Health service utilization for eating disorders: findings from a community-based study

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.

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.

Mental health first aid for eating disorders: pilot evaluation of a training program for the public

BACKGROUND

Eating disorders cause significant burden that may be reduced by early and appropriate help-seeking. However, despite the availability of effective treatments, very few individuals with eating disorders seek treatment. Training in mental health first aid is known to be effective in increasing mental health literacy and supportive behaviours, in the social networks of individuals with mental health problems. Increases in these domains are thought to improve the likelihood that effective help is sought. However, the efficacy of mental health first aid for eating disorders has not been evaluated. The aim of this research was to examine whether specific training in mental health first aid for eating disorders was effective in changing knowledge, attitudes and behaviours towards people with eating disorders.

METHODS

A repeated measures, uncontrolled trial was conducted to establish proof of concept and provide guidance on the future design of a randomised controlled trial. Self-report questionnaires, administered at baseline, post-training and 6-month follow-up, assessed the effectiveness of the 4-hour, single session, mental health first aid training.

RESULTS

73 participants completed the training and all questionnaires. The training intervention was associated with statistically significant increases in problem recognition and knowledge of appropriate mental health first aid strategies, which were maintained at 6-month follow-up. Sustained significant changes in attitudes and behaviours were less clear. 20 participants reported providing assistance to someone with a suspected eating disorder, seven of whom sought professional help as a result of the first aid interaction. Results provided no evidence of a negative impact on participants or the individuals they provided assistance to.

CONCLUSIONS

This research provides preliminary evidence for the use of training in mental health first aid as a suitable intervention for increasing community knowledge of and support for people with eating disorders to seek appropriate help.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12611001181998.

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.

Mental health impairment associated with eating-disorder features in a community sample of women

BACKGROUND AND AIMS

 Impairment in mental health associated with eating-disorder features was examined in a large, general population sample of women aged 18 to 42 years.

METHOD

 Participants (n = 5255) completed self-report measures of eating-disordered behaviour, mental health functioning, height and weight and socio-demographic information.

RESULTS

The most common eating-disorder features were extreme concerns about weight or shape (14.6%), subjective overeating (12.7%), objective overeating (10.6%) and extreme concerns about dietary intake (10.4%). In multivariable analysis, in which mental health functioning was regressed on eating-disorder features, while also controlling for age and body weight, objective overeating (β  =  -0.07), subjective overeating (β   = -0.07), extreme dietary restriction (β  =  -0.06) and extreme concerns about eating (β  =  -0.04) showed small, but statistically significant associations with mental health impairment, whereas extreme weight or shape concerns showed a very strong association (β  =  -0.24).

CONCLUSIONS

From a clinical perspective, the findings are consistent with the importance attached to the "over-evaluation" of weight or shape as a core component of eating-disorder psychopathology. From a public health perspective, the findings indicate the need to conceive of body dissatisfaction as a target for health promotion in its own right.

Online cognitive-behavioural treatment of bulimic symptoms: a randomized controlled trial

BACKGROUND

Manualized cognitive-behavioural treatment (CBT) is underutilized in the treatment of bulimic symptoms. Internet-delivered treatment may reduce current barriers.

OBJECTIVE

This study aimed to assess the efficacy of a new online CBT of bulimic symptoms.

METHOD

Participants with bulimic symptoms (n = 105) were randomly allocated to online CBT, bibliotherapy or waiting list/delayed treatment condition. Data were gathered at pre-treatment, post-treatment and 1-year follow-up.

OUTCOME MEASURES

The primary outcome measures were the Eating Disorder Examination Questionnaire (EDE-Q) and the frequency of binge eating and purging episodes. The secondary outcome measure was the Body Attitude Test.

RESULTS

Dropout from Internet treatment was 26%. Intention-to-treat ANCOVAs of post-test data revealed that the EDE-Q scores and the frequency of binging and purging reduced more in the online CBT group compared with the bibliotherapy and waiting list groups (pooled between-group effect size: d = 0.9). At 1-year follow-up, improvements in the online CBT group had sustained.

CONCLUSION

This study identifies online CBT as a viable alternative in the treatment of bulimic symptoms.

Community recognition and beliefs about anorexia nervosa and its treatment

OBJECTIVE

Mental Health Literacy (MHL), namely recognition, and beliefs about treatment concerning Anorexia Nervosa (AN) were examined in a community sample of male and female (n = 983) aged 15-94 years.

METHOD

A vignette describing a women suffering from the symptoms of AN was presented, followed by a respondent-based structured interview concerning recognition of the problem and treatment beliefs.

RESULTS

The majority of participants could identify the problem as that of an eating disorder, although only 16.1% could specifically identify it as AN. Many also believed the problem was primarily one of low self-esteem (32.5%). General practitioners and psychiatrists or psychologists were considered the most helpful treatment providers, while obtaining information about the problem and available services, followed by family therapy, were considered the most helpful treatments. Less than one-third of participants believed complete recovery was possible. Better AN MHL was found in younger, higher educated, and metropolitan domiciled females.

DISCUSSION

This study offers encouraging results in regard to AN MHL. In particular, there was moderate regard for the use of mental health specialists in the treatment of the disorder. However, there appears to be a misconception that AN is largely the manifestation of low self-esteem and confusion concerning the distinction between AN and bulimia nervosa. AN MHL was poorer in males and those with higher social and health disadvantage.

A retrospective look at the internal help-seeking process in young women with eating disorders

This qualitative study retrospectively explored the help-seeking process in women with eating disorders. Interviews were conducted with 14 college-age women suffering from anorexia nervosa, bulimia nervosa, or eating disorder NOS. Grounded theory was utilized to develop a preliminary model of the help-seeking process. Participants described a gradual shift from denial to increased awareness of self and the impact of the illness. This core process was transient in nature and influenced by interpersonal feedback, critical incidents, the women's general attitude toward help- seeking, and prior treatment experiences. Implications for clinicians include an increased focus on the transient awareness of self and the illness.

Self-change in eating disorders: is "spontaneous recovery" possible?

A limited series of community studies including non-treatment-seekers has shown that a considerable number of eating disorder patients do not enter the health care system but can be considered "clinically recovered" (remission of major symptoms) if followed up long enough. The possibility of "spontaneous recovery" (overcoming an eating disorder without professional treatment or formal help) often faces scepticism on the part of professionals. Clearly, self-change is an underestimated pathway to recovery from an eating disorder, but open-minded clinicians can learn a lot from it. Active coping and making use of one's "recovery capital" are key features of self-change even if maintenance of change is associated with social support and positive life changes.

Binge Eating Disorder psychopathology in normal weight and obese individuals

OBJECTIVE

Although Binge Eating Disorder (BED) is associated with obesity and unstable weight and the diagnosis was originally predicated with the obese in mind, obesity is not a criterion for BED. In fact, BED is not uncommon in nonobese individuals. The aim of this study was to compare the psychopathology of obese (BMI >30) and nonobese individuals (BMI < 30) with BED.

METHOD

Within a group of 174 individuals diagnosed with BED, 51 (29%) were classified as nonobese and 123 (71%) as obese. The Eating Disorder Examination (EDE) and Beck Depression Inventory (BDI) were administered to assess eating disorder psychopathology and depressive symptoms.

RESULTS

The nonobese BED group was significantly younger and was less likely to receive treatment. The obese group had more concerns about weight and reported more objective binge eating episodes. No differences were found on any other subscales of the EDE or BDI.

DISCUSSION

Our main finding was that there are more similarities than differences between the nonobese and obese individuals with BED. The severity of the psychopathology does not seem to be related to BMI. More awareness of the existence of nonobese individuals with BED is needed. Early detection and treatment may prevent the development of overweight and it's consequences.

Health-service use in women with binge eating disorders

OBJECTIVE

To compare health-care utilization between participants who met DSM-IV criteria for binge eating disorder (BED) and those engaged in recurrent binge eating (RBE) and to evaluate whether objective binge eating (OBE) days, a key measurement for diagnosing BED, predicted health-care costs.

METHOD

We obtained utilization and cost data from electronic medical records to augment patient reported data for 100 adult female members of a large health maintenance organization who were enrolled in a randomized clinical trial to treat binge eating.

RESULTS

Total costs did not differ between the BED and RBE groups (β = -0.117, z = -0.48, p = .629), nor did the number of OBE days predict total costs (β = -0.017, z = -1.01, p = .313).

DISCUSSION

Findings suggest that the medical impairment, as assessed through health care costs, caused by BED may not be greater than impairment caused by RBE. The current threshold number of two OBE days/week as a criterion for BED may need to be reconsidered.

Guided self-help treatment for recurrent binge eating: replication and extension

OBJECTIVE

The aim of this study was to replicate and extend results of a previous blended efficacy and effectiveness trial of a low-intensity, manual-based guided self-help form of cognitive-behavioral therapy (CBT-GSH) for the treatment of binge eating disorders in a large health maintenance organization (HMO) and to compare them with usual care.

METHODS

To extend previous findings, the investigators modified earlier recruitment and assessment approaches and conducted a randomized clinical trial to better reflect procedures that may be reasonably carried out in real-world practices. The intervention was delivered by master's-level interventionists to 160 female members of a health maintenance organization who met diagnostic criteria for recurrent binge eating. Data collected at baseline, immediately posttreatment, and at six- and 12-month follow-ups were used in intent-to-treat analyses.

RESULTS

At the 12-month follow-up, CBT-GSH resulted in greater remission from binge eating (35%, N=26) than usual care (14%, N=10) (number needed to treat=5). The CBT-GSH group also demonstrated greater improvements in dietary restraint (d=.71) and eating, shape, and weight concerns (d=1.10, 1.24, and .98, respectively) but not weight change.

CONCLUSIONS

Replication of the pattern of previous findings suggests that CBT-GSH is a robust treatment for patients with recurrent binge eating. The magnitude of changes was significantly smaller than in the original study, however, suggesting that patients recruited and assessed with less intensive procedures may respond differently from their counterparts enrolled in trials requiring more comprehensive procedures.

Barriers to help-seeking in young women with eating disorders: a qualitative exploration in a longitudinal community survey

Few with eating disorders (EDs) access evidence-based treatments. We conducted a prospective exploration of help-seeking by 57 community women with bulimic-type EDs using the Framework approach of familiarization, identifying themes, indexing, charting and mapping and interpretation. The mean age of the sample was 33 years. Results found women sought help for concerns regarding perceived (over) weight rather than for eating, although many women would have welcomed questions from professionals regarding eating behaviours. Empathy, providing information and hope were considered important features of health professionals to provide a positive experience of help-seeking. Specific personal barriers to treatment included low motivation, fear of stigma, and cost. Greater clinician and community awareness of and action on these issues would likely help close "the gap" for effective help-seeking by those with EDs.

Eating-disordered behavior in Australian and Singaporean women: a comparative study

OBJECTIVE AND METHOD

We used the Eating Disorder Examination Questionnaire (EDE-Q) to compare the specific eating disorder psychopathology of young adult women in Australia (n = 339) and Singapore (n = 164). All participants completed a brief questionnaire that included the EDE-Q, basic socio-demographic information, and self-reported height and weight.

RESULTS

Overall levels of eating disorder psychopathology, as measured by the EDE-Q global score, were very similar. There were also no differences between groups on the EDE-Q subscales. However, analysis at the item level indicated that Singaporean women were more fearful of losing control over their eating, more fearful of gaining weight or becoming fat, and more anxious at the prospect of regularly weighing themselves, than Australian women. Singaporean women were also more likely to report binge eating and laxative misuse, whereas excessive exercise was more common among Australian women. The findings were unaltered when between-group differences in body weight were statistically controlled.

DISCUSSION

The findings provide further evidence that levels of eating disorder psychopathology in some Asian countries may be as high as, if not higher than, those of Western nations. Potentially important differences between different cultural groups may be obscured when the assessment of eating disorder psychopathology is confined to summary-type measures.

A qualitative study of perceived social barriers to care for eating disorders: perspectives from ethnically diverse health care consumers

OBJECTIVE

The study aim was to identify and describe health consumer perspectives on social barriers to care for eating disorders in an ethnically diverse sample.

METHOD

We conducted an exploratory secondary analysis of qualitative data comprising transcripts from semi-structured interviews with past and prospective consumers of eating disorder treatment (n = 32). Transcripts were inputted into NVivo 8 for coding, sorting, and quantifying thematic content of interest within strata defined by ethnic minority and non-minority participants. We then examined the influence of key social barriers-including stigma and social stereotypes-on perceived impact on care.

RESULTS

The majority of respondents (78%) endorsed at least one social barrier to care for an eating or weight concern. Perceived stigma (or shame) and social stereotyping-identified both within social networks and among clinicians-had adversely impacted care for 59% and 19% of respondents, respectively.

DISCUSSION

Social barriers to care for eating and weight related concerns may be prevalent in the U.S. and impact both ethnic minority and non-minority health care consumers.

Cognitive behavioral guided self-help for the treatment of recurrent binge eating

OBJECTIVE

Despite proven efficacy of cognitive behavioral therapy (CBT) for treating eating disorders with binge eating as the core symptom, few patients receive CBT in clinical practice. Our blended efficacy-effectiveness study sought to evaluate whether a manual-based guided self-help form of CBT (CBT-GSH), delivered in 8 sessions in a health maintenance organization setting over a 12-week period by master's-level interventionists, is more effective than treatment as usual (TAU).

METHOD

In all, 123 individuals (mean age = 37.2; 91.9% female, 96.7% non-Hispanic White) were randomized, including 10.6% with bulimia nervosa (BN), 48% with binge eating disorder (BED), and 41.4% with recurrent binge eating in the absence of BN or BED. Baseline, posttreatment, and 6- and 12-month follow-up data were used in intent-to-treat analyses.

RESULTS

At 12-month follow-up, CBT-GSH resulted in greater abstinence from binge eating (64.2%) than TAU (44.6%; number needed to treat = 5), as measured by the Eating Disorder Examination (EDE). Secondary outcomes reflected greater improvements in the CBT-GSH group in dietary restraint (d = 0.30); eating, shape, and weight concern (ds = 0.54, 1.01, 0.49, respectively; measured by the EDE Questionnaire); depression (d = 0.56; Beck Depression Inventory); and social adjustment (d = 0.58; Work and Social Adjustment Scale), but not weight change.

CONCLUSIONS

CBT-GSH is a viable first-line treatment option for the majority of patients with recurrent binge eating who do not meet diagnostic criteria for BN or anorexia nervosa.

Identification and treatment of eating disorders in the primary care setting

Eating disorders, which are associated with a host of adverse medical morbidities, negative psychological sequelae, and considerable reductions in quality of life, should be diagnosed and treated promptly. However, primary care physicians may find it uniquely challenging to detect eating disorders in their early stages, before obvious physical problems arise and while psychological symptoms are subtle. Although psychological symptoms may dominate the presentation, the physician is an integral member of the treatment team and is in a unique role to diagnose and treat eating disorders. This clinical review surveys the eating disorders literature, identified by searching MEDLINE and PubMed for articles published from January 1, 1983, to September 30, 2009, using the following keywords: anorexia nervosa, bulimia nervosa, eating disorders, eating disorders NOS, binge eating, binge eating disorder, and night eating syndrome. This review also focuses on practical issues faced by primary care physicians in the management of these conditions and other issues central to the care of these complex patients with medical and psychiatric comorbid conditions.

Eating disorders "mental health literacy" in low risk, high risk and symptomatic women: implications for health promotion programs

Attitudes and beliefs concerning the nature and treatment of bulimia nervosa (BN) were compared among young adult women at low risk of an eating disorder (n = 332), at high risk (n = 83), or already showing symptoms (n = 94). Participants completed a self-report questionnaire that included a measure of eating disorder symptoms. A vignette of a fictional person suffering from BN was presented, followed by a series of questions addressing the nature and treatment of the problem described. High-risk and symptomatic participants were more likely than low-risk participants to report that they would not approach anyone for advice or help, were they to have BN or a similar problem, because they would not want anyone to know. Symptomatic participants were more likely to believe that someone with BN would be discriminated against, more likely to consider bulimic behaviors to be acceptable, and more likely to view BN as being common among women in the community, than low-risk participants, participants in the high-risk group being intermediate on each of these questions. The findings suggest that the attitudes and beliefs of individuals with eating disorder symptoms differ systematically from those of individuals at high risk, but who do not yet have symptoms, and from those at low risk. They also indicate specific attitudes and beliefs that may need to be addressed in prevention and early intervention programs. The potential benefits of assessing individuals' attitudes and beliefs concerning the nature and treatment of eating-disordered behaviour and tailoring program content accordingly may be worthy of investigation.

Prior use of extreme weight-control behaviors in a community sample of women with binge eating disorder or subthreshold binge eating disorder: a descriptive study

OBJECTIVE AND METHOD

The prior occurrence of regular extreme weight-control behaviors was examined in a community sample of women (n = 27) with binge eating disorder (BED) or subthreshold BED.

RESULTS

Approximately two thirds of participants (65.4%) reported the prior use of either purging at least weekly or nonpurging behaviors three or more times per week, for a period of 3 months or more, whereas 38.5% of participants reported either purging at least twice weekly or nonpurging behaviors five or more times per week. Comparatively few participants (11.1%) had ever met formal diagnostic criteria for BN.

DISCUSSION

Considerable overlap between disorders characterized by binge eating in the absence of extreme weight-control behaviors and those characterized by extreme weight-control behaviors in the absence of binge eating may be apparent when a longitudinal perspective is taken. Caution needs to be exercised in drawing conclusions concerning the extent of this overlap based on any one operational definition of the term "regular extreme weight-control behaviors".

Bulimic eating disorders in primary care: hidden morbidity still?

The current study examined the features of women with bulimic-type eating disorders (n = 24) attending primary care in two smaller urban regions of the USA. The assessment included measures of eating disorder psychopathology, medical comorbidity, impairment in role functioning, potential barriers to treatment and actual use of health services. Eating disorders, primarily variants of bulimia nervosa and binge eating disorder not meeting formal diagnostic criteria, were associated with marked impairment in psychosocial functioning. Although two-thirds of participants recognized a problem with their eating, less than 40% had ever sought treatment from a health professional for an eating or weight problem and only one in ten had sought such treatment from a mental health specialist. Only one-third had ever been asked about problems with eating by a primary care practitioner or other health professional. However, more than 80% had sought treatment from a health professional for symptoms of anxiety or depression. Most reported some degree of discomfort in discussing eating problems with others, and half reported that they would not be truthful about such problems if asked. Having an eating disorder was associated with several chronic medical conditions, including joint pain, gastrointestinal problems and fatigue. Although the small sample size limits any firm conclusions, the findings suggest that the health burden of bulimic-type eating disorders is substantial but remains largely hidden. Efforts may be needed to improve the eating disorders "mental health literacy" of both patients and primary care practitioners in order to facilitate early, appropriate intervention.

Screening for binge eating disorders using the Patient Health Questionnaire in a community sample

OBJECTIVE

To examine the operating characteristics of the Patient Health Questionnaire eating disorder module (PHQ-ED) for identifying bulimia nervosa/binge eating disorder (BN/BED) or recurrent binge eating (RBE) in a community sample and to compare true positive (TP) versus false positive (FP) cases on clinical validators.

METHOD

Two hundred and fifty-nine screen-positive individuals and a random sample of 89 screen negative cases completed a diagnostic interview. Sensitivity, specificity, and positive predictive value (PPV) were calculated. TP and FP cases were compared using t-tests and Chi-square tests.

RESULTS

The PHQ-ED had high sensitivity (100%) and specificity (92%) for detecting BN/BED or RBE, but PPV was low (10 or 19%). TP and FP cases did not differ significantly on frequency of subjective bulimic episodes, objective overeating, restraint, on BMI, and on self-rated health.

DISCUSSION

The PHQ-ED is recommended for use in large populations only in conjunction with follow-up questions to rule out cases without objective bulimic episodes.

Objective and subjective bulimic episodes in the classification of bulimic-type eating disorders: another nail in the coffin of a problematic distinction

We sought to further explore the validity of the distinction between objective bulimic episodes (OBEs) and subjective bulimic episodes (SBEs) in the study of bulimic-type eating disorders. Drawing on data obtained at the second, interview phase of a large-scale epidemiological study, we identified mutually exclusive subgroups of women with bulimic-type eating disorders who engaged in regular OBEs but not SBEs (n = 37) or regular SBEs but not OBEs (n = 52). These subgroups were compared on a wide range of outcomes, including socio-demographic characteristics, current levels of eating disorder psychopathology, general psychological distress and impairment in role functioning, current and lifetime impairment in quality of life specifically associated with an eating problem, (self)-recognition of an eating problem, health service utilization and use of psychotropic medication. The only difference between groups was that participants who reported regular OBEs were heavier than those who reported regular SBEs. The findings converge with those of previous research in suggesting that bulimic-type eating disorders characterized by regular SBEs, but not OBEs, do not differ in any clinically meaningful way from those characterized by regular OBEs, but not SBEs. Inclusion of bulimic-type eating disorders characterized by regular SBEs as a provisional category requiring further research in DSM-V appears warranted.

Eating disorders mental health literacy in Singapore: beliefs of young adult women concerning treatment and outcome of bulimia nervosa

AIM

We examined the eating disorders 'mental health literacy' of young adult women in Singapore.

METHODS

A self-report questionnaire was completed by 255 women recruited from three university campuses. A vignette of a fictional (female) person exhibiting the characteristic features of bulimia nervosa was presented, followed by a series of questions concerning the treatment and outcome of the problem described. A measure of eating disorder symptoms was included in the questionnaire.

RESULTS

Consulting a primary care practitioner, counsellor or psychologist; seeking the advice of a (female) family member or friend; getting advice about diet and nutrition; and taking vitamins and minerals were the interventions most often considered helpful. Participants were less positive about the benefits of psychiatristsand were ambivalent about the use of psychotropic medication. Participants' mothers were most often considered helpful as they are an initial source of help. Among participants with a high level of eating disorder symptoms, recognition of an eating problem was poor. A minority of participants believed that treatment would result in full recovery.

CONCLUSIONS

Aspects of the eating disorders mental health literacy of young Singaporean women may be conducive to low or inappropriate treatment seeking. Health promotion programmes need to target not only at-risk individuals, but also their family members and social circle.

Use of extreme weight-control behaviors in the absence of binge eating with and without subjective bulimic episodes: a community-based study

BACKGROUND AND METHODS

In a community sample of women who reported the use of extreme weight-control behaviors in the absence of binge eating, subgroups of participants who reported (n = 23) and who did not report (n = 42) recurrent subjective bulimic episodes (SBEs) were compared on a range of outcomes, including current levels of eating disorder and comorbid psychopathology.

RESULTS

Participants who reported SBEs had higher levels of eating disorder psychopathology, impairment in role functioning, and general psychological distress, than those who did not. Scores on these measures among participants who reported SBEs were similar to those of eating disorder patients receiving specialist treatment, whereas those of participants who did not have recurrent SBEs tended to be intermediate between eating disorder patients and healthy women.

DISCUSSION

The findings are consistent with the hypothesis that it is the combination of SBEs and extreme weight-control behaviors, rather than extreme weight-control behaviors per se, that indicates clinical significance.

Beliefs about eating and eating disorders

Beliefs about foods and binge eating may influence the development and maintenance of eating disorders and the likelihood that people will seek treatment. We found that the majority of a random sample of members of a large health maintenance organization considered binge eating a problem for which there are effective treatments. Self-reported binge eaters, however, were significantly less likely to agree that there are effective treatments. Two thirds of the sample reported that certain foods are addictive and also believed that strict dieting is an effective means of reducing binge eating. Therapeutic implications of these attitudes are discussed.

Gender difference in the prevalence of eating disorder symptoms

OBJECTIVE

This study examined gender differences in prevalence of eating disorder symptoms including body image concerns (body checking or avoidance), binge eating, and inappropriate compensatory behaviors.

METHOD

A random sample of members (ages 18-35 years) of a health maintenance organization was recruited to complete a survey by mail or on-line. Items were drawn from the Patient Health Questionnaire and the Body Shape Questionnaire.

RESULTS

Among the 3,714 women and 1,808 men who responded, men were more likely to report overeating, whereas women were more likely to endorse loss of control while eating. Although statistically significant gender differences were observed, with women significantly more likely than men to report body checking and avoidance, binge eating, fasting, and vomiting, effect sizes ("Number Needed to Treat") were small to moderate.

DISCUSSION

Few studies of eating disorders include men, yet our findings suggest that a substantial minority of men also report eating disorder symptoms.

Role of antiepileptic drugs in the management of eating disorders

Growing evidence suggests that antiepileptic drugs (AEDs) may be useful in managing some eating disorders. In the present paper, we provide a brief overview of eating disorders, the rationale for using AEDs in the treatment of these disorders and review the data supporting the effectiveness of specific AEDs in the treatment of patients with eating disorders. In addition, the potential mechanisms of action of AEDs in these conditions are discussed. Of the available AEDs, topiramate appears to have the broadest spectrum of action as an anti-binge eating, anti-purging and weight loss agent, as demonstrated in two placebo-controlled studies in bulimia nervosa and three placebo-controlled studies in binge-eating disorder (BED) with obesity. Topiramate may also have beneficial effects in night-eating syndrome and sleep-related eating disorder, but controlled trials in these conditions are needed. The results of one small controlled study suggest that zonisamide may have efficacy in BED with obesity. However, both topiramate and zonisamide are associated with adverse effect profiles that may limit their use in patients with eating disorders. Phenytoin may be effective in some patients with compulsive binge eating, particularly if co-morbid EEG abnormalities are present, but available data are too varied to allow definitive conclusions to be made. Carbamazepine and valproate may be effective in treating patients with bulimia nervosa or anorexia nervosa when they are used to treat an associated psychiatric (e.g. mood) or neurological (e.g. seizure) disorder; otherwise, both agents, particularly valproate, are associated with weight gain. In conclusion, AEDs have an emerging role in the management of some eating disorders.

Objectification Processes and Disordered Eating in British Women and Men

The present study extended the applicability of Objectification Theory to predict disordered eating in British women and men. Participants completed measures of self-objectification, body surveillance, body shame and disordered eating. Path analyses indicated strong support for the theoretical model in women, with body shame fully mediating the relation between self-objectification and disordered eating. Patterns were similar for men with two exceptions; body shame increased with lower self-objectification and disordered eating was directly increased with higher self-objectification. Findings extend Objectification Theory as a useful framework for identifying sociocultural influences on disordered eating in British women and men.

Recruitment for a guided self-help binge eating trial: potential lessons for implementing programs in everyday practice settings

OBJECTIVE

To explore effects of various recruitment strategies on randomized clinical trial (RCT)-entry characteristics for patients with eating disorders within an everyday health-plan practice setting.

METHODS

Randomly selected women, aged 25-50, in a Pacific Northwest HMO were invited to complete a self-report binge-eating screener for two treatment trials. We publicized the trials within the health plan to allow self-referral. Here, we report differences on eating-disorder status by mode and nature of recruitment (online, mail, self-referred) and assessment (comprehensive versus abbreviated) and on possible differences in enrollee characteristics between those recruited by strategy (self-referred versus study-outreach efforts).

RESULTS

Few differences emerged among those recruited through outreach who responded by different modalities (internet versus mail), early-versus-late responders, and those enrolling under more comprehensive or abbreviated assessment. Self-referred were more likely to meet binge-eating thresholds and reported higher average BMI than those recruited by outreach and responding by mail; however, in most respects the groups were more similar than anticipated. Fewer than 1% of those initially contacted through outreach enrolled.

CONCLUSIONS

Aggressive outreach and screening is likely not feasible for broader dissemination in everyday practice settings and recruits individuals with more similar demographic and clinical characteristics to those recruited through more abbreviated and realistic screening procedures than anticipated.

The rising prevalence of comorbid obesity and eating disorder behaviors from 1995 to 2005

OBJECTIVE

To measure the cooccurrence of obesity and eating disorder (ED) behaviors in the South Australian population and assess the change in level from 1995 to 2005.

METHOD

Two independent cross-sectional single stage interview based population surveys were conducted a decade apart. Self-reported height, weight, ED behaviors, and sociodemographics were assessed. Changes between the two time points were analyzed.

RESULTS

From 1995 to 2005 the population prevalence of comorbid obesity and ED behaviors increased from 1 to 3.5%. Comorbid obesity and ED behaviors increased more (prevalence odds ratio (POR) = 4.5; 95% confidence interval (CI) = 95% CI = [2.8, 7.4]; p < .001) than either obesity (POR = 1.6; 95% CI = [1.3, 2.0]; p < .001) or ED behaviors (POR = 3.1; 95% CI = [2.3, 4.1]; p < .001) alone.

DISCUSSION

Comorbid obesity and ED behaviors are an increasing problem in our society. Prevention and treatments efforts for obesity and EDs must consider and address this increasing comorbidity.

Public perceptions of binge eating and its treatment

OBJECTIVE

Attitudes and beliefs concerning a binge eating problem were examined in a community sample of men and women (n = 1031) aged 15 to 94 years.

METHOD

A vignette describing a fictional 32-year-old female obese binge eater was presented, followed by a series of questions concerning the nature and treatment of the problem described.

RESULTS

Most participants believed that binge eating is primarily a problem of low self-esteem or depression. Behavioral weight loss treatment and self-help interventions were the treatments considered most helpful, whereas few participants believed that psychotherapy would be helpful. General practitioners and dieticians were the treatment providers considered most helpful. Most participants were ambivalent about prognosis given treatment and pessimistic about outcome in the absence of treatment.

CONCLUSION

The fact that binge eating is viewed primarily as a problem of negative affect, and that specific psychotherapy is not highly regarded as a treatment, may go some way to explaining why most individuals with binge eating-type disorders do not receive appropriate treatment. The benefits of specific psychotherapy in stabilizing eating behavior and improving quality of life for obese binge eaters need to be communicated to sufferers and to the health professionals they are likely to contact.

Screening for eating disorders in primary care: EDE-Q versus SCOFF

OBJECTIVE AND METHODS

The comparative validity of the Eating Disorder Examination Questionnaire (EDE-Q) (22 items) and SCOFF (five items) in screening for cases of the more commonly occurring eating disorders was examined in a primary care sample of young adult women (n=257). Diagnoses were confirmed in a sub-group of interviewed participants (n=147).

RESULTS

Twenty-five cases, primarily variants of bulimia nervosa (BN) not meeting formal diagnostic criteria, were identified in the interviewed sample. An EDE-Q global score of >or= 2.80 yielded the optimal trade-off between sensitivity (Se) (0.80) and specificity (Sp) (0.80) (positive predictive value (PPV)=0.44), whereas a score of two or more positive responses on the SCOFF was optimal (Se=0.72, Sp=0.73, PPV=0.35). Validity coefficients for both measures varied as a function of participants' age and body weight, although these effects were more pronounced for the SCOFF.

CONCLUSIONS

Both measures performed well in terms of their ability to detect cases and to exclude non-cases of the more commonly occurring eating disorders in a primary care setting. The EDE-Q performed somewhat better than the SCOFF and was more robust to effects on validity of age and weight. These findings need to be weighed against the advantage of the SCOFF in terms of its brevity.