Association of biological, psychological and lifestyle risk factors for eating disturbances in adolescents

Self-Esteem and Risk Behaviours in Adolescents: A Systematic Review

Adolescence is recognised as a notoriously vulnerable period in the human life cycle. Influenced by a complex interplay of biological, psychological and social factors, adolescents show a marked propensity to engage in risk behaviours. A systematic review was conducted of studies published in the Web of Science, PsycInfo and MEDLINE databases over the last decade, with the aim of collecting studies on the relationship between self-esteem and risk behaviour in individuals aged 12-18 years. The aim was to confirm the role of high self-esteem as a consistent protective factor against risk behaviour. The results show that self-esteem is negatively related to risk behaviour. Our results also reflect the need for further research on how sociodemographic factors, among others, affect the relationship between self-esteem and risk behaviours. This review highlights the relevance of implementing specific educational interventions to strengthen self-esteem in adolescents, with the aim of preventing various risk behaviours that may emerge during adolescence and persist throughout life if not addressed early.

Bullying as a Risk Factor for Eating Disorder Behaviors Among Students: Secondary Analysis for a Cluster Randomized Controlled Trial

This study aimed to examine whether being a victim of bullying predicted body dissatisfaction and eating disorder behavior (EDB). In this study, we performed secondary analysis from a cluster randomized controlled trial among 5208 eight grade students from 73 public schools in three Brazilian cities. Data were collected in 2019 through an anonymous self-report questionnaire on bullying, body dissatisfaction, and EDB. We used factor analysis, multivariate linear regression, and multinomial logistic regression to verify whether being a victim of bullying during the baseline results in body dissatisfaction and EDB at the nine months follow-up for the control and intervention groups. Our results showed that being female (OR 1.41, 95% CI 1.22-1.63) is a risk factor for dissatisfaction by overweight. Bullying was not a predictor of body dissatisfaction; however, being a victim of bullying (β 0.40, 95% CI 0.35-0.46) is a predictor of having more EDB, independent of the exposure to the program. Therefore, bullying deserves attention in the school environment.

Global Proportion of Disordered Eating in Children and Adolescents: A Systematic Review and Meta-analysis

Importance

The 5-item Sick, Control, One, Fat, Food (SCOFF) questionnaire is the most widely used screening measure for eating disorders. However, no previous systematic review and meta-analysis determined the proportion of disordered eating among children and adolescents.

Objective

To establish the proportion among children and adolescents of disordered eating as assessed with the SCOFF tool.

Data Sources

Four databases were systematically searched (PubMed, Scopus, Web of Science, and the Cochrane Library) with date limits from January 1999 to November 2022.

Study Selection

Studies were required to meet the following criteria: (1) participants: studies of community samples of children and adolescents aged 6 to 18 years and (2) outcome: disordered eating assessed by the SCOFF questionnaire. The exclusion criteria included (1) studies conducted with young people who had a diagnosis of physical or mental disorders; (2) studies that were published before 1999 because the SCOFF questionnaire was designed in that year; (3) studies in which data were collected during COVID-19 because they could introduce selection bias; (4) studies based on data from the same surveys/studies to avoid duplication; and (5) systematic reviews and/or meta-analyses and qualitative and case studies.

Data Extraction and Synthesis

A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.

Main Outcomes and Measures

Proportion of disordered eating among children and adolescents assessed with the SCOFF tool.

Results

Thirty-two studies, including 63 181 participants, from 16 countries were included in this systematic review and meta-analysis. The overall proportion of children and adolescents with disordered eating was 22.36% (95% CI, 18.84%-26.09%; P < .001; n = 63 181) (I2 = 98.58%). Girls were significantly more likely to report disordered eating (30.03%; 95% CI, 25.61%-34.65%; n = 27 548) than boys (16.98%; 95% CI, 13.46%-20.81%; n = 26 170) (P < .001). Disordered eating became more elevated with increasing age (B, 0.03; 95% CI, 0-0.06; P = .049) and body mass index (B, 0.03; 95% CI, 0.01-0.05; P < .001).

Conclusions and Relevance

In this systematic review and meta-analysis, the available evidence from 32 studies comprising large samples from 16 countries showed that 22% of children and adolescents showed disordered eating according to the SCOFF tool. Proportion of disordered eating was further elevated among girls, as well as with increasing age and body mass index. These high figures are concerning from a public health perspective and highlight the need to implement strategies for preventing eating disorders.

Prevalence of Disordered Eating and Its Associated Factors From a Socioecological Approach Among a Sample of Spanish Adolescents: The EHDLA Study

Objectives: The aim of this study was twofold: a) to establish the prevalence of adolescents with disordered eating and b) to determine the factors associated with this prevalence in a sample of Spanish adolescents from the Valle de Ricote (Region of Murcia, Spain).

Methods: This cross-sectional study analyzed data from 730 adolescents (56.2% girls) from the EHDLA study. To determine the prevalence of disordered eating, the Sick, Control, One stone, Fat, Food (SCOFF) questionnaire was used. A socioecological approach was used to identify individual-, interpersonal-, or organizational-level factors associated with disordered eating.

Results: The prevalence of disordered eating was 30.1%. This condition was associated with female sex (odds ratio [OR] = 2.60; 95% confidence interval [CI], 1.81–3.73), immigrant status (OR = 2.22; 95% CI, 1.51–3.25), or excess weight (OR = 2.74; 95% CI, 1.93–3.89). Furthermore, for each additional hour slept, lower odds of having disordered eating were found (OR = 0.81; 95% CI, 0.67–0.98).

Discussion: Almost one-third of the sample of Spanish adolescents analyzed reported disordered eating. Female sex, immigrant status and excess weight are individual aspects that seem to be related to disordered eating among Spanish adolescents.

Self-esteem and socialisation in social networks as determinants in adolescents' eating disorders

Eating disorders are mental health illnesses that are influenced by various individual, family and social factors. The present study aimed to examine the influence of self-esteem and socialisation through social networks on eating disorder behaviours in adolescence. The sample was made up of 721 secondary school students (49.1% girls). The sample age ranged between 12 and 18 years (M = 13.89, SD = 1.37). Participants completed the Eating Attitudes Test-26 (EAT-26) to measure disordered eating attitudes and behaviours, the Rosenberg Self-Esteem Scale and the ESOC-39 scale, which measures socialisation through social networks, in addition to a brief initial sociodemographic survey. Descriptive and multivariate analyses were carried out with MANOVA. Low self-esteem was shown to increase behaviours linked to eating disorders globally. Likewise, high socialisation through social networks was also associated with a general increase in eating disorders during adolescence. The findings of the study provide empirical support for the need to develop prevention strategies that address the improvement in self-esteem and adequate socialisation through social networks during adolescence. The development of effective interventions along these lines could be helpful to treat the behaviours and attitudes that are observed in eating disorders.

Family Dysfunctional Interactive Patterns and Alexithymia in Adolescent Patients with Restrictive Eating Disorders

Adolescents diagnosed with Restrictive Eating Disorders (REDs) are at risk for alexithymia. REDs patients’ families show dysfunctional interactive patterns, and childhood family environment influences alexithymia development. We aimed to assess the relationship between family dysfunctional interactive patterns and patients’ alexithymia in a sample of adolescents diagnosed with REDs. Forty-five patients and their parents were enrolled. They participated in the clinical version of the Lausanne Triadic Play (LTPc), a standardized observational procedure to assess family functioning. We used the self-report questionnaire Toronto Alexithymia Scale (TAS-20) to assess patients’ alexithymia. The TAS-20 provides a multi-factorial measure of patients’ alexithymia: Difficulty in Identifying Feelings, DIF; Difficulty in Describing Feelings, DDF; Externally-oriented Thinking, EOT) and a total (TOT) score. DDF and EOT scores were significantly higher than DIF score. Patients’ families showed dysfunctional interactive patterns, with a predominance of collusive alliance. Patients from families characterized by collusive alliance had higher TOT scores compared to counterparts from families exhibiting a different interactive dysfunctional pattern. In families characterized by a collusive triadic alliance, the dysfunctional interactive pattern was linked with the risk of alexithymia in patients with REDs. Assessment of family relationships should be included in the routine consultation with adolescent patients affected by REDs.

Gastrointestinal and eating problems in women with Ehlers-Danlos syndromes

PURPOSE

Ehlers-Danlos syndromes (EDS) are a group of heritable conditions in which abnormal collagen synthesis leads to features such as joint hypermobility, skin abnormalities, and tissue fragility. Gastrointestinal (GI) symptoms are common among those affected. These may negatively impact eating behaviors, leading to weight/nutritional problems. We aimed to compare GI symptoms, disordered eating, and body mass index (BMI) between EDS patients and healthy controls, and to explore the link between these variables in EDS patients.

METHOD

In this cross-sectional study, women with EDS and healthy controls responded to an online survey assessing GI symptoms (heartburn/regurgitations, early satiety, nausea/vomiting, bloating, abdominal pain, dysphagia), food allergies/intolerances, disordered eating, history of eating disorders (ED), and BMI. We performed intergroup comparisons as well as multivariate analyses to explore the associations between disordered eating, GI symptoms, and BMI in the EDS group.

RESULTS

Sixty-six women with EDS and 39 healthy controls were included in the study. The EDS patients showed significantly more GI symptoms and food allergies/intolerances, increased prevalence of ED history, higher risk of current ED, and lower BMI than the controls. In the EDS group, the risk for ED was associated with GI symptoms; restricted eating was associated with GI symptoms, food allergies/intolerances, and dysphagia; uncontrolled eating was associated with GI symptoms; and BMI was associated with GI symptoms and food allergies/intolerances.

DISCUSSION

Our results are concordant with that of previous reports highlighting the high level of GI problems and disordered eating in women with EDS. In addition, and for the first-time, the association between both is evidenced in this specific population.

LEVEL OF EVIDENCE III

Case-control analytic study.

Assessing Family Functioning Before and After an Integrated Multidisciplinary Family Treatment for Adolescents With Restrictive Eating Disorders

The present study presents an investigation of family functioning in the families of adolescents with severe restrictive eating disorders (REDs) assessed before and 6 months after a multidisciplinary family treatment program that combined psychodynamic psychotherapy, parental role intervention, and triadic or family-centered interventions. Nutritional counseling and neuropsychiatric monitoring of the overall treatment and care process were also provided. Family functioning was assessed using the clinical version of the Lausanne Trilogue Play (LTPc), a semi-structured procedure for observing family dynamics, previously validated for this patient population. The LTPc is divided into four phases. In phase 1, the mother interacts with the patient while the father assumes the role of observer. In phase 2, the father plans an activity with the patient while the mother observes. In phase 3, all the family members interact. Finally, in phase 4, the parents talk while the adolescent observes. A significant change emerged in family functioning after the treatment, but only for the interactive phase 2, when the father is required to interact with the daughter while the mother silently observes. The results of this study suggest that a relatively brief multidisciplinary treatment program may significantly improve family functioning in the families of patients diagnosed with severe REDs. Although appropriate clinical trials are needed to further test the efficacy of this treatment, the results also reinforce the concept that treatment programs targeting the individual patient and both the parents should be a first-line approach in adolescents with severe REDs.

Being bullied and using drugs are associate with eating disorder symptoms in Brazilian students

OBJECTIVE

This study's main purpose is to evaluate factors associated with eating disorder (ED) symptoms among Brazilian adolescents.

METHOD

The sample consisted of 5,213 students, mean age 13.24 (SD ±0.01), in the eighth grade of 93 public schools from three Brazilian cities. Data were collected through an anonymous self-report questionnaire, assessing: sociodemographics, use of alcohol, tobacco, illicit drugs, binge drinking, bullying, and ED symptoms. We used confirmatory factor analysis and multivariate linear regression.

RESULTS

We found that high levels of bullying victimization, binge drinking and the use of unprescribed weight-loss substances were associated with higher levels of ED symptoms to both genders. However, only among girls, the higher age (β = .10; 95% CI = 0.02; 0.17) and the use of illicit drugs (β = .21; 95% CI = 0.094; 0.34) were associated with increase in the ED symptoms.

DISCUSSION

We demonstrate a significant association of ED symptoms with drug use and bullying, highlighting the importance of addressing these factors in the development of ED prevention strategies.

The relationship between perfectionism and eating-related symptoms in adolescents: A systematic review

The clinical significance of two major aspects of perfectionism, perfectionistic strivings (PS) and perfectionistic concerns (PC), in eating disorders (EDs) symptoms was well-established among adults. However, no systematic review has assessed evidence examining associations between both unidimensional and multidimensional perfectionism and EDs in early and middle adolescence. For this aim, three online databases (PsycINFO, Medline and PsycArticle) were searched for articles published until January 2019, and observational studies were considered. Study quality was systematically appraised, and results were summarized using a narrative synthesis approach. Fifty-one cross-sectional and 28 longitudinal studies were included. Most studies supported the relationship between perfectionism and EDs, with the majority adopting a unidimensional approach for assessing perfectionism. Among studies that employed multidimensional measures of perfectionism, the majority (n = 11) of evidence supported the relationship between eating symptoms and PC, while fewer (n = 5) studies provided significant unique associations with PS. These findings are consistent with the body of research suggesting the strength of the relationship between PC and EDs was greater than between PS and EDs. It was recommended that preventive interventions should be primarily focused on reducing self-critical perfectionism, since it resulted to be the most relevant perfectionistic dimension in the development of eating symptoms in adolescents.

Focus on family functioning in anorexia nervosa: new perspectives using the Lausanne Trilogue Play

31 families of female adolescents affected by anorexia nervosa (AN) and 20 of girls with emotional and behavioral disorders participated in a semi-standardized videotaped game: the Lausanne Trilogue Play (LTPc). We aimed to clarify if there is a typical AN family profile and if the LTPc procedure could predict the risk of developing AN. We confirmed that AN families exhibit dysfunctional alliances. Particularly because of the difficulty of the three members to be available to the interaction at least with their body (participation) and to comply with the role expected at each stage of the game (organization). Moreover, these families show a significant worse functioning, especially regards to the mother-daughter phase of the game, in focal attention and affective contact functional levels, while in triadic and couple phases they present lower scores than comparison group in all functional levels. Furthermore, we found that LTPc may predict the possibility of belonging to a family with a daughter with AN rather than one whose daughter has a different disorder. Therefore, LTPc would allow clinicians foresee the risk of developing AN and tailoring the most suitable therapeutic intervention and finally see its effectiveness using LTPc for later follow-up video feedback sessions.

Body image disorders associated with lifestyle and body composition of female adolescents

OBJECTIVE

To investigate the association between body image disorders and the lifestyle and body composition of female adolescents.

DESIGN

Cross-sectional study.

SETTING

The Body Shape Questionnaire (BSQ) and Silhouette Scale and Sociocultural Attitudes Towards Appearance Questionnaire-3 were used to evaluate the participants' body image. Body composition was evaluated by a Dual-Energy X-ray Absorptiometry equipment, and lifestyles were identified by latent class analysis (LCA) using the poLCA package for R.

PARTICIPANTS

Female adolescents aged 14-19 years old, in the city of Viçosa-MG, Brazil.

RESULTS

In total, 405 girls participated in the study. Almost half of the participants were dissatisfied with their current physical appearance (51·4 %), presented body perception distortions (52·9 %). 47·3 % of the adolescents were dissatisfied with their body according to the BSQ, and another 8 % severely so. Subjects with an 'Inactive and Sedentary' latent lifestyle were 1·71 times as likely to feel dissatisfied as those with active and sedentary or inactive and non-sedentary lifestyles (95 % CI 1·08, 2·90, P = 0·047). Body image disorders showed an association with decreased amounts of moderate and vigorous physical activity, high screen time, increased alcohol consumption and excess body fat.

CONCLUSIONS

Particular patterns of lifestyle and body composition seem to be associated in female adolescents with dissatisfaction with, distortion of and excessive concern about appearance. Specifically, physical inactivity, sedentary behaviour, alcohol consumption and high body fat percentage may be strongly linked to body image disorders.

Perfectionism and adolescent sleep quality: The mediating role of repetitive negative thinking

This study explores the mediating effects of repetitive negative thinking in the relationship between perfectionism and adolescent sleep quality. A sample of 1664 Chinese adolescents with a mean age of 15.0 years was recruited, and they completed four measures relating to perfectionism, sleep quality, worry, and rumination. The results showed that maladaptive perfectionism was positively correlated with poor sleep quality in adolescents, which was mediated by both worry and rumination. However, adaptive perfectionism was not significantly associated with adolescent sleep quality, and this relationship was suppressed by rumination (but not worry). The implications of these results are also discussed.

Mediating effects of body composition between physical activity and body esteem in Hong Kong adolescents: a structural equation modeling approach

This study investigated the mediating role of body mass index (BMI) in the relationship between physical activity and body esteem in adolescents. Nine hundred and five Hong Kong Chinese students aged 12-18 years participated in a cross-sectional study in 2007. Students' BMI was computed as an indicator of their body composition. Their physical activity level and body esteem were examined using the Physical Activity Rating for Children and Youth (PARCY) and Body Esteem Scale (BES), respectively. Structural equation modelling was used to investigate the mediating effects of BMI and physical activity in predicting body esteem, with stratification by sex. The overall fit of the hypothesized models was satisfactory in boys (NFI = 0.94; NNFI = 0.88; CFI = 0.95; RMSEA = 0.07) and girls (NFI = 0.89; NNFI = 0.77; CFI = 0.91; RMSEA = 0.11). When BMI was considered as a mediator, higher physical activity had a significant negative total effect on body esteem in boys, but not in girls. The indirect effect of higher physical activity on body esteem via BMI was positive in boys, but negative in girls.

CONCLUSIONS

Regular physical activity may help overweight adolescents, especially boys, improve their body esteem. Kinesiologists and health professionals could explore the use of physical activity prescriptions for weight management, aiming at body esteem improvement in community health programs for adolescents.

WHAT IS KNOWN

Among Western adolescents, negative body esteem is more pervasive in girls than in boys. There are consistent findings of the association between higher body mass index and lower body esteem in adolescents, but the association between physical activity and body esteem are equivocal.

WHAT IS NEW

A negative association between body mass index and body esteem was found in both Hong Kong adolescent boys and girls. The indirect effect of physical activity on body esteem via body mass index was positive in Hong Kong adolescent boys, but negative in girls.

Stigmatizing the other: An exploratory study of unintended consequences of eating disorder public service announcements

This research explores the intended and unintended consequences of eating disorder public service announcements. We assessed participants' attitudes toward eating disorders and people with eating disorders, willingness to interact with people with eating disorders, and experience with eating disorders (covariate) at Time 1. At Time 2, participants were randomly assigned to watch a stigmatizing or a non-stigmatizing eating disorder public service announcement. Exposure to the stigmatizing public service announcement resulted in more negative attitudes toward eating disorders and in less willingness to interact with people with eating disorders, but not in significantly more negative attitudes toward people with eating disorders. The discussion highlights the practical implications for health communication campaigns.