The Sum Is Greater than its Parts: Intersectionality and Measurement Validity of the Eating Disorder Examination Questionnaire (EDE-Q) in Latinx Undergraduates in the United States

Empirical Investigation of Different Factor Structures for the Eating Disorder Examination-Questionnaire in Adult Women With Anorexia Nervosa

The Eating Disorder Examination-Questionnaire (EDE-Q) is a widely used self-report measure of eating pathology. Despite widespread use, investigations of its factor structure have proved inconclusive and rarely supported the "original" interpretation. The current study evaluates several proposed factor solutions of the EDE-Q using latent variable analysis in a sample of adult women with anorexia nervosa (AN). A total of 804 patients from a specialist treatment center in the United States participated in the study. Confirmatory factor analysis was conducted on 22 EDE-Q items assessing attitudinal features of eating pathology. Findings suggested that three full-item versions (none of which was the "original" interpretation) fit the data adequately, with a brief, seven-item version showing excellent fit. The study is one of the first to examine this within a sample of women with AN and provides an empirical foundation for how best to use the EDE-Q among clinical and research participants with AN. Findings suggest that the "original" factor structure lacks structural validity in women with AN. Its use should generally be discouraged, and future work on screening and treatment outcomes might consider the EDE-Q7.

Bias-based bullying, self-esteem, queer identity pride, and disordered eating behaviors among sexually and gender diverse adolescents

OBJECTIVE

Limited research incorporates an intersectional approach when evaluating disordered eating behaviors among those holding minoritized social positions, such as lesbian, gay, bisexual, queer, questioning, and/or transgender/gender diverse (LGBTQ) adolescents. The current study assessed stigma experiences from peers at school, self-esteem, LGBTQ pride, and overlapping social positions as they relate to disordered eating behaviors among LGBTQ adolescents.

METHOD

Participants included 11,083 adolescents (Mage  = 15.6, SD = 1.3; 34.8% transgender/gender diverse) from a large national survey study of LGBTQ adolescents from 2017. Exhaustive Chi-square Automatic Interaction Detection analysis was used to identify bias-based bullying experiences (i.e., weight-based, identity-based), self-esteem, LGBTQ pride, and overlapping social positions (i.e., gender identity, sexual identity, race/ethnicity, body mass index (BMI) percentile) associated with the highest prevalence of unhealthy weight control behaviors, extreme unhealthy weight control behaviors, and past year binge eating.

RESULTS

Adolescents in the 28 identified groups with a high prevalence of disordered eating behavior held at least one structurally marginalized social position (e.g., high BMI), bias-based bullying experience, low self-esteem, or low LGBTQ pride in addition to being LGBTQ. Weight-based bullying was a salient risk-factor for disordered eating across social positions. Among adolescents with the same social positions, levels of self-esteem, LGBTQ pride, but no bias-based bullying experience, prevalence estimates of disordered eating were, on average, 23% lower.

DISCUSSION

LGBTQ adolescents with multiple marginalized social positions and related factors engage in disproportionately high prevalence disordered eating. Findings underscore the importance of addressing intersecting experiences of stigma to reduce disordered eating and promote health equity among adolescents.

PUBLIC SIGNIFICANCE

Multiply marginalized LGBTQ adolescents, most of whom also reported experiencing bias-based bullying from peers at school, reported disproportionately high prevalence disordered eating. In comparison groups of adolescents with no bias-based bullying experience, prevalence of disordered eating was, on average, 24% lower. Findings underscore the importance of addressing intersecting experiences of stigma to reduce disordered eating and promote health equity among adolescents.

Intersecting gender identity and racial/ethnic inequities in eating disorder risk factors, symptoms, and diagnosis among U.S. college students: An intersectional multilevel analysis of individual heterogeneity and discriminatory accuracy

INTRODUCTION

There are documented inequities in eating disorders (EDs) by gender and race/ethnicity, yet, little is known about population-level prevalence of ED risk factors, symptoms, and diagnosis at the intersection of diverse gender and racial/ethnic identities.

METHODS

Data from the Healthy Minds Study 2015-2019 (N = 251,310 U.S. university students) were used in a multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA). Participants were nested in 35 intersectional strata given by all combinations of 5 gender and 7 racial/ethnic categories. Multilevel logistic models with participants at level 1 and intersectional strata at level 2 were used to estimate stratum-specific predicted prevalence estimates for self-reported thin-ideal internalization, ED symptoms, and ED diagnosis. The variance partition coefficient (VPC) was calculated to quantify the contextual effect of the strata.

RESULTS

There was considerable heterogeneity in the predicted prevalence of our ED outcomes across the strata (e.g., .3%-18.3% for ED diagnoses). There were large disparities in all three outcomes, with transgender participants of color having a higher predicted prevalence than expected based on the additive effects of gender and race/ethnicity. Moderation by race/ethnicity was also apparent, such that racial/ethnic disparities were wider within the cisgender groups relative to the transgender groups. VPCs indicated that ~10% of the total variance in ED outcomes was due to intersectionality between gender and race/ethnicity, over and above variance due to individual-level differences.

CONCLUSION

Findings suggest that gender and racial/ethnic disparities in EDs are interrelated, underscoring the need to develop preventive interventions centering health equity.

PUBLIC SIGNIFICANCE

Despite evidence that sexism, racism, and cissexism (i.e., anti-transgender prejudice) can impact EDs risk, little research examines the social patterning of EDs at the intersection of diverse gender and racial/ethnic identities. Using data from a sample of 250,000 U.S. university students, this study found that gender and racial/ethnic disparities in eating disorder risk are interrelated, highlighting the need to develop health equity centered preventive interventions.

Comparison between the brief seven-item and full eating disorder examination-questionnaire (EDE-Q) in clinical and non-clinical female Norwegian samples

BACKGROUND

The Eating Disorder Examination-Questionnaire (EDE-Q) is among the most widely used self-report measures of eating disorder (ED) psychopathology. There is a need for brief versions of the EDE-Q that can be used for general assessment and screening purposes. A three-factor 7-item version (EDE-Q7) seems particularly promising but there is a need for more well-powered studies to establish the psychometric properties in both patient and community samples. Moreover, comparing the EDE-Q7 with the full EDE-Q would be beneficial in determining its utility. In the present study, we provide a psychometric comparison between the brief EDE-Q7 and the full EDE-Q in a large sample of both patients and community comparisons.

METHODS

We pooled available datasets collected in Norway to amass a large female sample comprising both patients (n = 1954, Mage = 28 years) and community comparisons (n = 2430, Mage = 31 years). We investigated the psychometric properties of both versions, including their internal consistency, factor structure, and ability to discriminate between patients and community comparisons.

RESULTS

The EDE-Q7 showed similar distributions of scores compared to the full EDE-Q but produced higher scores. Results indicated that the EDE-Q7 have acceptable internal consistency and is adequately able to discriminate between clinical and non-clinical samples. A cut-off threshold of 3.64 was optimal in discriminating between patients and comparisons. We also found support for the three-factor solution for the EDE-Q7, indicating good structural validity. In contrast, we did not find support for the originally proposed four-factor solution of the full EDE-Q.

CONCLUSIONS

We find that the brief EDE-Q7 performs close to the full EDE-Q in several respects. Our findings indicate that the brief EDE-Q7 may be a viable alternative to the full EDE-Q in situations where response burden is an issue (e.g., epidemiological studies). However, the EDE-Q7 may hold limited value over the full EDE-Q in clinical settings, due to the small number of items and lack of assessment of behavioral features.

Body satisfaction and disordered eating among male collegiate athletes: From point-prevalence to prediction

Body satisfaction (BS) predicts lower levels of eating disorders and disordered eating behaviors (ED/DE) among female athletes, though recent research suggests similar effects for male athletes. However, research on male athletes' BS and ED/DE is limited, particularly in relation to times of transition, such as occurred in the months immediately following COVID-19 being recognized as a global pandemic. In this study, we surveyed 1975 male collegiate athletes in April/May 2020 to assess their body satisfaction and ED/DE symptomatology to determine prevalence and prediction between the two. First, we determined athletes' ED classification: 18.5 % (clinical) and 4.7 % (subclinical). Second, although 60 % to 70 % of the athletes reported satisfaction across five body dimensions, they were significantly more satisfied with their body muscularity and least with their leanness and thinness. Third, through hierarchical regression, athletes' body satisfaction significantly explained their ED/DE symptomatology, explaining 34 % of the variance. Of the five BS dimensions, satisfaction with body size/shape (β = -0.19), current weight (β = -0.22), and thinness (β = -0.25) were associated significantly with lower DE. Our results add to the limited research that has demonstrated that during times of transition, such as when athletes retire from sport or experience a global health pandemic, female and male athletes' report more body image concerns and DE symptoms. Further, our results indicate that satisfaction is perceived as multidimensional by male athletes, and that specific dimensions (e.g., weight, thinness) are more strongly associated with disturbances in eating.

Validation of a Farsi version of the Eating Disorder Examination Questionnaire (F-EDE-Q) in adolescents and university students from Iran

BACKGROUND

Although the Farsi version of the Eating Disorder Examination-Questionnaire (F-EDE-Q) is frequently utilized to assess disordered eating in Iran, its factor structure, reliability, and validity have not been investigated in Iranian samples, which is the aim of the current investigation.

METHOD

Using convenience sampling, this study recruited 1112 adolescents and 637 university students to complete disordered eating and mental health-focused questionnaires, including the F-EDE-Q.

RESULTS

Confirmatory factor analyses of the 22 attitudinal items in the F-EDE-Q indicated that a brief seven-item, three-factor model (i.e., Dietary Restraint, Shape/Weight Overvaluation, Body Dissatisfaction with Shape and Weight) was the only factor structure that fit the data well for either sample. This brief version of the F-EDE-Q was invariant across gender, body weight, and age. Adolescent and university participants with higher weight reported higher average scores on each of the three subscales. Subscale scores showed good internal consistency reliability in the two samples. Further, supporting convergent validity, subscales were significantly associated with measures of body image-related preoccupation and bulimia symptoms, as well as measures of other theoretically related constructs including depressive symptoms and self-esteem.

CONCLUSION

Findings suggest that this brief, validated measure will enable researchers and clinical providers to appropriately assess disordered eating symptoms in adolescent and young adult Farsi-speaking populations.

Eating Disorder Examination-Questionnaire and Clinical Impairment Assessment norms for intersectional identities using an MTurk sample

OBJECTIVE

There are limited data to guide the interpretation of scores on measures of eating-disorder psychopathology among underrepresented individuals. We aimed to provide norms for the Eating Disorder Examination-Questionnaire (EDE-Q) and Clinical Impairment Assessment (CIA) across racial/ethnic, gender, and sexual identities, and sexual orientations and their intersections by recruiting a diverse sample of Amazon MTurk workers (MTurkers; N = 1782).

METHOD

We created a comprehensive, quantitative assessment of racial/ethnic identification, gender identification, sex assigned at birth, current sexual identification, and sexual orientation called the Demographic Assessment of Racial, Sexual, and Gender Identities (DARSGI). We calculated normative data for each demographic category response option.

RESULTS

Our sample was comprised of 68% underrepresented racial/ethnic identities, 42% underrepresented gender identities, 13% underrepresented sexes, and 49% underrepresented sexual orientations. We reported means and standard deviations for each demographic category response option and, where possible, mean estimates by percentile across intersectional groups. EDE-Q Global Score for a subset of identities and intersections in the current study were higher than previously reported norms for those identities/intersections.

DISCUSSION

This is the most thorough reporting of norms for the EDE-Q and CIA among racial/ethnic, sexual, and gender identities, and sexual orientations and the first reporting on multiple intersections, filling some of the gaps for commonly used measures of eating-disorder psychopathology. These norms may be used to contextualize eating-disorder psychopathology reported by underrepresented individuals. The data from the current study may help inform research on the prevention and treatment of eating-disorder psychopathology in underrepresented groups.

PUBLIC SIGNIFICANCE

We provide the most thorough reporting on racial/ethnic, sexual, and gender identities, and sexual orientations for the Eating Disorder Examination - Questionnaire and Clinical Impairment Assessment, and the first reporting on intersections, which fills some of the gaps for commonly used measures of eating-disorder psychopathology. These norms help inform research on the prevention and treatment of eating-disorder psychopathology in underrepresented groups.

The Perfect Storm: A Developmental-Sociocultural Framework for the Role of Social Media in Adolescent Girls' Body Image Concerns and Mental Health

In this theoretical review paper, we provide a developmental-sociocultural framework for the role of social media (SM) in adolescent girls' body image concerns, and in turn, depressive symptoms and disordered eating. We propose that the features of SM (e.g., idealized images of peers, quantifiable feedback) intersect with adolescent developmental factors (e.g., salience of peer relationships) and sociocultural gender socialization processes (e.g., societal over-emphasis on girls' and women's physical appearance) to create the "perfect storm" for exacerbating girls' body image concerns. We argue that, ultimately, body image concerns may be a key mechanism underlying associations between adolescent girls' SM use and mental health. In the context of proposing this framework, we provide empirical evidence for how SM may increase adolescent girls' body image concerns through heightening their focus on (1) other people's physical appearance (e.g., through exposure to idealized images of peers, celebrities, and SM influencers; quantifiable indicators of approval); and (2) their own appearance (e.g., through appearance-related SM consciousness; exposure to idealized self-images; encouraging over-valuing of appearance; and peer approval of photos/videos). Our framework highlights new avenues for future research on adolescent girls' SM use and mental health, which recognize the central role of body image.

Update on the epidemiology and treatment of eating disorders among Hispanic/Latinx Americans in the United States

PURPOSE OF REVIEW

This review provides a 6-year update on the prevalence and treatment of eating disorders among Hispanic/Latinx Americans in the United States.

RECENT FINDINGS

Prevalence of eating disorders tends to be lower in Hispanic/Latinx American adolescents and adults relative to non-Hispanic White peers. Numerous risk factors for disordered eating symptoms have been identified, including negative body image, depression, sexual assault and culturally specific risk factors, including ethnic discrimination and acculturative stress. Hispanic/Latinx individuals seek treatment less often with the most influential barriers being cost of treatment, eating disorder stigma, eating disorder shame and mental health shame in general. Limited research on the treatment for eating disorders continue to persist. Culturally adapted cognitive behavioural therapy yielded similar outcomes to traditional cognitive behaviour therapy and had better treatment adherence and retention rates.

SUMMARY

The medical and sociopolitical climate of the United States has changed significantly since our previous review. The need for research on the effectiveness of eating disorder treatments for Hispanic/Latinx Americans remains important for one of the fastest growing populations in the U.S.

Factor analytic support for the EDE-Q7 among American Indian/Alaska Native undergraduate women

OBJECTIVE

American Indian/Alaska Native (AI/AN) people have historically been excluded from eating disorder research. Consequently, not much is known about the validity of eating disorder assessment measures in this group. The purpose of the current study was to examine the factor structure of a short measure for eating pathology, the seven-item Eating Disorder Examination Questionnaire (EDE-Q7), in AI/AN undergraduate women. Exploratory analyses examined the measurement invariance of the EDE-Q7 across AI/AN, White, and Latinx undergraduates.

METHODS

A sample of 150 AI/AN undergraduate women completed the full EDE-Q (28 items) as part of two larger studies. The seven items comprising the EDE-Q7 were selected from the full measure to test the factor structure. Random samples of White and Latinx women of equal sample size were chosen from the larger studies to test measurement invariance.

RESULTS

Confirmatory factor analyses found support for the EDE-Q7 factor structure in AI/AN undergraduate women, and scores were strongly positively correlated with the original EDE-Q global scale and disordered eating behaviors. Exploratory analyses found support for the measurement invariance of the EDE-Q7 across AI/AN, White, and Latinx women. One-way ANOVAs showed no significant racial and ethnic differences on the EDE-Q7.

DISCUSSION

The current study found psychometric support for the EDE-Q7 in AI/AN undergraduate women and provided preliminary evidence that the EDE-Q7 can be meaningfully compared across AI/AN, White, and Latinx undergraduate women. Further research should continue to investigate the EDE-Q7 and other eating disorder measures in AI/AN and other historically excluded groups.

LEVEL OF EVIDENCE

V, cross-sectional descriptive study.

Exploring differential item functioning on eating disorder measures by food security status

PURPOSE

Food insecurity is associated with elevated eating disorder (ED) pathology, yet commonly used ED measures may not fully capture ED pathology in the context of food insecurity. The present study used differential item functioning (DIF) analyses to explore whether item endorsement on two commonly used ED questionnaires differed by food security status.

METHODS

Participants were 634 cisgender women recruited through Amazon's Mechanical Turk. DIF was explored for items on the Short Eating Disorder Examination Questionnaire (S-EDE-Q) and the Eating Disorder Diagnostic Scale for DSM-5 (EDDS-5). DIF analyses used a hybrid ordinal logistic regression/item response theory approach, with the presence of both statistical (p < .01) and clinical significance (pseudo ΔR² ≥ .035) indicating DIF.

RESULTS

There was no evidence of clinically significant DIF within the S-EDE-Q. Two items on the EDDS-5 exhibited statistically and clinically significant DIF, with moderate effect sizes. Specifically, compared to food-secure participants, food-insecure participants were more likely to report (1) eating large amounts of food when not physically hungry and (2) feeling disgusted, depressed, or guilty about overeating at lower levels of overall ED pathology but less likely to report these experiences at higher levels of overall ED pathology.

CONCLUSIONS

Findings highlight a potential need to adapt ED measures to fully capture ED pathology in food-insecure populations.

LEVEL OF EVIDENCE

Level III, well-designed cohort study.

An open invitation to productive conversations about feminism and the spectrum of eating disorders (part 1): basic principles of feminist approaches

Despite the long history of feminist research in the field and the clear relevance of questions of gender to this sphere, many continue to question the relevance of feminism for understanding and treating eating disorders in 2022. In this set of two papers, we explore some of the tensions, omissions and misconceptions which surround feminist approaches to eating disorders. At the core of these two papers is our assertion that such approaches can make significant contributions in the eating disorders field along six key lines: enriching the science of eating disorders, unpacking diagnostics, contextualizing treatment and prevention, attending to lived experiences, diversifying methodologies, and situating recoveries. In this first paper, we outline what feminist approaches are and dig into some key tensions that arise when feminist approaches come to the table. These include critiques of sociocultural approaches to understanding eating disorders, the relationship between feminist approaches and biological and genetic attributions for eating disorders, and the role of men. We then offer a key contribution that feminist approaches have made to eating disorders scholarship: an invitation to unpack diagnostic approaches and situate eating disorders within the landscape of food, weight, and shape concerns in the twenty-first century.

Establishing the optimal male cut-off point: confirmatory factor analysis of the eating disorder examination-questionnaire (EDE-Q) in a representative sample of Spanish university students

PURPOSE

Although the EDE-Q is derived from the "gold standard" for the assessment of eating disorders (ED), its factor structure is controversial, particularly in male samples. The aim of the study was to examine the psychometric properties and factor structure of the EDE-Q, as well as to establish a sensitive and specific cut-off point validated by EDE clinical interview.

METHODS

A series of Confirmatory Factor Analyses were performed among a representative sample of 796 male university students, of whom 139 were interviewed. Sensitivity and specificity were calculated by receiver-operating characteristic (ROC) analysis to determinate the most appropriate cut-off value.

RESULTS

The original factor structure was not confirmed, showing a better fit with a 2-factor solution. For the Spanish male sample, a cut-off ≥ 1.09 for at-risk of ED cases and ≥ 2.41 for clinical cases presents an optimal balance between sensitivity and specificity.

CONCLUSIONS

The establishment of specific cut-off points for males may help to reduce the under-diagnosis of ED in this population.

LEVEL OF EVIDENCE

III: evidence obtained from well-designed case-control study.

Where identities converge: The importance of intersectionality in eating disorders research

Disparities in eating disorder (ED) risk, diagnosis, and treatment for those who occupy multiple marginalized social identities (e.g., combined racial/ethnic and sexual minority statuses), underscore the need for advancing multicultural research in the ED field. In this article, we argue that intersectionality-informed approaches, which examine the ways in which one's multiple social identities interact to inform risk for ED outcomes, offer an established framework for identifying frequently underserved individuals who may be at greatest risk for EDs. We highlight preliminary intersectional research in EDs and offer suggestions for further progression. In particular, we encourage future intersectionality-informed research to incorporate a broader range of social identities (e.g., age, ability status), consider the ways in which these identities may be dimensional and fluid, and embrace strengths-based approaches to illuminate dimensions of identity that may serve as protective factors. To support such research, we describe quantitative and qualitative methods for pursuing questions of intersectionality in ED investigations. Given the success of intersectionality-informed research in other areas of psychopathology and its relevance to ED as suggested by initial research, the continued pursuit of these approaches in EDs has high potential to improve identification and treatment for patients who have too often been overlooked.