Andrea B. Goldschmidt

DISORDERED EATING ATTITUDES AND BEHAVIORS IN OVERWEIGHT YOUTH

Disordered eating attitudes and behaviors appear to be quite common in youth, and overweight youth have been identified as a subset of the population at particularly high risk for endorsing such symptoms. Overweight and eating disorder (ED) symptomatology independently confer significant threats to ones physical and psychosocial health, showing strong links with body weight gain and risk for ED development. When concurrent, the risk for negative health outcomes may be compounded. The purpose of this article is to review the current state of the literature as it concerns disordered eating and its correlates in overweight children and adolescents. Extant literature on the prevalence, distribution, correlates, and etiology of disordered eating attitudes and behaviors (i.e., negative attitudes toward shape and weight, unhealthy weight control behaviors, and binge eating) in overweight youth is reviewed and consolidated in order to make assessment and treatment recommendations for healthcare providers. The current literature suggests that early detection of disordered eating in overweight youth should be a priority to provide appropriate intervention, thereby helping to slow the trajectory of weight gain and prevent or reduce the long‐term negative consequences associated with both conditions. Future research should focus on explicating developmental pathways, and on developing novel prevention and treatment interventions for overweight youth exhibiting disordered eating patterns.

Reduction of Overweight and Eating Disorder Symptoms via the Internet in Adolescents: A Randomized Controlled Trial

PURPOSE Overweight in adolescence is a significant problem which is associated with body dissatisfaction and eating disorder (ED) behaviors. Cost-effective methods for early intervention of obesity and prevention of ED are important because of the refractory nature of both. This multisite RCT evaluated an Internet-delivered program targeting weight loss and ED attitudes/behaviors in adolescents. METHODS A total of 80 overweight adolescents 12-17 years of age completed Student Bodies 2 (SB2), a 16-week cognitive-behavioral program, or usual care (UC). RESULTS Body mass index (BMI) z-scores were reduced in the SB2 group compared with the UC group from baseline to post-intervention (p = .027; eta(p)(2) = .08). The SB2 group maintained this reduction in BMI z-scores at 4-month follow-up, but significant differences were not observed because of improvement in the UC group. The SB2 group evidenced greater increases in dietary restraint post-intervention (p = .016) and less improvement on shape concerns at follow-up (p = .044); however these differences were not clinically significant. No other statistically significant differences were noted between groups on ED attitudes or behaviors. The SB2 participants reported using healthy eating-related and physical activity-related skills more frequently than UC participants post-intervention (p = .001) and follow-up (p = .012). CONCLUSIONS Findings suggest that an Internet-delivered intervention yielded a modest reduction in weight status that continued 4 months after treatment and that ED attitudes/behaviors were not significantly improved. Group differences on weight loss were not sustained at 4-month follow-up because of parallel improvements in the groups. Future studies are needed to improve program adherence and to further explore the efficacy of Internet-delivery of weight control programs for adolescents.

Psychosocial and Physical Impairment in Overweight Adolescents at High Risk for Eating Disorders

Objective: Many overweight adolescents display elevated risk for the development of eating disorders, as seen in higher rates of weight/shape concerns and disordered eating behaviors, but the extent of impairment in this subset of high‐risk adolescents has not been explored.

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.

Ecological momentary assessment of stressful events and negative affect in bulimia nervosa.

OBJECTIVE Negative affect precedes binge eating and purging in bulimia nervosa (BN), but little is known about factors that precipitate negative affect in relation to these behaviors. We aimed to assess the temporal relation among stressful events, negative affect, and bulimic events in the natural environment using ecological momentary assessment. METHOD A total of 133 women with current BN recorded their mood, eating behavior, and the occurrence of stressful events every day for 2 weeks. Multilevel structural equation mediation models evaluated the relations among Time 1 stress measures (i.e., interpersonal stressors, work/environment stressors, general daily hassles, and stress appraisal), Time 2 negative affect, and Time 2 binge eating and purging, controlling for Time 1 negative affect. RESULTS Increases in negative affect from Time 1 to Time 2 significantly mediated the relations between Time 1 interpersonal stressors, work/environment stressors, general daily hassles, and stress appraisal and Time 2 binge eating and purging. When modeled simultaneously, confidence intervals for interpersonal stressors, general daily hassles, and stress appraisal did not overlap, suggesting that each had a distinct impact on negative affect in relation to binge eating and purging. CONCLUSIONS Our findings indicate that stress precedes the occurrence of bulimic behaviors and that increases in negative affect following stressful events mediate this relation. Results suggest that stress and subsequent negative affect may function as maintenance factors for bulimic behaviors and should be targeted in treatment.

Eating Disorder Symptomatology in Normal-Weight vs. Obese Individuals With Binge Eating Disorder

Although normal‐weight individuals comprise a substantial minority of the binge eating disorder (BED) population, little is known about their clinical presentation. This study sought to investigate the nature and severity of eating disturbances in normal‐weight adults with BED. We compared 281 normal‐weight (n = 86) and obese (n = 195) treatment‐seeking adults with BED (mean age = 31.0; s.d. = 10.8) on a range of current and past eating disorder symptoms using ANOVA and χ2 analyses. After controlling for age and sex, normal‐weight participants reported more frequent use of a range of healthy and unhealthy weight control behaviors compared to their obese peers, including eating fewer meals and snacks per day; exercising and skipping meals more frequently in the past month; and avoiding certain foods for weight control. They also endorsed more frequent attempts at dieting in the past year, and feeling more frequently distressed about their binge eating, at a trend level. There were no group differences in binge eating frequency in the past month, age at onset of binge eating, overvaluation of shape/weight, or likelihood of having used certain weight control behaviors (e.g., vomiting, laxative use) or having sought treatment for an eating disorder in the past. Based on our findings, normal‐weight individuals appear to be a behaviorally distinct subset of the BED population with significantly greater usage of both healthy and unhealthy weight control behaviors compared to their obese peers. These results refute the notion that distress and impairment in BED are simply a result of comorbid obesity.

Which Dieters Are at Risk for the Onset of Binge Eating? A Prospective Study of Adolescents and Young Adults

PURPOSE Dieting is a well-established risk factor for binge eating, yet the majority of dieters do not develop binge eating problems. The purpose of the current study was to examine psychosocial factors involved in the relation between dieting and binge eating over a 10-year follow-up period. METHODS A population-based sample (n = 1,827) completed surveys assessing eating habits, psychological functioning, and weight status at 5-year intervals spanning early/middle adolescence (time 1), late adolescence/early young adulthood (time 2), and early/middle young adulthood (time 3). Dieting, along with depression symptoms, self-esteem, and teasing experiences at time 1 and time 2, was used to predict new onset binge eating at time 2 and time 3, respectively. Interactions between dieting status and varying degrees of these psychosocial factors in relation to binge eating onset were also tested. RESULTS Dieters were two to three times more likely than nondieters to develop binge eating problems over 5-year follow-ups. At most time points, depression symptoms and self-esteem predicted binge eating onset beyond the effects of dieting alone. Detrimental levels of these factors among dieters (relative to nondieters) increased the likelihood of binge eating onset only during the later follow-up period. CONCLUSIONS Depression and self-esteem appear to be particularly salient factors involved in the relation between dieting and binge eating onset among adolescents and young adults. Early identification of these factors should be a priority to prevent the development of binge eating problems among already at-risk individuals.

Dimensions of Emotion Dysregulation in Bulimia Nervosa

The goal of this study was to examine associations between dimensions of emotion dysregulation and eating disorder (ED) symptoms in bulimia nervosa (BN). This investigation used baseline data from a BN treatment study that included 80 adults (90% women) with full or subthreshold BN. Participants completed the Difficulties in Emotion Regulation Scale (DERS) and the Eating Disorders Examination interview. The Eating Disorders Examination global score was significantly correlated with the DERS total score, as well as several DERS subscales: nonacceptance, impulse and strategies. Further, the DERS goals subscale was found to be uniquely associated with frequency of purging and driven exercise, although none of the subscales were associated with frequency of objective binge eating. Findings indicate that emotion dysregulation is associated with ED symptoms in BN, suggesting the utility of interventions that address emotion regulation skills deficits in the treatment of the disorder.

Eating Disorders with and without Comorbid Depression and Anxiety: Similarities and Differences in a Clinical Sample of Children and Adolescents

OBJECTIVE This study aimed to describe and compare the demographic and clinical characteristics of children and adolescents with an eating disorder (ED) and comorbid depression or anxiety. METHOD Data were drawn from intake assessments of children and adolescents at a specialist ED clinic. Demographic characteristics (e.g. age and gender) and clinical characteristics (e.g. body mass, binge eating and purging) were compared between 217 ED participants without comorbidity, 32 with comorbid anxiety, 86 with comorbid depression and 36 with comorbid anxiety and depression. RESULTS The groups with comorbid depression had more complex and severe presentations compared with those with an ED and no comorbid disorder and those with comorbid anxiety alone, especially in regard to binge eating, purging, dietary restraint and weight/shape concerns. DISCUSSION Depression and anxiety were differentially related to clinical characteristics of EDs. The findings have implications for understanding the relations between these disorders and their potential to impact outcome of ED treatments.

Momentary Affect Surrounding Loss of Control and Overeating in Obese Adults With and Without Binge Eating Disorder

Research suggests that loss of control (LOC) while eating (the sense that one cannot control what or how much one is eating) is a more salient feature of binge eating than the amount of food consumed. This study examined the unique contributions of LOC and episode size to negative affect surrounding eating episodes in binge eating disorder (BED) and obesity. Twenty‐two obese adults with (n = 9) and without (n = 13) BED completed daily records of eating patterns and mood using ecological momentary assessment (EMA). Linear mixed modeling revealed that across groups, greater premeal self‐reported LOC was associated with higher premeal negative affect independent of episode size. For individuals with BED, greater premeal self‐reported LOC was associated with higher postmeal negative affect, regardless of the amount of food eaten, whereas for obese controls, the combination of LOC and consumption of large amounts of food was associated with lower postmeal negative affect. Results indicate that LOC, but not the quantity of food consumed, is associated with momentary distress related to aberrant eating in BED. Findings also highlight the need for further research investigating the emotional context surrounding aberrant eating in obese individuals without BED.