Social, psychological and physical correlates of eating problems. A study of the general adolescent population in Norway

Investigating the Link between Eating Attitudes, Taste and Odour Preferences and the Chemical Senses

OBJECTIVES

To examine if higher degrees of pathological eating attitudes in a non-clinical sample are associated with odour and taste perception and preferences based on psychophysical ratings.

PARTICIPANTS AND METHODS

A total of 80 female university students completed the eating attitudes test (EAT-26), followed by four chemosensory measures including olfactory and gustatory perception plus perceptual ratings and preferences for food odours and tastes.

RESULTS

There were no significant correlations between EAT-26 scores and measures of olfactory and gustatory perception. However, a significant interaction effect indicated higher degrees of pathological eating attitudes may be associated with differential sensitivity to sweet and fatty food odours compared to those with lower levels of pathological eating attitudes.

CONCLUSIONS

This was the first study to examine pathological eating attitudes using food stimuli with a non-clinical sample. The results remain preliminary until replication. However, the findings highlight the need for development of measures of disordered eating attitudes and behaviours that go beyond caloric restriction.

Prospective associations between loneliness and disordered eating from early adolescence to adulthood

OBJECTIVE

Despite findings from numerous cross-sectional studies suggesting a substantial association between loneliness and different types of disordered eating, much remains unknown about the impact of confounding, the order of cause and effect, and gender differences in the relationship. Thus, this study followed a large, population-based, mixed-gender sample through adolescence and young adulthood, applying a random intercept cross-lagged panel model (RI-CLPM) approach to examine the bidirectional prospective associations between loneliness and disordered eating while ruling out the effect of unmeasured time-invariant confounders.

METHOD

A Norwegian sample of N = 2933 adolescents (54.2% female) was examined across four time points (T1, M_age  = 15.44, grades 7-12; T2, M_age  = 16.93; T3, M_age  = 21.84; and T4, M_age  = 28.33) from 1992 to 2005 using RI-CLPMs for overall disordered eating and specific forms for disordered eating (dieting and bulimic symptoms). Multigroup structural equation models were used to assess gender differences.

RESULTS

For male participants, high levels of loneliness at T1 predicted more overall disordered eating and more dieting at T2. Meanwhile, among female participants, disordered eating and bulimic symptoms at T2 predicted more loneliness at T3, whereas loneliness at T3 predicted more disordered eating and bulimic symptoms at T4, and vice versa.

DISCUSSION

The findings suggest a pattern of bidirectional associations between loneliness and disordered eating that varies by time points, gender, and type of eating problem. Preventive interventions and treatment should consider social factors involved in the onset and maintenance of eating problems in male adolescents and young adult women.

PUBLIC SIGNIFICANCE

This study contributes to the existing knowledge by examining for the first time the dynamic nature of the association between loneliness and disordered eating while accounting for all time-invariant confounding. Our findings reveal a pattern of bidirectional associations between loneliness and disordered eating that appears to vary by developmental period, gender, and type of eating problem. Our findings suggest that social factors have to be taken into account when designing prevention strategies aimed at disordered eating.

Access to Public Support Systems Related to Severity of Adversities and Resilience among Adolescents

Access to support systems is crucial for providing immediate assistance and treatment to children to counteract the long-term detrimental effects of various forms of violence. This study examines how adversity such as victimization of violence and self-injury behaviors among young people with their individual resilience is related to their access to support systems. The data used in our analysis are from two national youth surveys carried out in Norway in 2007 and 2015. We ask: To what degree do young people with experiences of violence gain access to support systems such as child welfare services, mental health services for children and youth, and pedagogical psychology services? Our results show that although not all young people who need help have gained access to support systems, victimization of violence and self-injury behavior significantly increase the likelihood of accessing these support systems. Our results also reveal a persistent effect of young people’s home socio-economic background on their unequal access to system support. More future research is needed on the subtle mechanisms and social–emotional implications of individual accessing system support from the macro-societal level and meso-system/family level.

Canadian 24-h Movement Guidelines, Life Stress, and Self-Esteem Among Adolescents

Background

Adolescence is often considered a period of heightened stress, and healthy active living behaviors may help those experiencing it to better cope with life stressors and increase their self-esteem. The 24-h movement guidelines for children and adolescents recommend ≥60 min per day of moderate-to-vigorous physical activity, ≤ 2-h per day of recreational screen time, and 9–11-h of sleep per night for school-aged children or 8–10-h per night for adolescents. The objective of this study was to examine the association of meeting the 24-h movement guidelines with life stress and self-esteem among students in Ontario, Canada.

Methods

Self-reported data on movement behaviors, life stress and self-esteem were derived from the 2019 cycle of the Ontario Student Drug Use and Health Survey, a cross-sectional and province-wide survey of students in grades 7–12 aged 11 to 20 years (N = 6,932). Multivariable ordered logistic regression analyses were adjusted for the complex sample design of the survey and for important covariates.

Results

Overall, meeting all combinations of movement behavior recommendations were associated with lower life stress and better self-esteem compared with meeting none of the recommendations, except meeting the physical activity only or screen time only recommendations that were not associated with lower life stress. Meeting all 3 recommendations was associated with lower life stress (OR: 0.40; 95 CI: 0.30–0.53) and better self-esteem (OR: 0.29; 95% CI: 0.21–0.40). There was a dose-response gradient between the number of recommendations met (3 > 2 > 1) and lower life stress (p < 0.001) and higher self-esteem (p < 0.001), with meeting all 3 recommendations being the best combination.

Conclusions

These findings suggest that meeting the recommendations of the 24-h movement guidelines is associated with lower life stress and better self-esteem among adolescents.

Positive Youth Development and Mental Well-Being in Late Adolescence: The Role of Body Appreciation. Findings From a Prospective Study in Norway

Although a vulnerable period, adolescence is a time of great potential for healthy development. Understanding factors that contribute to mental well-being in this period is of great importance to facilitate for healthy development. During the adolescence period the body goes through rapid and considerable changes, and the focus on body appearance and perfection is substantial at societal, media, and peer level. In this study, we investigated the association between dimensions characterizing positive youth development, and mental well-being among Norwegian adolescents 16-17 years 1 year later, and whether this association was mediated by degree of body appreciation. We further tested whether the indirect and direct paths between positive youth development dimensions and mental well-being were moderated by gender. We used data from the first and second follow-up of the control arm of the COMPLETE study, a cluster randomized controlled trial in upper secondary schools in Norway. Findings showed that positive youth development in grade 1, as measured by both a combined global PYD and the dimensions competence, and connection were significantly associated with mental well-being in grade 2 in models adjusted for mental well-being in grade 1, gender and perceived family affluence. Also, body appreciation in grade 1 significantly predicted mental well-being in grade 2 in models including each of global PYD, competence, connection, character, and caring dimensions. Contrary to our hypothesis, no mediating effects of body appreciation were observed, and no moderation of indirect effects by gender were observed.

Classification of subtypes of patients with eating disorders by correspondence analysis

BACKGROUND

Grouping eating disorders (ED) patients into subtypes could help improve the establishment of more effective diagnostic and treatment strategies.

AIM

To identify clinically meaningful subgroups among subjects with ED using multiple correspondence analysis (MCA).

METHODS

A prospective cohort study was conducted of all outpatients diagnosed for an ED at an Eating Disorders Outpatient Clinic to characterize groups of patients with ED into subtypes according to sociodemographic and psychosocial impairment data, and to validate the results using several illustrative variables. In all, 176 (72.13%) patients completed five questionnaires (clinical impairment assessment, eating attitudes test-12, ED-short form health-related quality of life, metacognitions questionnaire, Penn State Worry Questionnaire) and sociodemographic data. ED patient groups were defined using MCA and cluster analysis. Results were validated using key outcomes of subtypes of ED.

RESULTS

Four ED subgroups were identified based on the sociodemographic and psychosocial impairment data.

CONCLUSION

ED patients were differentiated into well-defined outcome groups according to specific clusters of compensating behaviours.

Bonding With Parents, Body Image, and Sociocultural Attitudes Toward Appearance as Predictors of Eating Disorders Among Young Girls

A more holistic approach to treatment and prevention focuses on identifying the multiple risk and protective factors for eating disorders. However, there is a lack of research verifying the nature of the relationship between patterns of bonding with parents, sociocultural attitudes toward appearance, body image, and their role in developing or preventing eating disorders. The main aim of the study was to verify whether there is a specific set of risk or/vs. protective factors/measures for behaviors and dispositions related to the development of eating disorders. The study group consisted of 134 young Polish females (M = 14.92; SD = 1.349), with an average body mass index. The variables were measured using the Parental Bonding Instrument, the Sociocultural Attitudes Toward Appearance Questionnaire-3, The Multidimensional Body-Self Relations Questionnaire, and the Eating Disorder Inventory 3. Stepwise regression analysis was applied. Statistical analysis showed that bonding with parents (including maternal overprotection), body image (including overweight pre-occupation, fitness evaluation, health orientation, and self-classified weight), and sociocultural attitudes toward appearance (such as searching for information, pressures, and internalization) are predictors of eating disorder risks. On the other hand, maternal and paternal care (aspects of patterns of bonding with parents), positive fitness evaluation, positive appearance evaluation, and satisfaction with one's body were found to be the most significant protective factors. The results may improve prevention and intervention aimed at increasing protective factors.

Adult height after gonadotropin-releasing hormone agonist treatment in girls with early puberty: A meta-analysis

OBJECTIVE

This analysis of previously published reports was performed to examine the effects of gonadotropin-releasing hormone (GnRH) agonist treatment on adult height and the factors associated with adult height outcomes.

CONTEXT

GnRH agonists are first-line agents in the treatment of precocious puberty. However, studies regarding the treatment effect on subjects with early puberty have reported inconsistent results.

DESIGN

A total of 14 studies identified from a search of electronic databases (AMED, EMBASE, MEDLINE and RISS) were included. Controlled studies with girls who developed puberty before 10 years of age and measurements of the adult heights of the subjects were selected. Studies using only long-acting GnRH agonists to suppress puberty were included. Adult height, duration of the treatment, age at the start of treatment and bone age advancement were analysed.

RESULTS

The mean age of the subjects ranged from 6.3 to 9.0 years. The meta-analysis showed a pooled mean difference in adult height of 3.2 cm and a 95% confidence interval of 1.3-5.1 cm. The height difference between the treated subjects and controls was significantly associated with the duration of treatment (P = .005) rather than the age at the start of treatment (P = .084) or the difference between bone age and chronological age (P = .427).

CONCLUSIONS

Administration of GnRH agonists in girls who develop early puberty and demonstrate advanced bone age may be effective for increasing adult height, especially if a sufficiently long treatment duration can be achieved.

Childhood body mass index in adolescent-onset anorexia nervosa

OBJECTIVE

Although weight history is relevant in predicting eating disorder symptom severity, little is known about its role in the etiology of anorexia nervosa (AN). This study aimed to determine whether BMI or BMI trajectory differed between individuals who later developed adolescent-onset AN and a comparison group of HCs between school grades 1 through 6.

METHOD

This study was based on longitudinal data that identified 51 adolescents with AN and 51 matched HCs. Cases were identified through community screening in Sweden and included individuals born in 1969 through 1977. Measured weights and heights were retrieved and BMIs and weight trajectories of the AN and HC groups were compared using growth curve analysis. Main outcome measures included measured BMI and BMI trajectories from grades 1-6. Secondary outcomes examined included ponderal index at birth and maternal body weight.

RESULTS

Individuals who later developed AN had higher BMIs than HCs between grades 1 and 6, by an average of 1.42 BMI-units. There was no difference in rate of weight gain between groups. Ponderal index at birth was higher for the AN as compared with HC group. Maternal weight did not differ significantly between groups.

DISCUSSION

These findings, combined with those previously reported on the premorbid BMIs of those with bulimia nervosa, suggest that a predisposition toward elevated premorbid BMIs during childhood characterizes those who later develop anorexia or bulimia nervosa. These findings are consistent with a transdiagnostic perspective and suggest shared risk factors for AN and obesity. © 2016 Wiley Periodicals, Inc. (Int J Eat Disord 2016; 49:1002-1009).

Predictors of change in psychosocial impairment secondary to an eating disorder

Eating disorders (ED) can significantly impair psychosocial health in patients. However, no published studies have so far used a standardized and specific instrument to evaluate predictive factors in ED-related psychosocial impairment. This prospective cohort study involved 177 patients receiving outpatient treatment for an ED at baseline and 115 patients at the 1-year follow-up. Patients completed three self-administered questionnaires: the Clinical Impairment Assessment (CIA), the Eating Attitudes Test-12 (EAT-12), and the Health-Related Quality of Life in ED-short form (HeRQoLED-s). Descriptive statistics, ANOVA, chi-square, and Fisher's exact test were applied to examine intervariable relationships. Multivariate linear regression was used to determine predictors of change in CIA scores. An improvement was reported by patients with restrictive anorexia nervosa (AN) compared to those with purgative AN. In the multivariate analysis, employment status, subtype of ED, and the bulimia and food preoccupation factor of the EAT-12 were significant predictors of change in the CIA scores.

Use of social networking sites and perception and intentions regarding body weight among adolescents

Objective

Social networking sites (SNSs) not only offer users an opportunity to link with others but also allow individuals to compare themselves with other users. However, the link between the use of SNSs and the dissatisfaction with body weight is largely unknown. We investigated the associations between the use of SNSs and the perception of body weight and related behaviours among adolescent men and women.

Methods

The study sample consisted of 4,468 (48.5% women) 11–19‐year‐old Canadian students in grades 7 to 12 who participated in the 2013 Ontario Student Drug Use and Health Survey.

Results

Overall, 54.6% of students reported using SNSs for 2 h or less per day, 28.0% reported using them for more than 2 h d⁻¹ and 17.4% reported infrequent or no use of SNSs (reference category). After adjustment for covariates, results showed that adolescent women who use SNSs for more than 2 h d⁻¹ had greater odds of dissatisfaction with body weight (odds ratio = 2.02; 95% confidence interval [CI]: 1.30–3.16). More specifically, they were more likely to perceive themselves as overweight (relative risk ratio [RRR] = 2.20; 95% CI: 1.34−3.60) compared with those who reported infrequent or no use of SNSs. Conversely, men who use SNSs for 2 h or less per day presented a lower risk for perceiving themselves as overweight (RRR = 0.68; 95% CI: 0.47−0.98) but not those who use SNSs for more than 2 h d⁻¹. Women who use SNSs for more than 2 h d⁻¹ reported a greater likelihood of trying to lose weight (RRR = 2.52; 95% CI: 1.62−3.90).

Conclusions

Our results showed that heavy use of SNSs is associated with dissatisfaction with body weight in adolescent women.

Sexuality in eating disorders patients: etiological factors, sexual dysfunction and identity issues. A systematic review

The scientific community appears to be less interested in sexuality of eating disorders (EDs) as compared to other psychiatric or medical comorbidities. However, a clear association between sexual problems and ED psychopathology was reported from different perspectives. The overarching goal of this systematic review was to evaluate the general approach of the scientific literature toward the topic of sexuality and EDs. In particular, four different categories of research have been individuated, encompassing the role of puberty, and sexual abuse in the pathogenesis of the disorders, sexual dysfunctions, and the association between sexual orientation and EDs psychopathology. Timing of puberty with its hormonal consequences and the changes in the way persons perceive their own body represent a crucial period of life for the onset of the disorder. Sexual abuse, and especially childhood sexual abuse are well-recognized risk factors for the development of ED, determining a worse long-term outcome. Recent research overcome the approach that considers sexual activity of EDs patients, in terms of hypersexuality and dangerous sexual behaviors, considering the sexuality of EDs persons in terms of sexual desire, satisfaction, orgasm and pain. Results from this line of research are promising, and describe a clear relationship between sexual dysfunction and the core psychopathological features of EDs, such as body image disturbances. Finally, the analysis of the literature showed an association between sexual orientation and gender dysphoria with EDs psychopathology and pathological eating behaviors, confirming the validity of research developing new models of maintaining factors of EDs related to the topic of self-identity.

Reciprocal relations between body satisfaction and self-esteem: A large 13-year prospective study of adolescents

Previous research has demonstrated that body satisfaction and self-esteem are highly correlated in adolescence, but reasons are poorly understood. We tested three explanations: (i) the two constructs are actually one; (ii) the correlation is explained by a third factor; (iii) there are prospective relationships between body satisfaction and self-esteem. A population based sample of Norwegian adolescents (n = 3251) was examined four times over a 13-year period. Confirmatory factor analysis showed that body satisfaction and self-esteem were separate constructs and the correlation between them was not attenuated when adjusting for 3rd variables. Autoregressive cross-lagged analysis showed reciprocal relations between body satisfaction and self-esteem. The prospective relationship between body satisfaction during adolescence and self-esteem in late adolescence and emerging adulthood was stronger than at later stages.

Resilience in young people living with violence and self-harm: evidence from a Norwegian national youth survey

The aim of this article is to explore the relationship between resilience and the psychological problems of young people who reported being victims of violence and who engaged in self-harm. We used data from a national survey conducted in 2007 asking young people in Norway (N=6,034; ages 18–19 years) about their experiences with violence during their childhood and during the past 12 months, and also about their mental health and experiences of self-harm. Our analyses revealed that resilience, as measured by the Resilience Scale for Adolescents, correlates significantly and negatively with psychological problems among all young people, and that this correlation is substantially stronger for those youths who reported violent experiences and those who engaged in self-harm.

Adaptation and validation of the Spanish version of the Clinical Impairment Assessment Questionnaire

The Clinical Impairment Assessment (CIA) assesses psychosocial impairment secondary to an eating disorder. The aim of this study was to create and validate a Spanish-language version of the CIA. Using a forward-backward translation methodology, we translated the CIA into Spanish and evaluated its psychometric characteristics in a clinical sample of 178 ED patients. Cronbach's alpha values, confirmatory factor analysis (CFA), and correlations between the CIA and the Eating Attitudes Test-12 and the Health-Related Quality of Life in ED-short form questionnaires evaluated the reliability, construct validity, and convergent validity, respectively. Known-groups validity was also studied comparing the CIA according to different groups; responsiveness was assessed by means of effect sizes. Data revealed a three-factor structure similar to that of the original CIA. Cronbach alpha coefficient of 0.91 for the total CIA score supported its internal consistency and correlations with other instruments demonstrated convergent validity. The total CIA score and factor scores also significantly discriminated between employment status, evidencing known-groups validity. Responsiveness parameters showed moderate changes for patients with restrictive eating disorders. These findings suggest that the CIA can be reliably and validly used in Spain in a number of different clinical contexts, by researchers and clinicians alike.

Reciprocal associations between depressive symptoms and disordered eating among adolescent girls and boys: a multiwave, prospective study

Symptoms of depression and eating disorders increase during adolescence, particularly among girls, and they tend to co-occur. Despite this evidence, there is meager research on whether depression increases the risk of future eating pathology, or vice versa, and we do not know whether these processes are different for adolescent girls and boys. Accordingly, this study explored the prospective reciprocal associations between depressive symptoms and disordered eating at different time points from preadolescence to mid-adolescence and tested the moderator effect of gender on these associations. A community-based sample of Spanish youth (N = 942, 49 % female) was assessed at ages of approximately 10-11 (T1), 12-13 (T2), 14-15 (T3), and 16-17 (T4) years. The bidirectional relationships between depressive symptoms and disordered eating were estimated in an autoregressive cross-lagged model with latent variables. A unidirectional, age-specific association between depressive symptoms at T1 and disordered eating at T2 was found. No other significant cross-lagged effect emerged, but the stability of the constructs was considerable. Gender did not moderate any of the links examined. Regardless of gender, the transition from childhood to adolescence appears to be a key period when depressive symptoms foster the development of disordered eating. These findings suggest that early prevention and treatment of depression targeting both girls and boys may result in lower levels of depressive symptoms and disordered eating in adolescence.

Risky, early, controversial. Puberty in medical discourses

This article comes within the compass of a research program (entitled CorAge. Bodily Experiences and AgePassages among 9-13 year-olds (ANR-09-ENFT-017) conducted between 2009 and 2013 about the emergence of a "new" age in life--"preadolescence"--as instanced in France (Alsace, Lorraine) and Italy (Venetia). The impressive amount of references to "early puberty" and "precocious puberty", in a context of feeling of a premature end of childhood, led us to make an in-depth study of this issue: first, through an analysis of international and French and Italian medical journals; second, through interviews with health professionals. Following the thesis of Foucault, we assume that the discourses on puberty timing participate of classifications of the child body drenched with moral representations of childhood, especially on gender and age issue. Our results: the question of whether a secular trend in puberty timing even exists continues to be debated between American and European scientists. Second, the terms "puberty", "precocious puberty", "early puberty" have been used to indicate a variety of puberty markers, increasing confusion. A controversy has focused on early breast development in girls, because this attribute is questioning the order of ages and gender. Moreover, psychosocial factors presented as accelerating early puberty, do not demonstrate the relation between earliness and risk behavior. The literature, as it is moved by the female precocity, creates a medical category to objectify the complex and flexible process of puberty and invent female child precocity. These differences between American and European scholars and the interviews with French and Italian health professional show a gap between the international literature and practitioners, clinicians and nurses who regularly work with children: they neither find pubertal advancement, nor increase of "true precocious puberty", although they share concerns about premature feminization of girls (France) or environmental toxicity (Italy) on children.

Secular trends in eating problems among Norwegian adolescents from 1992 to 2010

OBJECTIVE

This study examines secular trends in eating problems among adolescents between 1992 and 2010. The study aims further to investigate whether such trends can be accounted for by secular changes in putative risk factors.

METHOD

Three nationwide surveys of Norwegian senior high-school students were conducted in 1992, 2002, and 2010 (response rates 97.0, 91.0, and 83.2%). At each time point, approximately 3,000 adolescents participated. Eating problems were assessed by means of the Dieting and the Bulimia and Food Preoccupation subscales of the Eating Attitude Test-12. Moreover, a variety of potential risk factors that might account for time trends in such problems were measured.

RESULTS

Dieting scores increased almost linearly for both genders during the research period. No differences over time in Bulimia and Food Preoccupation scores were seen among boys, whereas these symptoms peaked in 2002 for girls with considerably lower levels in both 1992 and 2010. The increase in Dieting from 1992 to 2010 for both genders could be attributed in part to increasing body mass index levels and, to a lesser degree, to depressive symptoms among females. The girls' time trend in Bulimia and Food Preoccupation was to some extent related to changes in appearance satisfaction, alcohol intoxication, and global self-worth.

DISCUSSION

This study is one of few to statistically examine how secular trends in eating problems are related to changes in putative risk factors. The study does not however provide conclusive information on the causal direction between putative risk factors and eating problems.

Eating Behaviours and Body Weight Concerns among Adolescent Girls

This paper presents a global review of research done on adolescent eating behaviours and food choices and the probable factors underlying it. Worldwide adolescent girls tend to develop moderate to high level of disordered eating behaviour as a result of their excessive concern with body weight or obsession with thinness. The objective of the review is to understand the concerns over body weight and the current eating patterns of adolescent girls in the developed and developing countries.

The expression of excessive exercise co-segregates with the risk of developing an eating disorder in women

Excessive exercise (EE) is an important symptom of eating disorders (ED) and is a likely risk factor for developing ED, however, no population-based studies have been performed on the relationship between EE and obtaining ED diagnosis. The aim of this study was to examine the co-occurrence of EE and ED diagnosis in a general population of women. Data for 778 females (age min=30, max=55) from the Saint Thomas Twin Registry, London were used. Phenotypes analyzed included self-reported time spent on physical activity per week, ED diagnosis, Eating Disorder Inventory results (EDI-III), age, BMI and kinship (twin pair). Generalized Estimating Equation analysis showed that only EE (>5 h of exercise per week) and Bulimia Subscale of EDI-III were significantly associated with obtaining ED diagnosis throughout the life. These data revealed that the odds of ever being diagnosed with an ED are more than 2.5 times higher for excessive exercisers compared to individuals with lower activity levels. These data support the notion that EE may be an important risk factor for developing an ED in women.

Puberty as a critical risk period for eating disorders: a review of human and animal studies

This article is part of a Special Issue "Puberty and Adolescence". Puberty is one of the most frequently discussed risk periods for the development of eating disorders. Prevailing theories propose environmentally mediated sources of risk arising from the psychosocial effects (e.g., increased body dissatisfaction, decreased self-esteem) of pubertal development in girls. However, recent research highlights the potential role of ovarian hormones in phenotypic and genetic risk for eating disorders during puberty. The goal of this paper is to review data from human and animal studies in support of puberty as a critical risk period for eating disorders and evaluate the evidence for hormonal contributions. Data are consistent in suggesting that both pubertal status and pubertal timing significantly impact risk for most eating disorders in girls, such that advanced pubertal development and early pubertal timing are associated with increased rates of eating disorders and their symptoms in both cross-sectional and longitudinal research. Findings in boys have been much less consistent and suggest a smaller role for puberty in risk for eating disorders in boys. Twin and animal studies indicate that at least part of the female-specific risk is due to genetic factors associated with estrogen activation at puberty. In conclusion, data thus far support a role for puberty in risk for eating disorders and highlight the need for additional human and animal studies of hormonal and genetic risk for eating disorders during puberty.

Bariatric surgery for obese children and adolescents: a review of the moral challenges

BACKGROUND

Bariatric surgery for children and adolescents is becoming widespread. However, the evidence is still scarce and of poor quality, and many of the patients are too young to consent. This poses a series of moral challenges, which have to be addressed both when considering bariatric surgery introduced as a health care service and when deciding for treatment for young individuals. A question based (Socratic) approach is applied to reveal underlying moral issues that can be relevant to an open and transparent decision making process.

DISCUSSION

A wide range of moral issues with bariatric surgery for children and adolescents is identified in the literature. There is a moral imperative to help obese minors avoiding serious health problems, but there is little high quality evidence on safety, outcomes, and cost-effectiveness for bariatric surgery in this group. Lack of maturity and family relations poses a series of challenges with autonomy, informed consent, assent, and assessing the best interest of children and adolescents. Social aspects of obesity, such as medicalization, prejudice, and discrimination, raise problems with justice and trust in health professionals. Conceptual issues, such as definition of obesity and treatment end-points, present moral problems. Hidden interests of patients, parents, professionals, industry, and society need to be revealed.

SUMMARY

Performing bariatric surgery for obese children and adolescents in order to discipline their behavior warrants reflection and caution. More evidence on outcomes is needed to be able to balance benefits and risks, to provide information for a valid consent or assent, and to advise minors and parents.

Early childhood precursors for eating problems in adolescence: a 15-year longitudinal community study

BACKGROUND

This longitudinal community study investigated the role of individual risk factors in early childhood (before age five) for the development of eating problems in adolescence. Nine hundred twenty-one mothers completed the first questionnaire when their child was 1.5 years old, and again when their child was 2.5 (n = 784) and 4.5 (n = 737) years old. Three hundred seventy-three of these children completed the Eating Attitudes Test (EAT) when they were 16 years old.

RESULTS

Mother-rated early childhood sleep problems (assessed before the age of five) predicted self-rated eating problems in adolescents, with gender, birth weight, and a number of early childhood internal and environmental factors controlled. Unexpectedly, early childhood eating problems were not associated with later eating problems.

CONCLUSIONS

The possible role of sleep in the development of eating problems needs further investigation. In particular, mediating mechanisms should be studied more closely.

Eating disorders and their correlates in high school adolescents of Northern Italy

Objective – The study investigated eating disordered behaviours and life-habits correlated in a large sample of Northern Italian adolescents of both sexes. Methods – The study had a cross-sectional design. 2595 students (2,146 responders; mean age 17.2±1.7 years) attending high schools in Savona (Italy) in April and May 2001 were sampled. To assess eating attitudes, the Inventory for the Screening of Eating Disorders (ISED) was self-administered. Inquiries regarding possible risk factors for eating disorders were also made: socio-economic status, body weight, smoking and alcohol drinking habits, illegal drugs use. Results – Females scored significantly higher than males at ISED (13.4±7.7 vs. 7.6±5.8). 28.5% of females had a total ISED score above the cut-off point (18/19). Unhealthy eating behaviours were strongly associated with higher BMI, body image disturbance and illegal drugs use in both sexes; age had significant role only in males. No significant association between disordered eating behaviours and socio-economic status, smoking habit and alcohol consumption were found. Conclusions – Symptoms of eating disorders are quite spread in the Northern Italian female adolescents and associate with illegal drugs use. These data, with not negligible frequency of unhealthy eating behaviours and attitudes in males too, suggest that primary and secondary preventive interventions for teen-agers should be got ready.

Declaration of Interest: 1) the study received the financial support by Regione Liguria and ASL 2 of Savona; 2) the study didn't receive any forms of financing by pharmaceutical company support and any honoraria for consultancies or interventions was received by each author in the last two years; 3) any other involvements that might be considered a conflict of interest in connection with the submitted article. The authors state that if and when the manuscript accepted for publication, they automatically agree to transfer the copyright to the publisher

Menstrual concerns and intrauterine contraception among adolescent bariatric surgery patients

OBJECTIVE

Adolescent obesity has dramatically increased in recent decades, and along with that so have other medical comorbidities, such as hypertension, diabetes, hyperlipidemia, nonalcoholic steatohepatitis, polycystic ovary syndrome (PCOS), and pseudotumor cerebri. Obesity and related comorbidites may be contraindications to hormonal contraception, making contraception counseling of morbidly obese adolescents more challenging. Obese adolescent females seeking bariatric surgery need effective contraception in the postoperative period. This study is designed to determine the acceptance rate of the levonorgestrel-releasing intrauterine device (IUD) and describe common menstrual problems in obese adolescent bariatric surgery patients.

METHODS

This is a historic cohort study of adolescent females who underwent bariatric surgery over a 2-year period at a tertiary referral center for pediatric obesity. Data were systematically abstracted. The percent of patients with menstrual problems and the acceptance rate for the levonorgestrel-releasing IUD were determined.

RESULTS

Twenty-five adolescents met inclusion criteria. The mean age was 17.4 years (standard deviation [SD] 2.6), and the mean body mass index (BMI) was 51.4 (SD 6.3) kg/m(2). Eighty-four percent were white. Twenty-eight percent had menorrhagia, 32% had oligomenorrhea, 40% had dysmenorrhea, and 36% had PCOS. Ninety-two percent (23 of 25) underwent IUD placement.

CONCLUSIONS

There was a high prevalence of menstrual problems among this sample of severely obese adolescent females. The majority accepted the IUD, indicating it is a viable option among this population.

Eating attitudes and dieting behavior among religious subgroups of Israeli-Arab adolescent females

OBJECTIVES

The aim of the study was to compare the eating attitudes and behaviors, including weight concerns and dieting behavior, among three religious subgroups (Moslems, Druze, and Christians) and three age subgroups (12-13, 14-15, and 16-18 years old) of Israeli-Arab adolescent females.

METHODS

The sample consisted of 1141 Israeli-Arab adolescent females, including 926 (81.2%) Moslem, 128 (11.2%) Christian, and 87 (7.6%) Druze schoolgirls in the seventh to twelfth grades. Participants were assessed using the EAT-26 questionnaire.

RESULTS

The results showed that 75% of the students had a negative EAT-26 score (>20) and that 25% of the students had a positive EAT-26 score (<20). No significant differences were found in total scores, subscale scores, or scores above 20 between the age subgroups or the religious subgroups. The results demonstrated a high prevalence of disturbed eating attitudes and behaviors among Israeli-Arab adolescent schoolgirls.

DISCUSSION

Higher prevalence of disturbed eating attitudes found among Israeli-Arab schoolgirls as compared to their Jewish counterparts. Although our sample is a communal based, there still remains an open question as to why the desired "slenderness culture" evident in the results is not reflected in the number of ED clinic referrals, among clinical population. These discrepancies were discussed in light of ethnicity-specific factors that may influence the perceived severity of eating disorders and the receptiveness of primary practitioners to address them.

Alcohol intoxication and school dropout

The aim of the study was to investigate if alcohol intoxications predict dropout from senior high school over and beyond the effect of alcohol consumption and to seek out potential confounding or mediating mechanisms in the form of a longitudinal cohort-sequential survey. The participants were a nationally representative sample of Norwegian junior and senior high school students (n=5308). Measures used were of alcohol consumption, number of intoxications, school dropout, conduct problems, drug use, friends' problem behaviour, truancy, attitude to school, educational aspirations, grades, homework, youth centrism, leisure time activities, religiosity, depression, academic self-concept, attachment to parents. Intoxications did override the effect of alcohol consumption and predicted dropout. This effect was confounded by parental attachment, whereas truancy and associating with peers high in problem behaviour mediated the effect of intoxications. Frequent alcohol intoxications increase the risk for school dropout by means of increased truancy and differential association with counternormative peers.

Die Erfassung des Pubertätsstatus anhand der Pubertal Development Scale

Zusammenfassung. Die körperliche Entwicklung im Jugendalter hat auch für psychologische Fragestellungen eine große Bedeutung. Es liegen mehrere Verfahren vor, um den Pubertätsstatus ohne Rückgriff auf medizinische Verfahren, die oft teuer und Psychologen nicht direkt zugänglich sind, zu erfassen. Die amerikanische Pubertal Development Scale (PDS, Petersen, Crockett, Richards & Boxer, 1988 ) ist eines dieser Verfahren. Sie ermöglicht, fünf Entwicklungsstadien bei Jungen und Mädchen anhand von jeweils drei Kriterien zu differenzieren. Die vorliegende Studie überprüft verschiedene Gütekriterien einer deutschen Übersetzung. 106 Jungen und 108 Mädchen, im Durchschnitt 11,23 Jahre alt (SD = 0.89), wurden im häuslichen Kontext zu ihrer körperlichen Entwicklung befragt. Eine Fremdeinschätzung des Pubertätsstatus erfolgte durch die Eltern. Die Ergebnisse zeigen zum einen, dass sowohl die interne Konsistenz als auch verschiedene Maße der Kriteriumsvalidität zufriedenstellende Werte erreichen. Zum anderen zeichnen sich jedoch auch systematische Geschlechterunterschiede und Unterschiede in der Fremd- und Selbstbeurteilung ab, die bei der Anwendung und Interpretation der PDS zur Vermeidung von Fehleinschätzungen beachtet werden sollten. Weitere notwendige Validierungsschritte werden diskutiert.

Self-perception of body weight, weight management practices and goals, and other weight-related factors in central and eastern European adolescents

Self-perception of body weight, management practices and goals, and other weight-related factors were assessed among a sample of 2,566 adolescents from 30 high schools in Hungary, Slovakia, Czech Republic, Romania, Ukraine, and Poland. Students who perceived themselves as much too fat were more likely than those with other weight perceptions to engage in weight management practices to lose weight, have higher body mass index, rate themselves lower on physical attractiveness, and estimate higher percentages of their same-sex friends as trying to lose weight. Similar to other research, boys and girls differed on self-perception of weight and other weight-related factors. Cross-cultural comparisons between central and eastern European adolescents and U.S. adolescents, as well as east and southeast Asian youth are made. Implications for health education practice are discussed.

Public health implications of altered puberty timing

Changes in puberty timing have implications for the treatment of individual children, for the risk of later adult disease, and for chemical testing and risk assessment for the population. Children with early puberty are at a risk for accelerated skeletal maturation and short adult height, early sexual debut, potential sexual abuse, and psychosocial difficulties. Altered puberty timing is also of concern for the development of reproductive tract cancers later in life. For example, an early age of menarche is a risk factor for breast cancer. A low age at male puberty is associated with an increased risk for testicular cancer according to several, but not all, epidemiologic studies. Girls and, possibly, boys who exhibit premature adrenarche are at a higher risk for developing features of metabolic syndrome, including obesity, type 2 diabetes, and cardiovascular disease later in adulthood. Altered timing of puberty also has implications for behavioral disorders. For example, an early maturation is associated with a greater incidence of conduct and behavior disorders during adolescence. Finally, altered puberty timing is considered an adverse effect in reproductive toxicity risk assessment for chemicals. Recent US legislation has mandated improved chemical testing approaches for protecting children's health and screening for endocrine-disrupting agents, which has led to changes in the US Environmental Protection Agency's risk assessment and toxicity testing guidelines to include puberty-related assessments and to the validation of pubertal male and female rat assays for endocrine screening.

Gendered dimensions of obesity in childhood and adolescence

Background

The literature on childhood and adolescent obesity is vast. In addition to producing a general overview, this paper aims to highlight gender differences or similarities, an area which has tended not to be the principal focus of this literature.

Methods

Databases were searched using the terms 'obesity' and 'child', 'adolescent', 'teenager', 'youth', 'young people', 'sex', 'gender', 'masculine', 'feminine', 'male', 'female', 'boy' and 'girl' (or variations on these terms). In order to limit the potential literature, the main focus is on other reviews, both general and relating to specific aspects of obesity.

Results

The findings of genetic studies are similar for males and females, and differences in obesity rates as defined by body mass index are generally small and inconsistent. However, differences between males and females due to biology are evident in the patterning of body fat, the fat levels at which health risks become apparent, levels of resting energy expenditure and energy requirements, ability to engage in certain physical activities and the consequences of obesity for the female reproductive system. Differences due to society or culture include food choices and dietary concerns, overall physical activity levels, body satisfaction and the long-term psychosocial consequences of childhood and adolescent obesity.

Conclusion

This review suggests differences between males and females in exposure and vulnerability to obesogenic environments, the consequences of child and adolescent obesity, and responses to interventions for the condition. A clearer focus on gender differences is required among both researchers and policy makers within this field.

Attitudes and health behaviours of young adolescent omnivores and vegetarians: a school-based study

This study aimed to identify attitudes, health behaviours, social adjustment and self-reported health of vegetarian and omnivore teenagers and determine characteristics independently related to vegetarian status. Participants were 630 Grade 9 students, ages 13-15 years, in seven schools in Ontario, Canada. Vegetarian status was determined using a 19-item food inventory. The vegetarian group included lacto, ovo and/or lacto-ovo and semi-vegetarians. Omnivores consumed red meat at least monthly. Social adjustment factors included school misbehaviour, low academic performance, authority-defying risks and unsafe/illegal risks. Logistic regression estimated the relationship of characteristics to vegetarian status. The sample comprised 25 vegetarians (4%) and 605 omnivores. Analyses focussed mainly on females; 22 vegetarians and 315 omnivores. Dieting behaviours (current, frequent and past year), alcohol use, poorer social adjustment and poorer self-rated health were positively related to vegetarian eating (p<.05). Among females (using logistic regression), past year dieting (OR 9.88; 95% CI 2.19-44.47) and alcohol use (OR 2.91; 95% CI 1.02-8.32) predominated in the presence of attitudes that personal health and animal rights are very important. The model predicted 79.9% of cases. Teenage vegetarians were distinctive in health behaviours. The independent, positive association of alcohol use with vegetarian eating is a unique and concerning finding. Dieting behaviours were strongly, independently and positively linked to female vegetarian eating. Further studies with a greater range of behaviours would be useful to more fully characterize teenage vegetarians and explore subgroups.

Menarche, puberty, and first sexual activities in eating-disordered patients as compared with a psychiatric and a nonpsychiatric control group

OBJECTIVE

To examine chronology and experience of menarche, puberty, and first sexual activities in eating-disordered patients as compared with a psychiatric and a nonpsychiatric control group.

METHOD

We interviewed 150 females, namely 50 patients with anorexia or bulimia nervosa (ED), 50 patients with polysubstance dependence (PSD-CO), and 50 healthy controls (HE-CO) (defined by DSM-IV) on chronology and their experience of menarche, puberty, and first sexual activities adjusted for childhood sexual abuse.

RESULTS

ED women were similar to HE-CO in age at menarche and most sexual milestones, but differed significantly from PSD-CO women, who were "early starters." Regarding their experience of menarche, pubertal body changes, and first sexual activities, however, ED women rated these variables significantly more negatively than did either of the comparison groups. These significant differences remained after adjusting for sexual abuse.

CONCLUSION

These findings suggest a negative body attitude in ED patients already at pubertal age, namely years before onset of the disorder. Prospective data are needed.

Eating attitudes and their correlates among Canadian women concerned about their weight

OBJECTIVE

This article examines the components of the Eating Attitudes Test-26 (EAT-26) and their association with selected demographic, psychosocial and health measures among women aged 15 years or older identified as concerned about their weight and who were part of a representative sample of the Canadian population in 2002.

METHOD

An exploratory factor analysis was used to identify the factor structure of the EAT-26 and logistic regression models were constructed to examine the correlates of its first four dimensions.

RESULTS

Underweight women were more likely to report food and body image preoccupation and external pressure to eat while overweight women were less likely to do so. Being young was not associated with poor eating attitudes but self-esteem was negatively related to them. Self-esteem was, however, positively associated with self-imposed dieting.

DISCUSSION

The promotion of self-esteem may reduce the prevalence of poor eating attitudes and prevent their immediate and long-term negative consequences.

Comparative study of eating-related attitudes and psychological traits between Israeli-Arab and -Jewish schoolgirls

OBJECTIVE

The aims of the study were to examine weight concerns, dieting and eating behaviours in a group of Israeli-Arab schoolgirls as compared with Israeli-Jewish schoolgirls, as well as to investigate the reliability of the Arabic (Palestinian) version of the eating disorder inventory-2 (EDI-2).

METHOD

The sample consisted of 2548 Israeli schoolgirls, including 1885 Jewish and 663 Arab adolescents ranging in age from 12 to 18. The study was conducted in 1998-2003 from urban and rural residential settings in the northern part of Israel. The (EDI-2) was the assessment tool used, yielding scores on 11 sub-scales.

RESULTS

The Israeli-Arab schoolgirls scored significantly higher than the Israeli-Jewish schoolgirls in most EDI-2 sub-scales. In addition, the sub-scale inter-item consistency of the translated Arabic (Palestinian version) of the EDI-2 was found to be reliable.

DISCUSSION

The drive to be thin found among Israeli Arab schoolgirls is not reflected in their small number of ED clinic referrals. These discrepancies are discussed in light of the socio-cultural changes currently taking place in the Israeli Arab population due to the influence of Western-oriented life in Israel.

Valoración de la propia imagen corporal en adolescentes femeninas de 12 a 21 años de la ciudad de Reus

OBJECTIVE

To assess the degree of body image distortion in female adolescents and evaluate its association with the social esthetic model and the adoption of dietary measures.

METHOD

We performed a cross sectional, observational study in a random sample of female adolescents aged 12 to 21 years old. Information was gathered via two different sources. A structured questionnaire including sociodemographic and anthropometric items was administered to determine adolescents' desire to resemble advertising models, their satisfaction with trouser size, and whether they would follow an unsupervised diet, etc. A game consisting of 9 images of female shapes of increasing size was used to evaluate self-perceived body image. The subjects chose the shape they believed most closely resembled their own.

RESULTS

A sample of 401 subjects with a mean age of 17.6 (standard deviation = 2.6) years was evaluated. Seventy-five percent had normal weight, 11% were overweight, 13% were obese, and 0.8% were underweight. A total of 76.8% of the subjects had distorted body image and wished to look like advertising models (p < 0.001), 47.7% were dissatisfied with their trouser size (p < 0.001), and 15.3% were following special diets without supervision (p < 0.001).

CONCLUSIONS

The majority of adolescents aged between 13 and 21 years old were dissatisfied with their body image. A distorted body image translates into wanting to resemble advertising models and dissatisfaction with trouser size, which in turn leads to following unsupervised diets.

Pain in Adolescent Psychiatric Patients

BACKGROUND

  Little is known about the extent of pain among adolescent psychiatric patients, and the relationships with psychosocial factors and psychiatric symptoms.

METHOD

  A representative sample of 129 adolescent patients were assessed with measures including the Youth Self-Report, the Mood and Feelings Questionnaire, and instruments assessing self-perceptions, coping styles, stresses, sociodemographic factors, and childhood abuse.

RESULTS

  More than half of the adolescents (54%) reported to be bothered currently by frequent pain. Frequent pain correlated with depression, self-harm, suicide attempt, and with ruminative and emotion oriented coping. Adolescents suffering from frequent pain had more often experienced childhood abuse/neglect. A stepwise multiple regression analysis revealed that depression, alcohol intoxication and childhood neglect were the strongest concurrent predictors of frequent pain.

CONCLUSIONS

  Clinicians should ask child and adolescent psychiatric patients about pain, and be aware of possible connections with abuse/neglect, depression and suicidality.

Cohabitation reduces bulimic symptoms in young women

OBJECTIVE

This current study examines the relationship between cohabitation and changes in bulimic symptoms in young adults.

METHOD

A sample of 2601 initially noncohabitating adolescents was followed over a 5-year period and growth curve analyses were conducted.

RESULTS

Females who over the course of the study moved in with a partner had greater decreases in bulimic symptoms compared with female noncohabitators. This difference was highly significant, even if small in size. No such effect was found in males. When examining the frequency of bulimic behaviors in females, the most socially unacceptable bulimic behaviors were those most reduced by cohabitation, whereas less obtrusive bulimic behaviors were not reduced.

CONCLUSION

The results give some indication that social control exercised in close relationships may account for decreased bulimic symptoms in female cohabitators. Further studies are needed to confirm the importance of social control and to examine how it affects symptom reduction.

Sexual orientation as a risk factor for bulimic symptoms

OBJECTIVE

This study was carried out to examine whether sexual orientation predicts future bulimic symptoms and whether alleged risk factors associated with non-heterosexual sexual orientation explain the increased risk.

METHOD

A nationally representative sample of Norwegian high school students (age 14-19; N=2,924) completed self-reports about bulimic symptoms by means of the Bulimic Investigatory Test-Edinborough (BITE), same-sex sexual experience, degree of sexual attraction to the same sex, and alleged risk factors. They were reexamined 5 years later (T2).

RESULTS

Same-sex sexual experience before T1 increased the prevalence of bulimic symptoms at T2. Males who were attracted to the same sex at T1 had higher odds for bulimic symptoms compared with heterosexual males. These associations were still significant after controlling for initial bulimic symptoms and alleged risk factors.

CONCLUSION

Same-sex sexual experience in both genders and non-heterosexual sexual attraction among males predict future bulimic symptoms. Commonly advocated explanations for this elevated risk were not supported.

Suicide attempts among indigenous Sami adolescents and majority peers in Arctic Norway: prevalence and associated risk factors

The prevalence of suicide attempts and associated risk factors such as sociodemographic conditions, emotional/behavioural problems and parent-child relationships were examined among 591 indigenous Sami and 2100 majority adolescents in Arctic Norway. There were no significant ethnic differences in prevalence of suicide attempts. In both ethnic groups, suicidal ideation, anxious/depressed problems and eating behaviour problems were associated with suicide attempts. Cross-cultural differences in risk factors associated with suicide attempts existed. For Sami adolescents, factors diverging from the traditional cultural norms were associated with suicide attempts, such as alcohol intoxication, single-parent home and paternal overprotection (p</=.05). Vocational studies, not living together with parents, current smoking and experienced sexual intercourse were ethnic specific risk factors associated with suicide attempts among majority peers (p</=.05). Clinicians should take into account that risk factors can differ between ethnic groups and should be sensitive to culturally divergent behaviour.

Adolescents referred to specialty mental health care from local services and adolescents who remain in local treatment: what differs?

BACKGROUND

The study investigates whether adolescents referred to specialty mental health services from local services differ from adolescents who only have received help for psychiatric problems locally. If so, which factors associate strongest with referral?

METHOD

Adolescents (n = 76) from an adolescent population sample (N = 2,538) who had received help during the last year for mental problems from local services were compared to a clinical sample of adolescents (N = 129) referred to specialty mental health services from such local services. Comparisons were made according to scores on the Youth Self-Report (YSR); depressive symptoms; family functioning; attachment to parents; self-concept; coping styles; response styles; dysfunctional attitudes; negative life events; daily hassles; socio-demographics.

RESULTS

As compared to adolescents receiving help locally, adolescents in specialty mental health care scored higher on YSR internalising syndrome; YSR attention problems; YSR thought problems; suicidality; psychosocial stressors; knowing someone who had attempted suicide; parental divorce; substance use; recent moves; living in lodgings; lost a pal or boy/girlfriend; and lower on attachment to parents. Multivariate logistic regression analysis identified four factors associated with receiving specialty mental health care: low family functioning; moved previous year; knowing someone who had attempted suicide; own suicidality.

CONCLUSIONS

Family functioning as reported by the adolescents, and not mental health problems except for suicidality, was found to be the strongest associated with referral to specialty mental health services. Contrary to findings from many other studies, referral was associated with internalising problems, not externalising ones.

Diet and personality: Associations in a population-based sample

BACKGROUND

Large portions of the population of the United States of America fail to follow dietary recommendations. Psychological factors may contribute to non-adherence.

OBJECTIVE

Establish the associations between heritable personality styles, attitudes towards food, and habitual eating behavior.

DESIGN

Variables were assessed by questionnaire in a population-based sample of 629 subjects. Associations were established using correlation and regression analysis, taking gender, demographic, lifestyle and other factors into account.

RESULTS

Differences in personality style were reflected in diet. For example, hostility and anxiety-proneness was associated with greater likelihood to continue eating when satiated, while sociability and low impulsivity correlated with greater monitoring and control of dietary intake and body weight. Immaturity, aloofness, self-consciousness and self-gratification were associated with greater susceptibility to hunger and lack of persistence with increased snack and alcohol consumption. These associations differed for the sexes and were stronger for attitudes towards food than actual eating behavior. Taking other factors into account reduced the number of significant associations between diet and personality, particularly for habitual eating behavior.

CONCLUSIONS

Associations exist between personality and diet. However, the strength of these associations is influenced by demographic, lifestyle and other factors. These findings have implications for future studies and efforts aimed at changing unhealthy dietary habits.