Risk factors for anorexia nervosa and bulimia nervosa in Japan and compared to a U.S. sample.

OBJECTIVE: This study provides the first systematic investigation of environmental exposure to putative psychosocial risk factors for eating disorders in individuals with AN and BN in Japan. It also provides a comparison of risk factors for the development of AN and BN in Japan versus the United States. METHOD: Participants in Japan were 96 women with a current DSM-IV AN or BN primary diagnosis (AN, n = 60; BN, n = 36) and 57 women with no current psychiatric diagnosis (NC group). Participants in the United States were 137 women with a current DSM-IV AN or BN primary diagnosis (AN-U.S., n = 71; BN-U.S., n = 66). A standardized semi-structured interview retrospectively assessed exposure to risk factors prior to first symptom onset, which were analyzed using General Linear Model analyses. RESULTS: Perfectionism and negative affectivity, family relationship issues, and, to a lesser degree, parental psychopathology predicted the emergence of AN and BN in Japan. Physical and sexual abuse and family eating and weight concerns were not significant risk factors in Japan. Compared to their respective diagnostic U.S. groups, the Japanese AN group reported higher levels of individual mental health factors and lower levels of family dieting and family overweight, and the Japanese BN group reported higher levels on individual mental health factors, lower exposure to problems with their parents, and lower exposure to family weight and eating concerns. DISCUSSION: These country-specific data from Japan contribute to an increasingly nuanced and global understanding of risk factors for eating disorders.

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.

Antecedent life events of binge-eating disorder.

The present study investigated the occurrence of life events preceding the onset of disturbed eating in binge-eating disorder (BED). In a case-control design, 162 matched pairs of black and white women with BED and women with no current psychiatric disorder, and 107 matched pairs of women with BED and a current general psychiatric disorder were recruited from the community for the New England Women's Health Project. Life events in the year before the onset of disturbed eating were assessed retrospectively with an investigator-based interview. Women with BED reported exposure to a significantly greater number of life events during the year before onset of eating disturbances than both the non-psychiatric and psychiatric control women during the same period of time in their lives. Women with BED had a significantly higher risk of exposure to certain specific life events (e.g., critical comments about shape, weight, or eating; stress related to work, school or other sources; major changes in life circumstances and relationships; physical abuse; and feeling unsafe in a variety of settings) than the non-psychiatric control women, while differences between the BED and the psychiatric control group were less marked. There was no evidence for race-specific exposure to antecedent life events. The results suggest that a greater number and certain specific types of life events increase risk for the subsequent development of BED.

Prevalence and comorbidity of major depressive disorder in young black and white women.

OBJECTIVE: This study reports the prevalence and comorbidity of depression in two large samples of black and white young adult women. METHOD: Clinical interviews of participants in a follow-up study of the National Heart, Lung, and Blood Institute Growth and Health Study (NGHS-Wave II; N=378) were contrasted with a subsample of the National Comorbidity Survey (NCS; N=3749) to examine the rates and comorbidity of lifetime major depressive disorder in black and white women using methodology described by . The sequencing of disorders was also examined to determine which disorder was primary. Comorbidity and sequencing were examined for alcohol and drug use disorder, panic disorder, specific phobia, social phobia, and post-traumatic stress disorder. RESULTS: Prevalence estimates for depression, alcohol use disorder, and drug use disorder were higher for white women than for black women in both NGHS-Wave II and NCS. Over half of depressed participants in both samples had at least one comorbid disorder and depression was associated with an increased probability of all the investigated disorders. Only one ethnic difference was found in comorbidity, indicating that black women were more likely to have comorbid panic disorder than white women were. Depression was primary to alcohol and substance use disorders, whereas it was secondary to specific phobia and PTSD. CONCLUSIONS: High rates of comorbidity were found for both black and white women, though few ethnic differences in comorbidity were found. Preventive and treatment interventions are needed to address multiple disorders in young adult women.

Psychosocial and health consequences of adolescent depression in Black and White young adult women.

Depression in adolescent girls may result in negative consequences in young adulthood. The Center for Epidemiologic Studies Depression Scale (CES-D) was administered to 1,727 Black and White girls ages 16 to 18 years who participated in the National Heart, Lung, and Blood Institute's Growth and Health Study. Three years later, women in the depressed groups were more likely to be current smokers, had attained a lower level of education, and reported lower self-worth relative to the nondepressed group. Body dissatisfaction, eating concerns, and loneliness were greater in the depressed groups. Relative to Black women, White women who were moderately depressed during adolescence reported more health care services utilization in young adulthood. Prevention efforts for depressed adolescents should be broadly focused to improve young adult outcomes.

Abuse, bullying, and discrimination as risk factors for binge eating disorder.

OBJECTIVE: This study examined whether sexual and physical abuse, bullying by peers, and ethnicity-based discrimination are associated with an increased risk for developing binge eating disorder in black women and in white women and whether any increase in risk is specific for the development of binge eating disorder. METHOD: A community sample of 162 women with binge eating disorder and 251 healthy and 107 psychiatric comparison subjects was interviewed for exposure to the risk factors under investigation. RESULTS: White subjects with binge eating disorder reported significantly higher rates of sexual abuse, physical abuse, bullying by peers, and discrimination than healthy comparison subjects. Only rates of discrimination were significantly higher in white women with binge eating disorder than in matched psychiatric comparison subjects. In black women with binge eating disorder, rates of sexual abuse, physical abuse, and bullying by peers-but not discrimination-were significantly higher than in healthy comparison women. Rates of sexual abuse were significantly higher in black women with binge eating disorder than in psychiatric comparison subjects. CONCLUSIONS: Consistent with previous research examining ethnicity-specific patterns of risk for psychiatric disorder, we found both ethnic similarities (physical abuse and bullying by peers) and differences (sexual abuse and discrimination) in the risk for binge eating disorder.

Risk factors across the eating disorders.

This study sought to examine risk and onset patterns in anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED). Women with AN (n=71), BN (n=66), BED (n=160) and non-psychiatric controls (n=323) were compared retrospectively on risk factors, symptom onset, and diagnostic migration. Eating disorder groups reported greater risk exposure than non-psychiatric controls. AN and BED differed on premorbid personality/behavioral problems, childhood obesity, and family overeating. Risk factors for BN were shared with AN and BED. Dieting was the most common onset symptom in AN, whereas binge eating was most common in BN and BED. Migration between AN and BED was rare, but more frequent between AN and BN and between BN and BED. AN and BED have distinct risk factors and onset patterns, while BN shares similar risk factors and onset patterns with both AN and BED. Results should inform future classification schemes and prevention programs.

Clarifying boundaries of binge eating disorder and psychiatric comorbidity: a latent structure analysis.

Binge eating disorder (BED) presents with substantial psychiatric comorbidity. This latent structure analysis sought to delineate boundaries of BED given its comorbidity with affective and anxiety disorders. A population-based sample of 151 women with BED, 102 women with affective or anxiety disorders, and 259 women without psychiatric disorders was assessed with clinical interviews and self-report-questionnaires. Taxometric analyses were conducted using DSM-IV criteria of BED and of affective and anxiety disorders. The results showed a taxonic structure of BED and of affective and anxiety disorders. Both taxa co-occurred at an above-chance level, but also presented independently with twice-as-large probabilities. Within the BED taxon, diagnostic co-occurrence indicated greater general psychopathology, lower social adaptation, and greater premorbid exposure to parental mood and substance disorder, but not greater eating disorder psychopathology. Eating disorder psychopathology discriminated individuals in the BED taxon from individuals in the affective and anxiety disorders taxon. Diagnostic criteria of BED were more indicative of the BED taxon than were criteria of affective and anxiety disorders. The results show that at the latent level, BED was co-occurring with, yet distinct from, affective and anxiety disorders and was not characterized by an underlying affective or anxiety disorder.

The significance of overvaluation of shape and weight in binge eating disorder.

As publication of DSM-V draws near, research is needed to validate the diagnostic scheme for binge eating disorder (BED). Shape and weight overvaluation has stimulated considerable debate in this regard, given associations with psychosocial impairment and poor treatment outcome in BED. This study sought to further explore the convergent validity and diagnostic specificity of shape and weight overvaluation in BED. A total of 160 women with BED, and 108 women with non-eating disordered psychiatric disorders were recruited from the community. Women with BED were classified as more or less severe based on a global measure of eating-related psychopathology; subsequent receiver operating characteristics analysis determined that a threshold of at least "moderate" overvaluation best predicted membership into a more severe group. BED participants with threshold overvaluation exhibited poorer psychosocial functioning than those with subthreshold overvaluation, as well as participants with other psychiatric disorders. Discriminant function analysis revealed that threshold overvaluation predicted a diagnosis of BED versus other psychiatric disorder with 67.7% accuracy. Results suggest that shape and weight overvaluation is a useful diagnostic specifier in BED. Continued research is warranted to examine its predictive validity in natural course and treatment outcome studies.

Risk factors for binge-eating disorders: an exploratory study.

OBJECTIVE: This study examined a broad range of childhood risk factors for binge-eating disorders (bulimia nervosa or binge eating disorder, BN/BED), utilizing data that had been collected prospectively in the 10-year National Heart, Lung, and Blood Institute Growth and Health Study. METHOD: Forty-five women with a history of BED/BN (with onset age > 14 and <20 years) and 1,515 women who did not have a history of an eating disorder were included. RESULTS: Signal detection analysis indicated a single pathway that identified approximately 13% of the BED/BN cases. The pathway was based on an elevated level of perceived stress prior to the age of 14. CONCLUSION: Our findings suggest that eating disorders may have multiple and complex etiologies. This is the first study to suggest that elevated levels of perceived stress may precede the onset of binge-eating disorders. Whether this is a causal association remains a question.

Risk factors and patterns of onset in binge eating disorder.

OBJECTIVE: The current study examined risk factors in women with binge eating disorder (BED) who began binging before dieting (binge-first [BF]) compared with women with BED who began dieting before binging (diet-first [DF]). It further aimed to replicate findings regarding eating disorder and general psychopathology among BF versus DF subtypes. METHOD: One hundred fifty-five women with BED completed the Oxford Risk Factor Interview to retrospectively assess risk factors occurring before eating disturbance onset. Clinical interview assessed eating disorder and general psychopathology. RESULTS: Overall, no significant differences in risk factors emerged between the groups. The BF group had a significantly earlier onset of BED than the DF group. In contradistinction to previous studies, the DF group endorsed more eating disorder psychopathology and lifetime diagnosis of any substance use disorder. CONCLUSION: Limited support was seen for different risk factors in BF versus DF women, suggesting similar etiologic pathways in both subtypes.

Factors that influence food amount ratings by white, Hispanic, and Asian samples.

OBJECTIVE: Two studies explored in nonclinical samples variables that may influence meal size assessments. RESEARCH METHODS AND PROCEDURES: In Study 1, the contribution of dietary restraint, weight, depressive symptoms, and gender to ratings on the Food Amount Rating Scale was examined in 153 white women and 121 white men; in Study 2, the contribution of dietary restraint, weight, ethnicity, and ethnic group identification to Food Amount Rating Scale ratings was examined in 67 Asian, 81 Hispanic, and 107 white women. RESULTS: Study 1 indicated that food amounts were rated as larger when rated by male rather than female raters (male rater, mean=62.37, SD=1.14; female rater, mean=59.28, SD=0.89), for female rather than male targets (male target, mean=56.16, SD=0.97; female target, mean=64.87, SD=1.02), and by restrained rather than unrestrained eaters (restrained, mean=63.14, SD=1.11; unrestrained, mean=58.69, SD=0.91). Study 2 indicated that food amounts were rated as larger when rated by restrained eaters (restrained, mean=67.53, SD=1.21; unrestrained, mean=64.99, SD=1.09), Hispanic women (Asian, mean=64.59, SD=1.61; Hispanic, mean=68.71, SD=1.30; white, mean=65.41, SD=1.34), and underweight women (underweight, mean=70.38, SD=1.68; normal weight, mean=64.52, SD=0.93; overweight: mean=64.23, SD=1.64). DISCUSSION: Food amount judgments may be influenced by personal characteristics. Future research should examine whether variation in food amount judgments is related to dieting behavior, disordered eating, or obesity.

Toward an understanding of risk factors for binge-eating disorder in black and white women: a community-based case-control study.

BACKGROUND: This study sought to identify in white women risk factors specific to binge-eating disorder (BED) and for psychiatric disorders in general, and to compare black and white women on risk factors for BED. METHOD: A case-control design was used. Participants were recruited from the community and included 162 women who met DSM-IV criteria for BED and two comparison groups of women with no history of clinically significant eating disorder symptoms. The comparison women were matched to BED women on age, education and ethnicity and divided into a healthy comparison (HC) group, who had no current psychiatric disorder, and a psychiatric comparison (PC) group, who had a diagnosis of a DSM-IV Axis I psychiatric disorder. The study sample size was determined by the group with the least members (PC), including 107 women with BED and 214 matched comparison women. A broad range of risk factors was assessed with a Risk Factor Interview and the Parental Bonding Instrument. RESULTS: No significant effects for ethnicity by diagnostic group were found. BED women reported higher exposure to childhood obesity, family overeating or binge-eating, family discord, and high parental demands than PC women. The combined BED and PC group scored significantly higher than the HC group on measures of negative affect, parental mood and substance disorders, perfectionism, separation from parents, and maternal problems with parenting. CONCLUSIONS: These findings indicate that childhood obesity and familial eating problems are reliable specific risk factors for BED. Ethnicity does not appear to moderate risk for BED.

Night eating syndrome in young adult women: prevalence and correlates.

OBJECTIVE: The current study examined the prevalence and clinical significance of night eating syndrome (NES) in a community cohort of Black and White women. METHOD: We assessed 682 Black and 659 White women for NES, eating disorders, and psychiatric symptomatology. RESULTS: The prevalence was 1.6% (22 of 1,341; Blacks [n = 20]; Whites [n = 2]). Comparisons between identified Black women and the remaining Black participants revealed no significant differences in obesity, psychiatric comorbidity, or self-reported psychiatric distress. Comorbidity with eating disorders as outlined in the 4th ed. of the Diagnostic and Statistical Manual of Mental Disorders (Washington, DC: American Psychiatric Association) was low (n = 1 [4.5%]). Black NES women were significantly less likely than Black non-NES women to be overweight and significantly more likely to have two or more children. DISCUSSION: NES was rare in this sample of young women. Low comorbidity of NES with other eating disorders suggests that NES may be distinct from the DSM-IV recognized eating disorders. Longitudinal data are needed to determine the long-term health implications of this behavioral pattern.

Health services use in women with a history of bulimia nervosa or binge eating disorder.

OBJECTIVE: The current study examined health services use during the past 12 months in a sample of young women with a history of an adolescent eating disorder (bulimia nervosa [BN] or binge eating disorder [BED]). METHOD: A community sample of 1,582 young women (mean age = 21.5 years) was classified, based on a screening interview (and, for eating disorder diagnosis, confirmatory diagnostic interview), into one of three groups: BN or BED (n = 67), other psychiatric disorder (n = 443), and no adolescent psychiatric disorder (n = 1,072). RESULTS: A history of BN/BED in adolescence was associated with elevated health services use, but this was a general effect associated with having a psychiatric disorder, not an effect specific to the diagnosis of an eating disorder. Total service days, outpatient psychotherapy visits, and emergency department visits were elevated in the combined group of BN/BED and other psychiatric disorder participants relative to the healthy comparison group. The women with BN/BED did not differ significantly from the women with a non-eating-related psychiatric disorder in the use of these services. DISCUSSION: The similarity of health services use in young women with BN or BED and those with other psychiatric disorders underscores the clinical and economic impact of these eating disorders.

The food amount rating scale: development, reliability, and validity.

OBJECTIVE: Implied in measures of binge eating is the assumption that individuals agree on what comprises a large amount of food. However, whether individuals estimate food amounts similarly or whether estimation of food amounts varies as a function of personal characteristics is unknown. The Food Amount Rating Scale (FARS) is a standardized set of stimuli for assessing individuals' judgment of food amounts. RESEARCH METHODS AND PROCEDURES: Two versions of the FARS were developed, and their psychometric properties were assessed. These versions are the same in all respects except that the rater is instructed to rate various food amounts for the average woman on Form W and for the average man on Form M. RESULTS: Content validity was confirmed by 14 researchers and research assistants in the field of eating disorders. The FARS is a 24-item inventory with adequate test-retest reliability (Form W = 0.85; Form M = 0.87) and split-half reliability (Form W = 0.90; Form M = 0.89). Convergent validity is suggested by the finding that ratings for the average woman (Form W) were significantly higher than ratings for the average man (Form M). DISCUSSION: The FARS is a psychometrically sound tool for use in basic research focused on identifying whether the subjective judgment of food amounts varies as a function of personal characteristics and in clinical research where it may be important to know how individuals judge food amounts.

Self-harm and substance use in a community sample of Black and White women with binge eating disorder or bulimia nervosa.

OBJECTIVE: This study evaluated rates of self-harm and substance use in women with either bulimia nervosa (BN) or binge eating disorder (BED) and assessed whether differences in self-harm and substance use are related to sexual or physical abuse. METHOD: Alcohol abuse, self-harm, and use or abuse of various illicit drugs were evaluated in a sample of 53 women with BN and 162 women with BED. RESULTS: Self-harm and substance use generally did not differentiate BED and BN cases, but rates of self-harm and substance use were elevated among women with a history of sexual or physical abuse relative to women without such a history. DISCUSSION: Elevated rates of self-harm and substance use may not be related uniquely to BN diagnostic status, but may be related to a characteristic shared by women with BN and BED, such as a history of sexual or physical abuse.

Macronutrient intake in anorexia nervosa: The National Heart, Lung, and Blood Institute Growth and Health Study.

OBJECTIVE: To compare the macronutrient intake of females with or without a history of anorexia nervosa (AN) at three times: two years and one year before the onset of AN, and during the first year of the illness. STUDY DESIGN: Prospective cohort study with 3-day food intake records collected over 10 years. Subjects were 154 white females (aged 9 or 10 years at study entry), of whom 14 had AN and 140 were healthy females matched for age at study entry and parental education. RESULTS: Compared with the healthy girls, girls with AN reported significantly lower total energy intake and fat intake during the first year of the illness; the lower total energy intake was evident already at the 1-year (but not the 2-year) pre-onset assessment. CONCLUSIONS: To identify AN early on, health practitioners caring for adolescent girls should inquire about food intake and reluctance to eat certain foods, especially those containing fat.

Toward an understanding of health services use in women with binge eating disorder.

OBJECTIVE: This study examined health services use in community samples of 102 white and 60 black women with binge eating disorder (BED), 164 white and 85 black healthy comparison women, and 86 white and 21 black women with a noneating Axis I psychiatric disorder. RESEARCH METHODS AND PROCEDURES: Participants were matched on age, ethnicity, and education and were asked about their use of emergency room visits, outpatient physician visits for medical care, outpatient psychotherapy visits, and days spent in the hospital over the previous 12 months. Total health services use was computed. RESULTS: There were no between-group differences in outpatient physician visits or inpatient hospital days. Relative to healthy comparison women, women with BED and women with other Axis I disorders had increased total health services use, psychotherapy visits, and emergency department visits. Relative to women with noneating Axis I disorders, women with BED had less use of psychotherapy visits. Although obese white women were more likely to report emergency department visits than obese black women were, nonobese white women were less likely to report emergency department visits than nonobese black women were. DISCUSSION: That health services use by women with BED compared more with that of women with other Axis I disorders than with that of healthy women suggested that BED has clinical significance and is not benign in terms of its impact on the health care system. It appeared, however, that despite the availability of effective treatments, few women with BED received psychotherapy.