Using the eating disorder examination in the assessment of bulimia and anorexia: issues of reliability and validity

Some hope for a dimensional assessment? A critical review of psychometric validated (semi-)structured interview to assess eating disorders

OBJECTIVE

Given that eating disorders (EDs) are considered one of the deadliest mental illnesses, the development of appropriate assessment instruments is a necessity. Despite the extensive literature on assessing EDs, there has been a lack of focus on semi-structured interviews. The purpose of this article is to provide a comprehensive review of psychometrically validated semi-structured interviews for EDs.

METHODS

Included studies (N = 24) were required to present a semi-structured interview for EDs that has been validated through a psychometric process. The APA PsycNet, MEDLINE, APA Psycinfo, Pubmed, and Health & Psychosocial Instruments databases were searched. The literature search included publications through May 2024, with no earliest year restriction.

RESULTS

A total of six instruments were identified and reviewed in terms of conceptual design, purpose and content, psychometric characteristics, and strengths and limitations. Three main findings were highlighted: (a) only half of the instruments are up to date; (b) the instruments are based on either a categorical or a mixed categorical-dimensional approach; and (c) the predominance of the categorical approach.

CONCLUSIONS

The results are discussed regarding the conceptual approaches of the instrument to provide clinical and research implications. Despite the many strengths of the instrument, additional psychometric research is needed.

The risk of low energy availability among athlete females in Saudi Arabia: a cross-sectional study

Introduction

Low energy availability (LEA) is a state of inadequate energy reserves that results from a negative energy balance. This condition can lead to severe health risks such as amenorrhea and osteoporosis. Various causes for LEA, such as eating disorders and exercise addiction, have been reported in the literature. However, data in Saudi Arabia are lacking. This cross-sectional study measures the prevalence of LEA, eating disorders, and exercise addiction among adult females in Saudi Arabia and identifies possible associated risk factors.

Methods

The sample comprised 119 female athletes who filled out an online survey adapted from the LEA in Females Questionnaire, the Eating Disorder Examination Questionnaire, and the Exercise Addiction Inventory.

Results

Participants showed a high prevalence of LEA (66.4%), eating disorder (33.6%), and exercise addiction (10.1%), confirming the association between normal weight and LEA in females living in Saudi Arabia (p < 0.00).

Discussion and conclusion

With an increasing number of females in the country interested in following a healthy lifestyle, there is a need to raise the awareness of the population on the issues of LEA, eating disorders, and exercise addiction and their effects on the body by developing educational programs about energy intake and healthy physical activity routines.

The implications of the COVID-19 pandemic on eating disorder features and comorbid psychopathology among adolescents with anorexia nervosa and matched controls: a comparative cohort design study

PURPOSE

To examine implications of the COVID-19 pandemic on eating disorder (ED) features and psychopathology in female adolescents with anorexia nervosa (AN).

METHOD

In total 79 females with first-onset AN (aged 12-22 years) were included and were followed up across a period of 1 year. We assessed AN participants recruited pre-pandemic (n = 49) to those recruited peri-pandemic (n = 30). Pre- (n = 37) and peri-pandemic (n = 38) age-, and education-matched typically developing (TD) girls (n = 75) were used as a reference cohort. ED features and psychopathology were assessed at baseline. After 1 year of follow-up the association between pandemic timing and clinical course was assessed. Analyses of covariance were used to examine differences in ED features and psychopathology.

RESULTS

Peri-pandemic AN participants experienced less ED symptoms at baseline compared to pre-pandemic AN participants. In particular, they were less dissatisfied with their body shape, and experienced less interpersonal insecurity. In addition, the peri-pandemic AN group met fewer DSM-IV criteria for comorbid disorders, especially anxiety disorders. In contrast, peri-pandemic AN participants had a smaller BMI increase over time. In TD girls, there were no differences at baseline in ED features and psychopathology between the pre- and peri-pandemic group.

CONCLUSION

Overall, peri-pandemic AN participants were less severely ill, compared to pre-pandemic AN participants, which may be explained by less social pressure and peer contact, and a more protective parenting style during the pandemic. Conversely, peri-pandemic AN participants had a less favorable clinical course, which may be explained by reduced access to health care facilities during the pandemic.

LEVEL OF EVIDENCE

Level III: Evidence obtained from well-designed cohort or case-control analytic studies.

Validity and Consistency of the Arabic Version of the Eating Disorder Examination Questionnaire (EDE-Q) among Saudi Adults

The prevalence of eating disorders (EDs) is growing, and early screening is important to prevent related health complications. The Eating Disorder Examination Questionnaire (EDE-Q) has been widely used as a diagnostic tool to identify cases of EDs; however, a validated Arabic version of the tool is needed to help in the screening process of EDs. The aim of this study was to validate the Arabic version of EDE-Q. A cross-sectional study included a sample of 549 adults, who were recruited mainly from the four major provinces in Saudi Arabia. A forward–backward translation method was conducted, and then the tool was validated using the confirmatory factor analysis (CFA). The dataset was split for further convergent analysis using exploratory factor analysis (EFA) and CFA. The results of CFA from the main dataset did not support the four-factor original EDE-Q. The results of EFA from the first data-split suggested a three-factor EDE-Q-14 Arabic version. This was supported by the results of CFA of the second data-split. A total of five items were allocated in each shape and weight concern, and restraint component, with correlations ranging from 0.969 and 0.462 and from 0.847 to 0.437, respectively. A total of four items were allocated in eating concern, with correlations ranging from 0.748 to 0.556. The internal consistency of the global and the three subscales were high, with Cronbach’s α ranging from 0.762 to 0.900. Findings of the current study suggest that the Arabic version of the EDE-Q-14 is a valid and reliable tool to screen for EDs among adults in Saudi Arabia.

Examination of the Reliability and Validity of the Minnesota Multiphasic Personality Inventory-3 (MMPI-3) in a Preoperative Bariatric Surgery Sample

Presurgical psychological assessment of bariatric surgery candidates aims to identify psychosocial risk factors and provide treatment recommendations to facilitate optimal outcomes. Such assessment typically includes psychometric testing and a clinical interview. The Minnesota Multiphasic Personality Inventory (MMPI) has been commonly used as a broadband measure to assess a number of psychosocial domains in bariatric clinics. The newest version of the MMPI, the MMPI-3, was recently released. This study sought to (1) establish whether the MMPI-3 is comparable to the MMPI-2-RF in a sample of patients seeking bariatric surgery, (2) report reliability data for all MMPI-3 scale scores in this sample, and (3) explore associations between commonly used self-report symptom measures and substantive scales of the MMPI-3 to ascertain convergent and discriminant validity patterns. Six hundred and thirty-five presurgical patients completed the MMPI-3 in addition to the Patient Health Questionnaire-9 (PHQ-9), General Anxiety Disorder-7 (GAD-7), Alcohol Use Disorders Identification Test-Consumption (AUDIT-C), and Eating Disorder Examination-Questionnaire (EDE-Q). The majority (79.1%) of the sample was female, 65.5% was white, and 26.6% was Black. Scores on most of the MMPI-3 Emotional/Internalizing Dysfunction scales were meaningfully associated with the PHQ-9, GAD-7, and most EDE-Q subscales (except for Restraint). Meaningful discriminant patterns were observed as well. We conclude that the substantive scales of the MMPI-3 are reliable, comparable to their MMPI-2-RF counterparts, and evidence good convergent validity with extra-test measures assessing depression, anxiety, alcohol use, and eating disorder psychopathology in a preoperative bariatric sample.

Risk of Low Energy Availability, Disordered Eating, Exercise Addiction, and Food Intolerances in Female Endurance Athletes

Relative energy deficiency in sport (RED-S) is a complex syndrome describing health and performance consequences of low energy availability (LEA) and is common among female endurance athletes. Various underlying causes of LEA have been reported, including disordered eating behavior (DE), but studies investigating the association with exercise addiction and food intolerances are lacking. Therefore, the aim of this cross-sectional study was to investigate the association between DE, exercise addiction and food intolerances in athletes at risk of LEA compared to those with low risk. Female endurance athletes, 18-35 years, training ≥5 times/week were recruited in Norway, Sweden, Ireland, and Germany. Participants completed an online-survey comprising the LEA in Females Questionnaire (LEAF-Q), Exercise Addiction Inventory (EAI), Eating Disorder Examination Questionnaire (EDE-Q), and questions regarding food intolerances. Of the 202 participants who met the inclusion criteria and completed the online survey, 65% were at risk of LEA, 23% were at risk of exercise addiction, and 21% had DE. Athletes at risk of LEA had higher EDE-Q and EAI scores compared to athletes with low risk. EAI score remained higher in athletes with risk of LEA after excluding athletes with DE. Athletes at risk of LEA did not report more food intolerances (17 vs. 10%, P = 0.198), but were more frequently reported by athletes with DE (28 vs. 11%, P = 0.004). In conclusion, these athletes had a high risk of LEA, exercise addiction, and DE. Exercise addiction should be considered as an additional risk factor in the prevention, early detection, and targeted treatment of RED-S among female endurance athletes.

Eating disorder examination questionnaire (EDE-Q): validity and norms for Saudi nationals

PURPOSE

The aim of this study was to develop an Arabic version of the EDE-Q and to assess its psychometric properties and utility as a screener in the Saudi population. An additional aim was to establish EDE-Q norms for Saudis.

METHOD

EDE-Q data were collected in a convenience sample of the Saudi community (N = 2690), of which a subset was also subjected to the EDE interview (N = 98). Various models for the factor structure were evaluated on their fit by CFA. With ROC analysis, the AUC was calculated to test how well the EDE-Q discriminated between Saudis at high and low risk for eating disorders.

RESULTS

The original four factor model of the EDE-Q was not supported. Best fit was found for a three factor model, including the weight/shape concern scale, dietary restraint scale and eating concern scale. The ROC analysis showed that the EDE-Q could accurately discriminate between individuals at high and low risk for an eating disorder according to the EDE interview. Optimal cut off of 2.93 on the global score yielded a sensitivity of 82% and specificity of 80%. EDE-Q scores were fairly associated with BMI.

DISCUSSION

Psychometric characteristics of the Saudi version of the EDE-Q were satisfactory and results support the discriminant and convergent validity. Severity level of eating disorder pathology can be determined by the EDE-Q global score. Global scores were high compared to what is found in Western community samples, leading to high prevalence estimates for Saudis at high risk for eating disorders.

LEVEL OF EVIDENCE

Not applicable, empirical psychometric study.

The first 20 weeks of pregnancy is a high-risk period for eating disorder relapse

OBJECTIVE

Eating disorders (ED) are associated with adverse pregnancy outcome and pregnancy is associated with both relapse and remission of ED. Knowledge is lacking on the risk of ED relapse during pregnancy and the postpartum period for women in stable remission. This study examined the occurrence of perinatal ED relapse as well as obstetric and postpartum outcome in women with at least a 6-month ED remission before pregnancy.

METHOD

A total of 122 women in stable remission before pregnancy were included in a prospective longitudinal study. Changes in ED symptoms based on the Eating Disorder Examination were systematically evaluated at each antenatal visit and in the postpartum period.

RESULTS

A total of 30 (25%) women relapsed. Twenty women relapsed within the first 20 weeks of pregnancy and eight in the early weeks postpartum. Severe postpartum depression symptoms (33%) were frequent in women with ED relapse; hyperemesis gravidarum (30%) was frequently present independent of the woman's relapse status.

DISCUSSION

To prevent relapse of ED and possible consequences, attention to relapse in women in stable remission is especially important in early pregnancy and in the postpartum period.

Adaptation and validation of the Eating Disorder Examination-Questionnaire in English among urban Indian adolescents

OBJECTIVE

Eating pathology is a salient issue in India, with clinical features reported among adults and adolescents. However, there are currently no validated measures of disordered eating in the Indian context. The present study therefore aimed to validate a culturally appropriate English language version of the Eating Disorder Examination Questionnaire (EDE-Q), a widely used measure, among adolescents in India.

METHOD

We adapted and examined the factor structure, reliability, and construct validity of the EDE-Q among an urban sample of 1,413 Indian adolescents (mean age = 13 years; 45% girls).

RESULTS

In contrast to the original four-factor model, exploratory factor analysis identified a two-factor solution for girls and boys, which was verified by confirmatory factor analysis; a "Preoccupation and Control" subscale and a "Weight and Shape Concerns" subscale. The total scale comprised 15 items for girls and 18 items for boys. Test-retest reliability and internal consistency were satisfactory for the girls' and boys' scales (Cronbach's α = .91 for both) and their comprising subscales (αs ≥ .80). Concurrent validity was established through medium-high significant correlations with measures of body image and internalization of appearance ideals. Combining items common to both versions of the scale led to a psychometrically acceptable model which was largely invariant across both genders, thus facilitating gendered comparison.

DISCUSSION

Findings indicate the reliability and validity of the EDE-Q among English-speaking urban Indian adolescents. This will facilitate further research examining the prevalence and nature of eating pathology among adolescents in India.

The Presentation of Eating Disorders in Saudi Arabia

Objective: There is lack of information on the presentation of eating disorders (EDs) in Saudi Arabia using gold standard clinical tools. The present study aimed to provide data on the presentation of EDs in Saudi Arabia using clinically validated measures.

Method: Hundred and thirty-three individuals (33 male) with a mean age of 22 years (2.63) completed three measures: the Eating Disorder Examination (EDE), a semi-structured interview, the Eating Disorder Examination Questionnaire (EDE-Q), a self-report measure, and the Depression Anxiety and Stress Scale (DASS-21) to measure comorbid symptoms.

Results: Individuals in Saudi Arabia reported higher levels of restraint, eating concern and shape concern and a higher global score, but lower levels of weight concern on the EDE-Q compared to the EDE. Female participants reported a higher global score, alongside significantly higher scores on the restraint, shape concern and weight concern subscales than males. The most common ED subtype was other specific feeding or ED. Compared with Western community samples, symptom severity in this purposive sample obtained from community settings was significantly higher in this sample.

Discussion: Individuals with eating, weight and shape concerns in Saudi Arabia may feel more comfortable expressing their symptoms on a self-report tool compared with a face to face interview. However, it is possible that a self-report measure may over-estimate the severity of symptoms. The data suggest that clinicians in Saudi Arabia should regularly screen for EDs in all genders. It is also important to note that ED symptoms are a cause for concern in young people in Saudi Arabia.

Female Body Dissatisfaction and Attentional Bias to Body Images Evaluated Using Visual Search

One factor, believed to predict body dissatisfaction is an individual’s propensity to attend to certain classes of human body image stimuli relative to other classes. These attentional biases have been evaluated using a range of paradigms, including dot-probe, eye-tracking and free view visual search, which have yielded a range of – often contradictory – findings. This study is the first to employ a classic compound visual search task to investigate the relationship between body dissatisfaction and attentional biases to images of underweight and with-overweight female bodies. Seventy-one undergraduate females, varying their degree of body dissatisfaction and Body Mass Index (BMI), searched for a horizontal or vertical target line among tilted lines. A separate female body image was presented within close proximity to each line. On average, faster search times were obtained when the target line was paired with a uniquely underweight or with-overweight body relative to neutral (average weight only) trials indicating that body weight-related images can effectively guide search. This congruent search effect was stronger for individuals with high eating restraint (a behavioral manifestation of body image disturbance) when search involved a uniquely underweight body. By contrast, individuals with high BMIs searched for lines more rapidly when paired with with-overweight rather than underweight bodies, than did individuals with lower BMIs. For incongruent trials – in which a unique body was paired with a distractor rather than the target – search times were indistinguishable from neutral trials, indicating that the deviant bodies neither compulsorily “captured” attention nor reduced participants’ ability to disengage their attention from either underweight or with-overweight bodies. These results imply the existence of attentional strategies which reflect one’s current body and goal-directed eating behaviors.

Binge Eating Disorder in Patients with Type 2 Diabetes: Diagnostic and Management Challenges

Type 2 diabetes mellitus (T2DM) is associated with an increased risk of disordered eating behaviors including binge eating disorder (BED). Comorbid BED in patients with T2DM has been associated with adverse clinical outcomes such as higher body mass index (BMI) and depressive symptoms. Identifying and addressing this disorder in patients with T2DM is a significant challenge for health-care providers. The purpose of this narrative review is to discuss current perspectives on BED in the context of T2DM with implications for screening and management of these highly comorbid conditions. BED continues to be underrecognized and underdiagnosed. However, there are established tools that providers can use to screen for BED such as the SCOFF Questionnaire and Questionnaire on Eating and Weight Patterns-5. There are several effective treatments for BED including cognitive behavioral therapy, interpersonal therapy, and lisdexamfetamine dimesylate. However, few studies have examined the effects of these treatments in patients with co-morbid T2DM and BED.

Disordered Eating Behaviours and Eating Disorders in Women in Australia with and without Polycystic Ovary Syndrome: A Cross-Sectional Study

Psychological co-morbidities common in polycystic ovary syndrome (PCOS) may contribute to disordered eating and subsequent weight gain. This cross-sectional study aimed to determine the prevalence of disordered eating and a range of eating disorders and demographic risk factors associated with these behaviours within an Australian group of women with and without PCOS. Data from 899 women with (n = 501) and without (n = 398) PCOS were analysed as possibly indicative of disordered eating or eating disorders using the Eating Disorder Examination Questionnaire (EDE-Q) and The Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5) criteria. Disordered eating (p = 0.012) but not eating disorders (p = 0.076) were more prevalent in women with PCOS compared to controls. Increased body mass index (BMI) [Odds Ratio (OR): 1.03; 95%; Confidence Interval (CI): 1.01, 1.05, p = 0.012] and older age [OR: 1.05; 95%CI: 1.02, 1.08, p = 0.002] but not PCOS diagnosis [OR: 1.43; 95%CI: 0.96, 2.13 p = 0.078] increased the odds of disordered eating. Increased BMI [OR: 1.04; 95%CI: 1.02, 1.06, p < 0.001] and younger age [OR: -0.95; 95%CI: 0.93–0.95, p < 0.001] but not PCOS diagnosis [OR: 1.38; 95%CI: 0.97, 1.95, p = 0.076] increased the odds of an eating disorder. Clinicians are recommended to screen all women with PCOS for possible disordered eating behaviours, with particular attention to women with elevated BMI.

The feasibility of a binge eating intervention in Black women with obesity

INTRODUCTION

U.S. Black women have the highest rates of obesity and report frequent binge eating behaviors. To our knowledge, no intervention research has aimed to treat binge eating specifically among Black women. The purpose of this study was to investigate the feasibility and preliminary effect of Appetite Awareness Treatment (AAT), an 8-week cognitive-behavioral binge eating intervention, among Black women with obesity, and who report binge eating.

METHODS

Participants (N = 31), had a mean (±SD) age of 48.8 ± 12.8 years, a body mass index of 33.7 ± 3.9 kg/m², and reported at least one binge eating episode monthly over the last three months. Using a randomized controlled trial design, Black women were randomized to AAT or a wait-list control group (WAIT) group. We examined recruitment, attendance, retention, and adherence. Linear mixed models explored preliminary differences between the AAT and WAIT on the primary outcome variables of binge eating and eating self-efficacy measured at baseline and 8-weeks.

RESULTS

Approximately one-third of screened participants were eligible and did enroll. Participants completed 55% of homework assignments, and attended 59% of intervention sessions. Retention to AAT was 87.5%. Compared to participants in the WAIT group, AAT participants had greater decreases in binge eating scores and greater improvements in eating self-efficacy scores at the end of Week 8.

CONCLUSION

Results suggest that AAT is feasible among Black women with binge eating behaviors, with evidence of preliminary efficacy, providing a rationale for a trial of AAT in a larger sample of Black women.

Psychometric Properties of the Eating Disorder Examination–Questionnaire (EDE-Q): A Confirmatory Factor Analysis and Assessment of Measurement Invariance by Sex

The original, theoretically derived factor structure of the Eating Disorder Examination–Questionnaire (EDE-Q) has received limited empirical support and there is no consensus on an appropriate alternative. Moreover, there is a paucity of data on the factor structure of the EDE-Q across sexes. The goals of the current study were to evaluate models of the EDE-Q factor structure and to assess the best-fitting model for differences by sex. Twelve models were compared using confirmatory factor analysis in a sample of 940 undergraduates. Confirmatory factor analysis did not support the original factor structure. A four-factor model fit the data reasonably well with factors corresponding to themes of (a) dietary restraint, (b) preoccupation and restriction, (c) weight and shape concern, and (d) eating shame. The EDE-Q was found to be invariant by sex across all factors except Factor 3. The implications of these findings are discussed.

The Eating Disorder Examination Questionnaire: reliability and validity of the Italian version

PURPOSE

To examine the validity and reliability of a new Italian language version of the latest edition of the Eating Disorder Examination Questionnaire (EDE-Q 6.0).

METHODS

The sixth edition of the EDE-Q was translated into Italian and administered to 264 Italian-speaking inpatient and outpatient (257 females in their mid-20s) with eating disorder (75.4% anorexia nervosa) and 216 controls (205 females).

RESULTS

Internal consistency was high for both the global EDE-Q and all subscale scores. Test-retest reliability was good to excellent (0.66-0.83) for global and subscale scores, and for items assessing key behavioral features of eating disorders (0.55-0.91). Patients with an eating disorder displayed significantly higher EDE-Q scores than controls, demonstrating the good criterion validity of the tool. Confirmatory factor analysis revealed a good fit for a modified seven-item three-factor structure.

CONCLUSIONS

The study showed the good psychometric properties of the new Italian version of the EDE-Q 6.0, and validated its use in Italian eating disorder patients, particularly in young females with anorexia nervosa.

Measurement invariance of the Eating Disorder Examination in black and white children and adolescents

OBJECTIVE

The Eating Disorder Examination (EDE) was originally developed and validated in primarily white female samples. Since data indicate that eating pathology impacts black youth, elucidating the psychometric appropriateness of the EDE for black youth is crucial.

METHODS

A convenience sample was assembled from seven pediatric obesity studies. The EDE was administered to all youth. Confirmatory factor analyses (CFA) were conducted to examine the original four-factor model fit and two alternative factor structures for black and white youth. With acceptable fit, multiple-group CFAs were conducted. For measurement invariant structures, the interactive effects of race with sex, BMIz, adiposity, and age were explored (all significance levels p < .05).

RESULTS

For both black and white youth (N = 820; 41% black; 37% male; 6-18 years; BMIz -3.11 to 3.40), the original four-factor EDE structure and alternative eight-item one-factor structure had mixed fit via CFA. However, a seven-item, three-factor structure reflecting Dietary Restraint, Shape/Weight Overvaluation, and Body Dissatisfaction had good fit and held at the level of strict invariance. Girls reported higher factor scores than boys. BMIz and adiposity were positively associated with each subscale. Age was associated with Dietary Restraint and Body Dissatisfaction. The interactional effects between sex, BMIz, and age with race were not significant; however, the interaction between adiposity and race was significant. At higher adiposity, white youth reported greater pathology than black youth.

CONCLUSION

An abbreviated seven-item, three-factor version of the EDE captures eating pathology equivalently across black and white youth. Full psychometric testing of the modified EDE factor structure in black youth is warranted.

Acculturation and Eating Disorders in a Mexican American Community Sample

Our purpose was to investigate acculturation and eating disorders by examining the role of ethnic identity and by utilizing a bidimensional perspective toward two cultures. We predicted that orientation toward European American culture and lower ethnic identity would be positively associated with eating disorders. Participants were 188 Mexican American women recruited from the community (79 with eating disorders and 109 control women). The Structured Clinical Interview for DSM-IV-TR and Eating Disorder Examination were used to establish diagnoses. The Acculturation Rating Scale for Mexican Americans–II and the Multigroup Ethnic Identity Measure assessed Anglo orientation, Mexican orientation, and ethnic identity. Orientation toward Anglo American culture was significantly associated with eating disorders, whereas orientation toward Mexican culture and strength of ethnic identity were not associated with eating disorder status. Findings point to the role of Anglo cultural orientation in the development of eating disorders and underscore the need for future research to utilize bidimensional models.

Sexual Abuse and Eating Disorders in a Community Sample of Mexican American Women

The purpose of this study was to examine the association between sexual abuse and eating disorders in a voluntary community sample of Mexican American women. Eighty eating disorder cases were compared to 110 healthy controls on presence of sexual abuse and on characteristics of the abuse. The Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision) and the Eating Disorder Examination were used to determine diagnoses and psychiatric comorbidity. Results indicated that compared to controls, cases were more likely to report sexual abuse and had experienced more instances and longer duration of abuse. For the majority of cases, sexual abuse occurred before onset of eating disorder symptoms. There was no relationship between sexual abuse and type of eating disorder or psychiatric comorbidity. Sexual abuse seems to be a risk factor for disordered eating in Mexican Americans. Prolonged abuse and revictimization may increase this risk.

Classifying symptom change in eating disorders: clinical significance metrics for the Change in Eating Disorder Symptoms Scale

The purpose of this study was to determine clinically significant change criteria and change trajectories for the Change in Eating Disorder Symptoms Scale (CHEDS). Participants included non-eating disordered (n=95) and eating disordered (n=58) samples. The clinical sample was undergoing enhanced cognitive-behavior therapy (CBT-E) for eating disorders. Reliable change indices (RCI), cutscores, and change trajectories were calculated. CHEDS total score RCI was 12 points while the cutscore between eating disordered and non-eating disordered groups was 65. Trajectory models for benchmarking were successfully derived based on initial scores. The change indices and trajectories permit session-by-session analyses and benchmarking of change. These empirically-calibrated indices of patient change and progress allow for empirically-guided treatment decision-making.

The eating disorder examination: reliability and validity of the Italian version

OBJECTIVE

To examine the psychometric characteristics of the Italian language version of the latest edition of the eating disorder examination (EDE).

METHODS

An Italian version of the EDE (17th edition) was designed and administered to 185 in- and outpatients with eating disorders and 60 age-matched controls. Its internal consistency, inter-rater reliability, short-term (7-23 days) test-retest reliability and criterion validity were evaluated.

RESULTS

Internal consistency was high for all four original EDE subscales. Inter-rater reliability was excellent for global EDE scores and original subscales (≥0.93), and for eating disorder behaviours (≥0.89). Test-retest reliability was good for global EDE scores and original subscales (0.57-0.80), objective bulimic episodes and days, vomiting episodes, laxative and diuretic misuse episodes, and excessive exercising (≥0.82), but unsatisfactory for subjective bulimic episodes and days. Patients with eating disorders displayed significantly higher EDE scores than age-matched controls, demonstrating the good criterion validity of the instrument.

CONCLUSIONS

The Italian version of the EDE 17.0D has adequate psychometric properties and can therefore be recommended for examining Italian patients with eating disorders in clinical and research settings.

Examining the associations between overeating, disinhibition, and hunger in a nonclinical sample of college women

BACKGROUND

Binge eating (BE) has long been identified as a correlate of overweight and obesity. However, less empirical attention has been given to overeating with and without loss of control (LOC) in nonclinical samples.

PURPOSE

The goal of the present study was to examine the association of (1) established correlates of BE, namely, weight and shape concerns, dietary restraint, and negative affect, and (2) three additional correlates, disinhibition, hunger, and interoceptive awareness (IA), to overeating in a nonclinical sample of college women.

METHOD

Female students (n = 1,447) aged 18 to 21 years recruited from colleges in three Canadian metropolitan areas completed self-report questionnaires in class to assess sociodemographic and anthropomorphic characteristics, overeating, LOC, dietary restraint, negative affect, weight and shape concerns, IA, disinhibition, and hunger.

RESULTS

The established correlates of BE were significant correlates of all types of overeating and explained 33 % of the variance. Disinhibition was the most strongly associated correlate of overeating.

CONCLUSIONS

Findings suggest that established correlates of BE are associated with other types of overeating such as objective overeating (OOE), as are disinhibition and hunger.

Self-objectification, body image disturbance, and eating disorder symptoms in young Australian children

Self-objectification has been examined extensively in adult populations. Despite theoretical evidence suggesting that children may also be vulnerable to experiencing self-objectification, whether children do self-objectify has not been determined. Accordingly, the present study examined the degree to which children self-objectify. The prevalence of body image and eating disturbances in this population, and the relationship between self-objectification and these disturbances, were also investigated. Results from over 250 boys and girls aged 6-11 years revealed that young girls report levels of self-objectification that are similar to those observed among older girls and women. Self-objectification was also found to be meaningfully related to body image and eating disturbances in children. A significant proportion of children reported body dissatisfaction and a minority engaged in disordered eating behaviours in the four weeks prior to the assessment. These results suggest that children may be at risk of experiencing the negative psychological outcomes associated with self-objectification.

Maternal and family factors and child eating pathology: risk and protective relationships

BACKGROUND

Previous studies have found associations between maternal and family factors and child eating disorder symptoms. However, it is not clear whether family factors predict eating disorder symptoms specifically, or relate to more general child psychopathology, of which eating disorder symptoms may be one component. This study aimed to identify maternal and family factors that may predict increases or decreases in child eating disorder symptoms over time, accounting for children's body mass index z-scores and levels of general psychological distress.

METHODS

Participants were 221 mother-child dyads from the Childhood Growth and Development Study, a prospective cohort study in Western Australia. Participants were assessed at baseline, 1-year follow-up and 2-year follow-up using interview and self-report measures. Children had a mean age of 10 years at baseline and 46% were male. Linear mixed models and generalised estimating equations were used to identify predictors of children's eating disorder symptoms, with outcome variables including a global index of eating disorder psychopathology, levels of dietary restraint, levels of emotional eating, and the presence of loss of control ('binge') eating.

RESULTS

Children of mothers with a current or past eating disorder reported significantly higher levels of global eating disorder symptoms and emotional eating than other children, and mothers with a current or past eating disorder reported significantly more concern about their children's weight than other mothers. Maternal concern about child weight, rather than maternal eating disorder symptoms, was significant in predicting child eating disorder symptoms over time. Family exposure to stress and low maternal education were additional risk factors for eating disorder symptoms, whilst child-reported family satisfaction was a protective factor.

CONCLUSIONS

After adjusting for relevant confounding variables, maternal concern about child weight, children's level of family satisfaction, family exposure to stress, and maternal education are unique predictors of child eating disorder symptoms.

Overt and covert aggression in college women with bulimia nervosa

OBJECTIVE

This study examines the prevalence of overt and covert aggression in women with bulimia nervosa (BN) as well as the relationship between the severity of BN and the frequency of aggressive acts.

PATIENTS AND METHODS

20 female college students with BN and 20 control subjects completed self-report measures of aggressive behavior and eating disorder pathology. They also completed the Juvenile Health and Wellness Survey-76 to assess general risk taking and indices of sexual behavior and mental health.

RESULTS

BN subjects reported higher levels of both overt and covert aggression (p < .001). Overt aggression tended to be more premeditated, while the self-report of covert aggression behavior was more impulsive. Levels of aggressive behavior were significantly correlated with severity of BN (p < .01). Subjects with BN reported higher levels of risk-taking and sexual behaviors.

CONCLUSIONS

Aggression is an important clinical issue in BN. Subtypes of aggression suggest different pathways for overt and covert aggressive acts with impulsive covert aggression being more closely related to the binge-purge cycle. Awareness of subtypes of aggression in BN may have important clinical and treatment implications.

The dual-pathway and cognitive-behavioural models of binge eating: prospective evaluation and comparison

To evaluate and compare the dual-pathway, original cognitive-behavioural, and enhanced "transdiagnostic" cognitive-behavioural models of binge eating, using prospective data from a pre-adolescent sample. Models were tested using multilevel longitudinal structural equation modelling. Participants were 236 children (48% male) aged between 8 and 13 years at baseline, who were interviewed annually over a 2-year period. Binge eating was assessed using the Child Eating Disorder Examination. The dual-pathway and enhanced cognitive-behavioural models provided an acceptable fit to the data, whereas the original cognitive-behavioural model did not. Partial support is provided for the prospective validity of the dual-pathway and enhanced cognitive-behavioural models of binge eating in childhood. Results suggest that body dissatisfaction and weight and shape over-evaluation may both contribute to dieting behaviour in youth, and that dieting and affect-related difficulties both require consideration in theories of binge eating development.

Confirmatory factor analysis of the Eating Disorder Examination-Questionnaire (EDE-Q)

OBJECTIVE

To compare the goodness-of-fit of five models of Eating Disorder Examination-Questionnaire (EDE-Q) data, in clinical and community samples.

METHOD

The EDE-Q was administered to 228 eating disorder patients and 211 non-eating disordered university students. Confirmatory factor analysis was used to compare the validity of the original four EDE-Q subscales with that of brief one-factor, extended one-factor, two-factor, and three-factor models. Measurement invariance across the two samples was considered.

RESULTS

The only model to provide an acceptable fit to the data was the brief one-factor model consisting of eight Weight and Shape Concern items. Scores on this scale correlated highly with the original EDE-Q subscales.

CONCLUSION

The reliability of the EDE-Q may be increased if a modified scoring system is used. This complements findings from recent research with the Eating Disorder Examination (EDE).

The factor structure of the eating disorder examination in clinical and community samples

OBJECTIVE

To assess the factor structure of the Eating Disorder Examination (EDE) in three different samples and to compare the goodness-of-fit of five models of EDE data.

METHOD

The EDE was administered to eating disordered (n = 158), treatment-seeking obese (n = 170) and non-eating disordered community-based (n = 329) participants. Confirmatory factor analysis was used to compare the validity of the original four-factor EDE model with that of three-, two-, and one-factor models.

RESULTS

None of the tested models provided a "good fit" to the data in any sample, with the exception of a brief one-factor model in the eating disorder group. Estimations of internal consistency, reliability, and validity were superior for the one-, two-, and three-factor models compared to the four-factor model in all samples.

DISCUSSION

Overall, there was more support for a one-factor model of EDE data than for a multi-factorial model. It may be more appropriate to use Global EDE scores than individual subscale scores for research purposes.

Randomized controlled clinical trial of yoga in the treatment of eating disorders

PURPOSE

This was a pilot project designed to assess the effect of individualized yoga treatment on eating disorder outcomes among adolescents receiving outpatient care for diagnosed eating disorders (anorexia nervosa, bulimia nervosa, eating disorder not otherwise specified).

METHODS

A total of 50 girls and 4 boys aged 11-21 years were randomized to an 8-week trial of standard care vs. individualized yoga plus standard care. Of these, 27 were randomized to standard care and 26 to yoga plus standard care (attrition: n = 4). Standard care (every other week physician and/or dietician appointments) was required to meet ethical guidelines. The No Yoga group was offered yoga after study completion as an incentive to maintain participation. Outcomes evaluated at baseline, end of trial, and 1-month follow-up included Eating Disorder Examination (EDE), Body Mass Index (BMI), Beck Depression Inventory, State-Trait Anxiety Inventory, and Food Preoccupation questionnaire.

RESULTS

The Yoga group demonstrated greater decreases in eating disorder symptoms. Specifically, the EDE scores decreased over time in the Yoga group, whereas the No Yoga group showed some initial decline but then returned to baseline EDE levels at week 12. Food preoccupation was measured before and after each yoga session, and decreased significantly after all sessions. Both groups maintained current BMI levels and decreased in anxiety and depression over time.

CONCLUSIONS

Individualized yoga treatment decreased EDE scores at 12 weeks, and significantly reduced food preoccupation immediately after yoga sessions. Yoga treatment did not have a negative effect on BMI. Results suggest that individualized yoga therapy holds promise as adjunctive therapy to standard care.

The onset and course of binge eating in 8- to 13-year-old healthy weight, overweight and obese children

OBJECTIVES

This study aimed to (1) determine the prevalence of binge eating and overeating in 8- to 13-year-old children; (2) identify factors that cross-sectionally predict binge eating and overeating; and (3) identify factors that prospectively predict onset of binge eating and overeating.

METHODS

Participants were 259 boys and girls who were assessed at baseline and one-year follow-up, using a range of semi-structured interviews that included the Child Eating Disorder Examination.

RESULTS

At baseline, 9% of children reported binge eating and 6% reported overeating. Obese children were most at risk for these behaviours. Dietary restraint and the tendency to use food to regulate emotions were significant in predicting binge eating onset prospectively, and eating concern was significant in predicting binge eating cross-sectionally.

CONCLUSION

Results provide support for current cognitive-behavioural models of binge eating, and have implications for guiding binge eating prevention and intervention efforts with children.

Help seeking and barriers to treatment in a community sample of Mexican American and European American women with eating disorders

OBJECTIVE

The study examined treatment seeking for eating disorders in Mexican American and European American women.

METHOD

One hundred forty-five women with eating disorders (76 Mexican American, 69 European American) were diagnosed using the Structured Clinical Interview for DSM-IV-TR (SCID-IV) and Eating Disorder Examination (EDE).

RESULTS

Only 28% of the sample reported having sought treatment for their eating problems and only 17% had received treatment. Both groups were equally likely to believe they have significant eating problems and to want help. However, Mexican Americans were less likely to have sought treatment and, having sought help, were less likely to have been diagnosed or treated. European Americans were more likely to have utilized psychotherapists, psychiatrists, and psychotropic medications, whereas Mexican Americans largely had sought help from general practitioners for weight concern. The two groups endorsed similar barriers to treatment seeking.

CONCLUSION

Results support clinical impressions that eating disorders largely go undetected and untreated. Nonspecialists may be likely to fail to detect eating disorders.

Prevalence of eating disorders in Latina adolescents: associations with substance use and other correlates

PURPOSE

To estimate the occurrence and correlates of anorexia nervosa and bulimia nervosa-related symptoms in a Latina sample of U.S. adolescents.

METHOD

Approximately 1866 Latinas ranging in age from 11-20 years old are included in this study. These adolescents are a sub-sample from the National Longitudinal Survey on Adolescent Health. Along with self-reports of eating disorder-related variables, we measured related biological, contextual, behavioral, and psychosocial correlates, including use of various substances.

CONCLUSION

Chi-square analysis showed the prevalence in all Latina sub-groups was relatively consistent with the U.S. trends. Latinas of higher socioeconomic status were more at risk for eating disorders. Body dissatisfaction, negative affectivity, substance use, and low self-esteem were all positively correlated with eating disorder symptoms. These results suggest screening and treatment services are needed across groups of Latina adolescents.

The Association Between Patient Characteristics and the Therapeutic Alliance in Cognitive-Behavioral and Interpersonal Therapy for Bulimia Nervosa

The therapeutic alliance is an established predictor of psychotherapy outcome. However, alliance research in the treatment of eating disorders has been scant, with even less attention paid to correlates of alliance development. The goal of this study was to examine the relation between specific patient characteristics and the development of the alliance in 2 different treatments for bulimia nervosa (BN). Data derive from a large, randomized clinical trial comparing cognitive- behavioral therapy (CBT) and interpersonal therapy (IPT) for BN. Across both treatments, patient expectation of improvement was positively associated with early- and middle-treatment alliance quality. In CBT, baseline symptom severity was negatively related to middle alliance. In IPT, more baseline interpersonal problems were associated with poorer alliance quality at midtreatment.

Comparison of assessments of children's eating-disordered behaviors by interview and questionnaire

OBJECTIVE

In adults, interview methods may detect eating-disordered behaviors more accurately than self-report methods. However, no studies have investigated the relationships between interview and self-report assessments in children. We compared results from the Eating Disorder Examination adapted for Children (ChEDE) with the Adolescent version of the Questionnaire on Eating and Weight Patterns (QEWP-A) and with the Children's Eating Attitude Test (ChEAT) in a nontreatment sample of overweight and normal weight children.

METHOD

The ChEDE, QEWP-A, and ChEAT were administered to 46 overweight (body mass index [BMI] at or above the 85th percentile) and 42 normal weight (BMI at the 15th-85th percentile) children, 10 +/- 1.8 years, recruited from the community.

RESULTS

The ChEDE and QEWP-A were not concordant for the number or type of eating episodes that occurred in the past month. Compared with the ChEDE, the QEWP-A was reasonably specific, but it was not sensitive for the presence of objective (17 % sensitivity, 91% specificity) or subjective bulimic episodes (0 % sensitivity, 89 % specificity) during the past month. ChEDE and ChEAT global scores were significantly related (Kendall's tau = 0.286, p <.001), but specific items assessing guilt in relation to eating and preoccupation with food were not.

DISCUSSION

Although self-report methods of eating disorder assessment in children may provide some general information regarding eating psychopathology in non-treatment-seeking children, they do not accurately reflect the results of a structured interview.