Prevalence and predictors of parental concern for children's weight from 2002 to 2012.

OBJECTIVES: Public health initiatives to increase parental awareness about children's obesity have become more prominent in the past decade. These initiatives may contribute to increased concern in parents for their children's weight, even if their children are at a healthy weight. The aim of the present study was to document trends in parental (N = 365; 67.9% female) concern for their children's weight from 2002 to 2012 using surveys on health and eating behaviors. STUDY DESIGN: Participants (N = 365) were parents who completed surveys in 2002 and were followed up in 2012 as part of a longitudinal epidemiological study of eating attitudes and behavior. METHODS: McNemar's test and logistic regression models estimated changes in and predictors of parental concern. RESULTS: In 2002, 36.5% of participants indicated concern for their children's weight, which rose to 54.4% in 2012. Parents of overweight children were more likely to report concern than parents of average-weight children at baseline and 10-year follow-up. However, concern increased significantly even among parents of average-weight children, rising from 28.7% to 41.6% (McNemar's test statistic: 8.20, P = .002). Secondary analyses revealed that parents' baseline drive for thinness predicted increased likelihood of concern in these parents (odds ratio: 1.10, P = .04). CONCLUSION: Findings support the need for future research to examine consequences of societal messages about pediatric obesity.

Changes in genetic risk for emotional eating across the menstrual cycle: a longitudinal study.

BACKGROUND: Previous studies have shown significant within-person changes in binge eating and emotional eating across the menstrual cycle, with substantial increases in both phenotypes during post-ovulation. Increases in both estradiol and progesterone levels appear to account for these changes in phenotypic risk, possibly via increases in genetic effects. However, to date, no study has examined changes in genetic risk for binge phenotypes (or any other phenotype) across the menstrual cycle. The goal of the present study was to examine within-person changes in genetic risk for emotional eating scores across the menstrual cycle. METHOD: Participants were 230 female twin pairs (460 twins) from the Michigan State University Twin Registry who completed daily measures of emotional eating for 45 consecutive days. Menstrual cycle phase was coded based on dates of menstrual bleeding and daily ovarian hormone levels. RESULTS: Findings revealed important shifts in genetic and environmental influences, where estimates of genetic influences were two times higher in post- as compared with pre-ovulation. Surprisingly, pre-ovulation was marked by a predominance of environmental influences, including shared environmental effects which have not been previously detected for binge eating phenotypes in adulthood. CONCLUSIONS: Our study was the first to examine within-person shifts in genetic and environmental influences on a behavioral phenotype across the menstrual cycle. Results highlight a potentially critical role for these shifts in risk for emotional eating across the menstrual cycle and underscore the need for additional, large-scale studies to identify the genetic and environmental factors contributing to menstrual cycle effects.

Disordered eating and injuries among adolescent ballet dancers.

BACKGROUND: Ballet dancers are at elevated risk for eating disorders, but the extent to which disordered eating attitudes and behaviors represent a relatively benign adaptation to an environment that values extreme thinness, or a functionally impairing form of psychopathology, has sparked considerable debate. METHOD: To determine whether disordered eating is associated with role impairment in dancers, we evaluated its association with musculoskeletal injuries among 239 adolescent female ballet students. RESULTS: Dance students reported a variety of lifetime disordered eating behaviors to control weight including fasting (29.3%), vomiting (9.6%), and laxative use (4.2%). More than half (52.3%) reported a lifetime history of injury (stress fracture, broken bone, and/or medically treated tendonitis). A greater number of lifetime disordered eating behaviors was associated with a greater number of lifetime injuries (p=0.01). Moreover, vomiting history was associated with greater likelihood of injury (p=0.004) and increased time to recover from injury (median difference=22.8 days, p=0.006). CONCLUSION: Although the direction of causality cannot be determined from this retrospective design, these results suggest that disordered eating is associated with role-relevant functional impairment, even among members of a subculture that values extreme thinness.

Preliminary evidence that estradiol moderates genetic influences on disordered eating attitudes and behaviors during puberty.

BACKGROUND: Puberty moderates genetic influences on disordered eating attitudes and behaviors, with little genetic influence before puberty but large (50%) genetic effects during and after puberty. To date, however, nothing is known about the mechanisms that underlie these effects. Estradiol is a particularly promising candidate, as estrogens become elevated at puberty and regulate gene transcription within neurotransmitter systems important for eating-related phenotypes. The aim of this pilot study was to examine whether estradiol levels moderate genetic influences on disordered eating during puberty. METHOD: Participants included 198 female twins (ages 10-15 years) from the Michigan State University Twin Registry. Disordered eating attitudes and behaviors were assessed with the total score, weight preoccupation, body dissatisfaction and binge eating/compensatory behavior subscales of the Minnesota Eating Behavior Survey (MEBS). Afternoon saliva samples were assayed for estradiol levels. Moderation of genetic effects was examined by comparing twin correlations in low versus high estradiol groups. RESULTS: In the low estradiol group, monozygotic (MZ) and dizygotic (DZ) twin correlations for all MEBS scales were similar, suggesting little genetic influence. In the high estradiol group, the MZ twin correlation was more than double the DZ twin correlation, indicating the presence of genetic effects. Findings could not be accounted for by age, body mass index or the physical changes of puberty. CONCLUSIONS: Estradiol may be one important moderator of genetic effects on disordered eating during puberty. Larger twin studies are needed to replicate this pilot work and quantify the extent of genetic moderation.

A pilot study of personality pathology in patients with anorexia nervosa: modifiable factors related to outcome after hospitalization.

OBJECTIVE: To assess improvement in aspects of personality in patients hospitalized with anorexia nervosa (AN) and its relationship to improved depression, body mass index (BMI), and eating disorder outcome after treatment. METHOD: Twenty females hospitalized with AN completed intake and discharge assessments of BMI, depression and eating disorder severity, as well as personality pathology with the Minnesota Multiphasic Personality Inventory (MMPI-2) and the Revised NEO Personality Inventory (NEO PI-R). Clinical outcome for a subset of patients at 1-year post-hospitalization was determined. RESULTS: The only factor that predicted better versus worse outcome at 1-year post-hospitalization was change in Low Self-Esteem (LSE) from the MMPI-2. Improved LSE from admission to discharge predicted remission at 1-year post-hospitalization, while worsening LSE predicted relapse. Regardless of outcome, NEO PI-R Neuroticism remained pathologically elevated in AN patients during hospitalization. DISCUSSION: Pathological levels of neuroticism may represent a vulnerability factor for AN. In contrast, self-esteem appears to be a modifiable factor that predicts outcome following hospitalization, and may be an important target for treatment.

Long-term outcome of bulimia nervosa.

BACKGROUND: Since bulimia nervosa's introduction to the psychiatric nomenclature in 1979, data concerning long-term outcome have been largely unavailable. METHODS: Women with the diagnosis of bulimia nervosa between 1981 and 1987 who participated in 1 of 2 studies were located and invited to participate in follow-up assessments. RESULTS: More than 80% of the women from these studies participated in follow-up assessments and the results represent findings for 173 women. More than 10 years following presentation (mean+/-SD length of follow-up, 11.5+/-1.9 years), 11% of this sample met full criteria for bulimia nervosa, and 0.6% met full criteria for anorexia nervosa. An additional 18.5% met criteria for eating disorder not otherwise specified, and 69.90% of this sample were either in full or in partial remission. For predictive factors, only the duration of the disorder at presentation and history of substance use problems demonstrated prognostic significance. Baseline treatment condition was not associated with remission of disordered eating symptoms by the follow-up assessment. CONCLUSIONS: The findings suggest that the number of women who continue to meet full criteria for bulimia nervosa declines as the duration of follow-up increases; approximately 30%, however, continued to engage in recurrent binge eating or purging behaviors (incidence rate, 0.026 cases per person-years). A history of substance use problems and a longer duration of the disorder at presentation predicted worse outcome.

Outcome in bulimia nervosa.

OBJECTIVE: The authors sought to synthesize existing data on outcome for individuals diagnosed with bulimia nervosa in order to better understand long-term outcome and prognostic factors. METHOD: They reviewed 88 studies that conducted follow-up assessments with bulimic subjects at least 6 months after presentation. Findings are summarized for the areas of mortality, recovery, relapse, crossover, and prognostic variables. RESULTS: The crude mortality rate due to all causes of death for subjects with bulimia nervosa in these studies was 0.3% (seven deaths among 2,194 subjects); however, ascertainment rates and follow-up periods were small and likely to produce underestimation. Five to 10 years following presentation, approximately 50% of women initially diagnosed with bulimia nervosa had fully recovered from their disorder, while nearly 20% continued to meet full criteria for bulimia nervosa. Approximately 30% of women experienced relapse into bulimic symptoms, and risk of relapse appeared to decline 4 years after presentation. Few prognostic factors have been consistently identified, but personality traits, such as impulsivity, may contribute to poorer outcome. In addition, participation in a treatment outcome study was associated with improved outcome for follow-up periods less than 5 years. CONCLUSIONS: Treatment interventions may speed eventual recovery but do not appear to alter outcome more than 5 years following presentation. Long-term outcome for women diagnosed with bulimia nervosa remains unclear. However, this disorder may be chronic for at least a subset of women.

Ten-year stability and predictive validity of five bulimia-related indicators.

OBJECTIVE: The authors examined the temporal stability and predictive utility of bulimic symptoms and related variables over the course of 10 years, from 1982 to 1992. METHOD: The subjects were 459 women who were aged 18-22 years in 1982 and were surveyed in both 1982 and 1992. Each respondent completed five subscales of the Eating Disorders Inventory (bulimia, drive for thinness, maturity fears, perfectionism, and interpersonal distrust) and answered questions based on the DSM-III criteria for bulimia nervosa. RESULTS: The temporal stability of bulimic symptoms and related variables was relatively high. Bulimic status in 1982 conferred an approximately 15-fold increase in risk 10 years later. Drive for thinness and, to lesser degrees, maturity fears and perfectionism received support as long-term predictors of bulimic symptoms. CONCLUSIONS: Bulimic symptoms display high temporal stability and thus may affect long-term functioning and well-being. Later symptoms are related to scores on specific subscales of the Eating Disorders Inventory administered 10 years earlier. Assessment and therapy should be conducted accordingly.

Predictive validity of bulimia nervosa as a diagnostic category.

OBJECTIVE: The authors sought to investigate the predictive validity of bulimia nervosa as a diagnostic category. METHOD: More than 10 years after they appeared as patients with bulimia nervosa, 177 women (participation rate=79.7%) completed follow-up assessments. RESULTS: Among the women with a current eating pathology, most engaged in recurrent binge eating and purging. Anorexia nervosa and binge eating disorder were relatively uncommon. Eating disorder outcome was significantly related to the presence of mood, substance use, and impulse control disorders but not to the presence of anxiety disorders. CONCLUSIONS: These results support the validity of bulimia nervosa as a diagnostic category that is distinct from anorexia nervosa. Furthermore, these results suggest that bulimic symptoms are associated with disorders involving distress and disinhibition.

Recovery and relapse in anorexia and bulimia nervosa: a 7.5-year follow-up study.

OBJECTIVE: To assess the course and outcome of anorexia nervosa (AN) and bulimia nervosa (BN) at a median of 90 months of follow-up in a large cohort of women with eating disorders. METHOD: A prospective, naturalistic, longitudinal design was used to map the course of AN and BN in 246 women. Follow-up data are presented in terms of full and partial recovery, predictors of time to recovery, and rates and predictors of relapse. RESULTS: The full recovery rate of women with BN was significantly higher than that of women with AN, with 74% of those with BN and 33% of those with AN achieving full recovery by a median of 90 months of follow-up. Intake diagnosis of AN was the strongest predictor of worse outcome. No predictors of recovery emerged among bulimic subjects. Eighty-three percent of women with AN and 99% of those with BN achieved partial recovery. Approximately one third of both women with AN and women with BN relapsed after full recovery. No predictors of relapse emerged. CONCLUSIONS: The findings suggest that the course of AN is characterized by high rates of partial recovery and low rates of full recovery, while the course of BN is characterized by higher rates of both partial and full recovery.

Ovarian hormones and binge eating: exploring associations in community samples.

BACKGROUND: Significant associations between changes in ovarian hormones and binge eating are present across the menstrual cycle in women with bulimia nervosa. However, no study has examined these relationships in a non-clinical sample, despite the need for these data for designing risk-factor studies. METHOD: In study 1, we modified several continuous measures of binge eating and identified those that were most sensitive to menstrual-cycle fluctuations in a non-clinical sample of 10 women who completed measures for 35 days. In study 2, we explored associations between ovarian hormones and binge-eating scores in nine women who completed these same measures for 65 days and provided daily saliva samples for assays of estradiol and progesterone concentrations. RESULTS: In study 1, the Emotional Eating subscale of the Dutch Eating Behavior Questionnaire exhibited superior reliability and was most sensitive to predicted menstrual-cycle changes in binge eating (i.e. increased scores in the mid-luteal/premenstrual compared with follicular/ovulatory phases). In study 2, this scale showed predicted inverse associations with estradiol and positive associations with progesterone across the menstrual cycle that could not be accounted for by changes in negative affect. CONCLUSION: Associations between ovarian hormones and binge eating are robust and present in clinical and non-clinical samples. Findings support the ability to examine the role of ovarian hormones as risk factors for binge eating in large-scale prospective studies and twin studies.

Co-morbidity and disorder-related distress and impairment in purging disorder.

BACKGROUND: Recent studies suggest that purging disorder (PD) may be a common eating disorder that is associated with clinically significant levels of distress and high levels of psychiatric co-morbidity. However, no study has established evidence of disorder-related impairment or whether distress is specifically related to PD rather than to co-morbid disorders. METHOD: Three groups of normal-weight women [non-eating disorder controls (n=38), with PD (n=24), and with bulimia nervosa (BN)-purging subtype (n=57)] completed structured clinical interviews and self-report assessments. RESULTS: Both PD and BN were associated with significant co-morbidity and elevations on indicators of distress and impairment compared to controls. Compared to BN, PD was associated with lower rates of current and lifetime mood disorders but higher rates of current anxiety disorders. Elevated distress and impairment were maintained in PD and BN after controlling for Axis I and Axis II disorders. CONCLUSIONS: PD is associated with elevated distress and impairment and should be considered for inclusion as a provisional disorder in nosological schemes such as the Diagnostic and Statistical Manual to facilitate much-needed research on this clinically significant syndrome.

Weight-based stigmatization in children.

OBJECTIVE: To examine sex differences in children's weight-based stigmatization. DESIGN: School-based sample of children evaluating qualities of children of varying weights. SUBJECTS: Thirty-four children (age, 7-9 y; body mass index (BMI) 12.1-31.2 kg/m2). MEASURES: Drawings of children that varied by sex (boy, girl) and weight (thin, average, chubby) were presented to children. Parents provided written consent and demographic data. RESULTS: Children evaluated drawings of thin children most favorably and drawings of chubby children least favorably. Thin girls were rated more favorably than average or chubby girls, for whom ratings did not differ significantly. Conversely, chubby boys were rated less favorably than average or thin boys for whom ratings did not differ significantly. CONCLUSION: These patterns may further explain gender differences in motivation to lose weight.

Eating disorders and insulin-dependent diabetes mellitus.

The eating disorders anorexia nervosa and bulimia nervosa have been reported to occur in Type I diabetes mellitus. Although prevalence estimates vary, the most rigorous studies yield rates similar to the population at large. Intentional insulin omission is more common, especially in young diabetic women, and at times may indicate an eating disorder in Type I diabetic patients. Both diagnosable eating disorders and intentional insulin omission are associated with worse glycemic control and higher rates of secondary diabetic complications. Recognition of these conditions, followed by carefully coordinated treatment involving both diabetes care providers and mental health providers, is necessary to improve treatment outcome.

Symptom fluctuation in bulimia nervosa: relation to menstrual-cycle phase and cortisol levels.

BACKGROUND: Individuals with bulimia nervosa report significant symptom fluctuation, and some studies have suggested a premenstrual exacerbation of binge frequency. The purpose of this study is to explore the hormonal correlates of symptom fluctuation in bulimia nervosa. METHOD: For five consecutive weeks (one full menstrual cycle), eight women with bulimia nervosa and eight non-eating-disordered control women collected morning saliva samples and recorded several mood characteristics; the bulimic women also recorded binge and purge episodes. Subsequently, salivary cortisol and androgen levels were determined by radioimmunoassay. RESULTS: Bulimic symptoms were exacerbated in both the mid-luteal and premenstrual phases, when compared with the follicular and ovulatory phases (F(3,21) = 3.76, P = 0.026; contrast analysis t(7) = 3.47, P < 0.01). Fluctuation in cortisol was closely correlated with fluctuation of bulimic symptoms, with elevatedcortisol secretion following symptom exacerbation (r(24) = 0.64, P = 0.001). CONCLUSIONS: Bulimic symptom fluctuation appears to be related to two hormonal phenomena--phase of the menstrual cycle and cortisol secretion--with menstrual-cycle phase influencing bulimic symptom severity, and bulimic symptom severity effecting increases in cortisol secretion. Improved understanding of the hormonal causes and consequences of symptom fluctuation may lead to improved psychological and pharmacological treatments for bulimia nervosa.

Impact of definitions on the description and prediction of bulimia nervosa outcome.

OBJECTIVE: The authors sought to compare definitions of eating disorder outcome found in the bulimia nervosa literature and to determine the impact of definitions on the description and prediction of outcome. METHOD: Definitions of outcome were identified from studies involving a follow-up duration of at least 5 years. Definitions were applied to a sample of women (N = 173) assessed more than 10 years following presentation with bulimia nervosa. RESULTS: Across definitions, the percentage of women considered fully recovered ranged from 38% to 47% in the follow-up sample. Associations between eating disorder outcome and other measures of outcome were relatively unaffected by differences in definitions. Conversely, the significance of various prognostic variables differed substantially among definitions. DISCUSSION: Our findings suggest that differences in definitions influence the description and prediction of eating disorder outcome significantly. Consistency in defining recovery is needed in order to explore other areas of outcome such as relapse.

The future of risk factor research in understanding the etiology of eating disorders.

This article explores whether particular risk factors are best seen as precursors or as symptoms. Psychological, cultural, family, developmental, and biological risk domains that may be important in the etiology of eating disorders are briefly reviewed. We describe a 4-year prospective study assessing a wide range of risk factors for development of eating disorders in a large school-based sample of adolescents. For subjects who were relatively asymptomatic, a personality or temperamental characteristic of negative affect/esteem measured at study entrance was the only significant predictor of later risk score for both girls and boys. The significant comorbidity demonstrated in a separate group that had high risk for eating disorders suggests that negative affectivity may be a vulnerability factor for overall psychopathology rather than a predisposition specifically for eating disorders. Following subjects through the young-adult years and later may further clarify the range of influences affecting disordered eating. Primary prevention and early intervention programs in the schools are also recommended.

Importance of size in defining binge eating episodes in bulimia nervosa.

OBJECTIVE: This study sought to determine if amount of food consumed is important in defining binge eating episodes in individuals with bulimia nervosa (BN). METHOD: Women (N = 30) with DSM-IV BN (OBN) and women (N = 25) who would have met DSM-IV criteria for BN except that their binge episodes were not objectively large (SBN) were recruited from the community. Subjects completed telephone interviews and questionnaires. RESULTS: Results demonstrated no significant differences between women with OBN and SBN in levels of dietary restraint, disinhibition, or hunger; no significant differences in general psychopathology; and significant differences in frequency of binge/purge episodes and impulsiveness. Differences in impulsiveness remained after controlling for frequency of binge/purge episodes. DISCUSSION: These results partially validate current diagnostic criteria for bulimia nervosa and elucidate one factor, impulsiveness, that may be important in understanding objective binge episodes in bulimia nervosa.

Disordered eating in adolescent males from a school-based sample.

OBJECTIVE: The authors sought to describe a sample of adolescent males who reported disordered eating, to explore whether males with disordered eating are overweight or obese, and to determine if patterns displayed by females would be replicated with a male sample. METHOD: Three school-based adolescent samples were selected. (1) 27 males reporting disordered eating (2) 27 physically matched controls, and (3) 27 randomly selected controls. RESULTS: Findings indicated that boys reporting disordered eating expressed greater body dissatisfaction, depression, restraint, and poorer interoceptive awareness compared to matched and randomly selected controls. Negative Emotionality and poor Interoceptive Awareness scores showed the strongest associations with eating pathology. Body mass index and Negative Emotionality scores showed the strongest relationships to restrained eating. DISCUSSION: Previous results for female adolescents were replicated, suggesting that findings for females can be generalized to males. Disordered eating appears to exist in the absence of significant weight problems in adolescent males.

Relationship between depression and body dissatisfaction in women diagnosed with bulimia nervosa.

OBJECTIVE: Body dissatisfaction and depression have consistently demonstrated a positive association in women. This study sought to determine the independence of this association from bulimic symptomatology among women diagnosed with bulimia nervosa. METHOD: Participants were 101 women who completed a controlled treatment study of bulimia nervosa and participated in follow-up assessments 10 years later. RESULTS: Findings indicated that baseline levels of depression were independent of and superior to bulimic symptoms in prospectively predicting body dissatisfaction at follow-up assessment. DISCUSSION: Findings suggest that depression may be a better prognostic indicator of body dissatisfaction than bulimic symptoms in women diagnosed with bulimia nervosa. A model in which depression represents a contributing factor for the maintenance of body dissatisfaction is discussed.