K. Jean Forney

Psychosocial risk factors for eating disorders

OBJECTIVE One goal in identifying psychosocial risk factors is to discover opportunities for intervention. The purpose of this review is to examine psychosocial risk factors for disordered eating, placing research findings in the larger context of how etiological models for eating disorders can be transformed into models for intervention. METHOD A qualitative literature review was conducted focusing on psychological and social factors that increase the risk for developing eating disorders, with an emphasis on well-replicated findings from prospective longitudinal studies. RESULTS Epidemiological, cross-cultural, and longitudinal studies underscore the importance of the idealization of thinness and resulting weight concerns as psychosocial risk factors for eating disorders. Personality factors such as negative emotionality and perfectionism contribute to the development of eating disorders but may do so indirectly by increasing susceptibility to internalize the thin ideal or by influencing selection of peer environment. During adolescence, peers represent self-selected environments that influence risk. DISCUSSION Peer context may represent a key opportunity for intervention, as peer groups represent the nexus in which individual differences in psychological risk factors shape the social environment and social environment shapes psychological risk factors. Thus, peer-based interventions that challenge internalization of the thin ideal can protect against the development of eating pathology.

Examining the moderating role of social norms between body dissatisfaction and disordered eating in college students.

Body dissatisfaction is a well-replicated risk factor for disordered eating, yet not all individuals with body dissatisfaction exhibit disordered eating. This study examined the role of perceptions of social norms on the relationship between body dissatisfaction and disordered eating. Perceptions of descriptive and injunctive peer norms, body dissatisfaction, and disordered eating were examined in a non-clinical sample of college men and women using cross-sectional survey methods. For women, perceptions of the injunctive norms of peer thinness and peer acceptability moderated the relationship between body dissatisfaction and disordered eating with an additive effect; perceptions of the descriptive norm peer prevalence of disordered eating behaviors did not. In men, norms did not moderate the relationship between body dissatisfaction and disordered eating. Endorsement of injunctive norms is associated with reported disordered eating in women with high body dissatisfaction. Norm-based interventions may be best suited for women with high body dissatisfaction.

The medical complications associated with purging

OBJECTIVE Purging behaviors, including self-induced vomiting, laxative abuse, and diuretic abuse, are present across many of the eating disorders. Here we review the major medical complications of these behaviors. METHOD Although we identified over 100 scholarly articles describing medical complications associated with purging, most papers involved case studies or small, uncontrolled samples. Given the limited evidence base, we conducted a qualitative (rather than systematic) review to identify medical complications that have been attributed to purging behaviors. RESULTS Medical conditions affecting the teeth, esophagus, gastrointestinal system, kidneys, skin, cardiovascular system, and musculoskeletal system were identified, with self-induced vomiting causing the most medical complications. DISCUSSION Purging behavior can be associated with severe medical complications across all body systems. Mental health professionals should refer patients with purging behaviors to medical providers for screening and treatment as needed. The medical work-up for individuals with eating disorders should include a comprehensive metabolic panel, complete blood count, and a full body exam including the teeth to prevent severe complications. Medical providers should screen patients for purging behaviors and associated medical complications, even in the absence of an eating disorder diagnosis, to increase the detection of eating disorders. Recognizing the link between purging and medical complications can aid in identifying potential eating disorders, particularly those that often elude detection such as purging disorder.

Influence of peer context on the relationship between body dissatisfaction and eating pathology in women and men

OBJECTIVE This study examined the influence of peer context on the relationship between body dissatisfaction and eating pathology in women and men. METHOD Secondary analyses were conducted using survey data from a large community sample of women and men (N = 2,060). RESULTS The frequency of friend comments on weight and diet moderated the relationship between body dissatisfaction and eating pathology such that more frequent comments strengthened the relationship between body dissatisfaction and eating pathology in women. This effect was not significant in analyses of men. Instead, friend comments were directly related to eating pathology in men. DISCUSSION Both women and men may benefit from peer-led interventions, with the greatest potential benefits for women with high body dissatisfaction, consistent with results from selective peer-led prevention programs in sororities.

The role of loss of control eating in purging disorder

OBJECTIVE Purging Disorder (PD), an Other Specified Feeding or Eating Disorder (APA, 2013), is characterized by recurrent purging in the absence of binge eating. Though objectively large binge episodes are not present, individuals with PD may experience a loss of control (LOC) while eating a normal or small amounts of food. The present study sought to examine the role of LOC eating in PD using archival data from 101 women with PD. METHOD Participants completed diagnostic interviews and self-report questionnaires. Analyses examined the relationship between LOC eating and eating disorder features, psychopathology, personality traits, and impairment in bivariate models and then in multivariate models controlling for purging frequency, age, and body mass index. RESULTS Across bivariate and multivariate models, LOC eating frequency was associated with greater disinhibition around food, hunger, depressive symptoms, negative urgency, distress, and impairment. DISCUSSION LOC eating is a clinically significant feature of PD and should be considered in future definitions of PD. Future research should examine whether LOC eating better represents a dimension of severity in PD or a specifier that may impact treatment response or course.

A randomized controlled trial of The Body Project: More Than Muscles for men with body dissatisfaction

OBJECTIVE Pressures for men to conform to a lean, muscular ideal have, in part, contributed to eating disorder and muscle dysmorphia symptoms, yet few programs have been developed and empirically evaluated to help men. This study investigated the acceptability and efficacy of a cognitive dissonance-based (DB) intervention in reducing eating disorder and muscle dysmorphia risk factors in men with body dissatisfaction. METHOD Men were randomized to a two-session DB intervention (n = 52) or a waitlist control condition (n = 60). Participants completed validated measures assessing eating disorder risk factors preintervention, postintervention, and at 1-month follow-up. RESULTS Program ratings indicated high acceptability. The DB condition demonstrated greater decreases in body-ideal internalization, dietary restraint, bulimic symptoms, drive for muscularity, and muscle dysmorphia symptoms compared with controls (p values <  .02; between-condition Cohens d = .30-1.11) from pre- to postintervention. At one-month follow-up, the DB condition demonstrated significantly lower scores for all variables (p values <  .03; between-condition d = .29-1.16). Body-ideal internalization mediated intervention outcomes on bulimic and muscle dysmorphia symptoms. DISCUSSION Results support the acceptability and efficacy of The Body Project: More Than Muscles up to 1-month postintervention and should be examined against active control conditions.

The influence of gender and age on the association between "fat-talk" and disordered eating: an examination in men and women from their 20s to their 50s.

Fat-talk is a common experience in college-aged women, yet little is known about fat-talk in men and across the lifespan. Exposure to fat-talk was compared in a large sample of men (n = 819) and women (n = 1,696) across four age cohorts. Greater exposure to fat-talk was associated with increased disordered eating for men and women. Men experienced less fat-talk than women. Age was negatively associated with fat-talk in women but not in men. Weaker associations between fat-talk and disordered eating were found in men compared to women and in older individuals compared to younger individuals. Nonetheless, the positive association between fat-talk and disordered eating in men and women from late adolescence to midlife and beyond indicates a need to extend intervention programs to target fat-talk in men and women across the lifespan.

Incremental validity of the episode size criterion in binge‐eating definitions: An examination in women with purging syndromes

OBJECTIVE Of the two primary features of binge eating, loss of control (LOC) eating is well validated while the role of eating episode size is less clear. Given the ICD-11 proposal to eliminate episode size from the binge-eating definition, the present study examined the incremental validity of the size criterion, controlling for LOC. METHOD Interview and questionnaire data come from four studies of 243 women with bulimia nervosa (n = 141) or purging disorder (n = 102). Hierarchical linear regression tested if the largest reported episode size, coded in kilocalories, explained additional variance in eating disorder features, psychopathology, personality traits, and impairment, holding constant LOC eating frequency, age, and body mass index (BMI). Analyses also tested if episode size moderated the association between LOC eating and these variables. RESULTS Holding LOC constant, episode size explained significant variance in disinhibition, trait anxiety, and eating disorder-related impairment. Episode size moderated the association of LOC eating with purging frequency and depressive symptoms, such that in the presence of larger eating episodes, LOC eating was more closely associated with these features. Neither episode size nor its interaction with LOC explained additional variance in BMI, hunger, restraint, shape concerns, state anxiety, negative urgency, or global functioning. DISCUSSION Taken together, results support the incremental validity of the size criterion, in addition to and in combination with LOC eating, for defining binge-eating episodes in purging syndromes. Future research should examine the predictive validity of episode size in both purging and nonpurging eating disorders (e.g., binge eating disorder) to inform nosological schemes.

Determining Empirical Thresholds for “Definitely Large” Amounts of Food for Defining Binge-Eating Episodes

Binge episodes involve “definitely large” amounts of food, yet limited data exist regarding the upper limits of food consumption in non-binge eating episodes. Study 1 examined the concurrent validity of a self-report measure developed to measure “usual” food consumption. Results support good concurrent validity for most items across response versions. Study 2 identified the upper limits of normal food consumption (i.e., 85th percentile of participants’ largest reported usual servings). Thresholds differed across types of foods, and men reported higher thresholds than women for several foods. Type of food and gender should be considered when assessing for “definitely large” amounts of food.

Using modern methods for missing data analysis with the social relations model: A bridge to social network analysis

Abstract Social network analysis identifies social ties, and perceptual measures identify peer norms. The social relations model (SRM) can decompose interval-level perceptual measures among all dyads in a network into multiple person- and dyad-level components. This study demonstrates how to accommodate missing round-robin data using Bayesian data augmentation, including how to incorporate partially observed covariates as auxiliary correlates or as substantive predictors. We discuss how data augmentation opens the possibility to fit SRM to network ties (potentially without boundaries) rather than round-robin data. An illustrative application explores the relationship between sorority members’ self-reported body comparisons and perceptions of friends’ body talk.