Depressive symptoms and substance use among adolescent binge eaters and purgers: a defined population study

Weight perception, substance use, and disordered eating behaviors: comparing normal weight and overweight high-school students

Disordered eating behaviors and substance use are two risk factors for the development of serious psychopathology and health concerns in adulthood. Despite the negative outcomes associated with these risky behaviors, few studies have examined potential associations between these risk factors as they occur during adolescence. The importance of accurate or inaccurate weight perception among adolescents has received increased interest given documented associations with nutritional beliefs and weight management strategies. This study examined the associations among the perceptions of weight and substance use with disordered eating behaviors among a diverse sample of normal weight and overweight adolescent males and females. Data came from the 2007 National Youth Risk Behavior Survey (YRBS). The sample consisted of 11,103 adolescents (53.4% female; 44% Caucasian, 21% African American; 13% Hispanic; age responses ranged from 12 and under to 18 and over), with 31.5% meeting criteria for being either at-risk for obesity or already obese (i.e., overweight). As hypothesized, overestimation of weight among normal weight adolescents and accurate perceptions of weight among overweight adolescents were associated with higher rates of disordered eating behaviors. In normal weight adolescents, use of all three substances (tobacco, binge drinking, and cocaine) was associated with each disordered eating behavior. In contrast, findings revealed differences for overweight adolescents between the type of substance use and disordered eating behavior. Post hoc analyses revealed that gender moderated some of these relationships among overweight individuals. Implications for the development and implementation of secondary prevention programs aimed at reducing disordered eating behaviors, substance use, and obesity risk among normal and overweight adolescents are considered.

Eating disorder symptomatology and substance use disorders: prevalence and shared risk in a population based twin sample

OBJECTIVE

Research shows a significant association between eating disorders (ED) and substance use disorders (SUD). The objective of this study is to examine the prevalence, chronology, and possibility of shared familial risk between SUD and ED symptomatology.

METHOD

Subjects included 1,206 monozygotic and 877 dizygotic adult female twins. ED symptomatology included anorexia (AN) and bulimia nervosa (BN) diagnosis, symptoms associated with diagnostic criteria, and BN symptom count. SUD included alcohol, illicit drug, and caffeine abuse/dependence. Generalized estimated equation modeling was used to examine phenotypic associations, and Choleksy decompositions were used to delineate the contribution of genes and environment to comorbidity.

RESULTS

There were no significant differences between SUD prevalence in women with AN and BN. Women with BN reported BN preceded SUD development while the reverse was true for AN. Twin analyses showed possible familial overlap between BN symptomatology and all SUD examined.

DISCUSSION

Results suggest an important difference in the chronology of EDs and SUDs. Women with BN may be turning to substances to dampen bulimic urges. Women with AN may be engaging in substance use initially in an effort to lose weight. Results also suggest familial factors contribute to the comorbidity between BN and SUD.

Binge drinking in women at risk for developing eating disorders

OBJECTIVE

To determine binge drinking rates in college-age women at risk for eating disorders and to examine factors related to binge drinking over time.

METHOD

Participants were 480 college-age women who were at high risk for developing an eating disorder (ED) and who had a body mass index (BMI) between 18 and 32. Participants were assessed annually for 4 years.

RESULTS

Participants reported high rates of binge drinking and frequent binge drinking throughout college. Binge drinking was positively correlated with dietary restraint, coping using substances, coping using denial, and life events.

DISCUSSION

The study's findings suggest that binge drinking is highly prevalent in women at high risk for developing eating disorders. Results also indicated that binge drinking was related to dieting and maladaptive coping patterns. Intervention for women with strong weight and shape concerns should also address problematic alcohol use.

Eating disorders and substance abuse in Canadian men and women: a national study

The objective of this study was to examine the co-morbidity between eating disorders and substance use in a large nationally representative sample of Canadian women and men while including varied measures of substance consumption and a wide range of substance classes. The research was based on secondary analyses of data collected, using multistage stratified probability sampling, by Statistics Canada in the Mental Health and Well-being cycle 1.2 of the Canadian Community Health Survey (CCHS). Data were collected mostly in face to face interviews using the Computer Assisted Personal Interviewing method. Data included the Eating Attitude Test (EAT-26), and modules of the short form of the Composite International Diagnostic Interview (CIDI-SF) to assess alcohol and drug use, dependence and interference. Alcohol interference and amphetamine use were associated with the risk for an eating disorder in both women and men. In the women sample only, risk for an eating disorder was associated with illicit drug use, dependence and interference, as well as with the number of substance classes used. The study findings support the importance of developing assessment instruments and treatment strategies that address the co-occurrence of eating disorders and substance use for both women and men.

Eating disorders and substance abuse in Canadian women: a national study

AIMS

This study aimed to examine the comorbidity between eating disorders and substance use in a large nationally representative sample of Canadian adult women. Recent as well as life-time measures of substance use were used.

DESIGN

The research was based on secondary analyses of data collected, using multi-stage stratified probability sampling, by Statistics Canada in the Mental Health and Well-being cycle 1.2 of the Canadian Community Health Survey (CCHS).

MEASUREMENTS

The Eating Attitude Test (EAT-26) was used to measure risk of eating disorders. Alcohol use, dependence and interference, and illicit drug use, dependence and interference were measured using relevant modules from the short form of the Composite International Diagnostic Interview (CIDI-SF).

PARTICIPANTS

Data on a nationally representative sample of Canadian adult women, grouped into three age groups, were used for this research.

FINDINGS

Alcohol dependence and alcohol interference were associated significantly with the risk for an eating disorder in the three adult age groups. Significant associations were also found in the three age groups between risk for an eating disorder and the life-time abuse of and dependence on illicit drugs. Significant associations were found in the 15-24 and 25-44-year age groups when the 12-month time-frame was used.

CONCLUSIONS

The study findings support the call for the development of short screening instruments for adult women with eating disorders and substance abuse, as well as for the development of treatment strategies that address the co-occurrence of eating disorders and substance use

Associations between disordered eating behaviors and licit and illicit substance use and abuse in a university sample

OBJECTIVES

To examine associations between discrete eating disordered behaviors as well as clusters of eating disordered behaviors in relation to the use and abuse of a wide spectrum of substance classes, both licit and illicit, in a female university sample.

METHODS

Women with particular types of eating disordered behaviors were selected from a pool of 526 students who completed the Women's Health Survey. Analyses compared the frequencies of lifetime engagement in a wide range of licit and illicit substances between each of the eating disorder groups and the normal control group.

RESULTS

Associations were found between severe levels of alcohol consumption and binge eating, dieting with purging and the use of central nervous stimulants, and bingeing with dieting and tobacco use and the abuse of prescription medications.

CONCLUSION

Examining a broad range of substance classes, with differing physiological properties and effects, in relation to specific disordered eating behaviors, could contribute to theory development regarding the functions of the specific co-occurring behaviors.

Alcohol use in adolescents with eating disorders

Eating disorders, in particular bulimia nervosa and binge eating disorder are associated with co-morbid alcohol and drug abuse. School-based studies have shown significant associations between bulimic behaviors and various measures of alcohol, cigarette and other drug use and abuse. Amongst bulimic adolescents, substance use is related to an increased likeliness of high risk behaviors such as attempted suicide, stealing and sexual intercourse. In contrast with bulimics and binge eaters, restricting anorexics have low rates of co-morbid substance abuse. It appears that restricting anorexics, binge eaters and bulimics represent distinct subgroups within the eating disordered population and binge eaters and bulimics are more prone to alcohol use. It is possible that individuals with eating disorders turn to alcohol use/abuse as a way of coping with the problems caused by their eating disorder. Researchers have proposed that an addictive personality is an underlying trait, which predisposes individuals to both eating disorders and alcohol abuse. Eating disorders are often conceptualized as an addictive disorder. Opioid antagonists, such as naltrexone, may be useful in treating both eating and alcohol use disorders. There is also evidence that serotonin reuptake inhibitors, which are traditionally used to treat major depression, may be an effective treatment. Cognitive-behavioral therapy has been effective in treating alcohol use and eating disorders individually and may be an effective combined treatment for co-morbid eating disorders and alcohol use. Teaching healthy ways to cope with the stressful situations may also help decrease alcohol use and disordered eating behaviors.

Partial eating disorders among adolescents: a review

PURPOSE

Many adolescents do not fulfill all the DSM-IV criteria's for anorexia nervosa and bulimia, but do nevertheless suffer from partial eating disorders (EDs). This review focuses on the definition, epidemiology and clinical aspects of these disorders.

METHODS

Search on Medline & PsycINFO, review of websites, screening of bibliographies of articles and book chapters.

RESULTS

There is still no consensus on the definition of these disorders, which cover a wide range of severity. Affected adolescents often suffer from physical and psychological problems owing to co-morbidity or as a consequence of their eating patterns: chronic constipation, dyspeptic symptoms, nausea, abdominal pain, fatigue, headaches, hypotension, menstrual dysfunction as well as dysthymia, depressive and anxiety disorders, or substance misuse and abuse. In comparison with those who are unaffected, adolescents with partial ED are at higher risk of evolving into full ED. However, most of them evolve into spontaneous remission. Adolescents with partial ED engaged, over a period of several months, in potentially unhealthy weight-control practices, suffering from intense fear of gaining weight and a disturbed body weight/image should be offered therapeutic support.

CONCLUSION

Future research should focus on the exact delineation of various subtypes of clinical presentations in partial ED and on evidence-based treatment and follow-up of these various situations.

Dispositional correlates of addictive behaviors in college women: binge eating and heavy drinking

Binge eating and alcohol abuse are often conceptualized as addictive behaviors. As these behaviors are relatively common among undergraduate college women, we examined whether common dispositional variables underlie their occurrence. Three hundred and thirty-five undergraduate women completed self-report questionnaires about their eating and alcohol use habits as well as dispositional measures of impulsivity, tolerance of deviance, self-esteem, rejection sensitivity, extraversion-introversion, conscientiousness, and emotional stability. Multiple regression analyses showed that women who either binge eat or abuse alcohol, but not both, have similar dispositional characteristics. Both groups exhibited a high degree of impulsivity and endorsed socially deviant attitudes; thus, both groups could be viewed as "externalizers." In contrast, women who admitted to both addictive behaviors, i.e., binge eating as well as alcohol abuse, were not particularly impulsive or socially deviant, but manifested a high degree of emotional instability ("neuroticism"); thus, these women might be considered "internalizers." The theoretical and clinical implications of these findings are discussed.

Pathological dieting and alcohol use in college women--a continuum of behaviors

The relationship between dieting and bingeing severity and alcohol use was studied in a sample of women in their first year of college (n = 1384). The study was designed to replicate and extend earlier findings of a graded positive relationship between the dieting and bingeing severity and the frequency, intensity, and negative consequences of alcohol use in young women, while adjusting for known predictors of alcohol use. Prevalence of past month alcohol use, drinking enough to get high on half or more drinking occasions, and heavy drinking (>or= five drinks in a row) in these women were positively associated with dieting and bingeing severity in a graded manner across the entire range of these behaviors. Dieting and bingeing severity was also more closely associated with the frequency and intensity of alcohol use than measures of depression, parents' drinking level, and early age of first drink. Finally, dieting and bingeing severity was positively associated with the prevalence of negative consequences of alcohol use, such as blackouts and unintended sexual activity. These results suggest that the dysfunctional eating behaviors often associated with dieting could also be associated with dysfunctional alcohol use.

Effects of disordered eating and obesity on weight, craving, and food intake during ad libitum smoking and abstinence

Although there is empirical support for the association between smoking, disordered eating, and subsequent weight gain upon smoking cessation, there have been no prospective studies to track changes in eating patterns during smoking abstinence and explore underlying biobehavioral processes. To help fill these gaps, we recruited four groups of women (N=48, 12/group) based on presence vs. absence of obesity and on low vs. high risk of severe dieting and/or binge-eating to participate in a laboratory study of eating in the context of ad libitum smoking and smoking abstinence. Participants [mean age 31.3 years; Fagerstrom Test of Nicotine Dependence (FTND) 4.3; smoking rate 18.7 cigarettes/day] completed two sessions: one after ad libitum smoking, the other after 2 days' smoking abstinence, in counterbalanced order. After a half-day's restricted eating, participants watched a video, with measured amounts of preselected preferred food available throughout. Cigarettes were available during the ad libitum smoking session. High-risk women weighed more after 2 days' abstinence than during the ad libitum smoking condition, whereas low-risk women did not differ across conditions. Nicotine craving changed significantly more in anticipation of nicotine deprivation for high-BMI women than their low-BMI counterparts. Caloric intake was marginally attenuated during abstinence for low-BMI compared with high-BMI participants (P<.10), an effect primarily accounted for by differences in protein intake (P<.10). These findings suggest that low-BMI women may be less prone to weight gain during early abstinence, possibly because they compensate for metabolic changes induced by nicotine washout by eating less. Craving increases experienced by high-BMI women during abstinence under conditions of food deprivation may contribute to difficulty quitting in these women.

Depressive symptoms and adolescent eating and health behaviors: a multifaceted view in a population-based sample

BACKGROUND

Previous research has shown significant associations between depression and substance use and eating disordered behaviors. However, no research to date has described associations between depressive symptoms and nutritional intake or physical activity among adolescents in a nonclinical, population-based sample.

METHODS

Classroom surveys were completed by 4,734 ethnically diverse, middle- and high school students. Based on their depressive symptom scores, males and females were categorized with low-, moderate-, or high-depressive symptom status. Linear models were used to examine eating and health behavior variables by depressive symptom groups.

RESULTS

Depressive symptoms were positively associated with health-compromising attitudes such as perceived barriers to healthy eating and weight concerns, and health-compromising behaviors such as unhealthy weight-control behaviors and substance use, including caffeine. Depressive symptoms were negatively associated with health-promoting behaviors such as eating breakfast, lunch, and dinner. However, most associations between depressive symptoms and dietary micronutrients were not statistically significant. Health-promoting moderate-to-vigorous physical activity was negatively associated with depressive symptoms among males.

CONCLUSIONS

Adolescents who report depressive symptoms are at risk for other health-compromising attitudes and behaviors and are also less likely to engage in health-promoting behaviors. Depressive symptoms may be an underlying trait in the expression of health behaviors among adolescents.

Eating attitudes and the use of alcohol, tobacco, and exercise among male and female adolescents

OBJECTIVES

To determine the differences between male and female adolescents in the associations of disturbed eating attitudes with the use of smoking, alcohol, and exercise.

METHOD

Nonclinical adolescents-174 males and 157 females-completed the Eating Disorders Inventory (EDI) and a measure of engagement in the use of smoking, alcohol, and exercise. An analysis of variance (ANOVA) was used to determine the impact of Gender x Use of the behaviour upon eating and related attitudes.

RESULTS

Gender and use of smoking and alcohol were each related to eating attitudes. However, in the case of exercise, there were strong interactions of the behaviour and gender. Women who exercised regularly had higher levels of restriction, body dissatisfaction, and interoceptive awareness, whereas men did not.

CONCLUSIONS

It appears that men and women exercise for different reasons, in relation to their eating and related attitudes. It is possible that men exercise for positive goals (e.g., fitness), whereas women exercise to escape perceived negative consequences (e.g., weight gain). This is not the case for alcohol and tobacco use. These findings are discussed, and further research is proposed.

Perceived importance of being thin and smoking initiation among young girls

BACKGROUND

Smoking among adolescents remains unacceptably high and the difference in potential risk factors for smoking initiation between male and female adolescents has been explored. Although the association between smoking initiation and dieting behaviour has been observed among girls, the mechanism of the association is unknown.

OBJECTIVE

To examine prospectively the association between perceived importance of being thin at baseline and smoking initiation among girls.

DESIGN

A four year prospective cohort survey including perceived importance of being thin at baseline and smoking behaviour, conducted in 1993 and 1996.

SETTING AND PARTICIPANTS

273 Massachusetts female adolescents aged 12-15 years at baseline who reported having smoked no more than one cigarette by the time of the baseline survey, drawn from households sampled by random digit dialing.

MAIN OUTCOME MEASURE

Progression to established smoking, defined as having smoked 100 or more cigarettes in their lifetime.

RESULTS

After adjusting for age, smoking status at baseline, and race/ethnicity, girls who valued thinness most strongly and somewhat strongly were both more likely to have become established smokers, compared to the girls who valued thinness least strongly. The odds ratios are 4.5 (95% confidence interval (CI), 1.4 to 16.7) and 3.4 (95% CI 1.04 to 10.9), respectively.

CONCLUSIONS

The level of perceived importance of being thin among young female adolescents predicts future smoking initiation. Smoking prevention programmes designed for female adolescents may therefore benefit from the inclusion of content related to importance of being thin.

Prospective relations of body image, eating, and affective disturbances to smoking onset in adolescent girls: how Virginia slims

This study tested whether body image, eating, and affective disturbances prospectively predicted onset of cigarette smoking in adolescent girls (N = 496). Elevated body dissatisfaction and eating pathology, as well as elevated negative affectivity, showed significant univariate relations to subsequent onset of smoking. In the multivariate model, the effect for body image and eating disturbances remained significant, but the effect for negative affectivity did not. Results support the theory that body image and eating disturbances markedly increase risk for smoking initiation in adolescent girls and further establish the clinical significance of these disturbances. Results also support the theory that negative affect is a risk factor for smoking initiation but suggest that the self-medication model may have less predictive power than previously concluded.

Oral profiles of bulimic women: Diagnosis and management. What is the evidence?

This article is a critical appraisal of the literature on the oral complications of bulimia. The MEDLINE database yielded a total of 82 English-language reports published between 1966 and 2002 that were pertinent to the topic of oral manifestations and treatment of bulimia. The literature is composed primarily of reviews, letters, case reports with or without restorative management, and descriptive studies of small sample sizes. At present, retrospective case-control studies are the only studies available with levels of evidence in the vicinity of 3 to 4. From these studies it is apparent that bulimic women present with a variety of oral and pharyngeal signs and symptoms, including dental caries and tooth erosion, dental pain, increased levels of cariogenic bacteria, orthodontic abnormalities, xerostomia (the subjective complaint of a dry-mouth) and decreased saliva secretion (the objective measure), decreased salivary pH, decreased periodontal disease, parotid enlargement, and swallowing impairments. Dental erosion is the major finding associated with bulimia. Case reports describe restoration of damaged surfaces with porcelain-laminated veneers, dentin-bonded crowns with minimal tooth preparation, composites, and complete-coverage restorations. However, what is really needed is identification of oral markers of bulimic behavior for early detection of bulimic patients by dentists and by physicians that can prevent the deleterious effects of frequent vomiting on the oral/dental tissues.

Disordered eating and substance use in an epidemiological sample: I. Associations within individuals

OBJECTIVE

This study examined the strength of associations between disordered eating and eating disorders and substance use and substance use disorders (SU/SUDs) in an epidemiological sample.

METHODS

672 adolescent girls and 718 women completed structured interviews of lifetime eating disorders and substance use and misuse, as well as self-reported current disordered eating attitudes and behaviors.

RESULTS

Although effect sizes were small, eating attitudes and disorders were associated modestly with nicotine, alcohol, and drug use, and with nicotine dependence in adolescent girls. Alcohol use and misuse were related to eating attitudes and pathology in women. SU/SUDs were associated with restricting and bulimic behaviors and no prominent differences in associations were observed between substance classes. In contrast to findings in clinical populations, these community-based results were positive but generally weak, suggesting there is no strong, overarching relationship between eating and substance use problems.

DISCUSSION

These results have implications for the addiction model of eating disorders.

Disordered eating attitudes and behaviours in teenaged girls: a school-based study

BACKGROUND

Disordered eating attitudes and behaviours are common in older teens and young women in Western countries. Recent evidence suggests that the prevalence of these disorders is rising and that the age of onset has fallen. In the present study, disturbed eating attitudes and behaviours were evaluated in a large school-based population in Ontario in order to determine their prevalence and demographic distribution.

METHODS

Females, aged 12-18 years, from schools in Toronto, Hamilton and Ottawa were invited to complete questionnaires, including 3 subscales of the Eating Disorder Inventory (Drive for Thinness, Body Dissatisfaction, Bulimia), the Eating Attitudes Test-26 (EAT-26) and the Diagnostic Survey for Eating Disorders (DSED).

RESULTS

Questionnaires were completed by 1739 (70%) of the 2483 adolescent females who were approached. The mean age of subjects in the sample was 14.6 (standard deviation 1.9) years. Thirteen percent of those aged 12-14 years and 16% of those aged 15-18 years had scores above the recommended cut-off (> or = 20) for disordered eating on the EAT-26. Current dieting to lose weight was reported by 23% of participants. Binge eating with associated loss of control was reported by 15% of participants, self-induced vomiting by 8.2% and the use of diet pills by 2.4%. Laxative and diuretic misuse were uncommon. Dieting was associated with an increased risk of binge-eating and purging behaviours. Older age and body mass index in the highest quartile were independently related to symptoms of eating disorders.

INTERPRETATION

Disordered eating attitudes and behaviours were present in over 27% of girls aged 12-18 years and were seen to increase gradually throughout adolescence. Prevention programs to diminish the progression and impact of these disorders should be implemented and assessed.

Heavy drinking is associated with more severe psychosocial dysfunction among girls than boys in Finland

PURPOSE

To investigate social, psychological, and environmental factors related to heavy drinking by 15-year-old Finnish school pupils.

METHODS

Each of 240 pupils completed a questionnaire about alcohol use, smoking, and illicit drug use; an Offer Self-Image Questionnaire; an Inventory of Parent and Peer Attachment; and a Psychosomatic Symptoms Questionnaire. Teachers assessed each pupil according to a Social Skills Rating Scale. Academic achievement was assessed on the basis of report grades.

RESULTS

Heavy drinking was associated with smoking, trial of drugs, poor social skills in class, and poor school achievement in both boys and girls. In girls, heavy drinking was associated with psychosomatic symptoms and a negative social self-image. Girls who drank heavily also had more difficulty with concentration and externalizing problems and more problems with teachers than those who were abstinent or consumed alcohol moderately. The self-images of boys who drank heavily were more negative than those of alcohol-abstinent boys. In boys, heavy drinking was associated with higher numbers of peer relationships.

CONCLUSIONS

Heavy drinking is associated with more severe psychosocial dysfunction among girls than boys. It may be possible to identify girls at school who drink heavily and guide them toward treatment.

Adolescent binge/purge and weight loss behaviors: associations with developmental assets

PURPOSE

To study associations between binge/purge and weight loss behaviors and "developmental assets" among adolescent girls and boys.

METHODS

The Search Institute's Profile of Student Life: Attitudes and Behaviors self-report questionnaire was administered to 48,264 girls and 47,131 boys in grades 6 through 12 at schools in 213 cities or towns across the United States. The 156-item questionnaire measured 40 "developmental assets," or protective factors associated with successful adolescent development. Developmental assets were examined using multiple logistic regression among students who reported binge/purge behaviors, weight loss behavior, both, or neither.

RESULTS

Developmental assets related to positive identity were the strongest discriminators of binge/purge and weight loss behaviors in both girls and boys. Girls who reported binge/purge and weight loss behaviors were about half as likely to report feeling a sense of purpose [odds ratio (OR) = 0.45, 95% confidence interval (CI) = 0.40, 0.50] and high self-esteem (OR = 0.55, 95% CI = 0.49, 0.61), compared with girls not reporting either of these behaviors. Among boys the ORs were: sense of purpose OR = 0.53 (95% CI = 0.46, 0.61) and self-esteem OR = 0.76 (95% CI = 0.65, 0.88). Assets related to values about abstinence from alcohol, drugs, or sex ("restraint") were also significant correlates. Girls and boys who reported these values were less likely to report binge/purge and weight loss behaviors, compared with those who did not report these values (girls: OR = 0.56, 95% CI = 0.50, 0.63; boys: OR = 0.83, 95% CI = 0.70, 0.97).

CONCLUSIONS

Internal assets such as self-esteem, sense of purpose, and values related to abstinence from alcohol and sex appear to be protective against unhealthy eating behaviors and may reflect a general resilience that buffers against a broad range of health risk behaviors.

Population-based prevention of eating disorders: an application of the Rose prevention model

BACKGROUND

Several decades of concerted research on eating disorders have generated a broad range of proposed causal influences, but much of this etiologic research does not elucidate practical avenues for preventive interventions. Translating etiologic theory into community health interventions depends on the identification of key leverage points, factors that are amenable to public health intervention and provide an opportunity to maximize impact on the outcome of interest. Population-based preventive strategies, elaborated by epidemiologist Geoffrey Rose, can maximize the impact of public health interventions. In the case of eating disorders, Rose's model is instructive: Dieting stands out as risk behavior that may both fit Rose's model well and be a key leverage point for preventive intervention.

METHODS

Grounded in Rose's work, this article lodges a theoretical argument for the population-based prevention of eating disorders. In the introductory section, existing research on the epidemiology of dieting is reviewed, showing that it is extremely common among adolescent girls and women and that the behavior has been implicated as a causal factor for disordered eating. Next, new evidence is offered to build a case for how a population-wide reduction in dieting may be an effective strategy for prevention of eating pathology. Finally Rose's prevention framework is used to introduce a unique and provocative perspective on the prevention of eating disorders.

RESULTS

Dieting is a normative behavior in our culture with psychological and physiological effects in the causal chain leading to eating pathology. This behavior may represent an ideal target for population-based prevention.

CONCLUSIONS

Theoretical and empirical evidence suggests that a population-wide reduction in dieting may be a justifiable and effective strategy for prevention of eating pathology.

Overweight concerns and body dissatisfaction among third-grade children: the impacts of ethnicity and socioeconomic status

OBJECTIVE

To examine the prevalence of overweight concerns and body dissatisfaction among third-grade girls and boys and the influences of ethnicity and socioeconomic status (SES).

STUDY DESIGN

Nine hundred sixty-nine children (mean age, 8.5 years) attending 13 northern California public elementary schools completed assessments of overweight concerns, body dissatisfaction, and desired shape, height, and weight.

RESULTS

The sample was 44% white, 21% Latino, 19% non-Filipino Asian American, 8% Filipino, and 5% African American. Twenty-six percent of boys and 35% of girls reported wanting to lose weight, and 17% of boys and 24% of girls reported dieting to lose weight. Among girls, Latinas and African Americans reported significantly more overweight concerns than Asian Americans and Filipinas, and Latinas reported significantly more overweight concerns than whites. White and Latina girls also reported greater body dissatisfaction than Asian American girls. Some differences persisted even after controlling for actual body fatness. Higher SES African American girls reported significantly more overweight concerns than lower SES African American girls, but higher SES white girls reported less overweight concerns than lower SES white girls.

CONCLUSION

Overweight concerns and body dissatisfaction are highly prevalent among third-grade girls and boys, across ethnicity and SES. Young Latina and African American girls manifest equivalent or higher levels of disordered eating attitudes and behaviors as white and Asian American girls.

Smoking and weight control in adolescent females

This paper examines the association between smoking and various weight control techniques among adolescent girls in two school-based samples. Previous studies have relied heavily on clinical trials of adults and have focused mainly on dietary restraint rather than purging behavior. This study seeks to determine whether purging is associated with smoking and if purging and dietary restraint effects upon smoking are additive or synergistic. Data from adolescent girls were gathered from two school-based surveys conducted in the upper Midwest. Assessments were conducted for smoking, dietary restraint, diet pill use, and purging. Logistic regression was used to test for main and interaction effects. Analysis revealed significant associations between smoking and weight control. Purging was more highly associated with smoking than dietary restraint or diet pill use. The form of these associations was interactive rather than additive in both data sets. Nonpurging girls were significantly more likely to smoke if they were dieting or using diet pills than if they were not practicing dieting behavior. Thus, the effect of dieting and diet pill use on smoking is dependent on purging behavior. Weight control is associated with smoking behavior in adolescent girls but the form of these associations may be more complex than originally thought. Future research is needed to determine if there are two subtypes of smoking-weight control girls.

The relationship between eating disorders and substance use: moving beyond co-prevalence research

The frequent comorbidity of eating disorders and substance use has been demonstrated consistently by research. Less is known about the basis of this relationship. A review of the literature indicates that the hypotheses proposed to clarify the etiological relationship between eating disorders and substance use have not been supported sufficiently or consistently by empirical evidence. General criticisms include: a lack of well developed models, a reliance on co-prevalence data, and a lack of integration of knowledge from eating disorder and substance use research. It is suggested that an understanding of the etiological relationship between eating disorders and substance use will be arrived at only after fundamental inquiries into the functional relationship between eating disorders symptomatology and substance use patterns have been conducted. A behavioral assessment approach is offered as a means of evaluating the functional relationship between eating disorder symptomatology and substance use.

Binge eating and substance use among male and female adolescents

OBJECTIVE

This study examines the relationship between binge eating and substance use behaviors and attitudes in adolescents and explores gender differences and mental health correlates.

METHOD

The data are derived from the 1997 Ontario Student Drug Use Survey of public and Catholic school students. A weighted sample of 1,031 girls and 888 boys was categorized as nonbingers, past bingers, and noncompensating or compensating binge eaters.

RESULTS

Binge eaters, particularly those who compensated, were more likely to use all types of substances, particularly cannabis and drugs other than tobacco and alcohol. Binge eating was associated with more problematic and heavier substance use and with lowered self-esteem and more depression. Female bingers were more likely to report compensatory behaviors than male students but gender differences in the relationship between binge eating and substance use were few.

DISCUSSION

Adolescent binge eaters who engage in compensatory behaviors may be an appropriate target group for preventive programs in high schools.

Psychosocial factors associated with dieting behaviors among female adolescents

This study determined whether female adolescents who were attempting weight loss (dieters) differ from those who were not (nondieters) with respect to a set of psychosocial factors. The sample consisted of 2,536 normal-weight and underweight female adolescents who participated in the National Longitudinal Adolescent Health Survey. Psychosocial factors examined included depression (four measures), self-esteem, trouble in school, school connectedness, family connectedness, sense of community (two measures), grades, autonomy, and protective factors. MANCOVA revealed significant differences between dieters and nondieters. Self-esteem was the strongest contributing factor differentiating dieters and nondieters. These results have implications for health education and health promotion with regard to both primary and secondary prevention. Self-esteem building should be incorporated within the parameters of a comprehensive school health program and certainly should be a component in any nutrition education program aimed at preventing unhealthy dieting behaviors. By understanding the factors associated with these behaviors, it may be easier to identify individuals attempting weight loss despite being of normal or low body weight.

Development and evaluation of the McKnight Risk Factor Survey for assessing potential risk and protective factors for disordered eating in preadolescent and adolescent girls

OBJECTIVE

To describe the development, test-retest reliability, internal consistency, and convergent validity of the McKnight Risk Factor Survey-III (MRFS-III). The MRFS-III was designed to assess a number of potential risk and protective factors for the development of disordered eating in preadolescent and adolescent girls.

METHOD

Several versions of the MRFS were pilot tested before the MRFS-III was administered to a sample of 651 4th through 12th- grade girls to establish its psychometric properties.

RESULTS

Most of the test-retest reliability coefficients of individual items on the MRFS-III were r > .40. Alpha coefficients for each risk and protective factor domain on the MRFS-III were also computed. The majority of these coefficients were r > .60. High convergent validity coefficients were obtained for specific items on the MRFS-III and measures of self-esteem (Rosenberg Self-Esteem Scale) and weight concerns (Weight Concerns Scale).

CONCLUSIONS

The test-retest reliability, internal consistency, and convergent validity of the MRFS-III suggest that it is a useful new instrument to assess potential risk and protective factors for the development of disordered eating in preadolescent and adolescent girls.

An exploratory study of recreational drug use and nutrition-related behaviors and attitudes among adolescents

This study examined drug use and eating behaviors among adolescents. The data were collected by phone interviews from 401 northern Nevadan students in grades seven to twelve. Students were divided for comparison into three groups according to their involvement with drugs: Abstainers, conventional users, and high-risk users. Analyses indicated that high-risk users less frequently ate lunch, meals at home, and with their families, and ate more often at convenience stores, fast food restaurants, and with friends. In addition, female high-risk users had significantly more negative perceptions regarding their food choices than the other female groups, and were more concerned with dieting than their high-risk using male peers. Male and female high-risk users believed that their drug use affected their eating habits. Implications for prevention programming and future research are discussed.

Relation of drinking and eating to masculinity and femininity

The relationship between desirable and undesirable aspects of masculinity and femininity and drinking and eating was investigated. A sample of 144 university women in Australia completed questionnaires that assessed masculinity and femininity, reported drinking, alcohol dependence, eating restraint, frequency of dieting, and overeating. Evidence of a common underlying dimension linking aspects of problem drinking and overeating to undesirable masculine characteristics was found. The results are consistent with the view that women engage in excessive consummatory behaviors such as binging to deal with their gender-role conflict.

Dieting status and its relationship to eating and physical activity behaviors in a representative sample of US adolescents

OBJECTIVE

To determine whether adolescents engaging in extreme weight loss methods (i.e., vomiting and diet pills) and those using more moderate methods differ from each other in dietary intake (fruits, vegetables, and higher-fat foods) and physical activity, and to compare these variables in dieting and nondieting adolescents.

DESIGN

Data were obtained from the 1993 Youth Risk Behavior Survey.

SUBJECTS/SETTINGS

The survey was administered to a nationally representative sample of 16,296 adolescents in grades 9 through 12 in a school setting.

STATISTICAL ANALYSES

Data were analyzed for 16,125 adolescents. Associations between weight control behaviors and dietary intake and physical activity were examined using mixed-model logistic regressions, controlling for grade in school, race, parental education, region of the country, and urban vs nonurban residence.

RESULTS

Differences in dietary and physical activity were found among adolescents who use extreme weight loss methods and moderate methods, and between dieters and nondieters. Adolescents using moderate methods of weight control engaged in more health-promoting eating and exercise behaviors than did extreme dieters or nondieters. Girls categorized as extreme dieters were less likely to eat fruits and vegetables than were moderate dieters (odds ratio [OR] = .56) or nondieters (OR = .75), and were more likely than more moderate dieters (OR = .76) to have consumed 2 or more servings of high-fat foods during the previous day.

APPLICATIONS/CONCLUSIONS

Our findings suggest the importance of distinguishing between different types of dieting behaviors in clinical settings and research studies. Adolescents engaging in extreme weight control behaviors may be at particular risk for inadequate nutritional intake. In contrast, adolescents using more moderate methods may be consuming a more healthful diet than are nondieters. For all adolescents, nutrition guidance on healthful and safe weight control strategies is needed.

Adolescents engaging in unhealthy weight control behaviors: are they at risk for other health-compromising behaviors?

OBJECTIVES

This study sought to determine whether adolescents engaging in weight control behaviors are at increased risk for tobacco, alcohol, and marijuana use; suicide ideation and attempts; and unprotected sexual activity.

METHODS

Data were collected on a nationally representative sample of 16,296 adolescents taking part in the 1993 Youth Risk Behavior Survey.

RESULTS

Adolescents using extreme weight control behaviors were at increased risk for health-compromising behaviors, while associations with other weight control behaviors were weak and inconsistent.

CONCLUSIONS

The findings have relevance to clinical work with youth, provide a better understanding of disordered eating, and open up a number of opportunities for future research.

Potential risk factors associated with weight control behaviors in elementary and middle school girls

The purpose of this study was to examine the relationship between weight control behaviors and potential risk factors for disordered eating in a sample of young girls. The McKnight Risk Factor Survey was administered to 523 elementary and middle school girls. In the sample of elementary school girls, results from the multiple regression analyses indicated that frequency/severity of weight control behaviors was associated with body mass index (BMI), self-confidence, peers' weight-related pressures, ethnicity, and the interaction between having divorced/separated parents and BMI. Sensitivity to peers' weight-related pressures and BMI were also associated with weight control behaviors in the middle school girls, along with poor body image, substance use, having divorced/separated parents, and the interaction between having divorced/separated parents and father's pressure for thinness. Longitudinal research is needed to determine how risk factors change over time, beginning in elementary school and continuing through high school.

Bulimia and dextromethorphan abuse. A case study

The comorbidity of bulimia and substance abuse is significant. The substance that is abused may vary and the abuse potential for nonillicit substances may be overlooked. This paper presents the first case reported of dextromethorphan abuse and bulimia. It demonstrates the complexity of assessment and treatment of bulimia and substance abuse of over-the-counter medications.

Covariations of eating behaviors with other health-related behaviors among adolescents

PURPOSE

The study objectives are: (1) to examine and compare patterns of covariation of a wide range of health behaviors among adolescent boys and girls; (2) to determine whether eating behaviors are part of a larger construct of health-related behaviors and to identify the behaviors with which they share underlying similarities; and (3) to determine whether youth engaging in other health-compromising behaviors are at risk for unhealthy eating.

METHODS

Data were analyzed from the Minnesota Adolescent Health Survey, a classroom-administered questionnaire, completed by 36,284 adolescents, in grades 7-12 from 1986-87.

RESULTS

Among boys, factor analysis revealed five factors: (1) risk-taking behaviors, (2) school-related behaviors, (3) "quietly" disturbed behaviors (e.g., frequent dieting, self-induced vomiting, suicide attempts), (4) health-promoting behaviors; and (5) exercise. Eating behaviors loaded on the construct of health-promoting behaviors with brushing teeth and seat belt use. Among girls, four similar factors emerged; however, exercise loaded on the construct of health-promoting behaviors. Therefore, eating behaviors loaded with brushing teeth, seat belt use, and exercise among girls. Logistic regression analyses, controlling for sociodemographic and personal variables, revealed that boys and girls engaging in health-promoting behaviors were less likely to have unhealthy eating behaviors, while those engaging in quietly disturbed behaviors, risk-taking behaviors, and problematic school behaviors were more likely to have unhealthy eating behaviors.

CONCLUSIONS

Eating behaviors appear to be part of a health-promoting behavioral construct and should not be viewed in isolation from other behaviors. Although eating behaviors do not appear to be part of the "problem behavior syndrome," youth engaging in a wide range of health-compromising behaviors are at risk for unhealthy eating; emphasizing the need to target high-risk youth with health promotion programs.

High school students' attitudes and knowledge of food consumption and body image: implications for school based education

One-hundred-and-forty-one high school students from Holon between the ages of 14 and 18 years participated in the study. The aims of the study were to investigate their nutritional habits, ascertain their body image, measure their knowledge concerning nutrition and finally to determine their attitudes regarding overweight, obese people and dieting. The study is a cross-sectional survey and the students involved completed a self administered questionnaire anonymously at school. The response rate was 97%. Forty-four percent of the total study population expressed a subjective feeling of being obese while, in truth, only 10% of them were actually overweight, and 48% among all participants practised weight reduction diets (girls three times more than boys). In addition to that another 53% of the pupils expressed the desire to be thinner than they were (girls four times more than boys). Nine percent of the study group experienced self-induced anorectic episodes at sometime during the past few years. It was observed that the study group's knowledge concerning food composition and nutrition remains insufficient. As far as their attitude concerning obesity, it was observed that 31% of the students regarded obesity as a handicap. Students who were athletics demonstrated more severe and stricter attitudes towards nutrition and obesity. Most of the information concerning nutrition was obtained through the media. School education about food and nutrition only amounted to 28.3% of the total. Seventy-nine percent of the students believe that nutrition should be integrated into their curriculum. Forty-four percent of the students feel themselves to be overweight, and 53.4% want to be thinner. Half of the students were on various diets. The students' knowledge of food and nutrition, the risk of obesity and the danger of excessive diets was insufficient. Most students presented negative attitudes towards obesity and overweight people. The media was the principal source of information on all these areas. Our main conclusion is that an educational nutrition program should be given to pupils in school by physicians and dietitians during all the years of public school attendance. The instructions of these programs should emphasize the importance of balanced nutritional regimes, as well as the risk and consequences of extreme dieting.

Patterns of health-compromising behaviors among Minnesota adolescents: sociodemographic variations

OBJECTIVES

This study compared prevalence rates of health-compromising behaviors among boys and girls from different ethnic backgrounds in early, middle, and late adolescence and compared co-occurrences of such behaviors across gender and ethnic groups.

METHODS

The study population included 123 132 adolescents in grades 6, 9, and 12. Adolescents completed a classroom-administered statewide survey focusing on high-risk behaviors, including unhealthy weight loss, substance abuse, suicide risk, delinquency, and sexual activity.

RESULTS

Prevalence rates of most health-compromising behaviors differed by gender, increased with age, and tended to be highest among American Indian youth and lowest among Asian Americans. Strong associations were found between substance abuse and delinquency across all ethnic groups. Substance abuse and delinquency were associated with suicide risk across most ethnic groups. Covariations with sexual activity and unhealthy weight loss behaviors showed more ethnic variation.

CONCLUSIONS

Prevention interventions should take into account the tendency for health-compromising behaviors to co-occur and should be sensitive to demographic and socioeconomic differences in behavior patterns.

Dieting in sixth grade predicts alcohol use in ninth grade

Recent studies of community-based populations have shown that the comorbidity seen in clinical studies of individuals with eating disorders and substance abuse extends in a graded manner to subclinical levels of each dysfunction as well as to adolescent populations. We hypothesized that frequency of dieting in the sixth grade would predict later alcohol use in middle school students. Data from 1,905 participants in a middle school health promotion project were analyzed. We found a positive, graded relationship between the frequency of dieting in the sixth grade and the frequency of alcohol intake in the ninth grade. We also found that frequency of dieting in sixth grade was a more powerful predictor of future drinking than such parameters as others' approval of alcohol use, perceptions of peer use of alcohol, and personal feelings of shyness and self-satisfaction. Implications of these findings are discussed.

The spectrum of eating disturbances

OBJECTIVE

The purpose of this paper was to review and summarize the research literature on the spectrum of eating disturbances.

METHOD

Literature was searched using a computer data base to identify recent articles related to the prevalence and occurrence of disturbed eating patterns as well as full and partial syndrome eating disorders (EDs).

RESULTS

This review indicates that the prevalence of partial syndrome EDs in nonclinical populations is at least twice that of full syndrome EDs, and that there is a progression in some individuals from less to more severe disturbances in eating behavior.

DISCUSSION

These findings suggest the need for careful, scientific evaluation of risk factors for EDs in both children and adults. A longitudinal research program in progress is described which aims to identify the risk factors for EDs.

Eating disorders with and without substance use disorders: a comparative study of inpatients

We assessed the co-occurrence of DSM-III-R axis I and II disorders and self-reported psychologic distress in inpatients with eating disorders with and without substance use disorders (ED-SUD and ED groups, respectively) and in a matched comparison sample with substance use disorders but no eating disorder (SUD group). The three groups showed similar distributions of axis I disorders but differed in the distribution of axis II disorders. Cluster B personality disorders were diagnosed more frequently in SUD and ED-SUD groups than in the ED group. In contrast, cluster C personality disorders were diagnosed more frequently in the ED group than in SUD and ED-SUD groups. The SUD group reported greater psychologic distress than ED and ED-SUD groups. Possible implications of the observed group differences for psychologic models of why these disorders may be associated are considered.

Changes in psychological variables and health behaviors by dieting status over a three-year period in a cohort of adolescent females

PURPOSE

Psychologic and behavioral changes associated with frequent dieting were examined. Compared to nondieters, frequent dieters were hypothesized to show more adverse psychologic changes and increased use of unhealthy weight control behaviors, but possibly healthier eating and exercise behavior changes, over the three-year period of observation.

METHODS

A prospective study of female students, in grades 7-10 at baseline completed a health behavior survey in school once a year for a total of three years.

RESULTS

Restrained eating, body dissatisfaction and drive for thinness, self-induced vomiting, laxative use, diet pill use, and alcohol use, significantly increased, and physical appearance and self-concept significantly decreased among frequent dieters, compared to non-dieters. Changes in scores on five EDI subscales, eight self-esteem subscales, weight fluctuations, dietary intake, and physical activity patterns did not significantly differ over time by dieting status.

CONCLUSION

Dieting may reflect a general pattern of unhealthy behaviors adopted in adolescence, rather than act as a causal factor in promoting psychologic distress.

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

The characteristics and concurrent predictors of eating problems were identified. Ninety-seven per cent of a representative sample of Norwegian adolescents (N = 11315) completed a questionnaire containing a 12-item version of the Eating Attitudes Test (EAT) and measures of a large number of physiological, psychological and social factors previously suggested to be of aetiological importance. Social class, drug use and indicators of 'the model child' (high grades, high occupational aspirations and much homework) were not related to eating problems. Logistic regression analyses identified perceived obesity as the strongest associated factor, followed by gender, depression, excessive exercise and unstable self-perceptions. In addition, adopting idols with perfect bodies, body dissatisfaction, low self-worth, feminine sex-role orientation, lack of parental care, early pubertal timing, age and number of alcohol intoxications all added to the probability of eating problems. About 6% perceived themselves as obese in spite of subnormal BMI. Such misperceptions increased the risk of high scores on EAT.

The severity of dieting and bingeing behaviors in college women: interview validation of survey data

A combined survey and interview study was conducted to validate a categorical Dieting and Bingeing Severity Scale (DBSS), and to estimate the prevalence of eating disorders in young women. We hypothesized that assignment to the DBSS categories would be confirmed by clinical interviews such that interview-diagnosed eating disorders would be found with increasing frequency and severity at the upper end of the DBSS. Freshmen college women (n = 1367) completed a survey instrument addressing the frequency and severity of dieting, binge-eating, and other behaviors and attitudes related to weight control. Random stratified sampling procedures were used to select a subset of women (n = 306) from each DBSS category for structured clinical interviews for DSM-III-R (SCID). Survey respondents were assigned to one of six mutually exclusive DBSS categories: non-dieters (9% of sample), casual dieters (26%), moderate dieters (23%), intense dieters (21%), dieters at-risk (19%), and probable bulimia nervosa (2%). The DBSS effectively rank-ordered subjects according to the risk of having interview-diagnosed eating disorders. Women in the three most severe DBSS categories were significantly more likely to have current subthreshold and threshold level eating disorders, in particular bulimia nervosa and eating disorder not otherwise specified (EDNOS). The estimated prevalence of current bulimia nervosa was approximately 2% by both survey and interview methods. The prevalence of current EDNOS was 13%, more than six times greater than the prevalence of bulimia nervosa. The DBSS was found to be a reliable and valid measure of dieting and bingeing severity. The survey instrument may be useful in measuring the extent of, and changes in, pathological dieting in community-based samples of young women, and in studying comorbidity of dieting and bingeing severity with other psychiatric conditions including depression and substance use. The DBSS may also be useful in identifying risk factors associated with the onset of eating disorders.

Frequent dieting among adolescents: psychosocial and health behavior correlates

OBJECTIVES

The present study examined correlates of frequent dieting in 33,393 adolescents. It was hypothesized that frequent dieting would be correlated with negative psychosocial and health behavior outcomes.

METHODS

A comprehensive, school-based health behavior survey was administered in 1987 to public school students in grades 7 through 12 in Minnesota. Students self-reported dieting behavior; substance use; suicidal, sexual, and delinquent behavior; family and peer concerns; sick days; and abuse history. Differences on psychosocial and health behavior risk factors by dieting frequency and by purging status were assessed with multivariate logistic regression, with body mass index and demographic variables controlled.

RESULTS

Dieting frequency was associated with history of binge eating (females: odds ratio [OR] = 1.46, males: OR = 1.53); poor body image (females: OR = 0.56, males: OR = 0.63); lower connectedness to others (females: OR = 0.79); greater alcohol use (females: OR = 1.17); and greater tobacco use (females: OR = 1.08). Purging status was independently associated with negative risk factors in both males and females.

CONCLUSIONS

These findings suggest that frequent dieting efforts in adolescents should not be viewed in isolation, but rather in the broader context of health and risk-taking behaviors.

Psychological correlates of frequency and type of drug use among jail inmates

The comorbidity of drug abuse and various forms of psychopathology is pervasive and well documented. In particular, the incidence of depression, anxiety, and antisocial personality disorder is high among substance abusers relative to non-drug abusers. Offender populations have a high rate of substance abuse, and some studies suggest that the incidence of psychopathology may be even greater than in other drug using groups. In order to identify specific types of psychopathology as they relate to drug preferences and frequency of use among drug-using offenders, arrestees at the Baltimore City Detention Center were examined. During extensive interviews, drug-abusing arrestees provided information pertaining to their backgrounds, childhood histories, biological relatives, present behaviors, and criminal and drug histories. Additionally, several psychological inventories were administered to evaluate the presence of depression, anxiety, psychopathy, and impulsivity. Results indicate that the frequency with which subjects reported using specific drugs and drug of choice were significantly associated with particular measures of psychopathology. A composite measure of psychopathy was especially related to the frequency of alcohol, marijuana, and cocaine use. Subjects who reported using cocaine on a frequent basis scored high on measures of hostility and reported committing more property crimes, while violent crimes were more likely to be reported by subjects scoring high on the measure of psychopathy. Other noteworthy findings will be discussed along with the limitations of this study.