A latent profile analysis of the typology of bulimic symptoms in an indigenous Pacific population: evidence of cross-cultural variation in phenomenology.

BACKGROUND: Previous efforts to derive empirically based eating disorder (ED) typologies through latent structure modeling have been limited by the ethnic and cultural homogeneity of their study populations and their reliance on DSM-IV ED signs and symptoms as indicator variables. METHOD: Ethnic Fijian schoolgirls (n=523) responded to a self-report battery assessing ED symptoms, herbal purgative use, co-morbid psychopathology, clinical impairment, cultural orientation, and peer influences. Participants who endorsed self-induced vomiting or herbal purgative use in the past 28 days (n=222) were included in a latent profile analysis (LPA) to identify unique subgroups of bulimic symptomatology. RESULTS: LPA identified a bulimia nervosa (BN)-like class (n=86) characterized by high rates of binge eating and self-induced vomiting, and a herbal purgative class (n=136) characterized primarily by the use of indigenous Fijian herbal purgatives. Both ED classes endorsed greater eating pathology and general psychopathology than non-purging participants, and the herbal purgative class endorsed greater clinical impairment than either the BN-like or non-purging participants. Cultural orientation did not differ between the two ED classes. CONCLUSIONS: Including study populations typically under-represented in mental health research and broadening the scope of relevant signs and symptoms in latent structure models may increase the generalizability of ED nosological schemes to encompass greater cultural diversity.

Toward an understanding of risk factors for anorexia nervosa: a case-control study.

BACKGROUND: Prospective, longitudinal studies of risk factors for anorexia nervosa (AN) are lacking and existing cross-sectional studies are generally narrow in focus and lack methodological rigor. Building on two studies that used the Oxford Risk Factor Interview (RFI) to establish time precedence and comprehensively assess potential risk correlates for AN, the present study advances this line of research and represents the first case-control study of risk factors for AN in the USA. METHOD: The RFI was used for retrospective assessment of a broad range of risk factors, while establishing time precedence. Using a case-control design, 50 women who met DSM-IV criteria for AN were compared to those with non-eating disorder DSM-IV psychiatric disorders (n=50) and those with no psychiatric disorder (n=50). RESULTS: Women with psychiatric disorders reported higher rates of negative affectivity, maternal and paternal parenting problems, family discord, parental mood and substance disorder, and physical and sexual abuse than women with no psychiatric disorder. Women with AN specifically reported greater severity and significantly higher rates of negative affectivity, perfectionism and family discord, and higher parental demands than women with other psychiatric disorders. The role of weight and shape concerns was most salient in the year preceding onset of AN. CONCLUSIONS: Convergent data identifying common risk factors as well as those more severe in the development of AN are emerging to inform longitudinal risk factor and prevention studies for this disorder.

The relationship between meal frequency and body mass index in black and white adolescent girls: more is less.

OBJECTIVE: To document meal frequency and its relationship to body mass index (BMI) in a longitudinal sample of black and white girls from ages 9-19 years. DESIGN: Ten-year longitudinal observational study. SUBJECTS: At baseline, 1209 Black girls (539 age nine years, 670 age 10 years) and 1,166 White girls (616 age nine years, 550 age 10 years) were enrolled in the National Heart, Lung and Blood Institute Growth and Health Study (NGHS). MEASUREMENTS: Three-day food diaries, measured height and weight and self-reported physical activity and television viewing were obtained at annual in-person visits. RESULTS: Over the course of the study, the percentage of girls eating 3+ meals on all 3 days was reduced by over half (15 vs 6%). Participants who ate 3+ meals on more days had lower BMI-for-age z-scores. Black girls, but not white girls, who ate 3+ meals on more days were less likely to meet criteria for overweight. CONCLUSION: Meal frequency was related to BMI and should be considered when developing guidelines to prevent childhood overweight.

Health services use in eating disorders.

BACKGROUND: This study examined healthcare services used by adults diagnosed with an eating disorder (ED) in a large health maintenance organization in the Pacific Northwest. METHOD: Electronic medical records were used to collect information on all out-patient and in-patient visits and medication dispenses, from 2002 to 2004, for adults aged 18-55 years who received an ED diagnosis during 2003. Healthcare services received the year prior to, and following, the receipt of an ED diagnosis were examined. Cases were matched to five comparison health plan members who had a health plan visit close to the date of the matched case's ED diagnosis. RESULTS: Incidence of EDs (0.32% of the 104,130 females, and 0.02% of the 93,628 males) was consistent with prior research employing treatment-based databases, though less than community-based samples. Most cases (50%) were first identified during a primary-care visit and psychiatric co-morbidity was high. Health services use was significantly elevated in all service sectors among those with an ED when compared with matched controls both in the year preceding and that following the receipt of the incident ED diagnosis. Contrary to expectations, healthcare utilization was found to be similarly high across the spectrum of EDs (anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified). CONCLUSIONS: The elevation in health service use among women both before and after diagnosis suggests that EDs merit identification and treatment efforts commensurate with other mental health disorders (e.g. depression) which have similar healthcare impact.

Barriers to treatment for eating disorders among ethnically diverse women.

OBJECTIVE: This study examined barriers to treatment in an ethnically diverse community sample of women with eating disorders. METHOD: Participants were 61 women (22 Hispanics, 8 Asians, 12 Blacks, 19 Whites) with eating disorders. Diagnosis was determined using the Eating Disorder Examination. Treatment-seeking history, barriers to treatment seeking, ethnic identity, and acculturation were assessed. RESULTS: Although 85% of the sample reported wanting help for an eating problem, only 57% had ever sought treatment for an eating or weight problem. Individuals who had sought treatment reported being significantly more distressed about their binge eating than those who had not sought treatment and having begun overeating at a younger age. Of those who had sought help, 86% had not received any treatment for their eating problems. The main barriers to treatment seeking were financial reasons. CONCLUSION: Women from minority groups who have eating disorders are underdiagnosed and typically not treated.

Exploring the relationship between timing of menarche and eating disorder symptoms in Black and White adolescent girls.

OBJECTIVE: This study examined the relationship between timing of sexual maturation and eating disorders symptoms in adolescent girls. METHOD: Data were collected over 10 years for a cohort of 1,213 Black girls and 1,166 White girls who were either 9 or 10 years old at study entry. Annually, girls' height and weight were measured and, biannually, girls completed self-report measures of eating disorders symptoms. RESULTS: Early-onset menarche is a risk factor for the development of body image and dieting concerns, but the effect of timing is due to the impact of early and late maturation on body weight. DISCUSSION: Findings underscore the importance of adiposity as a risk factor for poor mental health.

A comparison of black and white women with binge eating disorder.

OBJECTIVE: Binge eating disorder was introduced in DSM-IV as a psychiatric disorder needing further study. This community-based study describes the relationship between race and clinical functioning in black and white women with and without binge eating disorder. METHOD: A group of 150 women with binge eating disorder (52 black, 98 white) and a race-matched group of 150 healthy comparison subjects were recruited from the community. Eating and psychiatric symptoms were assessed through interviews and self-report. RESULTS: Black and white women with binge eating disorder differed significantly on numerous eating disorder features, including binge frequency, restraint, history of other eating disorders, treatment-seeking behavior, and concerns with eating, weight, and shape. Black and white healthy comparison subjects differed significantly in obesity rates. CONCLUSIONS: For both black and white women, binge eating disorder was associated with significant impairment in clinical functioning. Yet, racial differences in clinical presentation underscore the importance of considering race in psychopathology research.

Bias in binge eating disorder: how representative are recruited clinic samples?

The aim of this study was to investigate sampling bias as it affects recruited clinic samples of binge eating disorder (BED). Demographic and clinical characteristics of a recruited clinic sample were compared with a community sample. The 2 groups met the same operational definition of BED and were assessed using the same primarily interview-based methods. Ethnicity, severity of binge eating, and social maladjustment were found to increase treatment seeking among participants with BED rather than levels of psychiatric distress or comorbidity. These findings suggest that previous studies using recruited clinic samples have not biased estimates of psychiatric comorbidity in BED.

Comparison of binge eating disorder and bulimia nervosa in a community sample.

OBJECTIVE: This study examined the relationship between binge eating disorder (BED), a newly proposed eating disorder, and bulimia nervosa (BN). METHOD: Three groups recruited from the community were compared: women with BED (n = 150), women with purging BN (n = 48), and women with nonpurging BN (n = 14). RESULTS: The three groups did not differ significantly in education, weight or shape concern, and current or lifetime prevalence of nine major mental disorders. Women with BED, compared with women with purging BN, were older, less likely to have a history of anorexia nervosa, and less likely to have been treated for an eating disorder. Obesity was more commonly associated with BED than with either subtype of BN. DISCUSSION: Our results lend some support to BED as an eating disorder distinct from purging BN. More research is needed to clarify the position of nonpurging BN relative to BED and purging BN.

Impact of timing of pubertal maturation on growth in black and white female adolescents: The National Heart, Lung, and Blood Institute Growth and Health Study.

OBJECTIVES: To evaluate the impact of early, mid-onset, and late maturation, as assessed by timing of menarche, on height, height velocity, weight, body mass index, and sum of skinfolds in a group of white and black girls. STUDY DESIGN: The Growth and Health Study recruited 9- and 10-year-old girls from Richmond, California, Cincinnati, Ohio, and Washington, DC. There were 616 white and 539 black participants recruited at age 9 and 550 white and 674 black participants recruited at age 10. Participants were seen annually for 10 visits. Longitudinal regression models were used to test for differences in each growth measure by timing of menarche across all ages and to determine whether these differences change with age. RESULTS: Mean age at menarche among white participants was 12.7 years, and among black participants, 12.0 years. According to race-specific 20th and 80th percentiles, early maturers were tallest at early ages and shortest after adult stature had been attained. Peak height velocity and post-menarche increment in stature were greatest in early maturers and least in late maturers. Weight was greatest in early and least in late maturers, as was body mass index. Sum of skinfolds was also greatest in early and least in late maturers. There was no impact of timing of maturation on two common measures of regional fat distribution. CONCLUSIONS: Girls who matured early were shorter in early adulthood, despite having greater peak height velocity and post-menarchal increment in height. Throughout puberty, early maturers had greater ponderosity and adiposity, although there was no association with regional distribution of fat.

Factors differentiating women and men who successfully maintain weight loss from women and men who do not.

The current study explored the relative contribution of exercise, coping responses, cognitive attributions, and emotional experiences to successful weight-loss maintenance in men and women. The data were collected via a large community-based survey on dieting and weight loss commissioned by Consumer Union. Men and women who met our criteria for successful (n = 277 men, n = 329 women) and unsuccessful (n = 277 men, n = 329 women) weight-loss maintenance were included in the sample. Successful weight-loss maintainers (Maintainers) reported having lost at least 10% of their highest adult weight and having maintained that weight loss for at least the three years immediately prior to the survey. Unsuccessful weight-loss maintainers (Regainers) reported not ever having been able to maintain a significant weight loss and having lost and regained a minimum of 10 to 19 pounds at least once. In response to a dietary lapse, Maintainers, as compared with Regainers, reported being more likely to use direct coping and less likely to seek help. The results imply that the most useful variables for differentiating between successful and unsuccessful weight-loss maintainers may involve how they respond to a dietary lapse.

Epidemiology and natural course of eating disorders in young women from adolescence to young adulthood.

OBJECTIVES: To describe the epidemiology of eating disorders (ED) in a community sample of adolescent girls; to compare the clinical characteristics of full-syndrome (FS) and partial-syndrome (PS) ED cases; and to provide information about the continuity between adolescent ED and young adult psychopathology. METHOD: A randomly selected sample of high school girls were assessed during adolescence (n = 891) and a year later (n = 810), and a stratified subset (n = 538) was assessed during their 24th year. The assessments included the Schedule for Affective Disorders and Schizophrenia for School-Age Children, the Longitudinal Interval Follow-up Evaluation, level of functioning, mental health treatment utilization, history of suicide attempt, and physical symptoms. RESULTS: The incidence of ED was less than 2.8% by age 18, and 1.3% for ages 19 through 23. Comorbidity with other psychopathology (89.5%), but especially depression, was very high. FS- and PS-ED groups differed significantly from a no-disorder comparison group on most outcome measures, and more than 70% of the adolescent FS- and PS-ED cases met criteria for an Axis I disorder in young adulthood. CONCLUSIONS: FS- and PS-ED are associated with substantial comorbidity, treatment seeking, impaired functioning, and risk for psychopathology in young adulthood.

One-year use and cost of inpatient and outpatient services among female and male patients with an eating disorder: evidence from a national database of health insurance claims.

OBJECTIVE: This study examined rates and cost of inpatient and outpatient treatment among 1,932 patients with an eating disorder. METHOD: One-year (1995) data were available through MarketScan, a national insurance database containing claims for 1,902,041 male patients and 2,005,760 female patients. RESULTS: Female patients (n = 1,756, 0.14% of all females) were significantly more likely to have been treated for an eating disorder than male patients (n = 176, 0.016% of all males), and females received more days of treatment than males. Outpatient treatment was the norm, regardless of gender or type of eating disorder. Average number of days (inpatient or outpatient) was less than the minimum recommended by standards of care. Age-adjusted costs for the treatment of anorexia nervosa and bulimia nervosa were comparable to the cost of treatment for schizophrenia. DISCUSSION: The utilization data are discussed in terms of barriers to care and treatment guidelines for eating disorders.

Subthreshold binge eating disorder.

OBJECTIVE: To examine the clinical features of subthreshold binge eating disorder (BED). METHOD: Participants were recruited directly from the community as part of an ongoing study of risk factors for BED. Forty-four women with subthreshold BED were compared with 44 women with BED and 44 healthy controls on demographic characteristics, body mass index (BMI), eating disorder symptomatology, and psychiatric distress. Diagnoses were established using the Eating Disorder Examination (EDE). Participants completed the EDE-Questionnaire, the Brief Symptom Inventory, and were measured and weighed. RESULTS: Adjusting for significant group differences in BMI, the two eating disorder groups did not differ significantly on measures of weight and shape concern, restraint, psychiatric distress, and history of seeking treatment for an eating or weight problem. DISCUSSION: Given the importance of diagnostic status for access to treatment, further evaluation of the severity criterion specified for BED is needed.

Recurrent binge eating in black American women.

CONTEXT: Recurrent binge eating is a core diagnostic feature of bulimia nervosa and binge eating disorder, and in samples of white women has been associated with obesity and psychiatric symptoms. Eating disorders have been believed to occur primarily among white women; in fact, the limited preliminary data available suggest that black women may be as likely as white women to report binge eating. OBJECTIVE: To examine race differences in prevalence of behavioral symptoms of eating disorders and clinically significant recurrent binge eating. DESIGN: Community survey. SETTING: General community in Connecticut and Boston, Mass. PARTICIPANTS: A community sample of 1628 black women and 5741 white women (mean age, 29.7 years) participated in a telephone survey designed to ascertain the presence, during the preceding 3 months, of binge eating and extreme weight control behaviors (vomiting, laxative or diuretic abuse, or fasting). MAIN OUTCOME MEASURE: Interviewer-based phone assessment of recurrent binge eating and behavioral symptoms of eating disorders. RESULTS: Black women were as likely as white women to report binge eating or vomiting during the preceding 3 months, and were more likely to report fasting and the abuse of laxatives or diuretics. Recurrent binge eating was more common among black women than among white women. In both race groups, recurrent binge eating was associated with elevated body weight and increased psychiatric symptoms. CONCLUSION: Results suggest that recurrent binge eating is a significant problem among black and white women. Health professionals need to be ready to respond to this health risk behavior.

Eating disorder symptoms in a cohort of 11 to 16-year-old black and white girls: the NHLBI growth and health study.

OBJECTIVE: This study sought to provide reference data for the Eating Disorder Inventory (EDI) with use of young adolescent black and white girls. Moreover, the study examined the relationship between race, age, socioeconomic status, and adiposity and each of the eight EDI scales. METHOD: To achieve these aims, data were used that had been collected in Years 3, 5, and 7 as part of the National Heart, Lung, and Blood Institute Growth and Health Study, a longitudinal cohort study of risk factors for obesity in black and white girls. For the present report, data were available from 2,228 girls in Year 3, 2,056 girls in Year 5, and 1,902 girls in Year 7. RESULTS: EDI scores were found to vary by race, age, socioeonomic status, and body weight of respondents. Black girls scored different from white girls on all EDI subscales. Scores on all but two subscales (Body Dissatisfaction, Drive for Thinness) decreased significantly with increasing age. Significant inverse associations were found between maximum parental education and all EDI subscales except Body Dissatisfaction and Perfectionism. Elevated body weight was associated significantly with Body Dissatisfaction, Drive for Thinness, Bulimia, Interoceptive Awareness, and Ineffectiveness. DISCUSSION: Our results illustrate the importance of taking into consideration the potentially confounding role of demographic characteristics and body weight when comparing different race or ethnic groups on the EDI.

Emotion-induced eating and sucrose intake in children: the NHLBI Growth and Health Study.

OBJECTIVE: Emotion-induced eating has been implicated as a risk factor for the development of obesity, yet no research has been done on emotion-induced eating in children. The National Heart, Lung, and Blood Institute Growth and Health Study (NGHS), a multicenter collaborative study of risk factors for obesity, developed an instrument for measuring emotion-induced eating in children and tested hypotheses regarding the association of emotion-induced eating with food intake and adiposity in preadolescent children. METHOD: Subjects were 1,213 black girls and 1,166 white girls who were 9 and 10 at study entry. Baseline data were utilized in this report. Girls were assessed by trained female health examiners who recorded height, weight, and indices of sexual maturation. Girls kept a 3-day food diary. Dietary data were coded and analyzed for total caloric and macro nutrient intake. A measure of emotion-induced eating was derived from seven questions about eating in response to emotions (Cronbach's alpha = .78). RESULTS: Black girls had significantly higher emotion-induced eating scores than white girls (10.8 vs. 9.7, p < .0001). For white girls, but not for black girls, emotion-induced eating was associated with increased intake of sucrose. In both races, a modest inverse association was found between body mass index and emotion-induced eating. DISCUSSION: Prospective studies are needed to explore further the role of emotion-induced eating and food intake and the role of emotion-induced eating in the development of obesity.

Psychiatric comorbidity of eating disorders in men: a national study of hospitalized veterans.

OBJECTIVE: This study examined eating disorders and their psychiatric comorbidity in a national sample of hospitalized male veterans. METHOD: Review of discharge summaries for 466,590 male patients from Veterans Affairs medical centers for fiscal year 1996 resulted in the identification of 98 men with a current ICD-9-CM diagnosis of an eating disorder. For the comorbidity analyses, eating disorder cases were matched with controls drawn randomly from the pool of male patients without an eating disorder, using age and race as matching variables. RESULTS: There was a high rate of comorbid substance use and mood disorder for men with anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS). Men with AN were also at high risk for comorbid schizophrenia/psychotic disorder, men with BN were at risk for comorbid personality disorder, and men with EDNOS were at special risk for comorbid organic mental disorder and schizophrenia/psychotic disorder. DISCUSSION: For each eating disorder, there was a distinct pattern of psychiatric comorbidity that deserves further study.