A two-stage epidemiologic study on prevalence of eating disorders in female university students in Wuhan, China.

BACKGROUND: The community prevalence of eating disorders among Chinese young women may now be similar to their western counterparts. AIM: To investigate the prevalence of eating disorders (ED) in female university students in Wuhan, China, using a two-stage design. METHOD: In stage one, 99.1% (N = 8,444) of eligible students (N = 8,521) completed the eating disorder inventory-1 (EDI-1) and a survey of relevant anthropomorphic data. A total of 421 women scored above the cut-off for EDE-1, as defined by a set of criteria similar to those of Keski-Rahkonen (Int J Eat Disord 39:754-762, 2006). 257 (61%) of these case-positive women and a random sample of case-negative women (312 out of 8,023, 4%) whose scores did not exceed the defined cut-off were interviewed using the eating disorder examination (EDE) and the structured clinical interview for DSM-IV axis I disorders (SCID-I). RESULTS: On interview with the SCID-I, 79 women were diagnosed with an ED. Among them, 10 had anorexia nervosa (AN), 21 bulimia nervosa (BN), and 48 binge eating disorder (BED) The results showed a prevalence rate of 1.05% (95% CI = 0.02-2.08) for AN, 2.98% (95% CI = 1.21-4.74) for BN, and 3.53% (95% CI = 1.75-5.30) for BED. CONCLUSION: The prevalence of ED among female university students in China is now similar to that of their western counterparts, and BED is the most common ED followed by BN and AN similarly.

From disordered eating to addiction: the "food drug" in bulimia nervosa.

The high prevalence of substance abuse in individuals with bulimia nervosa (BN) and the pervasive symptom substitution in many types of drug addiction suggest that a number of substances--including food--can impair an individual's self-control, even in the presence of negative consequences. Nonetheless, the neurobiological similarities between BN and drug addiction are not clearly established. This review explores how the specific eating patterns seen in BN (binge eating and purging, with intermittent dietary restriction) are particularly addictive and differentiate BN from other eating disorders and obesity. A number of peripheral and central biological aberrations seen in BN may result in altered reward sensitivity in these individuals, particularly through effects on the dopaminergic system. Neurobiological findings support the notion that BN is an addictive disorder, which has treatment implications for therapy and pharmacological manipulations.

PTSD in a one year old girl after the Wenchuan earthquake in Sichuan, China.

On May 12, 2008, at 2:28 PM, an earthquake measuring 8.0 on the Richter Scale struck Southwest China, with the epicenter in Wenchuan, a county about 92 km (about 58 miles) north-west of the Sichuan provincial capital of Chengdu. The earthquake destroyed about 6.5 million homes, leaving 4.8 million people homeless. Official figures stated that 69,196 are confirmed dead, including some 5,335 school children, while an additional 18,379 are listed as missing (Sina.com, 2009). An epidemiological survey conducted 2.5 months after the earthquake in two counties affected by the earthquake found the prevalence of post-traumatic disorder (PTSD) to be 45.5% in the heavily damaged county and 9.4% in the moderately damaged one (Kun et al., 2009).

Validity and reliability of the Chinese language version of the eating disorder examination (CEDE) in mainland China: Implications for the identity and nosology of the eating disorders.

PURPOSE: To investigate the crosscultural validity and reliability of the Chinese Language version of the Eating Disorder Examination (CEDE) in Wuhan, China, and to examine the psychopathological profile of eating disorder patients in central Mainland China. PARTICIPANTS AND METHOD: We administered the CEDE to 41 eating disorder patients (anorexia nervosa and bulimia nervosa) with 43 non-eating disorder controls. Specialists in eating disorders made the clinical diagnosis according to DSM-IV criteria. CEDE data between the two groups were compared. RESULTS: The CEDE demonstrates good internal consistency, test-retest reliability, and inter-examiner reliability. All CL-EDE subscales discriminated between patients with anorexia nervosa or bulimia nervosa from non-eating disordered controls. The CEDE has satisfactory sensitivity, specificity, and positive and negative predictive values. DISCUSSION: The CEDE is a useful instrument for the study of the growing clinical problem of the eating disorders in Mainland China. The finding that the characteristic fat phobia is prominent in this population of eating disordered patients and its implication on the identity and classification of the eating disorders are discussed.

Stigma of depression is more severe in Chinese Americans than Caucasian Americans.

Stigma of mental illness is a major obstacle to its diagnosis and treatment and may be worse among Asians than Caucasians. This study compared the stigma of depression in 50 Chinese Americans (CA) and 50 Caucasian Americans (WA). Subjects were asked to read 5 case vignettes in the following order: diabetes mellitus (DB), major depressive disorder (MDD), somatoform depression (SD), psychotic depression (PD), and fever of unknown origin (HA). Diagnosis of each case was not revealed. Subjects then rated their response to each case, on a Likert scale from "strongly disagree" to "strongly agree," to 25 statements that contained 6 stigma factors: fear, shame, cognitive distortion, social consensus, discrimination, and sanction. Composite scores constructed from ratings of each factor were used to calculate the severity of stigma. Stigma of all 5 cases was worse in CA than WA. Both groups ranked DB and HA to be least and PD to be most stigmatizing. CA rated SD to be less stigmatizing than MDD but not WA. We concluded that stigma formation and severity were determined by fear, shame, cognitive distortion, social communication, consensus, and sanction. Mental symptoms, particularly psychotic symptoms, were more stigmatizing than physical symptoms, especially for CA. Belief that depression was like a physical illness did not diminish its stigma.

Relationship between control and the intermediate term outcome of anorexia nervosa in Hong Kong.

OBJECTIVE: To examine the relationship between control and the intermediate term outcome of Chinese patients with anorexia nervosa. METHOD: 88 patients who fulfilled the DSM-III-R criteria for typical (fat phobic, n=63) and atypical (non-fat phobic, n=25) anorexia nervosa were contacted 9 years after the onset of illness. They completed the Morgan-Russell Outcome Assessment Schedule, Shapiro Control Inventory, and Eating Disorder Inventory-I. RESULTS: 62.2%, 32.4% and 5.4% of patients had good, intermediate, and poor outcome. Outcome was positively correlated with the overall general and specific sense of control, positive sense of control, and negatively with negative sense of control. Patients with good outcome exhibited the least negative modes of control and had the least desire for control. Typical and atypical patients showed similar but not identical control profiles. CONCLUSION: Healthier control was associated with better outcome of anorexia nervosa but their causal relationship was far from clear because of the cross-sectional nature of the present study. The Shapiro Control Inventory is a potentially useful instrument for studying control in eating disorders.

Five cases of male eating disorders in Central China.

OBJECTIVE: Despite the recent surge of eating disorders among women in large Asian cities, male eating disorder cases remain rare. The current article described 5 male eating disorder cases that presented within a period of 2 years in Wuhan, a city in central China. METHODS: The authors described 4 cases of anorexia nervosa (2 restrictive, 2 bulimic) and 1 case of normal weight bulimia nervosa. RESULTS: Fear of fat was reported for all 5 cases, and none of the cases reported homosexuality. DISCUSSION: Sociocultural changes and westernization most probably accounted for the increasing incidence of eating disorders among male and female youngsters in China today.

Energy expenditure is very high in extremely obese women.

To test the hypothesis that total energy expenditure (TEE) and resting energy expenditure (REE) are low in extremely obese individuals, factors that could contribute to maintenance of excess weight, a cross-sectional study was conducted in 30 weight stable, extremely obese women [BMI (mean +/- SEM) 48.9 +/- 1.7 kg/m(2)]. TEE was measured over 14 d using the doubly labeled water method, REE and the thermic effect of feeding (TEF) were measured using indirect calorimetry, and activity energy expenditure (AEE) was calculated as TEE - (REE + TEF). Body composition was determined using a 3-compartment model. Subjects were divided into tertiles of BMI (37.5-45.0; 45.1-52.0; and 52.1-77.0 kg/m(2)) for data analysis. TEE and REE increased with increasing BMI tertile: TEE, 12.80 +/- 0.5, 14.67 +/- 0.5, and 16.10 +/- 0.9 MJ/d (P < 0.01); REE, 7.87 +/- 0.2, 8.78 +/- 0.3, and 9.94 +/- 0.6 MJ/d (P < 0.001), and these values were 29-38% higher than published means of measured TEE in nonobese individuals. No significant differences were observed among BMI tertiles for AEE, TEF, or physical activity level (PAL = TEE/REE, overall mean 1.64 +/- 0.16). The Harris-Benedict and WHO equations provided the closest estimates of REE (within 3%), whereas the obese-specific equations of Ireton-Jones overpredicted (40%) and Bernstein underpredicted (21%) REE. Extremely obese individuals have high absolute values for TEE and REE, indicating that excess energy intake contributes to the maintenance of excess weight. Standard equations developed for nonobese populations provided the most accurate estimates of REE for the obese individuals studied here. REE was not accurately predicted by equations developed in obese populations.

Eating disorders: practical interventions.

The 4 currently recognized eating disorders are among the most common of psychiatric disorders to affect women in this country and are associated with chronic health impairments, although anorexia nervosa still carries a high mortality rate, including death by suicide. This review will focus primarily on the treatment of anorexia and bulimia nervosa and discuss interventions focused on engaging the patient, normalizing weight and nutritional status, changing dysfunctional attitudes and behaviors, and managing comorbid disorders such as major depression.

International psychiatry - an agenda for the way forward.

A news release from the World Health Organization (2003) suggested that a mere 10% of global health research is devoted to diseases that account for 90% of the global disease burden. While this comment refers primarily to research into infectious and parasitic diseases, a similar trend may well be true for psychiatry, taken from a global perspective. A cursory glance at recent issues of World Psychiatry, the official journal of the World Psychiatric Association, will reveal articles describing recent advances in antidepressant treatment and other pharmacotherapies, psychotherapy and psychoanalysis, personality disorders, attention-deficit hyperactivity disorder, and the genetics of mental illness. These topics are obviously important and the field cannot advance without such cutting-edge research. Most of the authors are, as expected, psychiatrists living and working in Western Europe or North America. This is also, of course, acceptable and important. The dissemination of scientific data is essential for advancing the field, and researchers who live and work in Europe and North America are generally the most qualified to do so. So, what's the problem?

Long-term changes in energy expenditure and body composition after massive weight loss induced by gastric bypass surgery.

BACKGROUND: Little is known about the determinants of individual variability in body weight and fat loss after gastric bypass surgery or about the effects of massive weight loss induced by this surgery on energy requirements. OBJECTIVES: The objectives were to determine changes in energy expenditure and body composition with weight loss induced by gastric bypass surgery and to identify presurgery predictors of weight loss. DESIGN: Thirty extremely obese women and men with a mean (+/- SD) age of 39.0 +/- 9.6 y and a body mass index (BMI; in kg/m(2)) of 50.1 +/- 9.3 were tested longitudinally under weight-stable conditions before surgery and after weight loss and stabilization (14 +/- 2 mo). Total energy expenditure (TEE), resting energy expenditure (REE), body composition, and fasting leptin were measured. RESULTS: Subjects lost 53.2 +/- 22.2 kg body weight and had significant decreases in REE (-2.4 +/- 1.0 MJ/d; P < 0.001) and TEE (-3.6 +/- 2.5 MJ/d; P < 0.001). Changes in REE were predicted by changes in fat-free mass and fat mass. The average physical activity level (TEE/REE) was 1.61 at both baseline and follow-up (P = 0.98). Weight loss was predicted by baseline fat mass and BMI but not by any energy expenditure variable or leptin. Measured REE at follow-up was not significantly different from predicted REE. CONCLUSIONS: TEE and REE decreased by 25% on average after massive weight loss induced by gastric bypass surgery. REE changes were predicted by loss of body tissue; thus, there was no significant long-term change in energy efficiency that would independently promote weight regain.

The intermediate-term outcome of Chinese patients with anorexia nervosa in Hong Kong.

OBJECTIVE: The authors determined the intermediate-term outcome of anorexia nervosa for Chinese patients in Hong Kong. METHOD: A consecutive series of 88 patients who fulfilled DSM-III-R criteria for typical (i.e., fat phobic [N=63]) and atypical (i.e., no fat phobia [N=25]) anorexia nervosa were contacted at least 4 years after onset of their illness for semistructured and self-rated assessments of outcome. RESULTS: Three patients (3.4%) died; the mortality ratio for this group against the expected standard for subjects of similar age and gender was 10.5 to 1. Eighty (94.1%) of the remaining 85 patients were successfully traced 9.0 years after onset of their illness. Good, intermediate, and poor outcomes were seen in 61.8%, 32.9%, and 5.3% of the subjects, respectively. Anorexia nervosa, bulimia nervosa, or eating disorder not otherwise specified was exhibited by 55.0% of the subjects (N=44). Lifetime depressive (81.6%) and anxiety (27.6%) disorders were common. Older age at onset and the presence of fat phobia independently predicted poor outcome. Patients with atypical anorexia nervosa were symptomatically stable, less likely to demonstrate bulimia, and had a better eating disorder outcome than patients with typical anorexia nervosa. CONCLUSIONS: The outcome profile of Chinese patients supported the cross-cultural disease validity of anorexia nervosa. The cultural fear of fatness not only shaped the manifest content but also added to the chronicity of the illness.

Body composition assessment in extreme obesity and after massive weight loss induced by gastric bypass surgery.

Body composition methods were examined in 20 women [body mass index (BMI) 48.7 +/- 8.8 kg/m(2)] before and after weight loss [-44.8 +/- 14.6 (SD) kg] after gastric bypass (GBP) surgery. The reference method, a three-compartment (3C) model using body density by air displacement plethysmography and total body water (TBW) by H(2)18O dilution (3C-H(2)18O), showed a decrease in percent body fat (%BF) from 51.4 to 34.6%. Fat-free mass hydration was significantly higher than the reference value (0.738) in extreme obesity (0.756; P < 0.001) but not after weight reduction (0.747; P = 0.16). %BF by H(2)18O dilution and air displacement plethysmography differed significantly from %BF by 3C-H(2)18O in extreme obesity (P < 0.05) and 3C models using (2)H(2)O or bioelectrical impedance analysis (BIA) to determine TBW improved mean %BF estimates over most other methods at both time points. BIA results varied with the equation used, but BIA better predicted %BF than did BMI at both time points. All methods except BIA using the Segal equation were comparable to the reference method for determining changes over time. A simple 3C model utilizing air displacement plethysmography and BIA is useful for clinical evaluation in this population.

Binge eating disorder in extreme obesity.

OBJECTIVE: To determine whether extremely obese binge eating disorder (BED) subjects (BED defined by the Eating Disorder Examination) differ from their extremely obese non-BED counterparts in terms of their eating disturbances, psychiatric morbidity and health status. DESIGN: Prospective clinical comparison of BED and non-BED subjects undergoing gastric bypass surgery (GBP). SUBJECTS: Thirty seven extremely obese (defined as BMI > or = 40 kg/m(2)) subjects (31 women, six men), aged 22-58 y. MEASUREMENTS: Eating Disorder Examination 12th Edition (EDE), Three Factor Eating Questionnaire (TFEQ), Structured Clinical Interview for the Diagnostic and Statistical Manual-IV (SCID-IV), Short-Form Health Status Survey (SF-36), and 24 h Feeding Paradigm. RESULTS: Twenty-five percent of subjects were classified as BED (11% met full and 14% partial BED criteria) and 75% of subjects were classified as non-BED. BED (full and partial) subjects had higher eating disturbance in terms of eating concern and shape concern (as found by the EDE), higher disinhibition (as found by the TFEQ), and they consumed more liquid meal during the 24 h feeding paradigm. No difference was found in psychiatric morbidity between BED and non-BED in terms of DSM-IV Axis I diagnosis. The health status scores of both BED and non-BED subjects were significantly lower than US norms on all subscales of the SF-36, particularly the BED group. CONCLUSION: Our findings support the validity of the category of BED within a population of extremely obese individuals before undergoing GBP. BED subjects differed from their non-BED counterparts in that they had a greater disturbance in eating attitudes and behavior, a poorer physical and mental health status, and a suggestion of impaired hunger/satiety control. However, in this population of extremely obese subjects, the stability of BED warrants further study.

Cognitive therapy, nutritional therapy and their combination in the treatment of bulimia nervosa.

BACKGROUND: This study compared the effectiveness of cognitive therapy (CT), nutritional therapy (NT), the combination of cognitive and nutritional therapy (CNT), against a control condition of support group (SG) in the treatment of bulimia nervosa. METHODS: One hundred female out-patients who fulfilled DSM-III-R criteria for bulimia nervosa were randomized to the four treatment groups. NT and CT were designed to cover different areas with minimal overlap, and CNT provided all of the features of both of these treatments. The control condition was conducted in a group self-help format. Each of the treatments lasted 14 weeks. RESULTS: All three active treatments as well as SG produced significant decreases in binge/vomit episodes. Intent-to-treat analysis found CNT and CT to be significantly more effective than SG in retaining subjects in treatment and completion of study, as well as in producing greater improvements in dysfunctional attitudes and self-control. CNT was superior to SG in achieving abstinence from bulimic behaviour. NT was superior to SG only in increase of self-control. Logistic regression found that the cognitive component, whether given alone or in conjunction with NT, and higher pre-treatment self-control scores were significant predictors for both completion of study and abstinence. CONCLUSION: CT (either alone, or in combination with nutritional therapy) remains the treatment of choice for bulimia nervosa. A treatment escalation approach should be tested for the treatment of bulimia with the more intensive and less widely available CT (with or without nutritional counselling) offered after patients have failed the less intensive and more widely available support group treatment.

Double-blind placebo-controlled administration of fluoxetine in restricting- and restricting-purging-type anorexia nervosa.

BACKGROUND: Anorexia nervosa is an often chronic disorder with high morbidity and mortality. Many people relapse after weight restoration. This study was designed to determine whether a selective serotonin reuptake inhibitor would improve outcome and reduce relapse after weight restoration by contributing to maintenance of a healthy normal weight and a reduction of symptoms. METHODS: We administered a double-blind placebo-controlled trial of fluoxetine to 35 patients with restricting-type anorexia nervosa. Anorexics were randomly assigned to fluoxetine (n = 16) or a placebo (n = 19) after inpatient weight gain and then were observed as outpatients for 1 year. RESULTS: Ten of 16 (63%) subjects remained on fluoxetine for a year, whereas only three of 19 (16%) remained on the placebo for a year (p =.006). Those subjects remaining on fluoxetine for a year had reduced relapse as determined by a significant increase in weight and reduction in symptoms. CONCLUSIONS: This study offers preliminary evidence that fluoxetine may be useful in improving outcome and preventing relapse of patients with anorexia nervosa after weight restoration.

Nonsurgical factors that influence the outcome of bariatric surgery: a review.

OBJECTIVE: Severe obesity (ie, at least 100% overweight or body mass index > or =40 kg/m2) is associated with significant morbidity and increased mortality. It is apparently becoming more common in this country. Conventional weight-loss treatments are usually ineffective for severe obesity and bariatric surgery is recommended as a treatment option. However, longitudinal data on the long-term outcome of bariatric surgery are sparse. Available data indicate that the outcome of bariatric surgery, although usually favorable in the short term, is variable and weight regain sometimes occurs at 2 years after surgery. The objective of this study is to present a review of the outcome of bariatric surgery in three areas: weight loss and improvement in health status, changes in eating behavior, and psychosocial adjustment. The study will also review how eating behavior, energy metabolism, and psychosocial functioning may affect the outcome of bariatric surgery. Suggestions for additional research in these areas are made. METHOD: Literature review. RESULTS: On average, most patients lose 60% of excess weight after gastric bypass and 40% after vertical banded gastroplasty. In about 30% of patients, weight regain occurs at 18 months to 2 years after surgery. Binge eating behavior, which is common among the morbidly obese, may recur after surgery and is associated with weight regain. Energy metabolism may affect the outcome of bariatric surgery, but it has not been systematically studied in this population. Presurgery psychosocial functioning does not seem to affect the outcome of surgery, and psychosocial outcome is generally encouraging over the short term, but there are reports of poor adjustment after weight loss, including alcohol abuse and suicide. CONCLUSIONS: Factors leading to poor outcome of bariatric surgery, such as binge eating and lowered energy metabolism, should be studied to improve patient selection and outcome. Long-term outcome data on psychosocial functioning are lacking. Longitudinal studies to examine the long-term outcome of bariatric surgery and the prognostic indicators are needed.

Somatoform disorders in Caucasian and Chinese Americans.

Somatization, broadly defined as the presentation of one or more medically unexplained somatic symptoms, refers both to the presentation of somatic symptoms in diagnosable psychiatric disorders such as major depression or anxiety as well as to the presentation of such symptoms in somatoform disorders. Although no comparative data exist, somatization is considered by many clinical investigators to be more common among Chinese than Caucasian patients, but it is unclear if this occurs because somatoform disorders are more prevalent among the Chinese or because Chinese patients with major depression or anxiety more often present with somatic complaints. We examined 85 consecutive Chinese American and 85 consecutive Caucasian American patients referred for psychiatric consultation and found the following: a) True somatization was significantly more common among Chinese American patients referred for psychiatric consultation; b) The somatoform symptom profiles of the two cohorts were different: Chinese American somatizers complained predominantly of cardiopulmonary and vestibular symptoms, whereas their Caucasian counterparts had symptoms that corresponded well with the categories listed in DSM-IV; c) In both cohorts of somatizers, a concurrent psychiatric disorder, most commonly major depression, was almost always present; and d) Among the Chinese American somatizers, pseudoneurological symptoms occurred most commonly in the form of abnormal sensations, whereas abnormal motor functions were more common among Caucasian Americans. Implications of the findings with respect to pathogenesis, treatment, and classification of somatization are discussed.