Who gets treated for an eating disorder? Implications for inference based on clinical populations.

BACKGROUND: The minority of people with an eating disorder receive treatment. Little is known about predictors of receiving treatment. METHODS: Using data from the Growing Up Today Study we identified correlates of receiving treatment for an eating disorder among the 1237 U.S. women who answered questions on treatment history in 2013 and reported meeting criteria for subthreshold eating disorder in ≥ 1 year between 1996 and 2013. Logistic regression models using generalized estimating equations were used to estimate the relative odds of receiving treatment. RESULTS: Approximately 11% of the women reported receiving treatment for an eating disorder. Independent of type of eating disorder, those who had received a diagnosis of depression or anxiety were more likely (odds ratio (OR) = 3.05 95% confidence interval (CI) 1.87-4.97) to receive treatment for an eating disorder. Women with obesity were approximately 85% less likely to receive treatment (OR = 0.13, 95% CI 0.04-0.46) regardless of their type of eating disorder or history of depression of anxiety diagnosis. CONCLUSIONS: Most women meeting criteria for an eating disorder do not receive treatment. Women with BED or obesity are the least likely to receive treatment.

The economic and social costs of body dissatisfaction and appearance-based discrimination in the United States.

This study estimated the social and economic costs of body dissatisfaction and appearance-based discrimination (specifically, weight and skin-shade discrimination) in the United States (USA) in the 2019 calendar year. We used a prevalence-based approach and a cost-of-illness method to estimate the annual cost of harmful appearance ideals for cases of body dissatisfaction and discrimination based on weight and skin shade. Impacts on conditions/illnesses such as eating disorders that are attributable to body dissatisfaction, weight discrimination and skin-shade discrimination were identified through a quasi-systematic literature review, which captured financial, economic, and non-financial costs. For each impact attributable to body dissatisfaction or appearance-based discrimination, annual health system and productivity costs (or labor market costs) were primarily estimated by using a population attributable fraction methodology. Only direct costs that resulted from body dissatisfaction and appearance-based discrimination were included (for example, costs associated with conditions such as depression attributable to body dissatisfaction or appearance-based discrimination). In contrast, indirect costs (e.g. costs associated with a health condition developed following skin bleaching, which was undertaken as a result of body dissatisfaction) were not included. In 2019 body dissatisfaction incurred $84 billion in financial and economic costs and $221 billion through reduced well-being. Financial costs of weight discrimination and skin-shade discrimination were estimated to be $200 billion and $63 billion, respectively, and reduced well-being was estimated to be $206.7 billion due to weight discrimination and $8.4 billion due to skin-shade discrimination. Sensitivity testing revealed the costs likely range between $226 billion and $507 billion for body dissatisfaction, between $175 billion and $537 billion for skin-shade discrimination, and between $126 billion and $265 billion for weight discrimination. This study demonstrates that the prevalence and economic costs of body dissatisfaction and weight and skin-shade discrimination are substantial, which underscores the urgency of identifying policy actions designed to promote prevention.

Appearance ideals in the USA have been widely critiqued for placing unfair burden on people of color and women of all race/ethnicity groups, but little is known about the economic consequences of biased appearance standards. To attain a comprehensive understanding of the economic impact of these harmful appearance ideals on the US economy, we estimated the one-year financial, economic and non-financial costs to the economy caused by body dissatisfaction, weight discrimination, and skin-shade discrimination. We considered a wide range of costs, including costs to the healthcare system, workplace, and other costs for individuals, households, employers, and government. We found that the impact of harmful appearance ideals on the USA economy is substantial. In 2019 body dissatisfaction incurred $84 billion in financial and economic costs and $221 billion through reduced well-being. Financial costs of weight discrimination and skin-shade discrimination were estimated to be $200 billion and $63 billion, respectively, and reduced well-being was estimated to be $207 billion due to weight discrimination and $8 billion due to skin-shade discrimination. Women of all race/ethnicity groups bore the bulk of the burden, shouldering 58% of the costs for body dissatisfaction and 66% for weight discrimination. Women bore 50% of the costs for skin-shade discrimination. These costs are substantial and underscore the urgency of identifying effective policy actions to reduce the damaging effects of harmful appearance ideals.

Eating disorder risk in rural US adolescents: What do we know and where do we go?

Adolescence is a vulnerable period for the development of eating disorders, but there are disparities in eating disorder risk among adolescents. One population that may be at increased risk but is vastly understudied, is adolescents residing in rural regions within the United States. Rural communities face many mental and physical health disparities; however, the literature on rural adolescent eating disorder risk is nearly nonexistent. In this paper we summarize the scant literature on disordered eating and eating disorder risk and prevalence among rural US adolescents. We also detail eating disorder risk factors that may have unique influence in this population, including socioeconomic status, food insecurity, healthcare access, body image, and weight stigma. Given the presence of numerous eating disorder risk factors, we speculate that rural adolescents may be a particularly vulnerable population for eating disorders and we propose critical next steps in research for understanding eating disorder risk among the understudied population of rural adolescents. PUBLIC SIGNIFICANCE: Rural adolescents may be at increased risk for eating disorders due to disproportionate burden of known risk factors, though this relationship remains understudied. We present a summary of the literature on prevalence and unique risk factors, proposing that this may be a high-risk population. We detail next steps for research to understand eating disorder risk in this population to inform future prevention, identification, and treatment efforts needed in this community.

Adolescent and emerging adult perceptions of eating disorder severity and stigma.

OBJECTIVE: Eating disorders are one of the deadliest mental health conditions, yet most individuals with eating disorders never receive treatment. Previous research has explored barriers to treatment among individuals diagnosed with eating disorders, but little is known about general adolescent and emerging adult perceptions of eating disorders, as compared to other mental health illnesses, a population at greatest risk for developing an eating disorder, and a population that may be important sources of information or support for peers. METHOD: A sample of adolescents and emerging adults aged 14-24 years (mean age 19 years) from MyVoice, a national text-message-based cohort (53% female, 38% male, 9% other, race/ethnicity 63% White, 10% Black or African American, 13% Asian, 9% Mixed Race, and 5% Other) provided open-ended responses to questions on the severity of eating disorders as compared to other mental health diagnoses, others' perceptions of eating disorders and potential treatment barriers. Responses were collected using a secure online platform and analyzed using content analysis. RESULTS: Among respondents (n = 792/1283), 91% felt that eating disorders were a mental health condition and 65% felt that eating disorders were as serious as other mental health conditions, while 21% said they were more serious than other mental health conditions. Responses to questions related to perception and barriers illustrated that beliefs of eating disorders involve blame, stigma, and overall lack of understanding. DISCUSSION: Findings from this study illustrate that there is a lack of understanding around eating disorders that could be addressed in youth-focused initiatives. PUBLIC SIGNIFICANCE: Adolescents and emerging adults understand that eating disorders are severe mental illnesses that are not taken seriously by others, especially in comparison with other mental health diagnoses. Adolescents and emerging adults report that individuals with eating disorders are blamed for their condition and face shame and stigma. The lack of understanding around eating disorders should be addressed in youth-focused prevention initiatives.

Greater social adversity is associated with more disordered eating attitudes and behaviors among children from Southeast Michigan.

OBJECTIVE: The objective of this study is to examine the association between indicators of social adversity, including socioeconomic status and race/ethnicity, and children's disordered eating behaviors and attitudes. METHODS: Children ages 8-10 years old (n = 183) were recruited from Michigan. Data were collected through in-home surveys. The Children's Eating Attitudes Test (ChEAT-24) measured disordered eating attitudes and behaviors in the sample. Cumulative social adversity was considered the sum of four binary variables: caregiver race/ethnicity, caregiver education, household income, and child-reported food security status. Linear mixed models examined the association between social adversity indicators and ChEAT-24 scores. RESULTS: Children of primary caregivers of color had significantly higher ChEAT-24 scores than children of white caregivers (p = .03). Children who reported food insecurity had significantly higher ChEAT-24 scores compared to children who reported food security (p = .01). Compared to children with the lowest social adversity score, children with the highest score had a 4.8-unit higher ChEAT-24 score (95% CI .3-9.4), after adjusting for covariates. A significant trend was observed for greater social adversity and higher ChEAT-24 score (p-trend = .02). CONCLUSION: A linear association was observed between greater social adversity and more disordered eating behaviors and attitudes among children in this sample. These findings emphasize the need for eating disorder research in children from racial/ethnic minorities and socioeconomically disadvantaged populations to support future prevention efforts. PUBLIC SIGNIFICANCE: Greater exposure to social adversity was associated with more disordered eating behaviors among preadolescent children. Given that eating disorders are understudied in lower-income and minority racial/ethnic populations, this study highlights the need for additional research to better support prevention and treatment efforts among children from socioeconomically diverse backgrounds.

Caregiver-reported household food insecurity and child-reported food insecurity in relation to eating disorder risk factors and symptoms among preadolescent children.

OBJECTIVE: To examine the relation of caregiver-reported household food insecurity (FI) and child-reported FI with eating disorder (ED) risk factors and symptoms, including effect modification by gender, in preadolescent children. METHOD: Data were from the Family Food Study, a cross-sectional study of households with incomes ≤200% of the federal poverty line in southeastern Michigan. Children aged 8-10 years (n = 194) and their female primary caregivers reported separately on FI status. Children reported ED risk factors/symptoms via the 24-item Children's Eating Attitudes Test (ChEAT-24), with higher scores indicating more ED risk factors/symptoms. Linear mixed models were used to examine associations between FI measures with the ChEAT-24 total score, plus subscale scores for dieting, food preoccupation, weight preoccupation, vomiting, and social pressure to eat/gain weight. Models were adjusted for child age, child gender, caregiver race/ethnicity, caregiver education, and household income. RESULTS: Among all children, child-reported FI, but not caregiver-reported household FI, was associated with more ED risk factors/symptoms. Child-reported FI (vs. no FI) was associated with higher average ChEAT-24 total score (ß = 2.41, 95% CI: 0.57, 4.25). Child-reported FI was also associated with more food preoccupation, more weight preoccupation, and more social pressure to eat. Caregiver-reported household FI was marginally associated with less dieting in girls, and child-reported FI was associated with more dieting in boys. DISCUSSION: Child-reported FI may be more salient than caregiver-reported household FI as a risk factor for ED-related outcomes in preadolescent children. Gender may modify the association between FI and dieting behavior. PUBLIC SIGNIFICANCE STATEMENT: More child-reported food insecurity, but not parent-reported household food insecurity, was associated with more eating disorder risk factors and symptoms among preadolescent boys and girls. These findings emphasize the need for future studies that investigate the role of food insecurity in the development of eating disorders, especially studies that measure child-reported experience of food insecurity.

Food insecurity and its associations with bulimic-spectrum eating disorders, mood disorders, and anxiety disorders in a nationally representative sample of U.S. adults.

PURPOSE: To examine cross-sectional associations between food insecurity and 12-month eating disorders, mood disorders, and anxiety disorders among U.S. adults. METHODS: This study used data collected between 2001 and 2003 from 2914 participants in the National Comorbidity Survey-Replication, a nationally representative sample of U.S. adults (mean age = 44.9 years; 53.4% female). Twelve-month food insecurity was assessed with a modified version of the Short Form U.S. Household Food Security Scale. Twelve-month DSM-IV diagnoses of mental disorders were based on the World Health Organization Composite International Diagnostic Interview. Modified Poisson regression models were conducted, adjusting for age, sex, race/ethnicity, education, and income-to-poverty ratio. RESULTS: Food insecurity was experienced by 11.1% of participants. Food insecurity was associated with greater prevalence of bulimic-spectrum eating disorders (prevalence ratio [PR] = 3.81; 95% confidence interval [CI] 2.26-6.42), mood disorders (PR = 2.53; 95% CI 1.96-3.29), and anxiety disorders (PR = 1.69; 95% CI 1.39-2.07). CONCLUSION: Results indicate that food insecurity is associated with a range of internalizing mental disorders, though these findings should be confirmed with contemporary data to reflect DSM-5 diagnostic updates and the economic effects of the COVID-19 pandemic. Findings from this study emphasize the need to expand food insecurity interventions and improve access to mental health services for food-insecure populations.

The scale matters: assessing body size with figure rating scales in a diverse sample of young adults.

PURPOSE: To explore intersectional differences in weight perception accuracy in a diverse sample of young adults using CDC-defined weight status labels and four separate figure rating scales (FRS). METHODS: This cross-sectional study of 322 18-25-year-olds with body mass index (BMI) ranging from 18.5 to 57.2 (MBMI = 26.01, SD = 6.46) enrolled participants as part of a larger university subject pool cohort in the U.S. MidSouth. Height and weight measurements were obtained. Participants (55% Black, 45% white; 74% female) selected images that best represented their current body size using four FRS and described their weight perception using five labels from "very underweight" to "very overweight/obese". Receiver operating characteristic (ROC) curve analyses were used to compare variability in classification of weight status by FRS and weight perception category across gender and race. RESULTS: Area under the curve (AUC) statistics indicated all scales were significantly better at classifying weight status than chance. Among Black females and Black males, the culturally adapted scale had the strongest discriminatory ability [(AUC = 0.93, SE = 0.02, p < 0.001, 95% CI = 0.89-0.97) and (AUC = 0.93, SE = 0.04, p < 0.001, 95% CI = 0.86-1.00), respectively]. Among white females, the silhouette scale had the strongest discriminatory ability (AUC = 0.93, SE = .03, p < 0.001, 95% CI = 0.88-0.99). Among white males, the photo-based scale had the strongest discriminatory ability (AUC = 0.84, SE = 0.06, p = 0.001, 95% CI = 0.71-0.96). Across all groups, weight perception labels were the weakest classifier of weight status. CONCLUSION: Weight perception labels are an ineffective method of assessing weight status and FRS accuracy varies by race and gender, suggesting the value of gender- and culturally tailored scales. LEVEL OF EVIDENCE: Level III. Evidence obtained from well-designed cohort or case-control analytic studies.

The set point: weight destiny established before adulthood?

PURPOSE OF REVIEW: Although the set point is one of the best understood weight defense mechanisms, how and when a set point is established and what causes its disruption are not well understood. The purpose of this review is to address these gaps in the literature by exploring studies on the establishment of the set point theory and the underlying metabolic processes that support its existence. RECENT FINDINGS: Research suggests that weight loss achieved through restricted energy intake and increased energy expenditure is difficult to maintain and is often followed by greater weight gain over time. It is hypothesized that such weight gain is driven by an individual's set point, a weight range in which the body seeks to remain by adjusting metabolism (e.g. by moderating energy expenditure based on energy intake in times of diet or energy fluctuation). Similar to adults, weight loss in adolescence results in decreased resting metabolic rate (RMR), and that the RMR remains suppressed even with weight restoration. SUMMARY: Recommending weight loss in youth results in metabolic adaptations to restore weight and weight inclusive approaches may be more appropriate to protect their health and wellbeing.

Relationships between patterns of weight-related self-monitoring and eating disorder symptomology among undergraduate and graduate students.

OBJECTIVE: To characterize patterns of weight-related self-monitoring (WRSM) among US undergraduate and graduate students and examine associations between identified patterns of WRSM and eating disorder symptomology. METHOD: Undergraduate and graduate students from 12 US colleges and universities (N = 10,010) reported the frequency with which they use WRSM, including self-weighing and dietary self-monitoring. Eating disorder symptomology was assessed using the Eating Disorder Examination Questionnaire. Gender-specific patterns of WRSM were identified using latent class analysis, and logistic regressions were used to identify differences in the odds of eating disorder symptomology across patterns of WRSM. RESULTS: Among this sample, 32.7% weighed themselves regularly; 44.1% reported knowing the nutrition facts of the foods they ate; 33.6% reported knowing the caloric content of the foods they ate; and 12.8% counted the calories they ate. Among women, four patterns of WRSM were identified: "no WRSM," "all forms of WRSM," "knowing nutrition/calorie facts," and "self-weigh only." Compared with the "no WRSM" pattern, women in all other patterns experienced increased eating disorder symptomology. Among men, three patterns were identified: "no WRSM," "all forms of WRSM," and "knowing nutrition/calorie facts." Only men in the "all forms WRSM" pattern had increased eating disorder symptomatology compared with those in the "no WRSM" pattern. DISCUSSION: In a large sample of undergraduate and graduate students, engaging in any WRSM was associated with increased eating disorder symptomology among women, particularly for those who engaged in all forms. Among men, engaging in all forms of WRSM was the only pattern associated with higher eating disorder symptomology.

Weight bias among public health trainees.

OBJECTIVE: To explore explicit beliefs about the controllability of obesity and the internalisation of negative weight-related stereotypes among public health trainees. DESIGN: Cross-sectional online survey assessing explicit beliefs about the controllability of obesity using the Beliefs About Obese Persons Scale (BAOP) and internalisation of weight bias using the Modified Weight Bias Internalization Scale (WBIS-M). Bivariate associations between BAOP and WBIS-M scores and demographic characteristics were examined using t tests or ANOVA with post hoc Tukey's tests. SETTING: School of Public Health at a large, Midwestern University. PARTICIPANTS: Public health students (n 322). RESULTS: Relative to students who identified as male, those who identified as female had a stronger belief that obesity is not within the control of the individual (P = 0·03), yet had more internalisation of weight bias (P < 0·01). Greater weight bias internalisation was also seen among students who perceived themselves to be of a higher weight status (P < 0·001) and those who were at risk for food insecurity (P < 0·01). CONCLUSIONS: Public health trainees may be more attuned to the complexities of weight relative to trainees in other health-related fields, but are still susceptible to internalisation of negative weight-related stereotypes.

Evaluating gender bias in an eating disorder risk assessment questionnaire for athletes.

Due to stigma, eating disorders are under-researched, underdiagnosed and undertreated among men. This is particularly pertinent among athletes, as athletic goals are a major risk factor for disordered eating in men. This gender stereotype may be reinforced by eating disorder risk assessment tools that better reflect female symptoms. We examine an eating disorder risk assessment questionnaire in a population of athletes to assess both (1) gender bias in individual items and (2) gender differences on a cognitive and behavioral subscale, identified through a factor analysis. Controlling for eating disorder risk, we found that female gender significantly predicted high risk scores on four items; male gender significantly predicted high risk scores on four other items. We also found that women were more likely to score above the median on a cognitive subscale than men with the same level of eating disorder risk, while men were more likely to score above the median on a behavioral subscale. These results may be applied practically to allow eating disorder risk assessment tools to better capture eating disorder risk independent of gender. These methods may be applied to other questionnaires and other social identities, to expand the scope of eating disorder research and treatment.

Parental perceptions of actual and ideal body weight in early childhood prospectively predict adolescent perceptions of actual and ideal body weight among a low-income population.

PURPOSE: To examine the longitudinal associations between parental perceptions of their child's actual weight (PPCA = parental perception of child's actual) and ideal weight (PPCI = parental perception of child ideal) in early childhood and the child's own perceptions of their actual weight (APA = adolescent perceived actual) and ideal weight (API = adolescent perceived ideal) during early adolescence among a low-income population. METHODS: Using a longitudinal study design, 136 child/parent pairs were asked to assess the child's actual and ideal weight using figure rating scales. When children were 4-7 years old, parents reported on their perception of their child's weight; when children were 10-12 years old, the child reported on their own weight perceptions. Actual weight, ideal weight, and the difference between ideal and actual weight perception were assessed at the respective timepoints. Regressions were used to examine the relationship between parental weight perceptions (PPCA and PPCI) and later adolescent weight perception (APA and API). RESULTS: On average, PPCI was higher than PPCA, whereas API was lower than APA. We found a positive relationship between PPCI and API (ß = 0.309, p = .029). PPCA was positively associated with API (ß = 0.304, p = .015) and marginally positively associated with the APA (ß = 0.242, p = .077). However, the difference between PPCI and PPCA did not predict either APA or API. CONCLUSIONS: Parental perception of their child's weight may relate to the adolescent's weight perception, particularly ideal weight. However, several null and marginal associations suggest that parental weight perception in early childhood may not be the most salient factor in determining weight perception in early adolescence. LEVEL OF EVIDENCE: Level III, well-designed longitudinal cohort study.

Understanding suicide risk and eating disorders in college student populations: Results from a National Study.

OBJECTIVE: To examine suicide risk by eating disorder severity and symptom presentation in a nationwide sample of college students. METHOD: The Healthy Minds Study is the largest mental health survey of college populations in the United States. We analyzed the most recent available data (2015-2017) with 71,712 randomly selected students from 77 campuses. We estimated associations between two measures of suicidality (ideation and attempts) and three validated measures of eating disorder symptoms (the SCOFF, weight concerns scale, and the eating disorder examination questionnaire binge and purge items). Importantly, we also controlled for co-occurring symptoms of depression and anxiety, based on validated screening tools. The large, diverse sample provided a unique opportunity to assess whether certain individual characteristics were associated with increased risk. RESULTS: Eating disorder symptoms, even at subthreshold levels, were highly predictive of suicidality. Relative to students with no apparent eating disorder symptoms, students with the highest symptom levels (a SCOFF score of 5) had 11 times higher odds of attempting suicide, while those with subthreshold symptoms had two times higher odds. We also observed a strong association between suicide attempts and eating disorder presentations that included purging. Students from marginalized backgrounds, particularly gender and sexual minorities, were at increased risk for suicide and eating disorders. DISCUSSION: In the largest known study to date, findings suggest that eating disorders should be a priority within broader campus suicide prevention efforts, should be assessed along a continuum of severity and symptom presentation, and should focus on reaching vulnerable students.

Disparities in eating disorder risk and diagnosis among sexual minority college students: Findings from the national Healthy Minds Study.

OBJECTIVE: To examine differences in eating disorder (ED) risk and diagnosis by sexual orientation in a national sample of college students. METHOD: Data from 178 U.S. colleges and universities participating in the Healthy Minds Study between 2016 and 2019 were analyzed (36,691 cisgender men, 81,730 cisgender women; 15.7% self-identifying as sexual minorities). Outcomes were ED risk (≥2 on the SCOFF) and self-reported lifetime ED diagnosis. Prevalence estimates adjusted for demographics and weight status were computed via logistic regression. RESULTS: Higher proportions of questioning (29.1%), bisexual (26.3%), and gay men (30.9%) exhibited elevated risk than heterosexual men (14.3%), and a higher proportion of gay men exhibited elevated risk than bisexual men. Higher proportions of questioning (34.5%) and bisexual women (34.6%) exhibited elevated risk than heterosexual women (27.6%); proportions of lesbian (28.1%) and heterosexual women were similar. Among those with elevated risk, higher proportions of bisexual (5.0%) and gay men (7.1%) and of questioning (14.7%), bisexual (18.1%), and lesbian women (19.6%) had been diagnosed relative to heterosexual men (2.0%) and heterosexual women (10.3%), respectively. DISCUSSION: Questioning and bisexual individuals appear to be particularly vulnerable; they may experience elevated ED risk relative to their heterosexual peers yet underdiagnosis relative to their gay or lesbian peers.

The association of disordered eating with health-related quality of life in U.S. young adults and effect modification by gender.

PURPOSE: To examine the relationship of disordered eating behaviors and eating disorder (ED) diagnosis in young adults with health-related quality of life (HRQL) and to assess the presence of effect modification by gender. METHODS: In 2013, participants (N = 9440, ages 18-31 years) in the U.S. Growing Up Today Study cohort reported use of disordered eating behaviors (dieting, diet pills, laxatives, or vomiting to control weight; binge eating with loss of control) over the past year, plus a lifetime history of ED diagnosis. The relative risk (RR) of less-than-full health (EQ-5D-5L health utility score < 1) and of any impairment (score > 1 on EQ-5D-5L dimensions) were compared across participants with and without disordered eating or ED diagnosis, using cross-sectional multivariable regression controlling for confounders. The association between HRQL and disordered eating or ED diagnosis was assessed using multivariable linear regression with the subsample reporting less-than-full health. The presence of effect modification by gender was also examined. RESULTS: Disordered eating behaviors and ED diagnosis were associated with significantly increased risk of less-than-full health. A significant gender interaction was found for only one variable-ED diagnosis; men who reported ever having received a diagnosis experienced worse decrements in HRQL than did women. Inclusion of BMI in estimation models revealed small attenuations. Across the weight spectrum, the presence of ED was associated with impairment across all EQ-5D-5L dimensions, except self-care. CONCLUSION: Disordered eating behaviors and a lifetime history of ED diagnosis are associated with significant decrements in HRQL, but only ED diagnosis is associated with a significant effect modification by gender.

Psychosocial, behavioral and clinical correlates of children with overweight and obesity.

BACKGROUND: Psychological and behavioral correlates are considered important in the development and persistence of obesity in both adults and youth. This study aimed to identify such features in youth with severe obesity (BMI ≥ 120% of 95thpercentile of sex-specific BMI-for-age) compared to those with overweight or non-severe obesity. METHODS: Youth with BMI ≥ 85th percentile were invited to participate in a prospective research registry where data was collected on attributes such as family characteristics, eating behaviors, dietary intake, physical activity, perception of health and mental well-being, and cardiometabolic parameters. RESULTS: In a racially/ethnically diverse cohort of 105 youth (65% female, median age 16.1 years, range 4.62-25.5), 51% had severe obesity. The body fat percent increased with the higher levels of obesity. There were no differences in the self-reported frequency of intake of sugar sweetened beverages or fresh produce across the weight categories. However, the participants with severe obesity reported higher levels of emotional eating and eating when bored (p = 0.022), levels of stress (p = 0.013), engaged in fewer sports or organized activities (p = 0.044), and had suboptimal perception of health (p = 0.053). Asthma, depression and obstructive sleep apnea were more frequently reported in youth with severe obesity. The presence of abnormal HDL-C, HOMA-IR, hs-CRP and multiple cardiometabolic risk factors were more common among youth with severe obesity. CONCLUSIONS: Youth with severe obesity have identifiable differences in psychosocial and behavioral attributes that can be used to develop targeted intervention strategies to improve their health.

Adolescent stress: A predictor of dieting behaviors in youth with overweight/obesity.

OBJECTIVE: To examine associations between psychological stress and dieting behavior along with the heterogeneity of this association by gender and race in a diverse sample of adolescents with overweight/obesity. METHODS: One hundred and sixty-one adolescents between the ages of 13-19 years of age with overweight/obesity (65% female; 53% non-Hispanic black/47% non-Hispanic white; age: 16.7 ± 1.7 years) were recruited from Southeast MI and included in this analysis. Psychological stress was measured using the Perceived Stress Scale, and dieting behavior was assessed using the dieting subscale from the Eating Attitudes Test (EAT-26) questionnaire. Multivariable linear regression models were conducted to examine the association between psychological stress and dieting behavior by gender and race. RESULTS: Psychological stress was significantly associated with dieting (ß = 0.18 ± 0.06; p < 0.01), with greater stress associated with greater frequency of dieting behavior. This relationship remained significant (ß = 0.15 ± 0.06; p = 0.016), even when controlling for covariates (age, body fat, gender, race, and pubertal development). There were no statistically significant differences in the association of psychological stress and disordered eating indices by gender or race/ethnicity (p's > 0.05). CONCLUSIONS: Increased psychological stress is associated with increased dieting behavior among adolescents with overweight/obesity. These findings suggest that psychological stress equally affects dieting behavior among adolescents with overweight/obesity, regardless of gender and race. Future studies should seek to identify the unique sources of psychological stress that contribute to increased dieting behavior among adolescents with overweight/obesity.

Youth Preferences for Weight-Related Conversations.

Little guidance is available to clinicians on how to talk about weight with their patients. The aim of this study is to explore youth preferences for weight-related conversations. Participants came from the National MyVoice Text Message Cohort. Between 7/2017 and 01/2018, 952 MyVoice participants provided open-ended responses via text message to three questions about weight-related conversations ("Has your doctor ever talked to you about weight?", "What did he or she say?", and "What should a doctor NOT say when talking about weight?"). The presence of themes was coded using standard qualitative methods. Of the 952 respondents, 568 (60%) reported that their doctor had talked with them about weight. Of these, 85% indicated that their doctor had notified them of their weight, BMI, or weight status and/or the need to change their body weight and 16% had doctors who provided advice about weight control. Eight themes emerged from the analysis of responses to the question "What should a doctor NOT say when talking about weight?". The two most common themes were: (1): Avoid stigmatizing terms/language (32%); and (2) Do not shame patient for their weight (25%). Findings suggest that weight-related conversations do not reflect the preferences of the youth they are designed to benefit. Youth recommended that clinicians focus on health and sustainable behavioral solutions, avoid stigmatizing language and comparing them to others, and be aware of the potential harm associated with making assumptions that conflate weight with health behaviors, morality, or appearance.

Development and Validation of the Eating Disorders Screen for Athletes (EDSA): A Brief Screening Tool for Male and Female Athletes.

OBJECTIVES: To develop and validate the Eating Disorders Screen for Athletes (EDSA), a brief eating disorders screening tool for use in both male and female athletes. METHODS: Data from Division I athletes at a Midwestern university (N=434) were used to conduct exploratory factor analysis (EFA) by gender. Data from athletes competing at various levels at universities across the United States (N=862) were then used to conduct confirmatory factor analysis (CFA) and receiver operator characteristic (ROC) curve analysis by gender. Athletes from a range of lean and non-lean sports were included. Gender-specific empirically derived cut-offs on the Eating Disorder Examination-Questionnaire were used to classify high eating disorder risk for ROC curve analysis. Measurement invariance by gender, level of competition, and sport type was also examined. RESULTS: A six-item, one-factor structure for the EDSA was supported by EFA and CFA in both genders, and internal consistency was good for both male (α=. 80) and female athletes (α=.86). ROC curve analyses indicated that the EDSA was highly accurate in predicting eating disorder risk status and identified a score of 3.33 as the optimal cut-off for both male (sensitivity=.96, specificity=.80) and female athletes (sensitivity=.96, specificity=.64). Results also supported strong measurement invariance for the EDSA by gender, level of competition (Division I versus club), and sport type (lean versus non-lean). CONCLUSIONS: The EDSA shows promise as a brief screening tool to identify male and female athletes at risk for eating disorders.