is closely associated with bulimia. The hypothesis that depression mediates the relationship between Internet addiction and bulimia symptoms was also tested.

METHODS

2,036 Chinese college students were assessed on Internet addiction, eating behaviors and depression. Binge eating, compensatory behaviors, weight concern, menarche and weight change were also reported. Multiple regression analysis was used to test the mediating effect of depression.

RESULTS

Internet addicts showed significantly higher scores on most subscales on EDI-1 than the controls. They reported significantly more binge eating, weight concern and weight change than the controls. Among all of the participants, depression was found to be a partial mediator in the relationship between Internet addiction and bulimia.

CONCLUSION

This survey provides evidence of the co-morbidity of Internet addiction and bulimia.

Gastrointestinal dysfunction in Chinese patients with fat-phobic and nonfat-phobic anorexia nervosa

Although gastrointestinal and other somatic symptoms are common in patients with anorexia nervosa (AN), and a growing cross-national literature indicates that not all anorexic patients exhibit the core diagnostic symptom of fat phobia, the relationship between somatic symptoms and anorexic illness remains unclear. Our objective was to evaluate gastrointestinal dysfunction (GD) in Chinese patients with fat phobic (FP) and nonfat phobic (NFP) anorexia nervosa. A total of 113 FP- and 28 NFP-AN outpatients underwent standardized clinical assessment and completed a new 8-item GD scale and other psychopathological measures. A majority (79.4%) of AN patients reported at least some gastrointestinal complaints on the GD scale (Cronbach's alpha = 0.78). FP-AN patients scored significantly higher than NFP-AN patients. The FP-AN with high GD group reported a higher level of specific and general psychopathology than the FP- and NFP-AN with low GD groups. Contrary to expectations, gastrointestinal symptoms were more common in FP-AN than NFP-AN patients. FP-AN with high GD was more severe than FP- and NFP-AN with low GD. The current fat phobic conceptualization of the anorexic illness may overlook its phenomenologic heterogeneity and reify a dichotomy that is inconsistent with patients' varied experience of food restriction.

Validation of the Korean version of the Eating Disorder Inventory-2: psychometric properties and cross-cultural comparison

PURPOSE

The purpose of the present study was to examine the validity and reliability of the Korean version of the Eating Disorder Inventory-2 (EDI-2) in Korean patients with eating disorders and healthy controls, and to investigate cultural differences of EDI-2 between a Korean group and a North American standardization sample.

MATERIALS AND METHODS

The Korean version of the EDI-2 was prepared after comprehensive clinical assessment of Korean patients with eating disorders (n=327) as well as female undergraduates (n=176). Results were compared between eating disorder subgroups (anorexia nervosa, bulimia nervosa and eating disorders not otherwise specified) and those of a North American standardization sample and healthy controls.

RESULTS

The results showed that the Korean EDI-2 had adequate internal consistency (0.77-0.93) and discriminated well between patients with eating disorders and healthy controls on all subscales. Significant differences in EDI-2 subscale scores between the eating disorder groups and the healthy control group were observed; however, there was no discernible difference among the eating disorder subgroups. When compared with a North American standardization sample, the Korean control group showed significantly higher scores for drive for thinness and asceticism. When patient groups were compared, the Korean group showed significantly lower scores for perfectionism.

CONCLUSION

As expected, the results accurately reflected psychometric properties of the Korean version of EDI-2 for eating disorder patients in Korea. These findings also suggest that common characteristics for the eating disorder exist as a whole rather than with significant difference between each subgroup. In addition, significant differences between the Korean and the North American groups for both patients and controls also demonstrated specific cultural differences.

Psychometric Properties of the Eating Disorder Inventory in Clinical and Nonclinical Populations in Taiwan

Objective. To examine psychometric properties and investigate factor structures of the Mandarin Chinese version of the Eating Disorder Inventory (C-EDI). Method. The Mandarin C-EDI and other self-administered questionnaires were completed by a group of female eating disorder (ED) patients ( n = 551) and a group of female nursing students ( n = 751). Internal consistency, and convergent and discriminant validities were evaluated. Exploratory and confirmatory factor analyses were conducted to examine the construct validity of the Mandarin C-EDI. Results. The Mandarin C-EDI had good internal consistency and convergent and discriminant validities. With a few exceptions, the original clinically derived eight EDI subscales were clearly identified and the factorial validity of the first-order eight-factor structure and the second-order two-factor structure showed an acceptable degree of fit to our empirical data in clinical patients. Discussion. The findings suggest that the Mandarin C-EDI is a valid tool for clinical use in Taiwan.

Childhood risk factors in Korean women with anorexia nervosa: two sets of case-control studies with retrospective comparisons

OBJECTIVE

The aim of this study was to investigate the characteristics of the risk factors for anorexia nervosa (AN) in Korean women.

METHOD

Two sets of case-control comparisons were conducted, in which 52 women with lifetime AN from Seoul, S. Korea, were compared with 108 Korean healthy controls and also with 42 women with lifetime AN from the UK in terms of their childhood risk factors. A questionnaire designed to conduct a retrospective assessment of the childhood risk factors was administered to all participants.

RESULTS

The Korean AN women were more likely to report premorbid anxiety, perfectionism, and emotional undereating and were less likely to report having supportive figures in their childhood than the Korean healthy controls. There were no overall differences in the childhood risk factors between the Korean and British women with AN.

DISCUSSION

Premorbid anxiety, perfectionism, less social support, and emotional undereating merit attention as risk factors in Korean AN. The current results are informative, but an epidemiologically robust prospective case-control study would be needed to validate these findings.

Validating the Eating Disorder Inventory-3 (EDI-3): A Comparison Between 561 Female Eating Disorders Patients and 878 Females from the General Population

The Eating Disorder Inventory (EDI) is used worldwide in research and clinical work. The 3(rd) version (EDI-3) has been used in recent research, yet without any independent testing of its psychometric properties. The aim of the present study was twofold: 1) to establish national norms and to compare them with the US and international norms, and 2) to examine the factor structure, the internal consistency, the sensitivity and the specificity of subscale scores. Participants were Danish adult female patients (N = 561) from a specialist treatment centre and a control group (N = 878) was women selected from the Danish Civil Registration system. Small but significant differences were found between Danish and international, as well as US norms. Overall, the factor structure was confirmed, the internal consistency of the subscales was satisfactory, the discriminative validity was good, and sensitivity and specificity were excellent. The implications from these results are discussed.

Should non-fat-phobic anorexia nervosa be included in DSM-V?

OBJECTIVE

Cross-cultural data suggest that rationales for food refusal vary in anorexia nervosa (AN), and a variant, termed non-fat-phobic AN (NFP-AN), has been described. This review evaluates whether data support modification of the requirement for intense fear of weight gain to meet AN criterion B in DSM-V.

METHOD

We performed a systematic search of the Medline and PsychInfo literature and evaluated the relevant publications by Robins and Guze's (Am J Psychiatry 126, 983-987, 1970) criteria as a standard for diagnostic validity. We also performed a meta-analysis comparing the severity of eating pathology in AN to (a) NFP-AN and (b) AN with low drive for thinness (low-DT-AN).

RESULTS

A modest literature indicates that NFP-AN has wide geographic distribution and occurs in both Western and non-Western populations alongside cases of typical AN. Aggregating across eligible studies, patients with NFP-AN or low-DT-AN score at least 2/3 of a standard deviation lower on measures of eating pathology than patients with conventional AN. Transcultural comparison of drive for thinness suggests significantly lower norms in non-Western cultures.

DISCUSSION

NFP-AN occurs with wide distribution. Further research is necessary on the course and outcomes of NFP-AN to characterize its congruence with, or distinction from, conventional AN. We discuss several options for including a description of NFP-AN in DSM-V.

The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: meta-analysis and implications for DSM

Eating disorder not otherwise specified (EDNOS) is the most prevalent eating disorder (ED) diagnosis. In this meta-analysis, the authors aimed to inform Diagnostic and Statistical Manual of Mental Disorders revisions by comparing the psychopathology of EDNOS with that of the officially recognized EDs: anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). A comprehensive literature search identified 125 eligible studies (published and unpublished) appearing in the literature from 1987 to 2007. Random effects analyses indicated that whereas EDNOS did not differ significantly from AN and BED on eating pathology or general psychopathology, BN exhibited greater eating and general psychopathology than EDNOS. Moderator analyses indicated that EDNOS groups who met all diagnostic criteria for AN except for amenorrhea did not differ significantly from full syndrome cases. Similarly, EDNOS groups who met all criteria for BN or BED except for binge frequency did not differ significantly from full syndrome cases. Results suggest that EDNOS represents a set of disorders associated with substantial psychological and physiological morbidity. Although certain EDNOS subtypes could be incorporated into existing Diagnostic and Statistical Manual of Mental Disorders (4th ed.; American Psychiatric Association, 1994) categories, others-such as purging disorder and non-fat-phobic AN-may be best conceptualized as distinct syndromes. (PsycINFO Database Record (c) 2009 APA, all rights reserved).

A cross-cultural comparison of the Eating Disorder Inventory

OBJECTIVE

A systematic analysis of data collected with the Eating Disorder Inventory (EDI) was made.

METHOD

A literature search identified 94 sources in which the mean values of the EDI or EDI-2 subscales were reported, comprising 310 samples differing by sex, age, diagnosis, language, ethnicity, or some other relevant attribute. The total number of respondents was 43,722, from 25 different countries, having used the EDI in one of the 16 languages (1-94).

RESULTS

The factorial structure of the aggregate means of the EDI subscales, for both clinical versus nonclinical and Western versus non-Western samples, was almost identical suggesting generalizability across languages and cultures. Non-Western participants scored higher than Western participants on virtually all EDI subscales, both in normal and eating-disordered samples. It was shown that age is a risk factor when someone is already diagnosed with an eating disorder but, in the general population, increasing age reduces the likelihood of being afflicted by eating disorders.

DISCUSSION

Symptoms of eating disorders are more pronounced in non-Western than in Western samples.

The correlation of Chinese mothers' eating attitudes and psychological characteristics with their children's eating attitudes, as well as the gender effect on eating attitudes of children

OBJECTIVE

No study has examined the connection between the mothers' weight concerns, their psychological characteristics as well as their educational level and their children's weight concerns in China. Nor has the gender effect on the eating attitudes of pre- to post-pubertal Chinese children been explored (aged 10-13).

METHOD

The children (girls N=138, boys N=103) were given a Chinese version of the EDI-C. Their mothers completed a Chinese version of the EDI-2. The Bivariate's (Pearson) correlation was used to examine the relationship between the mothers' weight concerns, psychological characteristics and educational level with their children's weight concerns. An Independent-Samples Ttest was conducted to comparing the EDI-C subscales of the girls and boys groups.

RESULTS

Regarding the mothers' and children's eating attitudes, there was a significant correlation between the mothers' weight concerns as well as their psychological characteristics with their children's eating attitudes. No significant relationship was found between the mothers' educational level and the children's eating attitudes. According to the scores of the EDI-C questionnaire, there was no general significant gender difference between Chinese children (aged 10-13). However, a differential gender effect on the body dissatisfaction of children was found for the subgroup of elders (aged 13) indicating a differential developmental dynamic.

CONCLUSIONS

The Chinese mothers' weight concerns and their psychological characteristics correlated with their children's eating attitudes. A gender effect on the Chinese children's eating attitudes (aged 13) was established.

Culture and eating disorders classification

OBJECTIVE

This paper discusses cultural considerations for classification of eating disorders.

METHOD

The literature on epidemiology and phenomenology of eating disorders in culturally diverse populations was selectively reviewed to identify methodologic challenges in classification and characterization of prevalence and phenomenology.

RESULTS

Prevalence of eating disorders among culturally diverse populations is incompletely characterized. Few studies address the epidemiology of eating disorders or provide qualitative data on variation in presentation in these populations. Unrecognized cultural diversity may result in misclassification of cases.

CONCLUSION

Development of culturally valid assessments, ethnographic data on indigenous nosologic correlates and idioms of distress, and attention to phenomenologic diversity may have critical impact on understanding clinical presentations and risk factors that may be culturally particular. A flexible classificatory system for the eating disorders may help to encompass their culturally based phenomenologic diversity, facilitate culturally sensitive and strategic prevention strategies, and reduce ethnic disparities in access to care for them.

Comparative study of eating-related attitudes and psychological traits between Israeli-Arab and -Jewish schoolgirls

OBJECTIVE

The aims of the study were to examine weight concerns, dieting and eating behaviours in a group of Israeli-Arab schoolgirls as compared with Israeli-Jewish schoolgirls, as well as to investigate the reliability of the Arabic (Palestinian) version of the eating disorder inventory-2 (EDI-2).

METHOD

The sample consisted of 2548 Israeli schoolgirls, including 1885 Jewish and 663 Arab adolescents ranging in age from 12 to 18. The study was conducted in 1998-2003 from urban and rural residential settings in the northern part of Israel. The (EDI-2) was the assessment tool used, yielding scores on 11 sub-scales.

RESULTS

The Israeli-Arab schoolgirls scored significantly higher than the Israeli-Jewish schoolgirls in most EDI-2 sub-scales. In addition, the sub-scale inter-item consistency of the translated Arabic (Palestinian version) of the EDI-2 was found to be reliable.

DISCUSSION

The drive to be thin found among Israeli Arab schoolgirls is not reflected in their small number of ED clinic referrals. These discrepancies are discussed in light of the socio-cultural changes currently taking place in the Israeli Arab population due to the influence of Western-oriented life in Israel.

Disordered eating related behaviors among Arab schoolgirls in Israel: an epidemiological study

OBJECTIVE

To examine the prevalence of disordered eating attitudes and behaviors among three religious subgroups of Arab schoolgirls in Israel (Moslems, Druze, and Christians).

METHOD

The sample consisted of 1,131 Arab schoolgirls in Israel, including 922 (81.5%) Moslem, 125 (11.1%) Christian, and 84 (7.4%) Druze adolescents, in the 7-12th grades. The sample was drawn from urban and rural residential settings from all parts of Israel using a clusters sampling method.

RESULTS

The Christian subgroup had a significantly lower total eating disorder inventory-2 (EDI-2) score than the Druze and Moslem subgroups, which had similar total EDI-2 scores. Significant differences were found between the three religious subgroups in all subscales, except in drive for thinness (DT), bulimia, body dissatisfaction, and asceticism. A total of 154 (13%) Arab schoolgirls scored higher than the cut-off point of >>14 on the EDI-DT subscale.

CONCLUSION

The results are discussed in light of the differences between the Christian, Druze, and Moslem subgroups and in terms of various aspects of Arab culture in Israel.

Factor structure of Eating Disorders Inventory-2 in a Spanish sample

OBJECTIVE

To present basic statistics and analyze factor structure of EDI-2 in an adolescent non-clinical sample from Spain.

METHOD

An Exploratory Factor Analysis (EFA) was carried out with Principal Axis Factoring (PAF) and oblimin rotation, using raw scores.

RESULTS

EFA presented a 21-factor structure with eigenvalues greater than 1. It was then forced into 11 and 5-factor solutions.

DISCUSSION

The eleven-factor structure does not correspond with the 11 scales. A five-factor structure seems to be better suited than other factor solutions and presented higher reliability coefficients.

Eating disorders and attitudes in Maltese and Italian female students

BACKGROUND

No study to date has investigated the frequency of eating disorders (ED) in Malta. The aim of the present study was to provide a cross-cultural comparison between Malta and Italy as regards the frequency of ED and problematic eating attitudes among female students.

SAMPLING AND METHODS

128 Maltese and 135 Italian female students aged 16-20 were surveyed. Subjects underwent a structured clinical interview and completed some self-reported questionnaires: the Eating Attitudes Test, the Inventory for the Screening of Eating Disorders and the Eating Disorders Examination-Screening Version.

RESULTS

The rates of ED are very similar in the two samples with the exception of the frequency of binge eating disorder which is zero in the Italian sample and 4% among Maltese students. Maltese female students weighed significantly more than their Italian counterparts. They also reported more frequent dieting, fear of fatness and experience of low self-esteem related to body shape and weight.

CONCLUSIONS

Despite the fact that Maltese female students have a greater tendency to be overweight and display more problematic eating and body attitudes, their risk of developing ED, with the exception of binge eating disorder, is similar to that of their Italian counterparts.

Inter-rater and test-retest reliability of the Spanish language version of the eating disorder examination interview: clinical and research implications

BACKGROUND

To examine the inter-rater and test-retest reliability of the Spanish Language version of the Eating Disorder Examination (S-EDE) in monolingual Latina women. Established measures are needed to study Latino groups, and short-term test-retest reliability findings are needed to provide context for clinical treatment and outcome studies.

METHODS

Inter-rater reliability (IRR) and short-term (5-14 days) test-retest reliability (TRR) of the S-EDE (using intraclass correlation coefficients [ICCs]) were examined in a non-clinical study group of 60 monolingual Latina women.

RESULTS

IRR was excellent for objective bulimic episodes (ICC = 0.99) but was modest for subjective bulimic episodes (ICC = 0.55). TRR was good for objective bulimic episodes (ICC = 0.79) but was unacceptable for subjective bulimic episodes (ICC = 0.22). IRR and TRR kappa coefficients (0.56 and 0.37, respectively) for identifying the presence or absence of objective bulimic episodes were modest. For the S-EDE subscales, both IRR (ICCs ranged from 0.80 to 0.98) and TRR (ICCs ranged from 0.67 to 0.90) were good to excellent.

CONCLUSIONS

These findings provide preliminary support for the reliability of the S-EDE for use with Latina women. The constructs of eating disorder psychopathology measured by the S-EDE subscales (restraint, eating concern, weight concern, and shape concern) and the core feature of binge eating (objective bulimic episodes) show high short-term consistency. The results for subjective bulimic episodes are consistent with previous studies that have questioned whether these eating behaviors are reliable indicators of eating disorders. Additional evaluation is needed with clinical groups.

Factor structure of the Eating Disorder Inventory-C

OBJECTIVE

The Eating Disorder Inventory-C (EDI-C) is a multidimensional self-report questionnaire for children and adolescents used to characterize differences in the symptoms of eating disorders. It is based on the EDI-2 questionnaire, which is designed for adults. Although the psychometric properties of the EDI and EDI-2 have been well characterized, no studies exist on the EDI-C. Thus, we aimed to establish the factor structure of the EDI-C questionnaire among children.

METHOD

A nonclinical sample of 898 children aged 9-16 years completed the EDI-C questionnaire at school.

RESULTS

Instead of the original 11-factor structure of the EDI-2, 5 factors with high reliability were extracted when 27 items with low communality were removed from analysis.

DISCUSSION

When the EDI-C is used, the reliability of the original 11 factors may be low. A modified subscale structure with five factors is proposed.

Prevalence and psychosocial correlates of disordered eating among Chinese pregnant women in Hong Kong

Three-hundred-and-fifty-nine Chinese pregnant women were surveyed to determine prevalence and psychosocial correlates of eating disturbance in pregnancy. About 9.8% of participants reported disordered eating symptoms. Prevalence of these symptoms was related to general factors of drive for thinness, body image dissatisfaction, and traditional gender role attitudes. These general factors were, in turn, associated with factors specific to pregnant women. In particular, drive for thinness was related to poor spousal support; body image dissatisfaction was related to poor maternal-fetal attachment; and traditional gender role attitudes were related to strong maternal-fetal attachment and spousal support. Limitations and implications of these findings are discussed.

The clinical presentation of Japanese women with anorexia nervosa and bulimia nervosa: a study of the Eating Disorders Inventory-2

OBJECTIVE

The current study described the clinical presentation of anorexia nervosa (AN) and bulimia nervosa (BN) in Japan utilizing the Eating Disorders Inventory-2 (EDI-2) and assessed whether the clinical profile of eating disorder cases in Japan differs significantly from North American data.

METHOD

Statistical comparisons of Japanese AN, BN, and non-eating-disordered (NonED) EDI-2 data were conducted across diagnostic groups and with the North American standardization sample.

RESULTS

The Japanese diagnostic groups reported significant between-group differences on all eight EDI-2 subscales. Compared with the standardization sample, all the Japanese groups reported significantly greater maturity fears, the Japanese AN-restricting subtype group (AN-R) reported lower levels of drive for thinness and perfectionism, the Japanese BN group reported lower levels of drive for thinness, and the Japanese NonED Group reported lower levels of drive for thinness and perfectionism but higher rates of ineffectiveness.

DISCUSSION

Differences between the Japanese and North American groups suggest that certain cultural differences exist in eating disorder profiles.

The Eating Disorder Inventory-2 in Japanese clinical and non-clinical samples: psychometric properties and cross-cultural implications

OBJECTIVE

To determine the usefulness of and cross-cultural differences in the Japanese version of the eating disorder inventory-2 (EDI-2).

METHOD

A Japanese version of the EDI-2 was administered to a consecutive series (1995-2001) of 91 Japanese eating disordered inpatients and 119 matched non-clinical controls. Scores were compared with each other and with those of Canadian data previously reported. Internal consistencies were also examined.

RESULTS

All subscales (except Ascetism) reached sufficient internal consistencies. The patients' mean scores were significantly higher than controls on most subscales. Restricting anorexics (AN-R) scored higher than controls on body dissatisfaction (BD) and Social Insecurity (SI) subscales. Purging bulimics (BN-P) scored higher than controls on most subscales, except for maturity fears (MF) and SI subscales. Scores of binge-eating/purging type anorexics (AN-B/P) were higher than controls on all subscales. AN-B/P and BN-P scored higher than AN-R on bulimia (B) subscale. Comparison with Canadian subjects showed that Japanese control subjects scored significantly higher on the MF, ineffectiveness (I), impulse regulation (IR), SI subscales, and lower on the perfectionism (P) subscale.

DISCUSSION

The EDI-2 is useful and reliable in understanding Japanese clinical and non-clinical samples. High MF and low P subscales in our samples confirm previous findings in Chinese samples suggesting meaningful cultural differences in the emphasis placed on family bonds and individual accomplishments. In addition, high I, IR, and SI scores in Japanese non-clinical samples may reflect recent problems in Japanese culture.

The development of eating pathology in Chinese-Australian women: acculturation versus culture clash

OBJECTIVE

Recent research suggests there has been an increase in the incidence of eating pathology among Asian women residing in the West. Two alternate explanations for the development of this eating pathology have been proposed; acculturation versus culture clash. The current study was designed to further examine the influence of acculturation versus culture clash on the development of eating pathology in Chinese-Australian women.

METHOD

Eighty-one Chinese-Australian women completed a questionnaire investigating their level of eating pathology, perceived sociocultural influences to lose weight, parental overprotection and care, self-perceptions of physical appearance, sociability and global self-worth, and the strength of their ethnic identity.

RESULTS

It was found that, overall, low levels of satisfaction with physical appearance, high levels of parental overprotection, and high levels of perceived pressure from best female friends to lose weight predicted greater eating pathology in both acculturated and traditional women. However, acculturated women who perceived higher levels of pressure from their fathers and best male friends to lose weight and traditional women who experienced higher levels of parental care reported the greatest eating pathology.

DISCUSSION

The findings suggest that there are both similarities and differences between the risk factors that correlate with eating pathology between acculturated and traditional women.

Are eating disorders culture-bound syndromes? Implications for conceptualizing their etiology

The authors explore the extent to which eating disorders, specifically anorexia nervosa (AN) and bulimia nervosa (BN), represent culture-bound syndromes and discuss implications for conceptualizing the role genes play in their etiology. The examination is divided into 3 sections: a quantitative meta-analysis of changes in incidence rates since the formal recognition of AN and BN, a qualitative summary of historical evidence of eating disorders before their formal recognition, and an evaluation of the presence of these disorders in non-Western cultures. Findings suggest that BN is a culture-bound syndrome and AN is not. Thus, heritability estimates for BN may show greater variability cross-culturally than heritability estimates for AN, and the genetic bases of these disorders may be associated with differential pathoplasticity.

Culture and validity of the Symptom Checklist-90-Revised and Profile of Mood States in a New Zealand student sample

New Zealand students' performance was examined on assessments of psychopathology and mood as compared to normative data from the United States. New Zealand university students (N = 137) completed the Symptom Checklist-90-Revised (SCL-90-R) and Profile of Mood States (POMS). Mean performances differed significantly from normative data for each SCL-90-R scale. No significant differences were found for the POMS scales. Within the sample, European (n = 82), Maori (n = 24), and Asian (n = 24) participants differed significantly on SCL-90-R obsessive-compulsive, phobic anxiety, and anxiety scales and POMS scales of tension and confusion. Implications for assessment of New Zealand samples are discussed.

A survey of anorexia nervosa using the Arabic version of the EAT-26 and "gold standard" interviews among Omani adolescents

OBJECTIVE

The purpose of this study was to assess the validity of the Eating Attitude Test (EAT) in identifying the presence and severity of eating pathology in male and female Omani urban adolescents and to establish cut-off scores that matched those of anorexia identified by gold standard interviews without fear of fatness criteria.

METHODS

Both females (n=126) and males (n=136) were screened using the Arabic version of the EAT-26 and interviewed using a semi-structured, Composite International Diagnostic Interview (CIDI) in order to investigate the relationship between false positives and false negatives at various EAT-26 cut-off points. A receiver operating characteristics (ROC) curve was calculated to discriminate the power of the EAT-26 for every possible threshold score.

RESULTS

The EAT-26 identified 29% of the subjects as probable anorexic cases as against 9.5% identified during the structured interview based on the anorexia gold standard (32% males and 68% females). The sensitivity and specificity of the EAT-26 were respectively 24% and 69.6%. When using the ROC curve, a cut-off score of 10 gave the best compromise between sensitivity (64%) and specificity (38%).

DISCUSSION

Although the EAT-26 is the most widely used screening instrument in cross-cultural studies, it does not appear to be reliable in identifying probable cases of anorexia among Omani adolescents. The use of a gold standard interview without fat phobia criteria indicated that the rate of anorexia nervosa may be more prevalent among males than previously estimated. This intriguingly high preponderance of males is discussed in terms of prevailing demographic trends in Oman.

Presence and severity of anorexia and bulimia among male and female Omani and non-Omani adolescents

OBJECTIVE

The population of Oman is a heterogeneous mix of nationalities providing a natural setting for studying the cross-cultural differences in the presence and severity of eating disorders as well as an opportunity for evaluating the performance of measurement instruments for these disorders.

METHOD

Disordered eating screening instruments (the Eating Attitude Test and the Bulimic Investigatory Test) were administered to Omani teenagers, non-Omani teenagers, and Omani adults.

RESULTS

On the Eating Attitude Test, 33% of Omani teenagers (29.4% females and 36.4% males) and 9% of non-Omani teenagers (7.5% of males and 10.6% females) showed a propensity for anorexic-like behavior. On the Bulimic Investigatory Test, 12.3% of Omani teenagers showed a propensity for binge eating or bulimia (13.7% females and 10.9% males). Among the non-Omani teenagers, 18.4% showed a tendency toward bulimia, with females showing a slightly greater tendency than males. In contrast, barely 2% of Omani adults showed either a presence of or a severity of disorderly behavior with food.

CONCLUSION

Omani teenagers scored significantly higher than other ethnic groups and Omani adults. This finding is discussed in the light of emerging evidence from many parts of the world suggesting that cultural transition, compounded by demographic constraints, plays a significant role in abnormal eating attitudes.

The Eating Disorder Inventory in evaluation of impaired eating behaviour in subjects requesting nutritional consultation

The present study evaluated impaired eating behaviour in women seeking participation in a diet-based programme of weight reduction or achievement of ideal body weight. Forty-seven obese, 42 overweight and 14 normal-weight subjects, attending an Italian university outpatient clinic completed the Eating Disorder Inventory (EDI). Forty-eight mothers of primary school children (25 normal-weight and 23 overweight) were used as controls. The EDI consists of 8 subscales, 3 evaluating psychopathology related to eating disorders (drive for thinness, bulimia, body dissatisfaction) and 5 evaluating general psychopathology (intereoceptive awareness, ineffectiveness, maturity fears, perfectionism, interpersonal distrust). Significantly altered scores in the first three subscales were observed both in normal-weight and overweight outpatients compared to the controls. The overweight outpatients scored higher than the obese patients in terms of drive for thinness and bulimia and higher than the normal-weight women for terms of bulimia, body dissatisfaction and drive for thinness. The overweight controls scored significantly higher than the normal-weight controls in the first three subscales in the remaining subscales, mean values were also higher in the overweight group, though significance was only reached in the interpersonal distrust and interoceptive awareness subscales. Impaired eating behaviour is frequent in subjects seeking participation in weight reduction or ideal body weight achievement programmes.

Eating disorders in the Far East

OBJECTIVE

To investigate eating disorders (EDs) prevalence rates among Asian populations and identify characteristics that distinguish them from their Western counterparts.

METHOD

Potential references were identified through an English-language literature search using Medline, Psychinfo, Dissertation Abstracts (1966 to 1999) and through extensive manual searching of textbooks, reviews and reference lists.

RESULTS

The majority of studies related to EDs were conducted in Japan and China and a few were conducted in Singapore, Malaysia, Taiwan, and Korea whereas there was none in the Philippines, Laos, Vietnam, Cambodia, Myanmar, Indonesia and Thailand. Prevalence rates in Japan range from 0.025 to 0.030% for anorexia nervosa (AN) and from 1.9 to 2.9% for bulimia nervosa (BN). Community studies in China have found the AN prevalence to be 0.01% and BN rates ranging from 0.5% to 1.3%. These rates are lower than ED rates in the West (particularly the U.S. and Britain). Body dissatisfaction (BD) and dieting rates, however, were similar to those in the West. BD rates ranged from 68% (Taiwan) to 81% (Korea) and dieting rates ranged from 34% (Taiwan) to 68% (Japan). Sociocultural and developmental risk factors were relevant to this population.

CONCLUSIONS

EDs in Asian populations have received little attention because they have been predominantly viewed as associated with Western culture. Classified by many as a "culture-bound syndrome" of the West, they may really be a culture-change syndrome.

Acculturation and disordered eating patterns among Mexican American women

OBJECTIVE

This quantitative study examined the relationship between acculturation and disordered eating patterns among different generations of Mexican American women.

METHOD

Participants included 139 Mexican American women (mean age = 29.1) drawn from local undergraduate courses and community agencies. The posttest-only design included a demographic measure, Acculturation Rating Scale for Mexican Americans (ARSMA), and the Eating Attitudes Test (EAT-26).

RESULTS

Of the five generations studied, second-generation women endorsed the most disordered eating patterns and the highest degrees of concurrent acculturation. Moreover, there was a significant, positive correlation between acculturation and Factor III of the EAT which highlights control of eating and perceived pressure from others to gain weight. Participants scoring beyond the EAT cut-off score endorsed bulimic symptoms.

DISCUSSION

Differing intergenerational ideals regarding weight may create special strains for second-generation Mexican American women. Criteria for disordered eating in a population previously not considered at risk should be further assessed and clinicians should be careful not to underdiagnose among this group.

Disordered eating in three communities of China: a comparative study of female high school students in hong kong, Shenzhen, and rural hunan

OBJECTIVE

To examine disordered eating and its psychological correlates among female high school students in three Chinese communities that lay on a gradient of socioeconomic development in China.

METHOD

796 Chinese students from Hong Kong, Shenzhen, and rural Hunan completed a demographic and weight data sheet, the Eating Attitudes Test (EAT-26), a Body Dissatisfaction Scale (BDS), the Beck Depression Inventory (BDI), and the Rosenberg Self-Esteem Scale (RSES).

RESULTS

Compared to students in Hunan and to a lesser extent students in Shenzhen, students from Hong Kong were slimmer, but desired a lower body mass index (BMI), reported more body dissatisfaction, exhibited a more typical EAT-26 factor structure, scored higher on the "fat concern and dieting" factor, and constituted more EAT-26 high scorers. Multiple regression analyses indicated that BDS was the most significant predictor of fat concern at each site, but this effect was strongest in Hong Kong. Hunan students had significantly higher BDI scores but lower fat concern than Shenzhen and Hong Kong students.

DISCUSSION

The consistent gradient of fat concern across the three communities gives credence to the view that societal modernization fosters disordered eating in women, possibly via the gendered social constraints that accompany it. It is also expressive of the marked socioeconomic heterogeneity within China nowadays. The predictable rising rate of eating disorders that follows global change will pose a growing public health challenge to Asian countries.

A generalizability study of the Eating Attitudes Test (EAT-12) in non-clinical adolescents

One of the most frequently used measures of eating and weight problems is the Eating Attitudes Test (EAT). The paper discusses conceptual heterogeneity in the EAT in the light of eating disorder continuum theory. Psychometric qualities of the Norwegian 12-item version of the EAT was based on a sample of 224 female and 261 male adolescents aged 14-15 years. Generalizability theory enabled us to study the impact of multiple sources of measurement errors of the EAT-12. The analyses suggest that acceptable generalizability is achieved by the present design on applying 4 items within 3 categories of the EAT. Alternative designs are suggested, and the utility of G-theory is discussed. The results also provide evidence of a gender difference in the structure of the universe score variance. Non-clinical adolescents' ways of organizing information about food and eating are discussed in the light of gender differences.

Multidimensionality in adolescent eating problems. A two-phase measurement study

The aims of this study were, firstly, to examine the factor structure of single items from several self-report methods used to measure eating disorder symptoms, and secondly, in search for a short assessment instrument to reduce the number of items within each factor. Factor analyses were employed to identify and confirm the constructs measured by a total of sixty items drawn from these assessment methods. In phase one, 508 secondary school pupils were recruited as subjects, and principal factor analysis identified three factors; body concern, dieting, and loss of control over eating. Twenty-nine items were retained, and in phase two subjected to a second data collection among 4129 secondary school pupils. Confirmatory factor analysis was employed to cross-validate the factor structure from phase one. The three-factor structure was confirmed satisfactorily for boys, but not for girls aged 12-14 years. For girls aged 14-16 years, it was confirmed when a number of items were omitted. The findings are discussed in relation to restraint theory and the continuum hypothesis.