Use of extreme weight control behaviors with and without binge eating in a community sample: implications for the classification of bulimic-type eating disorders

Community Women’s Lifestyle and Eating Disorders in the Era of COVID-19 Pandemic: A 15-Year Follow-Up Study

Most studies suggest that COVID-19 has adversely affected the quality of life and mental health, including eating disorders. However, studies have yet to examine longitudinally the impact of COVID-19 on eating disorder symptomatic individuals. This study aims to examine longitudinally the impact of the COVID-19 pandemic on the lifestyle and eating disorder symptoms of a symptomatic group of community-dwelling women. These women (n = 171) were enrolled in a longitudinal study, completed a COVID-19 modular self-report (post or Qualtrics, 2020/21), and participated in the current study. This study examined a 15th year follow-up. In 2020, 40% were tested for COVID-19. Of these, 87% had negative results; 5.3% self-isolated at home; 20.5% stopped working/studying in person; 28% continued online work/study; and 28% stopped work/studying in person. The pandemic affected sporting activities, music, and club activities (32.7% discontinued); 38% socialized in person; 16% socialized online; and 10% completely stopped socializing. Preliminary findings showed that the respondents showed no significant changes in levels of psychological distress (K10: 21.4 ± 9.8 vs. 19.0 ± 7.1, p < 0.171), and impaired quality of life (SF12: 50.9 ± 8.0 vs. 48.3 ± 9.5, p < 0.055) at 15-year follow-up. Eating disorder symptoms increased over time (EDE-Q global: 2.1 ± 1.4 vs. 2.9 ± 1.4, p < 0.013). Observed worsening of eating disorder-related symptoms during the COVID-19 pandemic may be due to interrupted eating patterns, exercise restrictions and the absence of social support. Provision and access to interventions to support those affected by eating disorders are a high priority, especially during these times. Further analyses with data imputation may find or further establish direct implications of COVID-19 in eating disorders.

Loss-of-Control-Eating Mediates the Relationship between Cannabis-Related Problems and Eating Pathology

The prevalence of eating pathology among college students has increased significantly in recent years. This coincides with increases in the use of cannabis, both nationally, but also among college students. Problematic cannabis use has been linked to eating pathology in prior research. Research also shows that cannabis may affect appetitive drives linked to food consumption. The current study tested the hypothesis that the association between problem cannabis use and eating pathology was mediated by greater loss of control eating. Cross-sectional data were collected from a sample of 805 college student cannabis users at a large Southeastern university in the U.S. The sample were primarily Caucasian (76%) and female (65.22%) with an average age of 20.15 (SD = 3.91). Participants completed surveys assessing eating outcomes (loss of control eating and eating pathology), cannabis use, and cannabis-related problems. The analysis used an observed variable path model. After controlling for cannabis use, cannabis-related problems were indirectly linked to eating pathology via loss of control eating (B = 0.109, SE = 0.025, p < .001), supporting the primary hypothesis. The direct relationship between cannabis-related problems and eating pathology was fully accounted for (B = 0.010, SE = 0.028, p = .724) by the indirect effect of loss of control eating. These data suggest that the association between problematic forms of cannabis use and eating pathology may be due to the association between cannabis problems and loss of control eating. While this may be due to changes in appetite and food evaluation as a function of more problematic use patterns, it may also be that individuals with problematic cannabis use have more problematic eating patterns due to deficits in adaptive coping strategies. Future research should seek to parse out these different potential explanations.

The role of eating expectancies and eating motives in the association between mood and loss-of-control eating: A national sample daily diary study

Loss-of-control eating (LOCE, the subjective inability to refrain from eating or cease eating), is highly mood-driven. Mood-related eating motives and eating expectancies have been identified as contributors to binge eating. However, little is known about how these factors relate to LOCE, much less their relationship with daily-level LOCE. This study assessed the impact of trait eating expectancies and daily eating motives on the relationship between daily affective states and LOCE. United States adults (n = 109) reporting recent LOCE participated in a ten-day diary study, completing two surveys per day regarding eating behaviors, mood, and motives. Data were analyzed at the within- and between-subject levels utilizing a Bayesian approach to examine pathways from mood to LOCE, mediated by eating motives and accounting for a moderating impact of baseline eating expectancies on the path leg between mood and motives. Negative mood was associated with LOCE at both the within- and between-subjects level by way of coping motives, and directly at the within-subjects level. Negative affect (NA) reduction expectancies did not moderate the indirect pathway. Positive mood was only associated with LOCE at the within-subjects level, via pleasure motives. This relationship was potentiated via reward expectancies. Therefore, although negative mood appears be a robust predictor of LOCE regardless of trait NA reduction expectancies, positive mood appears to have a specific set of conditions under which individuals are at increased likelihood of LOCE at the within-subjects level. These findings suggest that eating expectancies and motives for eating may be meaningful targets in LOCE interventions.

Exploring eating and exercise-related indicators during COVID-19 quarantine in Portugal: concerns and routine changes in women with different BMI

PURPOSE

The present study aimed to understand how quarantine associated with COVID-19 was experienced by women from different BMI groups (underweight, normal weight, pre-obesity, and obesity), by exploring the changes introduced in eating and exercise routines and the differences between BMI groups regarding shape concern, weight concern, and binge eating behaviours reported during this time.

METHODS

This study comprised 580 women aged between 18 and 65 years old, who completed self-report measures, during the mandatory confinement in Portugal due to COVID-19. The total sample was divided into four groups, according to their BMI.

RESULTS

Results revealed that overall, there were no significant differences between the groups regarding the eating and exercise routine changes introduced during quarantine. However, significant differences between the four groups were found in the reported body and eating-related difficulties (shape concern, weight concern, and binge eating behaviours), with the pre-obesity and obesity groups presenting significant higher levels.

CONCLUSIONS

Our study suggests that, even though the changes introduced to the eating and exercise routine are independent of BMI, the pre-obesity and obesity group represent a major vulnerability group for the development of eating disorders. We hope this study allows professionals to understand the need to develop different guidelines and strategies for the pre-obesity and obesity female population during the deconfinement period.

LEVEL OF EVIDENCE

Level V-Descriptive study.

Prediction model for abnormal eating behaviour among hospital nurses: A structural equation modelling approach

BACKGROUND

Nurses are at a high risk of developing abnormal eating behaviour. However, few studies have attempted to identify the factors that influence such behaviour.

AIM

This study identifies factors that can predict abnormal eating behaviour in hospital nurses.

DESIGN

This study adopted a cross-sectional, descriptive correlational research design.

METHODS

A literature review was used to establish a hypothetical model, comprising the eight factors of shift work, job stress, depression, sleep quality, fatigue, coping strategy (active coping and passive coping) and abnormal eating behaviour. A convenience sample of 298 nurses aged less than 45 was recruited from two university hospitals, and structured questionnaire was administered between March and April 2017. The hypothesized model was tested using structural equation modelling.

RESULTS

Sleep quality and passive coping directly affect abnormal eating behaviour, which implies that poor sleep quality and increased passive coping worsens the behaviour. Shift work and depression indirectly affect abnormal eating behaviours.

CONCLUSION

Nursing managers and health policy makers should adopt strategies such as improving the shift-work pattern, providing adequate rest time after a night shift and enabling coping strategies by providing educational programs for hospital nurses.

Correlates of disordered eating among gay men in Lebanon

The present cross-sectional design study examined six factors and their associations with disordered eating among 129 Lebanese men who identified themselves as gay. The factors under study were self-objectification, body dissatisfaction, shame-proneness, guilt-proneness, positive minority identity, and a sense of connectedness to the lesbian, gay, bisexual, and transgender (LGBT) community. Nongovernmental organizations that advocate for LGBT individuals assisted in the recruitment of participants. Data were analyzed through a hierarchical multiple regression, and age, education level, socioeconomic status, and religious affiliation were controlled for. The control variables alone explained 6% of the variance, and the six variables of interest within this study explained an additional 25% after being entered into the model. Self-objectification and shame-proneness were significantly, positively related to disordered eating among the participants in this study. In contrast to prior research, body dissatisfaction was not significantly associated with disordered eating in the present study. Results of this study indicate that self-objectification and shame-proneness might be important issues to consider in clinical work with gay Lebanese men exhibiting disordered eating symptomatology.

Cross-cultural adaptation and translation into Brazilian Portuguese of the instruments Sick Control One Stone Fat Food Questionnaire (SCOFF), Eating Disorder Examination Questionnaire (EDE-Q) and Clinical Impairment Assessment Questionnaire (CIA)

Introduction

Eating disorders (EDs) affect up to 13% of young people and are associated with significant morbidity and mortality. Nevertheless, important, internationally recognized instruments for brief ED screening (Sick Control One Stone Fat Food Questionnaire [SCOFF]), symptom severity assessment and diagnosis (Eating Disorder Examination Questionnaire [EDE-Q]) and assessment of ED-associated psychosocial impairment (Clinical Impairment Assessment Questionnaire [CIA]) were not yet available in Brazilian Portuguese. Our objective was to perform the cross-cultural adaptation and translation into Brazilian Portuguese of the instruments SCOFF, EDE-Q and CIA.

Method

The process involved a series of standardized steps, as well as discussions with experts. First, the relevance and adequacy of the scales’ items to our culture and population were extensively discussed. Then, two independent groups translated the original documents, creating versions that were compared. With the participation of external ED experts (i.e., who did not take part in the translation process), synthesized versions were produced. The syntheses were then applied to a focal group of patients with ED (n = 8). After that step, a preliminary version of the three scales in Brazilian Portuguese was produced and sent for back-translation by two English native speakers, who worked independently. A synthesis of the back-translations, along with the preliminary versions in Brazilian Portuguese, were sent to the original authors.

Results

The Brazilian Portuguese versions of SCOFF, EDE-Q and CIA were approved by the original authors and are now available for use.

Conclusion

This study provides important tools for the ED research field in Brazil.

Real-time changes in emotion regulation and loss of control eating

Difficulties in emotion regulation are an important theoretical construct implicated in the maintenance of loss of control eating. In this study, 45 community and college participants who reported loss of control eating at least once per week carried tablets for 2 weeks, responding to random assessments throughout each day. We compared trajectories of emotion regulation abilities before and after loss of control eating episodes (using average loss of control eating episode time to divide non-loss-of-control eating days). Emotion regulation abilities remained stable on non-loss-of-control eating days, but there was a significant increase in emotion regulation difficulties after loss of control eating episodes. These results suggest that increases in emotion regulation difficulties are not responsible for initiation of loss of control eating.

Real-time predictors and consequences of binge eating among adults with type 1 diabetes

BACKGROUND

Objective binge eating (OBE) is common among individuals with type 1 diabetes (T1D) and may have negative consequences for glycemic control. Recent studies have suggested that diabetes distress (i.e., emotional distress specific to diabetes and living with the burden of management) is a distinct emotional experience among individuals with diabetes. Preliminary studies have found diabetes distress is associated with eating disorder symptoms and poor glycemic control. The aim of the current study was to examine real-time emotional precursors and consequences of OBE in adults with T1D (i.e., general negative affect, specific emotional states and diabetes distress) using ecological momentary assessment methods. We also explore the impact of OBE on 2-h postprandial glycemic control relative to non-OBE eating episodes.

METHODS

Adults with T1D (N = 83) completed 3-days of ecological momentary assessment assessing mood and eating behavior using a telephone-based survey system. Participants were prompted to rate momentary affect, including level diabetes distress, at random intervals and reported on eating episodes. Participants also wore continuous glucose monitors allowing for ongoing assessment of glycemic control. Multi-level modeling was used to examine between- and within-person effects of momentary increases in emotions prior to eating on the likelihood of OBE and the impact of OBE on postprandial blood glucose. Generalized linear mixed models examined whether change in post-meal affect differed between OBE and non-OBE episodes.

RESULTS

Participants were predominately middle-aged (Mean = 42; SD = 12.43) Caucasian (87%) females (88%) reporting clinically significant eating disorder symptoms (76%). Nearly half of the sample (43%) reported OBE during the 3-day study period. The between-person effect for negative affect was significant (OR = 1.93, p < .05), indicating a 93% increased risk of OBE among individuals with higher negative affect compared to individuals with average negative affect. Between-person effects were also significant for guilt, frustration and diabetes distress (OR = 1.48-1.77, ps < .05). Analyses indicated that mean change in post-meal negative affect was significantly greater for OBE relative to non-OBE episodes (B = 0.44, p < .001). Blood glucose at 120 min postprandial was also higher for OBE than for non-OBE episodes (p = .03).

CONCLUSIONS

Findings indicate that individuals who tend to experience negative affect and diabetes distress before eating are at increased risk of OBE at the upcoming meal. Results also suggest that engaging in binge eating may result in greater subsequent negative affect, including diabetes distress, and lead to elevated postprandial blood glucose levels. These findings add to a growing literature suggesting diabetes distress is related to eating disordered behaviors among individuals with T1D.

Emotions before and after loss of control eating

Our study examined momentary mood and emotional instability pre- and post-loss of control (LOC) eating on non-LOC and LOC eating days, using randomly timed assessments. Community and university participants (n = 45) who endorsed LOC eating at least once per week completed 2 weeks of ecological momentary assessment. All negative moods and emotional instability were elevated on LOC eating days, but trajectories between days did not differ. Guilt exhibited an increasing trajectory prior to a LOC eating episode, but remained elevated after LOC eating episodes. Additional analyses revealed that size of the LOC eating episode did not change these results dramatically.

Symptoms predicting psychosocial impairment in bulimia nervosa

PURPOSE

The current study aimed to determine which particular eating disorder (ED) symptoms and related features, such as BMI and psychological distress, uniquely predict impairment in bulimia nervosa (BN).

METHODS

Two hundred and twenty-two adults with BN completed questionnaires assessing ED symptoms, general psychological distress, and psychosocial impairment. Regression analyses were used to determine predictors which account for variance in impairment.

RESULTS

Four variables emerged as significant predictors of psychosocial impairment: concerns with eating; concerns with weight and shape; dietary restraint; and general psychological distress.

CONCLUSIONS

Findings support previous work highlighting the importance of weight and shape concerns in determining ED-related impairment. Other ED symptoms, notably dietary restraint and concerns with eating, were also significant predictors as was psychological distress. Results suggest that cognitive aspects of EDs, in addition to psychological distress, may be more important determinants of impairment than behavioural symptoms, such as binge eating or purging.

Men who engage in both subjective and objective binge eating have the highest psychological and medical comorbidities

Data suggest that assessing for the presence of loss of control (LOC) while eating is more useful in identifying risk for excess weight gain and psychosocial comorbidities than focusing on the amount of food consumed during episodes of perceived overeating. Yet, most of this research has included children and women. The current study examined whether perceived overeating patterns with and without LOC were uniquely associated with eating- and weight-related comorbidities in a community sample of young men. Participants (N = 1114; 18-30 y) completed a brief online survey assessing body mass index (BMI); perceived overeating habits, including overeating without LOC (OEs), and subjective (SBEs) and objective binge eating episodes (OBEs); weight-related medical comorbidities; and disordered eating pathology. After adjusting for BMI and race/ethnicity, men who reported engaging in both OBE(s) and SBE(s) were the most likely to have a weight-related medical comorbidity, and reported the highest levels of dietary restraint, concerns about body fat, and excessive exercise pathology. Group differences remained even after adjusting for frequency of disordered eating episodes, a common indicator of severity of comorbid pathology. The current study's findings suggest that young men who engage in both OBE(s) and SBE(s) may be at the highest risk for chronic disease and psychological concerns, although additional studies with prospective data are necessary to confirm this hypothesis.

Nutrition Facts Use in Relation to Eating Behaviors and Healthy and Unhealthy Weight Control Behaviors

OBJECTIVE

Investigate the relationship between use of Nutrition Facts labels on packaged foods and weight-related behaviors.

DESIGN

Cross-sectional survey in 2015-2016.

PARTICIPANTS

Young adult respondents (n = 1,817; 57% women; average age 31.0 ± 1.6 years) to the Project Eating and Activity in Teens and Young Adults-IV survey, the fourth wave of a longitudinal cohort study.

VARIABLES MEASURED

Use of Nutrition Facts labels on packaged foods; healthy, unhealthy, and extreme weight control behaviors; intuitive eating; binge eating.

ANALYSIS

Linear and logistic regression models were adjusted for age, ethnicity/race, education, income, and weight status.

RESULTS

In women, greater Nutrition Facts use was associated with a 23% and 10% greater likelihood of engaging in healthy and unhealthy weight control behaviors, respectively, and a 17% greater chance of engaging in binge eating. In men, greater label use was associated with a 27% and 17% greater likelihood of engaging in healthy and unhealthy weight control behaviors, respectively, and a lower level of intuitive eating.

CONCLUSIONS AND IMPLICATIONS

Professionals advising patients and clients on weight management may consider possible gender differences in response to weight loss and management guidance. Since label use was related to engagement in some unhealthy behaviors in addition to healthy behaviors, it is important to consider how individuals may use labels, particularly those at risk for, or engaging in, disordered eating behaviors. Future research investigating potential relationships between Nutrition Facts use, intuitive eating, and binge eating is needed.

Driven exercise in the absence of binge eating: Implications for purging disorder

OBJECTIVE

Purging disorder (PD) is characterized by recurrent purging without objectively large binge-eating episodes. PD has received relatively little attention, and questions remain about the clinical significance of "purging" by exercise that is driven or compulsive (i.e., as extreme compensatory or weight-control behavior). The little available research suggests that individuals who use exercise as a compensatory behavior might have less eating-disorder psychopathology than those who purge by vomiting or laxatives, but those studies have had smaller sample sizes, defined PD using low-frequency thresholds, and defined exercise without weight-compensatory or driven elements.

METHOD

Participants (N = 2,017) completed a web-based survey with established measures of eating-disorder psychopathology, depression, and physical activity. Participants were categorized (regular compensatory driven exercise, PD-E, n = 297; regular compensatory vomiting/laxatives, PD-VL, n = 59; broadly defined anorexia nervosa, AN, n = 20; and no eating-disordered behaviors, NED, n = 1,658) and compared.

RESULTS

PD-E, PD-VL, and AN had higher eating-disorder psychopathology and physical activity than NED but did not significantly differ from each other on most domains. PD-VL and AN had higher depression than PD-E, which was higher than NED.

DISCUSSION

Findings suggest that among participants with regularly compensatory behaviors without binge eating, those who use exercise alone have similar levels of associated eating-disorder psychopathology as those who use vomiting/laxatives, although they have lower depression levels and overall frequency of purging. Findings provide further support for the clinical significance of PD. Clinicians and researchers should recognize the severity of driven exercise as a compensatory behavior, and the need for further epidemiological and treatment research.

Incremental validity of weight suppression in predicting clinical impairment in bulimic syndromes

Research has shown that weight suppression (WS; the difference between a person's highest and current body weight in pounds) is a robust predictor of weight gain and eating-disorder (ED) symptoms among individuals with bulimic syndromes. Given the important prognostic role that WS plays in ED course and outcome, we hypothesized that WS would represent a clinically useful indicator of impairment for bulimic syndromes. We further posited that WS would demonstrate incremental validity above-and-beyond other proposed indicators in explaining clinical impairment in bulimic syndromes. Participants were community-recruited adults (N = 101; 80.2% female) with full-threshold (n = 51) or subthreshold (n = 50) bulimia nervosa. Other indicators of impairment included body mass index, frequency of inappropriate compensatory behaviors, lifetime history of any internalizing disorder, and multiple purging. Clinical impairment was assessed with the clinical impairment assessment (CIA). Hierarchical linear regression tested whether WS added to the explanation of CIA score variance above-and-beyond other indicators of bulimic-syndrome impairment. WS was significantly associated with clinical impairment (p = .011), but did not demonstrate incremental validity over other independent variables in predicting CIA scores. WS explained an additional 1.7% of the variance in CIA scores above-and-beyond other variables and the independent effect of WS on CIA scores represented a medium-sized effect (Cohen's d = 0.521). Results suggested that WS may be an indicator of ED-related clinical impairment. Inquiring about WS could be an informative component of routine bulimic-syndrome assessment, given that WS explains some of the variance in clinical impairment in bulimic syndromes.

Developmental Trajectories of Boys' Driven Exercise and Fasting During the Middle School Years

Boys appear to engage in eating disorder behavior, particularly nonpurging compensatory behaviors such as driven exercise and fasting, at higher rates than previously thought. Little is known about the development of these behaviors in adolescent boys. In a sample of 631 non-binge eating and non-purging boys studied once in 5th grade and 6 times over the 3 years of middle school (grades 6 through 8), we found that (a) for some youth, driven exercise and fasting were present from grade 6; (b) different boys progressed along different trajectories of engagement in driven exercise and fasting, with some boys engaging in no driven exercise or fasting (65.8 % and 83.5 %, respectively), some boys engaging in driven exercise and fasting throughout middle school (25.2 % and 16.5 %, respectively), and other boys discontinuing engagement in driven exercise (9 %); (c) 5th grade depression, eating expectancies, and thinness expectancies predicted subsequent trajectory group membership; and (d) boys engaging in driven exercise and fasting in 8th grade remained distressed. Boys' engagement in driven exercise and fasting behavior merits the attention of researchers and clinicians.

Psychological need satisfaction, control, and disordered eating

OBJECTIVES

Unfulfilled basic psychological needs have been associated with disordered eating behaviours, but the mechanisms underlying that associations are not well understood. This study examined a two-stage path model linking basic psychological need satisfaction to disordered eating behaviours via issues of control.

METHODS

Female university students (N = 323; M_age  = 19.61), community participants (N = 371; M_age  = 29.75), and women who self-reported having been diagnosed with an eating disorder (ED; N = 41; M_age  = 23.88) completed measures of psychological need satisfaction (i.e., autonomy and competence), issues of control (i.e., feelings of ineffectiveness and fear of losing self-control [FLC]), and ED pathology.

RESULTS

Path analysis revealed that unsatisfied needs of autonomy and competence were indirectly related to disordered eating behaviours through feelings of ineffectiveness and FLC.

CONCLUSIONS

The results indicate that issues of control might be one of the mechanisms through which lack of psychological need satisfaction is associated with disordered eating. Although the model was constructed using cross-sectional data, these findings suggest potential targets for prevention and treatment efforts aimed at reducing disordered eating in young females.

PRACTITIONER POINTS

Our results indicate that young women with chronically unfulfilled basic psychological needs might be vulnerable to developing disordered eating behaviours. The observed patterns suggest that persistent experience of need frustration may engender an internal sense of ineffectiveness and lack of control, which then compels individuals to engage in disordered eating behaviours in an attempt to regain autonomy and competence. Interventions for eating disorders may be most effective when emphasizing the promotion of people's needs for autonomy and competence. Limitations The model was constructed using cross-sectional data. Future experimental and longitudinal studies are needed to confirm the temporal sequence from basic psychological needs to issues of control. The sample only consisted of young women. Further research should explore how thwarting of psychological need satisfaction functions in men. Our clinical sample was small and diagnosis was not confirmed through clinical interview; therefore, those data should be interpreted with caution.

The effects of media, self-esteem, and BMI on youth's unhealthy weight control behaviors

PURPOSE

Youth engage in a variety of methods to manage their weight, including unhealthy weight control behaviors (UWCBs). The purpose of this study was to examine factors associated with youth's engagement in UWCBs, including media influence, youth's BMI z-score and self-esteem.

METHODS

Participants were 179 youth, aged 10-17, attending a primary care clinic appointment. Youth completed questionnaires assessing frequency of UWCBs, global self-worth, and perception of media influence to lose weight. BMI z-score was calculated based on height and weight measurements obtained from medical charts. The SPSS macro, PROCESS, was used to conduct moderation analyses.

RESULTS

Over 40% of youth endorsed using at least one UWCB in the past year. Girls reported using more UWCBs and engaging in UWCBs more frequently than boys. For boys, media influence to lose weight was only related to UWCB frequency for those with a BMI z-score of 1.23 and above. For girls, media influence was only related to UWCB frequency for those with low to average levels of global self-worth.

CONCLUSIONS

Girls' and boys' use of UWCBs is impacted by different factors. Prevention efforts should consider targeting factors, such as weight status and self-esteem, which are uniquely associated with gender.

Slowing down and taking a second look: Inhibitory deficits associated with binge eating are not food-specific

Poor inhibitory control may contribute to the maintenance of binge eating (BE) among overweight and obese individuals. However, it is unknown whether deficits are general or specific to food (versus other attractive non-food stimuli), or whether observed deficits are attributable to increased depressive symptoms in BE groups. In the current study, we hypothesized that individuals with BE would display inhibitory control deficits, with more pronounced deficits occurring when food stimuli were used. Overweight or obese participants with (n = 25) and without (n = 65) BE completed a Stop Signal Task (SST) with distinct task blocks featuring food-specific stimuli, positive non-food stimuli, or neutral stimuli. The BE group exhibited poorer inhibitory control across SST stimuli types (p = .003, ηp(2)=.10), but deficits did not differ by stimuli type (p = .68, ηp(2) < .01). Including depression as a covariate did not significantly alter results. Results suggest individuals with BE display inhibitory control deficits compared to controls; however, deficits do not appear to be specific to stimuli type. Furthermore, inhibitory control deficits do not appear to be associated with mood disturbance in the BE group. Replication and further research is needed to guide treatment targets.

Sex differences in psychosocial impairment associated with eating disorder features in adolescents: A school-based study

OBJECTIVE

To examine sex differences in psychosocial impairment associated with eating disorder features (EDF) in adolescents.

METHOD

Questionnaires that assessed EDF (extreme dietary restriction, objective binge eating, subjective binge eating, purging, excessive exercise, and weight/shape overvaluation) and psychosocial impairment (general psychological distress and quality of life) were completed by a school-based sample of adolescent males (n = 531) and females (n = 1135) in the Australian Capital Territory region of Australia.

RESULTS

Each of the EDF assessed was associated with significant impairment in both male and female participants and this was the case for measures of both general psychological distress and quality of life, the only exception being that subjective binge eating was associated with elevated levels of distress in girls but not boys. The occurrence of subjective binge eating was associated with greater impairment in quality of life in girls than in boys. Otherwise, the effects of EDF on psychosocial functioning did not differ by sex. The prevalence of most EDF was higher in girls than in boys, although EDF were not uncommon in boys.

DISCUSSION

There appear to be few differences between male and female adolescents in terms of psychosocial impairment associated with EDF. The findings support the need for preventive interventions that seek to reduce the adverse impact of EDF in both boys and girls. The logistic and policy challenges inherent in such efforts warrant greater consideration. Further research is needed to elucidate the help-seeking behavior of young men with EDF who experience psychosocial impairment.

Affect regulation and purging: An ecological momentary assessment study in purging disorder

Research suggests that affect may play an important role in the propensity to purge among women with purging disorder (PD). However, prior work has been constrained to cross-sectional or laboratory designs, which impact temporal interpretations and ecological validity. This study examined negative affect (NA) and positive affect (PA) in triggering and maintaining purging in PD using ecological momentary assessment. Women with PD (N = 24) made multiple daily ratings of affect and behavior for 2 weeks. Multilevel models examined associations between affect and purging at different levels of analysis, including a novel analytic approach to address the specificity of changes in affect relative to purging behavior by comparing trajectories of change on purge versus nonpurge days. For trajectories of affect over time, NA increased before purging and decreased following purging on purge days; however, only the decrease in NA following purging was significantly different from the trajectory of NA on nonpurge days. Conversely, PA failed to increase before purging on purge days compared with a matched time-point on nonpurge days. These findings suggest unique roles of PA in triggering and NA in maintaining purging in PD and support models in which purging functions to regulate affect. For comparisons of ratings before and after purging, NA increased and PA decreased after purging, highlighting how different analytic strategies produce different findings requiring integration into affect regulation models. These data provide insight into why women with PD purge after consuming normal amounts of food, a crucial first step for developing effective interventions.

The independent and interacting effects of hedonic hunger and executive function on binge eating

Poor executive function (EF; pre-frontal cognitive control processes governing goal-directed behavior) and elevated hedonic hunger (i.e., preoccupation with palatable foods in the absence of physiological hunger) are theoretical risk and maintenance factors for binge eating (BE) distinct from general obesity. Recent theoretical models posit that dysregulated behavior such as BE may result from a combination of elevated appetitive drive (e.g., hedonic hunger) and decreased EF (e.g., inhibitory control and delayed discounting). The present study sought to test this model in distinguishing BE from general obesity by examining the independent and interactive associations of EF and hedonic hunger with BE group status (i.e., odds of categorization in BE group versus non-BE group). Treatment-seeking overweight and obese women with BE (n = 31) and without BE (OW group; n = 43) were assessed on measures of hedonic hunger and EF (inhibitory control and delay discounting). Elevated hedonic hunger increased the likelihood of categorization in the BE group, regardless of EF. When hedonic hunger was low, poor EF increased the likelihood of categorization in the BE group. Results indicate that the interplay of increased appetitive drives and decreased cognitive function may distinguish BE from overweight/obesity. Future longitudinal investigations of the combinatory effect of hedonic hunger and EF in increasing risk for developing BE are warranted, and may inform future treatment development to target these factors.

Prevalence and correlates of binge eating in seasonal affective disorder

Eating pathology in Seasonal Affective Disorder (SAD) may be more severe than hyperphagia during winter. Although research has documented elevated rates of subclinical binge eating in women with SAD, the prevalence and correlates of binge eating disorder (BED) in SAD remain largely uncharacterized. We examined the prevalence and correlates of binge eating, weekly binge eating with distress, and BED as defined by the DSM-IV-TR in SAD. We also tested whether binge eating exhibits a seasonal pattern among individuals with BED. Two samples were combined to form a sample of individuals with SAD (N=112). A third sample included non-depressed adults with clinical (n=12) and subclinical (n=11) BED. All participants completed the Questionnaire of Eating and Weight Patterns-Revised (QEWP-R) and modified Seasonal Pattern Assessment Questionnaire (M-SPAQ). In the SAD sample, 26.5% reported binge eating, 11.6% met criteria for weekly binge eating with distress, and 8.9% met criteria for BED. Atypical symptom severity predicted binge eating and BED. In the BED sample, 30% endorsed seasonal worsening of mood, and 26% reported a winter pattern of binge eating. The spectrum of eating pathology in SAD includes symptoms of BED, which are associated with atypical depression symptoms, but typical depression symptoms.

Stigmatizing attitudes and beliefs about bulimia nervosa: gender, age, education and income variability in a community sample

OBJECTIVE

Stigmatizing attitudes towards eating disorders negatively impacts treatment seeking. To determine the effect of interventions to reduce stigma, a measure of stigma that is simple to implement is required. This study aimed to develop a measure of stigmatizing attitudes and beliefs towards bulimia nervosa (SAB-BN) and evaluate the distribution of beliefs across gender, age, education, and income groups.

METHOD

Participants were 1828 community adults (890 men; 938 women) aged 18-65 sampled from the Australian Electoral Roll responded to a mailed questionnaire. Participants provided demographic information and completed the SAB-BN questionnaire.

RESULTS

Five components of stigmatizing attitudes and beliefs were identified; advantages of BN, minimization/low seriousness, unreliability, social distance, and personal responsibility. Stigma was low except on social distance and personal responsibility sub-scales, which indicated negative attitudes toward people with bulimia. Men compared with women and lower compared with higher education and income groups held significantly higher stigmatizing attitudes and beliefs. There were few differences between age groups in stigma. Differences between demographic groups provides evidence for known-groups validity.

DISCUSSION

The SAB-BN questionnaire provides a potentially useful tool for evaluating stigma in relation to BN. Results provide insight into components of stigma and the demographic groups to whom interventions should be targeted.

The role of loss of control eating in purging disorder

OBJECTIVE

Purging Disorder (PD), an Other Specified Feeding or Eating Disorder (APA, 2013), is characterized by recurrent purging in the absence of binge eating. Though objectively large binge episodes are not present, individuals with PD may experience a loss of control (LOC) while eating a normal or small amounts of food. The present study sought to examine the role of LOC eating in PD using archival data from 101 women with PD.

METHOD

Participants completed diagnostic interviews and self-report questionnaires. Analyses examined the relationship between LOC eating and eating disorder features, psychopathology, personality traits, and impairment in bivariate models and then in multivariate models controlling for purging frequency, age, and body mass index.

RESULTS

Across bivariate and multivariate models, LOC eating frequency was associated with greater disinhibition around food, hunger, depressive symptoms, negative urgency, distress, and impairment.

DISCUSSION

LOC eating is a clinically significant feature of PD and should be considered in future definitions of PD. Future research should examine whether LOC eating better represents a dimension of severity in PD or a specifier that may impact treatment response or course.

A preliminary examination of a nonpurging compensatory eating disorder

OBJECTIVE

To evaluate correlates of a compensatory eating disorder (CED) characterized by recurrent nonpurging compensatory behaviors in the absence of objectively large binge episodes among normal weight individuals who endorse undue influence of weight/shape on self-evaluation as possible indicators of clinical significance and distinctiveness.

METHOD

Women with CED (n = 20), women with bulimia nervosa (BN) (n = 20), and controls (n = 20) completed an interview and questionnaires assessing eating disorder and general psychopathology and weight history.

RESULTS

Compared with controls, women with CED reported significantly greater body image disturbance and disordered eating, higher anxiety proneness, increased perfectionism, and greater weight suppression. Compared with BN, CED was associated with significantly less body image disturbance, disordered eating, weight suppression, and lower likelihood of being overweight in childhood. However, CED and BN did not differ on anxiety proneness or perfectionism.

DISCUSSION

CED merits further examination to determine whether it is a clinically significant and distinct eating disorder.

Prevalence and correlates of unhealthy weight control behaviors: findings from the national longitudinal study of adolescent health

BACKGROUND

A recent study examined the prevalence, clinical correlates, age trends, and stability of unhealthy weight control behaviors (UWCB; purging and diet pill use) in a nationally representative sample of Norwegian boys and girls. The purpose of this study was to provide similar, comparative analyses for a nationally representative sample of American youth.

METHODS

Data were extracted from the restricted use data files of survey Waves I, II, and III of the National Longitudinal Study of Adolescent Health (Add Health), selecting all participants who at Wave I had provided information on age, sex, and UWCB. Using UWCB information, three groups were created (purging, diet pill use, and no recent UWCB "controls") and compared on indicators of adverse health or mental health.

RESULTS

Girls consistently were more likely than boys to report UWCB. UWCB were significantly associated with higher body mass index, self-perception of being overweight, low self-esteem, depression, and delinquency. Prevalence estimates for purging remained relatively constant across the three survey waves; in contrast, diet pill use was especially common at Wave III.

CONCLUSIONS

Age trends, gender differences, and clinical correlates of change in the likelihood of UWCB between Waves I-III were all identified in analyses comparing purging and diet pill use in American adolescents. Females and older adolescents were specifically more likely to engage in pill use than purging, and individuals with increased weight dissatisfaction, a history of delinquent behaviors, more depression symptoms, or lower self-esteem were more likely to engage in an unhealthy weight control behavior over time. While the Norwegian study found that prevalence of purging was lower among young adult participants, our results suggested that there were no significant differences in prevalence between age groups.

Predictors of disordered eating in adolescence and young adulthood

We investigated longitudinal predictors for disordered eating from early adolescence to young adulthood (12–34 years) across gender and different developmental phases among Norwegian young people. Survey data from a population-based sample were collected at four time points (T) over a 13-year time span. A population-based sample of 5,679 females and males at T1 and T2, 2,745 at T3 and 2,718 at T4 were included in analyses, and linear regression and random intercept models were applied. In adolescence, initial disordered eating and parental overprotectiveness were more strongly related to disordered eating among females, whereas loneliness was a stronger predictor for adolescent males. Initial disordered eating during early adolescence predicted later disordered eating more strongly in late- than mid-adolescence. In young adulthood, no significant gender-specific risk factors were found. The findings provide support for both shared and specific risk factors for the developmental psychopathology of disordered eating.

A school-based program implemented by community providers previously trained for the prevention of eating and weight-related problems in secondary-school adolescents: the MABIC study protocol

Background

The prevention of eating disorders and disordered eating are increasingly recognized as public health priorities. Challenges in this field included moving from efficacy to effectiveness and developing an integrated approach to the prevention of a broad spectrum of eating and weight-related problems. A previous efficacy trial indicated that a universal disordered eating prevention program, based on the social cognitive model, media literacy educational approach and cognitive dissonance theory, reduced risk factors for disordered eating, but it is unclear whether this program has effects under more real-world conditions. The main aim of this effectiveness trial protocol is to test whether this program has effects when incorporating an integrated approach to prevention and when previously-trained community providers implement the intervention.

Methods/design

The research design involved a multi-center non-randomized controlled trial with baseline, post and 1-year follow-up measures. Six schools from the city of Sabadell (close to Barcelona) participated in the intervention group, and eleven schools from four towns neighboring Sabadell participated in the control group. A total of 174 girls and 180 boys in the intervention group, and 484 girls and 490 boys in the control group were registered in class lists prior to baseline. A total of 18 community providers, secondary-school class tutors, nurses from the Catalan Government’s Health and School Program, and health promotion technicians from Sabadell City Council were trained and delivered the program. Shared risk factors of eating and weight-related problems were assessed as main measures.

Discussion

It will be vital for progress in disordered eating prevention to conduct effectiveness trials, which test whether interventions are effective when delivered by community providers under ecologically valid conditions, as opposed to tightly controlled research trials. The MABIC project will provide new contributions in this transition from efficacy to effectiveness and new data about progress in the integrated approach to prevention. Pending the results, the effectiveness trial meets the effectiveness standards set down by the Society for Prevention Research. This study will provide new evidence to improve and enhance disordered eating prevention programs.

Trial registration

Current Controlled Trials ISRCTN47682626

Quality of life impairment associated with body dissatisfaction in a general population sample of women

Background

In order to elucidate the individual and community health burden of body dissatisfaction (BD), we examined impairment in quality of life associated with BD in a large, general population sample of women.

Methods

Self-report measures of BD, health-related quality of life (SF-12 Physical and Mental Component Summary scales) and subjective quality of life (WHOQOL-BREF Psychological Functioning and Social Relationships subscales) were completed by 5,255 Australian women aged 18 to 42 years.

Results

Most participants (86.9%) reported some level of dissatisfaction with their weight or shape and more than one third (39.4%) reported moderate to marked dissatisfaction. Higher levels of BD were associated with poorer quality of life for all items of both quality of life measures, the degree of impairment being proportional to the degree of BD. Associations were strongest for items tapping mental health and psychosocial functioning, although greater BD was associated with substantially increased risk of impairment in certain aspects of physical health even when controlling for body weight. Post-hoc analysis indicated that the observed associations between BD and quality of life impairment were not accounted for by an association between BD and eating disorder symptoms.

Conclusions

In women, BD is associated with marked impairment in aspects of quality of life relating to mental health and psycho-social functioning and at least some aspects of physical health, independent of its association with body weight and eating disorder symptoms. Greater attention may need to be given to BD as a public health problem. The fact that BD is “normative” should not be taken to infer that it is benign.

Eating disorder prevention: current evidence-base and future directions

OBJECTIVE

This narrative review sought to (a) characterize prevention programs that have produced reliable, reproducible, and clinically meaningful effects in efficacy trials, (b) discuss effectiveness trials that have tested whether prevention programs produce intervention effects under ecologically valid real-world conditions, (c) discuss dissemination efforts and research on dissemination, and (d) offer suggestions regarding directions for future research in this field.

CONCLUSION

A literature revealed that 6 prevention programs have produced significant reductions in eating disorder symptoms through at least 6-month follow-up and that 2 have significantly reduced future eating disorder onset. Effectiveness trials indicate that 2 prevention programs have produced effects under ecologically valid conditions that are only slightly attenuated. Although there have been few dissemination efforts, evidence suggests that a community participatory approach is most effective. Lastly, it would be useful to develop programs that produce larger and more persistent reductions in eating disorder symptoms and eating disorder onset, focus more on effectiveness trials that confirm that prevention programs produce clinically meaningful effects under real-world conditions, conduct meditational, mechanisms of action, and moderator research that provides stronger support for the intervention theory of prevention programs, and investigate the optimal methods of disseminating and implementing evidence-based prevention programs.

The prevalence and correlates of binge eating disorder in the World Health Organization World Mental Health Surveys

BACKGROUND

Little population-based data exist outside the United States on the epidemiology of binge eating disorder (BED). Cross-national BED data are presented here and compared with bulimia nervosa (BN) data in the World Health Organization (WHO) World Mental Health Surveys.

METHODS

Community surveys with 24,124 respondents (ages 18+) across 14 mostly upper-middle and high-income countries assessed lifetime and 12-month DSM-IV mental disorders with the WHO Composite International Diagnostic Interview. Physical disorders were assessed with a chronic conditions checklist.

RESULTS

Country-specific lifetime prevalence estimates are consistently (median; interquartile range) higher for BED (1.4%; .8-1.9%) than BN (.8%; .4-1.0%). Median age of onset is in the late teens to early 20s for both disorders but slightly younger for BN. Persistence is slightly higher for BN (6.5 years; 2.2-15.4) than BED (4.3 years; 1.0-11.7). Lifetime risk of both disorders is elevated for women and recent cohorts. Retrospective reports suggest that comorbid DSM-IV disorders predict subsequent onset of BN somewhat more strongly than BED and that BN predicts subsequent comorbid disorders somewhat more strongly than does BED. Significant comorbidities with physical conditions are due almost entirely to BN and to a somewhat lesser degree BED predicting subsequent onset of these conditions. Role impairments are similar for BN and BED. Fewer than half of lifetime BN or BED cases receive treatment.

CONCLUSIONS

Binge eating disorder represents a public health problem at least equal to BN. Low treatment rates highlight the clinical importance of questioning patients about eating problems even when not included among presenting complaints.

Purging disorder: a comparison to established eating disorders with purging behaviour

This study is part of the larger Christina Barz Study, and it compared consecutively admitted patients with purging disorder (PurD; N = 225) with consecutively admitted patients with anorexia nervosa binge eating/purging subtype (AN-bp; N = 503) and bulimia nervosa purging subtype (BN-p; N = 756). Participants answered self-rating questionnaires on admission, at the end of inpatient treatment, and in a 5-year follow-up. Patients with PurD reported lower severity of general psychopathology than patients with AN-bp and lower severity of eating disorder symptoms than patients with AN-bp and BN-p on admission. Eating disorder symptoms of patients with PurD improved less during the course than of the comparison groups. Diagnostic perseverance was stronger in the PurD group than for patients with AN-bp; mortality was higher than for patients with BN-p. Predictors for better outcome differed for the groups. Our results provide new data about the long-term course of patients with PurD and indicate clinical relevance of the disorder.

Subjective binge eating with compensatory behaviors: a variant presentation of bulimia nervosa

OBJECTIVES

To determine whether a variant bulimic-type presentation, whereby one meets criteria for bulimia nervosa (BN) except that binge eating episodes are not objectively large (i.e., "subjective bulimia nervosa," SBN), has comparable clinical severity to established eating disorders, particularly BN.

METHOD

Treatment-seeking adults with BN (N = 112), SBN (N = 28), anorexia nervosa restricting type (AN-R) (N = 45), and AN-binge/purge type (AN-B/P) (N = 24) were compared.

RESULTS

Overall, SBN could not be meaningfully distinguished from BN. SBN and BN had equivalent eating pathology, depression and anxiety symptoms, low quality of life, impulsivity, Axis I comorbidity, and lifetime psychiatric history, and comparable clinical severity to AN-R and AN-B/P.

DISCUSSION

Individuals with SBN, differing from BN only by the smaller size of their binge eating episodes, had a form of eating disorder comparable in clinical severity to threshold AN and BN and warranting clinical attention. Health professionals and the community require greater awareness of this variant to optimize detection, treatment-seeking, and outcomes.

Self-recognition of eating-disordered behavior in college women: further evidence of poor eating disorders "mental health literacy"?

Self-recognition of eating-disordered behavior was examined among female college students (n = 94) with a high level of bulimic-type eating disorder symptoms. A vignette was presented describing a fictional young woman with bulimia nervosa. Participants were asked whether they might currently have a problem such as the one described, while also completing self-report measures of eating disorder symptoms, general psychological distress, and functional impairment. Less than half (47.9%) of participants believed that they currently had a problem with their eating. In both bivariate and multivariable analysis, the variables most strongly associated with self-recognition were overall levels of eating disorder psychopathology, prior treatment for an eating problem, and the use of self-induced vomiting as a means of controlling weight or shape. No other eating disorder behaviors were independently associated with self-recognition. The findings support the hypothesis that young women with eating disorder symptoms may be unlikely, or at least less likely, to recognize a problem with their eating behavior when that behavior does not entail self-induced vomiting. Health promotion and early intervention programs for eating disorders may need to address the perception that, among young women of normal or above-average body weight, only problems with eating that involve self-induced vomiting are pathological.

An investigation of objective and subjective types of binge eating episodes in a clinical sample of people with co-morbid obesity

BACKGROUND

Objective binge eating episodes (OBEs) refer to binge eating on an unusually large amount of food and are the core symptom in current definitions of bulimia nervosa (BN) and binge eating disorder (BED). Subjective binge eating episodes (SBEs) refer to eating on a small or moderate amount of food (that is perceived as large) and like OBEs are associated with loss of control (LOC). Reaching consensus on what is considered a large amount of food can however be problematic and it remains unclear if the size of a binge is an essential component for defining a binge eating episode. The aim of this study was to compare the eating disorder features and general psychopathology of subjects reporting OBEs with those reporting only SBEs.

METHODS

This is a retrospective secondary analysis of data from 70 obese participants at the recruitment phase of a multicentre trial for BED. Individuals who answered positively to the presence of binge eating and LOC over eating had their binge eating episodes further explored by interview and self-report. Two groups, those who reported current OBEs (with or without SBEs) and those who reported current SBEs only were compared for age, gender, marital status, body mass index (BMI), indicators of LOC over eating, severity of binge-eating and associated psychopathology.

RESULTS

The majority of participants in both the OBE and SBE groups endorsed the experience of at least four indicators of LOC. There were no significant differences between the groups. Both groups had high levels of binge-eating severity, moderate severity of associated depressive symptoms and frequent psychiatric co-morbidity.

CONCLUSION

Treatment seeking participants with obesity who reported SBEs alone were similar to those who reported OBEs in terms of eating disorder features and general psychopathology. These findings suggest that classificatory systems of mental illnesses should consider introducing SBEs as a feature of the diagnostic criteria for binge eating and, thus, facilitate the inclusion of participants with SBEs in treatment trials.

An exploratory investigation of purging disorder

OBJECTIVE

Purging Disorder (PD) is an understudied pattern of behaviors within the Eating Disorder Not Otherwise Specified (EDNOS) category. Such categorization may suggest that PD is not clinically significant as other eating disorders. However, evidence has suggested that PD is associated with significant impairments in psychosocial functioning and well-being. Despite the apparent clinical significance of PD, it remains to be determined if PD is distinct from other clinically significant eating disorders. The present study sought to assess the phenomenology, clinical significance, and distinctiveness of PD.

METHOD

Group scores on measures of eating pathology, body image disturbance, and psychological correlates were compared using MANOVA among a female undergraduate sample (N=94) meeting diagnostic criteria for PD (n=20), Bulimia Nervosa (BN; n=35), restrained eating (n=18), and healthy controls (n=21).

RESULTS

Overall, results indicated the PD group reported less severe symptoms than BN but more severe symptoms than controls. The PD and restraint groups were similar on most variables (including subjective binge behavior), with the exception of perfectionism and hunger.

DISCUSSION

Findings support the conceptualization of PD as existing along a spectrum of bulimic spectrum disorders rather than as a distinct diagnostic category.

Eating disorder symptom trajectories in adolescence: effects of time, participant sex, and early adolescent depressive symptoms

BACKGROUND

Adolescence is a period of developmental risk for eating disorders and eating disorder symptoms. This study aimed to describe the prevalence and trajectory of five core eating disorder behaviours (binge eating, purging, fasting, following strict dietary rules, and hard exercise for weight control) and a continuous index of dietary restraint and eating, weight and shape concerns, in a cohort of male and female adolescents followed from 14 to 20 years. It also aimed to determine the effect of early adolescent depressive symptoms on the prevalence and trajectory of these different eating disorder symptoms. Participants (N = 1,383; 49% male) were drawn from the Western Australian Pregnancy Cohort (Raine) Study, a prospective cohort study that has followed participants from pre-birth to age 20 years. An adapted version of the Eating Disorder Examination-Questionnaire was used to assess eating disorder symptoms at ages 14, 17 and 20 years. The Beck Depression Inventory for Youth was used to assess depressive symptoms at age 14. Longitudinal changes in the prevalence of eating disorder symptoms were tested using generalised estimating equations and linear mixed models.

RESULTS

Symptom trajectories varied according to the eating disorder symptom studied, participant sex, and the presence of depressive symptoms in early adolescence. For males, eating disorder symptoms tended to be stable (for purging, fasting and hard exercise) or decreasing (for binge eating and global symptom scores) from 14 to 17 years, and then stable to 20 years. For females, fasting and global symptom scores increased from age 14 to peak in prevalence at age 17. Rates of binge eating in females were stable from age 14 to age 17 and increased significantly thereafter, whilst rates of purging and hard exercise increased from age 14 to age 17, and then remained elevated through to age 20. Depressive symptoms at age 14 impacted on eating disorder symptom trajectories in females, but not in males.

CONCLUSIONS

Prevention, screening and intervention initiatives for adolescent eating disorders need to be tailored to gender and age. Purging behaviour appears to be an important target for work with early to middle adolescent females.

Classification of bulimic-type eating disorders: from DSM-IV to DSM-5

Proposed changes to the classification of bulimic-type eating disorders in the lead up to the publication of DSM-5 are reviewed. Several of the proposed changes, including according formal diagnostic status to binge eating disorder (BED), removing the separation of bulimia nervosa (BN) into purging and non-purging subtypes, and reducing the binge frequency threshold from twice per week to once per week for both BN and (BED), have considerable empirical evidence to support them and will likely have the effect of facilitating clinical practice, improving access to care, improving public and professional awareness and understanding of these disorders and stimulating the additional research needed to address at least some problematic issues. However, the omission of any reference to variants of BN characterized by subjective, but not objective, binge eating episodes, and to the undue influence of weight or shape on self-evaluation or similar cognitive criterion in relation to the diagnosis of BED, is regrettable, given their potential to inform clinical and research practice and given that there is considerable evidence to support specific reference to these distinctions. Other aspects of the proposed criteria, such as retention of behavioral indicators of impaired control associated with binge eating and the presence of marked distress regarding binge eating among the diagnostic for BED, appear anomalous in that there is little or no evidence to support their validity or clinical utility. It is hoped that these issues will be addressed in final phase of the DSM-5 development process.

Prevalence, incidence, impairment, and course of the proposed DSM-5 eating disorder diagnoses in an 8-year prospective community study of young women

We examined prevalence, incidence, impairment, duration, and course for the proposed DSM-5 eating disorders in a community sample of 496 adolescent females who completed annual diagnostic interviews over 8 years. Lifetime prevalence by age 20 was 0.8% for anorexia nervosa (AN), 2.6% for bulimia nervosa (BN), 3.0% for binge eating disorder (BED), 2.8% for atypical AN, 4.4% for subthreshold BN, 3.6% for subthreshold BED, 3.4% for purging disorder (PD), and combined prevalence of 13.1% (5.2% had AN, BN, or BED; 11.5% had feeding and eating disorders not elsewhere classified; FED-NEC). Peak onset age was 19-20 for AN, 16-20 for BN, and 18-20 for BED, PD, and FED-NEC. Youth with these eating disorders typically reported greater functional impairment, distress, suicidality, mental health treatment, and unhealthy body mass index, though effect sizes were relatively smaller for atypical AN, subthreshold BN, and PD. Average episode duration in months ranged from 2.9 for BN to 11.2 for atypical AN. One-year remission rates ranged from 71% for atypical AN to 100% for BN, subthreshold BN, and BED. Recurrence rates ranged from 6% for PD to 33% for BED and subthrehold BED. Diagnostic progression from subthreshold to threshold eating disorders was higher for BN and BED (32% and 28%) than for AN (0%), suggesting some sort of escalation mechanism for binge eating. Diagnostic crossover was greatest from BED to BN. Results imply that the new DSM-5 eating disorder criteria capture clinically significant psychopathology and usefully assign eating disordered individuals to homogeneous diagnostic categories.

Time trends in population prevalence of eating disorder behaviors and their relationship to quality of life

Objective

To examine temporal trends in the burden of eating disorder (ED) features, as estimated by the composite of their prevalence and impact upon quality of life (QoL) over a period of 10 years.

Methodology

Representative samples of 3010 participants in 1998 and 3034 participants in 2008 from the South Australian adult population were assessed for endorsement of ED features (objective binge eating, extreme dieting, and purging were assessed in both years; subjective binge eating and extreme weight/shape concerns were also assessed in 2008) and QoL using the Medical Outcomes Study Short Form (SF-36).

Principal Findings

From 1998 to 2008 significant increases in the prevalence of objective binge eating (2.7% to 4.9%, p<0.01) and extreme dieting (1.5% to 3.3%, p<0.01), but not purging, were observed. Lower scores on the SF-36 were significantly associated with endorsement of any of these behaviors in both 1998 and 2008 (all p<0.001). No significant difference was observed in the effect of the endorsement of these ED behaviors on QoL between 1998 and 2008 (all p>0.05). Multiple linear regressions found that in 1998 only objective binge eating significantly predicted scores on the mental health summary scale of the SF-36; however, in 2008 extreme weight/shape concerns, extreme dieting, and subjective binge eating were also significant predictors. Objective binge eating and extreme dieting were significant predictors of scores on the physical health summary scale of the SF-36 in both 1998 and 2008.

Conclusions and Significance

The prevalence of ED behaviors increased between 1998 and 2008, while their impact on QoL remained stable. This suggests an overall increase in the burden of disordered eating from 1998 to 2008. Given that binge eating and extreme dieting predict impairment in QoL, the necessity of interventions to prevent both under- and over-eating is reinforced.

Bulimic behaviors and alcohol use: shared genetic influences

Bulimic behaviors are frequently associated with alcohol use disorders. However, extant family and twin study findings have been inconsistent with regard to whether these behaviors share etiologic influences. A sample of 292 young adult, female twins was used to examine genetic and environmental factors underlying the association between binge eating and compensatory behaviors (e.g., vomiting)and alcohol use. Binge eating and compensatory behaviors were assessed using the Minnesota Eating Behavior Survey.Alcohol use was measured using the Alcohol Use Disorders Identification Test. Univariate models indicated that the heritability of binge eating, compensatory behaviors, and alcohol use was 41, 28, and 78%, respectively, with the remaining variance due to nonshared environmental effects.Bivariate models indicated that there was a moderate-to-large degree of overlap (genetic correlation = 0.31–0.61) in additive genetic factors between alcohol use and binge eating and compensatory behaviors, and no overlap in environmental effects. Findings suggest that these phenotypes co-aggregate in families and that similar genes or heritable traits may be contributing to their co-occurrence.

Prospective association of common eating disorders and adverse outcomes

OBJECTIVE

Anorexia nervosa and bulimia nervosa (BN) are rare, but eating disorders not otherwise specified (EDNOS) are relatively common among female participants. Our objective was to evaluate whether BN and subtypes of EDNOS are predictive of developing adverse outcomes.

METHODS

This study comprised a prospective analysis of 8594 female participants from the ongoing Growing Up Today Study. Questionnaires were sent annually from 1996 through 2001, then biennially through 2007 and 2008. Participants who were 9 to 15 years of age in 1996 and completed at least 2 consecutive questionnaires between 1996 and 2008 were included in the analyses. Participants were classified as having BN (≥ weekly binge eating and purging), binge eating disorder (BED; ≥ weekly binge eating, infrequent purging), purging disorder (PD; ≥ weekly purging, infrequent binge eating), other EDNOS (binge eating and/or purging monthly), or nondisordered.

RESULTS

BN affected ∼1% of adolescent girls; 2% to 3% had PD and another 2% to 3% had BED. Girls with BED were almost twice as likely as their nondisordered peers to become overweight or obese (odds ratio [OR]: 1.9 [95% confidence interval: 1.0-3.5]) or develop high depressive symptoms (OR: 2.3 [95% confidence interval: 1.0-5.0]). Female participants with PD had a significantly increased risk of starting to use drugs (OR: 1.7) and starting to binge drink frequently (OR: 1.8).

CONCLUSIONS

PD and BED are common and predict a range of adverse outcomes. Primary care clinicians should be made aware of these disorders, which may be underrepresented in eating disorder clinic samples. Efforts to prevent eating disorders should focus on cases of subthreshold severity.

Revisiting Classification of Eating Disorders-toward Diagnostic and Statistical Manual of Mental Disorders-5 and International Statistical Classification of Diseases and Related Health Problems-11

Two of the most commonly used nosological systems- International Statistical Classification of Diseases and Related Health Problems (ICD)-10 and Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV are under revision. This process has generated a lot of interesting debates with regards to future of the current diagnostic categories. In fact, the status of categorical approach in the upcoming versions of ICD and DSM is also being debated. The current article focuses on the debate with regards to the eating disorders. The existing classification of eating disorders has been criticized for its limitations. A host of new diagnostic categories have been recommended for inclusion in the upcoming revisions. Also the structure of the existing categories has also been put under scrutiny.

Quality of life impairment in a community sample of women with eating disorders

OBJECTIVE

Studies of quality of life among individuals with eating disorders have relied almost exclusively on clinical samples. We examined impairment in quality of life in a community sample of women with eating disorders recruited as part of an epidemiological study.

METHODS

Measures of health-related quality of life (Medical Outcomes Study 12-item Short-Form Physical and Mental Component Summary scales) and subjective well-being (WHOQOL-BREF Psychological Functioning and Social Relationships subscales) were completed by women with eating disorders (n = 159), primarily variants of bulimia nervosa and binge eating disorder, and a comparison group of healthy women (n = 232).

RESULTS

When compared with healthy women, women with eating disorders reported substantial impairment in aspects of quality of life relating to mental health, although item-level analysis indicated considerable variation in the extent to which specific aspects of emotional well-being were affected. Impairment in social relationship and in physical health was less pronounced and due, at least in part, to between-group differences in age, body weight and demographic characteristics. Impairment in certain aspects of perceived physical health was, however, apparent among women with eating disorders, even after controlling for between-group differences in body weight.

CONCLUSIONS

Community cases of women with eating disorders experience marked impairment in quality of life as this relates to mental health functioning and at least some impairment in physical health functioning. Personality characteristics and ego-syntonic aspects of eating-disordered behaviour may complicate the interpretation of findings relating to impairment in specific aspects of quality of life.

Comparing the health burden of eating-disordered behavior and overweight in women

OBJECTIVE AND METHODS

We compared the health burden of eating-disordered behavior with that of overweight in a community-based sample of women aged 18-42 years residing in the Australian Capital Territory region of Australia. Participants (n = 4643) completed self-report measures of eating disorder psychopathology, health-related quality of life and health service utilization. Body mass index (BMI) was derived from self-reported height and weight.

RESULTS

Overweight was associated with marked impairment in physical health functioning and comparatively little impairment in psychosocial functioning, whereas eating-disordered behavior was associated with marked impairment in psychosocial functioning and comparatively little impairment in physical health functioning. Further, (1) impairment in psychosocial functioning associated with eating-disordered behavior was greater than impairment in physical health functioning associated with overweight, and (2) impairment in physical health functioning associated with eating-disordered behavior was greater than impairment in psychosocial functioning associated with overweight. Overweight and eating-disordered behavior were associated with similarly elevated rates of primary care consultations during the past 6 months and of lifetime treatment from a health professional for an eating or weight problem.

CONCLUSIONS

In young adult women, the health burden of eating-disordered behavior may be more substantial than previously recognized. Better information concerning the spectrum of disordered eating that exists at the population level needs to be made available. Eating-disordered behavior warrants greater attention when considering the public health burden of obesity and in developing programs to reduce this burden.