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

Validation of the adult eating behavior questionnaire in a Norwegian sample of adolescents

Eating behaviors are related to health and well-being. To examine stability and change in eating behaviors throughout life, developmentally appropriate measures capturing the same eating behavior dimensions are needed. The newly developed Adult Eating Behavior Questionnaire (AEBQ) builds on the well-established parent-reported Children's Eating Behavior Questionnaire (CEBQ), and together with the corresponding Baby Eating Behavior Questionnaire (BEBQ), these questionnaires cover all ages. However, validation studies on adolescents are relatively sparse and have yielded somewhat conflicting results. The present study adds to existing research by testing the psychometric properties of the AEBQ in a sample of 14-year-olds and examining its construct validity by means of the parent-reported CEBQ. The current study uses age 14 data (analysis sample: n = 636) from the ongoing Trondheim Early Secure Study, a longitudinal study of a representative birth cohort of Norwegian children (baseline: n = 1007). Confirmatory factor analysis (CFA) was conducted to test the factorial validity of AEBQ. Construct validity was examined by bivariate correlations between AEBQ subscales and CEBQ subscales. CFAs revealed that a 7-factor solution of the AEBQ, with the Hunger scale removed, was a better-fitting model than the original 8-factor structure. The 7-factor model was respecified based on theory and model fit indices, resulting in overall adequate model fit (χ2 = 896.86; CFI = 0.924; TLI = 0.912; RMSEA = 0.05 (90% CI: 0.043, 0.051); SRMR = 0.06). Furthermore, small-to-moderate correlations were found between corresponding AEBQ and CEBQ scales. This study supports a 7-factor solution of the AEBQ without the Hunger scale and provide evidence of its construct validity in adolescents. Several of the CEBQ subscales were significantly associated with weight status, whereas this was the case for only one of the AEBQ scales.

Systematic review of prospective studies assessing risk factors to predict anorexia nervosa onset

BACKGROUND

According to case‒control studies, a multitude of factors contribute to the emergence of anorexia nervosa (AN). The present systematic review examines prospective studies specifically designed to evaluate the prediction of AN onset.

METHODS

According to the ARMSTAR 2 and PRISMA 2020 checklists, the PubMed, PsycINFO and Cochrane databases were searched. The methodological quality of the studies was assessed with the Downs and Black checklist.

RESULTS

Three articles concerning prospective studies of the general population were ultimately included in the review. The methodological quality of these studies was not optimal. Bidirectional amplification effects were observed between risk factors, some of which could have a relative predictive force as low bodyweight or body dissatisfaction. Even if not included according to specified criteria for this systematic review 11 longitudinal studies, with retrospective analysis of AN onset' prediction, were also discussed. None of these studies asserted the predictive value of particular risk factors as low body weight, anxiety disorders or childhood aggression.

CONCLUSIONS

To date there are insufficient established data to propose predictive markers of AN onset for predictive actions in pre-adolescent or adolescent populations. Future work should further evaluate potential risk factors previously identified in case‒control/retrospective studies within larger prospective investigations in preadolescent populations. It is important to clearly distinguish predisposing factors from precipitating factors in subjects at risk of developing AN.

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.

A systematic review of studies probing longitudinal associations between anxiety and anorexia nervosa

The current study aimed to establish whether anxiety predicts subsequent anorexia nervosa onset and maintenance. A systematic review of longitudinal studies assessing the association between stable anxiety exposures (e.g. trait anxiety/anxiety disorder pathology) and anorexia nervosa development or maintenance was undertaken. Eight studies met inclusion criteria. Seven probed the association between anxiety and anorexia nervosa onset, and one assessed the association between anxiety and anorexia nervosa maintenance. Individuals with anorexia nervosa were more likely to report childhood anxiety compared to healthy individuals, but whether childhood anxiety explains unique variance in anorexia nervosa development is unclear. Current evidence does not support longitudinal associations between specific anxiety disorders (independently of other anxiety disorders) and subsequent anorexia nervosa onset, however anxiety disorder diagnosis in general may predict increased anorexia nervosa risk. The single study probing the association between anxiety and anorexia nervosa maintenance did not find evidence supporting a relationship. The quality of individual studies was fair to high, however the body of evidence was of low quality. Further research that minimises bias, allowing for strong conclusions concerning longitudinal associations between anxiety and subsequent anorexia nervosa outcomes, is required to inform anorexia nervosa aetiology. This in turn may promote improved prevention and treatment.

Is bullying and teasing associated with eating disorders? A systematic review and meta-analysis

OBJECTIVE

Involvement in bullying and teasing has been associated with adverse health outcomes, including eating disorders (EDs). The purpose of this systematic review and meta-analysis was to examine the association between bullying/teasing and EDs.

METHOD

A systematic search was conducted. We included research articles that examined the association between bullying/teasing (victimization and perpetration) and EDs. Studies were required to compare ED cases with a reference group. We performed a qualitative synthesis of included studies. Additionally, a random-effects meta-analysis of odds ratios were performed to compare rates of bullying/teasing victimization between cases and healthy controls.

RESULTS

A total of 22 studies were included for review. Compared to healthy controls, those with EDs were significantly more likely to have been bullied and teased. Evidence of this association was particularly strong for bulimia nervosa and binge-eating disorder, but was more mixed for anorexia nervosa. It was unclear whether such victimization was more common in EDs compared to psychiatric controls. The meta-analysis showed that compared to healthy controls, those with EDs were twofold to threefold significantly more likely to have been teased about their appearance and bullied prior to onset of their ED. Few studies examined bullying perpetration. A number of methodological shortcomings of studies were noted.

DISCUSSION

Being victimized through bullying and teasing is associated with EDs, and may constitute a risk factor. Our review underscores the need for more studies, and highlights gaps in the literature. As many patients have been victims of bullying and teasing, addressing such experiences in treatment may be valuable.

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.

Feasibility and acceptability of a prevention program for eating disorders (Me, You and Us) adapted for young adolescents in Korea

PURPOSE

The aim of this study was to assess the adaptability and acceptability of a prevention program.

METHODS

A total of 169 Korean students (83 boys and 86 girls) with a mean age of 12.3 years from a 6th grade class at an elementary school participated in the study. Mental health social workers delivered Me, You and Us, a school-based body image intervention program originally developed in the UK, through a set of six sessions. The participants were assessed in terms of their body satisfaction and self-esteem before the program, after the program, and at 1-month follow-up. They were also surveyed about their satisfaction and acceptability levels after the program.

RESULTS

At baseline, girls had lower body satisfaction and self-esteem than boys, and their body satisfaction and self-esteem improved after the program. The improved body satisfaction was maintained at the 1-month follow-up. The efficacy of the program on body satisfaction was positively correlated with the frequency of their baseline level of "fat talk." The program was more effective in girls with possible symptoms of an eating disorder at baseline. 93.7% of boys and 77.4% of girls responded that they enjoyed the program.

CONCLUSIONS

The program Me, You and Us was well-accepted by early adolescents in Korea and it can play a role in increasing body satisfaction and self-esteem by reducing "fat talk" in 6th grade students.

LEVEL OF EVIDENCE

Level III, cohort study with intervention.

Emotional eating is learned not inherited in children, regardless of obesity risk

BACKGROUND

Emotional over-eating (EOE) and emotional under-eating (EUE) are common behaviours that develop in early childhood and are hypothesised to play a role in weight status. Data from a British twin cohort demonstrated that environmental, rather than genetic, factors shape individual differences in both behaviours in early childhood.

OBJECTIVE

The aim of this current study was to replicate this finding in a subsample (n = 398) of 4-year-old twins selected for high or low risk of obesity from another population-based cohort of British twins (the Twins Early Development Study).

METHODS

Parental ratings of child EOE and EUE were analysed using genetic model fitting.

RESULTS

Genetic influence was not significant, while shared environmental factors explained 71% (52-79%) of the variance in EOE and 77% (62-85%) in EUE. The two behaviours correlated positively (r = 0.53, 95% CI: 0.44, 0.61), and about two-thirds of the shared environmental factors influencing EOE and EUE were the same (rC  = 0.67, 95% CI: 0.51, 0.85).

CONCLUSIONS

Emotional eating in childhood is shaped by the home family environment; parents are therefore promising intervention targets.

Emotional Over- and Undereating in Children: A Longitudinal Analysis of Child and Contextual Predictors

Eating more or eating less in response to negative emotions, called emotional over- and undereating, is common in children, but research on the etiology of these behaviors is in its infancy. Drawing on a large, representative community sample of Norwegian children followed up on a biennial basis from 6 to 10 years of age (analysis sample: n = 802), child and contextual predictors (i.e., child temperament, depression symptoms, serious life events, family functioning, parental sensitivity and structuring) of change in emotional over- and undereating were examined. Results revealed that low (temperamental) soothability and less parental structuring at age 6 predicted increased emotional overeating at age 10 and that lower family functioning at age 6 predicted more emotional undereating during the same period.

Medical findings in women with anorexia nervosa in a korean population

OBJECTIVE

Eating disorders are a common clinical problem among young women in Asian countries. The aim of this study is to determine the medical effects of anorexia nervosa (AN) in the Korean population.

METHODS

We comprehensively investigated medical complications including haemodynamic, haematologic, endocrine, and bone density abnormalities in 67 Korean women with AN, together with 194 healthy Korean women of comparable age with a cross-sectional design.

RESULTS

In AN, 36.9% were anaemic, 50.8% were leukopenic, 35.5% were hypoproteinemic, 7.9% were hypokalemic, 9.5% had increased alanine aminotransferase, 6.3% were hyperbilirubinemia, 14.5% were hypercholesterolemia, 14.8% had decreased triiodothyronine. Osteopenia at any one site was identified in 43.3% and an additional 13.4% had osteoporosis. The lowest-ever body mass index was the main determinant of bone mineral density.

CONCLUSION

Our data in Korean patients with AN show high frequencies of laboratory abnormalities for medical complications. This study emphasizes the importance of recognizing AN as a medical risk in young Korean women.

The cognitive-interpersonal maintenance model of anorexia nervosa revisited: a summary of the evidence for cognitive, socio-emotional and interpersonal predisposing and perpetuating factors

AIM

To describe the evidence base relating to the Cognitive-Interpersonal Maintenance Model for anorexia nervosa (AN).

BACKGROUND

A Cognitive-Interpersonal Maintenance Model maintenance model for anorexia nervosa was described in 2006. This model proposed that cognitive, socio-emotional and interpersonal elements acted together to both cause and maintain eating disorders.

METHOD

A review of the empirical literature relating to the key constructs of the model (cognitive, socio-emotional, interpersonal) risk and maintaining factors for anorexia nervosa was conducted.

RESULTS

Set shifting and weak central coherence (associated with obsessive compulsive traits) have been widely studied. There is some evidence to suggest that a strong eye for detail and weak set shifting are inherited vulnerabilities to AN. Set shifting and global integration are impaired in the ill state and contribute to weak central coherence. In addition, there are wide-ranging impairments in socio-emotional processing including: an automatic bias in attention towards critical and domineering faces and away from compassionate faces; impaired signalling of, interpretation and regulation of emotions. Difficulties in social cognition may in part be a consequence of starvation but inherited vulnerabilities may also contribute to these traits. The shared familial traits may accentuate family members' tendency to react to the frustrating and frightening symptoms of AN with high expressed emotion (criticism, hostility, overprotection), and inadvertently perpetuate the problem.

CONCLUSION

The cognitive interpersonal model is supported by accumulating evidence. The model is complex in that cognitive and socio-emotional factors both predispose to the illness and are exaggerated in the ill state. Furthermore, some of the traits are inherited vulnerabilities and are present in family members. The clinical formulations from the model are described as are new possibilities for targeted treatment.

Different Patterns of Emotional Eating and Visuospatial Deficits Whereas Shared Risk Factors Related with Social Support between Anorexia Nervosa and Bulimia Nervosa

OBJECTIVE

Although it is thought that eating disorders result from the interplay of personal and sociocultural factors, a comprehensive model of eating disorders remains to be established. The aim of this study was to determine the extent to which the childhood factors and deficit in visuoperceptual ability contribute to eating disorders.

METHODS

A total of 76 participants - 22 women with anorexia nervosa (AN), 28 women with bulimia nervosa (BN), and 26 healthy women of comparable age, IQ, and years of education - were examined. Neuropsychological tasks were applied to measure the visuoperceptual deficits, viz. the Rey-Osterrieth complex figure test and the group embedded figures test (GEFT). A questionnaire designed to obtain retrospective assessments of the childhood risk factors was administered to the participants.

RESULTS

The women with both AN and BN were less likely to report having supportive figures in their childhood and poor copy accuracy in the Rey-Osterrieth test. The women with AN were more likely to report premorbid anxiety, childhood emotional undereating and showed poor performances in the GEFT. In the final model, the factors independently contributing to the case status were less social support in childhood as a common factor for both AN and BN, and childhood emotional undereating and poor ability in the low-level visuospatial processing for AN.

CONCLUSION

Our results suggest the disturbance in the food-emotion relationship and the deficit in low-level visuospatial processing in people with AN. Lower social support appears to contribute to an increase in vulnerability to both AN and BN.

Eating in eating disorders

The aim of this paper is to bring eating back into the centre of the eating disorder discourse. The ability to interrogate and understand the central processes of appetite has increased considerably since the discovery of leptin and the ability to observe brain function with scanning methodologies. This has led to substantial progress in understanding the biological causative and maintaining factors in eating disorders, opening up the possibility of translating the latest findings into new forms of treatment. The biological mechanisms underpinning symptoms evolution and course of illness will first be described, follows by a discussion on integrating the research evidence in fear and feeding into patient care.