Review of Risk Factors for Eating Disorders: Implications for Primary Prevention and Cognitive Behavioural Therapy

Disordered eating in a 10-year perspective from adolescence to young adulthood: Stability, change, and body dissatisfaction as a predictor

INTRODUCTION

Although there are many studies of disordered eating (DE) in adolescence, studies examining the longitudinal stability and change of DE and its longitudinal associations with other factors are still rather scarce. Such studies are important to inform parents and clinicians how stable DE is and to what extent it will go away with increased maturity. Longitudinal studies may also be of help in establishing predictors of long-term problems. The purpose of the present study was to investigate the stability of DE over a 10-year period from early adolescence to young adulthood, and to explore body dissatisfaction as a predictor in a 10-year perspective.

METHODS

Data were taken from a three-wave longitudinal project (SoL) with survey data collected among the students in Grades 7and 8 in a Swedish municipality in 2007 (T1), 1 year later (T2), and in a 10-year follow-up in 2017 (T3). DE was measured by the eight-item version of the Risk Behaviour Related to Eating Disorders (RiBED-8), and a quasi-clinical criterion of six or more critical answers on the RiBED-8 was used to classify DE cases.

RESULTS

Of the girls, 5.8% passed the cutoff for DE at T1, whereas 9.1% did so at T2 and 7.9% at T3. The boys showed markedly lower figures: 0.5% both at T1 and T2, and 1.5% at T3. There was significant individual stability of DE over the 10-year period, with almost 30% of the girls who passed the cutoff for DE at T1 also doing so 10 years later. Body dissatisfaction in early adolescence predicted the incidence of new cases of DE 10 years later, even when controlling for degree of DE in early adolescence. The results also indicate that DE in early adolescence may be a passing phase among adolescents who express relatively high body satisfaction.

CONCLUSIONS

The present results show a complex picture of different individual trajectories of DE, with degree of body satisfaction playing a significant role for the outcome in a 10-year perspective. Body dissatisfaction appears to be a risk factor for the development of new cases of DE, whereas body satisfaction may protect against the continuation of DE into adulthood.

Development of transdiagnostic clinical risk prediction models for 12-month onset and course of eating disorders among adolescents in the community

OBJECTIVE

To develop and internally validate risk prediction models for adolescent onset and persistence of eating disorders.

METHODS

N = 963 Australian adolescents (11-19 years) in the EveryBODY Study cohort completed online surveys in 2018 and 2019. Models were built to predict 12-month risk of (1) onset, and (2) persistence of a DSM-5 eating disorder.

RESULTS

Onset Model. Of the n = 687 adolescents without an eating disorder at baseline, 16.9% were identified with an eating disorder after 12 months. The prediction model was based on evidence-based risk factors for eating disorder onset available within the dataset (sex, body mass index percentile, strict weight loss dieting, history of bullying, psychological distress, weight/shape concerns). This model showed fair discriminative performance (mean AUC = .75). The most important factors were psychological distress, weight and shape concerns, and female sex. Diagnostic Persistence Model. Of the n = 276 adolescents with an eating disorder at baseline, 74.6% were identified as continuing to meet criteria for an eating disorder after 12 months. The prediction model for diagnostic persistence was based on available evidence-based risk factors for eating disorder persistence (purging, distress, social impairment). This model showed poor discriminative performance (mean AUC = .65). The most important factors were psychological distress and self-induced vomiting for weight control.

DISCUSSION

We found preliminary evidence for the utility of a parsimonious model for 12-month onset of an eating disorder among adolescents in the community. Future research should include additional evidence-based risk factors and validate models beyond the original sample.

PUBLIC SIGNIFICANCE

This study demonstrated the feasibility of developing parsimonious and accurate models for the prediction of future onset of an eating disorder among adolescents. The most important predictors in this model included psychological distress and weight and shape concerns. This study has laid the ground work for future research to build and test more accurate prediction models in diverse samples, prior to translation into a clinical tool for use in real world settings to aid decisions about referral to early intervention.

Many Facets of Eating Disorders: Profiling Key Psychological Features of Anorexia Nervosa and Binge Eating Disorder

Objective. The present study employs a profile analysis to identify and compare psychological features and core eating disorder (ED) symptoms in clinical samples of patients with anorexia nervosa (AN) and binge eating disorder (BED) and the general population (GP). Methods. A sample comprising 421 participants (142 patients with AN; 139 patients with BED; and 140 participants from the GP) was surveyed with the Eating Disorder Inventory-3 (EDI-3). Individuals with AN and BED were recruited and tested during their first week of a multidisciplinary inpatient program for weight loss and rehabilitation at the 'Rete DCA USL Umbria 1' (Eating Disorders Services), Italy. Results. The findings suggest distinct patterns of symptom presentation between the three samples across all the EDI-3 dimensions-with both the AN and BED groups scoring significantly higher than the GP. Patients with AN registered greater scores in all the psychological trait scales and the drive for thinness ED-specific dimension of the EDI-3 compared with their BED counterpart-which, instead, scored higher in the bulimia and body dissatisfaction subscales. These data support the transdiagnostic nature of the main risk factors for the onset and maintenance of EDs-which would vary in severity levels-and the existence of disease-specific pathways giving rise to AN and BED. Conclusion. This study for the first time compares patients with AN and BED with a non-clinical sample on main ED psychological features. This might inform classification approaches and could have important implications for the development of prevention and early intervention programs.

Hunger increases negative and decreases positive emotions in women with a healthy weight

The term 'hangry' is colloquially used to describe being "bad tempered or irritable as a result of hunger," but remarkably few studies have examined the effect of hunger on emotions. Yet, women attempting to restrict their food intake may be at risk of becoming entangled in a vicious cycle of hunger and negative emotions. That is, hunger may lead to negative emotions, which can lead to overeating and overeating can, in turn, provoke subsequent restriction leading to more hunger. Therefore the aim of this study was to examine the effect of hunger on positive and negative emotions in women with a healthy BMI, and the role of subclinical eating disorder symptoms in this effect. We randomly assigned women to a hunger condition (fasting for 14 h, n = 53) or satiated condition (eat breakfast before the study, n = 55), and they completed the Eating Disorder Examination Questionnaire and the Profile of Mood States in the lab. Hungry women reported overall higher negative emotions (higher tension, anger, fatigue, and confusion) and lower positive emotions (lower vigour and marginally lower esteem-related affect) than satiated women. Moreover, for satiated but not for hungry women, higher eating disorder symptoms were associated with lower esteem-related affect. These findings show that food restriction leads to negative emotions, and practitioners and individuals should be aware of these implications of food restriction on mental health. Second, clinicians and individuals should be wary of relatively low esteem-related affect when satiated in individuals with eating disorder symptoms, as it could serve as a maintaining factor in eating pathology.

Two randomized controlled trials of the efficacy of acceptance and commitment therapy-based educational course for body shape dissatisfaction

The main aim of this project was to explore the efficacy of Acceptance and Commitment Therapy (ACT)-based educational course in different formats (i.e., pure and guided self-help with different durations, and guided self-help with and without access to a discussion forum) for body shape dissatisfaction. Two randomized controlled studies (RCT) were carried out. In the first RCT, the participants were randomized to a 12- or 16-week guided self-help, a 16-week pure self-help, or a waitlist control condition. In the second RCT, the efficacy of 12-week guided self-help with or without access to a discussion forum was investigated. ACT-based self-help resulted in promising improvements in body shape dissatisfaction, and modest effects on general health indicators (i.e., symptom of depression, self-esteem, satisfaction with life, and quality of life). The findings also showed no additional effects of support, access to the online discussion forum, and longer duration of self-help, suggesting the 12-week self-help with or without support is a viable option for reducing body shape dissatisfaction.

Individual and relational risk factors for the development of eating disorders in adolescent aesthetic athletes and general adolescents

This study compared potential risk and protective factors, levels of disordered eating (DE), and their relationship among young aesthetic athletes (elite and non-elite) and controls (N = 725; 62.5 % females; mean age = 15.3, SD = 2.1). The participants completed self-report measures (McKnight Risk Factor Survey-IV, Contour Drawing Rating Scale and Eating Disorder Examination-Questionnaire). Female elite athletes showed a greater risk of developing eating disorders than non-elite athletes and controls, with no difference between the three groups of males. Multiple group analyses revealed important differences in DE predictors. Although social pressure is the strongest DE predictor in non-elite athletes and controls, in elite athletes, the strongest DE predictor is body image dissatisfaction. Parental influences, rather than self-esteem, are predictors of DE in elite athletes, unlike the other two groups. These results show that the risk and protective factors involved in the development of DE are not universally valid. The results highlight the importance of studying specific characteristics associated with DE in aesthetic athletes. Some implications for ED risk assessment and prevention are discussed.

Promoting positive body image among university students: A collaborative pilot study

The purpose of the present study was to pilot a prevention program designed to promote positive body image among university students. Thirty-seven undergraduate students from three Canadian universities were recruited to participate in the study. They were selected from a pool of students enrolled in a peer health education program facilitated by the university-based health promotion staff. Borrowing from the tenets of the non-specific vulnerability stressor model and the disease-specific social cognitive theory, the intervention focused on media literacy, self-esteem enhancement strategies, stress management skills and ways to recognize healthy versus unhealthy relationships. Separate ANOVAs revealed that participants reported significant improvements in body satisfaction and reductions in the internalization of media stereotypes between the baseline and post-program period. The program received a favorable response from the participating students, who appreciated the face-to-face format of the intervention, and from the university staff who expressed interest in embedding the strategies into their routine peer mentoring training activities. Limitations of the study and suggestions for future research are discussed.

Do coping strategies discriminate eating disordered individuals better than eating disorder features? An explorative study on female inpatients with anorexia and bulimia nervosa

The purpose of this explorative research was to examine how the COPE (Coping Orientation to Problem Experienced Inventory), an established instrument for measuring coping styles, and EDI-2 (Eating Disorder Inventory-2), a widely used questionnaire for assessing psychological and behavioural features of eating disorders (ED), discriminate among healthy individuals, inpatients with anorexia nervosa (AN) and inpatients with bulimia nervosa (BN). A discriminant analysis approach was used. Results showed that coping styles such as positive attitude, planning and social support are even more discriminative variables than eating disorder features. Implications for further studies are discussed.

Does perfectionism mediate or moderate the relation between body dissatisfaction and disordered eating attitudes and behaviors?

A link between perfectionism and disordered eating has been documented in previous studies. The purpose of the current study was to expand our knowledge of the specific role of perfectionism in disordered eating by examining perfectionism as a mediator or a moderator in the relation between body dissatisfaction and disordered eating (assessed using the EAT-26 and its subscales, and the Binge Scale). We sampled a large ethnically diverse sample of university women (N=520) using two measures of perfectionism: the Eating Disorder Inventory Perfectionism subscale (EDI-P) and the Multidimensional Perfectionism Scale (H-MPS). In general, socially prescribed and self-oriented perfectionism, but not other-oriented perfectionism, were correlated with disordered eating attitudes and behaviors, except binge eating. Furthermore, perfectionism was found to partially mediate and moderate the relation between body dissatisfaction and disordered eating, however the strength of these associations differed depending on both the particular measure of perfectionism (EDI-P versus H-MPS) and the specific dimension of perfectionism (self-oriented, socially prescribed, other-oriented) used in the analyses. The findings are discussed in relation to the need for more informed and theoretically sound models of the development and maintenance of disordered eating.