The epidemiology of bulimia nervosa: Two community studies

Recent studies of American college students suggest that the syndrome bulimia is common and that individual elements of the condition are even more widespread. In Britain, two community-based studies of the related syndrome bulimia nervosa have been reported. In the first, 499 women who fulfilled diagnostic criteria for bulimia nervosa were identified with the help of a women's magazine. These women closely resembled bulimia nervosa patients attending psychiatric hospitals. Although more than half reported that they wanted medical help, less than one-third had discussed their eating difficulties with a doctor and only 2.5% were currently receiving treatment. The second study investigated the eating habits and attitudes of 369 attenders at a family planning clinic. Of these, 20.9% reported current episodes of “binge-eating”; 2.9% currently used vomiting as a means of weight control; and 1.9% fulfilled diagnostic criteria for bulimia nervosa. Comparison of the two samples indicates that people with bulimia nervosa are prone to have been both overweight and underweight in the past. They also have more disturbed attitudes toward food, eating, body weight, and body shape and a considerably higher degree of psychological disturbance. These studies suggest that bulimia nervosa constitutes a significant undetected source of psychiatric morbidity. The service implications of these findings have yet to be examined.     

Knowledge about eating disorders in the community

One-hundred and forty-nine subjects (80 females and 69 males) were asked about their knowledge of anorexia and bulimia nervosa, the source of their knowledge, and the ways in which their knowledge of these disorders may have affected their attitudes towards eating, dieting, and related behaviors. Almost all subjects had heard of anorexia nervosa, whereas bulimia nervosa was less well known, particularly among males. Knowledge of anorexia nervosa was more detailed than that for bulimia nervosa. The mass media were the major sources of subjects' information about these disorders. Over one-third of females reported that their knowledge concerning anorexia and bulimia nervosa had affected their own eating or related attitudes in some way. The importance of the media in both promoting and preventing eating disorders is discussed.     

Self-Reported Eating Disorders of Black, Low-Income Adolescents: Behavior, Body Weight Perceptions, and Methods of Dieting

This study identified black, low-income adolescents who thought they had anorexia nervosa or bulimia nervosa, identified behaviors common to those who thought they had the disorders, and compared their actual and perceived body weight as well as methods of dieting. Of the 1,930 students in grades 7-12 who participated, about 12% thought they might have an eating disorder. These students also reported having food-related behaviors similar to individuals with eating disorders and which differed significantly from those reported by their peers. Gender was more likely to affect food behavior than age. Though most students were within their expected weight range, those with self-reported eating disorders perceived themselves to be heavier more often than their peers and when their actual weights were compared, they were more likely to weigh more. Of those who had dieted to lose weight, fasting was the most frequently reported restrictive method used.     

Analysis of self-reported eating and related behaviors in an adolescent population

A seventy-eight item questionnaire was constructed to collect data from adolescents about behaviors and attitudes regarding eating, food, weight, and physical appearance. It was administered to 2276 students between the ages of 13 and 18. One objective of the research was to identify clusters of behavioral and attitudinal characteristics which may be indicative of disturbed eating and other food-related behaviors. Another was to describe a large sample of adolescents in terms of such characteristics as weight for height and age, perceived ideal weight, and perceived physical attractiveness. Frequencies are reported, as well as the results of a factor analysis. A principal components factor analysis using varimax rotation defined eight orthogonal factors with eigenvalues greater than one. A number of these factors have implications for the increasing incidence among adolescents of such serious eating disorders as bulimia and anorexia nervosa.     

The eating behavior rating scale (EBRS): A measure of eating pathology in anorexia nervosa

The aims of this study were to develop an Eating Behavior Rating Scale (EBRS) for patients with anorexia nervosa, to quantify abnormalities of eating behavior in these patients, and to determine whether such behavior improves with inpatient management. Fifteen patients hospitalized with anorexia nervosa and 10 university students participated in the study. The eating behavior of the anorexia nervosa patients was significantly worse than that of the university students as measured by the EBRS. Although there was a significant improvement in the eating behavior of the anorexia nervosa patients during refeeding, it remained significantly worse than the students. Our findings also suggested that the degree of eating behavior pathology may be independent of the patients' attitudes to food and weight as well as other psychological variables assessed by the Eating Disorders Inventory.     

Dissimilarities in eating attitudes,body image distortion,depression, and self-esteem between high-intensity male runners and women with bulimia nervosa

It has been suggested that high-intensity exercise regimens in males bear a resemblance to the features of eating disorders and that male runners may resemble women with anorexia nervosa and bulimia nervosa with regard to eating and weight attitudes, negative body image, and negative psychological adjustment. Twenty high-intensity male runners were compared with 20 sedentary-moderate exercising male controls and 20 women with bulimia nervosa. Compared with the bulimia nervosa subjects, the male runners were not anxious about eating, overly preoccupied with food, excessive in binge-eating or purging behavior, negatively preoccupied with their weight, intent on losing weight, high on personality traits presumed to underlie eating disorders, nor depressed or low in self-esteem. The male groups of high-intensity runners and controls were not significantly different on any measure. These results suggest that high-intensity exercising in males is not analogous to anorexia nervosa and bulimia nervosa.     

Gender, ethnicity, self-esteem and disordered eating among college athletes

OBJECTIVE: This study was undertaken to compare ethnic and gender differences regarding self-esteem and various disordered eating attitudes and behaviors among elite college athletes. METHOD: A total of 1445 student athletes from 11 Division I schools were surveyed using a 133-item questionnaire. RESULTS: White female athletes reported significantly lower self-esteem than Black female, Black male and White male athletes. Black female athletes' self-esteem was equal to both Black and White male athletes. White female athletes reported significantly higher drive for thinness, body dissatisfaction, and more disturbed eating behaviors than Black female and both groups of male athletes. DISCUSSION: The current study demonstrates that White female athletes appear to be most at risk for having difficulty with eating disorders. Their reporting of significantly lower self-esteem indicates that this may be a risk factor that is more characteristic of this ethnic group. Questions are raised about what factors exist in the Black female culture that protect them from low self-esteem and disordered eating attitudes and behaviors.     

Standardized test meals in assessment of eating behavior in bulimia nervosa: Consumption of feared foods when vomiting is prevented

This study contrasted the amount of food eaten in the absence of vomiting by normal-weight bulimia nervosa patients and matched normal controls. Subjects were instructed to eat as much food as they comfortably could without vomiting afterwards in three standardized test meals: a complete dinner eaten in a laboratory situation, and spaghetti and candy eaten at home. Bulimia nervosa subjects ate a very small amount of food in each test meal when compared with control subjects. Bulimia nervosa subjects also reported greater anxiety and urge to vomit after eating. A content analysis of tape-recorded thoughts showed that bulimia nervosa subjects were more preoccupied with eating and expressed more negative food-related thoughts. The results support the hypothesis that women with bulimia nervosa are unable to eat normal amounts of “frightening” foods when they do not plan to vomit. This behavioral test of eating behavior appears to be useful for the assessment of bulimia nervosa.     

Eating disorders and altered eating behaviors in adolescents of normal weight in a Spanish city.

PURPOSE: To study the prevalence of altered eating behaviors or eating disorder-related behaviors among adolescents of normal weight that do not fulfill criteria for anorexia nervosa and bulimia nervosa. METHOD: Cross-sectional study by means of a self-completed questionnaire (School of Nutrition of Granada, Spain) and measurement of weight and height in a population of 491 schoolchildren aged 14-18 years. The statistical inferences and estimation of risk are based on comparison of proportions and means test, and the relative inequality of prevalences. RESULTS: Of 491 adolescents of normal weight, 9% (females 2:1) were following diets; 42% presented "recurrent episodes of binging" with the sensation of loss of self-control; and 41%% avoided specific types of food. Overall, 46.2% presented altered eating behavior. Factors significantly associated with this were the occurrence of periods of food abstinence and the use of purgatives [confidence interval 95% (CI 95%) prevalence ratio (PR) 1.41-2.02]. Compensatory behaviors were present in 33% of the adolescents, predominantly in females (CI 95% PR 1.79-3.07). The prevalences of abnormal eating behaviors were 16.3% for those related to anorexia (A-RB) and 17.1% for those related to bulimia (B-RB), with a clear predominance of females (2:1) and public education. There seems to be a greater aesthetic concern among those with B-RB and more worry about weight among those with A-RB. CONCLUSIONS: A high proportion of adolescents with abnormal eating behaviors and an altered perception of body fat may currently be diagnosed as having atypical eating disorder" (Diagnostic and Statistical Manual of Mental Disorders, Fourth Revision) considering that their body mass index was within normal range.     

Socially driven eating and restriction in the eating disorders

The aims of this study were: to develop a measure to examine the relationship between socially driven eating and specific eating behaviours; to examine whether different social situations increase or decrease eating in different diagnostic groups; and to determine whether dimensional links exist between responses to social triggers and different aspects of eating pathology. A clinical group of 107 eating-disordered women and 143 nonclinical women completed a measure of socially driven eating and restriction (the Social Eating Scale, or SES) and the Eating Disorders Inventory. The SES had good psychometric properties. Patients with binge-eating disorder (BED) ate more in all social situations, while those with anorexia nervosa ate less. In contrast, bulimia nervosa (BN) patients ate more in general social situations but less in situations where the social trigger was related to food, shape, or weight. There were consistent dimensional links between responses to social triggers and different aspects of eating pathology. These findings support the recent literature on social triggers of eating behaviours but stress the relevance of the mixed pathology of women with BN. The role of social triggers for eating might help to explain the effectiveness of interpersonal psychotherapy when applied to the eating disorders.     

Attitudes toward weight,body image,eating, menstruation,pregnancy, and sexuality in 81 cases of anorexia compared with 288 normal control school girls

Eighty-one girls suffering from anorexia nervosa and 288 control school girls filled in a questionnaire including 48 questions to assess their weight and their height, how they perceived their body size and experienced their body, their eating behavior, and some attitudes toward menstruation, pregnancy, and sexuality. The answers of these two groups were compared using the chi-square test. Specific problems of weight, body size, and eating disorders were frequent in the control group, but they were significantly more frequent in the anorexia nervosa group. The difference was particularly significant for the following points: difficulties with perceiving their body size, overestimation of body size, fear of gaining weight, fear of having a normal weight, and guilt after food intake. The attitude toward menstruation and the desire to have children were the same in both groups. The proportion of girls in whom pregnancy and sexuality induced fear or disgust was significantly higher in the anorexia nervosa group, although these attitudes only concern a minority of the patients. This study confirms that the tendency to overestimate body size, the fear of gaining weight, and the conflict about eating are important mechanisms in anorexia nervosa. Moreover, this study shows that anorexia nervosa does not signify the rejection of a sexually attractive and menstruating female body in every case.     

Gender Perspectives on Adolescent Eating Behaviors: A Study on the Eating Attitudes and Behaviors of Junior Secondary Students in Hong Kong

ObjectiveThis research aimed to investigate the eating attitudes and behaviors of junior secondary students in Hong Kong, with a specific focus on possible gender differences.DesignA survey was conducted in 2005 to solicit data about participants' food knowledge, eating attitudes and behavior, perceptions of cooking skills and body weight, and related factors influencing food choice.SettingTwenty-three secondary schools located in different district areas of Hong Kong.ParticipantsThe sample was composed of 836 students (41% male, 59% female) aged 11-18 years selected by random sampling.AnalysisCross-tabulation analyses were used to compare the responses by gender.ResultsRegardless of gender, less than half of the sample ate breakfast every day, and their consumption of fruits and vegetables was below recommended daily intakes. No significant differences were observed between respondents' eating habits and levels of food knowledge.Female students were more weight conscious than male students. Dissatisfaction about body weight was common among normal and underweight students. Cooking skills were generally valued as important life skills by both genders, though cooking skills were seen to be more relevant for girls.Conclusions and ImplicationsSchool nutrition education in Hong Kong should be designed to appeal to boys as well as girls, and effective implementation of nutrition education programs should inculcate healthful eating habits and sound cooking skills and address the needs of students with reference to gender differences. A more diversified approach could be employed through formal and informal curricula, prioritizing cooking skills and food advertising literacy in the curriculum.     

Self-image with regard to weight in a group of adolescent girls

The explanatory models generally accepted at the present time concerning eating disorders, particularly anorexia nervosa, are the multidimensional ones. Different factors have been put forward such as predisposing factors, facilitators, triggering and sustaining factors of Anorexia nervosa. Facilitators and triggering factors include those with a sociocultural origin such as social pressure to have a certain look, closely related to a low body weight. This study aims to discover the self-image of a group of female teenagers with respect to their weight, as well as to ascertain which attitudes derive from self-image. To this end a survey was conducted in two high schools in Tudela in June 1998. A hundred and thirty teenagers from 15 to 17 years old attending compulsory secondary education were surveyed. The results indicate that girls from this group have a negative self-image with respect to their body weight; most of them think they should be thinner and that is the reason why they change their behaviour in order to lose weight.     

Signs of anorexia and bulimia nervosa in high school girls reporting combinations of eating and mood symptoms: Relevance of self-report to interview-based findings

Scores from structured clinical interviews for DSM-III-R eating and mood disorders were compared across groups of high school girls who, on self-report, had indicated: (a) eating/ weight concerns and depression (n = 31), (b) eating/weight concerns without depression (n = 54), and (c) neither set of concerns (n = 75). Few girls had full eating disorders, however, clinical signs of anorexia and bulimia nervosa were often detected upon interview, largely in the group reporting concurrent eating and mood problems. Girls reporting eating concerns alone showed no larger number of clinical symptoms than did girls reporting low eating concerns. Results suggested that the isolation of cases at-risk of clinical-spectrum eating disturbances can be parsimoniously enhanced by complementing self-report measures of eating attitudes and behaviors with a measure of concurrent depression. © 1992 John Wiley & Sons, Inc.     

Eating disorder management in hospital patients: Current practice among dietitians in Australia

Aim:  To examine dietetic practice during the management of eating disorders in inpatient and daypatient settings.
Methods:  A survey was sent to dietitians working in the clinical management of eating disorders within Australia. Thirty-six qualified dietitians including all dietitians working at the specialist units in Australia participated in the study.
Results:  Most dietitians aim to meet patients' nutritional requirements by food alone without artificial feeding. High-energy supplements are the preferred method of increasing energy intake to eating disorder patients. Nasogastric feeding was a standard feeding practice for anorexia nervosa reported by one-third of dietitians. Total parenteral nutrition was not considered an option for nutritional rehabilitation. In the treatment of anorexia nervosa, variable energy intakes for individual patients were prescribed aiming for weight gain of up to 1.0 kg/week in inpatients and 0.5 kg/week in outpatients.
Conclusion:  In Australia, there is no standard nutritional management for anorexia and bulimia nervosa. This survey establishes a baseline for nutritional management and practice of dietitians working with patients with eating disorders. Further research is needed regarding use of nasogastric feeding, and weight gain targets in anorexia nervosa.     

Perceptions of weight and attitudes toward eating in early adolescent girls.

Sixth grade girls (n = 206) responded to questions about their weight, body image, dieting practices, and attitudes toward weight and eating. Results suggested that feeling too fat and wishing to lose weight were becoming normative for young adolescent girls in that the majority of girls wished to weigh less and said that they dieted at least occasionally. For most girls, weight concerns had emerged between the ages of 9 to 11. A sizeable proportion of girls seemed to have adopted a "dieting mentality," claiming to be avoiding fat, counting calories, thinking excessively about food, feeling guilty after eating and overeating, and exercising to lose weight. Such practices were common even among girls who did not describe themselves as overweight or who were satisfied with their appearance. The emergence of these attitudes and behaviors at increasingly younger ages is of grave concern, as several of them are risk factors for the development of serious eating disorders.     

Atypical eating disorders in young children

Eating disorders are considered rare in young children. However, we have admitted 8 prepubertal patients with atypical eating disorders. The 6 girls and 2 boys were 5-11 years old and had markedly abnormal eating behaviors for periods of 2 months to 10 years. Weights varied from 82% to 108% of desirable body weight. All patients refused to eat normal amounts or types of food and struggled with family and staff about eating and weight gain. Several displayed ritualistic, obsessive behaviors during meals. None had a distorted body image or fear of fatness, and none had anorexia nervosa or bulimia nervosa. Observed symptoms ranged from phobic food aversion with little weight loss or depression to very restrictive diets with bizarre eating behaviors, low weight, and significant depressive symptoms. A wide range of critical familial psychosocial problems was identified. All patients gained weight and demonstrated some improvement in eating behaviors in hospital. However, most children had significant associated psychopathology, which required treatment after discharge. Eating disorders may be more common in children than now believed, may be associated with major family conflict, and may not manifest distorted body image or fear of fatness as cardinal symptoms.     

Smoking, weight loss intention and obesity-promoting behaviors in college students

OBJECTIVE: To examine whether college smoking was associated with trying to lose weight and other weight-related behaviors. METHODS: We surveyed 300 students at the University of Kansas about smoking (ever, current, and amount), weight loss intention (y/n), weight-related attitudes, and eating and exercise behavior. Weight, height, and body fat were measured. RESULTS: About half the students (49%) self-identified as having ever smoked while 53 (17.6%) self-identified as current smokers. After controlling for sex, age, and ethnicity, ever smoking was not related to weight loss intention but was associated with greater pressure to maintain a healthy weight (p = 0.05), and having engaged in mild exercise on more days in the previous year (p = 0.05). Compared to nonsmokers, current smokers ate more at restaurants serving high calorie foods (p < 0.05) and ate more frequently in front of the TV (p < 0.01). Amount smoked was related to diminished use of exercise facilities (p = 0.03) and more frequent eating at restaurants serving high calorie foods (p < 0.05) and in front of the TV (p = 0.01). CONCLUSIONS: Current smoking among college students was related to weight loss intention. Despite wanting to lose weight, current smoking was concomitant with obesity-promoting behaviors such as eating higher calorie foods and eating in front of the TV. College-based interventions to prevent smoking initiation or promote smoking cessation should include a focus on healthy eating, exercise and healthful ways to lose or maintain weight.     

Osteoporosis knowledge, attitudes, and behaviors of female collegiate athletes

Female athletes often engage in harmful dietary and weight control practices that can impair bone health and hinder performance. To promote related positive health behavior practices, nutrition educators may be more effective if they understand the osteoporosis knowledge, attitudes, and behaviors among female athletes. A questionnaire including items related to osteoporosis and dietary calcium knowledge, attitudes, and behavioral practices was administered to 114 female collegiate athletes (19.6+/-1.4 years). Self-reported intakes of dairy product consumption were also obtained; subjects were asked how many times per week they drank milk and ate cheese, yogurt, and ice cream. The mean score for osteoporosis knowledge was 7.1+/-1.9 (out of 10 items). The mean score for favorable responses to attitude items was 2.1+/-0.8 (out of 3 items). Correct responses to dietary calcium knowledge items were 2.2+/-0.7 (out of 3 items). On average, subjects consumed 2.4+/-1.6 servings of dairy products per day; 31% of subjects consumed the recommended 3 or more servings per day. Osteoporosis knowledge, osteoporosis attitudes, and dietary calcium knowledge were not correlated (p > .05) with dairy product intake. Because of the importance of achieving a high peak bone mass to prevent osteoporosis, our data suggest that further research is needed regarding other factors that might influence dairy product intake among female athletes.     

Smoking,Weight Loss Intention and Obesity-Promoting Behaviors in College Students

Objective: To examine whether college smoking was associated with trying to lose weight and other weight-related behaviors.

Methods: We surveyed 300 students at the University of Kansas about smoking (ever, current, and amount), weight loss intention (y/n), weight-related attitudes, and eating and exercise behavior. Weight, height, and body fat were measured.

Results: About half the students (49%) self-identified as having ever smoked while 53 (17.6%) self-identified as current smokers. After controlling for sex, age, and ethnicity, ever smoking was not related to weight loss intention but was associated with greater pressure to maintain a healthy weight (p = 0.05), and having engaged in mild exercise on more days in the previous year (p = 0.05). Compared to nonsmokers, current smokers ate more at restaurants serving high calorie foods (p < 0.05) and ate more frequently in front of the TV (p < 0.01). Amount smoked was related to diminished use of exercise facilities (p = 0.03) and more frequent eating at restaurants serving high calorie foods (p < 0.05) and in front of the TV (p = 0.01).

Conclusions: Current smoking among college students was related to weight loss intention. Despite wanting to lose weight, current smoking was concomitant with obesity-promoting behaviors such as eating higher calorie foods and eating in front of the TV. College-based interventions to prevent smoking initiation or promote smoking cessation should include a focus on healthy eating, exercise and healthful ways to lose or maintain weight.