Disparities in eating disorder diagnosis and treatment according to weight status, race/ethnicity, socioeconomic background, and sex among college students.

OBJECTIVE: Eating disorders (EDs) present a significant threat to the health of adolescents and young adults, yet remain under-diagnosed and under-treated at a population-level. EDs have historically been thought to afflict "skinny, white, affluent girls" (the SWAG stereotype). As such, higher-weight individuals, racial/ethnic minorities, those from socioeconomically disadvantaged backgrounds, and males may not recognize their need for treatment, may not be properly screened for EDs, and/or may not be referred to treatment. METHOD: Using large-scale survey data from the healthy bodies study, we examined variations in prevalence of perceived need for ED treatment, ED diagnosis, past-year ED treatment, and treatment barriers according to weight status, race, socioeconomic background, and sex among undergraduate and graduate students with symptoms of an ED (N = 1,747). RESULTS: Among students with symptoms of an ED, 30.7% perceived a need for treatment, 10.5% had received a diagnosis, and 13.6% had received treatment in the past year. Individual characteristics were highly associated with perceived need, diagnosis, and past-year treatment. Females were more likely than males to perceive a need for treatment (OR = 1.97), to be diagnosed (OR = 4.66), and to be treated (OR = 1.64) for their ED symptoms. Socioeconomic background was associated with perceived need for treatment and past-year treatment, with students from affluent backgrounds having higher odds of perceiving need (OR = 1.52) and of receiving treatment (OR = 1.89) compared with their non-affluent peers. DISCUSSION: At a population-level, the unmet need for ED treatment disproportionately affects certain groups. Stereotypes about who develops EDs could contribute to disparities in ED treatment and outcomes.

Eating disorder symptoms among undergraduate and graduate students at 12 U.S. colleges and universities.

OBJECTIVES: We sought to estimate the prevalence of eating disorder symptoms in a large sample of U.S. college students and variations therein across student characteristics. METHODS: Participants were 9713 students from 12 colleges and universities participating in the Healthy Bodies Study. We used gender-stratified logistic regression to estimate bivariate correlates of elevated eating disorder symptoms, past-month objective binge eating, and past-month compensatory behaviors across student characteristics including age, degree-level, sexual orientation, race/ethnicity, first-generation status, citizenship, academic and extracurricular characteristics, and weight status. Eating disorder outcomes were based on the Eating Disorder Examination Questionnaire. RESULTS: We observed higher prevalence of objective binge eating among females relative to males (49% versus 30%, p<0.001), but similar prevalence of compensatory behaviors (31% versus 29%). Weight status was the most consistent predictor of eating disorder risk with significantly more symptoms seen among individuals with overweight and obesity. When compared to individuals with a healthy weight, those with overweight had greater eating disorder risk (males OR=3.5; females OR=2.0), binge eating (males OR=2.1; females OR=1.9), and use of compensatory behaviors (males OR=1.5; females OR=1.3). CONCLUSIONS: This study suggests smaller gender difference in prevalence of eating disorder symptoms than previously reported and identifies students with overweight/obesity as salient targets for campus-based eating disorder screening and early intervention efforts.

Eating disorder behaviours amongst adolescents: investigating classification, persistence and prospective associations with adverse outcomes using latent class models.

Diagnostic criteria for eating disorders (ED) remain largely based on clinical presentations, but do not capture the full range of behaviours in the population. We aimed to derive an empirically based ED behaviour classification using behavioural and body mass index (BMI) indicators at three time-points in adolescence, and to validate classes investigating prospective associations with adverse outcomes. Adolescents from the Avon Longitudinal Study of Parents and Children (ALSPAC) provided data on ED at age 14 (n = 6615), 16 (n = 5888), and 18 years (n = 5100), and had weight and height measured. Psychological and behavioural outcomes were assessed at 15.5/16 and 17.5/18 years. We fit gender- and age-stratified latent class models, and employed logistic regression to investigate associations between classes and later outcomes. One asymptomatic and two symptomatic (largely representing higher and lower frequency ED behaviours) classes were observed at each time-point, although their relative prevalence varied by age and gender. The majority of girls in symptomatic classes remained symptomatic at subsequent assessments. Girls in symptomatic classes had higher odds of subsequent anxiety and depressive disorders, binge drinking, drug use, and deliberate self-harm. Data analyses were underpowered amongst boys. The presence of two symptomatic classes (characterised by different ED behaviour frequency) and their prospective association with adverse outcomes suggest a need to refine diagnostic thresholds based on empirical data. Despite some instability of classes, particularly in mid-adolescence, evidence that half of girls in symptomatic classes remained symptomatic suggests persistence of ED behaviours in adolescence, and highlights a need for early identification to reduce chronicity.

Is obesity becoming the new normal? Age, gender and racial/ethnic differences in parental misperception of obesity as being 'About the Right Weight'.

INTRODUCTION: Younger children, non-Hispanic Black and male children who are overweight (body mass index (BMI) ⩾85th percentile) are at greater risk for being misperceived by their parents as having a healthy or normal weight, but less is known about the risk for weight misperception in the subpopulation of children with obesity (BMI⩾95th percentile). We assessed the gender, age and racial/ethnic differences in parental misperception of healthy or normal weight status in children with obesity. METHODS: We analyzed the data of 1445 children and adolescents aged 6-15 years with obesity obtained from the National Health and Nutrition Examination Surveys conducted from 2005 to 2012. Parental perception of the child's weight was obtained during an in-home interview. Anthropometric data on body weight were collected from the children during their physical and used to calculate gender and age-specific BMI percentiles. Logistic regression was used to calculate the adjusted odds ratios for parental misperception of their child's obesity as being 'about the right weight', using parents who perceived their children with obesity as being 'overweight' for reference. RESULTS: Boys aged 6-15 years with obesity were more likely to be misperceived as being 'about the right weight' by their parents (adjusted odds ratio (aOR): 1.40 (1.12-1.76) vs girls, P=0.0038). The subpopulations of children with obesity who were significantly less likely to be misperceived included girls aged 11-15 years (aOR: 0.46 (0.29-0.74) vs girls 6-10 years, P=0.0016) and Hispanic males (aOR: 0.58 (0.36-0.93) vs White males, P=0.02). CONCLUSIONS: Significant age differences in the odds for parental misclassification of obesity as 'about the right weight' were detected in female children, but not males. Hispanic males with obesity were significantly less likely to be misperceived as being 'about the right weight' when compared with their non-Hispanic White peers.

Helpful or harmful? Prospective association between weight misperception and weight gain among overweight and obese adolescents and young adults.

BACKGROUND/OBJECTIVE: Weight misperception is common among adolescents with obesity, but it is not known whether weight perception is related to future weight gain. The objective of the study was to examine the prospective association between accurate weight perception versus weight misperception and weight change among youth who are overweight or obese. SUBJECTS/METHODS: Using a subsample of The National Longitudinal Study of Adolescent to Adult Health Wave II cohort, we used linear regression modeling (adjusted for age, baseline body mass index (BMI), parental education, household percent federal poverty level, depression, race and ethnicity) to examine the prospective association between weight misperception (that is, perceiving oneself to be under or normal weight) among 2738 overweight and obese youth and subsequent BMI change from Wave II (1996) to Wave IV (2008-2009). Mean age at baseline (Wave II) was 15.9 (0.1). RESULTS: Fifty-seven percent of males and 80% of females accurately perceived themselves as overweight. In fully adjusted models, weight misperception was associated with less BMI gain among youth who were overweight and obese. Specifically, youth who perceived themselves to be at a healthy weight had lower BMI gains (males: ß= -1.43, 95% confidence interval (CI)=(-2.26, -0.60), P=0.001; females: ß= -1.35, 95% CI=(-2.59, -0.11), P=0.035) from Wave II to IV relative to those who accurately perceived themselves as overweight or obese. CONCLUSIONS: Contrary to commonly held assumptions, weight misperception among a non-clinical sample of youth who were overweight or obese predicted lower future weight gain. Efficacy of efforts to correct weight misperception should be rigorously examined to assess for both intended and unintended consequences.

Childhood hyperactivity/inattention and eating disturbances predict binge eating in adolescence.

BACKGROUND: Identifying childhood predictors of binge eating and understanding risk mechanisms could help improve prevention and detection efforts. The aim of this study was to examine whether features of attention-deficit/hyperactivity disorder (ADHD), as well as childhood eating disturbances, predicted binge eating later in adolescence. METHOD: We studied specific risk factors for the development of binge eating during mid-adolescence among 7120 males and females from the Avon Longitudinal Study of Parents and Children (ALSPAC), a cohort study of children in the UK, using data from multiple informants to develop structural equation models. Repeated assessment of eating disturbances during childhood (mid-childhood overeating, late-childhood overeating and early-adolescent strong desire for food), as well as teacher- and parent-reported hyperactivity/inattention during mid- and late childhood, were considered as possible predictors of mid-adolescent binge eating. RESULTS: Prevalence of binge eating during mid-adolescence in our sample was 11.6%. The final model of predictors of binge eating during mid-adolescence included direct effects of late-childhood overeating [standardized estimate 0.145, 95% confidence interval (CI) 0.038­0.259, p = 0.009] and early-adolescent strong desire for food (standardized estimate 0.088, 95% CI −0.002 to 0.169, p = 0.05). Hyperactivity/inattention during late childhood indirectly predicted binge eating during mid-adolescence (standardized estimate 0.085, 95% CI 0.007­0.128, p = 0.03) via late-childhood overeating and early-adolescent strong desire for food. CONCLUSIONS: Our findings indicate that early ADHD symptoms, in addition to an overeating phenotype, contribute to risk for adolescent binge eating. These findings lend support to the potential role of hyperactivity/inattention in the development of overeating and binge eating.

Body satisfaction, weight gain and binge eating among overweight adolescent girls.

OBJECTIVE: To examine if body satisfaction is associated with body mass index (BMI) change and whether it protects against the development of frequent binge eating among overweight and obese adolescent girls. METHODS: We used prospective data from nine waves of an ongoing cohort study of adolescents, the Growing Up Today Study. At enrollment in 1996, participants were 9-14 years old. Questionnaires were mailed to participants annually until 2001, then biennially through 2007. Girls who were overweight or obese in 1996 were included in the analysis (n = 1559). Our outcomes were annual change in BMI and incident frequent binge eating, defined as binge eating at least weekly and no use of compensatory behaviors. RESULTS: At baseline, 57.2% of the overweight and obese girls were at least somewhat satisfied with their bodies. During 11 years of follow-up, 9.5% (95% confidence interval (CI) (7.8, 10.8)) of the girls started to binge eat frequently. Controlling for BMI and other confounders, overweight and obese girls who reported being at least somewhat satisfied with their bodies made smaller BMI gains (ß = -0.10 kg m(-2), 95% CI (-0.19, -0.02)) and had 61% lower odds of starting to binge eat frequently (odds ratio (OR) = 0.39, 95% CI (0.24, 0.64)) than their less satisfied peers. Compared with girls who were the least satisfied with their bodies, girls who were the most satisfied had 85% lower odds of starting to binge eat frequently (OR = 0.15, 95% CI (0.06, 0.37)). The association between body satisfaction and starting to binge eat frequently was stronger for younger adolescents than older adolescents. CONCLUSIONS: Whereas body dissatisfaction is common among overweight and obese girls, body satisfaction may protect against excessive weight gain and binge eating. Prevention of body dissatisfaction must begin early and should be considered as a component of both obesity and eating disorder prevention programs.

Total energy intake, adolescent discretionary behaviors and the energy gap.

OBJECTIVE: To estimate total energy intake and the energy gap-the daily imbalance between energy intake and expenditure-associated with discretionary behaviors of adolescents, namely their leisure active behaviors (playing or participating in sports and heavy chores), leisure sedentary behaviors (television (TV) viewing and playing video and computer games), productive sedentary behaviors (reading or doing homework). DESIGN: Prospective observational study. PARTICIPANTS: A total of 538 students (mean age at baseline=11.7 years) from public schools in the Boston area studied prospectively from the fall of 1995 to the spring of 1997. MEASUREMENTS: Anthropometric assessment including height and weight, dietary assessment using a youth food frequency questionnaire and measures of TV, video, reading/doing homework and youth physical activity. RESULTS: We estimate the change in total energy intake for each hour change in discretionary activity using regression methods. A 1-h increase in watching TV is associated with a 106 kcal h(-1) increase in total energy intake (95% confidence interval (CI): 61-150 kcal day(-1)). A similar change of 92 kcal h(-1) (95% CI: 37-147 kcal day(-1)) is seen with playing video and computer games. The change in energy intake associated with an hour change in physical activity is 292 kcal h(-1) (95% CI: 262-321 kcal day(-1)). No significant change is associated with reading/doing homework. Assuming that typical energy expenditures are associated with these behaviors, reading/doing homework appears to be an 'energy neutral' activity, whereas watching TV and playing video and computer games is associated with an energy surplus. If we assume that physical activity levels are moderate (3.5 METs), then this is also an energy surplus activity. If physical activity is assumed to be vigorous for the entire time allotted (>6.0 METs), an energy deficit could be achieved. We validated these estimates by calculating regressions predicting change in weight. Results indicate that each hour increase in TV viewing is associated with a weight increase of 0.38 kg (95% CI: 0.17-0.59 kg), with no significant associations for the other behaviors. A model with change in BMI as the dependent variable produced similar results. CONCLUSION: Watching TV is an activity associated with a daily energy surplus. Although physical activity is thought of as an energy deficit activity, our estimates do not support this hypothesis. Reading/doing homework is the only discretionary activity examined which appears to be clearly energy neutral. The differential impacts of these discretionary behaviors on energy intake and the energy gap are discussed in relation to food-related advertisements aimed at children and adolescents.