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

The optimal cut-off score of the Eating Attitude Test-26 for screening eating disorders in Japan

PURPOSE

The Eating Attitude Test-26 (EAT-26) is a screening tool for eating disorders (EDs) in clinical and non-clinical samples. The cut-off score was suggested to be varied according to target population. However, no studies have examined the appropriateness of the originally proposed score of 20 for screening DSM-5 eating disorders in Japan. This study aimed to identify an appropriate cut-off score to better differentiate clinical and non-clinical samples in Japan for EDs.

METHODS

The participants consisted of 54 patients with anorexia nervosa restricting type, 58 patients with anorexia nervosa binge-eating/purging type, 37 patients with bulimia nervosa diagnosed according to DSM-5 criteria, and 190 healthy controls (HCs). Welch's t test was used to assess differences in age, body mass index (BMI), and total EAT-26 scores between HCs and patients with EDs. Receiver operating characteristic (ROC) analysis was conducted to identify the optimal cut-off score.

RESULTS

The HCs had significantly higher BMI and lower total EAT-26 mean scores than patients with EDs. The area under the ROC curve was 0.925, indicating that EAT-26 had excellent performance in discriminating patients with EDs from HCs. An optimal cut-off score of 17 was identified, with sensitivity and specificity values of 0.866 and 0.868, respectively.

CONCLUSIONS

The result supports the suggestions that optimal cut-off score should be different according to target populations. The newly identified cut-off score of 17 would enable the identification of patients with EDs who have been previously classified as non-clinical samples in the EAT-26 test.

LEVEL OF EVIDENCE

III: evidence obtained from case-control analytic study.

Eating disorders and related psychological features among Arabs and Jews in Israel: Does culture play a moderating role?

Eating disorders (EDs) have been documented in various cultural settings. A continuous increase in ED' rates among non-Western cultures (e.g., Arab cultures and East-Asian cultures) has been reported. We aimed to investigate the relations among culture, ED symptoms, and psychological features that are highly relevant in EDs through a cultural comparison of three groups. The groups included female university students in Israel with varying levels of exposure to Westernization: 118 Jewish students, 132 Arab students studying at a mixed university with a Jewish majority, and 111 Arab students studying at Sakhnin College, a college for Arab students only. The groups differed significantly on the Conservation Value dimension from the Short Portrait Values Questionnaire. Four psychological features were examined as predictors of ED symptoms: Interoceptive-deficits, Ineffectiveness, Asceticism, and Maturity-fear. The results revealed a comparable prevalence of self-reported ED symptoms among Arabs and Jews, with a small exception for bulimic symptoms, which were less prevalent among those in the Sakhnin group, who also scored lower on Ineffectiveness and higher on asceticism than the other groups. Testing the relations between the four psychological features and ED symptoms revealed that culture played a moderating role in predicting the strength of ineffectiveness and maturity-fear. Ineffectiveness was not a predictor among the Sakhnin group, whereas maturity-fear was not a predictor in the least conservative Jewish group. Asceticism and interoceptive-deficits predicted ED symptoms across all study groups. Our findings indicate that the problem of EDs may be similar among Arab and Jewish women in Israel. Moreover, despite some similarities in the relevance of some ED-related psychological features, other features are moderated by culture.

Body image as a multidimensional concept: A systematic review of body image facets in eating disorders and muscle dysmorphia

Body image disturbance is core to the psychopathology of eating disorders (EDs), and related disorders such as muscle dysmorphia (MD). Global measures of body image fail to quantify specific aspects of body image disturbance that characterizes EDs, and may be differentially associated to outcomes. The aim of this systematic review was to provide an overview of specific body image facets and synthesize findings from controlled studies that compared clinical ED/MD and control-comparison groups in body image disturbance. One-hundred sixty-seven studies met inclusion criteria, and reported on comparisons among 30,584 individuals in 28 body image facets, which were more broadly grouped into evaluative, perceptual, cognitive-affective and motivational categories for the purpose of the present review. Effect sizes were calculated as Cohen's d for every comparison between ED and control groups. Body dissatisfaction (evaluative category) was the most prevalent facet assessed across studies (62 %), and differences between clinical and control groups were the largest in this category, especially for bulimia nervosa (d = 1.37). Scarcity of studies with male and MD clinical samples, and use of single-item and non-validated measures, should encourage development of instruments for body image facets pertinent to EDs and MD that can be validly applied across gender.

The Complicated Relationship between Dieting, Dietary Restraint, Caloric Restriction, and Eating Disorders: Is a Shift in Public Health Messaging Warranted?

The origins of theories specifying dietary restraint as a cause of eating disorders can be traced to the 1970s. This paper will present an overview of the origins of dietary restraint theories and a brief historical review of evidence will be summarized. Recent research will be presented, including the results from the CALERIE Phase 1 study, as well as CALERIE Phase 2, which were NIH-sponsored randomized controlled trials. CALERIE 2 provided a test of the effect of two years of caloric restriction (CR) on the development of eating disorder syndromes and symptoms in comparison to a control group that did not alter eating behavior or body weight. The intervention was effective for inducing a chronic (two-year) reduction in total energy expenditure and increased dietary restraint but did not increase symptoms of eating disorders. The results of this recent investigation and other studies have not provided experimental support for conventional dietary restraint theories of eating disorders. These findings are discussed in terms of potential revisions of dietary restraint theory, as well as the implications for a paradigm shift in public health messaging related to dieting.

Risk factors for anorexia nervosa and bulimia nervosa in Japan and compared to a U.S. sample

OBJECTIVE

This study provides the first systematic investigation of environmental exposure to putative psychosocial risk factors for eating disorders in individuals with AN and BN in Japan. It also provides a comparison of risk factors for the development of AN and BN in Japan versus the United States.

METHOD

Participants in Japan were 96 women with a current DSM-IV AN or BN primary diagnosis (AN, n = 60; BN, n = 36) and 57 women with no current psychiatric diagnosis (NC group). Participants in the United States were 137 women with a current DSM-IV AN or BN primary diagnosis (AN-U.S., n = 71; BN-U.S., n = 66). A standardized semi-structured interview retrospectively assessed exposure to risk factors prior to first symptom onset, which were analyzed using General Linear Model analyses.

RESULTS

Perfectionism and negative affectivity, family relationship issues, and, to a lesser degree, parental psychopathology predicted the emergence of AN and BN in Japan. Physical and sexual abuse and family eating and weight concerns were not significant risk factors in Japan. Compared to their respective diagnostic U.S. groups, the Japanese AN group reported higher levels of individual mental health factors and lower levels of family dieting and family overweight, and the Japanese BN group reported higher levels on individual mental health factors, lower exposure to problems with their parents, and lower exposure to family weight and eating concerns.

DISCUSSION

These country-specific data from Japan contribute to an increasingly nuanced and global understanding of risk factors for eating disorders.

Psychological characteristics and eating attitudes in adolescents with drunkorexia behavior: an exploratory study

PURPOSE

Drunkorexia represents an emerging phenomenon that is still understudied especially among adolescents. The present study aimed to investigate the relation between drunkorexia and psychological characteristics relevant and commonly associated with existing forms of eating disorders.

METHODS

The sample was composed of 849 adolescents (513 boys, 334 girls, 2 unknown; range 14-22) who completed a survey composed of Compensatory Eating and Behaviors in Response to Alcohol Consumption Scale and Psychological scales of the Eating Disorders Inventory-3.

RESULTS

Our findings highlighted that drunkorexia was associated with low self-esteem, personal alienation, interoceptive deficits, emotional dysregulation, and asceticism. Hierarchical multiple regression analysis indicated that difficulties with emotion regulation and ascetic tendencies were significant predictors of drunkorexia among adolescents.

CONCLUSIONS

Our findings suggest the importance for programs preventing drunkorexia to be focused on training adolescents in using more adaptive strategies to manage emotions and accepting both emotional and physical signals without feeling guilty or threatened.

LEVEL OF EVIDENCE

Level V, descriptive study.

Anorexia nervosa and perfectionism: A meta-analysis

OBJECTIVE

Despite the multitude of research surrounding anorexia nervosa (AN) and perfectionism, there is yet to be a thorough investigation comparing perfectionism in those diagnosed with AN and other eating disorders, and other psychiatric diagnoses. The current meta-analysis aimed to explore these comparisons.

METHOD

Following the Preferred Reporting Items or Systematic Reviews Meta Analyses (PRISMA) guidelines, we identified empirical studies that compared maladaptive and/or adaptive perfectionism scores in those diagnosed with AN and either a non-clinical comparison group, people diagnosed with a non-AN ED, or people diagnosed with another psychological disorder (i.e., other DSM diagnoses). In total, we identified 23 studies, comprising 3,561 participants who were all female. Comparison groups extracted from the studies were a non-clinical group, bulimia nervosa (BN) diagnosis group, and another psychological diagnostic group.

RESULTS

When AN maladaptive perfectionism levels were compared against the comparison groups, the results showed that those diagnosed with AN were more perfectionistic compared to the non-clinical group (g = 1.00), and the other psychiatric diagnosis group (g = 0.41). People diagnosed with AN also had higher levels of adaptive perfectionism levels compared to the non-clinical group (g = 1.24). Comparisons between those diagnosed with AN and BN were statistically non-significant for maladaptive perfectionism.

DISCUSSION

Although publication bias potentially affected the psychological diagnosis group comparisons, findings suggest that maladaptive perfectionism is a factor associated with both AN and BN.

Psychometric properties of the eating disorder examination-questionnaire in Japanese adolescents

Background

Although the Eating Disorder Examination Questionnaire version 6.0 (EDE-Q) is one of the most widely used questionnaires for eating disorders in Western countries, no research has addressed the psychometric properties of the EDE-Q in a Japanese sample.

Methods

We explored the factor structure of the EDE-Q and examined the internal consistency of the derived scales for Japanese participants (Study I), the convergent validity with other eating disorder-related psychological measures (Study II) and the distinction between the derived two body image-related factors with psychological measures (StudyIII). The EDE-Q was administered to 1,430 undergraduate students in Study I and in Study II was subsequently assessed by two self-report measures of eating pathology, the Eating Attitudes Test (EAT-26) for 558 undergraduate students and the Eating Disorders Inventory-II (EDI-II) 111. In StudyIII, another 225 undergraduate students participated in an examination of the relationships of the derived body image-related subscales of the EDE-Q with the psychological measures of the Rosenberg Self-Esteem Scale, Beck Depression Inventory, Public Self-Consciousness Scale, and Multidimensional Perfectionism Scale.

Results

Exploratory factor analysis of the EDE-Q identified four meaningful factors. Of the original four EDE-Q factors, “Restriction” and “Eating Concern” were retained. However, the other two factors, “Shape” and “Weight” Concerns, were combined into two different factors: “Fear of Obesity” and “Self-Esteem Based on Shape and Weight”. Internal consistency of the derived four factors was adequate, and the relationships with EDI-II and EAT-26 measures demonstrated convergent validity. Analysis of the distinction between “Fear of Obesity” and “Self-Esteem Based on Shape and Weight” revealed that only “Self-Esteem Based on Shape and Weight” was significantly associated with the measures assessing psychopathology related to eating disorders.

Conclusions

This study describes restructured factors of the EDE-Q that were tested with undergraduate students. The distinction between two factors, “Fear of Obesity” and “Self-Esteem Based on Shape and Weight”, may further the understanding of the psychopathology of the eating disorders of adolescent Japanese subjects to facilitate future developments in research and treatment.

Combination of parity and pre-pregnancy BMI and low birth weight infants among Japanese women of reproductive age

This study aimed to examine the effects of parity and pre-pregnancy body mass index (BMI) on low birth weight (LBW) infants among Japanese women. Participants included 1,518 mothers (mean age 34.0 years) of singleton full-term infants in 2011. The incidence of LBW infants was 7.5% in primiparous women with BMI<18.5 (Group A; n=239), 4.0% in multiparous women with BMI<18.5 (Group B; n=124), 6.0% in primiparous women with 18.5≤BMI<25 (Group C; n=715), and 1.8% in multiparous women with 18.5≤BMI<25 (Group D; n=440). A multivariable logistic regression model revealed that mothers in Group A were more likely to deliver a LBW infant [odds ratio (OR) 6.41, 95% confidence interval (CI), 2.65-15.49] than were mothers in Group D. Being both underweight (OR 1.8, 95% CI: 1.05-3.11) and primiparous (OR 3.41, 95% CI: 1.82-6.44) were independently associated with LBW infants. This study demonstrated that the characteristics of primiparous and underweight in mothers are additively associated with LBW infants.

Autonomy and Submissiveness as Cognitive and Cultural Factors Influencing Eating Disorders in Italy and Sweden: An Exploratory Study

The aim of this exploratory study was to investigate the correlation between cultural and psychological factors in relation to predicting eating disorders in two different non-clinical Italian (n = 61) and Swedish (n = 31) female populations, thought to have different cultures and lifestyles. The Swedish sample would reflect an emancipated model of women pursuing autonomy and freedom but also an ideal of thinness, while the Italian sample would reflect a difficult transition from traditional submissiveness to modern autonomy. Both groups completed self-report instruments assessing cultural values (e.g., collectivism and individualism) and features of eating disorders (e.g., drive for thinness, bulimia, body dissatisfaction, self-esteem, parental criticism and perfectionism). Swedish women were found to display higher levels of bulimia, perfectionism, and individualism than Italian women, while regression analysis showed that in the Italian sample high levels of collectivism were correlated with measures of EDs. The results support the hypothesis that EDs are linked with both modern values of autonomy, independence and emancipation, and situations of cultural transition in which women are simultaneously exposed to traditional models of submission and opportunities for emancipation and autonomy.

Cross-cultural examination of beliefs about the causes of bulimia nervosa among Australian and Japanese females

OBJECTIVE

To identify similarities and differences in beliefs about the causes of Bulimia Nervosa (BN) held by Asian (Japanese) women and Western (Australian) women, and hence, to examine the applicability of belief models of eating disorders (ED) across different cultures.

METHOD

Four hundred three Japanese and 256 Australian female university students (aged 17-35 years) completed a questionnaire that gauged beliefs about the causes of BN.

RESULTS

Among the Australian women, the four-component structure of perceived causes (dieting and eating practices, family dynamics, socio-cultural pressure, and psychological vulnerability) found in Dryer et al. (2012) was replicated. Among the Japanese women, however, a three-component structure (without the psychological vulnerability component) was obtained. The groups also differed in the causal component they most strongly endorsed, that being socio-cultural pressure for the Australian women, and dieting and eating practices for the Japanese women.

DISCUSSION

The Japanese participants were found to endorse three out of the four Western-based causal explanations for BN, but the relative importance they placed on those explanations differed from that of the Australian participants. Further research is needed, particularly to establish whether Japanese women simply fail to see psychological vulnerability as a viable cause of BN, or there are in fact cultural differences in the extent to which such vulnerability causes BN.

Sociocultural influences on strategies to lose weight, gain weight, and increase muscles among ten cultural groups

This study determined how sociocultural messages to change one's body are perceived by adolescents from different cultural groups. In total, 4904 adolescents, including Australian, Chilean, Chinese, Indo-Fijian, Indigenous Fijian, Greek, Malaysian, Chinese Malaysian, Tongans in New Zealand, and Tongans in Tonga, were surveyed about messages from family, peers, and the media to lose weight, gain weight, and increase muscles. Groups were best differentiated by family pressure to gain weight. Girls were more likely to receive the messages from multiple sociocultural sources whereas boys were more likely to receive the messages from the family. Some participants in a cultural group indicated higher, and others lower, levels of these sociocultural messages. These findings highlight the differences in sociocultural messages across cultural groups, but also that adolescents receive contrasting messages within a cultural group. These results demonstrate the difficulty in representing a particular message as being characteristic of each cultural group.

Typical and atypical anorexia nervosa in a Japanese sample

OBJECTIVE

We examined the existence of nonfat-phobic anorexia nervosa (NFP-AN) and fat-phobic AN, with no evidence of distortions related to body shape and weight (AN-NED), in a Japanese sample and studied eating disorder pathology and psychopathology in NFP-AN and AN-NED.

METHOD

The study participants were 200 (52.2%) women with typical AN, 86 (22.5%) women with NFP-AN, and 97 (25.3%) women with AN-NED. Diagnosis of the three types of AN was made by structured clinical interviews. The Eating Attitudes Test (EAT) and the Eating Disorder Inventory (EDI) were administered to all the participants.

RESULTS

There were significant differences among the three groups in terms of duration of illness, maximum and minimum BMIs and AN subtypes. There was no transition from the NFP-AN and AN-NED groups to the typical AN group during the 2- to 7-year follow-up period. There were significant differences among the three groups in scores of the EAT, the EDI total, and all the subscales of the EDI.

DISCUSSION

Besides typical AN, there were two types of atypical AN in terms of fat phobia and body image disturbance in this Japanese sample. The findings of the current study suggest that there may be significant differences among the three groups in terms of eating disorder pathology and psychopathology.

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

PURPOSE

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Eating Disorder Inventory-2 (EDI-2)

Zusammenfassung. Das Eating Disorder Inventory-2 (EDI-2; Paul & Thiel, 2005 ) ist ein mehrdimensionales psychometrisches Selbstberichtsinstrument zur Erfassung pathologischen Essverhaltens und anderer für Anorexia nervosa (AN) und Bulimia nervosa (BN) relevanter psychopathologischer Variablen bei Erwachsenen. In der vorliegenden Arbeit wird über die bisher noch fehlende Normierung an einer deutschen nicht-klinischen Stichprobe von 1754 SchülerInnen im Alter von 10 bis 20 Jahren (MAlter = 15.8, SD = 1.7) berichtet. Zusätzlich werden erste geschlechtsspezifische Werte für 66 Patientinnen mit AN (MAlter = 16.2, SD = 1.7) und 22 Patientinnen mit BN (MAlter = 16.8, SD = 1.5) beschrieben. Die hier vorgestellten Normen für Kinder und Jugendliche sowie eine bereits vorgenommene psychometrische Evaluation ( Salbach-Andrae et al., 2010 ) ermöglichen zukünftig den Einsatz des EDI-2 in dieser Altersgruppe. Unabhängig von der Antwortversion können interna-tionale Vergleiche anhand geschlechtsspezifischer (und für weibliche Stichproben altersspezifischer) Normen vorgenommen werden.

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

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

Magnetic resonance spectroscopy of the anterior cingulate cortex in eating disorders

The anterior cingulate cortex plays a key role in eating disorders (ED), but it remains an open question whether there are deviations of the neurochemistry of this region in patients with ED. Seventeen adult female patients with ED (10 with bulimia nervosa, 7 with anorexia nervosa) were compared to 14 matched female healthy controls using single voxel magnetic resonance spectroscopy of the anterior cingulate cortex. Group comparisons did not reveal any differences between patients and controls, but a positive correlation between glutamate and myo-inositol signals with "drive for thinness" in patients with bulimia nervosa was found in exploratory correlation analyses.

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.

Psychometrische Gütekriterien des Eating Disorder Inventory (EDI-2) bei Jugendlichen

Ziel der vorliegenden Studie war die Überprüfung der psychometrischen Gütekriterien des deutschsprachigen Eating Disorder Inventory-2 (EDI-2) von Thiel et al. (1997 ) bei Jugendlichen. Es wurden die innere Konsistenz sowie konvergente und diskriminante Validität des EDI-2 an 371 Jugendlichen im Alter zwischen 13 und 18 Jahren überprüft und eine konfirmative Faktorenanalyse durchgeführt. Die Werte der inneren Konsistenzen sind für die Patientengruppe als hoch, für die beiden Kontrollgruppen als noch befriedigend einzustufen. Die Zusammenhänge mit anderen klinischen Messinstrumenten wiesen in die erwartete Richtung und stützen die externe Validität des EDI-2. Mittelwertsvergleiche der einzelnen Skalen des EDI-2 zwischen essgestörten Patientinnen (n = 71), weiblichen (n = 150) und männlichen Kontrollprobanden (n = 150) zeigten, dass der EDI-2 gut zwischen den verschiedenen Gruppen Jugendlicher differenzieren kann. Eine Diskriminanzanalyse ergab, dass insgesamt 86.0 % der Fälle korrekt klassifiziert werden konnten. Die konfirmative Faktorenanalyse bestätigte im Wesentlichen die Sechs-Faktorenstrukur des EDI-2 ( Thiel et al., 1997 ).

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

Clarifying criteria for cognitive signs and symptoms for eating disorders in DSM-V

OBJECTIVE

This article reviews literature relevant to challenges in clinical ascertainment of cognitively-based diagnostic criteria of anorexia nervosa (AN) and bulimia nervosa (BN) to examine whether revision might enhance their clinical utility.

METHOD

We performed a systematic literature search to identify publications relevant to clinical evaluation of cognitive symptoms of AN and BN.

RESULTS

The literature supports several reasons that individuals with an eating disorder may not endorse cognitive symptoms, despite their presence. These include limited insight, minimization, or denial, as well as intentional concealment related to perceived stigma, social desirability, or investment in maintaining behavioral symptoms. We also identified reasons that the word "refusal" in AN criterion A may render its application problematic.

DISCUSSION

We conclude that specific guidance for ascertainment of cognitive signs for AN and BN in the absence of patient disclosure or endorsement, longitudinal evaluation, and/or collateral data may improve clinical utility of these diagnostic criteria.

Abnormal eating attitudes in Mexican female students: a study of prevalence and sociodemographic-clinical associated factors

The objective of the study was to determine the prevalence of abnormal eating attitudes (AEA) in Mexican high school and university students in the city of San Luis Potosí, Mexico. By means of a transversal study with a weighted, random and multistage sampling process, we analyzed a representative sample of female students (N= 2006). The instrument was the Eating Disorder Inventory-2 (EDI-2), validated in Mexican population and a questionnaire of sociodemographic data. The prevalence of AEA was 12.6% and its frequency was significantly higher in high school than in university students. AEA cases were uniformly distributed among public and private institutions and a highly significant relationship between substances consumption and AEA was observed. A logistic regression model for AEA was obtained. Therefore, a profile of highly AEA was built based on sociodemographic data and a solid instrument validated in Mexican population, which can be employed as a screening and secondary prevention tool to design public health programs.

A cross-cultural comparison of the Eating Disorder Inventory

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

Comparison of the eating disorder inventory (EDI) in the Netherlands, Austria and Italy

OBJECTIVE

Comparison of scores of the Eating Disorder Inventory (EDI) in non-clinical females aged 15-35 years (total n = 2402) in three European countries with North-South variation.

METHODS

Participants were high school girls from the Netherlands (n = 642), Austria (n = 544) and Italy (n = 359), and college students from the Netherlands (n = 348), Austria (n = 114) and Italy (n = 395).

RESULTS

Age-dependent differences of EDI subscale scores were observed. Whereas in Dutch females weight and body shape concerns had a peak between 16 and 19 years, these concerns remained relatively constant in Italy and Austria. The Italian scores were significantly higher than the Dutch scores on almost all EDI subscales whereby effects were small or medium.

CONCLUSIONS

The scores may be influenced by socio-cultural factors, cultural traits, culture-specific social demands on young adults and differences in maturation between North and South Europe. National norms are necessary for different age, weight and sex groups.

Examining body image discrepancies and perceived weight status in adult Japanese women

This study examined potential differences and similarities between attitudes about body shape and eating behaviors in Japan versus America. Discrepancies between various body ideals (e.g., own versus ideal; Japanese versus American) and perceived weight status were examined in a sample of adult Japanese women. Forty-five adult Japanese women rated various body ideals using the Stunkard Body Shape Questionnaire. They also answered questions about their perceived body weight and completed the Eating Disorders Inventory (EDI-2). Participants rated the ideal body shape for Japanese women to be significantly thinner than for American women. Body image discrepancy predicted drive for thinness and bulimic symptoms as measured by the EDI-2. Furthermore, there was an interaction between perfectionism and perceived overweight status, such that among participants high on perceived weight status, perfectionism predicted greater bulimic symptomology. The relative importance of the internalization of the Western beauty ideal to the rise of eating disorders in Japan is discussed. Similarities between the findings of this study and studies conducted on American samples are highlighted, and areas for future research are proposed.

Sexual assault and disordered eating in Asian women

The link between sexual assault and disordered eating has yet to be clarified, especially for ethnic minority populations. Asian women, in particular, report low rates of both sexual assault and eating disorders compared to their Western counterparts, and studies suggest that these rates may be conservative. The literature indicates that there are cultural attitudes that contribute to non- and underreporting of sexual assault by Asian women and that these sociocultural factors may have an important role in the development of eating disorders as a response to sexual victimization. Research illustrates a relationship between sexual assault and eating disorders; eating disorders may serve as coping mechanisms for survivors of sexual assault by providing a mechanism for comfort, numbing, and distracting in an effort to rid the painful feelings in response to the assault. To stimulate future research, this article reviews the current literature on the development of eating disorders following a sexual assault and on the sociocultural factors linking both phenomena in Asian women, and offers avenues for investigation to increase our understanding of these relationships.

The tripartite influence model of body image and eating disturbance: a replication with a Japanese sample

OBJECTIVE

To examine the tripartite influence model of body image and eating disturbance as a viable sociocultural explanation for the development of eating and body image problems with young Japanese females.

METHOD

A sample of 289 Japanese female undergraduates completed a variety of measures designed to index family, peer, and media influences, as well as levels of body dissatisfaction, eating disturbances, and self-esteem.

RESULTS

The data were evaluated with structural equation modeling to test the tripartite model. Fit indices indicated a moderate fit to the overall tripartite model, replicating previous findings.

CONCLUSION

This study suggests that the sociocultural variables found to influence body image and eating disturbances in Japan are similar to those observed with US samples. The implications for prevention and intervention programs are discussed.

Anorexia nervosa in Asian-American adolescents: do they differ from their non-Asian peers

OBJECTIVE

This study reports on the clinical characteristics and phenomenology of anorexia nervosa (AN) in Asian-American adolescents, and compares them with a non-Asian sample.

METHOD

Data were obtained from a family therapy trial for adolescents with AN. Demographic details were collected and participants assessed on a series of structured interviews. Data from Asian participants were compared with that from non-Asians.

RESULTS

Asians scored lower on all the Eating Disorder Examination (EDE) subscales, significantly on the restraint subscale (1.48 vs. 2.80, p = 0.016) and weight concerns subscale (1.35 vs. 2.30, p = 0.026). They also scored higher on the Family Environment Scale achievement orientation subscale (6.50 vs. 4.81, p = 0.011).

CONCLUSION

Asians are demographically similar to their non-Asian peers but tend to come from higher-income families who were more achievement oriented. EDE scores suggest Asians tend to report fewer symptoms. The apparent lack of fat-phobia among Asians could be related to this overall under-reporting of symptoms.

Eating disorders and women's health: an update

Anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified have a significant impact on the health care and childbearing outcomes of the female population. Primary care contact for gynecologic care, childbearing, or infertility can serve as a critical entry point for the initial recognition of potentially devastating disorders that may result in permanent impairment and/or chronic debilitation. This review addresses the nature and prevalence of eating disorders and the management of pregnancy complicated by an active eating disorder or a history of an eating disorder. Genetic influences and intergenerational transmission of eating disorders are discussed. Finally, the increased risk for postpartum depression among women with a current or past eating disorder is examined. Factors critical to improving pregnancy outcome and reducing the risk for exacerbation or relapse in the postpartum period are identified.

Trans-cultural comparison of disordered eating in Korean women

OBJECTIVE

The presence of eating disorders in non-Western cultures is often attributed to the export of Western ideals. This study examines this hypothesis by comparing disordered eating attitudes and behaviors in Korean women with differing levels of exposure to Western culture.

METHOD

Second-generation Korean-Americans (n=167) and Korean immigrants (n=37) completed the Eating Attitudes Test (EAT-26), and data from native Koreans (n=937) were obtained from a previous epidemiological study, using a Korean-translated version of the EAT-26 (K-EAT-26). Korean-American and immigrant women completed the Suinn-Lew Asian Self-Identity Acculturation Scale (SL-ASIA).

RESULTS

Korean-American women scored significantly lower on the EAT-26 than Korean immigrants and native Koreans, who did not differ from each other. Korean-Americans were more Western-oriented than Korean immigrants, and acculturation levels were not correlated with EAT-26 scores in either group.

CONCLUSION

This study supports the importance of native cultural factors in the development of eating disorders in non-Western contexts.

Incidence, prevalence and mortality of anorexia nervosa and other eating disorders

PURPOSE OF REVIEW

The purpose of this review is to evaluate the recent literature on the incidence and prevalence of and mortality associated with eating disorders.

RECENT FINDINGS

General-practice studies show that the overall incidence rates of anorexia nervosa remained stable during the 1990s, compared with the 1980s. Some evidence suggests that the occurrence of bulimia nervosa is decreasing. Anorexia nervosa is a common disorder among young white females, but is extremely rare among black females. Recent studies confirm previous findings of the high mortality rate within the anorexia nervosa population.

SUMMARY

The incidence of anorexia nervosa is around eight per 100,000 persons per year. An upward trend has been observed in the incidence of anorexia nervosa in the past century till the 1970s. The most substantial increase was among females aged 15-24 years, for whom a significant increase was observed from 1935 to 1999. The average prevalence rates for anorexia nervosa and bulimia nervosa among young females are 0.3 and 1%, respectively. Only a minority of people with eating disorders, especially with bulimia nervosa, are treated in mental healthcare.

An open trial of outpatient group therapy for bulimic disorders: combination program of cognitive behavioral therapy with assertive training and self-esteem enhancement

The purposes of this study were to examine the therapeutic efficacy of combined group cognitive behavioral therapy (CGCBT) and to explore the characteristics of the patients who failed to complete it. Our group cognitive behavioral therapy combined with assertiveness training for alexithymia and self-esteem enhancement therapy were attended over a 10-week period. Twenty-five participants were enrolled in the study. The clinical symptoms were assessed before and after treatment, using rating scales including the Eating Disorder Inventory-2, the Bulimic Investigatory Test, Edinburgh, the Toronto Alexithymia Scale, the Rosenberg Self-Esteem Scale, and Global Assessment of Functioning. Sixteen participants (64%) completed the CGCBT program. Completion of the CGCBT resulted in significant improvements in reducing binge-eating behavior and improving social functioning. Eight patients (32%) significantly improved using the Clinical Global Impression Change (CGI-C). Stepwise logistic regression analysis of the results indicated that a lower age (P=0.04) and psychiatric comorbidity (P=0.06) were predictors of dropout from the CGCBT program. Our CGCBT program is a promising first-line treatment for bulimic outpatients. Lower age and the presence of comorbidity had effects on dropout rates.