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ERRATUM
Eating and Weight Disorders, Vol. 14, No. 1, March 2009, pp. 12-22
Multidisciplinary approach ro obesity by M.L. Donini, C. Savina, E. Castellaneta,
C. Coletti, M. Paolini, L. Scavone, C. Civale, P. Ceccarelli, S. Zaninotto, M. Tineri,
G. Grossi, M.R. De Felice, and C. Cannella
The first authors correct name is: L.M. Donini
Vol. 14: e30, June-September 2009
e30
Editorial
Dear Authors, Reviewers, Readers and Members of the Editorial Board,
The first issue of Eating and Weight Disorders appeared long ago, at the end of 1996, and
thanks to all who have submitted their articles to the journal and to the efforts done by all
members of the Editorial Board and the Editorial Office, the journal has gained increasing
credibility.
This year Eating and Weight Disorders is going through some major changes.
First of all, as scientific research nowadays is more and more being spread through the
Internet, Eating and Weight Disorders will be published online only, starting from issues
2 and 3, which will be published unified in October 2009.
Authors will receive a complimentary pdf file of their papers.
Moreover, since the urge for real-time dissemination of data is more stringent than ever,
the journal is implementing a new service for Authors and Readers. As of Autumn 2009, a
new Previews section will appear in the web site www.kurtis.it where manuscripts
accepted for publication will be e-published in their accepted author manuscript version
well ahead of printing. It will be possible to read and cite the manuscripts loaded in this
Previews section by a DOI number that will identify every article also in its final
published version.
In order to have their manuscripts loaded in this section Authors will be asked to pay a
processing charge of euros 180.00.
We do hope this service will be well received by Authors and Readers and that Eating
and Weight Disorders will become an even more indispensable tool for those involved in
the study, treatment and prevention of eating disorders and obesity.
Massimo Cuzzolaro
Editor-in-Chief
Vol. 14: e31-e41, June-September 2009
e31
REWIEW
ARTICLE
Key words:
Anorexia nervosa, bulimia
nervosa, eating disorders,
day treatment, day hospital,
partial hospitalisation.
Correspondence to:
Prof. Secondo Fassino,
Neurosciences Department,
Psychiatry Section,
Via Cherasco 11,
10126 Torino.
E-mail:
secondo.fassino@unito.it
Received: March 12, 2008
Accepted: December 5, 2008
Day hospital programmes for eating
disorders: A review of the similarities,
differences and goals
INTRODUCTION
In the last years eating disorders (EDs)
have received greater attention because of
their diffusion (1) and social and health
costs (2, 3).
Currently, treatment of EDs is performed
in outpatient, inpatient and day hospital
(DH) settings without a shared knowledge
about the best and most effective treatment
for each patient (4). Further studies are
required to clear this issue, specially as
regards DH treatments.
DH treatment usually involves medically
stable patients who require intensive treat-
ment with frequent contact and involve-
ment in groups, as recommended by the
American Psychiatric Association guide-
lines (5) and the National Institute for
Health and Clinical Excellence (NICE) (6).
The DH has unique characteristics: inten-
sive daily care is provided but, unlike inpa-
tient units, patients return home and main-
tain their social relations, allowing a daily
test of the improvements made and a pro-
gressive work on environmental risk factors.
Although DH treatments are widespread,
their description in the literature is lacking,
except for the pioneering descriptions of the
Toronto (7) and Munich programmes (8).
Recently, Zipfel et al. (9) and Lammers et
al. (10) reviewed the international DH treat-
ment programmes for EDs, underscoring
their advantages and disadvantages.
Nonetheless, these reviews have several lim-
itations: Zipfel et al. (9) describe only three
centres and Lammers et al. (10) underscore
with more detail the similarities than the dif-
ferences of the different models of care.
The first aim of this review is to compare
the different types of DH programme fully
described in the literature and to discuss
their similarities and differences. The sec-
ond aim of the article is to describe our DH
experience in Turin, Italy, and to compare
its features with the other centres found.
G. Abbate-Daga, C. Gramaglia, S. Preda, E. Comba, A. Brustolin, and S. Fassino
Eating Disorders Centre, Neurosciences Department, University of Turin, Turin
ABSTRACT. Day hospital (DH) treatments for eating disorders (EDs) provide intensive daily
care and allow patients to maintain and test their social relations and coping skills at home
and outside. Although widespread, their description is lacking. This review compares the dif-
ferent types of DH described in the literature and presents our DH experience in Turin, Italy.
We searched Psychinfo and Pubmed with the following keywords: anorexia nervosa, bulimia
nervosa, EDs, DH, day treatment and partial hospitalisation. We found and reviewed the DH
programmes of eleven specialised centres, which have some shared features but also many
differences, suggesting that DH treatments are still largely experimental. Briefly, the shared
elements are: biopsychosocial model as reference frame; cognitive-behavioural model or
techniques; behavioural contract; patients selection; body image therapy; involvement of
family; weight normalisation/weight gain and modification/normalisation of eating behaviour
as objectives. Nonetheless, shared opinions concerning inclusion criteria are lacking; the
duration of DH treatment is surprisingly different among centres (from 3 to 39 weeks); the
approach to eating and compensation behaviours ranges from control to autonomy; follow-
up and psychometric assessment can be either performed or not; psychological and behav-
ioural objectives can be different. This review suggests the existence of two different DH
models: the first has a shorter duration and is mainly symptom-focused; the second is more
individual-focused, has a longer duration and is focused on patients relational skills, psycho-
dynamic understanding of symptoms and more gradual changes in body weight. Further
investigation is required to make DH treatment programmes measurable and comparable.
(Eating Weight Disord. 14: e31-e41, 2009).
2009, Editrice Kurtis
G. Abbate-Daga, C. Gramaglia, S. Preda, et al.
MATERIALS AND METHODS
We searched the literature using Psychinfo
(1980-2007) and Pubmed (Medline 1980-2007),
with the following keywords: anorexia nervosa
(AN), bulimia nervosa (BN), EDs, DH, day treat-
ment and partial hospitalisation. We limited
our search to articles in English and to adult
patients. The reference list of the suitable arti-
cles was checked to identify additional interest-
ing studies.
Overall, we found 20 articles (two of these
were reviews) and 13 centres fully describing
their treatment programmes for EDs. Three of
them were excluded: the Bern Day Treatment
because the article was in German (11); the
Leicester Day Programme Treatment (12)
because the description of the DH treatment
was too limited; the Victoria articl e (13)
because it was only a letter to the editor and
therefore too limited.
This left 10 centres:
- Day Hospital Program (DHP) of the Toronto
Hospital in Canada (9, 10, 14);
- Treatment Centre for Eating Disorders (TCE)
in Munich, Germany (8, 9, 10, 15);
- Our Lady of the Lake Eating Disorders Pro-
gram in Baton Rouge, USA (9, 10, 16, 17);
- Eating Disorder Program (EDP) in Hoffman
Estates, USA (10, 18);
- Cullen Centre (CC) in Edinburgh, United
Kingdom (19);
- Amarum in Zutphen, The Netherlands (10);
- Oxford Adul t Eating Disorders Service
(OAEDS) in Oxford, United Kingdom (10, 20);
- Day Clinic Programme (DCP) in Freiburg,
Germany (21);
- Day Treatment Programme (DTP) in Chonan
City, South Korea (22),
- Wesley Private Hospital (WPH) in Sydney,
Australia (10, 23, 24).
Three papers (25-27) about the Day Clinic
Programme in Freiburg and the Day Treat-
ment Programme i n Chonan Ci ty were
excluded because in German and Korean,
respectively.
THE DAY HOSPITAL
PROGRAMME OF THE EATING
DISORDERS CENTRE, TURIN
The DH of the EDs Centre of Turin University
opened in July 2006 and is part of a more thor-
ough treatment programme, including also
outpatient and inpatient care.
DH treatment has a bio-psycho-social frame-
work with psychodynamic orientation. Psycho-
dynamic group therapy, with an open structure
of groups, and Adlerian individual psychother-
apy (28-30) are the main treatment tools (Tables
1 and 2). The psychodynamic groups encour-
age patients to examine their interpersonal
functioning, inner problems and the psychody-
namic meaning of symptoms. Cognitive-behav-
ioural techniques are used in a group setting to
help patients in developing strategies to chal-
lenge their irrational cognitions and exploring
alternatives to their unhealthy behaviours (31).
The DH of the EDs Centre of Turin University
follows a single model (the psychodynamic
one) and combines different strategies and pro-
cedures. Being based on a psychodynamic
model, the specific therapeutic agents are not
the core symptoms of EDs, but instead relation-
ships, the individuals personality and the clas-
sic psychodynamic tools (clarification, con-
frontation, interpretation). The advantage of
adopting broad tecniques versus a more
focused treatment is the possibility to plan indi-
vidualised care, avoiding the well known risks
of clinical trial in EDs (32). Furthermore, in the
psychodynamic theory the therapeutic agent
depends on the conscious use of the relation-
ship and not simply on single techniques.
The disadvantage of using broad tecniques is
the likelihood of including elements which are
not so essential in the treatment plan. On the
other hand, currently it is not clear which are
the most effective treatments for AN (4).
Goals of treatment are both nutritional and
psychological. The first include nutritional
rehabilitation, weight gain, modification of dis-
turbed eating behaviours, and identification of
e32 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
TABLE 1
Brief Adlerian Psychodynamic Psychotherapy (B-APP).
Referencial paradigms Objects Elements of the therapeutic process
Individual = psychosomatic unity integrated in the society Resolution of the focus problem Establish encouraging relationship with the therapist
Individual = build and regulate selfs image Decrease/non-increase of symptoms Identify the focus; relate symptoms with current
life situation
Bond and symbolic patterns regulate human relationships Increase of subjects quality of life Detect, in the focus problem, the areas for possible
changes
TABLE 2
The weeks organization of the Turin treatment day hospital.
Day hospital for eating disorders: A review
perpetuating factors. The latter include an
increase of patients awareness of the disorder
and of motivation to treatment, a psychody-
namic understanding of symptoms, a deeper
awareness and understanding of emotions, an
improvement in relational skills and social
adjustment, self-esteem and mood regulation.
The treatment programme aims to enhance
the maturation of personality together with the
change of symptomatic behaviours. The core of
treatment is represented by the association of a
therapeutic work focused on personality and on
the eating disordered symptom together with a
treatment setting where patients live, work and
eat together. Another important element is the
work on family and with the family (counseling).
Individual psychotherapy (weekly sessions)
with a psychodynamic Adlerian orientation
offers patients an opportunity of reflection and
elaboration of their experiences.
Group psychotherapy sessions take place
every day and enhance the expression of emo-
tions. The group setting allows to work on the
relational dynamics which take place hic et
nunc. This is particularly relevant in patients
with EDs, who have difficulties in recognizing
and understanding their emotions and building
significant and intimate relationships. The elabo-
ration of patients experiences and the mirroring
and empathic identification mechanisms activat-
ed by group therapy increase patients coopera-
tion skills and reduce their competitiveness.
The psychodynamic approach could also be
useful to strengthen patients improvement
after discharge, as described for outpatients
with other psychiatric disorders (33, 34).
The Turin DH can treat about ten patients at
the same time. Patients are admitted after diag-
nostic sessions and after signing a behavioural
contract; they are usually referred from outpa-
tient units, previous failed treatments or from
inpatient care. Inclusion criteria are a Diagnos-
tic and Statistical Manual of Mental Disorders -
fourth edition (DSM-IV) diagnosis of ED, either
AN or BN, medical stability and a body mass
index (BMI) >13.5 kg/m
. Patients
with a BMI <13.5 kg/m
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Pharmacotherapy: missing datum for DCP;
most centres except for TCE use psychiatric
medication when indicated (9/11).
Physical issues: medical monitoring (7/11); not
mentioned in four articles.
Staff: all centres have a multidisciplinary team
(no data for EDP and OAEDS) with 7 to 15
members.
Treatment planning: community meeting for
treatment plans (5/11); weekly supervision
meeting (1/11); goal setting (4/11); multidisci-
plinary ward meeting (1/11).
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patient-staff meeting (4/11); Friday meeting to
fix weekend nutritional goals (1/11).
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DISCUSSION
The DH programmes of the eleven EDs spe-
cialised centres reviewed share some features
but also show many differences, suggesting
that DH programmes are still largely experi-
mental and that each centre plans its own pro-
ject on the basis of some core issues which are
integrated with clinicians experience and
knowledge. This approach to DH treatment
planning is not wrong tout court, but it limits
the comparison of the different centres and a
thorough understanding of what is really effec-
tive in the treatment of EDs.
Significant evidence about DH treatment effi-
cacy for EDs and a gold standard for inten-
sive DH treatment are still missing.
Recently Fairburn (35) proposed a DH pro-
gramme driven by a treatment very focused on
core symptoms, according to his transdiagnos-
tical approach (36). This seems an interesting
way to discriminate whether very focused
treatments are better than individualised ones
using several techniques. Unfortunately models
like the one suggested by Fairburn require a
careful selection of patients and share the same
limits as trials involving EDs patients (32, 37).
However, some shared elements can be iden-
tified in most DH treatment programmes,
which are likely to represent the main core of
their therapeutic effect.
Elements shared by DH programmes
From a clinical point of view, all centres
share an intensive work on eating symptoma-
tology, either within the context of a cognitive-
behavioural model or with cognitive-behav-
ioural techniques. Discussion groups, meal
plan and several types of meal monitoring are
e37 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
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the main treatment tools. The behavioural con-
tract (which can show different degrees of
strictness) (10) and motivation assessment are
considered necessary by all centres.
The importance of motivation is supported by
the growing number of studies in literature
about the prognostic importance of the assess-
ment of patients stage of change and motiva-
tion (38). Another shared issue is body image
therapy, since body image disturbances play a
relevant role in maintaining EDs. Body image is
almost always disturbed in ED patients (5, 39,
40) and dissatisfaction with body image is a
predictor of suicide attempts (41). The increase
in body weight during DH treatment can
increase patients difficulties with their body
image, if these are not properly addressed (42).
Another relevant issue for treatment is family
involvement, which can take place in different
ways. The onset of EDs often takes place dur-
ing adolescence and parents of ED patients
show some typical relational and personality
patterns at the questionnaires, which might
play a pathogenic role (43, 44). Outpatients tri-
als showed the efficacy of family therapy (45).
As regards DH treatment, the family needs help
to understand and support patients psycholog-
ical, physical and eating changes. On the other
hand, patients understanding of family dynam-
ics is part of the therapeutic process (46).
As regards group functioning, all the centres
except one (including 20 patients) work with
small groups (8-12 patients) and share the opin-
ion that this is the proper number of patients to
allow positive group interactions and to work
on individual problems (10).
Differences among DH treatments
Given the shared issues discussed above, one
would expect not to find relevant differences
among the centres. Nonetheless, differences
are several.
Only few centres fix a BMI. Overall, the
impression is that decisions about BMI are
made according to patients clinical assess-
ment. Since a low BMI predicts the failure of
DH treatment (47), it should be carefully
accounted for. Other inclusion criteria are con-
tradictory: for example, three centres require
stable clinical conditions, while another accepts
patients undergoing a fast weight loss.
Only four centres mention the assessment of
patients capacity to relate in a group setting
and this suggests that group relational dynam-
ics are not always properly accounted for.
Moreover, most centres work with patients
who have failed to respond to other treatments,
while other ones accept patients when a DH
treatment is recommended, also as first treat-
ment attempt. In some cases patients are
admitted in DH after discharge from inpatient
treatment, making DH a sort of prolongation
of care in the context of a wider stepped care
programme.
The most striking difference is the duration
of DH treatment, which ranges from a mini-
mum of 3 weeks to a maximum of 39. A critical
review of data identifies 7 centres treating
patients for 2-3 months and 4 centres treating
patients for 6-9 months. This suggests the
hypothesis that, despite the shared elements
described above, two different levels of treat-
ment intensity exist in DH care. A first model of
DH has a shorter duration and is mainly symp-
tom-focused while a second one has a longer
duration and is focused on patients relational
skills, psychodynamic symptom understanding
and more gradual changes in body weight. This
hypothesis is supported by the fact that the 4
centres with a longer treatment duration work
also with individual psychotherapy, while 6 out
of the other 7 centres work mostly/only with
group therapy. Moreover, it is likely that short-
er treatments address patients in less severe
conditions.
Differences in treatment intensity emerge
also in the number of days/week, ranging from
3 to 7 days/week of DH treatment.
The approach to eating disordered and com-
pensation behaviours is included in all DH
treatment programmes and though some basic
principles are shared, it is quite different from
one centre to another. Some adopt a more con-
trolling approach, while others promote auton-
omy; several self-monitoring techniques are
used and some centres include activities as
buying and cooking food. No univocal indica-
tions exist for the frequency of weight con-
trols/week.
Though the importance of dieticians work is
acknowledged and despite the American
Dietetic Association guidelines (48), it is not
clear which are the best techniques to use.
DH programmes use a variety of techniques
for social skills and creative activities, including
assertiveness training, mindfulness training,
dance therapy and different types of art thera-
py. Each centre makes its own choices accord-
ing to theory of reference and available
resources, but these activities do not seem to
play a specific therapeutic role. Their meaning
seems to be that of supporting and lightening
the symptom-focused interventions which oth-
erwise would be monothematic and oppressing.
A last consideration is that no centre per-
forms interventions addressing perfectionism,
and despite its widely acknowledged role in the
pathogenesis of EDs (35, 36, 49, 50) this psy-
e38 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
Day hospital for eating disorders: A review
chopathological core is often unchanged after
DH treatment (42).
Treatment goals
A particular attention must be paid to treat-
ment goals. Apart from the Edinburgh CC,
which lacks recent publications, almost all cen-
tres share the objective of weight normalisation
or weight gain and of modification/norma-
lisation of eating behaviour. Only 4 centres out
of 11 work specifically on ED perpetuating fac-
tors and relapses.
As regards psychological and behavioural
objectives, there are several differences. Some
centres (4/11) focus attention on the psychologi-
cal issues of self-esteem, control and autonomy,
according to the cognitive theory about EDs.
Other centres underscore the importance of the
psychodynamic or cognitive understanding of
the symptom itself (5/11), which is relevant for
their healing process (46). Last, other centres
underscore the need to improve social (3/11) and
family (2/11) functioning.
Differences in treatment goals seem to reflect
the different emphasis the centres pose on
intrapsychic dynamics, relational dynamics and
social issues.
In conclusion, the work on symptoms is con-
sidered an essential and primary objective, but
all centres share the opinion that the intensive
treatment of patients is not complete if other
issues than symptoms are not addressed.
Conclusions
The DH therapeutic programmes reviewed do
not allow to identify univocal guidelines for type
of intervention, treatment intensity and dura-
tion. A consensus conference of experts is
required to define some shared concepts in
order to make DH treatment programmes more
homogenous, measurable and comparable.
Overall, two types of DH treatment can be
identified: a shorter, more symptom-focused
one, and a longer, more person-focused one.
In both cases, attention needs to be paid to
patients selection, motivation to change and
identification of treatment goals. Coherence
among treatment model, treatment tools, sever-
ity of clinical status and treatment goals needs
to be carefully checked.
Moreover, attention to patients group
dynamics, equipe group dynamics and
patients/staff dynamics needs to be under-
scored and emphasised.
A focus on psychodynamic formulation and
resistance to treatment is needed in those cen-
tres with a psychodynamic approach and a
specific attention on group dynamics (51). Per-
sonalisation of treatment programmes should
consider the study and assessment of personal-
ity (52), which is a specific treatment tool of the
Turin Centre.
In a multi-disciplinary quipe only some
members have a psychological training, and
the supervision on group dynamics is neces-
sary to increase the relational awareness of
equipe members. How one talks to patients can
be therapeutic or iatrogenic but the importance
of this fact is often underestimated by modern
psychiatry. Indeed, it is necessary for each staff
member to share and discuss his/her impres-
sions, emotions and behaviours with the other
ones in order to modulate his/her treatment
approach.
Last, further studies about outcome and fol-
low-up of DH treatment are required.
e39 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
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e41 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
Vol. 14: e42-e49, June-September 2009
e42
ORIGINAL
RESEARCH
PAPER
Key words:
Eating disorders, anorexia
nervosa, bulimia nervosa,
Mexican students.
Correspondence to:
Maria E. Jimnez-Capdeville,
Faculdad de Medicina,
Universidad Autnoma
de San Luis Potos,
Av. V. Carranza 2405,
Col. Los Filtros,
78210 San Luis Potos, SLP,
Mexico.
E-mail: mejimenez@uaslp.mx
Received: January 10, 2008
Accepted: October 13, 2008
Abnormal eating attitudes in
Mexican female students: A study
of prevalence and sociodemographic-
clinical associated factors
INTRODUCTION
Epidemiological studies on eating disor-
ders (ED) in Mexican population appeared
published first in 1993 (1, 2), and this report
has been followed by works performed
mostly in urban population by means of dif-
ferent assessment instruments (3-8).
Although ED have abruptl y increased
across very different world regions and cul-
tures, reaching epidemic proportions in
industrialized countries (9), current aware-
ness among Mexican society is still poor,
and these disorders are socially perceived
as diseases that strike only women from the
high-income stratus of the society. In fact,
the information about prevalence, clinical
profile and possible preventive interven-
tions available for health professionals such
as general physicians, nurses, psychiatrists
and psychologists is based on research con-
ducted in industrialized countries (10-17).
Early studies focused on the detection of
anorexia nervosa and bulimia nervosa
according to the diagnostic criteria for these
illnesses. Now we know that ED follow a
natural course that may start as body dissat-
isfaction accompanied by an intense desire
of losing weight that last during several
years, but their sporadic restrictive and
purgative behaviors do not satisfy all diag-
nostic criteria for a defined ED (20).These
cases remain as subthreshold or atypical
ED, until they progress to an ED (21) that is
usually classified under the concept of ED
not otherwise specified, which is assigned
when the symptoms of a subject do not ful-
fill the Diagnostic and Statistical Manual of
Mental Disorders - fourth edition (DMS-IV)
criteria for any ED. The main shortcoming
of this term, is that it determines a categori-
cal classification for statistical purposes, and
as recently reported in a study performed in
the United Kingdom, the categorical nature
of the diagnostic criteria leads to difficulties
in its application, resulting in up to 90.2% of
the population diagnosed with ED not oth-
erwise specified (22).Therefore, the term
abnormal eating attitudes (AEA) is a wider
concept that includes a continuous severity
range of inappropriate eating, which
encompasses abnormal eating behaviors
and psychological patterns together with
inadequate practices of weight control.
These characteristics are present along the
natural course of ED, from the initial light
J.R. Arellano
1
, M. Torres
2
, C. Rivera
3
, L. Moncada
4
, and M.E. Jimnez-Capdeville
1
1
Departamento de Bioqumica, Facultad de Medicina,
2
Departamento de Salud Pblica, Faculdad de Medicina,
Universidad Autnoma de San Luis Potos,
3
Instituto Mexicano del Seguro Social, Hospital General de Zona
No. 1,
4
Secretaria de Salud, Hospital Central Dr. Ignacio Morones Prieto, San Luis Potos, Mexico
ABSTRACT. The objective of the study was to determine the prevalence of abnormal eating
attitudes (AEA) in Mexican high school and university students in the city of San Luis Potos,
Mexico. By means of a transversal study with a weighted, random and multistage sampling
process, we analyzed a representative sample of female students (N= 2006). The instrument
was the Eating Disorder Inventory-2 (EDI-2), validated in Mexican population and a ques-
tionnaire of sociodemographic data. The prevalence of AEA was 12.6% and its frequency
was significantly higher in high school than in university students. AEA cases were uniform-
ly distributed among public and private institutions and a highly significant relationship
between substances consumption and AEA was observed. A logistic regression model for
AEA was obtained. Therefore, a profile of highly AEA was built based on sociodemographic
data and a solid instrument validated in Mexican population, which can be employed as a
screening and secondary prevention tool to design public health programs.
(Eating Weight Disord. 14: e42-e49, 2009).
2009, Editrice Kurtis
Abnormal eating attitudes in Mexican women
e43 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
symptoms through the subclinical and clinical
stages, allowing even the inclusion of subjects
in recovery or relapse phases (21). Under this
broader classification, the wide spectrum of
partial ED can be identified earlier, which is of
foremost importance for preventive programs,
treatment and follow-up procedures.
Three previous studies in students from Mex-
ico City, report prevalence data of risk symp-
toms related to eating disorders (RiSED) of
0.5% (2), 1.25% (23) and 15% (24). This great
variability could be the result of the different
instruments and criteria used to define abnor-
mal eating behaviors. When considering the
wide spectrum of RiSED, the prevalence
reported for female students is between 3 and
26% in industrialized countries (9), between 3.4
and 15.3% in 3 different cities from Spain (25-
27) and 12.2% in Chilean students (28).
In this context, we undertook an epidemio-
logical study of AEA in Mexican women. The
purpose of this work was to determine the
prevalence of AEA in Mexican high school and
university students in the city of San Luis Poto-
s, which is a medium-sized provincial city. The
instrument chosen for this transversal study
was the Eating Disorder Inventory-2 (EDI-2),
previously validated in Mexican population by
Garca et al. (29). The reliability and validity of
this instrument both as a screening and as a
diagnostic self-reporting instrument is widely
documented (27, 30-33). In addition, using five
questions of clinical interest plus a record of
sociodemographic variables, the different fac-
tors of the ED multidimensional profile were
analyzed and a logistic regression model was
built, which allowed the identification of those
factors that are highly associated with ED in
Mexican women.
MATERIALS AND METHODS
Participants
This was a cross-sectional study, where the
sampling scheme employed to select a repre-
sentative sample of female high school and uni-
versity students was a weighted, random and
multistage process. The city of San Luis Potos
was divided in 6 zones and the educative insti-
tutions (high schools and universities) were
identified. According to the rate of institutions
per zone, a sample was randomly chosen and,
within the selected establishments, a random
sample of students was invited to participate in
the study. The calculated sample size was 2000
participants, which represents 7 to 10% of the
feminine population aged between 15 and 25
years, who live in the city of San Luis Potos,
according to the census of the Instituto
Nacional de Estadstica, Geografa e Informti-
ca (INEGI, Mexico, 2000).
Instrument
The questionnaire applied to the participants
had two sections. The first part was designed
to assess the sociodemographic status of the
subjects by means of questions about age,
height, weight (34), occupation, religion, civil
status, economical dependency, cohabitants,
menstrual irregularities (35), presence of senti-
mental partner, children, availability of medical
services, practicing physical activities, main
transportation mean employed, study level of
the head of the family, consumption of sub-
stances (alcohol, tobacco, illegal drugs, medical
drugs without prescription), preference for a
given communication mean (TV, radio, inter-
net, magazines, etc.) and personal opinion
about the influence of communication means
towards a thin body image. The second section
was the EDI-2 (36), which consists of 91 ques-
tions with a Likert response scale (always, usu-
ally, often, sometimes, rarely and never). It is
composed by 11 subscales, and 3 of them char-
acterize abnormal eating behavior: drive for
thinness, bulimia and body dissatisfaction.
Eight subscales address the multidimensional
profile of characteristics often related to ED
(ineffectiveness, perfectionism, interpersonal
distrust, interoceptive awareness, maturity
fears, ascetic behavior, impulse regulation and
social insecurity). The internal validity of this
EDI version in Mexican population was tested
in 22 women diagnosed with ED and 25 age-
matched healthy women. Cronbachs alfa coef-
ficients were 0.85 for all subscales. For the
whole punctuation, sensitivity is 90%, specifici-
ty 84%, positive predictive value 83% and neg-
ative predictive value 88% (29).
We defined as AEA a determinant (sensitive
or specific) score in the whole EDI-2 test, plus a
determinant (sensitive or specific) score in at
least two subscales indicating risk symptoms
for abnormal eating behavior (drive for thin-
ness, bulimia and body dissatisfaction). Addi-
tionally, five questions were selected from the
whole questionnaire on the basis of their rele-
vance as clinical markers: I think about diet-
ing, I am terrified of gaining weight, I have
gone on eating binges where I felt that I could
not stop, I have the thought of trying to vomit
in order to lose weight and I do not feel satis-
fied with the shape of my body.
The proposal was submitted for evaluation
and approved by the Ethical Committee of the
Faculty of Medicine of the University of San
Luis Potos. After having obtained consent
J.R. Arellano, M. Torres, C. Rivera, et al.
e44 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
TABLE 1
Description of the studied population.
from the institutional authorities, the question-
naire was applied to groups of 20 to 50 stu-
dents who accepted to participate in the study
and to answer the questionnaire in an anony-
mous format in a maximum of 45 minutes.
Statistics
Two types of variables were analyzed, cate-
gorical and continuous. Mean and standard
deviation (SD) were reported for the continu-
ous variables, while frequency and percent dis-
tribution were used to describe the categorical
variables. Bivariate analysis was performed by
means of
2
test, considering a value of p lower
than 0.05 as a significant difference.
In the multivariate analysis, a logistic regres-
sion was performed according to Hossmer and
Lemeshow (37). Categorical and continuous
variables that displayed a value of p<0.25 after
the raw analysis were incorporated in an addi-
tive model, considering the presence of AEA as
the dependent variable. Categorical parameters
were transformed in dummy variables. The
quality of the final model was evaluated by
means of the
2
test by Hossmer and
Lemeshow. The values of sensitivity, specificity,
positive predictive value and negative predic-
tive value were obtained and confirmed graphi-
cally by means of the receiver operating curve
(ROC) plot. The statistical analysis was per-
formed employing the software Stata 8.0
RESULTS
The sample of participants in this study con-
sisted of 2006 women from 37 educative institu-
tions, 8 public and 13 private high schools, 4
faculties of a public university and 12 private
universities. One private high school, one pri-
vate university and 2 students from 2 different
participant institutions refused to participate in
the study. The population description is pre-
sented in Table 1. The average age was 17.5
years (SD 2.35) with ages ranging between 14
and 28, and body mass index (BMI) ranging
between 16 and 42.7 kg/m
2
, with a mean value
of 21.83.4 kg/m
2
. This variable was catego-
rized according to criteria established for Mex-
ican teenagers (38) as follows: low weight (<19),
normal weight (19.1-22.9), overweight (23-27)
and obesity (>27.1). From the total population
52.4% had normal weight. Concerning other
explored characteristics of the population,
close to 90% were single, catholic, living with
their parents, they referred studying as main
occupation, they did not have children and they
did not experience menstrual irregularities in
the last 3 months.
In our study, the prevalence of AEA was
12.6% (12.55-12.64, 95% confidence interval).
Table 2 contains the overall percentages of pos-
itive answers (which included: always, usually
and often) to the questions of clinical interest
and to the three EDI-2 subscales that charac-
terize abnormal eating attitudes, as well as the
same scores separated by type of institution
that the participant attended. We found a sig-
nificantly higher frequency of AEA in high
school than in university students (14.6 vs 9.7%,
p<0.001). The frequency of positive answers to
the clinical interest questions I think about
dieting, I am terrified of gaining weight and
I have the thought of trying to vomit in order
to lose weight was also significantly higher in
high school students, and they reported signifi-
cantly higher rates of body dissatisfaction
through the corresponding EDI-2 subscale
Anthropometric and Frequency Percentage
sociodemographic variables
Age
Less than 18 years old 1429 71.2
More than 18 years old 577 28.7
BMI
Low weight 382 19.0
Normal weight 1053 52.4
Overweight 432 21.5
Obesity 139 6.9
With whom the student lives
Both parents 1369 68.2
One parent 347 17.3
Others 290 14.4
Studying
High school 1171 58.3
University 835 41.6
Public institution 679 33.8
Private institution 1327 66.1
Medical service available 1574 78.4
Type of medical service
Private 510 32.4
Public (Institutional) 1064 67.5
Practicing a physical activity 1366 68.0
High influency mass media
TV 1613 80.4
Others 391 19.5
Education level of the head of the family
Illiterate/Elementary 312 15.6
Secondary/High school 685 34.3
Bachelors degree/Posgraduate studies 997 50.0
Consumption of substances
Tobacco 406 20.2
Alcohol 509 25.3
Illegal drugs 84 4.1
Medical drugs without prescription 122 6.0
Abnormal eating attitudes in Mexican women
e45 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
FIGURE 1
Relationship between abnormal eating attitudes (AEA) and body
mass index (BMI); numbers above columns indicate BMI population
percentage with AEA (AEA+) and without AEA (AEA-).
TABLE 2
Prevalence of abnormal eating attitudes (AEA). Population percentage with positive responses to the Eating Disorder Inventory-2 (EDI-
2) items of clinical interest, and population with determinant scores to the EDI-2 subscales that characterize abnormal eating behavior.
Numbers in parentheses are the number of individuals.
(Table 2). No significant differences were found
between public and private institutions in any
of the variables explored.
The relationship between AEA and other
variables of interest demonstrates that a signif-
icantly higher frequency of AEA was found
among students younger than 18 years old
(77.9% of all participants that presented AEA,
namely 196 out of 252 cases,
2
6.01, p=0.014)
and the prevalence of AEA was higher in over-
weight and obese students than in their lower
weight counterparts (
2
32.73, p<0.001) (Fig. 1).
Although only 3.1% of the total population
reported a menstrual delay of more than 8
weeks, we observed a significantly higher fre-
quency of this event among students with AEA,
since 5.8% of the participants from the AEA
group reported menstrual irregularities,
against only 2.7% from the non-AEA popula-
tion (
2
7.7, p=0.02) (39).
A highly significant relationship was found
between substances consumption (tobacco,
p=0.003, alcohol, illegal and medical drugs
without prescription p<0.001) and AEA, as
shown in Figure 2.
Finally, the positive answers to the five
selected questions of clinical interest showed a
highly significant correlation with the presence
of AEA (p<0.001) (Fig. 3). The highest score
was observed in the variable of body dissatis-
faction, since 92.4% of the participants diag-
nosed with AEA were unsatisfied with their
body shape, foll owed by the fear to gain
weight, presented by 91.2% of the AEA partici-
pants. Also, the number of participants that
reported vomit was 13 times higher in the AEA
group than in the students without AEA.
Regression
After the raw analysis, the variables that dis-
played a value of p<0.25 were considered sig-
nificant and sequentially added to build the
final model. The procedure had a sufficient
number of events per variable, and the select-
ed variables showed neither collinearity nor
interactions. The continuous variables present-
Total High schools Universities p Public Private p
institutions institutions
Prevalence of abnormal
eating attitudes
Women with AEA 12.6 (252) 14.6 (171) 9.7 (81) 0.001 14.2 (97) 11.6 (155) 0.096
EDI-2 items of clinical interest
I think about dieting 36.4 (731) 35.6 (418) 37.4 (313) 0.443 34.4 (234) 37.4 (497) 0.146
I am terrified of gaining weight 48.5 (973) 50.2 (589) 45.9 (384) 0.052 47.1 (320) 49.2 (653) 0.321
I have gone on eating binges 8.5 (172) 8.2 (97) 8.9 (75) 0.701 8.2 (56) 8.7 (116) 0.736
where I felt that I could not stop
I have the thought of trying to 10.6 (213) 12.0 (139) 8.8 (74) 0.023 11.1 (76) 10.3 (137) 0.575
vomit in order to lose weight
I do not feel satisfied with the 43.7 (878) 41.5 (486) 46.9 (392) 0.023 44.9 (305) 56.8 (573) 0.511
shape of my body
EDI-2 subscales
Drive for thinness 17.3 (344) 18.4 (213) 15.8 (131) 0.140 17.9 (120) 17.0 (224) 0.600
Bulimia 23.0 (463) 23.4 (274) 22.6 (189) 0.681 22.8 (155) 23.2 (308) 0.861
Body dissatisfaction 31.3 (630) 34.1 (399) 27.5 (230) 0.002 30.3 (206) 31.9 (423) 0.489
100
80
60
40
20
0
%
Low Normal Overweight Obesity
weight weight
93.4
6.5
11.6
16.9
22.3
88.3
83.1
77.7
AEA- AEA+
J.R. Arellano, M. Torres, C. Rivera, et al.
e46 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
TABLE 3
Final logistic regression model for the presence of abnormal eating
attitudes. The dependent variable is the presence of abnormal eating
attitudes (AEA). The model includes sociodemographic variables and
Eating Disorder Inventory-2 (EDI-2) items of clinical interest.
FIGURE 3
Group distribution of participants with a positive answer to the five
selected questions of clinical interest. Numbers above columns indicate
population percentage with abnormal eating attitudes (AEA+) and
without AEA (AEA-). See the text and Table 2 for the complete text of
each question.
FIGURE 2
Percentages of students who report use of alcohol, tobacco, med-
ical and illegal drugs. Numbers above columns indicate population
percentage with abnormal eating attitudes (AEA+) and without
AEA (AEA-).
ed a l i near gradi ent equi val ent to their
dichotomous outcome. The final model indi-
cates that the factors highly associated with
ED were BMI, influence of TV to keep a thin
body shape, and an affirmative answer to the 5
questions of clinical interest (Table 3). A posi-
tive answer to the questions I am terrified of
gaining weight, I have the thought of trying
to vomit in order to lose weight and I do not
feel satisfied with the shape of my body deter-
mines 1.5 to 4 times more probability for the
presence of AEA. The variables whose confi-
dence intervals included the zero value in the
coefficient and a value of one in the odds ratio
were maintained in the model due to their con-
ceptual value and its contribution to the fitness
of the model. The model showed a final sensi-
tivity of 55%, specificity of 95%, positive pre-
dictive value 73% and negative predictive
value 90%.
DISCUSSION
The prevalence of AEA among high school
and university female students found through
this study in a middle-size city from Mexico is
12.6%. In this city, considered as a traditional
province of the country, where most of the stu-
dents still live with their parents and refer to be
catholic, the cases of AEA were uniformly dis-
tributed among public and private institutions
and in all ranges of body weight. Importantly,
these disorders were significantly more frequent
in younger, high school students than in univer-
sity students, and significantly associated with
alcohol, tobacco and drugs consumption, as it
has been reported for other populations (30, 40-
45). In this context, our findings are similar to
the 16.1% prevalence of risky eating behaviors
in adolescents aged between 16 and 18 years
from Mexico City, the largest city of the country
with a population of more than 20 million people
(24), and it is also comparable to that reported in
industrialized countries. The employment of the
40
20
0
%
Tobacco Alcohol Illegal Medical
drugs drugs
19.2
27.3
35.3
9.1
17
23.9
3.4
4.5
AEA- AEA+
100
80
60
40
20
0
%
Dieting Terrified Binges Vomit Unsatisfied
29.8
AEA- AEA+
82.3
42
91.2
5.1
32.6
4.3
54.7
51.1
92.4
Variable OR (95% CI) COEF (95% CI)
Sociodemographic description
Age 0.86 (0.79-0.92) -0.15 (-0.22-0.07)
Body mass index 1.28 (1.11-1.46) 0.29 ( 0.15-0.43)
Practicing a physical activity 0.65 (0.47-0.90) -0.42 (-0.74-0.09)
TV influency 1.19 (0.82-1.71) 0.17 (-0.18-0.53)
Education level of the head 0.53 (0.39-0.73) -0.61 (-0.92-0.30)
of the family (Bachelors
degree/Posgraduate studies)
EDI-2 items of clinical interest
I think about dieting 1.04 (0.72-1.51) 0.04 (-0.32-0.41)
I am terrified of gaining weight 2.35 (1.61-3.42) 0.85 (0.47-1.23)
I have gone on eating binges 1.39 (0.85-2.25) 0.33 (-0.15-0.81)
where I felt that I could not stop
I have the thought of trying to 2.47 (1.60-3.80) 0.9 ( 0.77-1.33)
vomit in order to lose weight
I do not feel satisfied with 2.21 (1.45-3.38) 0.79 (0.37-1.21)
the shape of my body
OR: odds ratio; CI: confidence interval; COEF: coefficient.
Abnormal eating attitudes in Mexican women
e47 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
EDI-2 questionnaire validated in Mexican popu-
lation in this work gives a strong support to
these results, which offer a useful sociodemo-
graphic description of the female student popu-
lation for the design of prevention programs for
public health institutions. Also, the data present-
ed here rise concern about AEA as an increas-
ing public health problem in Mexico.
We consider important to underline that the
highest presence of AEA was found among
overweight and obese participants, which lead
us to confirm that these patterns of abnormal
eating include all BMI categories, as reported
elsewhere (46, 47). In a sample of more than
7000 adolescents studied by Unikel et al. in
Mexico City, they also found higher percent-
ages of AEA as BMI increased (7). In a clinic
specialized in obesity, Villagmez et al. found
that 86.7% of the patients presented comorbid-
ity with either bulimia, binge eating, obsessive-
compulsive disorder or ED not otherwise spec-
ified (8).Together with our results, this infor-
mation should be disclosed to parents, educa-
tors and practitioners of disciplines related to
adolescent health, who still have the tendency
to associate ED with low weight. Also, the lack
of a significant difference between private and
public schools confirms that AEA are neither
exclusive nor even more frequent among ado-
lescents and young women who grew up in
high-income families.
The striking significant relationship between
AEA and illegal/medical drugs and alcohol
consumption as well as smoking, indicates an
important comorbidity of ED and substance
abuse in this population. Therefore, when a
case of AEA is detected it would be worthwhile
to look for substance abuse markers and vice
versa, in order to have a better approach to the
case and, consequently, to provide an integral
treatment for the patient.
Concerning the pressure for thinness as a
factor related to ED, our results are in agree-
ment with those obtained by Bojorquez et al.,
who found a strong cultural influence to devel-
op AEA even in a semi-urban Mexican region
(5). Also, among Mexican ballet students Unikel
et al. found a significant relationship between
AEA and the pressure for thinness inherent to
their artistic activities (7).
The clinical relevance of this investigation is
that a profile to detect abnormal eating atti-
tudes was obtained based on sociodemograph-
ic data and a solid instrument validated in Mex-
ican population. Therefore, for a scholar assis-
tant, health assessor or general practitioner it
is possible to detect that a student younger
than 18 years old, with overweight or obesity,
who does not practice physical activity, who
considers TV an important influence towards a
thin body-shape, whose parents have a low
education level, and who provides an affirma-
tive answer to the five proposed questions of
clinical interest may develop an ED. In conse-
quence, an interview with qualified profession-
als will allow the early diagnosis. The preven-
tion strategies for ED are directed both to the
etiology of the disorder and to the support and
treatment for the patient. Nevertheless, given
the great difficulties to deal with the etiology of
these disorders, namely family dysfunction,
influence of the massive communication media
and gender inequity among others, the early
detection of AEA will allow a more effective
support and treatment of the patient.
The main shortcoming of this study was the
lack of interviews as gold standard for the
diagnosis of ED according to DSM-IV criteria.
Nevertheless, we are proposing this question-
naire as a screening and secondary prevention
tool that can be employed for large groups of
students. Other potential limitation is the
employment of auto-reported data of height
and weight, but based on a previous study by
Saucedo-Molina et al. (34), this information is
trustable and not significantly different from
the real value of these variables.
In conclusion, since one of the objectives of
this work was to build a solid screening instru-
ment to detect AEA among Mexican young
women, we provide through this study an
accessible instrument with a high specificity
and negative predictive value. The application
of this tool represents a short inversion of time
and the identification of AEA should motivate
an interview with the student for follow up of
her case by health specialists.
ACKNOWLEDGEMENTS
The authors greatly acknowledge E. Garca and V.
Vzquez from the Instituto Nacional de Ciencias
Mdicas y Nutricin Salvador Zubirn for providing
the validated version of EDI-2 for Mexican popula-
tion, and V. Olvera and L. Cisneros for technical
assistance. This research was partially supported by
the grant C-06-FAI-11-10.47 from the Universidad
Autnoma de San Luis Potos, Mexico.
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Vol. 14: e50-e55, June-September 2009
e50
ORIGINAL
RESEARCH
PAPER
Key words:
Parity, anthropometry, waist
circumference, Iraq.
Correspondence to:
Abbas Ali Mansour, MD,
FRCP (Edin),
Department of Medicine,
Basrah College of Medicine,
Consultant Physician,
Al-Faiha Hospital,
Hattin post office P.O. Box
142, 42002 Basrah, Iraq.
E-mail:
aambaam@yahoo.com
aambaam@gmail.com
Received: August 6, 2008
Accepted: October 17, 2008
Parity is associated with increased
waist circumference and other
anthropometric indices of obesity
The intra-abdominal (visceral) deposition
of adipose tissue, which characterizes
upper body obesity, is a major contributor
to the development of hypertension, insulin
resistance, diabetes mellitus and dyslipi-
daemia (1).
Waist circumference (WC) is a simple
anthropometric parameter that best corre-
lates with visceral fat (2).
There is growing interest in the effect of
childbearing on the development of chronic
medical conditions, including cardiovascu-
lar disease and diabetes (3-5). Potential
mechanisms include the influence of multi-
ple pregnancies on postpartum weight
retention (6, 7) and development of obesity
(8-10) or the influence of multiple exposures
to the metabolic changes of pregnancy,
including impaired insulin sensitivity and
central obesity (11), both of which parallel
the mechanisms underlying the develop-
ment of diabetes mellitus.
The association between parity and coro-
nary heart disease (CHD) risk in women has
been assessed in a number of prospective
studies (12-16). The majority found a posi-
tive association. Because pregnancy is a
state of relative insulin resistance, most
investigators have stressed biological path-
ways for this association. Previous studies
have emphasized two possible biological
mechanisms for the association between
parity and CHD in women. In the first, it is
proposed that each pregnancy permanently
resets ovarian function, leading to a
reduced lifetime exposure to estrogen (17).
A.A. Mansour
1
, and N.A.H. Ajeel
2
1
Department of Medicine, and
2
Head of Department of Community Medicine, Basrah College of Medicine,
Basrah, Iraq
ABSTRACT. BACKGROUND: There is growing interest in the effect of childbearing on the
development of chronic medical conditions. In the present study we aim at seeing whether
parity is associated with increased waist circumference (WC) and other anthropometric
indices of obesity, or not, in a sample of Iraqi women. METHODS: This was a cross section-
al study conducted during the period from January 2006 to the end of December 2007. Sub-
jects were women attending two primary health care centers in a rural district population in
Basrah (Abu-Al-khasib district), Iraq. RESULTS: A total of 9135 women with a mean age of
46.415.5 years were included in the study. The mean weight was 69.916.9 kg and the mean
WC was 92.715.0 cm with 78.9% of women having WC 80 cm. The mean and the standard
deviation of other anthropometric variables were 27.06.25 for body mass index (BMI),
0.570.09 for waist-to-height ratio (WHtR) and 0.890.08 for waist-to-hip ratio (WHpR). Body
weight, WC, BMI, WHpR, and WHtR progressively and significantly increased with increas-
ing parity (p<0.001). Increasing age and higher number of births were associated with a con-
sistent significant increase in the risk of increasing WC. While the reverse was true with
respect to education, the risk of increased WC significantly decreased with the increase in
education. The risk of increased WC was higher among housewives compared to employed
women. On multiple logistic regression analyses of parity and risk of increasing WC, the
number of births remained significantly and independently associated with increased WC
after adjustment for a range of potential confounders (age, BMI, employment, education, and
marital status). However, when parity was analyzed as a dichotomous variable (parous ver-
sus nulliparous), no significant association was found (p>0.05). CONCLUSION: Parity was
associated with increased WC and other anthropometric indices of obesity in a sample of
rural Iraqi women attending two primary health care centers.
(Eating Weight Disord. 14: e50-e55, 2009).
2009, Editrice Kurtis
Parity and obesity
e51 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
The established inverse association between
parity and breast cancer, a known estrogen-
dependent disease, provides support for this
hypothesis (18). Increasing number of children
was associated with increasing obesity in both
sexes and, in women, was also associated with
adverse lipid profiles and diabetes (3).
In the Rotterdam study they found that parity
was associated with obesity, low high density
lipoprotein cholesterol, and insulin resistance
in women aged 55 years (19). Higher number
of pregnancies or births was associated with a
consistent increase in the risk of metabolic syn-
drome in Chinese women even after adjust-
ment for a range of potential confounders (20).
On the contrary, parity is not associated with
increase in breast size in women after
menopause (21).
In the present study we aim at seeing
whether parity is associated with increased
WC and other anthropometric indices of obesi-
ty or not, in a sample of Iraqi women attending
two primary health care centers in Basrah
(Abu-Al-khasib district), Iraq.
METHODS
This was a cross sectional study involving
9135 women attending two primary health
care centers in a rural district population in
Basrah (Abu-Al-khasib district), Iraq. All non-
pregnant women attending for vaccination of
their children or for seeking medical care over
the study period were incl uded. Verbal
informed consent was obtained from al l
women included in the study. Data was collect-
ed by face-to-face interviews based on a ques-
tionnaire that included the following informa-
tion: womans age, marital status, number of
live births, education (years of school achieve-
ment), empl oyment, and smoking status
(women who smoked at least 1 cigarette per
day over the last year were considered as a
current smokers). For simplicity throughout
the study, the number of live births to women
was used to describe parity. All anthropomet-
ric measurements were performed by trained
research assistants, and measurements were
taken once. Standing height and weight mea-
surements were completed with subjects wear-
ing light-weight clothing and no shoes. Height
was measured to the nearest centimeter (cm)
and weight was measured to the nearest half
kilogram (kg). Hip circumference (the maxi-
mum circumference around the buttocks and
symphysis pubis) and WC (midway between
the lowest rib and the iliac crest) were mea-
sured in the standing position (22).
Body mass index (BMI) was calculated as
weight (kg) divided by height (meter squared)
and waist-to-height ratio (WHtR) by dividing
WC (cm) by height (cm). Waist-to-hip ratio
(WHpR) was calculated by dividing WC by hip
circumference for each subject. The respondent
was considered as diabetic if she was a known
case of diabetes (diagnosed by a physician
regardless of line of therapy or duration).
Hypertension was diagnosed if systolic blood
pressure was 140 mmHg, and/or diastolic
blood pressure 90 mmHg, or if the study
patient was currently being treated for hyper-
tension with medication. The study was con-
ducted during the period from January 2006 to
the end of December 2007.
Statistical analysis
Characteristics of the study population were
described by percentages, means, and standard
deviations (SD). In the comparisons for categor-
ical variables,
2
test was used. One way analy-
sis of variance (ANOVA) was used to compare
parity-adjusted means of continuous variables.
Odds ratios and 95% confidence intervals (95%
CI) were calculated and the significance was
defined as p<0.05. The association between par-
ity and WC was assessed using multiple logistic
regressions. The risk associated with parity was
evaluated using two different approaches: pari-
ty modeled 1) as a continuous variable (risk per
one additional live birth), and 2) as a dichoto-
mous variable (nulliparous versus parous). In
the multivariate model, adjustments were made
for the following variables: age, BMI, socioeco-
nomic factors including education and employ-
ment, and marital status. Age and BMI were
entered as continuous variables and other vari-
ables were categorials.
The Statistical Package for the Social Science
program (SPSS, Chicago, IL, USA, version
15.0) was used for statistical analysis.
RESULTS
Table 1 shows the descriptive characteristics
of the study sample according to parity. The
mean age of the studied women was 46.415.5
years (range 18 to 95 years). Most of the stud-
ied women were parous and women who had
had four or more live births represented 59.4%.
More than half (55.2%) were illiterate; only
12.3% were employed, and a minority (5.8%)
were smokers. Illiteracy rate was significantly
higher among women with 4 or more children,
while the reverse was true for employment.
Overall 17.7% of the studied women were
hypertensive and 18.1% were diabetic with no
A.A. Mansour, and N.A.H. Ajeel
e52 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
TABLE 2
Odds ratios (OR) and 95% confidence intervals (CI) for having increased waist circumference in relation to selected demographic
variables in Iraqi women; univariate analyses.
TABLE 1
Demographic and anthropometric characteristics of the study population according to parity in Iraqi women
(N=9135 women, aged 18-95 years).
significant increase in prevalence with the
increase in parity. The mean weight was 69.9
16.9 kg and the mean WC was 92.715.0 cm
with 78.9% of women having WC 80 cm. The
mean and the SD of other anthropometric vari-
ables were 27.06.25 for BMI, 0.570.09 for
WHtR and 0.890.08 for WHpR. Body weight,
WC, BMI, WHpR, and WHtR progressively and
significantly increased with increasing parity
(p<0.001).
Variables Nulliparous* 1=454 2=556 3=663 4+=5428 Total p
(N=2034)
Age (yr) 36.48-16.20 33.24-11.26 37.12-12.51 40.73-12.90 52.98-12.44 46.415.5 <0.001
Weight (kg) 64.11-15.87 66.72-16.25 69.67-16.46 72.3-17.05 72.23-16.93 69.916.9 <0.001
Body mass index (kg/m
2
) 24.73-5.85 25.52-5.85 26.65-5.83 27.63-6.26 28.09-6.22 27.06.25 <0.001
Waist circumference (cm) 84.69-14.91 86.56-13.87 89.33-13.70 91.34-14.33 96.83-13.83 92.715.0 <0.001
Waist-to-hip ratio 0.850.09 0.850.07 0.860.07 0.860.07 0.910.07 0.890.08 <0.001
Waist-to-height ratio 0.520.09 0.530.08 0.550.08 0.560.08 0.600.09 0.570.09 <0.001
Illiterate (%) 38.5 30.6 28.6 29.6 69.4 55.2 <0.000
Employed (%)** 27.2 18.5 19.6 15.5 5.1 12.3 <0.000
Hypertension (%) 17.5 19.2 18.0 19.2 17.5 17.7 >0.05
Diabetes (%) 17.9 20.9 18.9 17.9 17.9 18.1 >0.05
*Includes single women; **includes retired and students.
Data are meansSD unless otherwise indicated. For continuous variables, the p value is from analysis of variance; for categorical variables, the p value is from
the
2
test.
Age 80 <80 OR 95% CI p
<20 yr* 48 (31.2%) 106 (68.8%) 1
20-29 yr 701 (49.2%) 724 (50.8%) 2.138 1.497-3.054 0.0001
30-39 yr 1183 (71.8%) 465 (28.2%) 5.618 3.930-8.032 0.0001
40-49 yr 1609 (88.5%) 209 (11.5%) 17.00 11.741-24.618 0.0001
50 yr 3664 (89.6%) 426 (10.4%) 18.994 13.312-27.1 0.0001
Parity
0* 1176 (57.8%) 858 (42.2%) 1
1 300 (66.1%) 154 (33.9%) 1.421 1.148-1.759 0.001
2 406 (73.0%) 150 (27.0%) 1.975 1.606-2.429 0.0001
3 511 (77.1%) 152 (22.9%) 2.453 2.005-3.000 0.0001
+4 4812 (88.7%) 616 (11.3%) 5.699 5.047-6.436 0.0001
Education
Illiterate* 4177 (58.0%) 867 (44.9%) 1
6 yr 952 (13.2%) 240 (12.4%) 0.823 0.702-0.966 0.017
7-12 yr 1323 (18.4%) 499 (25.9%) 0.550 0.485-0.624 0.0001
>12 yr 753 (10.4%) 324 (16.8%) 0.482 0.415-0.560 0.0001
Employment
Employed* 755 (10.5%) 372 (19.3%) 1
Housewife 6450 (89.5%) 1558 (80.7%) 2.040 1.781-2.337 0.0001
*Reference group.
Parity and obesity
e53 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
TABLE 4
The association between parity, waist circumference (WC), and body
mass index (BMI).
TABLE 3
Logistic regression models of waist circumference on parity, age,
BMI, employment, education, and marital status.
Table 2 shows the association between select-
ed risk factors and WC of the studied women.
Increasing age and higher number of births
were associated with a consistent significant
increase in the risk of increasing WC. While the
reverse was true with respect to education, the
risk of increased WC significantly decreased
with the increase in education. The risk of
increased WC was higher among housewives
compared to employed women.
Results of multiple logistic regression analyses
of parity and risk of increasing WC are present-
ed in Table 3. The number of births remained
significantly and independently associated with
increased WC after adjustment for a range of
potential confounders (age, BMI, employment,
education, and marital status). However, when
parity was analysed as a dichotomous variable
(parous versus nulliparous), no significant asso-
ciation was found (p>0.05).
When the association between parity, WC,
and BMI was studied (Table 4), increasing parity
and WC were both found to be associated with
a significant increase in the risk of increasing
BMI. However the association between WC and
BMI was much stronger than that between pari-
ty and BMI (odds ratio 47.611; 95% CI 39.086-
57.997), thus controlling BMI may explain the
absence of an association between WC and par-
ity in the second model (Table 3, model 2).
DISCUSSION
This study included a good sample size of
women to assess the impact of parity on
anthropometric indices of obesity especially the
WC. Illiteracy constitutes 55.2% and 87.6%
were housewives. This was consolidated in
other studies in Iraq (23).
About 78.9% of our women had WC 80 cm.
This cutoff of 80 cm is used for diagnosis and is
a prerequisite for metabolic syndrome defini-
tion adapted by the International Diabetic Fed-
eration (IDF) in 2005 for Europids (24). The IDF
advice is to use European data for Eastern
Mediterranean and Middle East (Arab) regions
until more specific population data are avail-
able. This means that more than three quarters
of women had visceral obesity.
There was a progressive increase in weight,
BMI, WHpR, and WHtR with increasing parity.
A crucial issue is whether the observed rela-
tionship between the WC and reproduction was
due to biological processes initiated by concep-
tion, or whether other mechanisms are involved
(25). Most previous studies found a modest rela-
tionship between births and BMI, and an
increased trend of greater upper body fat distri-
bution with an increasing number of births in
women (10, 26-28). In the Atherosclerosis Risk
in Communities study, women of higher parity
had a higher mean BMI and WC at baseline
than women of lower parity (29), and, also in
Chinese women, BMI and WHpR were positive-
ly associated with the number of births after
adjusting for a range of potential confounders
(20). A British study found a relationship
between parity and measures of fatness (BMI
and WHpR) in both men and women aged 60-
79 years (3). There was a significant correlation
between parity number and body weight, BMI
and hip circumference in Turkey and Saudi
women (30, 31). Lifestyle factors associated with
having large families may lead to obesity in
both genders (3). Among 6512 Chilean-Hispanic
women, parity modestly influenced BMI, but
Model 1: Parity (number of births)
Variables in the Equation OR 95% CI p
Age 1.045 1.038-1.052 0.0001
Parity (number of live births) 1.091 1.060-1.123 0.0001
BMI 1.835 1.778-1.893 0.0001
Education 1.005 0.986-1.025 0.617
Employment 0.946 0.712-1.256 0.700
Marital status 0.598 0.468-0.765 0.0001
Model 2: Parity (nulliparous vs. parous)
Variables in the Equation OR 95% CI p
Age 1.053 1.046-1.059 0.0001
Parity (nulliparous vs. parous) 1.223 0.956-1.564 0.108
BMI 1.838 1.781-1.896 0.0001
Education 0.995 0.976-1.015 0.618
Employment 1.067 0.802-1.419 0.658
Marital status 1.797 1.326-2.434 0.0001
BMI
25 <25 OR 95% CI p
Parity
0* 876 1158 1
1 227 227 1.322 1.078-1.621 0.007
2 325 231 1.860 1.538-2.249 0.0001
3 423 240 2.330 1.944-2.792 0.0001
+4 3644 1784 2.700 2.432-2.997 0.0001
WC
<80 cm 113 1817 1
80 cm 5386 1819 47.611 39.086-57.997 0.0001
A.A. Mansour, and N.A.H. Ajeel
e54 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
this does not seem to be related to WC, WHpR
and WHtR after controlling by confounders
(age, low education, marital status, employ-
ment, smoking, smoking cessation, hyperten-
sion, diabetes, dyslipidaemia, parents obesity,
menarche and fetal macrosomia) (32).
No association between parity and diabetes
or hypertension was seen in this study. Most
reported associations between parity and dia-
betes have not been adjusted for age or body
adiposity, both of which are likely to be impor-
tant confounding factors (9). In the studies that
have presented results adjusted for age and
adiposity (33), the findings have been highly
inconsistent. In an extreme case, parity was
associated with a significantly reduced risk of
diabetes in one study (34).
The finding that parity was not significantly
related to WC when analysed as a dichotomy
(parous versus nulliparous) may be due to the
fact that women who had experienced at least
one live birth had significantly increased risk of
both overweight and increased WC compared
with nulliparous women, therefore adjusting
for any of these variables would reduce the
effect of the other.
CONCLUSION
Parity was associated with increased WC and
other anthropometric indices of obesity in a
sample of rural Iraqi women attending two pri-
mary health care centers.
COMPETING INTERESTS
The authors declare that they have no competing
interests.
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Vol. 14: e56-e65, June-September 2009
e56
ORIGINAL
RESEARCH
PAPER
Key words:
Elderly, weight loss, diet,
physical activity.
Correspondence to:
Dr. Luca Buseto,
Clinica Medica I,
Policlinico Universitario
di Padova,
Via Giustiniani 2,
35128 Padova, Italy.
E-mail: luca.busetto@unipd.it
Received: June 5, 2008
Accepted: October 17, 2008
Obesity treatment in elderly
outpatients: Predictors of efficacy
and drop-out
INTRODUCTION
The prevalence of obesity in the elderly
is increasing. According to a national
1999-2002 examination survey, the preva-
lence of obesity, defined as a body mass
index (BMI) 30 kg/m
2
, among American
adults aged more than 60 years was 30.5%
in men and 34.7% in women (1). Coupled
with the increase in the total number of
ol der persons i n the popul ati on, the
increased percentage of the older popula-
ti on that i s obese may cause a huge
increase in the absolute number of obese
older persons. Obesity causes serious
medical complications and impairs quality
of life in the elderly as in adults. Moreover,
in older persons, obesity can exacerbate
the age-related decline in physical function
and lead to frailty (2).
L. Busetto, M. Mazza, S. Salvalaio, F. De Stefano, M. Marangon, E. Cal,
S. Sampietro, and G. Enzi
Unit for Medical and Surgical Therapy of Obesity, Department of Medical and Surgical Sciences, University
of Padova, Padova, Italy
ABSTRACT. OBJECTIVE: Obesity is increasing in the elderly and it is associated with an
increased risk of medical complications, decline in physical function and disability. Very few
studies specifically evaluated the outcome of obesity treatment in the aging patients. Aim of
this work is therefore the evaluation of the efficacy of medical therapy in a group of obese
patients 65 years old. METHODS: The study has been performed on the clinical records of
obese outpatients treated at the medical branch of the Unit for Medical and Surgical Therapy
of Obesity at the University of Padova. Patients were recruited from January 1
st
, 2001 to June
30
th
, 2006 in order to have patients with at least one year of potential follow-up. In particular
two groups were enrolled: 100 patients 65 years old and 200 patients <65 years old. The
baseline characteristics, the prescriptions and the treatment outcome were compared.
RESULTS: Mean age of the elderly patients was 69.13.7 years (range 65-80 years). We did
not find any significant difference between elderly and adult patients in the sex distribution
(female patients 76% in the elderly group and 72% in the adult group; p=0.276) and in the
severity of overweight (body mass index: 37.86.0 kg/m
2
in the elderly; 37.26.3 kg/m
2
in
adults; p=0.425). The elderly group was characterized by a higher incidence of comorbidities
and a lower incidence of eating behavior disorders at baseline. No significant differences in
the dietary prescription were found, whereas physical activity was prescribed in 27/100
elderly patients (27%) and in 97/200 (48%) adults patients (p<0.000). Weight loss was evaluat-
ed by analyzing the percentage of patients reaching at least a 10% weight loss from baseline
after 12 months of treatment. In elderly patients still in active treatment after 12 months, only
5/28 (18%) patients reached the specified goal, whereas in adult patients still in treatment,
18/47 (38%) patients reached the goal (p<0.05). Lower age at baseline, female sex, and lower
body mass index were found to be the only significant predictors of 10% weight loss in logis-
tic regression. In our experience, drop-out rate after 12 months was similar in adults (77%)
and in older patients (72%). In a multivariate Cox regression model, the risk of drop-out was
reduced by married or widowed status, the prescription of physical activity at baseline, and
the presence of type 2 diabetes. The risk of drop-out was increased by the presence of
osteoarthritis. Even after adjustments for these confounding variables, age did not play any
significant role as drop-out predictor. CONCLUSION: Advanced age seems to be a predic-
tor of poor response to treatment in obese outpatients treated by conventional medical thera-
py. Drop-out rate was not significantly influenced by age.
(Eating Weight Disord. 14: e56-e65, 2009).
2009, Editrice Kurtis
Obesity treatment in the elderly
e57 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
Despite these considerations, studies specifi-
cally evaluating the outcome of obesity treat-
ment in the older patients are very scarce in the
literature and the appropriate clinical approach
to obesity in older persons is still controversial.
Weight loss may result in a decrease in both fat
mass and lean body mass and therefore it is
possible that weight loss in obese older persons
could worsen the age-related loss of muscle
mass, increase sarcopenia, and cause disability
(2). On the other hand, according to a recent
technical review and position statement on obe-
sity in older adults of the American Society for
Nutrition and the North American Association
for the Study of Obesity, weight-loss therapy
that minimizes muscle and bone losses may be
recommended for older persons who are obese
and who have functional impairments or meta-
bolic complications that can benefit from
weight loss (2). However, the efficacy in older
obese patients of the conventional therapeutic
approaches normally used in adults has been
poorly studied in the clinical setting. Some
intervention trials with therapeutic lifestyle
modifications specifically conducted in elderly
obese patients seem to suggest that lifestyle
intervention may produce a significant weight
loss in elderly people as in adult patients (3-5),
but none of these studies included a direct com-
parison between patients of different ages. In
this study we provided data about the efficacy
of medical therapy in a group of obese patients
65 years old. The outcome of the group of
patients 65 years old was compared with the
outcome of a large group of patients <65 years
old treated with an identical therapeutic pro-
gram. Predictors of efficacy and adherence to
the therapy were also investigated.
METHODS
The present study was designed as a retro-
spective survey, based on subjects attending
the medical outpatient service of the Unit for
Medical and Surgical Therapy of Obesity of the
University of Padova. Patients were randomly
recruited from the whole sample of obese
patients attending the service since January
2001 to June 2006, in order to have a minimum
potential follow-up of one year to the index
date of June 30, 2007. A total of 100 patients
65 years old and 200 obese outpatients <65
years old were selected. The only exclusion cri-
teria included: BMI <25 kg/m
2
, pregnancy,
endocrine diseases, cancer and severe mental
illness. Patients receiving an indication to
bariatric surgery and shifted to the surgical
outpatient service of our institution were also
excluded. Giving the restrospective nature of
the study no informed consent was obtained
from the patients.
All patients underwent at baseline a complete
clinical examination, which included a general
questionnaire, constructed in our center, con-
cerning sociodemographic and lifestyle data,
family and personal obesity history, previous
anti-obesity treatments; obesity-related comor-
bidities (hypertension, type 2 diabetes, dyslipi-
demia, hyperuricemia or gout, cardiovascular
diseases, sleep apnea, osteoarthritis and
depression) and eating behavior disorders
(binge eating disorder, sweet eating, grazing
and night eating). Education attainment was
measured in years of schooling. Civil status
was defined as single, married or widowed.
The level of physical activity was assessed with
questions on hours of mild, moderate, high and
vigorous activity undertaken each week and
scored from 1, which corresponds to sedentary
life, to 5, which corresponds to vigorous physi-
cal activity. Cigarette smoking was defined as
current, past or never. Alcohol intake was clas-
sified as abstinence, moderate alcohol intake
(corresponding to 1-250 ml of wine per day or
equivalent), medium (251-500 ml of wine per
day or equivalent) or high (>500 ml of wine per
day or equivalent). The diagnosis of binge eat-
ing disorder was based on the proposed diag-
nostic criteria of the Diagnostic and Statistical
Manual of Mental Disorders, fourth edition
(DSM-IV) (6). Sweet eating was diagnosed
when the patient craved simple carbohydrates,
and carbohydrate craving could be continuous-
ly present or triggered by emotional (anxiety,
stress) or physiological (premenstrual phase)
situations (7). Grazing was diagnosed when the
patient ate small quantities of foods repetitively
between meals, typically triggered by inactivity
and/or loneliness (7). Night eating syndrome
was defined according to the diagnostic crite-
ria proposed by Stunkard et al. (8).
At baseline all patients received a complete
clinical examination which included anthropo-
metric measurements. All anthropometric mea-
surements were performed with the subjects
wearing light clothes without shoes. Height was
measured to the nearest 0.01 m using a wall-
mounted stadiometer. Body weight was deter-
mined to the nearest 0.05 kg using a calibrated
balance beam scale. BMI was calculated as
weight (kg) divided by the height-squared (m
2
).
Treatment program
Treatment program in our centre was based
on a combination of mild hypocaloric diet, mod-
erate physical activity, and behavioral reinforce-
ment, in agreement with the Clinical Guidelines
L. Busetto, M. Mazza, S. Salvalaio, et al.
e58 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
on the Identification, Evaluation, and Treatment
of Overweight and Obesity in Adults of the
National Institutes of Health (9). The basis of the
program consisted in a first clinical evaluation
followed by individual control visits, planned
every 8 weeks at least. Follow-up visits were
scheduled time by time, but no routine recall
system for the patients with missed visits was
active. All visits were made by a physician
trained on obesity treatment. The costs of base-
line evaluation and follow-up visits were totally
or partially paid by the patient to the institution
according to the prices and regulations
imposed by the National Italian Health Service.
No direct payments to the physicians were per-
mitted. A general treatment plan was formulat-
ed at the baseline evaluation and regularly re-
examined during follow-up. On the follow-up
visits, the physician assisted the patient in the
monitoring of weight, and addressed certain
themes such as self-monitoring, reinforcement,
nutritional education and beneficial effects of
physical activity, in order to promote behav-
ioural modifications and dietary changes.
The daily energy content of the mild hypo-
caloric diet was individually calculated in order
to obtain a daily energy deficit of 400-600
kcal/day in respect to the estimated total daily
energy expenditure of the patient. Total daily
energy expenditure was estimated fromthe basal
metabolic rate calculated with the World Health
Organization (WHO) formula with correction for
habitual physical activity level (10). No diets with
daily energy content lower than 1000 kcal/day
were prescribed. The composition of the diet was
arranged to a target of 1520% of the energy
intake from proteins, 2530% from lipids and
5055% from carbohydrates. A high intake of
complex carbohydrates and fiber was recom-
mended and a particular emphasis was given to
the reduction of lipids, alcohol and sweet drinks.
Patients were strongly encouraged to adhere to
three main meals a day and two snacks largely
based on fresh fruit, but the distribution and
composition of meals may be individualized
according to patients preferences and needs.
The minimum physical activity level targeted
for patients with a baseline sedentary lifestyle
was represented by at least 3 hours per week of
physical activity (9). Moderate intensity physi-
cal activities were privileged, but the type of
physical activity may be adapted to patients
preferences and attitudes. Simple schemes of
progressive training were provided to patients
with baseline sedentary lifestyles, but not indi-
vidualized training program or formal collabo-
ration with professional trainers was active.
Anti-obesity drugs may be added to the ther-
apeutic program since baseline evaluation or
during follow-up according to the treating
physicians judgment in patients with BMI >30
kg/m
2
, or in patients with BMI >27 kg/m
2
and
significant obesity-related comorbidities. Only
two drugs with a labeled indication for obesity
treatment were available in Italy during the
study period: sibutramine and orlistat.
In agreement with international guidelines
(9), a primary goal of a moderate weight loss,
corresponding to 10% of the baseline body
weight, was set and discussed with the
patients. In case of attainment of the primary
goal, further therapeutic objectives may be
stipulated according to individual clinical con-
ditions, but a particular emphasis to weight
loss maintenance was given.
Statistical analysis
Statistical analysis was performed by using
the SSPS statistical package, version 15.0 (SSPS
Inc., Chicago, IL). Frequencies, mean values
and standard deviations were used to describe
the baseline characteristics of the elderly and
the adult group at baseline. Differences
between the two groups were evaluated by
unpaired Students t-test for numerical vari-
ables and Chi-square test for categorical vari-
ables. The efficacy of weight loss therapy was
evaluated by calculating in each study group
the overall weight loss and the percentage of
patients reaching the weight loss goal of at
least 10% of baseline body weight after 12
months of treatment. These two analyses were
conducted both in completers and according to
an intention-to-treat (ITT) model with the last
observation carried forward (LOCF). Predictors
of efficacy were tested by stepwise logistic
regression analysis. Adherence to therapy was
evaluated up to the third year of follow-up and
the difference in survival in active treatment
between the elderly and the adult group was
assessed with the log-rank test for comparison
of Kaplan-Meier survival curves. Predictors of
drop-out were investigated by multivariate
(Cox) regression analysis in the sample as a
whole. In all statistical analysis, a p-value less
than 0.05 was considered to be significant.
RESULTS
Baseline evaluation
The baseline characteristics of 100 obese out-
patients 65 years old and 200 obese outpa-
tients <65 years old attending the medical
branch of the Unit for Medical and Surgical
Therapy of Obesity of the University of Padova
are reported in Table 1. The two groups had a
similar sex distribution, with women represent-
Obesity treatment in the elderly
e59 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
TABLE 1
Clinical characteristics at the baseline evaluation in 100 patients 65
years old and in 200 patients <65 years old selected out of the popu-
lation of obese outpatients attending the medical branch of the Unit for
Medical and Surgical Therapy of Obesity, University of Padova, Italy.
ing about three quarters of the study popula-
tion. Mean age in elderly patients was 69.13.7
years, with a range from 65 to 80 years. In par-
ticular, 68 patients were 65-70 years old, 26
patients were 71-75 years old, and 6 patients
were 76-80 years old at baseline. In addition to
the obvious difference in the age at baseline,
elderly patients had significantly higher age at
the onset of obesity and duration of obesity
than adult patients.
No significant differences in baseline BMI
were observed between elderly and adult
patients in our study (Table 1). Despite a similar
degree of obesity, patients 65 years old were
more significantly affected by obesity-related
comorbidities. In particular, we observed a
higher prevalence of hypertension, type 2 dia-
betes, dyslipidemia, hyperuricemia, cardiovas-
cular diseases and osteoarthritis in the older
group (Table 1). On the contrary the prevalence
of most of the eating behavior disorders (binge
eating, sweet eating and grazing) was lower in
the elderly than in the adult patients. We did not
observe significant differences between the two
groups in the prevalence of depression and
night eating syndrome (Table 1). The higher
prevalence of metabolic, cardiovascular and
orthopedic comorbidities observed in elderly
patients translated in a more frequent use of
drugs: the mean number of drugs used at base-
line was 3.72.6 (range 0-12) in the elderly
patients and 1.61.9 (range 0-10) in the adult
patients (p<0.001). In particular, a more frequent
use of anti-hypertensive drugs and statins was
observed in the elderly group (data not shown).
Very few patients in both groups were already
in treatment with anti-obesity drugs at baseline
evaluation: only one patient in the elderly group
and one patient in the adult group were in treat-
ment with orlistat, none was taking sibutramine.
Very few patients in both groups reported an
acceptable level of physical activity, with a lower
prevalence in the elderly group (Table 1).
The majority of both the elderly and the adult
patients reported previous attempts of weight-
control therapy at baseline (Table 1). Previous
weight loss treatment with energy restriction
was reported by 66/100 (66%) patients in the
elderly group and by 158/200 (79%) patients in
the adult group (p=0.003). Behavioral therapy
was clearly under-used in both groups, with no
elderly patient and only four adult patients
reporting previous behavioral treatments. Final-
ly, 16/100 (16%) patients in the elderly group and
43/200 (21%) patients in the adult group reported
previous use of anti-obesity drugs. However,
only fewof the patients reporting previous use of
anti-obesity drugs referred previous use of drugs
currently indicated for obesity treatment in Italy
[6/43 (14%) patients reporting previous pharma-
cologic treatment with orlistat and 3/43 (7%)
with sibutramine in the adult group; 2/16 (12%)
patients reporting previous pharmacologic treat-
ment with orlistat and 1/16 (6%) with sibu-
tramine in the elderly group]. Most of the
patients in both groups reporting previous use of
anti-obesity drugs had been previously treated
with multi-ingredients formulations of unknown
composition or with short courses of ampheta-
mines or amphetamines-like drugs.
Treatment outcome
After the baseline evaluation, all patients
received a moderate energy deficit diet, with no
65 years old <65 years old
Demographic characteristics
Female sex, % 76/100 (76%) 144/200 (72%)
Age at baseline, yr 69.13.7 (65-80) 43.212.7 (16-64)***
Obesity history
Obesity family history, % 43/100 (43%) 130/200 (65%)***
Age at the onset of obesity, yr 39.415.7 (6-77) 24.511.3 (3-60)***
Duration of obesity, yr 29.615.0 (1-65) 18.412.2 (1-49)***
Previous dietary treatment, % 66/100 (66%) 158/200 (79%)**
Previous behavioral treatment, % 0/100 (0%) 4/200 (2%)
Previous use of anti-obesity drugs, % 16/100 (16%) 43/200 (21%)
Anthropometry
Body weight at baseline, kg 98.717.8 102.119.4
(56.5-167.0) (65.0-160.0)
BMI at baseline, kg/m
2
37.86.0 37.26.3
(25.5-54.2) (25.2-57.8)
Comorbidities
Hypertension, % 78/100 (78%) 83/200 (41%)***
Type 2 diabetes, % 21/100 (21%) 25/200 (12%)*
Dyslipidemia, % 49/100 (49%) 44/200 (22%)***
Hyperuricemia/Gout, % 12/100 (12%) 8/200 (4%)*
Cardiovascular diseases, % 15/100 (15%) 9/200 (4%)**
Sleep apnea, % 43/100 (43%) 92/200 (46%)
Osteoarthritis, % 73/100 (73%) 101/200 (50%)***
Depression, % 26/100 (26%) 56/200 (28%)
Eating behavior disorder
Binge eating disorder, % 5/100 (5%) 26/200 (13%)*
Sweet eating, % 13/100 (13%) 53/200 (26%)***
Grazing, % 14/100 (14%) 57/200 (28)%***
Night eating, % 4/100 (4%) 4/200 (2%)
Lifestyle
Previous or current smokers, % 35/100 (35%) 82/200 (41%)
High alcohol intake, % 8/100 (8%) 15/200 (7%)
Moderate to high physical activity, % 2/100 (2%) 32/200 (16%)***
Values are meansstandard deviation (range) for the numerical variables and per-
centage for the categorical variables. High alcohol intake was defined as an intake of
more than 250 ml of wine per day or equivalent. Moderate to high physical activity
was defined as at least 3 hours/week of brisk walking or equivalent. Unpaired Stu-
dents t-test for numerical variables and Chi-square test for categorical variables were
performed: *p<0.05; **p<0.01; ***p<0.001.
L. Busetto, M. Mazza, S. Salvalaio, et al.
e60 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
significant differences in prescribed daily ener-
gy intake between elderly and adult patients
(1334.7166.0 kcal/day vs 1376.3188.3 kcal/day;
p=0.074). Moderate intensity daily physical
activity was explicitly prescribed to 27/100
elderly patients (27%) and to 97/200 (48%)
adults patients, with a statistically significantly
difference in favor of the adult group (p<0.000).
Finally, 12/100 (12%) elderly patients and 29/200
(14%) adult patients received a prescription for
an anti-obesity drug (orlistat or sibutramine),
without significant differences between the two
groups (p=0.479). However, a clear difference
was observed in the type of anti-obesity drug
most frequently used: orlistat was prescribed in
6/200 (3%) adults and in 10/100 (10%) elderly
patients (p=0.028), while sibutramine was pre-
scribed in 23/200 (11%) adults and only in 2/100
(2%) elderly patients (p=0.002). This difference
in prescription was largely maintained during
follow-up (data not shown).
Weight loss in the first 3 years of follow-up in
elderly and adults patients, expressed as per-
centage of baseline body weight, is represented
in Figure 1. In completers (Fig. 1A), weight loss
was slightly, but not significantly lower in the
elderly group than in the adult group in the
first year of treatment (weight loss at 6 months:
5.75.5 vs 6.46.7%, p=0.560; weight loss at 12
months: 6.26.9 vs 8.68.9%, p=0.228). After-
ward, the weight loss curves of the two groups
were superimposable, but the significance of
the results was reduced by the very low num-
ber of patients still in active treatment after the
first year of follow-up. In the ITT analysis con-
ducted with the LOCF model (Fig. 1B), no sta-
tistically significant differences between elderly
and adults patients were found. The efficacy of
weight loss therapy was also evaluated in a cat-
egorical way, by calculating in each study
group the percentage of patients reaching the
weight loss goal of at least 10% of baseline
body weight after 12 months of treatment. In
elderly patients still in active treatment after 12
months, only 5/28 (18%) had a weight loss
10%. In adult patients still in treatment, 18/47
(38%) had a weight loss of 10%. The differ-
ence between the two groups resulted statisti-
cally significant with a better result in adult
patients (p<0.05). When this efficacy analysis
was repeated according to an ITT principle, the
10% weight loss goal after 12 months of treat-
ment resulted to be achieved in 7/100 (7.0%)
elderly patients and in 23/200 (11.5%) adult
patients (p=0.221).
Predictors of efficacy were investigated by
stepwise logistic regression models with
weight loss 10% of the baseline body weight
after 12 months of active treatment as the
dependent variable. In a first model the follow-
ing independent variables were tested: gender,
age at baseline, age at the onset of obesity,
duration of obesity, BMI at baseline, education
level, civil status, physical activity level, alcohol
intake, smoking, obesity family history, comor-
bidities (hypertension, type 2 diabetes, dyslipi-
demia, hyperuricemia/gout, cardiovascular dis-
eases, sleep apnea, osteoarthritis, depression),
and eating behavior disorders (binge eating
disorder, sweet eating, grazing, night eating).
In this model, only younger age at baseline,
female sex and low BMI at baseline were found
100 62 44 33 28 16 14 8 7
200 115 75 56 47 27 17 13 8
N: elderly
adults
8
7
6
5
4
3
2
1
0
0 3 6 9 12 18 24 30 36
%
w
e
i
g
h
t
l
o
s
s
f
r
o
m
b
a
s
e
l
i
n
e
Months of follow-up
16
14
12
10
8
6
4
2
0
0 3 6 9 12 18 24 30 36
%
w
e
i
g
h
t
l
o
s
s
f
r
o
m
b
a
s
e
l
i
n
e
FIGURE 1
Weight loss expressed as percentage of baseline body weight in 100
patients 65 years old (closed symbols) and in 200 patients <65
years old (open symbols) attending the medical branch of the Unit
for Medical and Surgical Therapy of Obesity, University of Padova,
Italy. Weight loss was reported both for patients still in active treat-
ment at each follow-up visit (panel A) and according to an intent-to-
treat analysis model with the last observation carried forward in
missing patients (panel B). Numbers of patients still in active treat-
ment at each follow-up visit are reported.
Obesity treatment in the elderly
e61 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
to be significant predictors of success (Table 2).
In a second model, the following independent
variables related to treatment prescription
were added to the variables already tested in
model 1: prescribed daily energy intake, pre-
scription of physical activity, prescription of
orlistat or sibutramine. The introduction of this
second group of variables did not significantly
modify the results of the stepwise logistic
regression analysis (Table 2). The total variabili-
ty of the dependent variable explained by the
models was 39.4% for the first model and
39.2%for the second model.
Adherence to therapy was very low both in
elderly and adult patients. Total rate of drop-
out after 12 months was 77%in the adult group
and 72%in the elderly group (p=0.210). Kaplan-
Meier estimates of survival in active treatment
were calculated up to the third year of follow-
up and the difference in survival between the
elderly and the adult group was assessed with
the log-rank test for comparison of Kaplan-
Meier survival curves (Fig. 2): survival rate was
not significantly different between the two
groups (p=0.522). Predictors of drop-out in the
whole sample were investigated by multivariate
Cox regression analysis. Gender, age at base-
line, age at the onset of obesity, duration of
obesity, BMI at baseline, education level, civil
status, physical activity level, alcohol intake,
smoking, obesity family history, comorbidities,
eating behavior disorders, prescribed daily
energy intake, prescription of physical activity
and prescription of orlistat or sibutramine
were entered in the analysis as possible predic-
tors of drop-out. Independent determinants of
drop-out according to this model are shown in
Table 3: married or widowed civil status, the
presence of type 2 diabetes and the prescrip-
tion of physical activity at baseline were found
to be protective factors against drop-out risk,
whereas the presence of osteoarthritis was
found to increase drop-out rate. Age was not
found to be an independent determinant of
drop-out also in multivariate adjusted analysis.
DISCUSSION
In this study, we analyzed the response and
the adherence to therapy of an adequate group
of elderly obese patients treated with a lifestyle
modification program, eventually associated
with pharmacologic therapy, in the non-experi-
mental setting of the usual outpatient clinical
activity of an Italian obesity centre. The out-
come of the group of patients 65 years old was
compared with the outcome of a large group of
patients <65 years old. At baseline, elderly
patients were characterized by a lower level of
spontaneous physical activity, by a higher
prevalence of comorbidities and by a lower
incidence of eating behaviour disorders. In our
setting, despite the use of exactly the same
treatment protocol in elderly and in adult sub-
jects, patients >65 years old received less fre-
quently a detailed prescription for physical
activity. The primary goal of a weight loss cor-
coefficient p
Model 1
Age at baseline -0.107 0.009
Female sex 3.148 0.010
BMI at baseline -0.147 0.040
Model 2
Age at baseline -0.106 0.009
Female sex 3.101 0.011
BMI at baseline -0.146 0.042
In Model 1 the following independent variables were tested: gender, age at base-
line, age at the onset of obesity, duration of obesity, BMI at baseline, education
level, civil status, physical activity level, alcohol intake, smoking, obesity family
history, comorbidities (hypertension, type 2 diabetes, dyslipidemia, hyper-
uricemia/gout, cardiovascular diseases, sleep apnea, osteoarthritis, depression),
eating behavior disorders (binge eating disorder, sweet eating, grazing, night
eating). In Model 2 the following independent variables related to treatment pre-
scription were added to the variables already tested in model 1: prescribed daily
energy intake, prescription of physical activity, prescription of orlistat or sibu-
tramine. BMI: body mass index.
TABLE 2
Determinants of success in stepwise multiple regression analysis. Suc-
cess was defined as a weight loss 10% of the baseline body weight
after 12 months of active treatment.
1.0
0.8
0.6
0.2
0.0
0 20 40 60 80 100
%
o
f
p
a
t
i
e
n
t
s
i
n
a
c
t
i
v
e
t
r
e
a
t
m
e
n
t
Months of follow-up
FIGURE 2
Kaplan-Meier estimates of survival in active treatment in 100 patients
aged 65 years (dotted line) and in 200 patients aged <65 years
(solid line) attending the medical branch of the Unit for Medical and
Surgical Therapy of Obesity, University of Padova, Italy.
L. Busetto, M. Mazza, S. Salvalaio, et al.
e62 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
responding to 10% of the baseline body weight
was reached in significantly fewer patients in
the elderly than in the adult group, and
advanced age was found to be an important
independent predictor of a reduced therapeutic
response, also after adjustment for other possi-
ble confounding factors. The drop out rate was
very high in both groups, but adherence to
therapy was not significantly affected by
patients age.
Our study had several important method-
ological limitations that may significantly affect
the reliability of our results. The first limit was
inherent to the design of the study, that was
not a prospective trial, but a retrospective
analysis of outpatient data collected during
routine clinical practice. Retrospective recruit-
ment exposed to possible bias in the selection
of patients. We tried to reduce this possibility
by selecting patients in a random order from
our clinical database, without the use of strict
inclusion or exclusion criteria, but possible
uncontrolled selection bias may well have
occurred. On the other hand, using a retro-
spective design for the study, we may affirm
that our data could be considered as a real
description of our current clinical practice and
therefore may be more useful than experimen-
tal data for the identification of our limits and
the suggestion of appropriate modifications to
the therapeutic protocol in elderly obese
patients. A second limit, probably again inher-
ent to the fact that our study is an on-field clini-
cal study and not a prospective clinical trial,
was represented by the few data collected on
the evolution of comorbidities during follow-
up. This is an important limitation because the
evaluation of obesity-related comorbidities
could be an important element in the evaluation
of treatment outcomes, in particular in the
elderly. Data on health-related quality of life
and functional dependence at baseline and dur-
ing follow-up were also lacking. Finally, the use
of simple questionnaires and not formal testing
for the diagnosis of eating behavior disorders
may cause an underestimation of their preva-
lence in the sample. However, the lower preva-
lence of eating behavior disorders found in the
elderly group of this study was in agreement
with the age-related decline in the prevalence
of binge eating disorder described in popula-
tion studies (11).
Despite all these important limitations, our
study could give interesting clinical information
because it represents one of the few studies on
obesity treatment in which a direct comparison
between elderly and adult patients was per-
formed. Some intervention trials with therapeu-
tic lifestyle modifications have been specifically
conducted in elderly obese patients. In the Trial
Of Nonpharmacologic interventions in the
Elderly (TONE), 585 obese elderly patients with
high blood pressure were randomized to a
lifestyle modification program targeted to
weight loss, to a dietetic program focused on
sodium intake, to a combination of both pro-
grams, or to the usual antihypertensive therapy.
In the lifestyle modification arm, mean weight
loss was 3.5-4.5 kg, significantly greater than in
the other groups (3). In the Arthritis, Diet, and
Activity Promotion Trial (ADAPT), 316 over-
weight or obese patients aged over 65 years
and affected by knee osteoarthritis were ran-
domized to usual lifestyle recommendations
(control group), to a diet program, to a physical
activity program, or to a combination of diet
and physical activity. A significant weight loss
was observed after 18 months in all groups
(5.7% of baseline body weight in the diet plus
physical activity group, 4.9% in the diet group,
3.7% in the physical activity group, and 1.2% in
the control group) (4). Finally, Villareal et al.
randomized a little group of 27 frail elderly
patients to a behavioral therapy program tar-
geted to weight loss and physical activity or to a
control group. The weight loss in the active
treatment arm was 8.4% of baseline body
weight, while there was no significant weight
loss in the control group. The treatment pro-
gram improved also the physical performance
and the muscular strength of the patients (5). All
these results seem to suggest that lifestyle inter-
vention may produce a significant weight loss
in elderly people as in adult patients (2), but
none of these studies included a direct compari-
son between patients of different ages. In our
study, the 6.2% weight loss obtained in the first
year of treatment in elderly patients was equiva-
coefficient p
Civil status: married -1.173 0.031
Civil status: widowed -1.400 0.031
Osteoarthritis at baseline 0.760 0.010
Type 2 diabetes at baseline -0.826 0.038
Prescription of physical activity -0.606 0.020
The following independent variables were entered in the analysis as possible pre-
dictors of drop-out: gender, age at baseline, age at the onset of obesity, duration
of obesity, body mass index at baseline, education level, civil status, physical
activity level, alcohol intake, smoking, obesity family history, comorbidities (hyper-
tension, type 2 diabetes, dyslipidemia, hyperuricemia/gout, cardiovascular dis-
eases, sleep apnea, osteoarthritis, depression), eating behavior disorders (binge
eating disorder, sweet eating, grazing, night eating), prescribed daily energy
intake, prescription of physical activity, prescription of orlistat or sibutramine.
TABLE 3
Determinants of drop-out in multivariate Cox regression analysis.
Obesity treatment in the elderly
e63 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
lent to or even higher than the body weight
reductions found in the above mentioned
papers (3-5), but it remained a bit lower than
the weight loss observed in adult patients. The
percentage of completer elderly patients that
reached the primary goal of a weight loss corre-
sponding to 10% of the baseline body weight at
the end of the first year of treatment (18%) was
approximately half of the percentage found in
the younger group (38%). The reduced
response to therapy found in elderly patients in
our study was in contrast with the results of an
analysis performed in patients of different ages
participating in the treatment arm of the Dia-
betes Prevention Program (DPP) (12). In the
DPP, 60% of patients >65 years old, but only
43% of patients <45 years old, reached the goal
of 7% weight loss after 24 weeks of intensive
lifestyle modifications (12). On the other hand,
several studies performed with different thera-
peutic techniques seem to confirm a higher
resistance to weight loss in elderly patients. In a
multicentric study comparing the outcome of
216 morbid obese patients >60 years old treated
with laparoscopic gastric banding in 26 Italian
surgical centers with the outcome of 5074 adult
patients treated with the same surgical tech-
nique in the same centers, the weight loss in the
elderly group was approximately half of the
weight loss observed in adults (13). A lower
weight loss in elderly patients was also found
after gastric by pass (14).
Several age-related factors may explain a
reduced responsivity to weight loss therapy in
elderly obese patients. Studies analyzing the
predictive factors for a successful outcome in
patients treated with gastric banding suggested
that age and other age-related factors, like
insulin resistance, low physical activity level
and worse health status, can all play a signifi-
cant role in reducing weight loss after the sur-
gical procedure (7, 15). In our study, elderly
patients had a higher prevalence of metabolic
diseases related to insulin resistance, had a low
physical activity level at baseline, and were
more affected by chronic diseases. However,
the results of multivariate analysis suggested
that age remains a negative predictive factor of
weight loss also after adjustment for all these
factors, suggesting that age itself, irrespective
of coexisting comorbidities, could play the
major predictive role, maybe in relation to the
known age-related changes in body composi-
tion and resting energy expenditure.
Apart from patient-related factors, the
reduced therapeutic response observed in
elderly patients in our study may be also relat-
ed to treatment-related factors. The daily ener-
gy content of the diet prescribed at baseline did
not result to be significantly different in elderly
and in adult patients. Considering that the
dietetic prescription was set with the use of the
WHO/Food and Agriculture organization
(FAO) formula, that calculates a lower basal
metabolic rate in people >65 years old, and that
the correction for the physical activity level
should be lower in the more sedentary elderly
group, a lower caloric prescription should have
been expected in elderly patients. The absence
of a significant difference in dietary prescrip-
tion between the two groups could be caused
by a conservative attitude of attending physi-
cians, driven by the awareness of the possible
negative effects of a low calorie diet on muscle
mass, sarcopenia and disability (2). However,
the decision to apply a more conservative level
of caloric restriction in elderly subjects may
have reduced the efficacy of the diet in this
group of patients. Physical activity was pre-
scribed less frequently in the elderly group
(27%) that in the adult group (48%) in our
study. Regular physical exercise may be not
essential for weight loss, but it is critical for
weight maintenance (9) and it is even more
important in the elderly for the prevention of
muscle mass loss during weight reduction (2,
12). The under-prescription of physical activity
in the elderly patients by the attending physi-
cians in our study may be driven by a perceived
greater difficulty in performing exercise in
older subjects, related both to the low level of
baseline spontaneous physical activity and to
the presence of respiratory, cardiovascular and
orthopaedic comorbidities. Finally, also the
prescription of anti-obesity drugs was signifi-
cantly different in the two groups of patients,
with a prevalent use of orlistat in elderly
patients and sibutramine in adults. The lower
utilization of sibutramine in older patients may
be explained by the higher prevalence in elder-
ly patients of potential cardiovascular con-
traindications to this drug and possibly by the
lower prevalence of eating behavior distur-
bances that may trigger the use of an anorectic
drug (2). The Sibutramine Cardiovascular OUT-
comes (SCOUT) trial is now treating subjects
most of whom have conditions that are explicit-
ly contraindicated for sibutramine therapy
under the current label (coronary artery dis-
ease, peripheral arterial occlusive disease or
stroke). Preliminary data from the 6-week sin-
gle-blind period of the SCOUT trial indicate
that weight management with the addition of
sibutramine is well tolerated even in high-risk
subjects with cardiovascular disease (16).
Accrual of more data about sibutramine safety
in high-risk subjects may promote a wider use
of this drug also in the elderly. Overall, it is dif-
L. Busetto, M. Mazza, S. Salvalaio, et al.
e64 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
ficult to quantify the role of these treatment-
related differences in explaining the reduced
efficacy of weight loss therapy in our elderly
patients. However, the results of multivariate
regression analysis did not seem to suggest an
important independent role for these factors, in
addition to that played by age and other bio-
logical factors (sex and BMI levels).
In our study a very high prevalence of drop-
outs was found. Drop-out rate was >50% after
6 months of treatment and 75% after 12
months, thus confirming the 77.3% drop-out
rate after 12 months previously found by our
group in another subset of patients (17). Simi-
lar drop-out rates have recently been reported
by other Italian groups. Cresci et al. reported a
drop-out rate of 78.9% after 8 months of treat-
ment in 57 patients assigned to an individual
behavior therapy program (18). Minniti et al.
had a drop-out rate of 54.2% after 6 months of
treatment in 72 patients individually treated
with cognitive behavioral therapy (19). Drop-
out rate was relatively lower, but still elevated,
in randomized trials with anti-obesity drugs. In
the Sibutramine Trial of Obesity Reduction and
Maintenance (STORM), the drop-out rate at 12
months was 42% in the treated group and 50%
in the placebo group (20). In the XENical in the
prevention of Diabetes in Obese Subjects
(XENDOS) study, the drop-out rate at the
fourth year of follow-up was 48% in the treat-
ed group and 66% in the placebo group (21).
Finally, in the Rimonabant in Obesity-North
America (RIO-North America) study, the drop-
out rate at 12 months was 45% in the treated
group and 49% in the placebo group (22).
Analyzing the effects of age on adherence to
therapy, we did not find significant differences
in drop-out rate at 12 months between elderly
(77%) and adult (72%) patients participating in
our study and age was not an independent pre-
dictor of drop-out in multivariate analysis. In
our study, the drop-out rate was more influ-
enced by social factors (single against married
or widowed civil status) and comorbidity status
(presence of osteoarthritis and absence of dia-
betes) than by age. These results confirm previ-
ous observations made by our group in a dif-
ferent set of patients, in which full-time
employment, absence of depressive symptoms
and presence of comorbidity, but not age at
baseline, were independent predictors of drop-
out in outpatient obese subjects (17). However,
the mechanisms by which these factors cause
drop-out in our patients remained to be eluci-
dated, since we did not collect any data about
personal reasons for drop-out directly from
patients. Other works previously investigated
the role of age on drop-out rate in outpatient
overweight and obese subjects and found con-
trasting results, with some studies showing no
age-related effects (23) and other studies sug-
gesting a protective role of age against drop-
out (19, 24-26). Differences in the age composi-
tion of the patients and in the correction for
other possible confounding variables could
probably explain these discrepancies.
In conclusion, our results suggest that weight
loss therapy may be even more difficult in over-
weight and obese elderly patients than in
younger patients. Further studies are needed in
order to determine if an adaptation of the ther-
apeutic protocol to the peculiar characteristics
and needs of the aged obese patients may be
useful in improving our success rates. In partic-
ular, the usefulness of physical activity proto-
cols specifically developed for elderly subjects
and the safety of pharmacologic therapy in
high-risk older patients need to be investigated.
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Vol. 14: e66-e76, June-September 2009
e66
ORIGINAL
RESEARCH
PAPER
Key words:
Stage of change, eating
disorder, psychometry.
Correspondence to:
Diann M. Ackard, PhD,
5101 Olson Memorial
Highway, Suite 4001,
Golden Valley,
MN 55422, USA.
E-mail:
diann@diannackard.com
Received: July 20, 2007
Accepted: November 4, 2008
A self-report instrument measuring
readiness to change disordered eating
behaviors: The Eating Disorders Stage
of Change
*
INTRODUCTION
The Transtheoretical Model (TTM) (1) is a
popular stage theory being used to examine
health behavior change and emphasizes the
importance of motivation and readiness to
change problematic behaviors (2). TTM
assumes that change is more likely to evolve
over time than be immediate, that psy-
chotherapy is a complex process, and that
treatment should focus on change while
acknowledging patient intentions (3). TTM
includes five stages: Precontemplation,
Contemplation, Preparation, Action, and
Maintenance (4, 5). In Precontemplation,
persons are not aware of having a problem
that needs to be changed or are not seri-
ously thinking about changing. Contempla-
tors are aware that a problem is in exis-
tence, think about changing, but have not
yet made a commitment to change. Individ-
uals in Preparation perceive the benefits of
changing, are intending to take action with-
in the next month, and may have made
some movement toward action, such as
developing a plan. In the Action stage, peo-
ple are actively changing their behavior and
the environmental conditions that affect
their behavior. Finally, Maintenance is
characterized by working to maintain the
changes made and prevent relapse.
Considerable research has been conduct-
ed on treatment outcome for several health
behaviors. For example, findings on the
assessment (6) and treatment outcome (7)
for smoking cessation indicate that
D.M. Ackard
1,2
, J.K. Croll
3
, S. Richter
2
, S. Adlis
4
, and A. Wonderlich
5
1
Pri vate Practi ce, Mi nneapol i s, MN,
2
Mel rose I nsti tute at Park Ni col l et, St Loui s Park, MN,
3
The Emily Program, St Paul, MN,
4
Health Research Center, Park Nicollet Institute, St Louis Park, MN,
5
St. Louis University, St Louis, MO, USA
ABSTRACT. OBJECTIVE: To evaluate the utility of the Eating Disorders Stage of Change
(EDSOC), a behavior-specific readiness questionnaire. METHOD: Patients (N=145) at a
multidisciplinary eating disorder treatment facility in the United States completed the
EDSOC and other questionnaires. RESULTS: One-week test-retest reliability was strong
across eating disorder diagnoses and age groups. Convergent validity was strongest when
the behavior in question was congruent with the diagnosis (e.g., purging behaviors for
bulimia nervosa diagnosis) and compared to the patients own intention to complete treat-
ment. Divergent validity was demonstrated against body mass index values and age. How-
ever, the EDSOC and Body Shape Questionnaire were inversely correlated, suggesting that
increased body shape concerns are associated with decreased intention to change a behav-
ior. CONCLUSION: This preliminary cost-effective, behavior-specific measure demonstrates
good psychometric properties and is appropriate for use with children and adults. Across
diagnosis, the instrument should be used by looking at each single item instead of summing
a total score across disparate eating disorder behaviors.
(Eating Weight Disord. 14: e66-e76, 2009).
2009, Editrice Kurtis
*
Supported by a grant from the Park Nicollet Institute (1709-02A; D. Ackard, Principal Investigator). Parts of this
manuscript were presented at the International Conference on Eating Disorders, Academy for Eating Disorders
Annual Meeting, Orlando, FL, April 29-May 2, 2004. The authors greatly appreciate the cooperation and support
of the Melrose Institute in conducting this research and the time and willingness of patients receiving treatment
there to participate in the study.
Eating Disorders Stage of Change
e67 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
researchers could categorize treatment failures
versus successes based upon the participants
readiness to change their smoking behavior (7,
8). Stage of change theory has been further
applied to the prevention of smoking acquisi-
tion among adolescents (9). TTM has been a
helpful application in interventions for enhanc-
ing exercise adoption (10-14) as well as smok-
ing, seat belt use, and stress reduction tech-
niques (15). However, findings for TTMs appli-
cation to weight management are mixed.
Boutelle et al. (16) reported an association
between stage of change and weight loss in a
study using telephone contact and mailings to
promote adult weight management, however,
Jeffery et al. (17) found that the stage of change
did not predict success in weight control. These
disparate results may be related to differences
in measuring readiness to change in the area of
weight management.
Measuring readiness to change eating disor-
der behaviors is complicated. Many patients
fighting eating disorders endorse the use of
more than one problematic behavior, and may
acknowledge different levels of readiness
depending on the behavior in question. For
example, a patient may be attempting to reduce
binge-eating behavior, but not interested in
reducing compulsive exercise. Furthermore,
some patients adopt new behaviors while ceas-
ing the use of others, thus monitoring a limited
subset of symptoms can distort the clinical pic-
ture. Consequently, assessment of readiness to
change an eating disorder behavior needs to
assess each symptom separately yet compre-
hensively by asking about a broad range of
symptoms.
Self-report, psychometrically sound mea-
sures of readiness to change are available, yet
are limited in their clinical and research use
when serving patients with a diverse clustering
of symptoms. Several studies have used mea-
sures that do not assess each symptom sepa-
rately; rather, they provide loose definitions of
the eating disorder symptoms as the problem
(18) or the eating disorder (19), combine
symptoms such as binge eating and purg-
ing;(20), or ask about only a subset of the
range of symptoms experienced by patients
(21-23) which limits the ability to report varying
readiness to change for different problematic
behaviors.
Interview methods, often considered more
comprehensive and preferable to self-report
assessments of complex constructs (24), are
available for assessing readiness to change eat-
ing disorder behaviors (25, 26), but take 45 to
75 minutes to complete. Albeit appropriate for
clinical use and studies with trained staff and
generous research time, interviews require a
greater commitment of staff time and training
than may be available in some settings.
The clinical utility of a comprehensive and
specific measure for assessing readiness to
change eating disorders behavior lies in the
opportunity to predict treatment outcome
based on stage of change and ideally to tailor
treatment interventions to stage of change.
Franko reported that baseline stage of change
was associated with treatment outcome for
short-term cognitive-behavioral group (CBT)
group therapy for patients with bulimia ner-
vosa (27). Similarly, Treasure et al. found
among bulimia nervosa patients that more
advanced stage of change was related to reduc-
tion in binge eating frequency and greater
development of therapeutic rapport (28). Hasler
et al. found stage of change to be associated
with behavioral change, emotional involve-
ment, and continued treatment (29) among out-
patients. Similar results, of stage of change
being associated with need for hospitalization,
have been found among individuals receiving
eating disorders treatment at an inpatient set-
ting (30). However, Wolk and Devlin found that
baseline stage of change was not related to
treatment outcome for those who received
CBT, but was associated with treatment out-
come for those receiving interpersonal treat-
ment (IPT) (20). It is possible that different ther-
apeutic interventions have greater effects
depending on the stage of change of the
patient, and that the inconsistencies in the
results may be related, in part, to assessment
complications.
This study sought to enhance the field of eat-
ing disorder assessment by evaluating the reli-
ability and validity of a new measure designed
to assess stage of change for specific behaviors
among a treatment-seeking population of
patients with eating disorders. The proposed
Eating Disorders Stage of Change (EDSOC)
measure is a self-report instrument designed to
separately assess the specific stage of change
for eight different eating disorder behaviors.
Test-retest reliability across one week, conver-
gent val idity, and divergent validity was
assessed (31).
MATERIALS AND METHODS
Participants
Participants in this study included a sample
of 145 patients (143 females, 2 males) from four
levels of eating disorders treatment (outpatient,
intensive outpatient, partial hospital, and inpa-
tient) at a hospital-based clinic, the Melrose
D.M. Ackard, J.K. Croll, S. Richter, et al.
e68 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
Institute at Park Nicollet in St. Louis Park, MN.
Patients were diagnosed at intake by psychiatric
clinical interview following the Diagnostic and
Statistical Manual of Mental Disorders - fourth
edition (DSM-IV) criteria: diagnoses were
anorexia nervosa (38%), bulimia nervosa
(16.9%) or eating disorder not otherwise speci-
fied (EDNOS) (45.1%). The study aimed to
attract a diverse group of individuals seeking
treatment for an eating disorder, consequently
the only exclusion criteria was age younger
than 12 years. Participants were recruited at
any point in their treatment (e.g., at intake into
treatment, in the midst of treatment, or near
discharge) and from all treatment milieus by
trained clinical staff at the treatment facility.
Recruitment was facilitated by hanging study
announcements in patient waiting rooms and
by clinician invitation for each patient. They
were not paid for their participation.
Potential participants were asked to complete
the Eating Disorders Stage of Change mea-
surement study, and a description of the study
was provided to them by a trained staff person.
Participation was voluntary. All individuals
consented to participate in the study by active
consent if 18 years of age or older, or by assent
and parental consent procedures if the individ-
uals age was 12 to 17 years. Data were collect-
ed in compliance with the Park Nicollet Health
Services Protocol Review Committee and Insti-
tutional Review Board.
At Time 1, participants completed the EDSOC
questionnaire, measures used to gather demo-
graphic information, eating disorder-related
questionnaires, and measures of other symp-
toms and experiences to evaluate convergent
and divergent validity. Several pieces of infor-
mation were extracted at Time 1 from the indi-
viduals medical chart: eating disorder diagno-
sis, body mass index (BMI) value at current or
most recent visit, and current level of treatment.
Finally, a member of the participants treatment
team (either the psychotherapist or dietitian)
was asked to rate the participants readiness to
change. All participants were contacted approx-
imately one week later (median time between
Time 1 and Time 2 administrations = 1.1 weeks)
to complete the EDSOC again as their Time 2
test-retest reliability assessment.
Female participants averaged 22.9 [standard
deviation (SD)=8.6] years of age; the average
for males was 22.5 (SD=6.4). Means for BMI at
time of study completion were 21.0 (SD=4.0) for
females and 23.6 (SD=2.9) for males, and by
diagnosis at intake evaluation were 19.2 (2.9)
for anorexia nervosa, 24.4 (3.4) for bulimia ner-
vosa, and 21.5 (4.2) for EDNOS (p<0.0001; post-
hoc tests show all groups significantly different
from the others at p<0.05). All participants
were Caucasian, and most study participants
were receiving outpatient treatment (68.9%),
whereas others were enrolled in the intensive
outpatient (4.4%), partial hospital (18.5%), or
inpatient (8.1%) programs.
Measures
Demographic information
All participants were asked to report their
gender and age.
Information obtained from medical chart
A trained research staff person collected the
participants current eating disorder diagnosis
as determined by psychiatric interview at
intake assessment, current treatment milieu,
and most recent BMI, calculated using stan-
dard anthropometric procedures for measur-
ing height and weight.
Questionnaires
EDSOC (Appendix A). The EDSOC was
adapted from a previously-reported Stage of
Change Scale (20) to assess three stages of
readiness to change (Precontemplation, Con-
templation, and Preparation) across eight sepa-
rate eating disorder behaviors (binge-eating,
fasting, restricting, self-induced vomiting, laxa-
tive use, diet pill use, diuretic use, metabolic
enhancement use). It is designed to reduce limi-
tations with other self-report instruments,
notably non-specificity of eating disorder
behavior and length of questionnaire.
Three questions are asked for each behavior:
Do you intend to stop (behavior) in the next 6
months? and Do you intend to stop (behav-
ior) in the next 30 days? and In the past year,
before coming to this clinic, have you had defi-
nite plans to stop (behavior) (either on your
own or with outside help) and have you actual-
ly attempted to carry out these plans? Partici-
pants were asked to answer yes or no to
each of the questions above. The participant
could also check a box indicating that she or he
did not engage in that specific behavior.
A Stage of Change (Precontemplation, Con-
templation, or Preparation) score for each sepa-
rate eating disorder behavior is generated.
Answering no to the first question yields a
score of Precontemplation. Answering yes to
the first question, but at least one no to the
second or third questions yields a score of Con-
templation. For a score of Preparation, the par-
ticipant must answer yes to all three questions.
Stages of Change Questionnaire (SOC-Q)
(18). The SOC-Q is a 32-item questionnaire
designed to assess readiness stage (Precontem-
plation, Contemplation, Action, and Mainte-
Eating Disorders Stage of Change
e69 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
nance) for a nondescript problem. In the cur-
rent study, participants were asked to report
their agreement with each statement with
respect to the eating disorder as the identified
problem. The questionnaire has a 5-point Likert
format in which 1 indicates strong disagree-
ment and 5 indicates strong agreement with a
specific statement. Each response loads onto a
single readiness stage (8 responses per stage).
Psychometric properties of this instrument are
well established among smokers (Cronbachs
alpha=0.88) (18) and seem to be stable among
individuals with eating disorders (coefficient
alpha ranging from 0.73 to 0.90) (26). Internal
consistency (Cronbachs alpha) among the cur-
rent sample ranged from 0.84 for those in Pre-
contemplation according to the SOC-Q to 0.89
for those in the Action stage of change.
Participants own rating of intention to
complete treatment. The participant was
asked to answer yes, maybe/unsure, or
no to the question Do you plan to complete
your treatment for the eating disorder?. In
order to match responses from the EDSOC
with those from the self-report intention to
complete treatment, no responses were
coded as Precontemplation, maybe/unsure as
Contemplation, and yes responses as Prepa-
ration.
Psychotherapist or dietitian rating of par-
ticipants readiness to change. Clinic psy-
chotherapists and dietitians were given train-
ing, along with printed definitions and descrip-
tions of stages of change by the research team
for use in rating participants readiness to
change. For example, staff were given the fol-
lowing description for Precontemplation: This
is the stage in which people are unaware of
having problems or for other reasons are not
thinking seriously about changing. In this
stage, individuals may be defensive or distant
about the problems. They may be more willing
to help others change. Precontemplaters may
feel coerced into changing. He or she may be at
high risk for dropping out of treatment, or for
passivel y attending their appointments.
Research staff were also available to respond to
questions from clinicians about stage of
change. A member of the participants clinical
team (either the psychotherapist or dietitian
working closely with the participant) was asked
to rate the participants readiness to change
(Precontemplation, Contemplation, or Prepara-
tion/Action), using three choices of stages to
match EDSOC scoring.
Body Shape Questionnaire (BSQ) (32, 33).
The BSQ was designed to assess cognitive and
affective aspects of body weight and shape
concerns among individuals with eating disor-
ders or body image disturbance. The measure
has established reliability (test-retest=0.88) and
concurrent and convergent validity among
both female and male participants (33). Internal
consistency among the current sample was 0.97
(Cronbachs alpha).
Statistical analyses
Descriptive statistics provide a description of
the sample, including gender, age, BMI, eating
disorder diagnosis and treatment milieu. Inter-
nal consistency for the EDSOC was established
using Cronbachs alpha, calculated separately
for each eating disorder behavior. For all
analyses using a specific eating disorder behav-
ior included in the EDSOC, only those partici-
pants who endorsed engaging in that specific
behavior were included in the analyses.
The test-retest method, in which the same
people are retested by the same test after a
period of time (one-week), was used to deter-
mine reliability using Spearmans correlation
coefficient, and was calculated separately by
diagnosis and by age group (<18 vs 18 years).
Spearmans correlation coefficient is consid-
ered to be a better indicator of reliability for
ordinal data because it uses ranks and not
numbers to calculate the correlation. For ordi-
nal data, it is difficult to assume that the dis-
tances between categories are equal. For
example, is the arduousness of the steps to
move an individual from Precontemplation to
Contemplation the same level of difficulty as
those to move from Contemplation to Prepara-
tion? Correlations were calculated separately
for each eating disorder symptom by correlat-
ing stage of change, as calculated by the
EDSOC, at Time 1 with those from Time 2.
Because the instrument is measuring readiness,
an unstable trait that changes over the course
of treatment, the retest was conducted at a
close interval (one-week). The correlation coef-
ficient is minimally estimated to be moderate,
defined by Cohen as +/- 0.30 to 0.49 (34),
reflecting overall strength of the correlation yet
allowing for some variability across the one-
week interval.
Convergent val i di ty i s concerned wi th
demonstrating that two independent methods
of inferring an attribute are similar. To exam-
ine convergent validity, Spearmans correla-
tions were generated across diagnosis and
across age group for each behavior using the
EDSOC and three similar measures: the SOC-
Q, the participants own rating of their inten-
tion to complete treatment, and a clinicians
rating of the participants stage of change. In
addition, a single stage of change score (using
the lowest stage of change for any eating dis-
D.M. Ackard, J.K. Croll, S. Richter, et al.
e70 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
order behavior) obtained from the EDSOC was
compared to the overall SOC-Q score, partici-
pants rating of their intent to complete treat-
ment, and clinicians rating of the participants
stage of change using Spearmans correlation
coefficient.
A measure possesses divergent validity in the
sense of measuring something theoretically
disparate. Therefore, measures of different
attributes should not correlate to an extremely
high degree (e.g., be less than a large correla-
tion as defined by Cohen as |0.50|) (34). Diver-
gent validity was assessed across diagnosis and
across age group by examining Spearmans
correlation coefficients between the EDSOC
and age, BMI, and overall score on the BSQ.
Spearmans correlation coefficients should be
low to establish divergent validity.
RESULTS
Internal consistency
Internal consistency reliability was measured
using Cronbachs alpha. Internal consistency, in
order of increasing correlation, was 0.33 for fast-
ing, 0.33 for laxative use, 0.43 for dietary restric-
tion, 0.46 for self-induced vomiting, 0.47 for
diuretic use, 0.52 for diet pill use, 0.77 for use of
metabolic enhancers, and 0.78 for binge eating.
Test-retest reliability
The EDSOC demonstrated reasonable test-
retest reliability over a period of one-week
across eating disorder diagnoses and age
groups (see Tables 1A for results by diagnosis
and 1B for results by age group). The strength
of the test-retest reliability was generally high-
est for those behaviors that are congruent with
the diagnosis. For example, the reliability of
fasting and restricting behaviors among
patients with anorexia nervosa was strong and
interpreted as a large effect according to
Cohen (34), as was that of binge-eating and
various compensatory behaviors among
patients with bulimia nervosa. The picture for
patients diagnosed with EDNOS was more var-
ied, as could be expected, as the diagnosis itself
captures a broader range of presenting behav-
iors. Test-retest reliability by age group also
showed strong reliability and large effects
among children aged 12-17 and among adults
18 years of age or older, with the exception of
binge eating among adults which showed only
a moderate effect.
Convergent validity
Convergent validity estimates were variable
across diagnosis and age group (see Table 2A
for results by diagnosis and 2B for those by
age group), but generally stronger with those
behaviors that are congruent with the diagno-
sis, and stronger between the EDSOC measure
and the patients own rating of his or her
intention to complete treatment than the clini-
cian rating of stage of change and the SOC-Q.
For example among patients with anorexia
nervosa, the EDSOC rating for diet pill use
was strongly correlated with the SOC-Q over-
all score and showed higher agreement with
the patients own intention to complete treat-
ment than the clinician rating. Results strati-
TABLE 1B
Test-retest reliability across one week, by behavior, for the Eating
Disorders Stage of Change (EDSOC): Spearmans correlation
by age group.
TABLE 1A
Test-retest reliability across one week, by behavior, for the Eating
Disorders Stage of Change (EDSOC): Spearmans correlation
by diagnosis.
AN (N=51) BN (N=21) EDNOS (N=53)
Binge eat N/A (N=0) 0.667 (N=16) 0.276 (N=12)
Fast 0.866* (N=10) 0.258 (N=8) 0.375 (N=9)
Restrict 0.896* (N=31) 0.330 (N=15) 0.626* (N=31)
Purge 0.474 (N=8) 0.845* (N=15) 0.786* (N=23)
Laxative use 0.500 (N=3) 1.000* (N=3) 0.395 (N=5)
Diet pill use 0.866 (N=3) 1.000* (N=4) 1.000* (N=5)
Diuretic use N/A (N=0) 1.000* (N=3) 1.000* (N=3)
Metabolic N/A (N=1) 1.000* (N=5) 1.000* (N=4)
enhancement use
*Significant at p=0.05. Spearmans correlation coefficient was used because the
data are ordinal. The number of respondents noted in parentheses refers to the
number of persons completing all three questions for the EDSOC behavior listed
(not all respondents endorsed use of all behaviors).
AN: anorexia nervosa; BN: bulimia nervosa; EDNOS: eating disorder not other-
wise specified; N/A: not assessed.
Children (N=42) Adults (N=103)
Binge eat 0.581 (N=6) 0.345 (N=32)
Fast 0.569 (N=7) 0.553* (N=26)
Restrict 0.575* (N=23) 0.687 *(N=64)
Purge 0.897* (N=9) 0.629* (N=44)
Laxative use N/A (N=1) 0.817* (N=12)
Diet pill use N/A (N=2) 0.839* (N=12)
Diuretic use N/A (N=0) 1.000* (N=6)
Metabolic enhancement use N/A (N=0) 0.905* (N=11)
*Significant at p=0.05. Spearmans correlation coefficient was used because the
data are ordinal. The number of respondents noted in parentheses refers to the
number of persons completing all three questions for the EDSOC behavior listed
(not all respondents endorsed use of all behaviors).
N/A: not assessed.
Eating Disorders Stage of Change
e71 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
TABLE 2B
Convergent validity between each behavior listed in the Eating Disorders Stage of Change and values on similar constructs by age group.
TABLE 2A
Convergent validity between each behavior listed in the Eating Disorders Stage of Change and values on similar constructs by diagnosis.
fied by children and adults showed good con-
vergent validity with the exception of a few
outliers (e.g., among children, the SOC-Q
score with EDSOC purging and the clinician
rating with EDSOC laxative use; among adults,
the SOC-Q score with EDSOC purging, laxa-
tive, or diuretic use).
Divergent validity
Divergent validity was measured by Spear-
mans correlation coefficients, and results are
listed in Table 3A by diagnosis and Table 3B by
age group. Divergent validity values were gen-
erally low (indicating good divergent validity)
across diagnosis and age group when compar-
ing the EDSOC behaviors with BMI. There
were some significant associations between
age and EDSOC behaviors by diagnosis (laxa-
tive use with AN; purging, laxative use and diet
pill use with BN) with stronger correlations
indicating that higher age was associated with
higher stage of change. Furthermore, and per-
haps not entirely unexpected, there were sig-
nificant associations between the BSQ and
intention to change, with greater body shape
concerns being associated with lower intention
to change eating disorder behaviors (particu-
larly among patients diagnosed with EDNOS,
and also among children for fasting behavior
and among adults for restricting and purging
behaviors).
DISCUSSION
The current study investigated the utility of a
self-report measure assessing stage of change
among individuals receiving treatment for an
eating disorder. The EDSOC measure was
found to have good internal consistency and
Children (N=42) Adults (N=103)
SOC-Q
1
Patient intent
2
Clinician rating
2
SOC-Q
1
Patient intent
2
Clinician rating
2
Binge eat 0.394 50.0% 33.3% 0.183 57.8% 56.3%
Fast 0.704* 23.1% 55.5% 0.268 51.0% 45.9%
Restrict 0.595* 17.9% 38.7% 0.288* 35.6% 41.2%
Purge -0.060 37.5% 28.6% 0.093 60.0% 47.7%
Laxative use N/A 100% 0.0% -0.008 66.7% 44.4%
Diet pill use 0.775 50.0% 25.0% 0.383 45.0% 50.0%
Diuretic use N/A N/A N/A 0.040 50.0% 50.0%
Metabolic enhancement use N/A N/A N/A 0.406 50.0% 36.3%
*Significant at p=0.05.
1
Spearmans correlation coefficient used because the data are ordinal.
2
Simple percent agreements (# agreed/total).
N/A: not assessed; SOC-Q: Stages of Change Questionnaire.
AN (N=51) BN (N=21) EDNOS (N=53)
SOC-Q
1
Patient Clinician SOC-Q
1
Patient Clinician SOC-Q
1
Patient Clinician
intent
2
rating
2
intent
2
rating
2
intent
2
rating
2
Binge eat 0.274 25.0% 40.0% 0.310 61.9% 55.0% -0.162 57.9% 50.0%
Fast 0.294 47.4% 35.3% 0.236 38.5% 50.0% 0.345 50.0% 53.3%
Restrict 0.409* 26.1% 41.5% 0.301 35.0% 47.4% 0.270 30.4% 37.1%
Purge -0.145 52.9% 38.5% 0.353 65.0% 52.6% -0.129 51.9% 40.9%
Laxative use -0.073 57.1% 33.3% 0.632 71.4% 71.4% -0.596 77.7% 16.7%
Diet pill use 0.541 66.7% 16.7% 0.889* 60.0% 80.0% 0.383 30.0% 50.0%
Diuretic use N/A N/A N/A 0.866 66.7% 66.7% -0.487 40.0% 33.3%
Metabolic enhancement use N/A 66.7% 33.3% 0.725 80.0% 50.0% 0.833 16.7% 25.0%
*Significant at p=0.05.
1
Spearmans correlation coefficient used because the data are ordinal.
2
Simple percent agreements (# agreed/total).
AN: anorexia nervosa; BN: bulimia nervosa; EDNOS: eating disorder not otherwise specified; N/A: not assessed; SOC-Q: Stages of Change Questionnaire.
D.M. Ackard, J.K. Croll, S. Richter, et al.
e72 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
test-retest reliability over a one-week period
with both children and adults, particularly with
behaviors that are congruent with the diagno-
sis. Divergent validity was found to be good
with BMI and age (with a few exceptions in
which older age was associated with greater
readiness to change a particular behavior), but
less so with the BSQ. There were several
instances, particularly among EDNOS patients,
in which higher scores on the BSQ (indicating
greater body shape concerns) were associated
with lower stage of change, perhaps due to
poor body image being a maintaining factor
behind the continuation of these behaviors.
Convergent validity estimates were varied, but
strongest for behaviors that are congruent
with the diagnosis, and when comparing the
EDSOC measure to the patients rating of his
or her own intention to complete treatment
compared to clinician rating or the SOC-Q
overall score. This may reflect that patients
know themselves better than their clinicians,
and that the SOC-Q, a general stage of change
measure that asks patients their intention to
change the eating disorder as the identified
problem, is not specific enough to measure a
complex disorder. These results mirror those
of other health behavior researchers who have
encountered difficulties measuring stage of
change for a multi-symptom disorder with
likely differing stages of change for each
symptom (19-23).
The EDSOC was designed to bridge the
chasm between self-report instruments that do
not capture the complexity of eating disorder
behaviors and interviews that can be costly in
time and monies. The Readiness and Motiva-
tion Interview (RMI) appears to be the most
comprehensive and thorough assessment avail-
able for measuring stage of change among
TABLE 3B
Divergent validity between each behavior listed in the Eating Disorders Stage of Change and values on three disparate constructs
by age group.
TABLE 3A
Divergent validity between each behavior listed in the Eating Disorders Stage of Change and values on three disparate constructs
by diagnosis.
AN (N=51) BN (N=21) EDNOS (N=53)
Age BMI BSQ Age BMI BSQ Age BMI BSQ
Binge eat -0.293 -0.218 0.000 0.017 0.209 0.217 0.184 0.043 -0.408
Fast 0.056 -0.142 -0.394 0.376 0.132 -0.037 0.073 0.085 -0.506*
Restrict 0.104 0.074 -0.241 -0.183 -0.101 -0.071 0.012 0.127 -0.416*
Purge 0.245 0.273 0.135 0.482* 0.162 -0.145 0.075 -0.021 -0.514*
Laxative use 0.882* -0.621 0.367 0.805* 0.158 0.474 -0.280 -0.160 -0.730*
Diet pill use 0.549 -0.439 -0.343 0.889* 0.447 0.000 -0.137 -0.090 -0.719*
Diuretic use N/A N/A N/A 0.866 0.000 0.000 N/A -0.948* -0.316
Metabolic enhancement use N/A N/A N/A 0.725 -0.258 -0.725 -0.532 -0.494 -0.617
*Significant at p=0.05. Spearmans correlation coefficient used because the data are ordinal.
AN: anorexia nervosa; BMI: body mass index; BN: bulimia nervosa; BSQ: Body Shape Questionnaire; EDNOS: eating disorder not otherwise speci-
fied; N/A: not assessed.
Children (N=42) Adults (N=103)
Age BMI BSQ Age BMI BSQ
Binge eat 0.287 -0.274 -0.181 0.013 0.085 -0.141
Fast 0.080 0.090 -0.579* 0.119 -0.109 -0.354
Restrict 0.079 -0.012 -0.324 -0.022 0.097 -0.328*
Purge -0.157 0.111 -0.006 0.032 0.088 -0.266*
Laxative use N/A N/A N/A 0.357 -0.271 -0.085
Diet pill use 0.544 -0.775 -0.775 0.251 -0.128 -0.250
Diuretic use N/A N/A N/A 0.418 -0.261 -0.365
Metabolic enhancement use N/A N/A N/A 0.070 -0.024 -0.388
*Significant at p=0.05. Spearmans correlation coefficient used because the data are ordinal.
BMI: body mass index; BSQ: Body Shape Questionnaire; N/A: not assessed.
Eating Disorders Stage of Change
e73 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
populations of individuals with eating disor-
ders (25, 26). Its use in conjunction with a clini-
cal interview provides specific information on
an individuals readiness to change each specif-
ic behavior, and this information can be clini-
cally useful toward tailoring the treatment
intervention and milieu toward the readiness of
the individual. However, the RMI can take over
one hour for trained staff to administer, and
consequently may not be a feasible option for
all research and clinical settings.
To date, the bulk of research on stage of
change and treatment outcome in eating disor-
ders has demonstrated that readiness to
change can predict symptom use among some
populations receiving specific types of treat-
ment (20, 27-30). While future research is
needed to determine whether stage of change
can be applied more broadly to many theoreti-
cal orientations and therapeutic milieus, eating
disorder treatment programs should consider
offering therapeutic interventions by readiness
to change disordered eating behaviors. Several
research studies have investigated tailoring
treatment programs to an individuals stage of
change, but results have varied and may be
related to differences in assessing stage of
change. For example, Tantillo et al. developed
a relational/motivational group for women
with eating disorders in the contemplation
phase (35), and the authors presented ideas on
how to integrate relational and motivation the-
ories to enhance treatment outcome for this
high-risk group. Feld et al. examined the
effects of providing Motivational Enhancement
Therapy (MET) to eating disorder (mixed diag-
noses) patients prior to treatment (36), and
found that stage of change scores were not
significant predictors of treatment outcome for
those in Precontemplation or Contemplation
stages, but were significant for those in Action
phase from pre-treatment to post-treatment.
Touyz et al. developed 3- and 5-day hospital
programs for individuals struggling against
anorexia nervosa (37), incorporating interven-
tions from motivational, cognitive, and behav-
ioral therapies, including psychoeducation,
cost/benefit analysis, describing the future
with and without the eating disorder, enhance-
ment of self-efficacy for change, identifying
barriers to change and factors that support
change, externalization of the eating disorder,
and relapse prevention. Data on the effective-
ness of these programs in increasing treatment
efficacy are being collected, but are not yet
available.
Geller et al. found that stage of change pre-
dicted decision to enroll in treatment, dropout
of treatment, maintain symptom change follow-
ing treatment, and maintenance of symptom
change at 6-month follow-up among a group of
64 women entering residential treatment for an
eating disorder (38). The thoroughness of their
assessment (being able to assess stage of
change for specific symptoms and not combin-
ing symptoms) is a considerable strength of
their study. However, other sites may not be
able to replicate their procedures for collecting
stage of change data due to the cost of staff
time.
The current study should be considered in
the context of several strengths and limitations.
The development of a cost-effective, specific
measure to assess readiness to change eating
disorder behaviors is a strong point of this
study. The measure is easy to administer and
score, and thus has applications in both
research and clinical settings. The study partic-
ipants were diverse with respect to age, BMI,
eating disorder diagnosis, point in treatment,
treatment milieu, and self-report readiness to
change. However, future studies could use a
larger sample. Furthermore, the EDSOC mea-
sure focused only on the main weight-related
behaviors associated with eating disorders and
did not address other factors of interest (such
as previous treatment history) or other symp-
toms of clinical significance, such as compul-
sive exercise, body and shape checking, ritual-
ized eating, and obsessive-compulsive traits, or
cognitive and affective elements associated
with eating disorders. In addition, the results
from this sample of individuals seeking treat-
ment for an eating disorder are not easily gen-
eralized to all individuals struggling against
eating disorders; although the current sample
was large, only a small number of respondents
reported the use of some symptoms of interest.
Finally, it is important to acknowledge that
readiness to change is a complex construct,
thus a single measure may not be able to gath-
er the same amount or quality of information
as gleaned in an extensive interview.
The EDSOC questionnaire is an efficient and
cost-effective measure assessing Precontempla-
tion, Contemplation, or Preparation stages for
eating disorder behavior change. The EDSOC
demonstrates good internal consistency and
test-retest reliability over a one-week period
and across diagnoses and age groups. Diver-
gent validity was good as compared to age and
BMI, but results showed significant associa-
tions between the BSQ and stage of change,
suggesting that increased body shape concerns
are associated with decreased intention to
change eating disorder behavior. Convergent
validity was best when the behavior in question
was congruent with the patients diagnosis,
D.M. Ackard, J.K. Croll, S. Richter, et al.
e74 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
APPENDIX A
EATING DISORDERS STAGE OF CHANGE
Please answer the following questions by checking yes or no for each question. The questions are broken down
by a specific behavior. If you do not engage in the behavior listed, check the box at the top of that behavior, skip the
questions for that behavior, and go on to the next behavior.
Binge eating Check here if you do not binge eat
Do you intend to stop binge eating in the next 6 months? Yes No
Do you intend to stop binge eating in the next 30 days? Yes No
In the past year, before coming to this clinic, have you had definite
plans to stop binge eating (either on your own or with outside help)
and have you actually attempted to carry out these plans? Yes No
Fasting Check here if you do not fast
Do you intend to stop fasting in the next 6 months? Yes No
Do you intend to stop fasting in the next 30 days? Yes No
In the past year, before coming to this clinic, have you had definite
plans to stop fasting (either on your own or with outside help)
and have you actually attempted to carry out these plans? Yes No
Restricting my intake Check here if you do not restrict
Do you intend to stop restricting in the next 6 months? Yes No
Do you intend to stop restricting in the next 30 days? Yes No
In the past year, before coming to this clinic, have you had definite
plans to stop restricting (either on your own or with outside help)
and have you actually attempted to carry out these plans? Yes No
Self-induced vomiting / Purging Check here if you do not purge
Do you intend to stop purging in the next 6 months? Yes No
Do you intend to stop purging in the next 30 days? Yes No
In the past year, before coming to this clinic, have you had definite
plans to stop purging (either on your own or with outside help)
and have you actually attempted to carry out these plans? Yes No
Use of laxatives to lose or maintain weight Check here if you do not use laxatives
Do you intend to stop using laxatives in the next 6 months? Yes No
Do you intend to stop using laxatives in the next 30 days? Yes No
In the past year, before coming to this clinic, have you had definite
plans to stop using laxatives (either on your own or with outside help)
and have you actually attempted to carry out these plans? Yes No
Use of diet pills to lose or maintain weight Check here if you do not use diet pills
Do you intend to stop using diet pills in the next 6 months? Yes No
Do you intend to stop using diet pills in the next 30 days? Yes No
In the past year, before coming to this clinic, have you had definite
plans to stop using diet pills (either on your own or with outside help)
and have you actually attempted to carry out these plans? Yes No
Use of diuretics (water pills) to lose or maintain weight Check here if you do not use diuretics
Do you intend to stop using diuretics in the next 6 months? Yes No
Do you intend to stop using diuretics in the next 30 days? Yes No
In the past year, before coming to this clinic, have you had definite
plans to stop using diuretics (either on your own or with outside help)
and have you actually attempted to carry out these plans? Yes No
Use of metabolic enhancements (ephedrine, etc.) Check here if you do not use metabolic
enhancements
Do you intend to stop using metabolic enhancers in the next 6 months? Yes No
Do you intend to stop using metabolic enhancers in the next 30 days? Yes No
In the past year, before coming to this clinic, have you had definite
plans to stop using metabolic enhancers (either on your own or with
outside help) and have you actually attempted to carry out these plans? Yes No
Eating Disorders Stage of Change
e75 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
and when measured against the patients own
rating of his or her intention to complete treat-
ment. This preliminary instrument shows good
psychometric properties among children and
adults, particularly when assessing the behav-
iors that are most congruent with the patients
eating disorder diagnosis.
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Vol. 14: e77-e83, June-September 2009
e77
ORIGINAL
RESEARCH
PAPER
Key words:
Internet addiction, eating
disorders, China, students.
Correspondence to:
Zhuoli Tao,
Department Psychology,
School of Social
Development,
Fudan University,
Handan Road nr. 220,
200433 Shanghai, China.
E-mail: zhuolitao@yahoo.de
Received: April 8, 2008
Accepted: November 5, 2008
Is there a relationship between Internet
dependence and eating disorders?
A comparison study of Internet
dependents and non-Internet
dependents
INTRODUCTION
The explosive growth of Internet use in
the last decade had a great influence on
psychological research in understanding
its role in communication and interper-
sonal behavi or ( 1) . Researchers pai d
increased attention to the addictive poten-
tial of the Internet (2). The terms Internet
addiction, pathological Internet users
or problematic Internet users have been
used to describe problematic, excessive
use of the Internet (3-8). The proper detec-
tion and diagnosis of Internet addition is
difficult, as there is no unique classifica-
tion in the Diagnostic and Statistical Man-
ual of Mental Disorders - Fourth Edition
(DSM-IV) (9). Griffiths gave the first defin-
ition for an Internet- related disorder:
Internet Addiction Disorder (IAD) is a
behavioral addiction, which has six core
components: salience, mood modification,
tolerance, withdrawal symptoms, conflict,
and relapse (2).
Griffiths found that the source of this
addiction can be created from one or
more aspects of Internet use including the
process of typing, the medium of commu-
nication, the lack of face-to-face contact,
Internet content, or online social activities
(2, 8).
A second definition for an Internet-
related disorder was offered by Young. It
was called pathological Internet use
(PIU). Young used the criteria of patholog-
ical gambling in DSM-IV as a model. If the
individuals meet five of eight criteria for
Internet addiction, they will be defined as
dependent. These include: (A) preoccupa-
tion with the Internet, (B) need for longer
amount of ti me onl i ne, ( C) repeated
attempts to reduce Internet use (D) with-
drawal when reducing Internet use, (E)
time management issues, (F) environmen-
tal distress (family, school, work, friends),
(G) deception around time spent online,
and (H) mood modification through Inter-
net use (4, 5, 8).
Z.L. Tao
1
, and Y. Liu
2
1
Department of Department of Psychology, School of Social Development, Fudan Univeristy, Shanghai,
2
Health Education Institute, Health Department of Yunnan Province, Kunming, China
ABSTRACT. OBJECTIVE: Several studies have examined the underlying psychopathology
in overuse of the Internet, including depression, social anxiety, and substance dependence. A
relationship between these psychological disorders appears to exist. No links have been
established between Internet dependence and eating disorders. METHOD: Fifty-four Inter-
net dependents were compared with a control group concerning symptomatic aspects of eat-
ing disorders and psychological characteristics related to eating disorders. They all belonged
to 1199 respondents of Chinese secondary school and college students between the ages of
12 and 25 years old. A Mann-Whitney U-test was used to determine the difference between
Internet dependent groups and non-Internet dependent groups concerning Eating Attitudes
Test and Eating Disorder Inventory scores. RESULTS: Females and male Internet depen-
dents rated themselves with significantly higher symptomatic aspects of eating disorders
than control groups. Female and male Internet dependents showed significantly higher psy-
chological characteristics related to eating disorders than control groups. CONCLUSIONS:
A relationship between Internet dependence and eating disorders appears to exist.
(Eating Weight Disord. 14: e77-e83, 2009).
2009, Editrice Kurtis
Z.L. Tao, and Y. Liu
Several studies have examined underlying
psychopathology in excessive use of the Inter-
net, including depression, social anxiety, and
substance dependence (10). A relationship
between these psychological disorders appears
to exist (7). Rierdan (11) believes that method-
ological problems have hindered the power of
these studies.
Research by Young and Rodgers (12) has
demonstrated that a significant level of depres-
sion is associated with pathological Internet
use. Eating disorders are related with depres-
sion (13).
Armstrong et al. (14) found that low self-
esteem is associated with Internet dependence;
bulimics exhibit low self-esteem and a strong
desire to please others (15). Laceys study
shows that addictive behaviors are common in
bulimic women (13). Adolescents with Internet
addiction had a higher risk of substance use
experience (16). Questions have been raised as
to whether Internet dependents also are at a
high risk of eating disorders.
Therefore, the following hypotheses have
been developed:
1. Internet dependents show significantly high-
er scores related to symptomatic aspects of
eating disorders (determined by drive for
thinness, bulimia and body dissatisfaction)
than non-Internet dependents;
2. Internet dependents show significantly high-
er scores concerning psychological charac-
teristics related to eating disorders (deter-
mined by the ineffectiveness, perfectionism,
interpersonal distrust, interoceptive aware-
ness and maturity fears) than non-Internet
dependents.
This current survey was conducted with a
sample of Chinese secondary school and col-
lege students. Originally this survey was
designed to compare mental health between
two racegroups in China: Han Chinese (majori-
ty in China, over 90% of China 1.3 billion popu-
lation are ethnically Han Chinese) and Uiguren
Chinese (a Muslim minority of 8 million people
living in West China).
METHOD
Participants
This survey was administered by the School of
Social Science, University of Goettingen, Ger-
many, and Health Education Institute, Health
Department of Yunnan Province in China.
The data for this survey were collected from
February to April 2006 using a cohort of 1252
Chinese secondary school and college stu-
dents aged 12 to 25 years (mean =18.99, stan-
dard deviation =2.92) in two cities: Nanjing
(five million inhabitants) and Urumqi (three
million inhabitants). There were seven data
col l ecti on si tes (one uni versi ty and two
schools in Nanjing and two universities and
two schools in Urumqi). Authorities, teachers
and students had previously received a writ-
ten description of the survey. Consent forms
were distributed to secondary school stu-
dents, seeking the signature of at least one
parent. The test takers were informed that
participation was voluntary and anonymous.
The questi onnai re was transl ated by the
Author into Chinese for the Han participants,
and it was also translated into Uiguren for
Uiguren participants by native Uiguren. Stu-
dents responded to self-administered ques-
tionnaires in the classroom during a 20-30
minute session. The available questionnaire
was returned by 1199 participants (95.67%),
including 767 girls (63.9% of respondents) and
432 boys (36.1% of respondents). Both sec-
ondary school students and college students
completed more than 80% of the question-
naire items. Missing values for both groups
were replaced with the mean responses of
same-gender participants of the same age.
The secondary school students obtained the
parents written consents.
According to Youngs Internet addiction
diagnosis criteria (17), participants were con-
sidered addicted when answering yes to
five (or more) of the eight yes or no ques-
tions. In this survey the participants were con-
sidered to be in the control groups if they had
not been considered as addicted in terms of
Youngs criteria and on average, spent no more
than 10 hours per week online for non-academ-
ic aims. There was a male control group
(N=278) and a female control group (N=611).
Assessment instruments
Demographic features
The demographic characteristics of the par-
ticipants were obtained through a question-
naire covering the participants gender, age,
height, weight.
The Eating Attitudes Test (EAT-26)
The EAT-26 (18) is a shortened version of the
EAT-40 questionaire. The EAT-40 is a self-
reporting instrument for the study of eating
disorders within clinical and non-clinical
groups; it was devised by Garner and Garfinkel
(19). A factor analytical study (20) identified
three subscales (Dieting, Bulimia and Oral
control) and found that the EAT-26 did not
lose internal reliability or discriminatory diag-
nostic validity (21).
e78 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
Internet dependence and eating disorders
Cronbachs for the EAT was 0.83 for female
participants and 0.79 for male participants,
indicating an acceptable degree of internal con-
sistency for the questionnaire.
The Eating Disorder Inventory (EDI)
The original EDI-1 (22) is a 64-item self-
report instrument that measures psychological
and behavioral traits common in individuals
with an eating disorder (23). The EDI is pro-
posed to measure not only symptomatic
aspects of eating disorders (determined by the
Drive for thinness, Bulimia and Body dis-
satisfaction subscales) but also the fundamen-
tal psychological characteristics (determined by
the Ineffectiveness, Perfectionism, Inter-
personal distrust, Interoceptive awareness
and Maturity fears subscales) (24).
Aschenbrenner et al. (25) used the first three
subscales of EAT-26 (Dieting, Bulimia and
Oral control), the last six subscales of EDI-1
(Body dissatisfaction, Ineffectiveness, Per-
fectionism, Interpersonal distrust, Intero-
ceptive awareness) and indicated in their sur-
vey an acceptable degree of validity and relia-
bility. The instrument has been adapted in this
present survey.
Cronbachs for the EDI was 0.83 for female
participants and 0.85 for male participants,
again indicating an acceptable degree of inter-
nal consistency for the questionnaire.
The questionnaire for Internet addiction
Youngs (17) screening instrument of Internet
addiction was used to measure addictive Inter-
net use that modified the DSM-IV criteria for
pathological gambling to classify subjects as
addicted or non-addicted. The questionnaire is
one of the most frequently used diagnostic
questionnaires for Internet addiction (8, 12, 26).
Cronbachs for the questionnaire for Inter-
net addiction was 0.82 for female participants
and 0.80 for male participants, again indicating
an acceptable degree of internal consistency
for the questionnaire.
The full questionnaire is in the Appendix.
Internet usage pattern
Internet usage patterns were measured by
asking participants about the average amount of
time they spent online for non-academic aims
per week. Participants were code 1 meaning 0-
10 hours per week, 2 meaning 11-20 hours per
week, 3 meaning 21-30 hours per week, and 4
meaning higher than 30 hours per week.
Data analysis
Data analyses were conducted with SPSS
13.0 (SPSS Inc., Chicago, IL, USA). An indepen-
dent samples T-test was conducted to establish
the difference between Internet dependent
groups and non-Internet dependent groups
concerning demographic information. A
Mann-Whitney U-test was used to determine
the difference between Internet dependent
groups and non-Internet dependent groups
concerning EAT and EDI scores. Statistical sig-
nificance was based on two-sided tests evaluat-
ed at the 0.05 level of significance.
RESULTS
Data showed that 54 participants (4.5%) of
the 1199 participants according to Youngs
definition of Internet addiction (18) were con-
sidered Internet dependents. Among the 54
Internet addicts there were 22 girls (2.9% of
all 767 girls) and 32 boys (7.4% of all 432
boys). The physical characteristics of each of
the two groups (female Internet dependent
group and female non-Internet dependent
group; male Internet dependent group and
male non-Internet dependent group) are sum-
marized in Table 1. As assessed by the body
mass index (BMI), the male Internet depen-
dents were significantly heavier in compari-
son with the male Non- Internet dependent
group. However, there were no differences
between the two compared groups regarding
age, height, and weight.
The comparison between Internet dependent
groups and non-Internet dependent groups
concerning scores on the EAT and the EDI are
shown in Table 2. One subscale of the EAT is
named EAT sum; the subscale is the sum of
the three subscales of the EAT (Diet behavior,
Bulimia, Oral control).
The female Internet dependents rated them-
selves significantly higher on Diet behavior,
Bulimia, Oral control and EAT sum on
the EAT than the female non-Internet depen-
dent group; they considered themselves also
significantly higher in Ineffectiveness and
Interoceptive awareness on the EDI than the
female non-Internet dependent group. By con-
trolling for BMI (exclude the BMI>24, female
overweight group), there was no significant
change in the table.
With respect to the Ineffectiveness and
Interoceptive awareness subscales the male
Internet dependents rated themselves signifi-
cantly higher than the non-Internet dependent
group. By controlling for BMI (exclude the
male overweight group, BMI>25), the male
Internet dependents demonstrated significantly
higher on Oral control (Z=-3.033, p=0.002)
and EAT sum (Z=-2.781, p=0.005) on the EAT
than the male non-Internet dependent group,
e79 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
Z.L. Tao, and Y. Liu
significantly higher in Ineffectiveness (Z=
-3.324, p= 0.001) and Interoceptive awareness
(Z=-3.2, p=0.001) on the EDI than the male non-
Internet dependent group.
DISCUSSION
The survey shows that the female Internet
dependents rated themselves as having signifi-
cantly more Diet behavior, Bulimia, Oral
control and EAT sum than the non-Internet
dependent group on the EAT. The male Inter-
net dependents (exclude overweights, BMI>25)
perceived themselves as having significantly
more Oral control and EAT sum than the
non-Internet dependent group.
This could mean that a relationship between
eating disorders and Internet dependents
exists, although the direction of the relation-
ship is unknown.
By employing Griffithss theory (2) the con-
nection between Internet addiction and eating
disorder can be pictured as follows:
1. added salience - substance becomes the
most important thing in a persons life;
2. mood modification - substances are used to
change mood states;
3. relapse - the person returns to addictive
behavior, even after a period of abstinence.
e80 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
Female Female T p Male Male T p
Internet Non-Internet Internet non-Internet
dependents dependents dependents dependents
M (SE) M (SE) M (SE) M (SE)
N 22 611 32 278
Age 18.68 (3.01) 18.92 (3.77) 0.21 0.77 18.59 (4.82) 17.59 (3.92) 2.53 0.18
Height 1.60 (0.05) 1.62 (0.13) 0.13 0.67 1.68 (0.31) 1.71 (0.12) 4.69 0.37
Weight 50.32 (8.65) 51.90 (7.43) 1.44 0.33 63.66 (14.88) 60.93 (10.28) 2.21 0.18
BMI 19.51 (2.92) 19.80 (2.37) 1.74 0.57 21.84 (3.04) 20.81 (2.76) 0.72 0.05*
*Significant at the 0.05 level. BMI: body mass index; M: mean; SE: standard error.
Female Female Z p Male Male Z p
Internet non-Internet Internet non-Internet
dependents dependents dependents dependents
Mean rank Mean rank Mean rank Mean rank
(sum of ranks) (sum of ranks) (sum of ranks) (sum of ranks)
Diet behavior 438.71 (8335.5) 300.17 (176800.5) -3.415 0.001** 155.9 (4677) 145.42 (38101) -0.676 0.499
Bulimia 403.32 (7663) 301.31 (177473) -2.817 0.005** 157.5 (4725) 145.24 (38053) -0.872 0.383
Oral control 443.45 (8425.5) 300.02 (176710.5) -3.61 0.000*** 171.07 (5132) 143.69 (37646) -1.737 0.082
EAT sum 454.68 (8639) 299.66 (176497) -3.793 0.000*** 169.18 (5075.5) 143.9 (37702.5) -1.561 0.118
Body dissatisfaction 305.29 (5800.5) 298.79 (172702.5) -0.162 0.871 161 (4830) 140.88 (35925) -1.271 0.204
Ineffectivness 417.53 (7515.5) 293.23 (168605.5) -3.044 0.002** 174.75 (5242.5) 140.41 (36085.5) -2.154 0.031*
Perfectionism 238.82 (4060) 301.79 (175640) -1.482 0.138 158.88 (4766.5) 141.7 (36274.5) -1.079 0.28
Interpersonal distrust 330.68 (6283) 299.51 (174017) -0.775 0.438 151.5 (4393.5) 140.92 (35792.5) -0.664 0.507
Interoceptive
awareness 409.25 (7366.5) 291.4 (166388.5) -2.92 0.003** 173.38 (4854.5) 135.13 (33648.5) -2.412 0.016*
Maturity fears 294.82 (5601.5) 299.14 (172901.5) -0.108 0.914 145.87 (4376) 139.86 (36494) -0.385 0.7
*Significant at the 0.05 level; **significant at the 0.01 level; ***significant at the 0.001 level.
TABLE 1
Demographic information compared between Internet dependent and non-Internet dependent groups.
TABLE 2
Scores on the Eating Attitudes Test and the Eating Disorder Inventory of Internet dependent and non-Internet dependent groups.
Internet dependence and eating disorders
1. The Internet dependents stated that: for me,
the Internet is not a tool; it is a kind of habit or
everyday routine (26). Some people make
friends online, maintaining friendships and
finding support when those friendships end
(8). They find it difficult to form friendships in
real life because of, for example, shyness or
low self-confidence (1). For many people, the
Internet is an escape from reality and a way to
ease the pressures of everyday life (8).
Bulimic patients are invariably concentrated
on the thought of food and eating, weight and
shape. Such a person is highly worried about
her weight, shape and eating, to the extent
that it is one of the most important things that
makes them feel good or bad about them-
selves (27).
2. When bulimic patients or Internet dependents
feel lonely or depressed, they use binge eating
or Internet surfing to change moods in a short
time. The Internet dependents stay online for
pleasure (28). The disinhibition effect is also
a phenomenon that has been found with
online behavior (1). Marahan-Martin and
Schumacher (29) assumed that Internet
dependents were more socially disinhibited
online than non-addicts.
Clinically, the patients explained that the
behaviors (bulimic, self-damaging, addictive
behavior) were related with a similar sense of
being out of control, and that the patterns of
behavior fluctuated and were usually inter-
changeable. Usually the behaviors (bulimic,
self-damaging, addictive behavior) have a sim-
ilar function of reducing or blocking unpleas-
ant or distressing feelings (13).
3. Usually Internet addictions have negative
effects on school, family, health and finance
(26). Most Internet dependents had tried to
withdraw from the internet, but they felt
depressed and the withdrawal usually failed.
People who binge eat usually make an effort
to keep to extremely strict diets in between
episodes of binge eating. However, it is diffi-
cult to be successful with very strict diets
and repeated failures are common (27).
The result of this survey shows that Internet
dependents are more inclined toward bulimia
than anorexia (anorexia patients control them-
selves well). Welch and Fairburn (30) reported
in a UK study that substance abuse was also
higher among those with bulimia than among
those with restricting anorexia.
The survey shows that the female Internet
dependents rated themselves as having signifi-
cantly more Diet behavior, Bulimia, and
Oral control than the non-Internet dependent
group on the EAT. The male Internet dependents
(exclude overweights, the BMI>25) perceived
themselves as having significantly more Oral
control than the non-Internet dependent group.
The relationship between bulimia and Internet
addiction is not clear, but it may be a parallel
symptom rather than a consequence of the addic-
tion. Lacey (13) reported the symptoms (bulimic,
self-damaging, addictive behavior) can switch
when a bulimic patient moves from just abusing
food to other aberrant self-damaging behaviors,
the multi-impulsive disorder rapidly escalates, in
turn encompassing further behavioral or addic-
tive problems. The higher rated Diet behavior
and Oral control may be a consequent compen-
satory behavior of bulimia. Binge eating is fol-
lowed by compensatory behaviors (31). Case
studies are necessary to examine the link between
bulimia and Internet addiction in further studies.
Low self-esteem is associated with addictive
behaviors (29). Craig (34) assumed that the peo-
ple who hold negative views of themselves use
addictive substances to withdraw from their low
self-confidence. This survey supports the find-
ings of Armstrong et al. (14), who found that low
self-esteem is associated with Internet depen-
dence. In this survey, self-esteem has been esti-
mated through the Ineffectiveness subscale in
the EDI questionnaire. In this survey, the Inter-
net dependent groups perceived themselves as
significantly more ineffective compared with the
non-Internet dependent groups.
This survey shows that the Internet depen-
dent groups considered themselves as signifi-
cantly higher in respect to Interoceptive
awareness on the EDI than the non-Internet
dependent groups.
The Interoceptive awareness subscale of
the EDI was used to measure and identify the
internal and external stimulus, such as hunger
or fill to eating (35).
The anorexia and bulimia patients scored sig-
nificantly higher than the control group on the
Interoceptive awareness subscale of the EDI,
which overlaps conceptually with alexithymia
(22, 36). Alexithymia patients demonstrated
great difficulties identifying and describing
subjective feeling states, distinguishing
between feelings and bodily sensations, and
they are characterized by an impoverished and
constricted fantasy life and a cognitive style
that is literally and externally oriented (37, 38).
The patients with anorexia nervosa showed
characteristics of alexithymia, particularly diffi-
culty in distinguishing emotional states from
bodily sensations (20). Davis and Marsh (39)
assumed that difficulty in identifying the emo-
tional states of bulimia patients was linked with
the onset of bulimic behaviors.
The Internet dependent groups rated them-
selves significantly higher on the Interoceptive
e81 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
Z.L. Tao, and Y. Liu
awareness subscales. The Internet dependents
actually did nothing but hang around on the
Internet (26). The Internet dependents showed
increased preoccupation with online activities
(1). It can be explained in the following way: they
were stimulated for such a long time by the
information on the Internet that the sensitivity of
their feeling would have decreased. Further
study should focus on transmission between the
Interoceptive awareness of Internet depen-
dents and their increased preoccupation.
The Internet dependent groups rated them-
selves significantly higher on the Interoceptive
awareness and Ineffectiveness subscales than
the non-Internet dependents groups. The results
show that Interoceptive awareness, similar to
Ineffectiveness or Low self-esteem, may be a
good indicator of Internet addiction.
Several limitations should be considered in this
survey. Due to the small sample of Internet
addicts, however, there can only be a limited
generalization of this study findings. Second, the
age range of the sample goes from early adoles-
cence well into adulthood. This is problematic in
terms of ensuring that the measures used are
valid both for children and adolescents and
adults. Third, the Internet dependents did not
score significantly higher on Body dissatisfac-
tion than the non-Internet dependent groups.
This weakens the Authors claims. Therefore a
case report is necessary. Fourth, the article is
based on the subjective self report survey, so for
the sake of validity, further studies are needed to
replicate the findings.
ACKNOWLEDGEMENTS
We are grateful to all the school and college students
who participated in this Project.
We wish to thank Mrs.Wang Ying and Mr. Gu
Minkang for the assistance with the manuscript.
W wish to thank Mrs. Zhou Lu, Mrs. Pia Ruenger for
the correction with the manuscript, and Mr. Matthias
Stadler, PhD, for his review and helpful l
e82 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
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e83 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
Vol. 14: e84-e91, June-September 2009
e84
ORIGINAL
RESEARCH
PAPER
Key words:
Perfectionism, impulsivity,
obsessive-compulsive,
anorexia nervosa, bulimia
nervosa, personality.
Correspondence to:
Helen Davies,
Eating Disorders Unit,
PO59, Institute of Psychiatry,
Kings College London,
De Crespigny Park,
London, SE5 8AF, UK.
E-mail:
Helen.Davies@iop.kcl.ac.uk
Received: June 3, 2008
Accepted: December 2, 2008
Multidimensional self reports
as a measure of characteristics
in people with eating disorders
INTRODUCTION
Various personality characteristics are
associated with eating disorders (ED),
including elevated levels of perfectionism,
impulsivity and obsessive-compulsiveness
(1-4). Knowing the extent to which these
constructs are present in people with ED
could improve understanding and help to
develop and plan better treatment. One way
these characteristics can be measured is
using self-report assessments. These come
in formats which yield a single unidimen-
sional score and those which yield multidi-
mensional and global scores (5-7). It is pos-
sible that dissection of the multidimensional
elements could provide a better under-
standing of characteristics maintaining ED
than the unidimensional score. For exam-
ple, in one study, it was found that by
manipulating one of the dimensions of per-
fectionism (personal standards), significant
changes occurred in eating attitudes and
behaviour (8). However, although this high-
lights the therapeutic value of targeting
specific aspects of a characteristic, the
extent to which multidimensional self
reports have been used to measure complex
characteristics in ED is variable. The cur-
rent study has explored perfectionism,
impulsivity and obsessive-compulsive char-
acteristics using multidimensional self
reports in groups of people with anorexia
nervosa (AN), bulimia nervosa (BN) and in
healthy controls (HC).
Perfectionism: self reports
In the 1990s, a unidimensional description
of perfectionism was replaced by several
multidimensional conceptualisations (5, 9,
10). The Frost Multidimensional Perfection-
ism Scale (FMPS) (5) has shown strong
validity (11) and approximately 30% of ED
studies have used this scale (12). The FMPS
assesses several dimensions of perfection-
ism with individuals displaying a varying
amount of overall perfectionism and vary-
ing amounts of each of the characteristics
assessed by the subscale (5). Two main fac-
tors underlie the subscales, these are
achievement striving, which includes per-
sonal standards and organisation, and
H. Davies, P.-C. Liao, I.C. Campbell, and K. Tchanturia
Eating Disorders Unit, Institute of Psychiatry, Kings College London, London, UK
ABSTRACT. This study used multidimensional self report assessments to measure perfec-
tionism, impulsivity and obsessive compulsive characteristics in females with anorexia ner-
vosa (AN), bulimia nervosa (BN) and in matched healthy controls (HC). The Frost Multidi-
mensional Perfectionism Scale (FMPS), Barrett Impulsivity Scale (BIS) and Obsessive Com-
pulsive Inventory-Revised (OCI-R) scale were completed by 107 participants (AN=30, BN=26,
HC=51), in parallel with clinical measures. Results show that people with AN have the high-
est scores on the dimensions of the FMPS as well as on the overall score; the AN and BN
groups have the highest scores on the dimensions and on the overall score of the OCI-R; on
the BIS, the AN and BN groups have the highest scores on the attention subscale, but there
are no group differences on the overall BIS scores. In relation to the FMPS, the global score,
and the subscales concern over mistakes and doubts about actions are all highly correlated
with both eating pathology (Eating Disorder Examination Questionnaire, EDE-Q) and low
global functioning (Structured Clinical Interview for DSM IV, SCID). The subscale obsessing
on the OCI-R shows a strong correlation with eating pathology. The overall score and also
the subscales of the BIS do not show strong correlations with eating pathology or poor glob-
al functioning. In conclusion, therapies should seek to address these specific areas which are
highly correlated with eating disorder pathology.
(Eating Weight Disord. 14: e84-e91, 2009).
2009, Editrice Kurtis
Multidimensional self reports in ED
e85 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
maladaptive perfectionism, which include con-
cern over mistakes, parental expectations and
doubts about actions (10).
The FMPS scale has been used to examine
people with AN and BN as well as to compare
people with ED with other psychiatric groups.
Most studies have compared AN and HC and
have found elevations in both achievement
striving and maladaptive perfectionism in
the AN group (13, 14). Fewer studies (with
more inconsistent findings) have used the
FMPS to examine patients with BN (15). The
FMPS has not been used to compare differ-
ences between AN and BN groups, although a
different multidimensional scale designed by
Hewitt and Flett (1991) found no differences in
how these groups scored on perfectionism (16).
Bulik et al. (17) found that individuals with an
ED scored higher on perfectionism than other
psychiatric groups, with the concern over mis-
takes and doubts about actions subscales
being especially elevated.
Impulsivity: self reports
Unidimensional measures of impulsivity have
found that people with BN have significantly
higher impulsivity than people with AN (18).
Multidimensional self reports measuring impul-
sivity have been used less frequently in ED.
However, one multidimensional measure which
has been used is the Barratt Impulsivity Scale-
Version 11 (BIS) (6). This is a well-validated
self-report measure with three subscales
including attentional impulsivity, motor impul-
sivity and non-planning impulsivity (19) and
has been used widely in studies with other psy-
chiatric groups (20, 21).
One study using the BIS in ED found this
group to be more impulsive on the attention-
subscale than HC: however, the AN group
were significantly less impulsive than the BN
and HC groups on the motoric and non-plan-
ning subscales (22). Another study also found
that the ED group scored significantly higher
on attentional impulsivity than the HC group:
however, only the people with BN and the AN
binge purge (ANBP) subtype showed elevations
on the motoric subscale and only the people in
the BN group showed elevations on the non-
planning subscale (23).
Obsessive-compulsive self reports
In the last decade, several self-report instru-
ments aimed at measuring obsessive-compul-
sive characteristics have been developed. For
example, the Padua Inventory (24), the Van-
couver Obsessional Compulsive Inventory (25),
the Yale Brown Obsessive Compulsive Scale
(26), the Maudsley Obsessive Compulsive
Inventory (MOCI) (27) and the Obsessive-Com-
pulsive Inventory-Revised (OCI-R) (7). The OCI-
R has good reliability and is a comprehensive
and non-biased instrument for ascertaining
obsessive-compulsive characteristics as well as
representing the complex phenomenology of
obsessive-compulsive characteristics (28). Fur-
thermore, it is brief, and allows the gathering
of a large amount of information quickly and
with low intensity of researcher input. In addi-
tion, it does not use a dichotomous scoring sys-
tem such as earlier versions of the Yale Brown
Obsessive Compulsive Scale.
Self-report measures for obsessive-compul-
sive behaviours in people with ED have pro-
duced mixed results with some identifying the
relative obsessional nature of people with AN
compared to those with BN (29-31), whilst
other studies have found that AN and BN sub-
jects do not differ in obsessive-compulsive
traits (32, 33).
Current study
This study used the FMPS, BIS and OCI-R to
a) compare people with clinically diagnosed AN
and BN to see if there are any group differ-
ences in how they score on multidimensional
measures of perfectionism, impulsivity and
obsessive-compulsiveness, and b) to explore
associations between the subscales of these
measures with ED symptomatology and with
global functioning.
METHODS
Participants
A total of 107 females participated in the
study, including 56 clinical participants 30
who met the Diagnostic and Statistical Manual
of mental Disorders - Fourth Edition (DSM-IV)
criteria for AN and 26 for BN. Exclusion crite-
ria included psychosis and severe suicidal
ideation as assessed by the Structured Clinical
Interview for DSM-IV Axis I and II disorders
(SCID) (34). ED participants were recruited
from the South London and Maudsley NHS
Trust and an ED volunteer database. Fifty-one
HC were recruited from the local community
using adverts placed in local libraries, leisure
centres and supermarkets. The study was
approved by the local Ethics Committee. Each
participant was provided with an information
sheet and written consent was obtained before
starting the study.
Procedure
The assessments took place at the Institute of
Psychiatry, Kings College London. During the
Eating Weight Disord., Vol. 14: N. 2-3 - 2009
H. Davies, P.-C. Liao, I.C. Campbell, et al.
e86 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
initial screening stage, a trained clinician admin-
istered the SCID to confirm any co-morbid
symptoms. Demographic and clinical variables
such as age, body mass index [BMI=(weight in
kg) / (height in m
2
)] and duration of illness were
obtained.
Measures
Self-report measures were administered to
participants including:
- The Global Assessment of Functioning Scale
(GAF) (DSM-IV) is a scale which measures
global functioning based on the SCID screen-
ing module. The scale ranges from 1 to 100
and has five anchor points (i.e. 1-20, 21-40
etc.) with higher scores indicating better life
functioning (34).
- The Eating Disorder Examination Question-
naire (EDE-Q) is a 36-item self-report measure
adapted from the EDE interview (35). The
EDE-Q requires participants to recall the fre-
quency of various ED related symptoms over
the previous 28 days. Scores on the EDE-Q are
divided into four subscales: a) restraint, b) eat-
ing concern, c) shape concern, and d) weight
concern. The global score is the average score
of the mean of each of the four subscales. The
scores are on a scale from 0-6.
- The FMPS (5) is a 35-item self-report ques-
tionnaire designed to assess the major dimen-
sions of perfectionism. Items are rated on a 5-
point scale ranging from 1 (= strongly dis-
agree) to 5 (= strongly agree). These dimen-
sions are: a) concern over mistakes, e.g. If I
fail at school/work, I am a failure as a person;
b) personal standards, e.g. I set higher goals
than most people; c) parental expectations, e.g.
My parents set very high standards for me; d)
doubts about actions, e.g. It takes me a long
time to do something right; and e) organisa-
tion e.g. Organisation is very important to me.
In the current study, the coefficient value for
the total perfectionism score was 0.93. The
range for the overall score is 35-175.
- The BIS (6) is a 30 item self-report measure of
impulsiveness. Items are rated on a 4-point Lik-
ert scale ranging from 1 (= rarely/never) to 4 (=
almost always/always). The BIS-11 consists of
three impulsivity subscales; a) attention, e.g. I
am restless at talks or lectures; b) motoric, e.g. I
buy things on impulse; and c) non-planning,
e.g. I say things without thinking. The coeffi-
cient was 0.82. The range for the overall
score is 30-120.
- The OCI-R (7) has 18 items scored on a 5-point
Likert scale 0-4. It has six subscales: a) wash-
ing, b) checking, c) ordering, d) obsessing, e)
hoarding, and f) mental neutralising. The OCI-
R retained good psychometric properties from
the original OCI questionnaire: it has high test
retest reliability (0.74-0.90), convergent (0.74-
0.98) and discriminant validity (0.53-0.85). The
range of the overall score is 0-72.
Data analysis
Statistical analysis was conducted using
SPSS for Windows (version 13). A series of
one-way analyses of variance (ANOVA) were
performed to compare demographic and clini-
cal variables such as age, estimated IQ, BMI, ill-
ness duration, SCID and self-report assessment
data. Bivariate correlations were conducted to
examine relationships between symptom sever-
ity (as measured by the SCID) and psychologi-
cal variables FMPS, BIS and OCI-R and rela-
tionships between EDE-Q and psychological
variables.
RESULTS
Demographic and clinical characteristics
Demographic characteristics and clinical
variables are summarised in Table 1. There is
no difference in any of the demographic char-
acteristics between the three groups (ie age
and years of education), but significant differ-
ences were found in BMI, lowest BMI and
duration of illness. As expected, the AN group
have the lowest BMI (15.5) and lowest ever BMI
(11.9); the BN group have a slightly longer
duration of illness (10.4 vs 8.7 years).
Significant differences were found in global
functioning as measured by the GAF: the AN
group have the lowest global score (37.9),
which means the poorest level of functioning
out of the three groups, and the BN group are
intermediate (63.5) between them and the HC
group (86.9). The HC group have the highest
level of functioning. Compared to the HC
group, the AN and BN groups have significant-
ly higher but similar scores (3.6 and 3.4 respec-
tively) on the EDE-Q, but there is no significant
difference between these two groups.
Psychological characteristics
Both the AN and BN groups have significant-
ly raised levels of perfectionism than the HC
group on the overall score and on all dimen-
sions of the FMPS (Table 2). On three of the
dimensions concern over mistakes, doubts
about actions and organisation the AN group
have significantly higher scores than the BN
group: the largest difference is seen in the con-
cern over mistakes subscale.
On the BIS, there is no significance differ-
ence in the overall scores. Only the attentional
impulsivity subscale shows people with AN
Multidimensional self reports in ED
e87 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
and BN to have significantly higher scores
than the HC group. In the motoric subscale the
AN group have significantly lower scores than
the BN and HC group. In the non-planning
subscale the AN group show significantly less
impulsivity than the HC group, and the BN
group are intermediate between the AN and
HC groups but the differences are not signifi-
cant. It appears, therefore, that the overall
score on the BIS does not di scri minate
between the AN, BN and HC groups: however,
in people with AN, both non-planning impul-
sivity and motor impulsiveness are lower than
in the HC group.
On the OCI-R, the overall scores show that
both the AN and BN are significantly higher
than the HC group and that there is no signifi-
cant difference between the AN and BN groups
on the OCI-R overall score. The AN and BN
groups score significantly higher than the HC
group on five of the six subscales. On the sixth
subscale (hoarding), there was no significant
difference between the AN, BN or HC groups.
Correlations
Potential relationships between personality
characteristics (FMPS, BIS and OCI-R) ED
symptoms (EDE-Q) and global functioning
characteristics (GAF) were explored using
multivariate correlation coefficients (Table 3).
There was a high correlation between ED
symptomatology and the overall score of the
FMPS (0.735) and the OCI (0.683) but not with
impulsivity. A high overall score on the FMPS
is also highly correlated (-0.692) with poor
global functioning, but interestingly, scoring
high on the OCI is not as highly correlated
with poor global functioning (-0.431). Signifi-
cant high correlations (r=0.50 to 1.0) were
found between four of the subscales of the
FMPS and the EDE-Q. Significant high corre-
lations were found between two of the sub-
scales of the FMPS and the GAF. Significant
high correlations were found between three of
the six subscales of the OCI-R and the EDE-Q.
Only small significant correlations were found
between two of the BIS subscales and the GAF
and EDE-Q.
DISCUSSION
We have used multidimensional self reports
of perfectionism, impulsivity and obsessive-
compulsiveness to identify possible differences
between people with AN, BN and HC. We have
also examined these constructs in relation to
ED symptomatology and global functioning.
Our data obtained from the FMPS shows
that people with ED report significantly higher
levels of perfectionism than HC participants:
this is consistent with other studies which have
used this measure (13-15). However, in the cur-
rent study, we also found that people with AN
have higher levels of perfectionism than the
BN group on three of the five dimensions (con-
cern over mistakes, doubts about action and
organisation), thus the AN group are showing
elevated levels of the maladaptive factor of
perfectionism (10). This is of note because sev-
eral of the studies which have compared per-
fectionism between AN and BN groups using
the perfectionism (EDI-P) subscale of the Eat-
ing Disorders Inventory (EDI) (36) found no
difference between AN and BN groups (12).
The EDI perfection subscale was originally
developed as a general measure of perfection-
ism yielding one score, therefore, it appears
that the multidimensional structure of the
FMPS has identified differences in dimensions
of perfectionism reported by people in these
ED subgroups.
Our data obtained using the BIS shows
some consistency with two other studies
which have used this measure in people with
ED (22, 23) in that we have found higher
impulsivity on the attention dimension in both
the AN and BN groups. Potential explanations
for this could be that anxiety is higher in the
ED group and this exacerbates attention
TABLE 1
Demographic and clinical characteristics of the three groups:
anorexia nervosa (AN), bulimia nervosa (BN) and healthy
controls (HC).
AN BN HC F p Post hoc
N=30 N=26 N=51
Age 26.8 27.8 29.4 0.9 0.395 N/A
(8.3) (6.1) (9.6)
Education (yr) 15.3 15.9 15.1 0.5 0.636 N/A
(3.0) (3.5) (2.9)
Current BMI 15.5 25.3 23.1 48.7 0.000 HC>AN
(1.3) (4.7) (3.8) BN>AN
Lowest ever BMI 11.9 18.9 19.9 52.9 0.000 HC>AN
(1.3) 4.6) (2.5) BN>AN
Illness duration* 8.7 10.4 N/A 1.2 0.275 N/A
(6.0) (6.41)
GAF global score 37.9 63.5 86.9 341.1 0.000 HC>BN
(11.5) (7.1) (6.1) HC>AN
BN>AN
EDE-Q global score 3.6 3.4 0.8 78.2 0.000 AN>HC
(1.7) (1.7) (0.8) BN>HC
*Illness duration is compared between eating disorders groups only.
BMI: body mass index; GAF: Global Assessment of Functioning Scale; EDE-Q:
Eating Disorder Examination Questionnaire; N/A: not assessed.
H. Davies, P.-C. Liao, I.C. Campbell, et al.
e88 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
impulsivity (37) or alternatively that it reflects
cognitive sequelae of nutritional distress (38).
Conversely, the AN group have significantly
lower impulsivity than the HC group on both
of the other two subscales, motoric impulsivity
and non-planning impulsiveness. This sup-
ports the findings in the FMPS and OCI which
shows people with AN adhere to perfectionis-
tic and obsessional characteristics over impul-
sive characteristics. What is of note, however,
is that the BN group do not show higher levels
of impulsivity than the HC group. Empirical
studies indicate that impulsivity is associated
more with people with ED, particularly when
there is a binge eating behaviour (29, 39).
However, our data shows that the scores for
TABLE 2
Psychological characteristics: self reports.
AN BN HC F p Significant
N=30 N=26 N=51 post hoc
M (SD) M (SD) M (SD) tests
FMPS
Overall score 95.9 (28.7) 84.9 (24.2) 57.3 (14.1) 33.7 0.000 AN>HC
BN>HC
Concern over mistakes 26.1 (8.0) 20.0 (8.5) 10.7 (5.3) 47.6 0.000 AN>HC
BN>HC
AN>BN
Personal standards 22.0 (5.6) 20.5 (5.5) 14.7 (4.8) 21.7 0.000 AN>HC
BN>HC
Parental expectation 11.2 (4.7) 10.5 (6.1) 7.8 (4.0) 5.2 0.007 AN>HC
BN>HC
Doubts about actions 10.8 (2.5) 9.1 (3.6) 5.2 (2.6) 38.6 0.000 AN>HC
BN>HC
AN>BN
Organisation 20.3 (3.3) 17.8 (4.6) 15.1 (3.9) 16.3 0.000 AN>BN
BN>HC
AN>BN
BIS
Overall score 61.3 (11.1) 65.8 (12.7) 65.4 (10.3) 1.5 0.216 N/S
Attentional impulsiveness 18.3 (3.3) 18.0 (4.5) 15.7 (3.5) 5.6 0.005 AN>HC
BN>HC
Motor impulsiveness 19.6 (4.9) 23.8 (4.3) 23.1 (5.2) 6.2 0.003 AN<HC
AN<BN
Non-planning impulsiveness 23.3 (5.2) 24.8 (5.8) 26.4 (4.5) 3.6 0.009 AN<HC
OCI-R
Overall score 22.3 (14.1) 22.8 (17.0) 9.0 (7.4) 15.9 0.000 AN>HC
BN>HC
Checking 3.4 (2.8) 2.8 (2.8) 1.5 (2.0) 5.7 0.004 AN>HC
BN>HC
Hoarding 3.7 (2.5) 3.7 (3.5) 2.6 (2.4) 2.2 0.106 N/S
Mental neutralising 1.7 (2.5) 2.7 (3.1) 0.6 (1.2) 8.6 0.000 AN>HC
BN>HC
Obsessing 4.4 (3.8) 5.2 (3.9) 1.4 (1.9) 16.2 0.000 AN>HC
BN>HC
Ordering 6.5 (3.9) 5.4 (4.0) 2.2 (2.2) 18.0 0.000 AN>HC
BN>HC
Washing 2.3 (3.4) 2.7 (3.9) 0.5 (1.1) 6.7 0.002 AN>HC
BN>HC
N indicates the number of participants. Means (M) and standard deviations (SD) presented in brackets and significant p values are shown in bold.
AN: anorexia nervosa; BN: bulimia nervosa; HC: healthy controls; FMPS: Frost Multidimensional Perfectionism Scale; BIS: Barratt Impulsivity Scale; OCI-R:
Obsessive-Compulsive Inventory-Revised; N/S: no significance between groups.
Multidimensional self reports in ED
e89 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
the BN group are similar to the HC group.
This is also the finding of the Claes study (40),
which found that the BN group had similar
levels of impulsivity as HC. This is of interest
because it does not seem consistent with
behavioural styles associated with binge eat-
ing and BN whereby eating is out of control at
the consequence of future negative feeling.
Furthermore, our HC group are age-matched
females and thus not considered a particularly
impulsive group of community sample individ-
uals. One interpretation of our data may come
from the way the clinical group is willing to
report on their levels of impulsiveness. Per-
haps the cognitive factors such as feeling rest-
less and agitated are easier to report than
behavioural dimensions which suggest being
out of control.
Our data obtained from the OCI-R show that
there is no significant difference between AN
and BN groups but people in both groups
report significantly higher scores than the HC
participants overall and also on five of the six
subscales. The hoarding subscale is the excep-
tion where there is no significant difference
between the three groups. This relates to cur-
rent literature on OCD and hoarding which
suggests that hoarding is not as frequent as the
other symptoms of OCD (41, 42).
The data showing that there is no difference
between the AN and BN groups on the OCI-R is
consistent with previous studies (32, 33) which
found no difference between AN and BN self-
report obsessive-compulsive characteristics.
As can be seen in Table 3, we found signifi-
cant correlations between subscales of the self-
report measures and eating symptomatology
and global functioning. In relation to perfec-
tionism, the overall score on the FMPS is high-
ly correlated with ED pathology (EDE-Q global
score), with concern over mistakes being the
subscale with the highest correlation. It is also
of note that it is also the global score on the
FMPS and concern over mistakes and doubts
about actions that are most highly correlated
with poor global functioning (SCID).
In relation to impulsivity, the overall scores on
the BIS are not correlated with ED pathology or
poor global functioning. Moreover, the correla-
tions with attentional impulsiveness are small
(0.36 with the EDE-Q and -0.29 with the SCID).
In relation to obsessive-compulsive charac-
teristics, ED pathology is highly correlated with
the overall score and in particular with the
mental neutralising, obsessing and ordering
subscales. However, none of these obsessive-
compulsive characteristics which are highly
correlated with ED pathology are highly corre-
lated with poor global functioning, ie in con-
trast to the measures of perfectionism which
are correlated with both ED pathology and
poor global functioning.
We conclude that the group of people with
AN have the lowest level of global functioning
and that those with BN have levels that are
intermediate between the AN and the HC
groups. Perfectionism is a significant charac-
teristic of both the BN and AN groups as is
obsessive-compulsiveness: however, impulsiv-
ity, as measured by the overall score on the
BIS is not. In general, the patterns seen when
examining the subscores of the three ques-
tionnaires mirror the overall scores. There
are, however, a few exceptions. In the FMPS,
the concern over mistakes, doubts about
actions and organisation subscores are signif-
icantly higher in the AN than the BN group.
Secondly, although there are no overall differ-
ences between the three groups on the BIS
scores, attentional impulsiveness is higher in
the two ED groups.
The high correlations between ED pathology
and most elements of perfectionism and several
elements assessed by the OCI suggest that
these characteristics should be considered as
potential therapeutic targets for intervention.
Finally, the data suggest that characteristics of
perfectionism are more detrimental to global
TABLE 3
Correlations between self-report measures, eating disorder
symptomatology and global functioning.
EDE-Q SCID global
global score functioning score
FMPS 0.735** -0.692**
FMPS-CM 0.725** -0.699**
FMPS-PS 0.562** -0.514**
FMPS-PE 0.631** -0.340**
FMPS-DA 0.702** -0.361**
FMPS-O 0.472** -0.459**
BIS-Attention 0.363** -0.286**
BIS-Motor 0.006 0.230*
OCI (global) 0.683** -0.431**
Checking 0.420** -0.382**
Hoarding 0.397** -0.182
Mental Neutralising 0.562** -0.220*
Obsessing 0.631** -0.329**
Ordering 0.595** -0.483**
Washing 0.481** -0.318**
r>0.50 and >-0.50 shown in bold. *p<0.05; **p<0.01.
EDE-Q: Eating Disorder Examination Questionnaire; SCID: Structured Clinical
Interview for DSM-IV Axis I and II disorders; FMPS-CM: Frost Multidimensional
Perfectionism Scale - Concern over mistakes; FMPS-PS: Personal standards; FMPS-
PE: Parental Expectation; FMPS-DA: Doubts about actions; FMPS-O: Organisa-
tion; BIS: Barratt Impulsivity Scale; OCI: Obsessive Compulsive Inventory.
H. Davies, P.-C. Liao, I.C. Campbell, et al.
e90 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
functioning than those associated with obses-
sive-compulsiveness.
The strengths of this study are that it extends
the multidimensional self-report literature with
regard to perfectionism, impulsivity and obses-
sive-compulsive characteristics and also using
clinical ED groups and comparing these with
HC. Unfortunately no subtyping of AN patients
is used and perhaps if this was the case AN-BP
would show resemblance to the BN cohort.
Our data could be extended with the use of
experimental measures which would produce
behavioural data.
CONCLUSIONS
The use of multidimensional self reports in
the field of ED can be a useful tool for under-
standing the degree to which psychological
constructs such as perfectionism, impulsivity
and obsessive-compulsiveness are reported
by people with clinically diagnosed ED. This
study has raised issues especially in relation
to perfectionism and impulsivity. AN and BN
groups have been compared using the FMPS,
with results showing people in the AN group
have elevated scores in more dimensions of
perfectionism. Previous measures of perfec-
tionism, which yielded one overall score,
found not difference between these groups.
Furthermore, the dimension concern over
mistakes was found to have the strongest
correlation with eating symptomatology and
poor functioning. This perhaps reinforces the
maladaptiveness of having elevated levels in
this factor of perfectionism. If such a finding
is replicated in further studies, this dimension
coul d benefit from a targeted treatment.
Finally, data from the BIS raised some inter-
esting questions. The ED group had raised
scores on only the attention subscale and
there were no differences between the three
groups in the overall score. This may be due
to an under-reporting in the ED group on the
questions which tap aspects of behavioural
impulsivity. Perhaps, therefore, a behavioural
paradigm is the way forward in understand-
ing more precisely levels of impulsivity in
people with ED.
ACKNOWLEDGEMENT
This work was part of the ARIADNE programme
(Applied Research into Anorexia Nervosa and Not
Otherwise Specified Eating Disorders), funded by a
Department of Health NIHR Programme Grant for
Applied Research (RP-PG-0606-1043).
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Vol. 14: e92-e97, June-September 2009
e92
ORIGINAL
RESEARCH
PAPER
Key words:
Obesity, weight stigma,
just world beliefs,
Protestant work ethic,
weight controllability.
Correspondence to:
Robert A. Carels,
Department of Psychology,
Bowling Green State
University,
Bowling Green,
OH 43403, USA.
E-mail: rcarels@bgsu.edu
Received: July 28, 2008
Accepted: December 10, 2008
Internalized weight stigma and its
ideological correlates among weight
loss treatment seeking adults
INTRODUCTION
Weight stigma among children and adults
is widespread (1, 2). In nearly all areas of liv-
ing, including interpersonal relationships,
education, employment, and health care,
obese persons are often mischaracterized
and mistreated (1, 2). Despite the ubiquity of
weight stigma, there is little consensus on
why heavier individuals are universally
maligned (1).
While the etiology of weight stigma is
complex, research suggests that it is often
greater among individuals who embrace
certain etiological views of obesity or ideo-
logical views of the world (3-5). For instance,
Allison et al. (3) found that people who
believe obesity is largely within the persons
control tend to have more negative attitudes
toward obese persons than do individuals
who believe obesity cannot be controlled by
the obese person. Similarly, Crandall (4, 5)
observed an association between greater
negative attitudes toward obese persons and
greater endorsement of ideological beliefs
that people get what they deserve in life (i.e.,
just world beliefs) and that hard work and
determination lead to good things (i.e., the
Protestant work ethic). It appears that people
who hold these etiological and ideological
beliefs infer that obese persons either
deserve their negative plight or have not
worked hard enough to reverse their highly
controllable negative condition.
Unlike other stigmatized groups (e.g.,
minorities) (6), researchers have been sur-
prised to observe internalized weight stigma
among obese persons (7). For example,
using procedures such as the Implicit Asso-
ciations Test (IAT), obese people evidence an
implicit anti-fat bias (6, 7). Similarly, on per-
sonality attribute rating measures, obese
people sometimes evidence an explicit anti-
fat bias (i.e., endorsing unflattering adjec-
tives, such as excessive laziness, when
describing obese people) (6, 7).
R.A. Carels, K.M. Young, C.B. Wott, J. Harper, A. Gumble, M. Wagner Hobbs,
and A.M. Clayton
Department of Psychology, Bowling Green State University, Bowling Green, OH, USA
ABSTRACT. There are significant economic and psychological costs associated with the
negative weight-based social stigma that exists in American society. This pervasive anti-fat
bias has been strongly internalized among the overweight/obese. While the etiology of
weight stigma is complex, research suggests that it is often greater among individuals who
embrace certain etiological views of obesity or ideological views of the world. This investiga-
tion examined 1) the level of internalized weight stigma among overweight/obese treatment
seeking adults, and 2) the association between internalized weight stigma and perceived
weight controllability and ideological beliefs about the world (just world beliefs, Protestant
work ethic). Forty-six overweight or obese adults (BMI 27 kg/m
2
) participating in an 18-
week behavioral weight loss program completed implicit (Implicit Associations Test) and
explicit (Obese Persons Trait Survey) measures of weight stigma. Participants also complet-
ed two measures of ideological beliefs about the world (Just World Beliefs, Protestant Ethic
Scale) and one measure of beliefs about weight controllability (Beliefs about Obese Persons).
Significant implicit and explicit weight bias was observed. Greater weight stigma was consis-
tently associated with greater endorsement of just world beliefs, Protestant ethic beliefs and
beliefs about weight controllability. Results suggest that the overweight/obese treatment
seeking adults have internalized the negative weight-based social stigma that exists in Ameri-
can society. Internalized weight stigma may be greater among those holding specific etiolog-
ical and ideological beliefs about weight and the world.
(Eating Weight Disord. 14: e92-e97, 2009).
2009, Editrice Kurtis
Weight stigma
e93 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
The economic and psychological costs of
internalized weight stigma and obesity-related
discrimination are substantial (8-12). Compared
to thin individuals, obese individuals are con-
sistently less likely to be hired and promoted
and more likely to receive lower wages (8, 11,
12). Among obese persons, stigmatizing experi-
ences predict binge eating, psychological dis-
tress, body image disturbance, and poor self-
esteem (9, 10, 13). Also, in women of varying
body mass indexes (BMIs), a greater number of
stigmatizing experiences predict an increased
desire to avoid exercise (14).
Most studies conducted on weight stigma
examine the beliefs about or behavioral dis-
crimination displayed toward obese people by
the non-obese (15). Studies that examine the
overweight or obese often assess the impact of
stigmatizing experiences on psychological
well-being (9, 10). Only a few studies have
examined the correlates of internalized weight
stigma among overweight/obese treatment
seeking adults (7, 9, 10). The first aim of this
investigation is to examine the level of internal-
ized weight stigma among overweight/obese
treatment seeking adults. Because explicit and
implicit measures of stigma are commonly
unrelated (16), the study employed both explicit
[Obese Persons Trait Survey (OPTS) (17)] and
implicit (IAT) (18) assessments of anti-fat bias.
A second aim is to examine the association
between internalized weight stigma and etio-
logical beliefs about weight controllability as
well as ideological beliefs about the world,
such as just world beliefs (i.e., the belief that
people get what they deserve in life), and the
Protestant work ethic (i.e., the belief that hard
work and determination lead to good things). It
was hypothesized that 1) overweight/obese
treatment seeking adults would evidence both
implicit and explicit weight bias, and 2) weight
bias would be greater among those embracing
etiological beliefs that weight is controllable
and ideological beliefs that the world is just
and that hard work and determination lead to
good things.
MATERIALS AND METHODS
Participants
Fifty-eight overweight and/or obese adults
were recruited through advertisements in local
newspapers and campus e-mail at a Midwest-
ern University to take part in a behavioral
weight loss intervention (see Table 1 for sample
characteristics). Participants were included if
they were 1) overweight/obese (BMI 27
kg/m
2
), and 2) non-smokers; and excluded if
they had 1) cardiovascular disease, 2) muscu-
loskeletal problems preventing moderate physi-
cal activity, or 3) insulin-dependent diabetes.
All participants received their physicians med-
ical clearance. Forty-six participants completed
baseline questionnaires.
Study design
During a baseline weight loss program orien-
tation session, height and weight were assessed,
the IAT for weight stigma (16) was administered,
and participants were instructed to complete
online questionnaires [OPTS, Beliefs about
Obese Persons (BAOP), Just World Scale (JWS],
Protestant Ethic Scale (PES)].
Assessments and measures
Obese Persons Trait Survey.
The OPTS (17) consists of 20 items listing
stereotypical traits, including 10 negative (e.g.,
lazy, undisciplined, unattractive) and 10 posi-
tive stereotypes (e.g., sociable, honest, intelli-
gent). Participants were asked to estimate the
percentage (0-100%) of obese persons who
possess these traits, as well as their confidence
in their estimates (on a 9-point Likert scale). In
this investigation, participants were asked to
complete the survey a second time and to esti-
mate the percentage (0-100%) of normal weight
persons who possess these traits, as well as
their confidence in their estimates (on a 9-point
Likert scale). Higher scores indicate stronger
negative and positive traits on the OPTS sub-
scales, respectively. The OPTS has been found
to be reliable for both the positive and negative
traits subscales (17). For this investigation,
Cronbach alpha was 0.86 for negative stereo-
types for obese persons, 0.78 for positive
stereotypes for the obese persons, 0.92 for neg-
ative stereotypes for normal weight persons,
and 0.85 for positive stereotypes for normal
weight persons.
Demographics N % M SD
Female 52 89.7
Married 42 72.4
Caucasian 54 93.1
College degree 27 46.5
Income $45,000 35 50.4
Age 47.6 10.3
Baseline BMI 36.6 7.1
BMI: body mass index; M: mean; SD: standard deviation.
TABLE 1
Demographic characteristics.
Eating Weight Disord., Vol. 14: N. 2-3 - 2009
R.A. Carels, K.M. Young, C.B. Wott, et al.
e94 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
Beliefs About Obese Persons Scale
The BAOP (3) assesses stereotypical percep-
tions of the controllability of obesity (e.g., In
many cases, obesity is the result of a biological
disorder). The BAOP consists of 8 six-point Lik-
ert items. Higher scores on the BAOP indicate
a stronger belief that obesity is not under the
obese persons control. Normative and reliabili-
ty data for the measure is available (3). For this
investigation, Cronbachs alpha was 0.60.
Protestant Ethic Scale
The PES (19) consists of 19 six-point Likert
response questions that assess the extent to
which individuals believe that hard work and
determination lead to success (e.g., Anyone
who is willing and able to work hard has a
good chance of succeeding). Higher scores on
the PES indicate a belief that hard work is valu-
able in its own right and as a key to success.
The PES has been found to be associated with
various prejudices (20). For this investigation,
Cronbach alpha was 0.80.
Just World Scale
The JWS (21) consists of 20 six-point Likert
scale items that measure the extent to which
individuals perceive others/themselves as
deserving of their fates in a multitude of situa-
tions (e.g., By in large, people get what they
deserve). Higher scores indicate greater belief
in a just world. For this investigation, Cron-
bachs alpha was 0.82.
Implicit Associations Test
The IAT is a widely used measure of implicit
attitudes that are typically related to social prej-
udice (18). The IAT is based on the idea that
stimuli classification is facilitated and thus
faster when category pairs match implicit asso-
ciations. Therefore, participants are expected
to categorize stimuli faster when categories are
paired in such a way that matches the way con-
cepts are already related in their minds. Pro-
cessing speed is used as an indirect measure of
an individuals association between two con-
cepts (i.e., obesity and negative stereotypes).
The pencil and paper IAT used in this investi-
gation have been used in prior studies examin-
ing implicit weight-based stigma (7, 16). At the
top of each page of the IAT, target category
labels (i.e., Fat People, Thin People) and attribute
category labels (i.e., Good, Bad; Motivated, Lazy)
are listed with respective subordinate stimuli
(e.g., Fat People: fat, obese, large). Below these
labels, the target and attribute categories are
paired on the top of each side of a column (e.g.,
Fat People/Bad, Thin People/Good). Participants
then classify a list of words (subordinate stimuli,
e.g., fat, slim, terrible, wonderful) into their
appropriate category by checking off a circle in
the appropriate column as quickly as possible.
On one page, the target and attribute categories
are paired in a way to match implicit negative
associations with weight (e.g., Fat People and
Lazy heading one side of the column and Thin
People and Motivated heading the other side of
the column), and on the next page, the target
and attribute categories are paired in a way to
contradict expected associations (e.g., Fat Peo-
ple and Good heading one side of the column
and Thin People and Bad heading the other side
of the column).
Individuals are given 20 seconds and told to
go as quickly as possible, not to make judg-
ments about the words, and not to correct any
mistakes that they make. To familiarize them
with the IAT procedure before proceeding to
the weight-based IAT, participants complete a
practice IAT in which the target category labels
are bugs and flowers and attribute category
labels are good and bad (7, 16).
Body weight
Body weight was measured using a digital
scale (BF-350e; Tanita, Arlington Heights, IL) to
the closest 0.1 lb, and height (baseline only)
was measured in inches to the closest 0.5 inch
using a height rod on a standard spring scale.
RESULTS
Forty-six participants (79.3%) completed
baseline measures. Analysis of variance
(ANOVA) and
2
analyses were used to examine
differences in demographic variables between
survey completers and non-completers. Survey
completers had a significantly lower average
BMI [mean (M) =35.6, standard deviation (SD)
=6.5] than non-completers (M=41.0, SD=8.2),
F(1,54)=5.1, p=0.03. Also, survey completers
were more likely to be Caucasian,
2
(2,58)=9.25,
p=0.01, and female,
2
(1,58)=3.5, p=0.06, than
survey non-completers.
Implicit bias
Consistent with prior research (16), implicit
anti-fat bias was calculated by subtracting the
number of correct responses in the mis-
matched condition (i.e., Fat People and Moti-
vated) from correct responses in the matched
condition (i.e., Fat People and Lazy). To control
for individual differences in the number of
items completed and maximize reliability,
scores were transformed using the strategy
outlined by Teachman, Gapinski, Brownell and
Rawlins (16).
Weight stigma
e95 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
Paired-sample t-tests were conducted to
examine implicit weight bias. On the IAT, sig-
nificantly more items were correctly classified
when the target category Fat People was
paired with the attribute category Bad (M=21.4,
SD=6.8) versus the attribute Good (M=11.1,
SD=4.6; t(45) = 14.96, p<0.01). Similarly, more
items were correctly classified when the target
category Fat Peopl e was paired with the
attribute category Lazy (M=22.4, SD=6.5) ver-
sus Motivated (M=12.0, SD=5.3; t(45)=13.53,
p<0.01). There was not a significant difference
between the number of correctly classified
items in the Lazy-Motivated condition com-
pared to the Bad-Good condition. However,
the correlation between correctly classified
items in each condition was significant, r=0.35,
p=0.02, indicating that the greater the implicit
belief that obese people are bad, the greater the
implicit belief that obese people are lazy.
Explicit bias
Paired-sample t-tests were conducted to
examine explicit weight bias (Table 2). On the
OPTS, participants estimated that obese people
possessed significantly more positive attributes
(M=61.1, SD=11.6) than negative attributes
(M=54.8, SD=11.2; t(45)=2.46, p=0.02). Partici-
pants also estimated that obese people pos-
sessed significantly more positive attributes
(M=61.1, SD=11.6) than normal weight individu-
als (M=57.3, SD=12.1; t(45)=2.20, p=0.03). How-
ever, participants also estimated obese people
to have significantly more negative attributes
(M=54.8, SD=11.2) than normal weight individu-
als (M=43.9, SD=10.6; t(45)=-5.32, p<0.01). When
the difference between positive traits attributed
to normal weight and obese persons (M=-3.3,
SD=9. 9) was compared to the difference
between negative traits attributed to normal
weight and obese persons (M=-10.4, SD=12.7),
the difference was significant, t(45)=-2.9, p<0.01
(Table 2). Thus, although participants estimated
that obese people possess significantly more
positive traits than negative traits and they esti-
mated more positive traits among obese indi-
viduals than normal weight individuals, partici-
pants also described obese persons much more
negatively than they described individuals who
are normal weight, and the negative bias was
significantly more pronounced than the posi-
tive bias. Pearson correlations indicated that
implicit (IAT) and explicit measures (OPTS) of
weight stigma were unrelated to each other.
Relationships between etiological beliefs,
ideological beliefs, and weight stigma
Pearson correlations were used to examine
the relationships between weight stigma mea-
sures (i.e., OPTS, IAT) and etiological (i.e.,
BAOP) and ideological beliefs (i.e. JWS, PWS).
The more that participants endorsed belief in a
just world, the greater the implicit bias, r=0.29,
p=0.024, and the more likely they were to
attribute negative personality traits to obese
persons (i.e., OPTS), r=0.34, p=0.011. Belief in a
just world was not associated with the attribu-
tion of positive personality traits to obese per-
sons.
The more that participants endorsed views
consistent with the Protestant work ethic, the
more likely they were to attribute negative per-
sonality traits to obese persons, r=0.49,
p<0.001. Endorsement of the Protestant work
ethic was not associated with the attribution of
positive personality traits to obese persons or
implicit weight bias.
The more that individuals believed that obesi-
ty is not under ones control, the less likely they
were to attribute negative personality traits to
obese persons, r=-0.60, p=0.01. Beliefs about
the controllability of obesity were not associat-
ed with the attribution of positive personality
traits to obese persons or implicit weight bias.
DISCUSSION
The significant economic and psychological
costs of internalized weight stigma and obesity-
related discrimination are substantial and
increasingly well-documented (8-12). Consis-
tent with previous research (6, 7), in this inves-
tigation, the overweight/obese treatment seek-
ing adults appear to have internalized the per-
vasive negative weight-based social stigma that
exists in American society. The implicit nega-
tive weight bias in this sample was equal to, or
stronger than, the weight bias observed in
prior research with normal and overweight
individuals (7, 16, 22). Also, consistent with
prior research (6, 7, 22), in this investigation,
evidence for an explicit weight bias was mixed,
TABLE 2
Means and standard deviations of weight stigma measures.
Weight
Obese Normal
OPTS: Positive
d
61.1 (11.6)
a,b
57.3 (12.1)
a,b
OPTS: Negative
d
54.8 (11.2)
a,c
43.9 (10.6)
a,c
OPTS: Obese Persons Trait Survey.
a
Obese: OPTS-positive versus OPTS-negative;
b
OPTS-postive: obese versus normal
weight;
c
OPTS-negative: obese versus normal weight;
d
Difference OPTS-posi-
tive/negative obese versus OPTS-postive/negative normal weight.
All subscripts p0.05.
R.A. Carels, K.M. Young, C.B. Wott, et al.
e96 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
and only emerged when ratings of obese indi-
viduals were examined relative to ratings of
normal weight individuals. For example, when
only ratings of personality attributes among
obese adults were examined, no explicit bias
was evident. The participants in this investiga-
tion rated obese people significantly more posi-
tively than they rated obese people negatively,
and rated obese people significantly more posi-
tively than they did normal weight people. Yet,
overweight/obese adults in this sample also
rated obese people significantly more negative-
ly than they rated normal weight people when
comparing obese people to normal weight peo-
ple. Ultimately, the negative bias toward obese
persons was much stronger than the positive
bias toward obese persons. Thus, the explicit
weight bias in this investigation was subtle and
only evident relative to the ratings of normal
weight individuals. Consistent with previous
research (16, 23), explicit and implicit measures
were uncorrelated, suggesting a lack of aware-
ness or conscious denial of in-group bias.
Researchers have convincingly argued that
certain ideological worldviews (4, 5), as well as
etiological beliefs about the causes of obesity (1,
3), may exacerbate weight-based stigma. Con-
sistent with Crandalls observations among col-
lege students (4), ideological beliefs that obese
persons deserve their negative plight (i.e., just
world belief) or they have not worked hard
enough to reverse their negative condition (i.e.,
Protestant work ethic) were related to greater
weight stigma. Also, consistent with previous
research among children and adults, the more
obesity was deemed as controllable, the more
weight stigma increased (3, 24). Interestingly,
participants endorsement of just world beliefs
and Protestant work ethic ideology were posi-
tively related to their ratings of negative person-
ality traits, but not their ratings of positive per-
sonality traits (i.e., OPTS). In other words, the
presence of these ideological beliefs did not
diminish positive attitudes, but rather exacerbat-
ed negative attitudes towards obese persons.
Greater endorsement of the belief that people
in this life get what they deserve (just world
belief) was significantly associated with
greater implicit bias when the target category
Fat People was paired with the attribute Bad.
This association was not evident when the tar-
get category Fat People was paired with the
attribute Lazy. As people internalize the belief
that good things happen to good people and
bad things happen to bad people, the implicit
link between obesity and badness may be
strengthened. This finding suggests that the
type of ideological worldview that an individual
holds may plausibly influence the type and
strength of the implicit bias that an individual
possesses. The association between implicit
bias where the target category Fat People was
paired with the attribute Lazy and a greater
belief that hard work has a value in its own
right and is a key to success (i.e., Protestant
work ethic) was in the expected direction, but
failed to meet conventional standards for statis-
tical significance (r=0.19, p>0.1).
This investigation has several limitations that
should be noted. The small sample may have
limited power to detect relationships among
constructs, and the self-selected over-
weight/obese individuals participating in a
weight loss program may limit the generaliz-
ability of these findings to people attempting to
lose weight on their own by using different
methods, people participating in professional-
ly-led programs (e.g., very low kcal diets), or to
people attempting to maintain a previous
weight loss. In addition, the majority of the
weight loss participants in this investigation
were female (89.7%). According to Puhl and
Brownell (1), studies indicate that the economic
disadvantages related to obesity seem to be
specific to, or at least more common for
women, thus indicating greater weight bias
against women. It is unclear whether similar
relationships would be observed in a sample of
weight loss treatment seeking men. In this
investigation, although consistent with prior
research (3), the alpha reliability of the BAOP
was somewhat low (0.60). The low alpha may
suggest that peoples stereotypical percep-
tions of the controllability of obesity may repre-
sent a multidimensional rather than a unidi-
mensional latent construct. Finally, because the
OPTS does not specifically ask whether partici-
pants perceive the traits to be true of them-
selves, the presumption that the weight bias
may suggest a negative view of the self was not
verified. It is not clear whether the over-
weight/obese persons in this investigation
identified themselves as belonging to the cate-
gory/group of obese persons. However,
given that the participants were beginning a
weight loss program it is highly plausible that
they viewed themselves to be overweight.
This investigation has several implications. It
is possible that participant estimates of obese
persons may, in part, reflect a view of self.
Therefore, seeing the obese (and consequently,
themselves) as competent and as possessing
positive personality attributes might benefit
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absence of these positive views might, in turn,
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reduced self-efficacy for weight loss success.
Weight stigma
e97 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
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Vol. 14: e98-e105, June-September 2009
ORIGINAL
RESEARCH
PAPER
Key words:
Dietary restraint, emotional
eating, weight change,
intentional weight loss.
Correspondence to:
Kayoung Lee,
Department of Family
Medicine,
Busan Paik Hospital,
633-165 Kaegum-dong.
Busan Jin-Gu,
Busan, South Korea
E-mail:
kayoung.fmlky@gmail.com
Received: September 3, 2008
Accepted: December 12, 2008
Relationship of eating behavior to
long-term weight change and body
mass index: The Healthy Twin study
INTRODUCTION
Eating behavior is an important factor
affecting nutritional intake and body size,
but it is difficult to assess because no valid
measurement instrument can be applied
across genders, weight status, and cultural
background. The Dutch Eating Behavior
Questionnaire (DEBQ), developed by Van
Strien et al. (1), is one of the most frequently
used scales implemented for examining
three domains: restrained eating behavior,
emotional eating behavior, and external
eating behavior. Restrained eating behavior
is defined as a tendency to restrict food
intake consciously, either to prevent weight
gain or to promote weight loss by control-
ling both energy intake and types of foods
eaten. Emotional eating behavior is the ten-
dency to overeat in the presence of negative
mood states such as anxiety, depression, or
loneliness. External eating behavior is the
tendency to overeat in relation to external
stimuli such as palatable foods.
Many previous studies using different
scales of measuring eating behavior such as
Eating Inventory, Three Factor Eating
Questionnaire, and other alternative ques-
tionnaires have reported that increased
emotional or external overeating behaviors
are generally associated with higher body
mass index (BMI) (2-5), but studies have not
consistently agreed on the relationship
between restrained eating behavior and
BMI. Some studies have reported that high-
er dietary restraint scores are related to
higher BMI (2, 3, 5-7), while others have
reported an inverse or no significant rela-
tionship (4, 5, 8, 9). Even a few studies using
the DEBQ have showed a mixed result for
the relationship between weight gain and
dietary restraint (10, 11). In patients with
seasonal affective disorder, seasonal body
weight gain was higher among those with
high BMI, high emotional eating and high
restrained eating (10). In contrast, patients
diagnosed with diabetes and who had a
tendency to overeat (emotionally or exter-
nally induced) without dietary restraint
were more likely to gain their weight after 4
years (11).
Given the inconsistency of findings of
studies using different restraint scales and
even the same restraint scale, the relation-
J. Sung
1
, K. Lee
2
, and Y.-M. Song
3
1
Department of Epidemiology, Seoul National University School of Public Health, Seoul,
2
Department of Fam-
ily Medicine, Busan Paik Hospital, Inje University College of Medicine, Busan,
3
Department of Family Medi-
cine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
ABSTRACT. This study examined the relationships of the Dutch Eating Behavior Question-
naire (DEBQ) subscales with weight change and with current body mass index (BMI). A total
of 1576 adult twins and their families (578 Korean men, 998 Korean women, age 44.512.9
years) participating in the Healthy Twin study completed a survey that included the DEBQ,
self-reported weight at 20 years old and intentionally lost weight over the past 4 years. Their
anthropometric measurements were taken. Using the general linear models, restrained eat-
ing was positively associated with weight gain from 20 years old to current age [beta (B)
=1.01, standard error (SE)=0.27, p<0.001], and with current BMI (B=0.33, SE=0.09, p<0.001)
after adjusting for demographics, health-related behaviors, energy intake, and emotional and
external eating. Likewise, emotional eating was positively associated with weight gain
(B=0.83, SE=0.28, p<0.001), and with current BMI (B=0.35, SE=0.10, p=0.003) after adjusting
those factors, and restrained and external eating. However, external eating was not associat-
ed with both outcomes. In conclusion, high restrained eating or emotional eating may be
indicators for long-term weight gain and high BMI in Korean twins and their families.
(Eating Weight Disord. 14: e98-e105, 2009).
2009, Editrice Kurtis
e98
EWD_09_18_Sung.qxp:EWD_ 4-11-2009 10:11 Pagina 98
Eating behavior and weight change
e99 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
ships of dietary restraint to weight change or
BMI are as controversial as ever. This may
perhaps be related with different construct of
scal es regardi ng i ntenti on and action of
dietary restraint as intention of dietary restric-
tion does not always go with action of eating
restriction (12).
As dietary restraint would induce overeating,
so intentional weight loss would result in
weight gain. Excessive dietary restraint for
intentional weight loss may lead to counter-
regulating response such as overeating and
weight gain following a period of that cycle.
However, it is not clear that restrained eating
behavior which is separated from emotional or
external eating behavior is related to current
BMI and weight change.
Therefore, this study was carried out to
assess the independent relationship of each
subscales of the DEBQ with both self-reported
long-term weight change and measured cur-
rent BMI among Korean adult same-sex twins
and their families.
MATERIALS AND METHODS
Subjects
Study participants were the 1576 adult
enrollees (578 men, 998 women) of the Healthy
Twin study, which recruited adult same-sex
twin pairs aged 30 years or older and their
first-degree family members regardless of the
number of family members. The overall
methodology of this multicenter cross-sectional
survey has been described previously (13). The
Healthy Twin study was advertised in a nation-
wide newspaper and through posters in about
300 hospitals and health-related governmental
agencies. Individual twins and their families
who were willing to participate in the Healthy
Twin study answered a questionnaire and visit-
ed one of the centers to undergo a health
examination, clinical tests, biochemical tests,
and physical measurements. Written informed
consent was obtained from all participants. The
study protocol was approved by the Ethics
Committees at the Samsung Medical Center
and Busan Paik Hospital.
Surveys
The survey included questions about demo-
graphics, past/current medical history (cardio-
vascular disease, hypertension, dyslipidemia,
and diabetes mellitus), smoking and alcohol
habits, physical activity, food frequency, eating
behaviors, weight at 20 years old, and attempt
to lose weight over the past 4 years.
Participants were classified according to the
following lifestyle characteristics: smoking sta-
tus (current smoker and 400 cigarettes/lifetime,
ex-smoker and 400 cigarettes/lifetime, or <400
cigarettes/lifetime) (14); alcohol consumption
(non-alcohol user, ex-alcohol user, or current
alcohol user); exercise regularity (regular or
irregular exercise at moderate-intensity); edu-
cational level (9 years, 1014 years, or 15
years); marital status (unmarried, married, or
divorced/widowed/separated).
Total calorie intake was measured using a
validated 103-item semi-quantitative food fre-
quency questionnaire (15); this was self-admin-
istered with the help of research assistants.
Respondents were required to rate their intake
frequency (9-point scale from negligible intake
to three times per day) of each item over the
past year and their average intake amount of
each item (less than reference, reference, more
than reference). The mean intake for total calo-
ries (kcal/day) was calculated using a computer
program (Korean Genomic Epidemiological
Cohort Study Information System, version 1.0).
Eating behavior
A validated Korean version of the DEBQ was
used to assess eating behavior (17). The DEBQ
is a 33-item self-assessment scale for assessing
three eating behavior domains: the restrained
subscale (10 items), the emotional eating sub-
scale (13 items) and the external eating subscale
(10 items). Respondents were required to rate
each item on a 5-point scale ranging from 1
(seldom) to 5 (very often). Item scores for each
subscale were added to obtain an overall sub-
scale score, and then the overall subscale score
was divided by the number of subscale items to
calculate score per subscale (16). Higher scores
indicate a greater tendency to exhibit the
behavior assessed by that subscale. For this
dataset, internal reliability coefficients (Cron-
bachs alpha) were 0.92 for the restrained sub-
scale, 0.94 for the emotional eating scale, and
0.86 for the external eating scale. Factor analy-
sis also reproduced the same factor structure
as in the previous validation study using the
Korean version.
Weight change, attempt to lose weight,
and current body mass index
Respondents were required to answer ques-
tions about their body weight (kg) at the age of
20 years and attempt to lose weight over the
past 4 years (yes vs no). Body weight change
from the age 20 years old to current age was
calculated by subtracting the self-reported
body weight at 20 years old from the measured
current body weight. Trained research coordi-
nators and assistants measured the body
Eating Weight Disord., Vol. 14: N. 2-3 - 2009
EWD_09_18_Sung.qxp:EWD_ 4-11-2009 10:11 Pagina 99
J. Sung, K. Lee, and Y.-M. Song
e100 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
weight (kg) and height (cm) of each participant
using a digital balance (Tanita Co, Seoul,
Korea) and stadiometer (Samwha Co., Seoul,
Korea). Measurements were taken twice for
each participant (weight to the nearest 0.1 kg
and height to the nearest 0.1 cm) as he or she
wore light clothing but no shoes, and analyses
used the averaged value of the two measure-
ments. BMI was calculated by dividing the
weight in kilograms by the square of the height
in meters. Subjects with a BMI25 kg/m
2
were
classified as overweight (17).
Statistical analyses
Because eating behavior scores were not dis-
tributed normally, they were standardized by
Z-transformation, specific to gender. Means of
scores of eating behavior subscales, BMI at the
age of 20 years and current age, and weight
change from the age 20 years old to current
age between genders were compared using
independent t-test. Proportions of categorical
variables between genders were compared
using chi-square tests. Spearman correlations
were also calculated between DEBQ subscales.
Weight change and current BMI were com-
pared between tertiles of DEBQ subscales, spe-
cific to gender using one way analysis of vari-
ance and post-hoc analysis using Scheffe
method. General linear models were used to
analyze relationships between z-transformed
subscales and weight change from 20 years old
to current age after adjusting for demograph-
ics (family variable, age, sex, marital status,
education level, and medical history), health-
related behaviors (exercise, smoking status,
and alcohol use), weight at 20 years old,
attempt to lose weight over the past 4 years,
and total energy intake. To take into account
correlations among families, a family variable
was included as a random effect, and the other
confounding variables were allocated as fixed
effects. Similar analyses were performed for
the relationship with current BMI. Statistical
significance was set at p<0.05. All statistical
analyses were conducted using the SPSS 12.0K
software package for Windows (Release 12.0.1;
SPSS Inc., Chicago, IL, USA).
TABLE 1
Comparison of characteristics between genders in subjects of the Healthy Twin Study.
Men Women p-value
(N=578) (N=998)
MeanSD
Age (years) 45.013.5 44.212.6 0.238
DEBQ Restrained eating subscale 1.960.8 2.571.0 <0.001
Emotional eating subscale 1.280.4 1.510.7 <0.001
External eating subscale 2.570.7 2.800.8 <0.001
Reported BMI at 20 years (kg/m
2
) 21.52.1 20.42.3 <0.001
Weight change from 20 years old to current age (kg) 8.387.3 6.167.5 <0.001
Current body mass index (kg/m
2
) 24.22.7 23.23.2 <0.001
Total intake (kcal/day) 1909862 1729928 <0.001
N (%)
Twin 253 (43.8) 493 (49.4) 0.032
Attempt to lose weight over the past 4 years 100 (18.7) 239 (26.8) <0.001
Education 15 years 205 (35.7) 278 (28.9) 0.007
Divorced/widowed/separated 25 (4.3) 136 (13.7) <0.001
Smoking/lifetime <400 cigarettes 151 (26.5) 888 (89.8) <0.001
Non-alcohol user 85 (14.9) 394 (39.9) <0.001
Regular exercise 226 (41.0) 291 (29.6) <0.001
Medical history Cardiovascular disease 21 (3.6) 25 (2.5) 0.215
Hypertension 68 (11.8) 112 (11.2) 0.743
Dyslipidemia 26 (4.5) 39 (3.9) 0.637
Diabetes mellitus 38 (6.8) 38 (3.8) 0.015
DEBQ: Dutch Eating Behavior Questionnaire.
Not all variables included all subjects.
EWD_09_18_Sung.qxp:EWD_ 4-11-2009 10:11 Pagina 100
Eating behavior and weight change
e101 Eating Weight Disord., Vol. 14: N. 2-3 - 2009
RESULTS
Significant differences appeared in weight
change from 20 years old to current age and
DEBQ scores between men and women. Men
had significantly greater weight change
between the age of 20 years and current age and
a significantly higher current BMI than women,
while women scored higher than men on all
three subscales and attempted to lose weight
over the past 4 years (Table 1). Spearmans cor-
relations for the relations between the subscales
were significant. Score of restrained eating was
positively and significantly correlated with
scores of emotional eating and external eating.
Scores of emotional eating and external eating
were positively correlated with total calorie
intake, while there was a negative relationship
between score of restrained eating and total
calorie intake (p<0.05) (Table 2).
Weight change and current BMI were signifi-
cantly related with tertiles of restrained and
emotional eating subscales; however, they were
not significantly related with tertiles of external
TABLE 3
Associations of the Dutch Eating Behavior Questionnaire (DEBQ) subscales with weight change
from 20 years old to current age in subjects of the Healthy Twin study.
TABLE 2
The Spearman correlations between the Dutch Eating Behavior Questionnaire (DEBQ) subscales, calorie intake,
weight change, and current body mass index (BMI).
Restrained Emotional External Total intake Weight
eating eating eating (calorie) change (kg)
Emotional eating 0.30*
External eating 0.22* 0.43*
Total intake (calorie) -0.06* 0.06* 0.11*
Weight change from 20 years to current age (kg) 0.13* 0.03 -0.04 0.06*
Current BMI (kg/m
2
) 0.17* 0.05* -0.06* 0.05* 0.71*
*p<0.05.
Beta SE p-value
Adjusted for family variable*