How many therapists? Practical guidance on investigating therapist effects in randomized controlled trials for eating disorders.

OBJECTIVE: An important question in implementation/dissemination research is whether the efficacy of a given treatment varies in part based on the therapist delivering the treatment. This study sought to provide practical guidance to researchers in the field of eating disorders for building measurement of therapist effects into the design of a typical, relatively small randomized controlled trial (RCT). METHOD: Using assumptions based on past trials of eating disorder treatments, Monte Carlo simulations were used to examine 12 different scenarios based on crossing the number of therapists (between two and five) and the estimated therapist effect size (small, medium, and large). Patient sample size and study design were held constant. RESULTS: There was reasonable power (≥70%) to detect the therapist effect with three or four therapists and a large effect size. DISCUSSION: Several practical implications for testing therapist effects in RCT are discussed.

Social network media exposure and adolescent eating pathology in Fiji.

BACKGROUND: Mass media exposure has been associated with an increased risk of eating pathology. It is unknown whether indirect media exposure--such as the proliferation of media exposure in an individual's social network--is also associated with eating disorders. AIMS: To test hypotheses that both individual (direct) and social network (indirect) mass media exposures were associated with eating pathology in Fiji. METHOD: We assessed several kinds of mass media exposure, media influence, cultural orientation and eating pathology by self-report among adolescent female ethnic Fijians (n=523). We fitted a series of multiple regression models of eating pathology, assessed by the Eating Disorder Examination Questionnaire (EDE-Q), in which mass media exposures, sociodemographic characteristics and body mass index were entered as predictors. RESULTS: Both direct and indirect mass media exposures were associated with eating pathology in unadjusted analyses, whereas in adjusted analyses only social network media exposure was associated with eating pathology. This result was similar when eating pathology was operationalised as either a continuous or a categorical dependent variable (e.g. odds ratio OR=1.60, 95% CI 1.15-2.23 relating social network media exposure to upper-quartile EDE-Q scores). Subsequent analyses pointed to individual media influence as an important explanatory variable in this association. CONCLUSIONS: Social network media exposure was associated with eating pathology in this Fijian study sample, independent of direct media exposure and other cultural exposures. Findings warrant further investigation of its health impact in other populations.

Demographic and clinical characteristics of individuals utilizing an internet-based digital coaching program for recovering from binge eating.

OBJECTIVE: While digital coaching self-help interventions to facilitate behavioral change are offered increasingly on the Internet, few studies have examined who uses them. This study examined demographic and clinical characteristics of adults who accessed a self-help program for binge eaters made available to them via their employers or health plans. METHOD: Cross-sectional data from 4,051 men and women who registered for the online program during a 13-month period were used. Gender differences and differences across three diagnostic groupings based on self-reported symptoms were tested using t-tests and ANOVAs (dimensional variables) or Chi-Square analyses (categorical variables). RESULTS: More women (3,053) than men (998) accessed the program. A majority of participants reported binge eating below frequency levels required for a clinical diagnosis, yet reported high levels of motivation to overcome their eating binges. Few had received prior treatment for an eating disorder. Although women reported greater symptomatology on most variables, these differences typically reflected small effects. Comparisons of diagnostic subgroups found few differences between those with probable diagnoses of bulimia nervosa or binge eating disorder. DISCUSSION: Digital coaching programs may be a viable treatment option, particularly for individuals with infrequent binge eating who otherwise might not seek or receive treatment.

Behavioral symptoms of eating disorders in Native Americans: results from the ADD Health Survey Wave III.

OBJECTIVE: To examine prevalence and correlates (gender, Body Mass Index) of disordered eating in American Indian/Native American (AI/NA) and white young adults. METHOD: We examined data from the 10,334 participants (mean age 21.93 years, SD = 1.8) of the National Longitudinal Study of Adolescent Health (ADD Health) Wave III for gender differences among AI/NA participants (236 women, 253 men) and ethnic group differences on measures of eating pathology. RESULTS: Among AI/NA groups, women were significantly more likely than men to report loss of control and embarrassment due to overeating. In gender-stratified analyses, a significantly higher prevalence of AI/NA women reported disordered eating behaviors compared with white women; there were no between group differences in prevalence for breakfast skipping or having been diagnosed with an eating disorder. Among men, disordered eating behaviors were uncommon and no comparison was statistically significant. DISCUSSION: Our study offers a first glimpse into the problem of eating pathology among AI/NA individuals. Gender differences among AI/NA participants are similar to results reported in white samples. That AI/NA women were as likely as white women to have been diagnosed with an eating disorder is striking in light of well documented under-utilization of mental health care among AI/NA individuals.

Eating patterns in patients with spectrum binge-eating disorder.

OBJECTIVE: We sought to describe meal and snack frequencies of individuals with recurrent binge eating and examine the association between these eating patterns and clinical correlates. METHOD: Data from 106 women with a minimum diagnosis of recurrent binge eating were used. Meal and snack frequencies were correlated with measures of weight, eating disorder features, and depression. Participants who ate breakfast every day (n = 25) were compared with those who did not (n = 81) on the same measures. RESULTS: Breakfast was the least, and dinner the most, commonly consumed meal. Evening snacking was the most common snacking occasion. Meal patterns were not significantly associated with clinical correlates; however, evening snacking was associated with binge eating. DISCUSSION: Our findings largely replicated those reported in earlier research. More research is needed to determine the role of breakfast consumption in binge eating.

Health-service use in women with binge eating disorders.

OBJECTIVE: To compare health-care utilization between participants who met DSM-IV criteria for binge eating disorder (BED) and those engaged in recurrent binge eating (RBE) and to evaluate whether objective binge eating (OBE) days, a key measurement for diagnosing BED, predicted health-care costs. METHOD: We obtained utilization and cost data from electronic medical records to augment patient reported data for 100 adult female members of a large health maintenance organization who were enrolled in a randomized clinical trial to treat binge eating. RESULTS: Total costs did not differ between the BED and RBE groups (ß = -0.117, z = -0.48, p = .629), nor did the number of OBE days predict total costs (ß = -0.017, z = -1.01, p = .313). DISCUSSION: Findings suggest that the medical impairment, as assessed through health care costs, caused by BED may not be greater than impairment caused by RBE. The current threshold number of two OBE days/week as a criterion for BED may need to be reconsidered.

A qualitative study of perceived social barriers to care for eating disorders: perspectives from ethnically diverse health care consumers.

OBJECTIVE: The study aim was to identify and describe health consumer perspectives on social barriers to care for eating disorders in an ethnically diverse sample. METHOD: We conducted an exploratory secondary analysis of qualitative data comprising transcripts from semi-structured interviews with past and prospective consumers of eating disorder treatment (n = 32). Transcripts were inputted into NVivo 8 for coding, sorting, and quantifying thematic content of interest within strata defined by ethnic minority and non-minority participants. We then examined the influence of key social barriers-including stigma and social stereotypes-on perceived impact on care. RESULTS: The majority of respondents (78%) endorsed at least one social barrier to care for an eating or weight concern. Perceived stigma (or shame) and social stereotyping-identified both within social networks and among clinicians-had adversely impacted care for 59% and 19% of respondents, respectively. DISCUSSION: Social barriers to care for eating and weight related concerns may be prevalent in the U.S. and impact both ethnic minority and non-minority health care consumers.

Screening for binge eating disorders using the Patient Health Questionnaire in a community sample.

OBJECTIVE: To examine the operating characteristics of the Patient Health Questionnaire eating disorder module (PHQ-ED) for identifying bulimia nervosa/binge eating disorder (BN/BED) or recurrent binge eating (RBE) in a community sample and to compare true positive (TP) versus false positive (FP) cases on clinical validators. METHOD: Two hundred and fifty-nine screen-positive individuals and a random sample of 89 screen negative cases completed a diagnostic interview. Sensitivity, specificity, and positive predictive value (PPV) were calculated. TP and FP cases were compared using t-tests and Chi-square tests. RESULTS: The PHQ-ED had high sensitivity (100%) and specificity (92%) for detecting BN/BED or RBE, but PPV was low (10 or 19%). TP and FP cases did not differ significantly on frequency of subjective bulimic episodes, objective overeating, restraint, on BMI, and on self-rated health. DISCUSSION: The PHQ-ED is recommended for use in large populations only in conjunction with follow-up questions to rule out cases without objective bulimic episodes.

Nocturnal eating: association with binge eating, obesity, and psychological distress.

OBJECTIVE: To examine clinical correlates of nocturnal eating, a core behavioral symptom of night eating syndrome. METHOD: Data from 285 women who had participated in a two-stage screening for binge eating were utilized. Women (n = 41) who reported one or more nocturnal eating episodes in the past 28 days on the eating disorder examination and women who did not report nocturnal eating (n = 244) were compared on eating disorder symptomatology, body mass index (BMI), and on measures of psychosocial adjustment. RESULTS: Nocturnal eaters were significantly more likely to report binge eating and differed significantly from non-nocturnal eaters (with responses indicating greater disturbance) on weight and shape concern, eating concern, self-esteem, depression, and functional impairment, but not on BMI or dietary restraint. Group differences remained significant in analyses adjusting for binge eating. DISCUSSION: This study confirms the association between nocturnal eating and binge eating previously found in treatment seeking samples yet also suggests that the elevated eating disorder symptoms and decreased psychosocial adjustment observed in nocturnal eaters is not simply a function of binge eating.

Adaptation and evaluation of the Clinical Impairment Assessment to assess disordered eating related distress in an adolescent female ethnic Fijian population.

OBJECTIVE: Measurement of disease-related impairment and distress is central to diagnostic, therapeutic, and health policy considerations for eating disorders across diverse populations. This study evaluates psychometric properties of a translated and adapted version of the Clinical Impairment Assessment (CIA) in an ethnic Fijian population. METHOD: The adapted CIA was administered to ethnic Fijian adolescent schoolgirls (N = 215). We calculated Cronbach's alpha to assess the internal consistency, examined the association between indicators of eating disorder symptom severity and the CIA to assess construct and criterion validity, and compared the strength of relation between the CIA and measures of disordered eating versus with measures of generalized distress. RESULTS: The Fijian version of the CIA is feasible to administer as an investigator-based interview. It has excellent internal consistency (alpha = 0.93). Both construct and criterion validity were supported by the data, and regression models indicated that the CIA predicts eating disorder severity, even when controlling for generalized distress and psychopathology. DISCUSSION: The adapted CIA has excellent psychometric properties in this Fijian study population. Findings suggest that the CIA can be successfully adapted for use in a non-Western study population and that at least some associated distress and impairment transcends cultural differences.

Validity and reliability of a Fijian translation and adaptation of the Eating Disorder Examination Questionnaire.

OBJECTIVE: Assessment of disordered eating has uncertain validity across culturally diverse populations. This study evaluated Eating Disorder Examination Questionnaire (EDE-Q) performance in an ethnic Fijian study population. METHOD: The EDE-Q was translated, adapted, and administered to school-going Fijian adolescent females (N = 523). A subsample (n = 81) completed it again within approximately 1 week. We assessed feasibility, internal consistency, and test-retest reliability; evaluated construct validity through factor analysis and correlation with similar constructs; and examined the marginal utility of an additional question on traditional purgative use. RESULTS: Internal consistency reliability was adequate for the global scale and subscales (Cronbach's alpha = 0.66-0.91); retest reliability was adequate for both the languages (range of ICCs, 0.50-0.79, and of kappas, 0.46-0.81, excluding purging items). Construct validity was supported by significant correlations with measures of similar constructs. Factor analysis confirms multiple dimensions of eating disorder symptoms but suggests possible culture-specific variation in this population. The majority of respondents endorsing traditional purgative use (58%) did not endorse conventional EDE-Q items assessing purging. DISCUSSION: The EDE-Q is a valid measure of eating disorder pathology for ethnic Fijian adolescent females and measures a unitary underlying construct.

Youth health-risk behavior assessment in Fiji: the reliability of Global School-based Student Health Survey content adapted for ethnic Fijian girls.

OBJECTIVE: The Global School-based Student Health Survey (GSHS) is an assessment for adolescent health-risk behaviors and exposures, supported by the World Health Organization. Although already widely implemented - and intended for youth assessment across diverse ethnic and national contexts - no reliability data have yet been reported for GSHS-based assessment in any ethnicity or country-specific population. This study reports test-retest reliability for GSHS content adapted for a female adolescent ethnic Fijian study sample in Fiji. DESIGN: We adapted and translated GSHS content to assess health-risk behaviors as part of a larger study investigating the impact of social transition on ethnic Fijian secondary schoolgirls in Fiji. In order to evaluate the performance of this measure for our ethnic Fijian study sample (n=523), we examined its test-retest reliability with kappa coefficients, % agreement, and prevalence estimates in a sub-sample (n=81). Reliability among strata defined by topic, age, and language was also examined. RESULTS: Average agreement between test and retest was 77%, and average Cohen's kappa was 0.47. Mean kappas for questions from core modules about alcohol use, tobacco use, and sexual behavior were substantial, and higher than those for modules relating to other risk behaviors. CONCLUSIONS: Although test-retest reliability of responses within this country-specific version of GSHS content was substantial in several topical domains for this ethnic Fijian sample, only fair reliability for the module assessing dietary behaviors and other individual items suggests that population-specific psychometric evaluation is essential to interpreting language and country-specific GSHS data.

The validity and clinical utility of purging disorder.

OBJECTIVE: To review evidence of the validity and clinical utility of Purging Disorder and examine options for the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-V). METHOD: Articles were identified by computerized and manual searches and reviewed to address five questions about Purging Disorder: Is there "ample" literature? Is the syndrome clearly defined? Can it be measured and diagnosed reliably? Can it be differentiated from other eating disorders? Is there evidence of syndrome validity? RESULTS: Although empirical classification and concurrent validity studies provide emerging support for the distinctiveness of Purging Disorder, questions remain about definition, diagnostic reliability in clinical settings, and clinical utility (i.e., prognostic validity). DISCUSSION: We discuss strengths and weaknesses associated with various options for the status of Purging Disorder in the DSM-V ranging from making no changes from DSM-IV to designating Purging Disorder a diagnosis on equal footing with Anorexia Nervosa and Bulimia Nervosa.

The validity and clinical utility of night eating syndrome.

OBJECTIVE: To review the empirical literature for evidence in support of inclusion of Night Eating Syndrome (NES) in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. METHOD: Based on a literature search using PubMed, 47 empirical studies of NES were identified. RESULTS: The literature reflects use of varying definitions; progress has been made toward reliable measurement of night eating symptoms; evidence regarding a differentiation of NES from "normalcy" or from other eating disorders is based largely on samples of convenience; only one controlled treatment study has been published. DISCUSSION: There are limited data supporting the clinical utility and validity of NES; several options regarding the inclusion of NES in DSM-V are discussed.

Gender difference in the prevalence of eating disorder symptoms.

OBJECTIVE: This study examined gender differences in prevalence of eating disorder symptoms including body image concerns (body checking or avoidance), binge eating, and inappropriate compensatory behaviors. METHOD: A random sample of members (ages 18-35 years) of a health maintenance organization was recruited to complete a survey by mail or on-line. Items were drawn from the Patient Health Questionnaire and the Body Shape Questionnaire. RESULTS: Among the 3,714 women and 1,808 men who responded, men were more likely to report overeating, whereas women were more likely to endorse loss of control while eating. Although statistically significant gender differences were observed, with women significantly more likely than men to report body checking and avoidance, binge eating, fasting, and vomiting, effect sizes ("Number Needed to Treat") were small to moderate. DISCUSSION: Few studies of eating disorders include men, yet our findings suggest that a substantial minority of men also report eating disorder symptoms.

Exploring the typology of night eating syndrome.

OBJECTIVE: There is an ongoing debate about the definitions and clinical significance of night eating syndrome (NES). This study explored potential subtypes based on night eating patterns and features reported to be associated, with NES in a representative community sample of 8,250 individuals aged 15-39 years. METHOD: Latent class analysis was used to identify NES subtypes among 2,068 participants who reported night eating behavior. RESULTS: A four-class solution was judged best. Two classes appear to characterize individuals who eat very late or eat a large proportion of their daily intake after 7 pm, and two other classes are characterized by high rates of depressive symptoms. Results do not support an association between night eating and obesity in young adults. Late night eating is associated with high caloric intake, high sodium intake, and low protein intake. CONCLUSION: Evidence supports the validity of a definition of NES based on eating very late at night.

What's love got to do with it? Family cohesion and healthy eating behaviors in adolescent girls.

OBJECTIVE: To examine the association between family cohesion and behaviors linked to health or overweight in adolescents. METHOD: Cross-sectional analyses of family cohesion and eating behaviors of 2,379 girls (followed from ages 9-19) who participated in the National Heart, Lung, and Blood Institute Growth and Health Study (NGHS). Height and weight measurements were obtained on an annual basis. Family cohesion was measured by the Family Adaptability and Cohesion Evaluation Scale (FACES) III. Food diaries were used to assess frequency of breakfast consumption and intake of milk, soda, fruits, and vegetables. RESULTS: Family cohesion was significantly associated with less soda intake and higher rates of breakfast consumption. Ingestion of milk, fruits, and vegetables was predicted by family cohesion at the trend level. CONCLUSION: Understanding the role of familial factors in adolescent eating behaviors is an important research priority. Strengthening family cohesion may be a valuable goal toward promoting the health of adolescents, increasing breakfast eating and decreasing soda consumption.

Disordered eating and substance use in high-school students: results from the Youth Risk Behavior Surveillance System.

OBJECTIVE: To examine the association between disordered eating (fasting, diet product use, and vomiting or laxative use) and use of 10 substances (cigarettes, alcohol, marijuana, cocaine, inhalants, heroin, methamphetamines, ecstasy, steroids, and hallucinogens) in a nationally representative adolescent sample. METHOD: Participants were 13,917 U.S. high-school students participating in the 2005 Youth Risk Behavior Surveillance System. RESULTS: Disordered eating was significantly associated with the use of each substance. Using effect size estimates that take base rates into consideration, for female students, associations between substance use and disordered eating were weak for all but three forms of substance use: current smoking, binge drinking, and inhalants. Among male students, strong (marijuana, steroids, and inhalants) or moderate effects (all other substances) were observed. CONCLUSION: Future research needs to focus on inhalant use and methamphetamine use in males. Increased medical attention should be directed toward adolescents who practice disordered eating behaviors because they are also at elevated risk for using cigarettes, alcohol, inhalants, methamphetamines, and steroids.

Ethnic differences in weight control practices among U.S. adolescents from 1995 to 2005.

OBJECTIVE: To examine trends in weight control practices from 1995 to 2005. METHOD: The Youth Risk Behavior Surveillance System biennially assesses five weight control behaviors among nationally representative samples of United States high school students. RESULTS: Across time, more females than males dieted (53.8% vs. 23.8%), used diet products (10% vs. 4.3%), purged (7.5% vs. 2.7%), exercised (66.5% vs. 46.9%), or vigorously exercised (42.8% vs. 36.8%). All weight control behaviors among males increased during the decade. Black females were less likely than Hispanic females, who were less likely than White females, to practice weight control. White males were less likely than Black males, who were less likely than Hispanic males, to practice weight control. The ethnic difference in weight control practices is consistent across time. CONCLUSION: All male adolescents are at increasing risk for developing eating disorder symptomatology, and Black females appear to continue to resist pressure to pursue thinness.

Childhood overweight and cardiovascular disease risk factors: the National Heart, Lung, and Blood Institute Growth and Health Study.

OBJECTIVE: To estimate the prevalence and incidence of overweight in African-American and Caucasian girls, and to examine associations between adolescent overweight and cardiovascular disease (CVD) risk factors. STUDY DESIGN: In the National Heart, Lung and Blood Institute Growth and Health Study (NGHS), annual measurements were obtained from girls followed longitudinally between age 9 or 10 and 18 years; self-reported measures were obtained at age 21 to 23 years. A total of 1166 Caucasian girls and 1213 African-American girls participated in the study. Childhood overweight as defined by the Centers for Disease Control and Prevention (CDC) was the independent variable of primary interest. Measured outcomes included blood pressure and lipid levels. RESULTS: Rates of overweight increased through adolescence from 7% to 10% in the Caucasian girls and from 17% to 24% in the African-American girls. The incidence of overweight was greater at age 9 to 12 than in later adolescence. Girls who were overweight during childhood were 11 to 30 times more likely to be obese in young adulthood. Overweight was significantly associated with increased percent body fat, sum of skinfolds and waist circumference measurements, and unhealthful systolic and diastolic blood pressure, high-density lipoprotein cholesterol, and triglyceride levels. CONCLUSION: A relationship between CVD risk factors and CDC-defined overweight is present at age 9.