Eating disorders in a general practice population. Prevalence, characteristics and follow-up at 12 to 18 months

Diseases of affluence? A systematic review of the literature on socioeconomic diversity in eating disorders

The stereotype that eating disorders (ED) primarily present among individuals of higher socioeconomic status (SES) has long persisted in popular and professional perception. This belief has likely contributed to disparities in ED identification and treatment, particularly among those of lower SES backgrounds. The objective of this article was to systematically review the literature investigating socioeconomic diversity in distinct ED diagnoses. A PRISMA search was conducted to identify studies that empirically assessed the association between ED pathology and indicators of SES via PubMed and PsycINFO. This search generated 13,538 articles, of which 62 articles published between 1973 and August 2020 met criteria for inclusion in the review. Included studies were primarily cross-sectional and covered diagnoses of anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED), with quality ratings of poor, fair, and good. Results are examined in the context of studies' sampling methods, operationalization of SES, and statistical analyses. There is no consistent pattern of evidence to suggest a relationship between high SES and ED. Instead, all ED present across a wide range of socioeconomic backgrounds. Limitations included the predominance of cross-sectional study designs and poor to fair quality ratings. Future research should include adequately powered, community-based longitudinal studies that examine how sociocultural factors, including SES, intersect to influence ED risk and treatment outcome. The existing data suggest an urgent need to prioritize affordable and accessible ED treatment.

Identifying Risk Factors for Disordered Eating among Female Youth in Primary Care

Eating disorders are a serious, life-threating condition impacting adolescents and young adults. Providers in primary care settings have an important role in identifying disordered eating (DE) symptoms. Unfortunately, symptoms go undetected in 50% of patients in medical settings. Using the behavioral health screen, this study identified DE risk profiles in a sample of 3620 female adolescents and young adults (ages 14-24), presenting in primary care. A latent class analysis with twenty psychosocial factors identified three DE risk groups. The group at highest risk for DE was characterized by endorsement of internalizing symptoms and a history of trauma. The next risk group consisted of those with externalizing symptoms, particularly substance use. The group at lowest risk for DE reported more time spent with friends compared to their peers. Primary care providers and psychiatric teams can benefit from knowing the psychosocial risk patterns affiliated with DE, and using brief, comprehensive screening tools to identify these symptoms.

Relationship between disordered eating and self-identified sexual minority youth in a sample of public high school adolescents

PURPOSE

To investigate the relationship between selected disordered eating behaviors and self-reported sexual minority status (gay/lesbian, bisexual, and unsure) among a representative sample of high school adolescents.

METHODS

The 2013 Centers for Disease Control and Prevention (CDC)-sponsored Connecticut Youth Risk Behavior Survey was utilized (N = 2242). Unadjusted and adjusted logistic regression analyses, separated by gender, examined sexual minority adolescents (gay/lesbian, bisexual, and unsure) and selected eating behaviors. Analyses adjusted for race, age, cigarette use, binge drinking, organized school activity participation, body mass index (BMI), and depression.

RESULTS

Gay males were significantly more likely to report exercising or eating less to lose weight in the unadjusted models (p < 0.05) and fasting, vomiting, and taking diet pills in both adjusted (p < 0.05) and unadjusted models (p < 0.01) when compared to the referent heterosexual males. Bisexual females were significantly more likely to report fasting, vomiting, and taking diet pills in the unadjusted model (p < 0.05) when compared to the referent heterosexual females and significantly less likely to report exercising or eating less to lose weight in the adjusted models (p < 0.05).

CONCLUSIONS

Although additional studies are needed owing to small sample sizes, preliminary findings support previous research suggesting that high school-aged sexual minority youth subgroups are a priority target population for increased efforts to prevent disordered eating.

Prospective associations between problematic eating attitudes in midchildhood and the future onset of adolescent obesity and high blood pressure

BACKGROUND

Clinically diagnosed eating disorders may have adverse cardiometabolic consequences, including overweight or obesity and high blood pressure. However, the link between problematic eating attitudes in early adolescence, which can lead to disordered eating behaviors, and future cardiometabolic health is, to our knowledge, unknown.

OBJECTIVE

We assessed whether variations in midchildhood eating attitudes influence the future development of overweight or obesity and high blood pressure.

DESIGN

Of 17,046 children who participated in the Promotion of Breastfeeding Intervention Trial (PROBIT), we included 13,557 participants (79.5% response rate) who completed the Children's Eating Attitudes Test (ChEAT) at age 11.5 y and in whom we measured adiposity and blood pressure at ages 6.5, 11.5, and 16 y. We assessed whether ChEAT scores ≥85th percentile (indicative of problematic eating attitudes) compared with scores <85th percentile at age 11.5 y were associated with new-onset overweight, obesity, high systolic blood pressure, or high diastolic blood pressure between midchildhood and early adolescence.

RESULTS

After controlling for baseline sociodemographic confounders, we observed positive associations of problematic eating attitudes at age 11.5 y with new-onset obesity (OR: 2.18; 95% CI: 1.58, 3.02), new-onset high systolic blood pressure (OR: 1.34; 95% CI: 1.05, 1.70), and new-onset high diastolic blood pressure (OR: 1.25; 95% CI: 0.99, 1.58) at age 16 y. After further controlling for body mass index at age 6.5 y, problematic eating attitudes remained positively associated with new-onset obesity (OR: 1.80; 95% CI: 1.28, 2.53); however, associations with new-onset high blood pressure were attenuated (OR: 1.14; 95% CI: 0.89, 1.45 and OR: 1.09; 95% CI: 0.86, 1.39 for new-onset systolic and diastolic blood pressure, respectively).

CONCLUSIONS

Problematic eating attitudes in midchildhood seem to be related to the development of obesity in adolescence, a relatively novel observation with potentially important public health implications for obesity control. PROBIT was registered at clinicaltrials.gov as NCT01561612 and isrctn.com as ISRCTN37687716.

Barriers to access and utilization of eating disorder treatment among women

Anorexia, bulimia, and other specified feeding or eating disorders (OSFED) are psychiatric disorders recognized in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). One difference of eating disorders compared to other psychiatric disorders is the physical effects of the disease. Although anorexia is easier to physically detect than bulimia and OSFED, many women remain undiagnosed and untreated. Even if an eating disorder is recognized by the individual, barriers to clinical diagnosis and treatment persist. This study examines the barriers to treatment among women with anorexia, bulimia, and OSFED using Andersen's Behavioral Model. The physical, psychological, and personality trait differences among the eating disorder subgroups may affect treatment utilization and access.

Detecting eating disorder patients in a general practice setting: a systematic review of heterogeneous data on clinical outcomes and care trajectories

PURPOSE

The incidence and prevalence of eating disorders (ED) is low in general practice (GP) settings. Studies in secondary care suggest that the general practitioner has an important role to play in the early detection of patients with EDs. The aim of this study was to describe the effect (clinical outcomes and care trajectory) of screening for EDs among patients in general practice settings.

METHODS

A systematic review was conducted on Medline, PsycINFO, CINAHL, Embase and WOS. The studies included were to have been carried out in a primary care setting, with screening explicitly performed in GP practices and follow-up information.

RESULTS

Ten studies met the inclusion criteria. For all ED patients, there was an increase in the frequency of consultations in GP setting, referrals to psychiatric resources and drug prescriptions such as antidepressants, following screening procedures. Clinical outcomes remained unclear and heterogeneous. One study focused on the course and outcome of ED patients identified by screening in the GP setting and reported recovery for anorexia nervosa (AN) and BN in more than half of the cases, after 4.8 years of mean follow-up. In this study, early age at detection predicted better recovery.

CONCLUSION

Most of the literature on the role of the GP in screening for and managing EDs consists of opinion papers and original studies designed in a secondary care perspective. The impact of systematically screening for EDs in a primary care setting is not clarified and requires further investigation in collaborative cohort studies with a patient-centered approach, and outcomes focused on symptoms.

Eating disorders and eating pathology in young adult and adult patients with ESSENCE

BACKGROUND

Little is known about the prevalence and incidence of traditional eating disorders (EDs, e.g., anorexia nervosa (AN), bulimia nervosa and binge eating disorder (BED)) in individuals with childhood onset neuropsychiatric disorders, including attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorders (ASD). The aim of the present study was to examine the prevalence of EDs and eating pathology in young adults and adults with ADHD and/or ASD, and to investigate the relationship between EDs and associated symptoms, on the one hand, and other psychiatric disorders, intelligence, and BMI, on the other hand, in this population.

METHODS

In an outpatient setting, 228 consecutively referred adults were neuropsychiatrically evaluated and assessed with regard to intelligence (WAIS-III), psychiatric comorbidities (SCID-I), personality disorders (SCID-II), eating disorders (SCID-I) and eating pathology (Eating Attitudes Test (EAT)).

RESULTS

For the entire sample, a total of 18 individuals (7.9%) had a current or previous eating disorder, with AN and BED being the most frequent. The male:female ratio was 1:2.5. According to EAT, 10.1% of the individuals scored within the range of severely disturbed eating behavior, and 13% moderately disturbed eating behavior. Individuals with ADHD more often affirmed eating pathology such as focusing on thoughts of calories and body dissatisfaction compared to individuals with ASD.

CONCLUSIONS

Eating disorder symptomatology seems to be overrepresented in adults with neuropsychiatric disorders compared with the general population. The gender ratio for EDs in adults with neuropsychiatric disorders is not nearly as skewed as in the general population.

Eating disorders in military and veteran men and women: A systematic review

OBJECTIVE

Eating disorders (EDs) have serious consequences for psychological and physical health. They have high mortality rates and are among the most costly disorders to treat. However, EDs remain understudied in military and veteran populations. The aim of this review was to examine prevalence estimates and associated symptomatology of EDs among military and veteran men and women and to identify factors that may put these individuals at risk for the development of an ED for the purposes of improving detection, intervention, and treatment.

METHOD

A thorough literature review was conducted using the databases PsycINFO and PubMed. All articles with a focus on EDs in military/veteran samples were considered.

RESULTS

Studies reveal high prevalence estimates of EDs among military/veteran men and women. Unique features of military life may increase the risk for development of an ED, including: military sexual trauma, strict weight and physical fitness requirements, and combat exposure. A history of trauma was common in individuals diagnosed with an ED in military and veteran samples.

DISCUSSION

The high rates of EDs among military and veteran samples underscore the importance of further research, as well as the importance of screening and intervention efforts, in these understudied populations.

The relationships among social comparisons, body surveillance, and body dissatisfaction in the natural environment

We examined the relationships among social comparisons (i.e., body, eating, and exercise), body surveillance, and body dissatisfaction in the natural environment. Participants were 232 college women who completed a daily diary protocol for 2 weeks, responding to online surveys 3 times per day. When the contemporaneous relationships among these variables were examined in a single model, results indicated that comparing one's body, eating, or exercise to others or engaging in body surveillance was associated with elevated body dissatisfaction in the same short-term assessment period. Additionally, individuals with high trait-like engagement in body comparisons or body surveillance experienced higher levels of body dissatisfaction. Trait-like eating and exercise comparison tendencies did not predict unique variance in body dissatisfaction. When examined prospectively in a single model, trait-like body comparison and body surveillance remained predictors of body dissatisfaction, but the only more state-like behavior predictive of body dissatisfaction at the next assessment was eating comparison. Results provide support for the notion that naturalistic body dissatisfaction is predicted by both state- and trait-like characteristics. In particular, social comparisons (i.e., body, eating, and exercise) and body surveillance may function as proximal triggers for contemporaneous body dissatisfaction, with eating comparisons emerging as an especially important predictor of body dissatisfaction over time. Regarding trait-like predictors, general tendencies to engage in body comparisons and body surveillance may be more potent distal predictors of body dissatisfaction than general eating or exercise comparison tendencies.

[Prevalence of eating disorders assessed using eating attitudes test-26 and their relevant factors in Japanese working women]

OBJECTIVE

The purpose of the present study was to investigate the prevalence of eating disorders and their relevant factors in Japanese women.

METHODS

Anonymous self-administered questionnaire surveys of 3023 working women aged 20-39 were conducted during health checkups in Tokyo, Nagoya, Osaka, and Fukuoka in 2012. Eating disorders were assessed using Eating Attitudes Test-26 (EAT-26). The factors related to EAT-26 scores ≥20 were analyzed by multiple logistic regression.

RESULTS

The prevalences of eating disorders among the participants with EAT-26 scores ≥20 were 2.4% [95% confidence interval (95% CI): 1.8-2.9%] of all the participating women aged 20-39, 3.4% (95% CI: 2.5%-4.3%) of women in their 20s, and 1.2% (95% CI: 0.6%-1.8%) of women in their 30s. Logistic regression analysis showed that EAT-26 scores of ≥20 were associated with the following variables: perceived ideal BMI ≤17.5 kg/m(2) (OR: 4.55, 95% CI: 2.08-9.93), change in body weight in the previous six months (OR: 2.83, 95% CI: 1.61-4.95), being 20-29 years of age (OR: 2.64, 95% CI: 1.42-4.89), and the perception of being fat (OR=2.54, 95% CI: 1.24-5.18).

CONCLUSIONS

The prevalence of eating disorders with EAT-26 scores ≥20 was 2.4% (95% CI: 1.8%-2.9%) among Japanese working women aged 20-39. EAT-26 scores ≥20 were most closely associated with a perceived ideal BMI of ≤17.5 kg/m(2). Eating disorders may be more prevalent among women who want to lose weight to achieve a BMI of ≤17.5 kg/m(2), and these women should be carefully monitored.

Examining an elaborated sociocultural model of disordered eating among college women: the roles of social comparison and body surveillance

Social comparison (i.e., body, eating, exercise) and body surveillance were tested as mediators of the thin-ideal internalization-body dissatisfaction relationship in the context of an elaborated sociocultural model of disordered eating. Participants were 219 college women who completed two questionnaire sessions 3 months apart. The cross-sectional elaborated sociocultural model (i.e., including social comparison and body surveillance as mediators of the thin-ideal internalization-body dissatisfaction relation) provided a good fit to the data, and the total indirect effect from thin-ideal internalization to body dissatisfaction through the mediators was significant. Social comparison emerged as a significant specific mediator while body surveillance did not. The mediation model did not hold prospectively; however, social comparison accounted for unique variance in body dissatisfaction and disordered eating 3 months later. Results suggest that thin-ideal internalization may not be "automatically" associated with body dissatisfaction and that it may be especially important to target comparison in prevention and intervention efforts.

Non-medical use of prescription stimulants for weight loss, disordered eating, and body image

OBJECTIVE

There has been minimal research on the non-medical use of prescription stimulants (NMUPS), such as Adderall and Ritalin, normally used to treat Attention Deficit Hyperactivity Disorder (ADHD) for the purpose of weight loss. The current study examined the prevalence and correlates of this use in a young adult sample.

METHOD

College students (N=707) completed an online survey assessing NMUPS, in general and for weight loss, disordered eating behaviors and attitudes, body image, and recreational drug use.

RESULTS

Overall, 4.4% of participants reported NMUPS for the purpose of weight loss with 56.7% reporting receiving the medication from friends. Individuals reporting NMUPS for weight loss had higher body image concerns and had higher eating disorder symptomatology. Vomiting for weight loss as well as laxative, diet pill, or diuretic use were robustly associated with NMUPS for weight loss.

DISCUSSION

Results suggest that NMUPS for weight loss is relatively common and that this behavior is related to other harmful behaviors. Eating disorder prevention and intervention work should include this behavior when assessing unhealthy weight control behaviors.

Prospective associations of parental smoking, alcohol use, marital status, maternal satisfaction, and parental and childhood body mass index at 6.5 years with later problematic eating attitudes

BACKGROUND

Few studies have prospectively investigated whether early-life exposures are associated with pre-adolescent eating attitudes.

OBJECTIVE

The objective of this study is to prospectively investigate associations of parental smoking, alcohol use, marital status, measures of maternal satisfaction, self-reported parental body mass index (BMI) and clinically measured childhood BMI, assessed between birth and 6.5 years, with problematic eating attitudes at 11.5 years.

METHODS

Observational cohort analysis nested within the Promotion of Breastfeeding Intervention Trial, a cluster-randomised trial conducted in 31 maternity hospitals and affiliated polyclinics in Belarus. Our primary outcome was a Children's Eating Attitudes Test (ChEAT) score 22.5 (85th percentile), an indicator of problematic eating attitudes. We employed multivariable mixed logistic regression models, which allow inference at the individual level. We also performed instrumental variable (IV) analysis using parents' BMIs as instruments for the child's BMI, to assess whether associations could be explained by residual confounding or reverse causation.

SUBJECTS

Of the 17 046 infants enrolled between 1996 and 1997 across Belarus, 13 751 (80.7%) completed the ChEAT test at 11.5 years.

RESULTS

In fully adjusted models, overweight children at age 6.5 years had a 2.14-fold (95% confidence interval (CI): 1.82, 2.52) increased odds of having ChEAT scores 85th percentile at age 11.5 years, and those who were obese had a 3.89-fold (95% CI: 2.95, 5.14) increased odds compared with normal-weight children. Children of mothers or fathers who were themselves overweight or obese were more likely to score 85th percentile (P for trend 0.001). IV analysis was consistent with a child's BMI causally affecting future eating attitudes. There was little evidence that parental smoking, alcohol use, or marital status or maternal satisfaction were associated with eating attitudes.

CONCLUSION

In our large, prospective cohort in Belarus, both parental and childhood overweight and obesity at 6.5 years were associated with pre-adolescent problematic eating attitudes 5 years later.

One-year temporal stability and predictive and incremental validity of the body, eating, and exercise comparison orientation measure (BEECOM) among college women

This study examined the one-year temporal stability and the predictive and incremental validity of the Body, Eating, and Exercise Comparison Measure (BEECOM) in a sample of 237 college women who completed study measures at two time points about one year apart. One-year temporal stability was high for the BEECOM total and subscale (i.e., Body, Eating, and Exercise Comparison Orientation) scores. Additionally, the BEECOM exhibited predictive validity in that it accounted for variance in body dissatisfaction and eating disorder symptomatology one year later. These findings held even after controlling for body mass index and existing measures of social comparison orientation. However, results regarding the incremental validity of the BEECOM, or its ability to predict change in these constructs over time, were more mixed. Overall, this study demonstrated additional psychometric properties of the BEECOM among college women, further establishing the usefulness of this measure for more comprehensively assessing eating disorder-related social comparison.

Associated Factors of Unhealthy Eating Patterns among Spanish University Students by Gender

This study has examined bio-socio-demographic and psychopathological factors probably associated with unhealthy eating patterns among university students and to estimate a multifactorial model following the associated factors by gender. Adjusted odds ratios were calculated to describe associations on basis of Eating Disorder Inventory (EDI) stratified by gender in a representative sample of Spanish university students (n = 2551). The high EDI scorers for both sexes presented higher prevalence of dieting, body dissatisfaction, levels of psychopathology and lower self-esteem than the low EDI scorers. The results suggest that older students and higher self-esteem scores present lower scores in the EDI. In the female population, depression, paranoid dimension, dieting and body dissatisfaction were associated with population with unhealthy eating patterns. In the male sample, dieting, body dissatisfaction and interpersonal sensibility were also associated with unhealthy eating patterns. The results corroborate that abnormal eating patterns tend to affect specific vulnerable groups. We do not know the precise mechanisms through which these risk behaviors and attitudes, such as dieting or body dissatisfaction, may facilitate the later development of an eating disorder.

Mental disorders in primary care

Current estimates indicate that 50% of the population experience at least one mental disorder in their lifetime and that at least 25% have suffered a mental disorder in the past year. recognition, diagnosis, treatment, and referral depend overwhelmingly on general practitioners, at least one third of whose consultations have a direct and explicit psychological component. Yet despite this intensive familiarization with the presentation of mental pathology, and the appropriateness of the primary care setting to its management, even the most recent surveys indicate that performance is best described by the rule of diminishing halves: only half the patients with a thresh-old disorder are recognized; only half of those recognized are treated; and only half of those treated are effectively treated. There is no single solution to this problem, only multiple solutions, which must be aimed, consistently and simultaneously, at the patient, practitioner, practice, and research levels.

Development and validation of the Body, Eating, and Exercise Comparison Orientation Measure (BEECOM) among college women

We constructed and validated a measure of comparison dimensions associated with eating pathology, namely, the body, eating, and exercise comparison orientation measure (BEECOM). Participants were 441 undergraduate women. In Study 1, items were generated and refined via exploratory factor analysis, yielding three interpretable factors (i.e., body, eating, and exercise comparison orientation). Confirmatory factor analysis was then used to confirm the three-factor structure of the BEECOM and to investigate the potential presence of a higher-order factor. Given that the lower-order factors loaded strongly onto a higher-order factor, it is appropriate to use a total BEECOM score, in addition to subscale scores. Further, the BEECOM's scores yielded evidence of internal consistency and construct validity in this sample. Study 2 demonstrated two-week test-retest reliability of the BEECOM among college women. Overall, the BEECOM demonstrated good psychometric properties and may be useful for more comprehensively assessing eating disorder-related social comparison behavior.

Prevalence and correlates of dieting in college women: a cross sectional study

BACKGROUND

Dieting is a common practice among young women, irrespective of age, race, ethnicity, and weight. We aimed to determine the prevalence of dieting and its relationship with eating behavior, body weight, and body mass index (BMI) in college women.

METHODS

This was a cross-sectional survey of female students aged 18-35 years (n = 308). Measures included BMI, restraint, disinhibition, hunger, dieting, weight loss, and perceived weight.

RESULTS

A high percentage of college females consider themselves overweight or obese, despite having a BMI in the normal range. Dieting was practised by 43%, and 32% were avoiding weight gain, despite 78% having a healthy BMI. Women classified themselves as overweight or obese (27%), while only 11% were actually in these categories. Exercise was a common method of weight loss and positive associations were observed between dieting and BMI. Assessment of eating behavior showed that 27% were classified as high-restraint. Restraint and disinhibition were positively correlated with BMI.

CONCLUSION

Despite the widespread availability of nutrition information, there is incongruity in measured and perceived BMI in young educated women. Dieting practices and BMI are associated with restraint and disinhibition. Nutrition professionals should consider educating college women about healthy body weight regardless of their clients' BMI.

Coping and social support as potential moderators of the relation between anxiety and eating disorder symptomatology

Trait anxiety and eating disorder (ED) symptomatology are often thought to be inextricably linked. Because anxiety often precedes an ED, predicts poor outcome, and persists even after recovery from an ED, it is important to examine whether certain factors have the ability to potentially attenuate anxiety's effect on eating pathology. In the current study, we examined two possible moderating factors: coping skills and social support. Participants were 96 females seen at one point for an ED at a Midwestern clinic, including 53 with a current ED diagnosis and 43 who no longer met criteria for an ED and who were at varying levels of recovery. Results revealed that emotion-oriented coping moderated the relation between anxiety and ED symptoms. Individuals who were high in trait anxiety and who reported low levels of emotion-oriented coping reported much lower levels of ED symptomatology than those with high trait anxiety and high emotion-oriented coping. Contrary to our hypotheses, task-oriented coping, avoidance-oriented coping, and perceived social support (total, family, friend, and special person) did not emerge as moderators of the relation between trait anxiety and eating pathology. Results provide growing support that factors that interact with anxiety can lessen anxiety's effect on eating pathology. Implications for treatment and future directions are discussed.

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

Bulimic eating disorders in primary care: hidden morbidity still?

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

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

OBJECTIVE

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

METHOD

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

RESULTS

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

DISCUSSION

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

Psychological treatments for bulimia nervosa and binging

BACKGROUND

A specific manual-based form of cognitive behavioural therapy (CBT) has been developed for the treatment of bulimia nervosa (CBT-BN) and other common related syndromes such as binge eating disorder. Other psychotherapies and modifications of CBT are also used.

OBJECTIVES

To evaluate the efficacy of CBT, CBT-BN and other psychotherapies in the treatment of adults with bulimia nervosa or related syndromes of recurrent binge eating.

SEARCH STRATEGY

Handsearch of The International Journal of Eating Disorders since first issue; database searches of MEDLINE, EXTRAMED, EMBASE, PsycInfo, CURRENT CONTENTS, LILACS, SCISEARCH, CENTRAL and the The Cochrane Collaboration Depression, Anxiety & Neurosis Controlled Trials Register; citation list searching and personal approaches to authors were used. Search date June 2007.

SELECTION CRITERIA

Randomised controlled trials of psychotherapy for adults with bulimia nervosa, binge eating disorder and/or eating disorder not otherwise specified (EDNOS) of a bulimic type which applied a standardised outcome methodology and had less than 50% drop-out rate.

DATA COLLECTION AND ANALYSIS

Data were analysed using the Review Manager software program. Relative risks were calculated for binary outcome data. Standardised mean differences were calculated for continuous variable outcome data. A random effects model was applied.

MAIN RESULTS

48 studies (n = 3054 participants) were included. The review supported the efficacy of CBT and particularly CBT-BN in the treatment of people with bulimia nervosa and also (but less strongly due to the small number of trials) related eating disorder syndromes.Other psychotherapies were also efficacious, particularly interpersonal psychotherapy in the longer-term. Self-help approaches that used highly structured CBT treatment manuals were promising. Exposure and Response Prevention did not enhance the efficacy of CBT.Psychotherapy alone is unlikely to reduce or change body weight in people with bulimia nervosa or similar eating disorders.

AUTHORS' CONCLUSIONS

There is a small body of evidence for the efficacy of CBT in bulimia nervosa and similar syndromes, but the quality of trials is very variable and sample sizes are often small. More and larger trials are needed, particularly for binge eating disorder and other EDNOS syndromes. There is a need to develop more efficacious therapies for those with both a weight and an eating disorder.

Outcome of eating disorders

Both Anorexia Nervosa (AN) and Bulimia Nervosa (BN) are marked by a serious course and outcome in many of the afflicted individuals. In AN, there are an almost 18-fold increase in mortality including a high suicide rate, chronic courses in approximately 20 per cent of the cases, and more than half of the patients showing either a complete or a partial eating disorder in combination with another psychiatric disorder or another psychiatric disorder without an eating disorder. Mitigating factors of the outcome include onset of the disorder during adolescence and longer duration of follow-up. Vomiting, bulimia and purgative abuse, chronicity, and obsessive-compulsive features represent unfavourable prognostic factors in various studies. The longer-term outcome of BN is only slightly better result as compared to AN; however, the rate of mortality is low. Diagnostic crossover from bulimia nervosa to other eating disorders is a rather rare phenomenon, whereas the high rates of partial eating disorders may explain a large proportion of chronic courses. Social adjustment and the quality of personal relationship normalize in the majority of the affected patients. At present, the study of prognostic factors in bulimia nervosa does not allow any definite conclusions.

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.

College students’ mental models for recognizing anorexia and bulimia nervosa

Knowledge about eating disorders influences lay people's ability to recognize individuals with anorexia nervosa (AN) and bulimia nervosa (BN) and refer them to professional treatment. We assessed mental models (stored knowledge) of AN and BN in 106 college students. Results indicated that most students have general, but not specific, information about AN and BN's symptoms, consequences, causes, duration, and cures. They also believe that people with eating disorders tend to be young, White women. These findings suggest that lay recognition of eating disorders may be based primarily on observations of dysfunctional eating behaviors and therefore facilitated by additional knowledge.

Recurrent binge eating (RBE) and its characteristics in a sample of young women in Germany

OBJECTIVE

To examine the characteristics of recurrent binge eating (RBE) in a non-treatment-seeking sample from the general population. RBE individuals are described in terms of socio-economic status, general psychopathology, and comorbidity rates of mental disorders.

METHOD

Participants were 1877 German females aged 18-24 years from a population-based epidemiological study.

RESULTS/DISCUSSION

The point prevalence of RBE in our sample was 0.9% (N = 17). Compared to healthy women, subjects with RBE suffered more often from comorbid mental disorders and also exhibited more general psychopathology: They were similar to women with other mental disorders and other eating disorders (EDs). RBE seems to be a syndrome of clinical significance itself and might be an important risk factor for the development of further EDs, especially binge eating disorder (BED) and other mental disorders.

Gender, eating behavior, and personality characteristics in physically active students

The aim of this paper was to examine associations between personality traits, eating disorder (ED) behavior, exercise, and gender. The participants (n=1482: 905 women and 577 men) were students from four universities in Norway. The subjects filled out a compound questionnaire including demographics, weekly hours of exercise, type of sport, Karolinska Scales of Personality (KSP), and the Eating Disorder Inventory (EDI). Because of the data collection procedure, it is difficult to provide a clear-cut response rate in this study. The results showed that the risk ratio for women who scored 40 or higher on the EDI was three times higher compared with men. ED behavior did not seem to be associated with high weekly hours of physical activity in general. There were significant gender differences in personality traits. However, women and men with high scores on the EDI showed no differences on the KSP scales, except on "detachment" and "indirect aggression". The most important predictors for weekly hours of physical activity were the EDI scales "drive for thinness" and "body dissatisfaction", and the personality variables "extraversion" and "neuroticism". The factors that contributed most to the differences between students who scored 40 or higher on the EDI and those who scored below 40 on the EDI were neuroticism, BMI, gender, and age.

High prevalence of abnormal eating and weight control practices among U.S. high-school students

OBJECTIVE

This study sought to determine the prevalence and to identify correlates of abnormal eating and weight control practices in U.S. high-school students.

METHOD

A three-stage cluster design technique was used to select 15,349 students from 144 different high schools. Each completed the 1999 Youth Risk Behavior Survey (YRBS) Questionnaire.

RESULTS

Abnormal eating and weight control practices during the past month were reported by over 26% of female students and 10% of male students. Rates of abnormal eating and weight control practices varied by ethnicity and geographic location. Other correlates of abnormal eating and weight control practices included having an underweight body mass index (BMI): (OR=1.39, 95% CI=1.01-1.91), exercising to control weight in past 30 days (OR=1.51, 95% CI=1.30-1.76), dieting to control weight in past 30 days (OR=3.89, 95% CI=2.65-5.73), and interactions between gender and both weight perception and weight satisfaction.

DISCUSSION

The high proportion of U.S. high-school students who have participated in abnormal eating and weight control practices in the past month demands immediate attention. The identified correlates may help target prevention and control programs.

Nonresponse bias in a general population survey of eating-disordered behavior

OBJECTIVE

To investigate nonresponse bias in a two-phase epidemiologic study of eating-disordered behavior.

METHOD

Self-report questionnaires were delivered to a community sample of women aged 18-45 drawn from the electoral roll. Follow-up interviews were completed with a subgroup of respondents. Eating disorder psychopathology, general physical and mental health, and sociodemographic characteristics were compared among early (n = 259) and late (n = 71) respondents at the first phase of the study and among individuals with whom interviews were completed (n = 208) and individuals declining to be interviewed (n = 63) at the second phase.

RESULTS

With respect to levels of eating disorder psychopathology, and on all other measures, individuals who responded at the first phase of the study only after repeated reminders did not differ from those who responded to the initial mailout, and individuals who declined to be interviewed did not differ from individuals with whom interviews were completed.

CONCLUSIONS

Nonresponse bias among individuals declining to be interviewed is unlikely to pose a problem in two-phase epidemiologic studies of eating disorders. Further research is needed to examine the characteristics of nonrespondents at the first phase of such studies.

Validity of the Eating Disorder Examination Questionnaire (EDE-Q) in screening for eating disorders in community samples

In order to examine the concurrent and criterion validity of the questionnaire version of the Eating Disorders Examination (EDE-Q), self-report and interview formats were administered to a community sample of women aged 18-45 (n = 208). Correlations between EDE-Q and EDE subscales ranged from 0.68 for Eating Concern to 0.78 for Shape Concern. Scores on the EDE-Q were significantly higher than those of the EDE for all subscales, with the mean difference ranging from 0.25 for Restraint to 0.85 for Shape Concern. Frequency of both objective bulimic episodes (OBEs) and subjective bulimic episodes (SBEs) was significantly correlated between measures. Chance-corrected agreement between EDE-Q and EDE ratings of the presence of OBEs was fair, while that for SBEs was poor. Receiver operating characteristic (ROC) analysis, based on a sample of 13 cases, indicated that a score of 2.3 on the global scale of the EDE-Q in conjunction with the occurrence of any OBEs and/or use of exercise as a means of weight control, yielded optimal validity coefficients (sensitivity = 0.83, specificity = 0.96, positive predictive value = 0.56). A stepwise discriminant function analysis yielded eight EDE-Q items which best distinguished cases from non-cases, including frequency of OBEs, use of exercise as a means of weight control, use of self-induced vomiting, use of laxatives and guilt about eating. The EDE-Q has good concurrent validity and acceptable criterion validity. The measure appears well-suited to use in prospective epidemiological studies.

Antecedents and consequences of binge eating episodes in women with an eating disorder

The aim of this study was to explore antecedents and sequelae of binge eating episodes. A sample of eating disorders (n = 154 women) was selected from a total of 1849 female respondents (out of 2500) recruited as part of a general population-based survey. Included participants met DSM-III-R criteria for anorexia nervosa (AN), bulimia nervosa (BN) or eating disorder not otherwise specified (EDNOS) based on the Survey for Eating Disorders (SEDs). Preliminary criteria for binge eating disorder (BED) were added. Results indicated that the most frequently reported antecedents and consequences of binge eating were emotional and physiological factors. There were significant differences between the different ED subgroups in their frequency of binge eating episodes. Regarding antecedents of a binge eating episode, the SEDs-defined ED subgroups had overall differences in frequency on "stomach feeling". In particular, the BN-group reported "euphoria" more frequently than the BED and EDNOS-groups. Concerning consequences of a binge eating episode, there were overall differences between the ED subgroups on "fall asleep", and in addition a borderline significance was found for "disturbed by others" (p = 0.059). None of the eight women in the AN group reported "euphoria" as a factor that terminated a binge eating episode. The findings may have important implications with regard to prevention and treatment of ED.

Coming to Terms With Risk Factors for Eating Disorders: Application of Risk Terminology and Suggestions for a General Taxonomy

The aims of the present review are to apply a recent risk factor approach (H. C. Kraemer et al., 1997) to putative risk factors for eating disorders, to order these along a timeline, and to deduce general taxonomic questions. Putative risk factors were classified according to risk factor type, outcome (anorexia nervosa, bulimia nervosa, binge-eating disorder, full vs. partial syndromes), and additional factor characteristics (specificity, potency, need for replication). Few of the putative risk factors were reported to precede the onset of the disorder. Many factors were general risk factors; only few differentiated between the 3 eating disorder syndromes. Common risk factors from longitudinal and cross-sectional studies were gender, ethnicity, early childhood eating and gastrointestinal problems, elevated weight and shape concerns, negative self-evaluation, sexual abuse and other adverse experiences, and general psychiatric morbidity. Suggestions are made for the conceptualization of future risk factor studies.

Review of the prevalence and incidence of eating disorders

OBJECTIVE

To review the literature on the incidence and prevalence of eating disorders.

METHODS

We searched Medline using several key terms relating to epidemiology and eating disorders and we checked the reference lists of the articles that we found. Special attention has been paid to methodologic problems affecting the selection of populations under study and the identification of cases.

RESULTS

An average prevalence rate for anorexia nervosa of 0.3% was found for young females. The prevalence rates for bulimia nervosa were 1% and 0.1% for young women and young men, respectively. The estimated prevalence of binge eating disorder is at least 1%. The incidence of anorexia nervosa is 8 cases per 100,000 population per year and the incidence of bulimia nervosa is 12 cases per 100,000 population per year. The incidence of anorexia nervosa increased over the past century, until the 1970s.

DISCUSSION

Only a minority of people who meet stringent diagnostic criteria for eating disorders are seen in mental health care.

Prevalence of bulimic behaviours and eating attitudes in schoolgirls from Trinidad and Barbados

We investigated eating attitudes and the prevalence of bulimic disorders in a group of 362 schoolgirls from the islands of Trinidad and Barbados using key questions from the Bulimia Investigatory Test, Edinburgh (BITE) and additional questions for the exploration of eating attitudes and dieting practices. A random sample of 92 girls were interviewed using the DSM-III-R Bulimia Diagnostic Interview. Only three subjects (0.8%) scored over the cut-off point on the BITE. None of the interviewees was diagnosed as having bulimia nervosa. Two hundred and forty-five girls (67.7%) reported being terrified of becoming fat and fat-fear was associated with higher Body Mass Index, dieting and exercising for losing weight. Girls of African origin were found to have a more unusual eating pattern and more concerns about their eating habits. The prevalence of bulimic disorders in Caribbean schoolgirls is still very low, but they are a population at increasing risk since they share the western ideals of slimness and engage in dieting behaviours.

Causes and recovery in anorexia nervosa: the patient's perspective

OBJECTIVE

We explored anorexic patients' subjective accounts of the causes of their anorexia and of the factors that fostered recovery. Subjective accounts could assist in understanding this complicated and often intractable disorder.

METHOD

All female new referrals to an eating disorders service underwent extensive interviews including open-ended questions about their beliefs concerning the causes of their anorexia nervosa and factors that led to recovery. Responses were categorized by two independent raters.

RESULTS

The most commonly mentioned perceived causes were dysfunctional families, weight loss and dieting, and stressful experiences and perceived pressure. The three most commonly cited factors contributing to recovery were supportive nonfamilial relationships, therapy, and maturation.

DISCUSSION

Individuals with anorexia nervosa perceive both external (family environment) and personal factors (dieting and stress) as contributory to their disorders. The results underscore the importance of interpersonal factors in recovery from anorexia nervosa and suggest that attention to this area in treatment may be beneficial.

Four simple questions can help screen for eating disorders

Current screening instruments for eating disorders are cumbersome to administer and have not been validated in primary care populations. We compared the performance characteristics of 2 screening tools, the SCOFF clinical prediction guide, and a new set of questions, the Eating disorder Screen for Primary care (ESP), using the Questionnaire for Eating Disorders Diagnosis as the independent standard, in 104 consecutive patients from a primary care practice and 129 university students. Twelve percent of the combined population had an eating disorder. One or no abnormal responses to the ESP ruled out an eating disorder (likelihood ratio [LR] 0.0), whereas 3 or more abnormal responses ruled one in (LR 11). The SCOFF questions were less sensitive than predicted (1 or no abnormal responses, LR 0.25), but were as effective at ruling in an eating disorder (3 or more abnormal responses, LR 11).