Eating and Weight Disorders Vol.14 Issue 02-03 200906-09 Electronic

e29
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 must show

motivation for treatment and have some capac-
ity to relate in a group setting. Exclusion crite-
ria are an acute suicide or medical risk, sub-
stance abuse or dependence, comorbid psy-
chotic symptoms or BMI<13.5 kg/m
. Patients
with a BMI <13.5 kg/m
are excluded because

inpatients treatments is more suitable for the
severity of their clinical status.
The average length of stay is 24-26 weeks,
from Monday to Friday for about 7 hours per
day. In DH, patients eat lunch and a snack in
the mid-morning with the assistance of nurses
and dietician (assisted eating), who help and
support patients facing difficulties during
meals. All patients have an individually bal-
anced meal plan prescribed by the dietician.
Patients are weighed in underwear before the
snack, from three times to once a week; when
underweight, their target weight is set individ-
ually and the medical staff can decide whether
to use or not intravenous feeding.
The staff consists of a psychiatrist, 2 half-day
psychiatrists, a half-day clinic psychologist, 2
psychiatry trainees, 5 nurses, a dietician, a con-
sultant nutritionist, a consultant supervisor and
a consultant music therapist. Every week a con-
sultant nutritionist evaluates patients physical
health status. Psychiatric drugs (antidepres-
sants, antipsychotics, BDZ and mood stabilis-
ers) for comorbid psychiatric symptoms
(depression, anxiety, mood instability) are pre-
scribed when indicated.
RESULTS
Eighteen suitable articles and two reviews
were analyzed. The main features of each cen-
Monday Tuesday Wednesday Thursday Friday
8.30-9.30 Welcome and Welcome and Welcome and Body image therapy Welcome and
pharmacologic therapy pharmacologic therapy pharmacologic therapy phfarmacologic therapy
9.30-10.30 Dietistic visits Individual psycotherapy Music therapy Nutritional visits Cognitive behavioural
tecniques
10.30-11.00 Assisted snack Assisted snack Assisted snack Assisted snack Assisted snack
11.30-12.30 Psychodinamic group Psychodinamic group Psychodinamic group Psychodinamic group Psychodinamic group
13.00-13.45 Assisted eating Assisted eating Assisted eating Assisted eating Assisted eating
14.00-15.00/30 Psychiatric visits Reading group Creative group Psychiatric visits Recreation
tre included in this study are listed in Table 3.
The DCP in Freiburg and the CC in Edin-
burgh are the only centres treating ED patients
together with patients suffering from other
psychiatric disorders.
The main variables of the centres studied are
the following:
Main features of the programmes:
- the centres opened in different years (from
1980 to 2006);
- treatment orientation: cognitive behavioural
in most cases (9/11), psychodynamic in 2/11
cases. The WPH began as psychodynamic
but after 4 years turned to cognitive behav-
ioural;
- duration of treatment: highly variable, from
3 to 39 weeks (mean 15,04 weeks; standard
deviation=10,22);
- behavioural contract: in all centres except
for CC and DTP.
Treatment goals: modification and normalisa-
tion of eating behaviour (10/11), nutritional
rehabilitation and weight gain (8/11), relapse
prevention (3/11), promotion of autonomy,
social adjustment, self-control and self-esteem
(4/11), understanding of symptoms (4/11),
identification and resolution of perpetuating
processes (6/11), reduction of over-evaluation
of shape and weight (5/11).
Group activities:
- treatment type: mostly group (5/11), only
group (2/11), group and individual (4/11);
- treatment tools: bio-psycho-social frame-
work (6/11) and cognitive behavioural
groups (10/11) are the main treatment tools.
Issues addressed in individual and group
activities:
- body attitude: (missing for CC) body-image
group (10/11) in every centre, often associat-
ed with other body-shape oriented activities;
- coping skills: the most common activities are
assertiveness training (6/11) and social skills
training (4/11);
- interpersonal functioning: (missing for CC
and DCP) group work on interpersonal rela-
tionship (6/11), interpersonal psychotherapy
(2/11), Yalom group (1/11), Good bye
group (1/11);
- nonverbal expression: art, creative and mu-
sic therapy (9/11);
- family functioning: all the centres involve
family in treatment (missing datum for DCP)
and the most common approach is family
therapy (6/11);
- other issues: housing facilities (2/11), ED
patients with other psychiatric patients
(2/11), vegetarian menu (1/11), operant
behaviour methods (10/11), residence group
with apartment-like housing (1//11), explicit
use of operant principles and of mindfulness
(1/11), recreation (2/11), 2-day camp (1/11),
readiness and motivational therapy (1/11),
structural process-model and related skills
(1/11); CC is close to shops and restaurants.
Follow-up:
- only five centres perform a follow-up (5/11):
outpatient support group (1/11); monthly
outpatients visits (1/11); weekly group thera-
py sessions (2/11); weekly individual psy-
chotherapy for 6 months (1/11); weekly
relapse prevention group (1/11).
Other variables studied (not listed in tables)
are:
Conditions for admission:
- inclusion criteria: diagnosis of ED according
to DSM-IV criteria (6/11), failure of previous
treatments (3/11); motivation to change/for
treatment (7/11); medical stability (3/11);
capacity to relate in a group (4/11);
- exclusion criteria: suicide risk (10/11), med-
ical risk (6/11), substance dependence (8/11),
psychosis (4/11).
Treatment of eating disordered behaviours:
meal plan (9/11), assisted eating (6/11), self-
monitoring (5/11), nutrition group (8/11), psy-
choeducation (4/11), CBT (7/11), cooking
(4/11).
Day treatment is part of a larger eating disor-
der programme in all centres (11/11).
Group size: from 5 to 20 (mean 9,8; standard
deviation 3,68); missing for CC.
Group structure: half open (1/11), closed
(1/11), open (7/11); missing for CC and DCP.
Days a week: three (1/11), four (3/11), five
(7/11), seven (1/11). The WPH has 5-day or 3-
day treatments; the DHP in the years 1995-
2000 lasted 4 days/week.
Patients features:
- diagnosis: mostly AN (3/11); mostly BN
(1/11); only BN (1/11); AN, BN and ED not
otherwisw specified (EDNOS; 1/11). Missing
datum for five centres;
- average duration of patients illness: from
4.19 to 9.4 years (7.421.86 years). Missing
datum for five centres;
- BMI: highly variable according to the rate of
anorexic and bulimic patients, from 17.03 to
23.9 kg/m (20.492.41 kg/m). Missing
datum for five centres.
Weight control: (missing for CC and DCP)
daily weighing (3/11), weighing group (2/11),
weekly weighing (3/11), individual weighing:
3, 2, 1 time/week (2/11).
When underweight: most centres (8/11) fix an
objective for weight gain/week (which can vary
and in the DHP is fixed only for anorexics); liq-
uid nutritional supplements (2/11); individual
target weight range (2/11).
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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).
Group functioning: community meeting (5/11);
patient-staff meeting (4/11); Friday meeting to
fix weekend nutritional goals (1/11).
Tests: (missing in three centres) assessment is
performed with different tests at admission
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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
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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-
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.
REFERENCES
1. Van Son G.E., van Hoeken D., Bartelds A.I., van Furth
E.F., Hoek H.W.: Time trends in the incidence of eating
disorders: a primary care study in The Netherlands.
Int. J. Eat. Disord., 39, 565-569, 2006.
2. Crow S.J., Nyman J.A.: The cost-effectiveness of ano-
rexia nervosa treatment. Int. J. Eat. Disord., 35, 155-
160, 2004.
3. Simon J., Schmidt U., Pilling S.: The health service use
and cost of eating disorders. Psychol. Med., 35, 1543-
1551, 2005.
4. Fairburn C.G., Harrison P.J.: Eating disorders. Lancet,
361, 407-416, 2003.
5. American Psychiatric Association: Treatment of
patients with eating disorders, third edition. American
Psychiatric Association. Am. J. Psychiatry, 163, 7
Suppl., 4-54, 2006.
6. Wilson G.T., Shafran R.: Eating disorders guidelines
from NICE. Lancet, 365, 79-81, 2005.
7. Piran N., Kaplan A., Kerr A., Shekter-Wolfson L.,
Winocur J., Gold E., Garfinkel P.E.: A day hospital pro-
gram for anorexia and bulimia. Int. J. Eat. Disord., 8,
511-521, 1989.
8. Gerlinghoff M., Backmund H., Franzen U.: Evaluation
of a day treatment program for eating disorders. Eur.
Eat. Disord., 6, 96-106, 1998.
9. Zipfel S., Reas D.L., Thornton C., Olmsted M.P.,
Williamson D.A., Gerlinghoff M., Herzog W., Beumont
P.J.: Day hospitalisation programs for eating disor-
ders: a systematic review of the literature. Int. J. Eat.
Disord., 31, 105-117, 2002.
10. Lammers M.W., Exterkate C.C., De Jong C.A.J.: A
Dutch day treatment program foe anorexia and
bulimia nervosa in comparison with internationally
described programs. Eur. Eat. Disord. Rev., 15, 98-
111, 2007.
11. Reisch T., Thommen M., Csontos Z., Tschacher W.: Die
Berner Psychotherapie-Tagesklinik: evaluation und
einordnung in die psychiatrische versor-gungskette
[Evaluation of the Bern Day Treatmetn Program and
ist position in the psychiatric network]. Psychother.
Psychosom. Med. Psychol., 52, 56-63, 2002.
12. Birchall H., Palmer R.L., Waine J., Gadsby K., Gatward
N.: Intensive day programme treatment for severe
anorexia nervosa - the Leicester experience.
Psychiatric Bulletin, 26, 334-336, 2002.
13. Rodriguez C., Fernandez-Corres B., Perez M.J., Iruin
A., Gonzalez-Pinto A.: Partial hospitalization and out-
come of anorexia nervosa. Eur. Psychiatry, 17, 236-
237, 2002.
14. Olmsted M.P., Kaplan A.S., Rockert W.: Relative effica-
cy of a 4-day versus 5-day day hospital program. Int. J.
Eat. Disord., 43, 441-449, 2003.
15. Franzen U., Backmund H., Gerlinghoff M.: Day treat-
ment group programme for eating disorders: reasons
for drop-out. Eur. Eat. Disord. Rev., 12, 153-158, 2004.
16. Stewart T.M., Williamson D.A.: Multidisciplinary treat-
ment of eating disorders, part 1. Behav. Modif., 28,
812-830, 2004.
17. Stewart T.M., Williamson D.A.: Multidisciplinary treat-
ment of eating disorders, part 2. Behav. Modif., 28,
831-853, 2004.
18. Levitt J.L., Sansone R.A.: The treatment of eating dis-
order clients in a community-based partial hospitaliza-
tion program. Journal of Mental Health Counselling,
25, 140-151, 2003.
19. Freeman C.: Day patient treatment for anorexia ner-
vosa. British Review of Bulimia and Anorexia Nervosa,
6, 3-8, 1992.
20. Peake K.J., Limbert C., Whitehead L.: An evaluation
of the Oxford adult eating disorders service between
1994 and 2002. Eur. Eat. Disord. Rev., 13, 427-435,
2005.
21. Zeeck A., Herzog T., Hartmann A.: Day clinic or inpa-
tient care for severe bulimia nervosa? Eur. Eat. Disord.
Rev., 12, 79-86, 2004.
22. Kong S.: Day treatment programme for patients with
eating disorders: randomised controlled trial. J. Adv.
Nur., 51, 5-14, 2005.
23. Touyz S., Thornton C., Rieger E., George L., Beumont
P.: The incorporation of the stage of change model in
the day hospital treatment of patients with anorexia
nervosa. Eur. Child. Adolesc. Psychiatry, 12, Suppl. 1,
I65-71, 2003.
24. Thornton C., Beumont P., Touyz S.: The Australian
experience of the day programs for patients with eat-
ing disorders. Int. J. Eat. Disord., 32, 1-10, 2002.
25. Zeeck A., Hartmann A., Wetzler-Burmeister E.,
Wirsching M.: [Comparison of inpatient and day clinic
treatment of anorexia nervosa.] Z. Psychosom. Med.
Psychother., 52, 190-203, 2006. German.
26. Zeeck A., Herzog T., Kuhn K., Hartmann A., Scheidt
C., Wirsching M.: [Partial hospitalisation -- indication
and characteristic aspects of the setting, shown by the
example of the day clinic in Freiburg/Germany]
Psychother. Psychosom. Med. Psychol., 52, 492-9,
2002. German.
27. Kong S.S.: [The study for development of day hospital
program of eating disorders.] Taehan Kanho Hakhoe
Chi., 34, 25-34, 2004. Korean.
28. Fassino S., Abbate Daga G., Amianto F., Leombruni P.,
Fornas B., Garzaro L., D'Ambrosio G., Rovera G.G.:
Outcome predictors in anorectic patients after 6
months of multimodal treatment. Psychother.
Psychosom., 70, 201-208, 2001.
29. Fassino S., Abbate Daga G., Delsedime N., Busso F.,
Pier A., Rovera G.G.: Baseline personality character-
istics of responders to 6-month psychotherapy in eat-
ing disorders: preliminary data. Eat. Weight Disord.,
10, 40-50, 2005.
30. Ferrero A., Pier A., Fassina S., Massola T., Lanteri A.,
Daga G.A., Fassino S.: A 12-month comparison of brief
psychodynamic psychotherapy and pharmacotherapy
treatment in subjects with generalised anxiety disor-
ders in a community setting. Eur. Psychiatry, 22, 530-
539, 2007.
31. Garner D.M., Garfinkel P.E.: Handbook of treatment
for eating disorders, 2nd ed. New York, Guilford
Press, 1997.
32. Halmi K.A., Agras W.S., Crow S., Mitchell J., Wilson
G.T., Bryson S.W., Kraemer H.C.: Predictors of treat-
ment acceptance and completion in anorexia nervosa:
implications for future study designs. Arch. Gen.
Psychiatry, 62, 776-781, 2005.
33. Maina G., Rosso G., Crespi C., Bogetto F.: Combined
brief dynamic therapy and pharmacotherapy in the
treatment of major depressive disorder: a pilot study.
Psychother. Psychosom., 76, 298-305, 2007.
34. Abbass A.A., Hancock J.T., Henderson J., Kisely S.:
Short-term psychodynamic psychotherapies for com-
mon mental disorders. Cochrane Database Syst. Rev.,
8, CD004687, 2006.
35. Fairburn C.G: Cognitive behaviour therapy and Eating
disorder. New York, Guilford Press; 2008.
36. Wade T.D., Bergin J.L., Martin N.G., Gillespie N.A.,
Fairburn C.G.: A transdiagnostic approach to under-
standing eating disorders. J. Nerv. Ment. Dis., 194,
510-517, 2006.
37. Halmi K.A: The perplexities of conducting randomized,
double-blind, placebo-controlled treatment trials in
anorexia nervosa patients. Am. J. Psychiatry, 165,
1227-1228, 2008.
38. Castro-Fornieles J., Casul V., Saura B., Martnez E.,
Lazaro L., Vila M., Plana M.T., Toro J.: Predictors of
weight maintenance after hospital discharge in ado-
lescent anorexia nervosa. Int. J. Eat. Disord., 40, 129-
135, 2007.
39. Ruuska J., Kaltiala-Heino R., Rantanen P., Koivisto
A.M.: Are there differences in the attitudinal body
image between adolescent anorexia nervosa and
bulimia nervosa? Eat. Weight Disord., 10, 98-106,
2005.
40. Benninghoven D., Tetsch N., Kunzendorf S., Jantschek
G.: Perceptual body image of patients with anorexia or
bulimia nervosa and their fathers. Eat. Weight Disord.,
12, 12-19, 2007.
41. Stein D., Orbach I., Shani-Sela M., Har-Even D.,
Yaruslasky A., Roth D., Meged S., Apter A.: Suicidal
tendencies and body image and experience in anorexia
nervosa and suicidal female adolescent inpatients.
Psychother. Psychosom., 72, 16-25, 2003.
42. Manara F., Manara A., Todisco P.: Correlation
between psychometric and biological parameters in
anorexic and bulimic patients during and after an
intensive day hospital treatment. Eat. Weight Disord.,
10, 236-244, 2005.
43. Fassino S., Svrakic D., Abbate-Daga G., Leombruni P.,
Amianto F., Stanic S., Rovera G.G.: Anorectic family
dynamics: temperament and character data. Compr.
Psychiatry, 43, 114-120, 2002.
44. Fassino S., Amianto F., Daga G.A., Leombruni P.,
Garzaro L., Levi M., Rovera G.G.: Bulimic family
dynamics: role of parents personality: a controlled
study with the Temperament and Character Inventory.
Compr. Psychiatry, 44, 70-77, 2003.
45. Lock J., le Grange D.: Family-based treatment of eating
disorders. Int. J. Eat. Disord., 37, Suppl., S 64-67, 2005.
46. Fassino S., Pier A., Levi M., Gramaglia C., Amianto
F., Leombruni P., Abbate Daga G.: Psychological treat-
ment of eating disorders. A review of the literature.
Panminerva Med., 46, 189-98, 2004.
47. Howard W.T., Evans K.K., Quintero-Howard C.V.,
Bowers W.A., Andersen A.E.: Predictors of success or
failure of transition to day hospital treatment for inpa-
tients with anorexia nervosa. Am. J. Psychiatry, 156,
1697-1702, 1999.
48. Duyff R.: American Dietetic Association. Complete
Food and Nutrition Guide. John Wiley and Sons,
Inc., 2006.
49. Bulik C.M., Tozzi F., Anderson C., Mazzeo S.E., Aggen
S., Sullivan P.F.: The relation between eating disor-
ders and components of perfectionism. Am. J.
Psychiatry, 160, 366-368, 2003.
50. Bardone-Cone A.M., Wonderlich S.A., Frost R.O.,
Bulik C.M., Mitchell J.E., Uppala S., Simonich H.:
Perfectionism and eating disorders: current status and
future directions. Clin. Psychol. Rev., 27, 384-405, 2007.
51. Mace C., Binyon S.: Teaching psychodynamic formula-
tion to psychiatric trainess. Part 1: Basics of formulation.
Advances in Psychiatric Treatment, 11, 416-423, 2005.
52. Mezzich J.E.: Psychiatry for the person: articulating
medicines science and humanism. World Psychiatry,
6, 65-67, 2007.
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.

Abnormal eating attitudes in Mexican women
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.
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.
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
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+
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.
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.
REFERENCES
1. Gmez-Peresmitr G.: Variables cognoscitivas y actitu-
dinales asociadas con imagen corporal y desrdenes
del comer: problemas de peso. Revista Investigacin
Psicolgica, 3, 95-112, 1993.
2. Mancilla-Daz J., Gmez-Peresmitr G., lvarez-Rayn
G., Franco-Paredes K., Vzquez-Arvalo R., Lpez-
Aguilar X., Acosta-Garca M.: Trastornos del compor-
tamiento alimentario en Mxico. In: Mancilla J., Gmez
G. (Eds.) Trastornos Alimentarios en Hispanoamrica.
Mxico Distrito Federal, Editorial Manual Moderno,
2006, pp. 123-171.
3. lvarez G., Mancilla J., Vzquez R.: Propiedades psi-
comtricas del test de bulimia (BULIT). Psicologa
Contempornea, 7, 74-85, 2000.
4. lvarez-Rayn G., Mancilla-Daz J., Vzquez-Arvalo
R. , Unikel-Santoncini C., Cabal lero-Romo A.,
Mercado-Corona D.: Validity of the eating attitudes
test: A study of the Mexican eating disorders patients.
Eat. Weight Disord., 9, 243-248, 2004.
5. Bojorquez I., Unikel C.: Prevalence of disordered eat-
ing among mexican teenage women from a semi-
urban area: Its relation to the cultural hypothesis. Eur.
Eat. Disord. Rev., 12, 197-202, 2004.
6. Unikel C., Gmez-Peresmitr G.: Validez de constructo
de un instrumento para la deteccin de factores de
riesgo en los trastornos de la conducta alimentaria en
mujeres mexicanas. Salud Mental, 27, 38-48, 2004.
7. Unikel C., Saucedo-Molina T., Villatoro J., Fleiz C.:
Conductas alimentarias de riesgo y distribucin del
ndice de masa corporal en estudiantes de 13 a 18
aos. Salud Mental, 25, 49-57, 2002.
8. Villagmez L., Corts J., Barrera E., Saucedo D.,
Alcocer L.: Comorbilidad de la obesidad con los
trastornos de la conducta alimentaria. Rev. Invest.
Clin., 55, 535-545, 2003.
9. Makino M., Tsuboi K., Dennerstein L.: Prevalence of
eating disorders: a comparison of western and non-
western countries. MedGenMed., 6, 49, 2004.
10. Bloks H., Wijbrand H., Callewaert I., van Furth E.:
Stability of personality traits in patients who received
intensive treatment for a severe eating disorder. J.
Nerv. Ment. Dis., 192, 129-138, 2004.
11. Caballero A., Sunday S., Halmi K.: A comparison of
cognitive and behavioral symptoms between Mexican
and American eating disorder patients. Int. J. Eat.
Disord., 34, 136-141, 2003.
12. Favaro A., Zanetti T., Huon G., Santonastaso P.:
Engaging teachers in an eating disorder preventive
intervention. Int. J. Eat. Disord., 38, 73-77, 2005.
13. Franko D., Keel P.: Suicidality in eating disorders:
occurrence, correlates, and clinical implications. Clin.
Psychol. Rev., 26, 769-782, 2006.
14. Mukai T., Crago M., Shisslak C.: Eating attitudes and
weight preoccupation among female high school stu-
dents in Japan. J. Child. Psychol. Psychiat., 35, 677-688,
1994.
15. Steffen K., Roerig J., Mitchell J., Uppala S.: Emerging
drugs for eating disorder treatment. Expert Opin.
Emerg. Drugs, 11, 315-336, 2006.
16. Uher R., Murphy T., Friederich A., Dalgleish T.,
Brammer M., Giampietro V., Phillips M., Williams S.:
Functional neuroanatomy of body shape perception in
healthy and eating-disordered women. Biol. Psychia-
try, 58, 990-997, 2005.
17. Youssef G., Plancherel B., Laget J., Corcos M., Flament
M., Hulfon O.: Personality trait risk factors for attempt-
ed suicide among young women with eating disorders.
Eur. Psychiatry, 19, 131-139, 2004.
18. de Souza-Ferreira J., da Veiga G.: Eating disorder risk
behavior in Brazilian adolescents from low socio-eco-
nomic level. Appetite, 51, 249-255, 2008.
19. Sepulveda A., Carrobles J., Gandarillas A.: Gender,
school and academic year differences among Spanish
university students at high-risk for developing an eat-
ing disorder: an epidemiologic study. B.M.C. Public
Health, 28, 98-102, 2008.
20. American Psychiatric Association. Diagnostic and
Statistical Manual of Mental Disorders (4th edition
reviewed text). Barcelona, Masson, 2004.
21. Chamay-Weber C., Narring F., Michaud P.: Partial eat-
ing disorders among adolescents: A review. J.
Adolesc. Health, 37, 417-427, 2005.
22. Zimmerman M., Francione-Witt C., Chelminski I., Young
D., Tortolani C.: Problems applying the DSM-IV eating
disorders diagnostic criteria in a general psychiatric out-
patient practice. J. Clin. Psychiatry, 69, 381-384, 2008.
23. Unikel C., Gmez G.: Trastornos de la conducta ali-
mentaria: Formas indiferenciadas y conductas alimen-
tarias patolgicas en mujeres mexicanas. Psicologa
Conductual, 7, 417-429, 1999.
24. Unikel C., Villatoro J., Medina M., Bautista C., Alcntar
E., Hernndez S.: Conductas alimentarias de riesgo en
adolescentes mexicanos. Datos en poblacin estudiantil
del Distrito Federal. Rev. Invest. Clin., 52, 140-147, 2000.
25. Gandarillas A., Febrel C., Galan I., Leon C., Zorrilla B.,
Bueno R.: Population at risk for eating disorders in a
Spanish region. Eat. Weight Disord., 9, 179-185, 2004.
26. Lahortiga-Ramos F., Irala-Estvez J., Cano-Prous A.,
Gual-Garca P., Martnez-Gonzlez M., Cervera-Enguix
S.: Incidence of eating disorders in Navarra (Spain).
Eur. Psychiatry, 20, 179-185, 2005.
27. Pelaez-Fernndez M., Labrador-Encinas F., Raich-
Escursell R.: Epidemiologa de los trastornos del com-
portamiento alimentario en Espaa. In: Mancilla J.,
Gmez G (Eds.) Trastornos Alimentarios en Hispa-
noamrica. Mxico Distrito Federal, Editorial Manual
Moderno, 2006, pp. 89-122.
28. Aguirre-Calvo M., Lpez-Crcamo C., Bhar-Astudillo
R., Cordella-Masini P., Urrutia-Francotte.: Estado actu-
al de los trastornos del comportamiento alimentario en
Chile. In: Mancilla J., Gmez G (Eds.) Trastornos
Alimentarios en Hispanoamrica. Mxico Distrito
Federal, Editorial Manual Moderno, 2006, pp. 57-87.
29. Garca E., Vzquez V., Lpez J., Martnez D.: Validez
interna y utilidad diagnstica del Eating Disorder
Inventory en mujeres mexicanas. Salud Pub. Mex., 45,
206-210, 2003.
30. Curran H., Robjant K.: Eating attitudes, weight con-
cerns and beliefs about drug effects in women who use
ecstasy. J. Psychopharmacol., 20, 425-431, 2006.
31. Latzer Y., Tzischinsky O., Azaiza F.: Disordered eating
related behaviors among Arab schoolgirls in Israel:
An epidemiological study. Int. J. Eat. Disord., 40, 43-
48, 2007.
32. Milos G., Spindler A., Schnyder U.: Psychiatric comor-
bidity and Eating Disorder Inventory (EDI) profiles in
eating disorder patients. Can. J. Psychiatry, 49, 179-
184, 2004.
33. Pike K., Mizushima H.: The clinical presentation of
Japanese women with anorexia nervosa and bulimia
nervosa: a study of the Eating Disorders Inventory 2.
Int. J. Eat. Disord., 37, 26-31, 2005.
34. Saucedo-Molina T., Unikel-Santoncini C., Ameth-
Villatoro-Velzquez J., Fleiz-Bautista C.: Curvas per-
centilares del ndice de masa corporal. Autoinforme de
peso y estatura de estudiantes mexicanos. Acta
Pediatr. Mx., 24, 23-28, 2003.
35. Swenne I., Belfrage E., Thurfjell B., Engstrom I.:
Accuracy of reported weight and menstrual status in
teenage girls with eating disorders. Int. J. Eat. Disord.,
38, 375-379, 2005.
36. Garner D.: The Eating Disorders Inventory-2 Profes-
sional Manual. Odessa, Psychological Assessment
Resources, 1991.
37. Hossmer D., Lemeshow J.: Applied logistic regression.
New Jersey, John Wiley & Sons, 1989.
38. Saucedo T., Gmez-Peresmitr G.: Validez diagnstica
del ndice de masa corporal en una muestra de adoles-
centes mexicanos. Acta Pediatr. Mx., 18, 19-27, 1997.
39. Austin S., Ziyadeh N., Vohra S., Forman S., Gordon C.,
Prokop L., Keliher A., Jacobs D.: Irregular menses
linked to vomiting in a nonclinical sample: findings
from the national eating disorders screening program
in high schools. J. Adolesc. Health, 42, 450-457, 2008.
40. Conason A., Sher L.: Alcohol use in adolescents with
eating disorders. Int. J. Adolesc. Med. Health, 18, 31-
36, 2006.
41. Courbasson C., Smith P., Cleland P.: Substance use
disorders, anorexia, bulimia, and concurrent disor-
ders. Can. J. Public Health, 96, 102-106, 2005.
42. Gutirrez R., Unikel C., Mora J., Villatoro J., Medina-
Mora M.: El consumo de drogas en una muestra de
mujeres estudiantes que presentan conductas alimen-
tarias de riesgo. Salud Mental, 24, 55-61, 2001.
43. Penas-Lledo E., Sancho L., Waller G.: Eating attitudes
and the use of alcohol, tobacco, and exercise among male
and female adolescents. Eat. Behav., 3, 101-111, 2002.
44. Piran N., Gandalla T.: Eating disorders and substance
abuse in Canadian women: A national study. Addic-
tion, 102, 105-113, 2007.
45. Thompson-Brenner H., Eddy K., Franco D., Dorer D.,
Vashchenko M., Herzog D.: Personality pathology and
substance abuse in eating disorders: a longitudinal
study. Int. J. Eat. Disord., 41, 203-208, 2008.
46. Castellini G., Lapi F., Ravaldi C., Vannacci A., Rotella
C., Faravelli C., Ricca V.: Eating disorder psy-
chopathology does not predict the overweight severity
in subjects seeking weight loss treatment. Comp.
Psychiatry, 49, 359-363, 2008.
47. Rich S., Thomas C.: Body mass index, disordered eat-
ing behavior, and acquisition of health information:
examining ethnicity and weight-relate issues in a col-
lege population. J. Am. Coll. Health, 56, 623-628, 2008.
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
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.

Parity and obesity
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
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
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
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.
sis of type 2 diabetes? Diabetes Res. Clin. Pract., 66,
287-291, 2004.
5. Kritz-Silverstein D., Barrett-Connor E., Wingard D.L.:
The effect of parity on the later development of non-
insulin-dependent diabetes mellitus or impaired glu-
cose tolerance. N. Engl. J. Med., 321, 1214-1219, 1989.
6. Scholl T.O., Hediger M.L., Schall J.I., Ances I.G., Smith
W.K.: Gestational weight gain, pregnancy outcome,
and postpartum weight retention. Obstet. Gynecol., 86,
423-427, 1995.
7. Rosenberg L., Palmer J.R., Wise L.A., Horton N.J.,
Kumanyika S.K., Adams-Campbell L.L.: A prospec-
tive study of the effect of childbearing on weight
gain in African-American women. Obes. Res., 11,
1526-1535, 2003.
9. Manson J.E., Rimm E.B., Colditz G.A., Stampfer M.J.,
Willett W.C., Arky R.A., Rosner B., Hennekens C.H.,
Speizer F.E.: Parity and incidence of non-insulin-depen-
dent diabetes mellitus. Am. J. Med., 93, 13-18, 1992.
10. Gunderson E.P., Murtaugh M.A., Lewis C.E.,
Quesenberry C.P., West D.S., Sidney S.: Excess gains
in weight and waist circumference associated with
childbearing: The Coronary Artery Risk Development
in Young Adults Study (CARDIA). Int. J. Obes. Relat.
Metab. Disord., 28, 525-535, 2004.
11. Branchtein L., Schmidt M.I., Mengue S.S., Reichelt
A.J., Matos M.C., Duncan B.B.: Waist circumference
and waist-to-hip ratio are related to gestational glu-
cose tolerance. Diabetes Care., 20, 509-511, 1997.
12. Ness R.B., Schotland H.M., Flegal K.M., Shofer F.S.:
Reproductive history and coronary heart disease risk
in women. Epidemiol. Rev., 16, 298-314, 1994.
13. Green A., Beral V., Moser K.: Mortality in women in
relation to their childbearing history. B.M.J., 297, 391-
395, 1988.
14. Ness R.B., Harris T., Cobb J., Flegal K.M., Kelsey J.L.,
Balanger A., Stunkard A.J., D'Agostino R.B.: Number
of pregnancies and the subsequent risk of cardiovas-
cular disease. N. Engl. J. Med., 328, 1528-1533, 1993.
15. Dekker J.M., Schouten E.G.: Number of pregnancies
and risk of cardiovascular disease. N. Engl. J. Med.,
329, 1893-1894, 1993; author reply 1894-1895.
16. Sattar N., Greer I.A.: Pregnancy complications and
maternal cardiovascular risk: opportunities for inter-
vention and screening? B.M.J., 325, 157-160, 2002.
17. Bernstein L., Pike M.C., Ross R.K., Judd H.L., Brown
J.B., Henderson B.E.: Estrogen and sex hormone-bind-
ing globulin levels in nulliparous and parous women. J.
Natl. Cancer. Inst., 74, 741-745, 1985.
18. McPherson K., Steel C.M., Dixon J.M.: ABC of breast
diseases. Breast cancer-epidemiology, risk factors, and
genetics. B.M.J., 321, 624-628, 2000.
19. Humphries K.H., Westendorp I.C., Bots M.L., Spinelli
J.J., Carere R.G., Hofman A., Witteman J.C.: Parity and
carotid artery atherosclerosis in elderly women: The
Rotterdam Study. Stroke, 32, 2259-2264, 2001.
20. Lao X.Q., Thomas G.N., Jiang C.Q., Zhang W.S., Yin P.,
Schooling M., Heys M., Leung G.M., Adab P., Cheng
K.K., Lam T.H.: Parity and the metabolic syndrome in
older Chinese women: the Guangzhou Biobank Cohort
Study. Clin. Endocrinol. (Oxf.), 65, 460-469, 2006.
21. den Tonkelaar I., Peeters P.H., van Noord P.A.: Increase
in breast size after menopause: prevalence and determi-
nants. Maturitas, 48, 51-57, 2004.
22. Seidell J.C., Kahn H.S., Williamson D.F., Lissner L.,
Valdez R.: Report from a Centers for Disease Control
and Prevention Workshop on use of adult anthropom-
REFERENCES
1. Kopelman P.G.: Obesity as a medical problem. Nature,
404, 635-643, 2000.
2. Valsamakis G., Chetty R., Anwar A., Banerjee A.K.,
Barnett A., Kumar S.: Association of simple anthropo-
metric measures of obesity with visceral fat and the
metabolic syndrome in male Caucasian and Indo-
Asian subjects. Diabet. Med., 21, 1339-1345, 2004.
3. Lawlor D.A., Emberson J.R., Ebrahim S., Whincup
P.H., Wannamethee S.G., Walker M., Smith G.D.,
British Womens Heart and Health Study, British
Regional Heart Study: Is the association between par-
ity and coronary heart disease due to biological
effects of pregnancy or adverse lifestyle risk factors
associated with child-rearing? Findings from the
British Womens Heart and Health Study and the
British Regional Heart Study. Circulation, 107, 1260-
1264, 2003.
4. Cheung N.W.: Is parity associated with earlier diagno-
Parity and obesity
etry for public health and primary health care. Am. J.
Clin. Nutr., 73, 123-126, 2001.
23. Sultan A.S.: Medicine in the 21st century: the situation
in a rural Iraqi community. Patient. Educ. Couns., 68,
66-69, 2007.
24. Alberti K.G., Zimmet P., Shaw J.: IDF Epidemiology
Task Force Consensus Group. The metabolic syn-
drome--a new worldwide definition. Lancet, 366, 1059-
1062, 2005.
25. Kravdal O.: Is the relationship between childbearing
and cancer incidence due to biology or lifestyle?
Examples of the importance of using data on men. Int.
J. Epidemiol., 24, 477-484, 1995.
26. Gunderson E.P., Abrams B.: Epidemiology of gesta-
tional weight gain and body weight changes after
pregnancy. Epidemiol. Rev., 22, 261-274, 2000.
27. Arroyo P., Avila-Rosas H., Fernndez V., Casanueva
E., Galvn D.: Parity and the prevalence of overweight.
Int. J. Gynaecol. Obstet., 48, 269-272, 1995.
28. Coitinho D.C., Sichieri R., DAquino Bencio M.H.:
Obesity and weight change related to parity and
breast-feeding among parous women in Brazil. Public
Health Nutr., 4, 865-870, 2001.
29. Nicholson W.K., Asao K., Brancati F., Coresh J.,
Pankow J.S., Powe N.R.: Parity and risk of type 2 dia-
betes: the Atherosclerosis Risk in Communities Study.
Diabetes Care, 29, 2349-2354, 2006.
30. Ertem M., Bahceci M., Tuzcu A., Saka G., Ozturk U.,
Gokalp D.: The association between high parity and
obesity in women living in South-eastern Turkey. Eat.
Weight Disord., 13, e4-e7, 2008.
31. Khalid M.E.: The prevalence of abdominal obesity and
its associated risk factors in married, non-pregnant
women born and living in high altitude, southwestern,
Saudi Arabia. Saudi. Med. J., 28, 1875-1880, 2007.
32. Koch E., Bogado M., Araya F., Romero T., Daz C.,
Manriquez L., Paredes M., Romn C., Taylor A.,
Kirschbaum A.: Impact of parity on anthropometric
measures of obesity controlling by multiple confounders:
a cross-sectional study in Chilean women. J. Epidemiol.
Community Health., 62, 461-470, 2008.
33. Hanley A.J., McKeown-Eyssen G., Harris S.B., Hegele
R.A., Wolever T.M., Kwan J., Zinman B.: Association
of parity with risk of type 2 diabetes and related meta-
bolic disorders. Diabetes Care., 25, 690-695, 2002.
34. Cowan L.D., Go O.T., Howard B.V., Devereux R.B.,
Pettitt D.J., Fabsitz R.R., Lee E.T., Welty T.K.: Parity,
postmenopausal estrogen use, and cardiovascular
disease risk factors in American Indian women: the
Strong Heart Study. J. Womens Health., 6, 441-449,
1997.
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
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.

Obesity treatment in the elderly
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.
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 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-
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.
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.
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.
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.
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-
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.
REFERENCES
1. Hedley A.A., Ogden C.L., Johnson C.L., Carroll M.D.,
Curtin L.R., Flegal K.M.: Prevalence of overweight and
obesity among US children, adolescents, and adults,
1999-2002. J.A.M.A., 291, 2847-2850, 2004.
2. Villareal D.T., Apovian C.M., Kushner R.F., Klein S.:
American Society for Nutrition; NAASO, The Obesity
Society. Obesity in older adults: technical review and
position statement of the American Society for
Nutrition and NAASO, The Obesity Society. Obes.
Res., 13, 1849-1863, 2005.
3. Whelton P.K., Appel L.J., Espeland M.A., Applegate
W.B., Ettinger W.H. Jr., Kostis J.B., Kumanyka S., Lacy
C.R., Johnson K.C., Folmar S., Cutler J.A.: Sodium
reduction and weight loss in the treatment of hyper-
tension in older persons: a randomized controlled trial
of nonpharmacologic interventions in the elderly
(TONE). TONE Collaborative Research Group.
J.A.M.A., 279, 839-846, 1998.
4. Messier S.P., Loeser R.F., Miller G.D., Morgan T.M.,
Rejeski W.J., Sevick M.A., Ettinger W.H. Jr., Pahor M.,
Williamson J.D.: Exercise and dietary weight loss in
overweight and obese older adults with knee
osteoarthritis. The Arthritis, Diet, and Activity
Promotion Trial (ADAPT). Arthritis Rheum., 50, 1501-
1510, 2004.
5. Villareal D.T., Banks M., Sinacore D.R., Siener C., Klein
S.: Effects of weight loss and exercise on frailty in
obese older adults. Arch. Intern. Med., 166, 860-866,
2006.
6. American Psychiatric Association. Diagnostic and sta-
tistical manual of mental disorders (4th ed., Text
Revision). Washington, DC, American Psychiatric
Association, 2000.
7. Busetto L., Segato G., De Marchi F., Foletto M., De
Luca M., Caniato D., Favretti F., Lise M., Enzi G.:
Outcome predictors in morbidly obese recipients of an
adjustable gastric band. Obes. Surg., 12, 83-92, 2002.
8. Stunkard A., Berkowitz R., Wadden T., Tanrikut C.,
Reiss E., Young L.: Binge eating disorder and the night
eating sindrome. Int. J. Obes. Relat. Metab. Disord., 20,
1-6, 1996.
9. NHLBI Obesity Education Initiative Expert Panel on
the Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults. Clinical guidelines
on the identification, evaluation, and treatment of
overweight and obesity in adults-the evidence report.
Obes. Res., 6, 51S-209S, 1998.
10. FAO/WHO/UNU. Energy and protein requirements.
Report of a joint FAO/WHO/UNU Expert Con -
sultation. World Health Organization Tech. Rep. Ser.,
724, 1-206, 1985.
11. Grucza R.A., Przybeck T.R., Cloninger C.R.: Prevaklence
and correlates of binge eating disorder in a community
sample. Compr. Psychiatry, 48, 124-131, 2007.
12. Wing R.R., Hamman R.F., Bray G.A., Delahanty L.,
Edelstein S.L., Hill J.O., Horton E.S., Hoskin M.A.,
Kriska A., Lachin J., Mayer-Davis E.J., Pi-Sunyer X.,
Regensteiner J.G., Venditti B., Wylie-Rosett J., for the
Diabetes Prevention Program Research Group:
Achieving weight and activity goals among diabetes
prevention program lifestyle participants. Obes. Res.,
12, 1426-1434, 2004.
13. Busetto L., Angrisani L., Basso N., Favretti F., Furbetta
F., Lorenzo M., for the Italian Group for Lap-Band:
Safety and efficacy of laparoscopic adjustable gastric
banding in the elderly. Obesity, 16, 334-338, 2008.
14. Sugerman H.J., DeMaria E.J., Kellum J.M., Sugerman
E.L., Meador J.G., Wolfe L.G.: Effects of bariatric
surgery in older patients. Ann. Surg., 240, 243-247, 2004.
15. Dixon J.B., OBrien P.E.: Selecting the optimal patient for
LAP-BAND placement. Am. J. Surg., 184, 17S-20S, 2002.
16. Torp-Pedersen C., Caterson I., Coutinho W., Finer N.,
Van Gaal L., Maggioni A., Sharma A., Brisco W.,
Deaton R., Shepherd G., James P., on the behalf of the
SCOUT Investigators: Cardiovascular responses to
weight management and sibutramine in high-risk sub-
jects: an analysis from the SCOUT trial. Eur. Heart J.,
28, 29152923, 2007.
17. Inelmen E.M., Toffanello E.D., Enzi G., Sergi G., Coin
A., Busetto L., Manzato E.: Predictors of drop-out in
overweight and obese outpatients. Int. J. Obes. Relat.
Metab. Disord., 29, 122-128, 2005.
18. Cresci B., Tesi F., La Ferlita T., Ricca V., Ravaldi C.,
Rotella C.M., Mannucci E.: Group versus individual
cognitive-behavioral treatment for obesity: results after
36 months. Eating Weight Disord., 12, 147-153, 2007.
19. Minniti A., Bissoli L., Di Francesco V., Fantin F.,
Mandragona R., Olivieri M., Fontana G., Rinaldi C.,
Bosello O., Zamboni M.: Individual versus group ther-
apy for obesity: comparison of dropout rate and treat-
ment outcome. Eating Weight Disord, 12, 161-17, 2007.
20. James W.P., Astrup A., Finer N., Hilsted J., Kopelman
P., Rssner S., Saris W.H., Van Gaal L.F.: Effect of
sibutramine on weight maintenance after weight loss:
a randomised trial. STORM Study Group. Sibutramine
Trial of Obesity Reduction and Maintenance. Lancet,
356, 2119-2125, 2000.
21. Torgerson J.S., Hauptman J., Boldrin M.N., Sjstrm
L.: XENical in the prevention of Diabetes in Obese
subjects Study: a randomized study of 191 orlistat as
an adjunct to lifestyle changes for the prevention of
type 2 diabetes in obese patients. Diabetes Care, 27,
155-161, 2004.
22. Pi-Sunyer F.X., Aronne L.J., Heshmati H.M., Devin J.,
Rosenstock J., for the RIO-North America Study
Group: Effect of Ri monabant, a cannabi noi d-1
receptor bocker, on wight and cardiometabolic risk
factors in overweight or obese patients. RIO-North
America: a randomized controlled trial. J.A.M.A.,
295, 761-775, 2006.
23. Teixeira P.J., Going S.B., Houtkooper L.B., Cussler
E.C., Metcalfe L.L., Blew R.M., Sardinha L.B., Lohman
T.G.: Pretreatment predictors of attrition and success-
ful weight management in women. Int. J. Obes. Relat.
Metab. Disord., 28, 1124-1133, 2004.
24. Dalle Grave R., Calugi S., Molinari E., Petroni M.L.,
Bondi M., Compare A., Marchesini G. for the QUO-
VADIS Study Group: weight loss expectations in obese
patients and treatment attrition: an observational mul-
ticentre study. Obes. Res., 13, 1961-1969, 2005.
25. Andersson I., Rossner S.: Weight development,
dropout pattern and changes in obesity-related risk
factors after two years treatment of obese men. Int. J.
Obes. Relat. Metab. Disord., 21, 211-216, 1997.
26. Honas J.J., Early J.L., Frederickson D.D., OBrien M.S.:
Predictors of attrition in a large clinic-based weight-
loss program. Obes. Res., 11, 888-894, 2003.
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.

*
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
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).
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.
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-
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-
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.
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
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.
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.
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.
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,
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
plans to stop fasting (either on your own or with outside help)
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
plans to stop restricting (either on your own or with outside help)
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
plans to stop purging (either on your own or with outside help)
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
plans to stop using laxatives (either on your own or with outside help)
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
plans to stop using diet pills (either on your own or with outside help)
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
plans to stop using diuretics (either on your own or with outside help)
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
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
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.
health behaviors. Am. J. Health Promot., 14, 22-30,
1999.
16. Boutelle K.N., Dubbert P., Vander Weg M.: A pilot
study evaluating a minimal contact telephone and mail
weight management intervention for primary care
patients. Eat. Weight Disord., 10, e1-e5, 2005.
17. Jeffery R.W., French S.A., Rothman A.J.: Stage of
change as a predictor of success in weight control in
adult women. Health Psychol., 18, 543-546, 1999.
18. McConnaughy E.A., Prochaska J.O., Velicer W.F.:
Stages of change in psychotherapy: measurement and
sample profiles. Psychotherapy: Theory, Research,
Practice, 20, 368-375, 1983.
19. Gusella J., Butler G., Nichols L., Bird D.: A brief ques-
tionnaire to assess readiness to change in adolescents
with eating disorders: Its application to group therapy.
Eur. Eat. Disord. Rev., 11, 58-71, 2003.
20. Wolk S.L., Devlin M.J.: Stage of change as a predictor
of response to psychotherapy for bulimia nervosa. Int.
J. Eat. Disord., 30, 96-100, 2001.
21. Rieger E., Touyz S., Beumont P.: The Anorexia
Nervosa Stages of Change Questionnaire (ANSOCQ):
Information regarding its psychometric properties. Int.
J. Eat. Disord., 32, 24-38, 2002.
22. Rieger E., Touyz S., Schotte D., Beumont P., Russell J.,
Clarke S., Kohn M., Griffiths R.: Development of an
instrument to assess readiness to recover in anorexia
nervosa. Int. J. Eat. Disord., 28, 387-396, 2000.
23. Jordan P.J., Redding C.A., Troop N.A., Treasure J.,
Serpell L.: Developing a stage of change measure for
assessing recovery from anorexia nervosa. Eat.
Behav., 3, 365-385, 2003.
24. Sullivan V., Terris C.: Contemplating the stages of
change measures for eating disorders. Eur. Eat.
Disord. Rev., 9, 287-291, 2001.
25. Geller J., Drab D.L.: The Readiness and Motivation
Interview: a symptom-specific measure of readiness of
change in the eating disorders. Eur. Eat. Disord. Rev.,
7, 259-278, 1999.
26. Geller J., Cockell S.J,. Drab D.L.: Assessing readiness
for change in the eating disorders: the psychometric
properties of the Readiness and Motivation Interview.
Psychol. Assess., 13, 189-198, 2001.
27. Franko D.: Ready or not? Stages of change as predic-
tors of brief group therapy outcome in bulimia ner-
vosa. Group, 21, 39-45, 1997.
28. Treasure J.L., Katzmann M., Schmidt U., Troop N.,
Todd G., deSilva P.: Engagement and outcome in the
treatment of bulimia nervosa: first phase of a sequen-
tial design comparing motivation enhancement thera-
py and cognitive behavioural therapy. Behav. Res.
Ther., 37, 405-418, 1999.
29. Hasler G., Delsignore A., Milos G., Buddeberg C.,
Schnyder U.: Application of Prochaska's transtheoreti-
cal model of change to patients with eating disorders.
J. Psychosom. Res., 57, 67-72, 2004.
30. Ametller L., Castro J., Serrano E., Martinez E., Toro J.:
Readiness to recover in adolescent anorexia nervosa:
Prediction of hospital admission. J. Child Psychol.
Psychiatry, 46, 394-400, 2005.
31. Nunnally J.C., Bernstein I.H.: Psychometric Theory.
New York, NY, McGraw-Hill, Inc, 1994.
32. Cooper P.J., Taylor K.J., Cooper Z., Fairburn C.G.: The
development and validation of the Body Shape
Questionnaire. Int. J. Eat. Disord., 6, 485-494, 1987.
33. Rosen J.C., Jones A., Ramirez E., Wazman S.: Body
REFERENCES
1. Prochaska J.O.: Systems of psychotherapy: a transthe-
oretical analysis. Homewood, IL, Dorsey Press, 1979.
2. Prochaska J.O., DiClemente C.O.: Transtheoretical
therapy: toward a more integrative model of change.
Psychotherapy: Theory, Research, Practice, 19, 276-
288, 1982.
3. Prochaska J.O., DiClemente C.O.: The Transtheoretical
Approach: crossing traditional boundaries of therapy.
Homewood, IL, Dorsey Press, 1984.
4. Prochaska J.O., DiClemente C.O., Norcross J.C.: In
search of how people change: Applications to addic-
tive behaviors. Am. Psychol., 47, 1102-1114, 1992.
5. Prochaska J.O., Velicer W.F., Rossi J.S., Goldstein
M.G., Marcus B.H., Rakowski W.: Stages of change
and decisional balance for 12 problem behaviors.
Health Psychol., 13, 39-46, 1994.
6. Prochaska J.O., Velicer W.F., DiClemente C.O., Fava J.:
Measuring processes of change: applications to the
cessation of smoking. J. Consult. Clin. Psychol., 56,
520-528, 1988.
7. DiClemente C.O., Prochaska J.O., Fairhurst S.K.,
Velicer W.F., Velasquez M.M., Rossi J.S.: The process
of smoking cessation: an analysis of precontemplation,
contemplation, and preparation stages of change. J.
Consult. Clin. Psychol., 59, 295-304, 1991.
8. Prochaska J.J., Velicer W.F., Prochaska J.O., Delucchi
K., Hall S.M.: Comparing intervention outcomes in
smokers treated for single versus multiple behavioral
risks. Health Psychol., 25, 380-388, 2006.
9. Velicer W.F., Redding C.A., Anatchkova M.D., Fava
J.L., Prochaska J.O.: Identifying cluster subtypes for
the prevention of adolescent smoking acquisition.
Addict. Behav., 32, 228-247, 2007.
10. Marcus B.H., Owen N.: Motivational readiness, self-
efficacy and decision-making for exercise. J. Appl. Soc.
Psychol., 22, 3-16, 1992.
11. Marcus B.H., Rakowski W., Rossi J.S.: Assessing moti-
vational readiness and decision making for exercise.
Health Psychol., 11, 257-261, 1992.
12. Marcus B.H., Rossi J.S., Selby V.C., Niaura R.S.,
Abrams D.B.: The stages and processes of exercise
adoption and maintenance in a worksite sample.
Health Psychol., 11, 386-395, 1992.
13. Marcus B.H., Bock B.C., Pinto B.M., Forsyth L.H.,
Roberts M.B., Traficante R.M.: Efficacy of an individu-
alized, motivationally-tailored physical activity inter-
vention. Ann. Behav. Med., 20, 174-180, 1998.
14. O'Hea E.L., Boudreau E.D., Jeffries S.K., Carmack
Taylor C.L., Scarinci I.C., Brantley P.J.: Stage of
change movement across three health behaviors: the
role of self-efficacy. Am. J. Health Promot., 19, 94-102,
2004.
15. Costakis C.E., Dunnagan T., Haynes G.: The relation-
ship between the stages of exercise adoption and other
Shape Questionnaire: studies of validity and reliability.
Int. J. Eat. Disord., 20, 315-319, 1996.
34. Cohen J.: Statistical power for the behavioral sciences.
Hillsdale, NJ, Erlbaum, 1988.
35. Tantillo M., Nappa Bitter C., Adams B.: Enhancing
readiness for eating disorders treatment: a relation-
al/motivational group model for change. Eating
Disorders: Journal of Treatment and Prevention, 9,
203-216, 2001.
36. Feld R., Woodside D.B., Kaplan A.S., Olmsted M.P.,
Carter J.C.: Pretreatment motivational enhancement
therapy for eating disorders: a pilot study. Int. J. Eat.
Disord., 29, 393-400, 2001.
37. Touyz S., Thornton C., Rieger E., George L., Beumont
P.: The incorporation of the stage of change model in
the day hospital treatment of patients with anorexia ner-
vosa. Eur. Child Adolesc. Psychiatry, 12, i65-i71, 2003.
38. Geller J. , Drab-Hudson D.L., Whisenhunt B.L.,
Srikameswaran S.: Readiness to change dietary
restriction predicts outcomes in the eating disorders.
Eating Disorders: Journal of Treatment and
Prevention, 12, 209-224, 2004.
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.

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).
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
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
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,
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.
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.
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
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
REFERENCES
1. Niemz K., Griffiths M., Banyard P.: Prevalence of
pathological Internet use among university students
and correlations with self-esteem, the General Health
Questionaire (GHQ), and disinhabition. Cyberpsychol.
Behav., 8, 562-570, 2005.
2. Griffith M.D.: Internet addition: Does it really exist? In:
Gackenbach J. (Eds.), Psychology and the Internet:
intrapersonal, interpersonal and transpersonal appli-
cations. New York, Academic Press, 1998, pp. 61-75.
3. Thombs D.L.: Introduction to addictive behaviors. New
York, The Guilford Press, 1994.
4. Young K.S.: Caught in the Net: how to recognize the
signs of Internet addiction and a winning strategy for
recovery. New York, Wiley, 1998a.
5. Young, K.S.: Internet addiction: The emergence of a
new clinical disorder. Cyberpsychol. Behav., 1, 237-
244, 1998b.
6. Lin Q.H., Yan G.G.: Online behaviors and Internet
addictions among college students. Chin. Mental.
Heal., 15, 281-283, 2001.
7. Davis P.A.: A cognitive-behavioral model of pathologi-
cal Internet use. Computer. Human. Behav., 17, 187-
195, 2001.
8. Leung L.: Net-generation attributes and seductive
properties of the internet as predictors of online activi-
ties and Internet addiction. Cyberpsychol. Behav., 7,
333-348, 2004.
tistical manual of mental disorders, 4th ed. Washington,
DC, American Psychiatric Association, 1995.
10. Kraut R., Patterson M., Lundmark V., Kiesler S.,
Mukopadhyay T., Scherlis W.: Internet paradox - a social
technology that reduces social involvement and psycho-
logical well-being? Am. Psychol., 53, 1017-1031, 1998.
11. Rierdan J.: Internet-depression link? Am. Psychol., 54,
781-782, 1999.
12. Young K.S., Rodgers R.C.: The relationship between
depression and Internet addiction. Cyberpsychol.
Behav., 1, 25-28, 1998c.
13. Lacey J.H.: Self-damaging and addictive behaviour in
bulimia nervosa: a catchment area study. Br. J.
Psychiatry., 163, 190-194, 1993.
14. Armstrong L., Phillips J.C., Saling L.L.: Potential deter-
minants of heavier Internet usage. Int. J. Hum.
Comput. Stud., 53, 537-550, 2000.
15. Hayaki J., Friedmann M.A., Whisman M.A., Delinsky
S.S., Brownell K.D.: Sociotropy and bulimic symptoms
in clinical and nonclinical samples. Int. J. Eat. Disord.,
34, 172-176, 2003.
16. Ko C.H., Yen J.Y., Cheng C.C., Chen S.H., Wu K.J.,
Yen, C.F.: Tridimensional personality of adolescents
with Internet addiction and substance use experience.
Can. J. Psychiatry., 51, 887-894, 2006.
17. Young K.S.: Internet addiction: evaluation and treat-
ment. Stud. Br. Med. J., 7, 351-352, 1999.
18. Garner D.M., Olmsted M.P., Bohr, Y.: The Eating
Attitudes Test: psychometric feature and clinical corre-
lates. Psychol. Med., 12, 871-878, 1982.
19. Garner D.M., Garfinkel P.E.: The Eating Attitude Test:
an index of the symptoms of anorexia nervosa.
Psychol. Med., 9, 273-279, 1979.
20. Garner D., Garfinkel, P.: Perceptive and cognitive dis-
turbances. Anorexia nervosa: a multidimensional per-
spective. New York, Brunner/Mazel, 1982, pp.123-163.
APPENDIX 1
Internet addiction was measured by Youngs screen-
ing instrument for addictive Internet use. Respondents
were considered addicted when answering yes to
five (or more) of the eight yes or no questions.
1. Do you experience a tolerance in that you have a
need for increased amounts of Internet use to
achieve the desired effect?
2. Do you find there is a diminished effect with contin-
ued use of the same time spent on the Internet?
3. Do you spend longer periods of time on the Internet
than you intended?
4. Do you spend a great deal of time in activities to
stay online longer?
5. Have you given up any social, occupational, or
recreational activities because of the Internet?
6. Have you continued to use the Internet despite
knowledge of having a persistent or recurrent
problem that is likely to have been caused or exac-
erbated by the Internet (e.g., work-related prob-
lems, academic problems, financial problems, or
family problems)?
7. Have you made unsuccessful attempts to cut down
how much time you spend online?
8. Do you have a lack of desire to cut down on the
amount of time you spend online?
21. Eagles J.M., McLeod I.H., Mercer G., Watson F.:
Seasonality of eating pathology on the eating attitudes
test in a nonclinical population. Int. J. Eat. Disord., 27,
335-340, 2000.
22. Garner D.M., Olmsted M.P., Polivy J.: Development
and validation of multidimensional Eating Disorder
Inventory for anorexia nervosa and bulimia. Int. J. Eat.
Disord., 2, 15-34, 1983.
23. Franko D.L., Striegel-Moore R.H., Barton B.A.,
Schumann B.C., Garner D.M., Daniels S.R., Schreiber
G.B., Grawford P.B.: Measuring eating concerns in
black and white adolescent girls. Int. J. Eat. Disord., 35,
179-189, 2004.
24. Kinzel J.F., Traweger C., Guenther V., Biebl W.: Family
background and sexual abuse associated with eating
disorders. Am. J. Psychiatry., 151, 1127- 1131, 1994.
25. Aschenbrenner K., Aschenbrenner F., Kirchmann H.,
Strauss B.: Strungen des Essverhaltens bei
Gymnasiasten und Studenten. Psychoth. Psychosom.
Med. Psychol. (in German), 6, 259-263, 2004.
26. Tsai C.C., Lin S.S.J.: Internet addiction of adolescents
in Taiwan: an interview study. Cyberpsychol. Behav.,
6, 649-652. 2003.
27. Cooper M., Todd G., Wells A.: Bulimia nervosa - A
cognitive therapy programme for clients. London and
New York, Jessica Kingsley Publishers, 2000, p. 22.
28. Young K.S.: Psychology of computer use. XL.
Addictive use of the Internet: a case that breaks the
stereotype. Psychol. Rep., 79, 899-902, 1996.
29. Marlatt A.G., Baer J.S., Donovan D.M., Kivlahan D.R.:
Addictive behaviours: etiology and treatment. Annu.
Rev. Psychol., 39, 223-252, 1988.
30. Welche S.L., Fairburn C.C.: Impulsivity or comorbidity
in bulimia nervosa: a controlled study of deliberate-
self-harm and alcohol and drug misuse in a community
sample. Br. J. Psychiatry, 169, 451-458, 1996.
31. Cooper M., Todd G., Wells A.: Bulimia nervosa - A
cognitive therapy programme for clients. London/New
York, Jessica Kingsley Publishers, 2000, p. 26.
32. Buddeberg-Fischer B., Bernet R., Sieber M., Schmid,
J., Buddeberg, C.: Epidemiology of eating behaviour
and weight distribution in 14- to 19-year-old Swiss stu-
dents. Acta. Psychiatr. Scand., 93, 293-304, 1996.
33. Lee S., Kwok K., Liau C., Leung T.: Screening Chinese
patients with eating disorders using the Eating
Attitudes Test in Hong Kong. Int. J. Eat. Disord., 32,
91-97, 2002.
34. Craig R.J.: The role of personality in understanding
substance abuse. Alcohol.Treat. Quart., 13, 17-27, 1995.
35. Bruch H.: The golden cage. New York, Vintage, 1979.
36. Sexton M.C., Sunday S.R., Hurt S., Halmi K.A.: The
relationship between alexithymia, depression, and axis
II psychopathology in eating disorder inptients. Int. J.
Eat. Disord., 23, 277-286, 1998.
37. Lesser I.R.A.: Review of the alexithymia concept.
Psychosom. Med., 43, 531-543, 1981.
38. Taylor G.J.: Alexithymia: concept, measurement, and
implications for treatment. Am. J. Psychiatry, 141, 725-
732, 1984.
39. Davis M.S., Marsh L.: Self-love, self-control and alex-
ithymia: narcissistic features of two bulimic adoles-
cents. Am. J. Psychother., 15, 224-232, 198.
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
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.

Multidimensional self reports in ED
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.
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
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.
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.
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.
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).
REFERENCES
1. Bruch H.: Thin fat people. J. Am. Med. Womens
Assoc., 28, 4, 187-188, 1973.
2. Bulik C.M., Sullivan P.F., Weltzin T.E., Kaye W.H.:
Temperament in eating disorders. Int. J. Eat. Dis., 17,
251-261, 1995.
3. Klump K.L., Bulik C.M., Pollice C., Halmi K.A., Fichter
M., Berrettini W.H.: Temperament and character in
women with anorexia nervosa. J. Nerv. Mental Dis.,
188, 559-567, 2000.
4. Cassin S.E., von Ranson K.M.: Personality and eating
disorders: A decade in review. Clin. Psych. Rev., 25,
895-916, 2005.
5. Frost R.O., Marten P., Lahart C., Rosenblate R.: The
dimensions of perfectionism. Cog. Ther. Res., 14, 5,
449-468, 1990.
6. Barratt E.S.: Impulsiveness subtraits: arousal and
information processing. In: Spence J.T., Izard C.E.
(Eds.), Motivation, emotion and personality.
Amsterdam, Elsevier, 137-156, 1985.
7. Foa E.B., Huppert J.D., Leiberg S., Langner R., Kichic
R., Hajcak G.: The obsessive-compulsive inventory:
development and validation of a short version.
Psychol. Assess., 14, 485-496, 2002.
8. Shafran R., Lee M., Payne E., Fairburn C.G.: The
impact of manipulating personal standards on eating
attitudes and behaviour. Behav. Res. Ther., 897-906,
2006.
9. Hewitt P.L., Flett G.L.: Perfectionism in the self and
social contexts: Conceptualisation, assessment and
association with psychopathology. J. Pers. Soc.
Psychol., 60, 456-470, 1991.
10. Terry-Short L.A., Owens R.G., Slade P.D., Dewey M.E.:
Positive and negative perfectionism. Pers. Ind. Diff., 18,
663-668, 1995.
11. Enns M.W., Cox B.J.: The nature and assessment of
perfectionism: A critical analysis. In: Flett G.L., Hewitt
P.L. (Eds.), Perfectionism: theory, research and treat-
ment. Washington, DC, American Psychiatric
Association, 2002, pp. 33-62.
12. Bardone-Cone A.M., Wonderlich S.A., Frost R.O.,
Bulik C.M., Mitchell J.E., Uppala S., Simonich H.:
Perfectionism and eating disorders: Current status and
future directions. Clin. Psych. Rev., 27, 384-405, 2007.
13. Halmi K.A., Sunday S.R., Strober M., Kaplan A.,
Woodside D.M., Fichter M.: Perfectionism in anorexia
nervosa: Variation by clinical subtype, obsessionality
and pathological eating behaviour. Am. J. Psychiatry,
157, 1799-1805, 2000.
14. Bastiani A.M., Rao R., Weltzin T., Kaye W.H.: Per-
fectionism in anorexia nervosa. Int. J. Eat. Dis., 17, 147-
152, 1995.
15. Lilenfeld L.R.R., Stein D., Bulik C.M., Strober M.,
Plotnicov K., Pollice C., Rao R., Merikangas K.R., Nagy
L., Kaye W.H.: Personality traits among current eating
disordered, recovered and never ill first-degree rela-
tives of bulimic and control women. Psychol. Med., 30,
1399-1410, 2000.
16. Davis C.: Normal and neurotic perfectionism in eating
disorders: An interactive model. Int. J. Eat. Dis., 22,
421-426, 1997.
17. Bulik C.M., Tozzi F., Anderson C., Mazzeo S.E., Aggen
S., Sullivan P.F.: The relation between eating disorders
and components of perfectionism. Am. J. Psychiatry,
160, 366-368, 2003.
18. Fahy T., Eisler I.: Impulsivity and eating disorders. Br.
J. Psychiatry, 162, 193-197, 1993.
19. Spinella M.: Normative data and a short form of the
Barratt impulsiveness scale. Int. J. Neurosci., 117, 359-
368, 2007.
20. Dougherty D.M., Bjork J.M., Huckabee H.C., Moeller
F.G., Swann A.C.: Laboratory measures of aggression
and impulsivity in women with borderline personality
disorder. Psych. Res., 85, 3, 315-326, 1999.
21. Zilberman M.L., Tavares H., El-Guebaly N.: Relation-
ship between craving and personality in treatment-
seeking women with substance-related disorders.
B.M.C. Psychiatry, 3, 1, 1-5, 2003.
22. Claes L., Vandereycken W., Vertommen H.: Impulsive
and compulsive traits in eating disordered patients com-
pared with controls. Pers. Indiv. Diff., 32, 707-714, 2002.
23. Rosval L., Steiger H., Bruce K., Israel M., Richardson
J., Aubut M.: Impulsivity in women with eating disor-
ders: problem of response inhibition, planning or
attention? Int. J. Eat. Disord., 39, 7, 590-593, 2006.
24. Sanavio E.: Obsessions and compulsions: the Padua
Inventory. Behav. Res. Ther., 26, 167-177, 1988.
25. Thordarson D.S., Radomsky A.S., Rachman S., Shafran
R., Sawchuk C.N., Hakstian A.R.: The Vancouver
Obsessional Compulsive Inventory (VOCI). Behav. Res.
Ther., 42, 1289-1314, 2004.
26. Goodman W.K., Price L.H., Rasmussen S.A., Mazure
C., Fleischmann R.L., Hill C.L.: The Yale-Brown
Obsessive Compulsive Scale. I. Development, use and
reliability. Arch. Gen. Psych., 46, 1006-1011, 1989.
27. Hodson R.J., Rachman S.: Obsessional-compulsive
complaints. Behav. Res. Ther., 15, 5, 389-95, 1977.
28. Mataix-Cols, D., Conceicao do Rosario-Campos M.,
Leckman J.F.: A multidimensional model of obsessive-
compulsive disorder. Am. J. Psychiatry, 162, 2, 228-
238, 2005.
29. Vitousek K., Manke F.: Personality variables and disor-
ders in anorexia nervosa and bulimia nervosa. J.
Abnorm. Psychol., 103, 137-147, 1994.
30. Serpell L., Livingston A., Neiderman M., Lask B.:
Anorexia nervosa: obsessive-compulsive disorder,
obsessive-compulsive personality disorder, or neither?
Clin. Psychol. Rev., 22, 5, 647-669, 2002.
31. Yaryura-Obias M.A., Pinto A., Neziroglu F.: The integra-
tion of primary anorexia nervosa and obsessive-compul-
sive disorder. Eat. Weight Disord., 6, 4, 174-180, 2001.
32. Anderluh M.B., Tchanturia K., Rabe-Hesketh S.,
Treasure J.: Childhood obsessive-compulsive personal-
ity traits in adult women with eating disorders:
Defining a broader eating disorder phenotype. Am. J.
Psychiatry, 160, 242-247, 2003.
33. Kaye W., Bulik C.M., Thornton L., Barbarich N.,
Masters K.: Price Foundation Collaborative Group.
Comorbidity of anxiety disorders with anorexia and
bulimia nervosa. Am. J. Psychiatry, 161, 2215-2221,
2004.
34. First M.B., Spitzer R.L., Gibbon M., Williams J.B.W.:
Structured Clinical Interview for DSM-IV-TR Axis I
Disorders, Research Version, Non-patient Edition.
(SCID-I/NP). New York, Biometrics Research, New
York State Psychiatric Institute, 2002.
35. Fairburn C.G., Beglin S.J.: Assessment of eating disor-
ders: interview or self-report questionnaire? Int. J. Eat.
Disord., 16, 4, 363-370, 1994.
36. Garner D.M., Olmsted M.P., Polivy J.: Development
and validation of a multidimensional eating disorder
inventory for anorexia and bulimia nervosa. Int. J. Eat.
Disord., 9, 1-15, 1983.
37. Lyke J.A., Spinella M.: Associations among aspects of
impulsivity and eating factors in a nonclinical sample.
In. J. Eat. Disord., 36, 229-233, 2004.
38. Jones B., Duncan C., Brouwers P., Mirsky A.:
Cognition in eating disorders. J. Clin. Exp.
Neuropsychol., 13, 711-728, 1991.
39. Wonderlich S.A., Mitchell J.E.: Eating disorders and
comorbidity: Empirical, conceptual and clinical impli-
cations. Psychopharm. Bull., 33, 381-390, 1997.
40. Claes L., Nederkoorn C., Vandereycken W., Guerrieri
R., Vertommen H.: Impulsiveness and lack of inhibito-
ry control in eating disorders. Eat. Behav., 7., 3, 196-
203, 2006.
41. Frost R.O., Krause M.S., Steketee G.: Hoarding and
obsessive-compulsive symptoms Behav. Modif., 20,
116-132, 1996.
42. Pertusa A., Fullana M., Singh S., Alonso P., Menchn
J., Mataix-Cols D.: Compulsive Hoarding: OCD
Symptom, Distinct Clinical Syndrome, or Both? Am. J.
Psychiatry, 165, 1289-1298, 2008.
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
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.

Weight stigma
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.
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.
R.A. Carels, K.M. Young, C.B. Wott, et al.
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
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.
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
these treatment seeking adults in their self-
image and in their weight loss efforts. The
absence of these positive views might, in turn,
reflect diminished views of the self, including
reduced self-efficacy for weight loss success.
Weight stigma
For example, a recent investigation revealed
that greater internalized weight stigma among
the overweight/obese contributed to greater
binge eating, a condition known to adversely
influence weight loss treatment outcomes (13)
The current study suggests that internalized
weight stigma is evident among over-
weight/obese treatment seeking adults. It will
be important to assess whether peoples stig-
matizing experiences are related to weight loss
outcomes. Perhaps, what is most clear from
this investigation is that overweight/obese
treatment seeking adults have internalized the
pervasive negative weight-based social stigma
that exists in American society.
10. Ashmore J.A., Friedman K.E., Reichmann S.K.,
Musante G.J.: Weight-based stigmatization, psycho-
logical distress, and binge eating behavior among
obese treatment-seeking adults. Eat. Behav., 9, 203-
209, 2008.
11. Pagan J.A., Davila A: Obesity, occupational attainment,
and earnings. Soc. Sci. Q., 78, 756-770, 1997.
12. Register C.A., Williams D.R.: Wage effects of obesity
among young workers. Soc. Sci. Q., 71, 130-141, 1990.
13. Puhl R. M., Moss-Racusin C.A., Schwartz M.B. :
Internalization of weight bias: Implications for binge
eating and emotional well-being. Obesity, 15, 19-23,
2007.
14. Vartanian L.B., Shaprow J.G.: Effects of weight stigma
on exercise motivation and behavior. J. Health
Psychol., 13, 131-138, 2008.
15. Greenleaf C., Starks M., Gomez L., Chambliss H.,
Martin S.: Weight-related words associated with fig-
ure silhouettes. Body Image, 1, 373-384, 2004.
16. Teachman B.A., Brownell K.D.: Implicit anti-fat bias
among health professionals: Is anyone immune? Int. J.
Obes., 25, 1525-1531, 2001.
17. Puhl R.M., Schwartz M., Brownell K.D.: Impact of per-
ceived consensus on stereotypes about obese people:
A new approach for reducing bias. Health Psychol., 24,
517-525, 2005.
18. Greenwald A.G., McGhee D.E., Schwartz J.L.K.:
Measuring individual differences in implicit cognition:
the Implicit Association Test. J. Pers. Soc. Psychol., 74,
1464-1480, 1998.
19. Mirels H.L., Garrett J.B.: The Protestant Ethic as a per-
sonality variable. J. Consult. Clin. Psychol., 36, 40-44,
1971.
20. Katz I., Hass R.G.: Racial ambivalence and American
value conflict: correlational and priming studies of dual
cognitive structure. J. Pers. Soc. Psychol., 55, 893-905,
1988.
21. Rubin Z., Peplau L.A.: Who believes in a just world?
Journal of Social Issues, 31, 65-89, 1975.
22. Schwartz M.B., Vartanian L.R., Nosek B.A., Brownell
K.D.: The influence of one's own body weight on implic-
it and explicit anti-fat bais. Obesity, 14, 440-447, 2006.
23. Bessenhoff G.R., Sherman J.W.: Automatic and con-
trolled components of prejudice toward fat people:
evaluation versus stereotype activation. Soc. Cogn., 18,
329-353, 2000.
24. Musher-Eizenman D., Holub S.C., Miller A.B. ,
Goldstein S.E., Edwards-Leeper L.: Body size stigmati-
zation in preschool children: the role of control attribu-
tions. J. Pediatr. Psychol., 29, 613-620, 2004.
REFERENCES
1. Puhl R.M., Brownell K.D.: Psychosocial origins of obe-
sity stigma: toward changing a powerful and pervasive
bias. Obes. Rev., 4, 213-227, 2003.
2. Puhl R.M., Latner J.D.: Sitgma, obesity, and the health
of the nation's children. Psychol. Bull., 133, 557-580,
2007.
3. Allison D.B., Basile V.C., Yuker H.E.: The measurement
of attitudes toward and beliefs about obese persons.
Int. J. Eat. Disord., 10, 599-607, 1991.
4. Crandall C.S.: Prejudice against fat people: ideology
and self-interest. J. Pers. Soc. Psychol., 66, 882-894,
1994.
5. Crandall C.S., Schiffhauer K.L.: Anti-fat prejudice:
Beliefs, values, and American culture. Obes. Res., 6,
458-460, 1998.
6. Rudman L.A., Feinburg J., Fairchild K.: Minority mem-
bers' implicit attitudes: automatic ingroup bias as a
function of group status. Soc. Cogn., 20, 294-320, 2002.
7. Wang S.S., Brownell K.D., Wadden T.A.: The influence
of the stigma of obesity on overweight individuals. Int.
J. Obes., 28, 1333-1337, 2004.
8. Rothblum E.D., Brand P.A., Miller C.T., Oetjen H.A.:
The relationship between obesity, employment dis-
crimination, and employment-related vicitimization. J.
Vocat. Behav., 37, 251-266, 1990.
9. Friedman K.E., Reichmann S.K., Costanza P.R., Zelli
A., Ashmore J.A., Musante G.J.: Weight stigmatization
and ideological beliefs: relation to psychological func-
tioning in obese adults. Obesity, 13, 907-916, 2005.
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
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.

e98
EWD_09_18_Sung.qxp:EWD_ 4-11-2009 10:11 Pagina 98
Eating behavior and weight change
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.
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
J. Sung, K. Lee, and Y.-M. Song
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).
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.
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*
Restrained eating 1.14 0.25 <0.001

Emotional eating 0.86 0.25 0.001
External eating 0.32 0.25 0.214
Adjusted for family variable*, age and gender

Emotional eating 1.01 0.25 <0.001
Adjusted for family variable*, age, gender, and BMI at 20 years

Adjusted for family variable*, age, gender, BMI at 20 years, intentional weight loss, demographics,
health-related behaviors, energy intake, and other subscales

Emotional eating 0.83 0.28 0.003
DEBQ, Dutch Eating Behavior Questionnaire.
*General linear model included z-transformed each subscale and family variable as a random effect;

other variables as fixed effects.
Demographics included marital status, education level, and medical history; health-related behaviors included exercise, smoking status, and alcohol use.
eating subscale. Subjects in the highest tertile of
restrained and emotional eating subscales were
more likely to gain their weight from 20 years
old to current age and also have higher BMI
than those in the lowest tertile. Moreover,
weight change and current BMI were more
likely to be higher in subjects of the highest ter-
tile of restrained eating subscale compared to
those in the lowest tertile regardless of levels of
emotional eating subscale (Fig. 1 and 2).
Table 3 and 4 show the relationship of DEBQ
subscales as continuous variables to weight
change and current BMI. The scores of
restrained or emotional eating subscale were
independently and positively associated with
weight gain from the age of 20 years to current
age and with a higher current BMI, after adjust-
ing for attempt to lose weight over the past 4
years, weight at 20 years old, demographics
including age and gender, health-related behav-
iors, total energy intake, and other DEBQ sub-
scales. In the adjusted models, weight at 20
years old was negatively associated with weight
change [beta (B)=-0.47, standard error
(SE)=0.045, p<0.001] and positively associated
with current BMI (B=0.12, SE=0.016, p<0.001). In
the same models, subjects who had tried weight
loss over the past 4 years were more likely to
gain weight (B=1.58, SE=0.61, p=0.010) and have
higher current BMI (B=0.52, SE=0.22, p=0.016).
DISCUSSION
The main finding of the current study is both
restrained eating and emotional eating mea-
sured using the DEBQ were associated with
self-reported long-term weight gain and higher
current BMI, respectively in Korean twins and
their families. This study is unique because
there has been a paucity of studies about the
relationship of eating behavior in terms of long-
term change of weight (3, 6, 11), while numer-
ous studies showed those relationships with
current weight status or short-term weight
change (2-11). The results of the current study
also give important information because diverse
factors and other DEBQ subscales were adjust-
ed and independent association of each eating
behavior subscale was able to be assessed.
As the term dietary restraint refers to a ten-
dency to reduce calorie intake for achieving
desired weight, the positive relationships
between those factors may be contrary to the
definition of scale. However, some studies
regarding restrained eating and weight change
or current BMI which were mostly assessed
using the Eating Inventory-Cognitive Restraint
scal e also showed positive relationships
between those factors (3, 6, 7), while negative
associations were reported in other studies (8,
9). The discrepancy in the relationships may be
given by differences in characteristics of sub-
jects such as underlying weight status, gender,
and associated eating disorders, difference in
measured scales, and study design such as
prospective or cross-sectional design.
FIGURE 1
Mean weight change from 20 years to current age
according to tertiles of restrained and emotional eating in
subjects of the Healthy Twin Study. *p<0.05 using post-
hoc comparison (Scheffe method) with 1
st
tertile of
restrained eating subscale in each tertile of emotional
eating subscale.
FIGURE 2
Mean body mass index (BMI) at current age in relation to
tertiles of restrained and emotional eating in subjects of
the Healthy Twin Study. *p<0.05 using post-hoc compar-
ison (Scheffe method) with 1
st
tertile of restrained eating
in each tertile of emotional eating.
9
8
7
6
5
4
3
2
1
0
W
e
i
g
h
t
c
h
a
n
g
e
(
k
g
)
Em
otional eating
R
e
s
t
r
a
i
n
e
d
e
a
t
i
n
g
1st
2nd
3rd
1st
*
*
*
*
*
*
2nd
3rd
25
24.5
24
23.5
23
22.5
22
21.5
21
20.5
C
u
r
r
e
n
t
B
M
I
(
k
g
/
m
2
)
Em
otional eating
R
e
s
t
r
a
i
n
e
d
e
a
t
i
n
g
1st
2nd
3rd
1st
2nd
3rd
*
*
*
*
*
*
TABLE 4
Associations of the Dutch Eating Behavior Questionnaire (DEBQ) subscales with current body mass index
in subjects of the Healthy Twin study.
In the current study, we assessed restrained
eating, BMI, and self-reported weight change
simultaneously. Therefore, the positive relation-
ships between those factors may reflect higher
weight change or higher current BMI initiates
dietary restraint in subjects and results in high-
er scores of retrained scale. The interpretation
is supported by a trend of lower calorie intake
in subjects with higher restrained eating
although the association was weak. Alternative-
ly, although subjects exhibiting high levels of
dietary restraint might have lost weight in the
short term, they might be at increased risk for
higher BMI and weight gain over the long term
due to counter-regulatory eating. This influ-
ence of dietary restraint on the tendency to
overeat is supported by previous studies (18, 19)
and the significant and positive correlations
found within our dataset between scores for
dietary restraint and scores for emotional and
external eating that reflect overeating tendency.
However, it has been accepted that restrained
eaters selected using the DEBQ-Restrained Eat-
ing scale tend to eat less than unrestrained
eaters in the natural environment and they do
not show the counter-regulatory eating that
was revealed by restrained eaters categorized
using the Restraint Scale (20).
We observed subjects scoring high on the
restrained eating were more likely to have high
scores on the emotional eating. This finding
suggested individuals high in dietary restraint
may be vulnerable to emotional eating. It has
been suggested that food restriction and nega-
tive emotional states trigger overeating and
may have their greatest impact on eating when
they coincide (21). This theory was confirmed
in the current study. The individuals scoring
high in emotional eating as well as in
restrained eating gained their weight much
more compared to those scoring low in both
emotional eating and restrained eating (Fig. 1).
A similar result was also reported regarding
seasonal weight change (10).
We found no positive association between
external eating and either weight gain or cur-
rent BMI, while previous studies using the
DEBQ have reported that food cravings medi-
ated the positive association between external
eating and BMI (22) and were related to high
external eating scores and weight gain (11).
Our findings had some limitations. First, it
was not clear whether eating behavior is a
consequence or a cause of weight change and
current BMI. This limitation can be addressed
using prospective studies. One prospective
B SE p-value
Adjusted for family variable*
External eating -0.02 0.08 0.787
Adjusted for family variable*, age and gender

Adjusted for family variable*, age, gender, and BMI at 20 years

Adjusted for family variable*, age, gender, BMI at 20 years, intentional weight loss, demographics,
health-related behaviors, energy intake and other subscales

External eating -0.08 0.10 0.443
SE: standard error.
*General linear model included z-transformed each subscale and family variable as a random effect;

other variables as fixed effects.
Demographics included marital status, education level, and medical history; health-related behaviors included exercise, smoking status, and alcohol use.
study of a general population suggested that
baseline dietary restraint did not predict
change in BMI two years later, but that a high
baseline BMI predicted a greater increase in
dietary restraint (7). Second, the accuracy of
reported weight change may have influenced
the results. Although previous studies have
suggested a high correlation between self-
reported past weight and actual weight, accu-
rate recall of past weight may be influenced by
subjects eating behavior, age, weight status,
cognitive function, and elapsed time (23, 24).
Finally, our subjects were twins and their fam-
ilies and, thus, may not be representative of a
general population. Among men, no differ-
ences appeared in scores for the three scales
between twins and families, whereas, among
women, scores for restrained eating behavior
differed significantly between twins and fami-
lies after adjusting for current BMI and age.
However, it is not evident that twinning affect-
ed the accuracy of our findings.
In conclusion, our studies indicated that
restrained eating and emotional eating assessed
using the DEBQ were associated with weight
gain since the age of 20 years and with current
BMI in Korean adults. Therefore, individuals
scoring high in both scales may be considered
as a high risk group for weight gain or higher
BMI. Further studies are necessary to identify
the causal pathway and usefulness of promoting
dietary restraint to control weight for those who
already exhibit high levels of dietary restraint.
ACKNOWLEDGEMENT
All authors participated in study design and conduct-
ing the study. K. Lee and J. Sung worked for the data
interpretation. K. Lee and Y. Song contributed to edit-
ing the manuscript. This study was supported by a
grant of the Korea Centers for Disease Control and
Prevention (Serial number 2005-347-2400-2440-215,
2006-347-2400-2440-215).
4. Hays N.P., Bathalon G.P., McCrory M.A., Roubenoff
R., Lipman R., Roberts S.B.: Eating behavior correlates
of adult weight gain and obesity in healthy women
aged 5565 y. Am. J. Clin. Nutr., 75, 476-483, 2002.
5. Provencher V., Drapeau V., Tremblay A., Desprs J.P.,
Lemieux S.: Eating behaviors and indexes of body
composition in men and women from the Qubec fam-
ily study. Obes. Res., 11, 783-792, 2003.
6. Tholin S., Rasmussen F., Tynelius P., Karlsson J.:
Genetic and environmental influences on eating
behavior: The Swedish Young Male Twins study. Am.
J. Clin. Nutr., 81, 564-569, 2005.
7. de Lauzon-Guillain B., Basdevant A., Romon M.,
Karlsson J., Borys J.M., Charles M.A.; FLVS Study
Group: Is restrained eating a risk factor for weight
gain in a general population? Am. J. Clin. Nutr., 83,
132-138, 2006.
8. Foster G.D., Wadden T.A., Swain R.M., Stunkard A.J.,
Platte P., Vogt R.A.: The eating inventory in obese
women: Clinical correlates and relationship to weight
loss. Int. J. Obes. Relat. Metab. Disord., 22, 778-785,
1998.
9. Masheb R.M., Grilo C.M.: On the relation of attempt-
ing to lose weight, restraint, and binge eating in outpa-
tients with binge eating disorder. Obes. Res., 8, 638-
645, 2000.
10. Kruchi K., Reich S., Wirz-Justice A.: Eating style in
seasonal affective disorder: who will gain weight in
winter?. Compr. Psychiatry, 38, 80-87, 1997.
11. Van Strien T., Van de Laar F.A., Van Leeuwe J.F.J.,
Lucassen P.L.B.J, Van den Hoogen H.J.M., Rutten
G.E.H.M., Van Weel C.: The dieting dilemma in
patients with newly diagnosed Type 2 diabetes: does
dietary restraint predict weight gain 4 years after diag-
nosis?. Health Psychol., 26, 105-112, 2007.
12. Larsen J.K., van Strien T., Eisinga R., Herman C.P.,
Engels R.C.: Dietary restraint: intention versus behav-
ior to restrict food intake. Appetite, 49, 100-108,2007.
13. Sung J., Cho S., Lee K., Ha M., Choi E., Choi J., Kim H.,
Kim Y., Yoo K., Park C., Song Y.: Healthy Twin: A twin-
family study of Korea Protocols and current status.
Twin Res. Hum. Genet., 9, 844848, 2006.
14. Boffetta P., Agudo A., Ahrens W., Benhamou E.,
Benhamou S., Darby S.: Multicenter case-control study
of exposure to environmental tobacco smoke and lung
cancer in Europe. J. Natl. Cancer Inst., 90, 1440-1450,
1998.
15. Ahn Y., Lee J.E., Cho N.H., Shin C., Park C., Oh B.S.,
Kim K.: Validation and calibration of semi-quantitative
food frequency questionnaire: with participants of the
Korean Health and Genome study. Korean J.
Community Nutr., 9, 173-182, 2004.
16. Kim H., Lee I., Kim J.: A study of the reliability and
validity of the Korean version of the Eating Behavior
Questionnaire. Korean Journal of Clinical Psychology,
15, 141-150, 1996.
17. National Institute of Health. Clinical guidelines on the
identification, evaluation, and treatment of overweight
and obesity in adults: The evidence report. Bethesda,
MD, National Heart, Lung, and Blood Institute, 1998.
18. Cepeda-Benito A., Fernandez M.C., Moreno S.:
Relationship of gender and eating disorder symptoms
to reported cravings for food: construct validation of
state and trait craving questionnaires in Spanish.
Appetite, 40, 47-54, 2003.
REFERENCES
1. Van Strien T., Frijters J.E.R., Bergers G.P.A., Defares
P.B.: The Dutch Eating Behavior Questionnaire
(DEBQ) for assessment of restrained, emotional, and
external eating behavior. Int. J. Eat. Disord., 5, 295-
315, 1986.
2. Steinle N.I., Hsueh W.C., Snitker S., Pollin T.I., Sakul
H., St Jean P.L., Bell C.J., Mitchell B.D., Shuldiner A.R.:
Eating behavior in the Old Order Amish: heritability
analysis and a genome-wide linkage analysis. Am. J.
Clin. Nutr., 75, 1098-1106, 2002.
3. Keski-Rahkonen A., Bulik C.M., Pietilinen K.H., Rose
R.J., Kaprio J., Rissanen A.: Eating styles, overweight
and obesity in young adult twins. Eur. J. Clin. Nutr.,
61, 822-829, 2007.
19. Hill A.J.: The psychology of food craving. Proc. Nutr.
Soc., 66, 277-285, 2007.
20. Lowe M.R.: Dietary restraint and overeating. In:
Fairburn C.G., Brownell K.D. (Eds.), Eating disorders
and obesity. 2nd Ed. New York, Guilford Press, 2002,
pp. 88-92.
21. Waller G.: The psychology of binge eating. In:
Fairburn C.G., Brownell K.D. (Eds.), Eating disorders
and obesity. 2nd Ed. New York, Guilford Press, 2002,
pp. 98-102.
22. Burton P., Smit H.J., Lightowler H.J.: The influence of
restrained and external eating patterns on overeating.
Appetite, 49, 191-197, 2007.
23. Perry G.S., Byers T.E., Mokdad A.H., Serdula M.K.,
Williamson D.F.: The validity of self-reports of past body
weights by U.S. adults. Epidemiology, 6, 61-66, 1995.
24. Tamakoshi K., Yatsuya H., Kondo T., Hirano T., Hori
Y., Yoshida T., Toyoshima H.: The accuracy of long-
term recall of past body weight in Japanese adult men.
Int. J. Obes. Relat. Metab. Disord., 27, 247-252, 2003.
ORIGINAL
RESEARCH
PAPER
Key words:
Eating disorders,
physical activity, exercise,
treatment, clinical practice.
Correspondence to:
Jan H. Rosenvinge, PhD,
University of Troms,
Huginbakken 32,
N-9037 Troms, Norway.
E-mail: jan.rosenvinge@uit.no
Physical activity in treatment units
for eating disorders: Clinical practice
and attitudes
INTRODUCTION
Exercise is defined as planned, structured
and regular physical activity (PA) intended to
improve performance, fitness and/or health
(1). Regular PA is important in the preven-
tion and treatment of somatic as well as men-
tal disorders (2). The effect of PA as a treat-
ment option for mental disorders is best doc-
umented for depression and anxiety (3, 4). In
the treatment of eating disorders (ED),
notably normal weight bulimia nervosa (BN),
PA has been shown not inferior to cognitive
therapy (3), and particular effects are
improved aerobic fitness and body composi-
tion (5). Similar effects of PA have also been
reported in the treatment of binge eating dis-
order (BED) (6-8). In anorexia nervosa (AN),
PA as part of the treatment may increase the
quality of life, psychological well-being,
socializing, body composition and physical
fitness (9-13). To our knowledge, no studies
have reported harmful effects of integrating
PA in treatment programmes for ED.
On the other hand, excessive PA is men-
tioned in the international classification sys-
tems International Classification of Diseases
- Tenth Revision (ICD-10) and Diagnostic
and Statistical Manual of Mental Disorders
- Fourth Edition (DSM-IV) as one of the
weight compensatory behaviours patients
with ED may engage in (14, 15). Excessive
PA may serve as an affect regulator, and
reflect a wish to burn off calories in the pur-
suit of thinness (16-18). Moreover, ED
patients who are excessively physically
active have more symptoms of anxiety,
depression and compulsivity, poorer out-
come and higher risk of relapse (19-21).
Studies indicate that 37-80% of patients
with ED are excessively physical active,
depending on diagnosis, duration of illness
and how excessive PA is defined (22, 23).
Although high percentages, the rather wide
range may, to some extent, be attributed to
the fact that previous studies have used var-
ious terms to define excessive or non-
healthy PA, like excessive PA, hyperactivity,
S. Bratland-Sanda
1,2
, J.H. Rosenvinge
3
, K.A.R. Vrabel
1
, C. Norring
4
,
J. Sundgot-Borgen
2
, . R
1
, and E.W. Martinsen
5,6
1
Research Institute, Modum Bad Psychiatric Centre, Vikersund,
2
Department of Sports Medicine, Norwegian
School of Sports Sciences, Oslo,
3
Department of Psychology, University of Troms, Troms, Norway,
4
Department of Behavioural, Social and Legal Sciences (Psychology), rebro University, and Stockholm
Centre for Eating Disorders, Stokholm, Sweden,
5
Institute of Psychiatry, University of Oslo,
6
Clinic and
Mental Health, Aker University Hospital, Oslo, Norway
ABSTRACT. OBJECTIVE: Physical activity (PA) in eating disorders (ED) may be harmful,
but in a therapeutic setting also beneficial. The purpose of this survey was to examine these
contradictory aspects of PA in ED specialist treatment settings. We examined whether
1) PA is assessed by the unit, 2) the units have guidelines for managing excessive PA, 3) the
units have staff with higher education and special competence in PA and exercise science,
4) how units regard PA in ED, 5) whether regular PA is integrated in the treatment pro-
grams, and 6) how the units rate the role of PA in the treatment of ED compared with other
mental disorders. METHODS: Of the 49 units located in Scandinavia and the United King-
dom, 41 (84%) responded to a questionnaire. RESULTS: In 28 units (68%) PA was
assessed regularly. Excessive PA was considered a harmful symptom in ED, and most
units reported guidelines to manage excessive PA. Thirty-two units included PA in their
treatment programmes. Clinicians found PA most relevant in the treatment of obesity and,
except for binge eating, less for ED. CONCLUSION: PA was more commonly integrated
in treatment compared to previous studies. Future research should address how to manage
excessive PA, and the potential beneficial role of PA in the treatment of ED.

e106
Physical activity in units for eating disorders
compulsive exercise, obligatory exercise, exer-
cise dependence, exercise addiction and exer-
cise abuse (24-27) For this study, excessive PA
was more operationally defined as behaviours
exceeding the units limits for weekly amount
of moderate-to-vigorous intensity PA.
Excessive PA may be dangerous, increasing
the risk of arrhythmias and cardiac arrest. This
may happen even among athletes, in particular
in sports with strenuous PA of long duration,
such as long distance running (28). ED patients
with poor nutrition status and electrolyte
imbalance, who are physically active to the
same amount as these athletes, may be at risk
for fatal outcomes. Hence, it is important to
integrate management of excessive PA in treat-
ment of ED. Previous studies on management
of excessive PA have used strategies like moti-
vational interviewing, monitoring of PA, educa-
tion and a group exercise programme (29-31).
Whether PA in ED is harmful or beneficial
may depend on the amount and intensity of PA,
and the motivation for doing it. In treatment set-
tings little is known about how the harmful
aspects of physical exercise may be prevented
and the beneficial effects enhanced. One previ-
ous study based on patient records (16) found a
rather non-systematic registration of PA. Anoth-
er study (32) found that although clinicians may
acknowledge the importance of excessive PA as
pathological in ED, they seldom assess the level,
type, duration and intensity of PA or use guide-
lines for restricting it. Also, there are substantial
variations across countries in the emphasis put
on excessive PA in the treatment of ED (32).
Moreover, a recent study from the United King-
dom (UK) (33) reported differences across ED
units on how to manage excessive amounts of
PA, and whether PA should be a part of the
treatment programme. These studies generate
further questions. The first study (32) examined
units from other parts of the world, such as Aus-
tralia and Asia, which raises the issue of an
impact of general as well as professional cultural
differences in the understanding and manage-
ment of PA in ED. The second study (33) from
UK only examined excessive PA in inpatient ED
treatment units. This raises the question of
whether previous results apply to only a smaller
segment or a broader spectrum of ED units.
In the current survey, we included both in-
and outpatient units, and we introduced a pos-
sible, yet moderate cultural difference dimen-
sion. The aim was to explore differences across
types of units and countries addressing the fol-
lowing research questions:
1) Is PA assessed by the units?
2) Do the units have guidelines for managing
excessive PA?
3) Do the units have staff with higher education
and special competence in PA and exercise
science?
4) How do the units regard PA in ED?
5) Is regular PA integrated in the treatment
programmes?
6) How do the units rate the role of PA in the
treatment of ED compared with other mental
disorders?
Sample
The sample consisted of specialist ED treat-
ment units from Norway, Sweden, Denmark
and UK. A specialist ED treatment unit was
defined as a public or private centre within the
specialist health care system, which predomi-
nantly treats patients with any kind of DSM-
IV/ICD-10 ED as the main diagnosis, and
where most patients have been unsuccessfully
treated at lower levels of care. We consulted
the academical and clinical networks for EDs in
the various countries to ensure that all eligible
units were contacted. In total 49 units were
identified, and 41 agreed to participate. The
response rate in Norway and the UK was 100%
(N=7 in both countries). In Sweden 23 (77%)
units out of 30 participated, and in Denmark
the response rate was 80% (N=5 of 6).
Design, data collection
and questionnaire items
We used a cross sectional design, and mailed
a questionnaire electronically to the clinical
directors of the units who were responsible for
outlining the treatment policy. No attempt was
made to collect demographic information about
the directors, their profession or clinical compe-
tence, as this was not the focus of our study. In
completing the questionnaire directors were
explicitly instructed to reflect the policy and
strategies of the unit, and not their private opin-
ions. To accomplish this, they were allowed to
consult staff members of their choice. Questions
included assessment of PA, assessment of physi-
cal fitness (i.e. cardio-respiratory fitness includ-
ing ECG and lung capacity, muscle strength,
muscular endurance and/or flexibility), assess-
ment of body composition (i.e. total body mass,
amount of lean body mass, amount of adipose
tissue/percentage of body fat, and/or assessment
of bone mineral density to classify osteopenia or
osteoporosis), management of excessive
amounts of PA (i.e. amounts of PA exceeding the
acceptable weekly PA amount during the treat-
ment), and attitudes towards PA. Data appeared
partly as dichotomous variables, partly as
S. Bratland-Sanda, J.H. Rosenvinge, K.A.R. Vrabel, et al.
responses to 9-point scaled statements, where 1
indicated a complete disagreement, 5 a neutral
opinion, and 9 a full agreement. Six statements
were related to excessive PA, and seven to the
importance of PA as a part of the treatment pro-
gramme. Information was also collected about
whether the units had qualified staff members
(e.g. physiotherapists or clinical exercise physi-
ologists) responsible for integrating PA in the
treatment programmes.
Data were analyzed with the SPSS version
14.0 using t-tests, chi square, analysis of vari-
ance (ANOVA) with Sheffes post-hoc test and
linear regression. Due to skewness of the num-
ber of ED patients treated within the different
units, these data are presented with median
and quartiles (Q
1
, Q
3
). Level of significance was
set to 0.05 if not otherwise stated, and Hedges
g was used to estimate the effect size. Values
0.8 indicated a large effect.
RESULTS
Characteristics of units
The median number of ED patients treated in
the past 12 months was 60 (Q
1
, Q
3
=25, 120). The
units treated either outpatients only (N=16),
inpatients only (N=6) or both in- and outpa-
tients (N=19). Ten units treated only adoles-
cents, 10 only adults, 19 both adolescents and
adults, while two units failed to provide this
kind of information. More UK units treated
only adolescents compared to Scandinavian
units [
2
(6)=18.03, p<0.01]. Twenty-four units
(60%) had employees with special competence
in PA, and of these 7 were outpatient units, 4
were inpatient units and 13 treated both in- and
outpatients [this represents 44%, 66% and 72%
of the different units, respectively,
2
(2)=2.99;
p=0.26]. The PA competent employees were
exercise physiologists (N=2 units) and physio-
therapists (N=22 units). There were no statisti-
cally significant differences across the four
countries regarding the number of patients
treated per unit per year or the number of units
with employees with special competence in PA.
Twenty-eight units (68%) reported that they
systematically assessed frequency, type and
intensity of PA using self report as well as clini-
cal interviews. Two units used systematic staff
observations to assess PA, while in three units,
patients kept PA-logs during the treatment peri-
od. Nine units (22%) measured body composi-
tion (all assessed bone mineral density), and two
(5%) used self-report and medical screening to
measure physical fitness. Swedish units were
more likely [
2
(6)=17.11, p<0.01] to measure PA.
Standardized assessment of PA at admission
was unrelated to whether a unit had employees
with higher education in PA [
2
(2)=2.85; p=0.24].
Units treating both adolescents and adults were
more likely [
2
(4)=12.05, p<0.02] to include mea-
surement of PA at admission. However, a multi-
ple regression analysis accounting for 30% of
the variance (adj. R
2
) showed that this trend was
related to treating younger patients (=-0.57; t=-
3.76, p<0.001). No statistically significant impact
on the PA assessment was found with respect to
country, number of patients in the units, guide-
lines to manage excessive PA or the presence of
PA-specialized staff members.
There was an overall agreement [mean=7.4;
standard deviation (SD)=2.4] to the statement
that the unit had guidelines to stop or limit
excessive PA. No significant differences existed
between units of different countries, outpa-
tient/inpatient ratio, treatment strategies or age
groups treated. The guidelines included psy-
cho-educative strategies, restriction of PA for
patients with very low body weight and somat-
ic instability, exercise free days for the entire
unit, as well as contracts and individual plans
to regulate the amount of weekly PA. These
individual plans were regularly evaluated.
Attitudes towards excessive physical
activity
There was a universally fair agreement about
excessive PA as an important and harmful clini-
cal feature in ED (Table 1). Two statements, i.e.
limiting PA when body mass index (BMI) is
low, and viewing PA as a dysfunctional coping
strategy, yielded significant differences across
countries [F(3)=34.45, p<0.001, and F(3)=4.77,
p<0.01, respectively]. Post-hoc comparisons
(Sheffes test) showed that the Swedish units
were most in favour (mean=8.9, SD=0.3) of lim-
iting PA when BMI is low (BMI15). The differ-
ence compared to other countries was statisti-
cally significant (Norway=6.7, SD=1.8; p<0.01,
Hedges g=2.52, Denmark=4.5, SD=2.9; p<0.001,
Hedges g=4.22, and UK=3.3, SD=2.2; p<0.001,
5.32). British and Danish units tended to dis-
agree most with this. Agreement with the state-
ment that PA is a dysfunctional coping strategy
was more homogenous in terms of the small
range. Post-hoc comparisons yielded a statisti-
cally significant disagreement only between
Swedish (8.2, SD=1.1) and Danish units (5.8,
SD=1.9; p<0.02, Hedges g=1.96).
Physical activity integrated in treatment
of eating disorders
Thirty-two (82%) units included regular PA in
their treatment programmes, no difference
existed regarding unit location (country), type
of unit or age groups treated. Among the units
giving more detailed information, 11 reported
that patients received individual plans from an
exercise specialist or physiotherapist when they
were somatically stabile. Six units reported use
of group activities once or twice per week.
Types of activities varied from walks, bowling,
ball games, horse riding, Nordic walking,
strength exercises, swimming, water gymnas-
tics, tai chi, qui gong and yoga. All units where
regular PA was part of the treatment empha-
sized the importance of teaching the patients
the difference between the excessive exercise
and normal healthy PA. No statistically signifi-
cant differences were found among countries or
regarding unit characteristics (treating adoles-
cents, adults or both; inpatients, outpatients or
both). Also, there was a strong overall agree-
ment with the statement that PA is a part of the
therapy programme (mean=7.2, SD=2.7). The
units slightly disagreed (mean=4.5, SD=2.4) with
a stronger version of this issue, i.e. that PA is
equally important as psychotherapy in the treat-
ment of ED. A Fishers exact test showed that
units with competent personnel responsible for
planning PA were more likely to include PA in
their treatment programme (p<0.001).
The role of physical activity in the
treatment of eating disorders compared
with other mental disorders
The units were generally positive to including
PA in the treatment of obesity, BED and
depression, and to a lesser degree AN (Table 2).
The units agreed more to the importance of PA
in treatment of BN compared to AN (t=-2.1,
p=0.04), and to PA in treatment of BED com-
pared to BN (t=-3.6, p=0.001) and AN (t=-4.3,
p<0.001). No statistically significant differences
were found regarding unit characteristics
(country, inpatient/outpatient treatment and
Total sample Units Norway Units Sweden Units Denmark Units UK
PA in ED is Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Compulsive rather than joyful 7.87 (1.29) 7.14 (0.69) 8.26 (1.21) 7.00 (2.16) 7.86 (0.90)
Dysfunctional affect regulation
a
strategy to accomplish coping and control 7.65 (1.49) 7.00 (2.00) 8.23 a (1.06) 5.75 (1.89) 7.57 (0.79)
Should only be limited with low BMI 7.15 (2.67) 6.67 (1.75) 8.91
b
(0.29) 4.50 (2.89) 3.29 (2.21)
Way of self injury
a
6.13 (2.12) 5.57 (1.81) 6.23 (2.54) 6.00 (2.00) 6.43 (0.79)
Wish to improve physical fitness
a
4.56 (2.34) 3.86 (2.67) 4.87 (2.53) 3.75 (2.22) 4.71 (1.38)
Not a core symptom of ED 2.37 (1.77) 1.86 (0.90) 2.57 (1.95) 3.50 (2.65) 1.57 (0.79)
a
Units from Sweden differ from units from Denmark (p<0.01);
b
units from Sweden differ from units from Denmark and UK (p<0.001).
BMI: body mass index; SD: standard deviation.
TABLE 1
Attitudes towards the nature of physical activity (PA) in eating disorders (ED) for the total sample and by national units,
using a Likert responses format range of 1 (no agreement) to 9 (full agreement).
Total sample Units Norway Units Sweden Units Denmark Units UK
How important is PA in treating Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Overweight 8.52 (0.75) 8.40 (0.55) 8.70 (0.66) 8.50 (0.56) 8.00 (1.15)
Depression 7.83 (1.39) 7.60 (1.14) 8.30 (0.86) 8.00 (0.82) 7.43 (1.27)
Binge eating disorders 7.56 (1.41) 8.00 (1.00) 7.90 (1.62) 7.75 (1.00) 7.71 (1.38)
Bulimia nervosa 6.90 (1.64) 7.20 (1.10) 6.95 (2.00) 7.25 (1.26) 6.86 (1.21)
Anxiety disorders 6.76 (1.96) 6.60 (0.55) 7.00 (2.15) 8.00 (1.41) 6.43 (1.40)
Anorexia nervosa 6.22 (2.35) 7.20 (1.10) 5.75 (2.79) 7.50 (1.00) 7.43 (1.00)
Mental disorders in general 7.38 (1.61) 7.60 (1.14) 7.70 (1.17) 8.00 (1.41) 6.86 (1.57)
SD: standard deviation.
TABLE 2
Attitudes about the role of physical activity (PA) as part of treatment in different illnesses in total and
by national samples using a Likert response format range of 1 (no agreement) to 9 (full agreement).
age groups treated). Units with an employee
with specialized competence in PA were more
positive to incorporating such activities in the
treatment of mental disorders in general
(p<0.02), in anxiety disorders (p<0.04) and in
BN (p<0.003).
DISCUSSION
The main findings from this survey are that
most of the responding units specialized in
treating ED regard excessive PA as a harmful
symptom in ED, and most units reported that
they had guidelines to handle it. At admission
the frequency, intensity and duration of PA are
regularly assessed, and PA is integrated in
treatment programmes. Also, PA is viewed as
more relevant in treating obesity and BED than
AN and BN.
Interestingly, assessing PA was more likely to
occur in units for younger patients. Future
studies should aim to replicate this finding, and
explore possible explanations, for instance
related to heuristics towards adults in general
or older ED patients in particular as being less
physically active.
Assessing PA was unrelated to whether a
unit had an employee specially educated in PA,
or whether the units had guidelines to manage
excessive PA. Also, several units did not report
details about their PA assessment, and hence it
could be everything from posing simple ques-
tions like are you physically active? to using
specific and standardized instruments. This is a
matter of concern as self report of PA as well
as general staff member reports may result in
over- or underreport (34). To improve data
quality it is our opinion that personnel specially
educated in PA should do such assessments,
covering the type, motives and intensity, dura-
tion and frequency of PA, further, if the patient
has a history of sports participation, and, if so,
obtaining type of sports and level of competi-
tion. As expected, however, units with person-
nel educated in PA were more likely to include
PA in their treatment programme. This further
illustrates the need to include this kind of per-
sonnel in the clinical staff, as the dose and pre-
scription of PA should be seen together with
the nutritional and somatic status of the
patient. The higher rate of Swedish units
reporting that they assessed PA upon admis-
sion to treatment may be due to some national
specialities. However, the results should be
interpreted carefully due to the low number of
units from Norway, Denmark and UK. Yet, the
level of general agreement differs from previ-
ous findings (33), and the conformity in
answers may be explained by a close coopera-
tion between clinicians in most of the respond-
ing units from especially Norway, Sweden and
Denmark.
The findings that most units assessed level of
PA and implemented PA in the treatment pro-
grammes is a surprising contradiction to the
findings of Hechler et al. (32). Although the
methods they used were not identical to those
of the present study, the differences are still
noteworthy, and may point to cultural differ-
ences as part of their study was conducted in
Asia and Australia. Alternatively, there may
have been an increase in focusing on assess-
ment of PA frequency and amount, and the use
of structured and planned regular PA in the
treatment of ED. The idea of PA and exercise as
an important part of treatment for different
somatic and mental disorders is not new, but it
has been re-established during the last
decades. Therefore, it is possible that such a
change is seen also in other areas of treatment.
It is important to mention that the there was a
great variety of PA listed, and none of the units
specified the amount of PA.
Our findings correspond well with previous
research (32), indicating a general agreement in
the clinical field about excessive PA as a core
ED symptom and a dysfunctional strategy to
manage stress and negative affect. There was
an overall agreement to the statement that the
units have guidelines to stop excessive PA. This
is interesting as there is no consensus regard-
ing how to define excessive exercise and how to
manage it. No guidelines have been published
or evaluated, and understandably none of the
units specified what these guidelines were or
who developed them. This could indicate that
local, unpublished guidelines have been devel-
oped. Developing national or international
guidelines for assessing and managing harmful
PA, as well as implementing beneficial PA, in
treatment programmes and testing their useful-
ness in practice is a challenge for future work.
Most units recognize PA as potentially both
harmful and beneficial in ED, and use PA as
part of their ED treatment. Excessive PA is
rarely seen in other mental disorders, where a
sedentary life style is the rule. Therefore, the
finding that there was a more positive attitude
and acceptance for PA in treatment of over-
weight and depression was expected. There
was also a more positive attitude towards PA in
the treatment of BN compared to AN, as well
as in the treatment of BED compared to BN
and AN. This is consistent with agreeing to
limit PA in ED patients with a low BMI. Still
some national differences were detected.
Swedish clinics were most in agreement to
restriction of PA in low weight patients only,
while a more restrictive attitude was detected
in the other countries. This may be related to
differences in opinion about the nature and
role of PA, as well as to differences in admis-
sion procedures.
In ED, however, PA can be a double-edged
sword, and it is a challenge in clinical work to
balance the duration, intensity and frequency to
prevent that PA becomes excessive. To accom-
plish this goal of reducing the harmful aspects
and increase the benefits of PA, the need for
professional skills and competence in exercise
science is emphasized. The clinicians judge PA
to be most important in the treatment of obesity
and binge eating disorder, and this corresponds
well to the limited literature in the field. More
research is needed to explore the benefits of PA
in the treatment of the various ED.
Limitations
The small sample size opens for type II errors,
and within-group multivariate comparisons
may be unstable and should be interpreted with
caution. Apart from the UK units treating adult
patients, the survey comprised almost all spe-
cialized units in Scandinavia. It is possible that
the eight units that did not participate in the
study could have been more negative to assess-
ing and implementing PA in their treatment
programme. They may not have wanted to dis-
play this attitude to the authors of the survey,
with a known reputation for their engagement
and expertise in PA and exercise science. Also,
we cannot exclude that the responses were
influenced by the clinical directors personal
opinions although they were specifically told to
reflect the units policies and attitudes. On the
other hand, the clinical directors are expected
to have an influence on the units treatment
strategies, therefore this might not be an issue.
All things considered, however, the survey find-
ings may have an acceptable external validity
and be representative for ED specialist centres
in UK and Scandinavia. Another concern is that
differences may be concealed due to the fact
that questions were not specified for various ED
diagnoses, and the rather simple measures of
PA-level. Finally, exploring variations of
allowed amount of weekly PA across units
could have yielded interesting differences, but
this was not the focus of the present study.
CONCLUSIONS
Most of specialized ED treatment units in
Scandinavia and UK report that they assess PA
upon admission, and that regular PA is a part of
treatment programmes. The general clinical
opinion is that excessive PA is a core symptom
of ED. The units acknowledge the importance of
PA in the treatment of EDs, especially BN and
BED, but to a lesser extent than in treatment of
mental disorders in general. We have limited
knowledge about the potentially beneficial
effects of regular PA in the various ED, and such
knowledge is strongly needed. Future research
should also focus on how to help patients with
ED towards normalization of their level of PA.
REFERENCES
1. Caspersen C.J., Powell K.E., Christenson G.M.:
Physical activity, exercise, and physical fitness: defini-
tions and distinctions for health-related research.
Public Health Rep., 100, 126-131, 1985.
2. Haskell W.L., Lee I.M., Pate R.R., Powell K.E., Blair
S.N., Franklin B.A., Macera C.A., Heath G.W. ,
Thompson P.D., Bauman A.: Physical activity and pub-
lic health: updated recommendation for adults from
the American College of Sports Medicine and the
American Heart Association. Med Sci. Sports Exerc.,
39, 1423-1434, 2007.
3. Martinsen E.W.: Exercise and depression. Int. J. Sport
Exerc. Psychol., 4, 469-483, 2005.
4. Meyer T., Broocks A.: Therapeutic impact of exercise
on psychiatric diseases: guidelines for exercise testing
and prescription. Sports Med., 30, 269-279, 2000.
5. Sundgot-Borgen J., Rosenvinge J.H., Bahr R. ,
Schneider L.S.: The effect of exercise, cognitive thera-
py, and nutritional counselling in treating bulimia ner-
vosa. Med. Sci. Sports Exerc., 34, 190-195, 2002.
6. Fossati M., Amati F., Painot D., Reiner M., Haenni C.,
Golay A.: Cognitive-behavioral therapy with simulta-
neous nutritional and physical activity education in
obese patients with binge eating disorder. Eat. Weight
Disord., 9, 134-138, 2004.
7. Levine M.D., Marcus M.D., Moulton P.: Exercise in the
treatment of binge eating disorder. Int. J Eat. Disord.,
19, 171-177, 1996.
8. Pendleton V.R., Goodrick G.K., Poston W.S., Reeves
R.S., Foreyt J.P.: Exercise augments the effects of cog-
nitive-behavioral therapy in the treatment of binge eat-
ing. Int. J Eat. Disord., 31, 172-184, 2002.
9. Duesund L., Skrderud F.: Use the body and forget the
body: treating anorexia nervosa with adapted physical
activity. Clin. Child. Psychol. Psychiatry, 8, 53-72, 2003.
10. Tokumura M., Yoshiba S. , Tanaka T., Nanri S.,
Watanabe H.: Prescribed exercise training improves
exercise capacity of convalescent children and adoles-
cents with anorexia nervosa. Eur. J Pediatr., 162, 430-
431, 2003.
11. Thien V., Thomas A., Markin D., Birmingham C.L.: Pilot
study of a graded exercise program for the treatment of
anorexia nervosa. Int. J. Eat. Disord., 28, 101-106, 2000.
12. Carraro A., Cognolato S., Bernardis A.L.F.: Evaluation
of a programme of adapted physical activity for ED
patients. Eat. Weight Disord., 3, 110-114, 1998.
13. Szabo C.P., Green K.: Hospitalized anorexics and resis-
tance training; Impact on body composition and psy-
chological well-being. A preliminary study. Eat.
Weight Disord., 7, 293-297, 2002.
14. American Psychiatric Association (APA). Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV).
Wasington, DC, APA, 1994.
15. World Health Organization. The ICD-10 classification
of mental and behavioural disorders: diagnostic crite-
ria for research. Geneva, WHO, 1993.
16. Kron L., Katz J.L., Gorzynski G., Weiner H.: Hyper-
activity in anorexia nervosa: a fundamental clinical fea-
ture. Compr. Psychiatry, 19, 433-440, 1978.
17. Vansteelandt K., Pieters G., Vandereycken W., Claes L.,
Probst M., Van Mechelen I.: Hyperactivity in anorexia
nervosa: a case study using experience sampling
methodology. Eat. Behav., 5, 67-74, 2004.
18. Holtkamp K., Hebebrand J., Herpertz-Dahlmann B.:
The contribution of anxiety and food restriction on
physical activity levels in acute anorexia nervosa. Int. J.
Eat. Disord., 36, 163-171, 2004.
19. Solenberger S.E.: Exercise and eating disorders: a 3-
year inpatient hospital record analysis. Eat. Behav., 2,
151-168, 2001.
20. Brewerton T.D., Stellefson E.J., Hibbs N., Hodges E.L.,
Cochrane C.E.: Comparison of eating disorder patients
with and without compulsive exercising. Int. J. Eat.
Disord., 17, 413-416, 1995.
21. Kaye W.H., Gwirtsman H., Ebert G.T., Peterson R.:
Caloric consumption and activity levels after weight
recovery in anorexia nervosa: a prolonged delay in
normalization. Int. J. Eat. Disord., 5, 489-502, 1986.
22. Davis C., Woodside D.B., Olmsted M.P., Kaptein S.:
Psychopathology in the eating disorders: the influence
of physical activity. J. Appl. Biobehav. Res., 4, 139-156,
1999.
23. Ro O., Martinsen E.W., Rosenvinge, J.H.: [Treatment
of bulimia nervosa--results from Modum Bads
Nervesanatorium]. Tidsskr. Nor Laegeforen., 122, 260-
265, 2002.
24. Adkins E.C., Keel P.K.: Does excessive or compul-
sive best describe exercise as a symptom of bulimia
nervosa? Int. J. Eat. Disord., 38, 24-29, 2005.
25. Bamber D., Cockerill I.M., Rodgers S., Carroll D.: Its
exercise or nothing: a qualitative analysis of exercise
dependence. Br. J. Sports Med., 34, 423-430, 2000.
26. Mond J.M., Hay P.J., Rodgers B., Owen C.: An update
on the definition of excessive exercise in eating dis-
orders research. Int. J. Eat. Disord., 39, 147-153, 2006.
27. Hausenblas H.A., Symons Downs, D.: Exercise depen-
dence: a systematic review. Psychol. Sports Exerc., 3,
89-123, 2002.
28. Ng B., Maginot K.R.: Sudden cardiac death in young
athletes: trying to find the needle in the haystack.
W.M.J., 106, 335-342, 2007.
29. Long C., Hollin C.R.: Assessment and management of
eating disordered patient who over-exercise: a four-
year follow-up of six single case studies. J. Mental
Health, 4, 309-316, 1995.
30. Long C., Smith J.: Treatment of compulsive over-exer-
cising in anorexia nervosa: a case study. Behav.
Psychother., 18, 295-306, 1990.
31. Calogero R.M., Pedrotty K.N.: The practice and
process of healthy exercise: an investigation of the
treatment of exercise abuse in women with eating dis-
orders. Eat. Disord., 12, 273-291, 2004.
32. Hechler T., Beumont P., Marks P., Touyz S.: How do
clinical specialists understand the role of physical
activity in eating disorders? Eur. Eat. Disorders Rev.,
13, 125-132, 2005.
33. Davies S., Parekh K., Etelapaa K., Wood D., Jaffa T.:
The inpatient management of physical activity in
young people with anorexia nervosa. Eur. Eat. Disord.
Rev., 16, 334-340, 2008.
ORIGINAL
RESEARCH
PAPER
Key words:
Anorexia nervosa, MMPI-2,
NEO PI-R, low self-esteem,
neuroticism, personality
Correspondence to:
Laurie McCormick, MD,
University of Iowa,
Carver College of Medicine,
Department of Psychiatry,
Psychiatric Iowa
Neuroimaging Center,
200 Hawkins Drive,
W278 GH, Iowa City,
IA 52242, USA.
E-mail:
laurie-mccormick@uiowa.edu
A pilot study of personality pathology
in patients with anorexia nervosa:
Modifiable factors related to outcome
after hospitalization
INTRODUCTION
Anorexia nervosa (AN) is a serious psychi-
atric disorder with a high mortality rate (1).
Many AN patients require inpatient treat-
ment, which in duration parallels that for
severe schizophrenia (2). Despite the develop-
ment of specialized eating disorder programs
over the past 50 years, AN patients still have a
relatively poor prognosis even after intensive
hospitalization to restore weight and improve
psychological functioning (3, 4). Relapse rates
after hospitalization are high, ranging from
22 to 51% in several outcome studies (5-8).
Although the presence of low minimal body
weight and extremes in age of onset, social
withdrawal and poor family relations have
been associated with poor outcome (4, 9-11),
prognostic predictors of outcome are still rel-
atively few and unreliable.
Various types of personality pathology
have been implicated as vulnerability fac-
tors for developing and maintaining a
chronic relapsing course of AN (12-14). Per-
sonality traits associated with AN include
being negativistic, obsessional, perfection-
istic, emotionally inhibited, vulnerable and
highly reactive to stress, and harm avoidant
(15-20). Many of these traits are heritable
and exist in unaffected family members (21-
23), are present premorbidly (15, 24, 25) and
persist even after recovery (16).
In terms of outcome, older studies that
have analyzed long-term follow-up assess-
ments (ranging from 7 to 27 years after hos-
pitalization for AN) using the Minnesota Mul-
tiphasic Personality Inventory (MMPI-2) have
found that former patients with good clini-
cal outcomes score significantly lower at fol-
low-up on several Clinical scales including
scales 1 (Hypochondriasis), 2 (Depression),
and 7 (Psychasthenia) when compared to
former patients with poor outcomes (26-
28). Other studies looking at predicting AN
outcome with the MMPI have reported that
lower admission scores on scale 9 (Hypoma-
nia) may predict successful outcome (29),
whereas higher discharge scores on
L.M. McCormick
1
, P.K. Keel
2
, M.C. Brumm
1
, D.B. Watson
3
, V.L. Forman-Hoffman
4
,
and W.A. Bowers
1
1
Department of Psychiatry, Carver College of Medicine,
3
4
Department of General
Medicine, Clinical Epidemiology and Geriatrics, University of Iowa, Iowa City, Iowa,
2
Department of
Psychology, Florida State University, Tallahassee, Florida, USA
ABSTRACT. OBJECTIVE: To assess improvement in aspects of personality in patients hos-
pitalized with anorexia nervosa (AN) and its relationship to improved depression, body mass
index (BMI), and eating disorder outcome after treatment. METHOD: Twenty females hospi-
talized with AN completed intake and discharge assessments of BMI, depression and eating
disorder severity, as well as personality pathology with the Minnesota Multiphasic Personality
Inventory (MMPI-2) and the Revised NEO Personality Inventory (NEO PI-R). Clinical outcome
for a subset of patients at 1-year post-hospitalization was determined. RESULTS: The only
factor that predicted better versus worse outcome at 1-year post-hospitalization was change
in Low Self-Esteem (LSE) from the MMPI-2. Improved LSE from admission to discharge pre-
dicted remission at 1-year post-hospitalization, while worsening LSE predicted relapse.
Regardless of outcome, NEO PI-R Neuroticism remained pathologically elevated in AN
patients during hospitalization. DISCUSSION: Pathological levels of neuroticism may repre-
sent a vulnerability factor for AN. In contrast, self-esteem appears to be a modifiable factor
that predicts outcome following hospitalization, and may be an important target for treatment.

e113
EWD_09_19_McCormick*.qxp:EWD_ 4-11-2009 10:13 Pagina 113
L.M. McCormick, P.K. Keel, M.C. Brumm, et al.
Hypochondriasis and scale 6 (Paranoia) may pre-
dict poorer outcomes (26). Of note, the above
studies looked at the 10 MMPI Clinical scales, but
not the 15 accompanying Content scales. Even
though many aspects of personality pathology
improve with weight restoration and recovery,
others remain higher than in the normal popula-
tion (12, 30, 31). It is still unclear which pre-treat-
ment personality factors predict post-treatment
outcome, assuming that these factors are stable
over time. Also, the association between eating
disorder changes, personality factor changes
and outcome has not been fully explored.
Some aspects of personality may be influenced
by depression and/or malnutrition, and others
may reflect stable aspects of AN that influence
risk and outcome. Patients suffering with active
AN often have high levels of depression that
improve during the weight restoration process
of treatment (32), even without the use of psy-
chotropic medication (33). However, depression
improvement is not directly correlated with
body weight changes (33), suggesting that other
factors are involved. Similarly, the use of psy-
chotropic medication has not been found to
improve outcome of AN (34). While the Clinical
scales of the MMPI-2 are influenced by changes
in depression, the Revised NEO Personality
Inventory (NEO PI-R) is thought to be reliable
regardless of the degree of depression (35). The
NEO PI-R has been used to show that eating dis-
order symptoms are strongly related to neuroti-
cism (36, 37), but whether change in this mea-
sure is related to long-term outcome is not
known.
This retrospective study included 20 female
AN patients who had standardized assessments
of depression, eating disorder symptomatology
and personality pathology before and after full
weight restoration during inpatient hospitaliza-
tion. Only females were included because this
disorder occurs predominately in women and
women are known to have higher rates of per-
sonality pathology (38, 39). We sought to iden-
tify which personality factors changed during
the hospitalization and weight restoration
process and which remained stable. We also
sought to identify which changes were associ-
ated with remission versus relapse at 1-year
post-hospitalization, and which remained
pathological regardless of outcome.
Participants
After obtaining approval from the Institu-
tional Review Board at the University of Iowa,
we conducted a retrospective chart review of
female patients hospitalized on the inpatient
eating disorders unit at the University of Iowa
Hospitals and Clinics (UIHC) between Novem-
ber 1994 and May 1997. Eligible patients
included 20 individuals who underwent an
extensive battery of clinical and personality
testing as part of clinical care received from
the Eating Disorder Program. All patients met
The Diagnostic and Statistical Manual of Men-
tal Disorders - Fourth Edition (DSM-IV) criteria
for AN, with the exception of one patient who
met all criteria except amenorrhea; we included
this participant as a subject with AN because
amenorrhea has been widely criticized as lack-
ing validity in the diagnosis of AN (40, 41). Age
on admission ranged from 18 to 44, with a
mean of 27.6 [standard deviation (SD)=9.45]. All
patients were admitted voluntarily and not
under court commitment. Complete demo-
graphics are displayed in Table 1.
Clinical and personality assessment
All patients completed a battery of clinical and
personality assessments at both admission and
discharge (i.e., pre- and post-weight restora-
tion). The average duration between tests was
57.025.01 days (range 17-101). Testing and
body mass index (BMI) assessment were com-
pleted within 6.15.45 days of admission and
again within 4.78.52 days of discharge. Mea-
sures of eating disorder severity included the
Age 27.69.4
Education (yr) 14.11.9
BMI (kg/m
2
)
Upon intake testing (admission) 16.02.3
Upon follow-up testing (discharge) 20.31.1
Age of onset 17.26.4
Age of first hospitalization 21.57.3
Duration of illness (yr) 10.58.5
Duration of hospitalization (days) 68.726.4
Diagnostic subtype
AN (restricting) 11 (55%)
AN (binge/purge) 7 (35%)
AN (unspecified) 2 (10%)
Comorbid depression 11 (55%)
Partial hospitalization 6 (30%)
Antidepressant use
Upon admission 13 (65%)
Upon discharge 14 (70%)
AN: anorexia nervosa; BMI: body mass index.
TABLE 1
Demographics of 20 female subjects with anorexia nervosa
hospitalized for weight restoration.
Personality and outcome in anorexia
Eating Attitudes Test (EAT) and the Eating Dis-
order Inventory-2 (EDI-2). Depressive symptoms
were assessed using the Beck Depression Inven-
tory (BDI). Personality inventories included the
Content scales of the MMPI-2, and the NEO PI-
R. We chose to only include the 15 MMPI Con-
tent scales (and not the 10 Clinical scales)
because several studies have already explored
the relationship between the Clinical scales and
AN outcome; and also in an effort to minimize
the problem of multiple comparisons.
Assessment of clinical outcome
We were able to conclusively determine clini-
cal outcome at 1-year post-hospitalization for
15 patients. Initial assessment of clinical out-
come was made on the basis of retrospective
chart review and direct correspondence (i.e.,
follow-up questionnaires mailed by a depart-
mental social worker within three years of dis-
charge). This initial assessment method was
used to determine outcome for 13 patients. A
secondary outcome questionnaire was mailed
to the seven patients whose outcome could not
be determined from the initial assessment; we
used this secondary assessment method to
determine outcome for two additional patients.
We defined relapse at 1-year post-hospital-
ization according to two criteria: (a) readmis-
sion to a partial or inpatient unit for eating-dis-
order-related treatment; and/or (b) a drop in
BMI below 17.5 kg/m
2
. The BMI component to
our definition stems from DSM-IV and Interna-
tional Classification of Deseases - Tenth Revi-
sion (ICD-10) diagnostic criteria for AN.
Patients who met at least one of these criteria
were assigned to the relapse group, whereas
patients who met neither criterion were
assigned to the remission group. In cases
where a conclusive assessment of outcome
could not be reached, patients were assigned to
the unknown group.
To account for possible violations of nor-
mality inherent in a small sample size, the bulk
of analyses performed were non-parametric
in nature. Changes between admission and
discharge assessments were analyzed with a
Wilcoxon signed-rank test. A Mann-Whitney
U test was performed to assess the relation-
ship between clinical symptom severity and
both comorbid depression and antidepressant
use. A repeated measures analysis was per-
formed to confirm differences between out-
come groups (including the unknown group)
at 1-year post-hospi tal i zati on. Al though
repeated measures anal yses of vari ance
(ANOVAs) assume parametric data, they are
quite robust against violations of normality
(42).
Covariates included BDI scores and BMI (as
measured on testing dates). Correlations
between changes in BDI, BMI and personality
scores were assessed using Spearman correla-
tion coefficients. For all tests, p<0.05 was the
threshold for establishing statistical significance.
Statistical analysis was performed using a com-
mercially available statistical package (SPSS for
Windows version 15; SPSS, Chicago, IL, USA).
RESULTS
Relapse and remission groups
At 1-year post-hospitalization, we determined
that 8 patients (40%) were still in remission, 7
(35%) had relapsed, and 5 (25%) had unknown
outcomes. Of the 7 patients who relapsed, 6
were actually readmitted to an Eating Disorders
Treatment program (4 at a BMI below 17.5, 2
above), whereas one patient had a sustained
(i.e., >3 month) drop in BMI below 17.5 but was
not readmitted until 18 months post-discharge.
One patient (whose outcome was unknown) left
the hospital against medical advice at a dis-
charge BMI of 16.9 kg/m
2
because her insur-
ance refused further coverage; otherwise, after
weight restoration in a controlled environment,
the discharge BMI for the other 19 participants
ranged from 19.47-21.87 kg/m
2
. There was no
significant difference between groups on any of
the demographic information.
Modifiable psychological factors
during hospitalization
Severe levels of self-reported depressive
symptoms (as assessed by the BDI) and eating
disorder symptomatology were present on
admission and most improved significantly by
discharge (Table 2). Elevated personality
pathology, as defined by MMPI-2 and NEO PI-
R scores that were 1.5 SD above normal (i.e., T
scores 65.0), were present in many areas on
admission and several improved significantly at
time of discharge. The only MMPI-2 Content
scale that remained elevated at time of dis-
charge was Low Self-Esteem (LSE). Scores on
the NEO PI-R Neuroticism domain were elevat-
ed on admission and changed very little during
hospitalization. The facet scores of Neuroticism
that remained elevated at discharge were
Depression, Self-Consciousness and Vulnera-
bility to Stress. NEO PI-R personality domains
of Extraversion, Openness to Experience,
Agreeableness, and Conscientiousness were
within normal limits at admission and dis-
charge. Those patients with comorbid depres-
sion or antidepressant use on admission or dis-
charge when compared to those patients
without did not have higher levels of person-
ality pathology at either time point.
Modifiable psychological factors during
hospitalization predict outcome at one-
year post-hospitalization
A repeated measures ANOVA indicated no
significant differences between outcome groups
in either BMI or BDI scores (Table 3). In terms
of personality measures, a significant between-
subjects finding indicated that the remission
group scored lower than the relapse group on
the MMPI Content scale measure of Health
Concerns (at both admission and discharge). In
addition, there were significant group interac-
tion effects for the MMPI-2 Content scale mea-
sures of LSE and negative treatment indicators
(TRT), suggesting that patients still in remission
at 1 year improved on these measures during
hospitalization whereas patients who relapsed
displayed the opposite trend. After controlling
for change in depression and BMI during hos-
pitalization, the above differences remained sig-
nificant for LSE (F=11.0, p<0.001), but not for
TRT. When we additionally controlled for the
potential confounds of duration of illness and
hospital length, we found that the LSE finding
still remained significant (F=8.8, p<0.004). In
general, several MMPI measures remained ele-
vated at discharge among the relapse group,
but not for the remission group. However, the
NEO PI-R Neuroticism facets of Self-Conscious-
ness and Vulnerability to Stress remained in the
pathological range even for those in remission
at 1-year follow-up, suggesting that these may
be vulnerability factors for AN or lasting scar
effects from the illness.
Correlational results
Many changes in personality pathology that
occurred during hospitalization correlated
with changes in depression and LSE, but not
with change in BMI (Table 4). After controlling
for baseline depression and BMI, lower base-
line Vulnerability to Stress from the Neuroti-
cism facet score of the NEO PI-R predicted a
greater change in LSE by the time of discharge
from the hospital (r=-0.52, p<0.027). Duration
of hospitalization had no relationship with
change in eating disorder symptoms or any
psychological factor.
DISCUSSION
Although patients hospitalized with active AN
were admitted with high levels of eating disorder
symptomatology, depression and personality
pathology, most measures improved significantly
during hospitalization. While many factors
improved across 1-year outcome groups, the
only factor that significantly improved for the
remission group and tended to worsen for the
relapse group was the MMPI-2 LSE Content
scale. These results suggest that self-esteem, as
measured by the MMPI-2, is a psychological
component that is modifiable with inpatient
Admission Discharge Z
BDI
a
26.29.2 11.712.1 -3.6**
EAT
b
44.118.3 18.615.3 -3.5**
EDI-2
a
Drive for Thinness 14.46.8 9.57.7 -2.9**
Bulimia 3.43.7 0.61.3 -2.7**
Body Dissatisfaction 17.57.1 15.59.8 -0.8
Ineffectiveness 14.77.4 7.27.1 -3.1**
Perfectionism 8.93.7 6.74.9 -2.3*
Interpersonal Distrust 7.84.6 3.83.6 -2.9**
Interoceptive Awareness 13.06.9 6.55.6 -3.1**
Maturity Fears 4.34.4 3.14.8 -1.4
Asceticism 8.94.5 5.24.8 -3.2**
Impulse Regulation 6.55.6 2.42.5 -2.8**
Social Insecurity 10.13.6 4.63.8 -3.3**
MMPI-2 (Content scales)
Anxiety 66.511.0 62.29.9 -1.4
Fears 49.813.9 49.411.9 0.0
Obsessiveness 63.29.9 60.58.4 -0.7
Depression 70.710.8 62.712.2 -2.6*
Health Concerns 65.711.4 55.711.0 -3.4**
Bizarre Mentation 52.510.1 50.89.2 -0.9
Anger 53.07.3 54.310.0 -0.5
Cynicism 51.311.0 50.310.1 -0.3
Antisocial Practices 47.57.6 47.07.9 -0.3
Type A Behavior 51.19.9 52.813.3 -0.8
Low Self-Esteem 72.311.7 66.114.2 -1.9
Social Discomfort 61.814.9 54.814.9 -2.7**
Family Problems 53.110.0 53.810.7 -0.2
Work Interference 66.911.8 61.010.6 -2.2*
Negative Treatment Indicator 66.611.7 60.613.1 -1.9
NEO PI-R
N-Neuroticism Domain 67.79.1 67.110.4 -0.1
N1-Anxiety 63.88.9 63.510.0 -0.2
N2-Hostility 57.511.4 58.112.0 -0.4
N3-Depression 71.88.0 69.011.8 -1.1
N4-Self-consciousness 71.06.9 68.610.7 -1.2
N5-Impulsiveness 46.514.9 47.413.9 -0.7
N6-Vulnerability to Stress 68.112.1 68.210.1 -0.1
BDI: Beck Depression Inventory, EAT: Eating Attitudes Test; MMPI-2: Minnesota
Multiphasic Personality Inventory; NEO PI-R: Revised NEO Personality Inventory;
a
N=19;
b
N=17; *p0.05; **p0.01; Z based on positive ranks from Wilcox-
on signed ranks test.
TABLE 2
Pretreatment and post-treatment measures of eating disorder severity
and personality pathology in anorexia nervosa subjects hospitalized
for weight restoration.
treatment and for which degree of improvement
has an impact on long-term outcome that is inde-
pendent of change in depression and BMI. After
controlling for depression severity and BMI on
admission, lower levels of Vulnerability to Stress
at intake were related to a greater change in LSE
during the hospitalization process. In addition,
elevated scores on the NEO PI-R Neuroticism
domain appears to be an AN vulnerability facto-
ry that is unrelated to outcome.
Although there are studies suggesting that
higher BMI on admission and/or longer dura-
tion of inpatient treatment are associated with
better outcomes (43-45), we found no signifi-
cant differences in admission or discharge BMI
or duration of hospitalization between outcome
groups. Although there was a trend for the
relapse group to have a higher BMI on admis-
sion (17.21.8 vs 15.62.4), BMI at discharge
was similar (20.30.9 vs 20.80.5), suggesting
that relapsers were just slower to restore
weight during their hospitalization.
Chronic low self-esteem commonly occurs
in patients with eating disorders even in the
absence of depression (46) and is thought to
be an etiological feature of AN (47). Compared
to age-matched normal controls, AN patients
have significantly higher levels of submissive
behavior and a more unfavorable social com-
parison of themselves to others (48, 49). High
levels of body dissatisfaction and neurotic per-
fectionism related to body image are related
to low self-esteem and have been reported to
increase relapse rates after treatment (50, 51).
Studies by Silverstone (48) and Halmi (20)
have shown that higher self-esteem on admis-
si on to the hospi tal (as measured by the
Rosenberg Self-esteem Questionnaire) predicts
1-year post-hospitalization
Remission Relapse Unknown Repeated measures
(N=8) (N=7) (N=5) F-values
Admission Discharge Admission Discharge Admission Discharge WS BS Int
BMI 15.62.4 20.30.9 17.21.8 20.80.5 14.92.5 19.51.5 81.0** 2.7 0.7
BDI 22.16.9 6.86.5 27.010.8 18.717.8 32.46.8 11.28.3 46.8** 1.7 2.9
MMPI-2 Content scales
Anxiety 66.913.3 57.99.3 63.18.0 65.310.8 70.611.4 64.69.0 2.7 0.5 1.9
Fears 52.613.0 52.116.0 43.710.0 45.36.6 53.819.2 50.810.4 0.1 0.9 0.4
Obsessiveness 65.312.0 60.38.0 59.18.7 61.39.9 65.67.5 59.68.6 1.7 0.2 1.3
Depression 70.113.9 56.69.2 68.39.2 67.015.6 75.07.2 66.28.6 8.1* 0.9 1.9
Health Concerns 58.811.1 47.36.6 69.06.7 62.79.7 72.212.9 59.210.9 19.6** 5.9* 0.8
Bizarre Mentation 53.411.1 51.39.5 49.16.0 50.98.3 55.813.3 49.811.6 1.0 0.2 1.0
Anger 50.89.3 55.011.0 53.66.4 56.311.3 55.84.8 50.26.9 0.1 0.1 2.2
Cynicism 51.011.6 50.511.8 51.09.7 52.411.4 52.213.9 47.05.1 0.5 0.1 0.9
Antisocial Practices 46.47.9 45.36.8 48.46.5 50.610.3 47.89.9 44.84.9 0.2 0.6 0.9
Type A Behavior 51.810.8 53.513.1 52.19.9 56.116.2 48.610.2 47.08.9 0.4 0.5 0.5
Low Self-Esteem 72.510.1 59.912.0 66.710.6 72.716.1 79.813.4 67.613.4 7.6* 0.7 6.9**
Social Discomfort 62.110.3 50.19.9 61.017.0 57.717.2 62.220.7 58.019.0 8.4* 0.1 1.7
Family Problems 50.510.1 48.58.6 53.711.3 56.19.4 56.48.5 59.013.6 0.2 1.5 0.4
Work Interference 66.614.9 58.97.0 61.99.0 63.613.8 74.26.5 60.611.9 8.1* 0.4 3.6
Negative Treatment Indicator 62.612.1 55.49.5 64.78.7 67.414.7 75.411.8 59.213.8 7.9* 1.3 4.6*
NEO PI-R
N-Neuroticism Domain 67.311.5 62.412.2 65.96.5 69.67.4 70.88.9 71.210.0 0.0 0.8 1.4
N1-Anxiety 63.09.3 62.612.0 61.98.0 66.07.3 67.810.3 61.211.3 0.3 0.1 2.6
N2-Hostility 58.915.1 54.413.4 60.08.8 64.711.4 51.86.9 54.87.4 0.4 1.1 2.7
N3-Depression 69.69.5 63.914.6 69.97.3 72.010.1 78.02.0 72.86.6 1.2 1.9 1.0
N4-Self-Consciousness 71.47.2 65.911.8 71.17.3 69.99.9 70.07.3 71.211.1 0.9 0.1 1.1
N5-Impulsiveness 46.415.7 42.313.3 46.716.2 49.712.0 46.415.3 52.217.4 0.9 0.2 3.4
N6-Vulnerability to Stress 71.510.6 65.811.4 59.99.5 68.910.6 74.013.4 71.28.1 0.0 1.3 2.7
WS: within-subjects main effect; BS: between-subjects main effects; Int: between-subjects interactions; BMI: body mass index; BDI: Beck Depression Inventory,
MMPI-2: Minnesota Multiphasic Personality Inventory; NEO PI-R: Revised NEO Personality Inventory; *p<0.05; **p<0.01.
TABLE 3
Relationship between changes in personality pathology during hospitalization in subjects
with anorexia nervosa and outcome at 1-year post-hospitalization.
a better outcome. However, our study found
that admission levels of LSE did not differenti-
ate outcome groups; rather, it was the change
in LSE that distinguished the remission group
(who improved on LSE with hospitalization)
from the relapse group (who did not improve
on LSE). This is consistent with other theories
that describe core poor self-esteem as a major
factor contributing to the maintenance of AN
(49, 53-56).
The results of this study suggest that self-
esteem probably changes as a function of treat-
ment, and, thus, is not independent of treatment.
The theoretical basis of psychotherapy that was
delivered during the hospitalization process was
cognitive-behavioral therapy (CBT), which did
not specifically focus on personality modifica-
tion. However, Fairburn et al. (52) have dis-
cussed how CBT as a model of treatment may be
tailored to improve self-esteem and assertive-
ness in patients with eating disorders. Neuroti-
cism on the other hand is a personality trait that
has been shown to predict the onset of AN and
remain abnormally high even after remission
(25, 57). One study that did follow-up assess-
ments of neuroticism with the Multidimensional
Personality Questionnaire (MPQ) found that
neuroticism was reduced in those AN patients
who were in remission (58). However, whereas
neuroticism on the MPQ is highly influenced by
depressive symptoms, the NEO PI-R Neuroti-
cism scale has construct validity that is not easily
influenced by depressive states (35). In this study
we were able to show that even though depres-
sive symptoms improved in both the remission
and relapse groups, neuroticism scores did not.
Strengths of this study include a large battery
of assessments on admission and discharge
from the hospital for 20 patients with active AN
as well as follow-up data for outcome at 1-year
post-hospitalization for a majority of these
patients. Limitations include a small sample size
that precluded adjustments for multiple com-
parisons; thus, some findings may reflect Type
I errors. In addition, we were unable to deter-
mine outcome for all patients, and our defini-
tion of outcome was somewhat crude. For
instance, it was unclear that patients assigned
to the remission group actually sustained full
remission since our definition only reflected a
lack of re-hospitalization and maintenance of a
BMI of at least 17.5, and thus did not account
for other possible markers of relapse (e.g.,
body image disturbance). Furthermore, an
assumption had to be made that similar treat-
ment as usual occurred in all patients after dis-
charge, as information about medication post-
discharge was not available. A larger longitudi-
nal study is needed to clarify the clinical effects
of change in personality pathology and self-
esteem during hospitalized treatment to identi-
fy enduring markers of vulnerability to disease
as well as modifiable psychological factors that
could be the focus of new therapies to achieve
and maintain long-term remission from AN.
REFERENCES
1. Birmingham C.L., Su J., Hlynsky J.A., Goldner E.M.,
Gao M.: The mortality rate from anorexia nervosa. Int.
J. Eat. Disord., 38, 143-146, 2005.
2. McKenzie J.M., Joyce P.R.: Hospitalization for anorexia
nervosa. Int. J. Eat. Disord., 11, 235-241, 1992.
3. Herzog D.B., Dorer D.J., Keel P.K., Selwyn S.E.,
Ekeblad E.R., Flores A.T., Greenwood D.N., Burwell
R.A., Keller M.B.: Recovery and relapse in anorexia
and bulimia nervosa: a 7.5-year follow-up study. J. Am.
Acad. Child Adolesc. Psychiatry, 38, 829-837, 1999.
4. Steinhausen H.C.: The outcome of anorexia nervosa in
the 20th century. Am. J. Psychiatry, 159, 1284-1293,
2002.
BDI change BMI change LSE change
Rho Rho Rho
MMPI-2 (Content scales) change
Anxiety 0.48* -0.24 0.63**
Fears 0.29 0.00 0.52*
Obsessions 0.73** 0.00 0.50*
Depression 0.70** -0.46* 0.83**
Health Concerns 0.68** -0.11 0.64**
Bizarre Mentation 0.56* 0.07 0.46*
Anger 0.73** -0.02 0.40
Cynicism 0.55* 0.25 0.30
Antisocial Practices 0.43 -0.17 0.56*
Type A Behavior 0.62** 0.07 0.59**
Low Self-Esteem 0.67** -0.38 -
Social Discomfort 0.10 -0.26 0.56*
Family Problems 0.07 -0.05 0.29
Work Interference 0.69** -0.30 0.68**
Negative Treatment Indicator 0.75** -0.49* 0.76**
NEO PI-R Neuroticism change
N-Neuroticism (domain) 0.58** -0.28 0.75**
N1-Anxiety 0.68** -0.38 0.71**
N2-Hostility 0.40 -0.19 0.61**
N3-Depression 0.71** -0.44* 0.79**
N4-Self-consciousness 0.48* -0.14 0.62**
N5-Impulsiveness 0.27 0.18 0.22
N6-Vulnerability to Stress 0.69** -0.29 0.67**
BDI: Beck Depression Inventory; BMI: body mass index; LSE: Low Self Esteem
from the MMPI-2; MMPI-2: Minnesota Multiphasic Personality Inventory;
NEO PI-R: Revised NEO Personality Inventory; *p<0.05; **p<0.01; Rho
reported as Spearmans Rho.
TABLE 4
Correlation between change in depression, BMI and Low
Self-Esteem vs MMPI-2 and NEO PI-R personality pathology in
anorexia nervosa subjects hospitalized for weight restoration.
5. Deter H.C., Herzog W.: Anorexia nervosa in a long-
term perspective: results of the Heidelberg-Mannheim
Study. Psychosom. Med., 56, 20-27, 1994.
6. Morgan H.G., Russell G.F.: Value of family background
and clinical features as predictors of long-term out-
come in anorexia nervosa: four-year follow-up study of
41 patients. Psychol. Med., 5, 355-371, 1975.
7. Pike K.M.: Long-term course of anorexia nervosa
Response, relapse, remission, and recovery. Clin.
Psychol. Rev., 18, 447-475, 1998.
8. Strober M., Freeman R., Morrell W.: The long-term
course of severe anorexia nervosa in adolescents: sur-
vival analysis of recovery, relapse, and outcome pre-
dictors over 10-15 years in a prospective study. Int. J.
Eat. Disord., 22, 339-360, 1997.
9. Martin F.E.: The treatment and outcome of anorexia
nervosa in adolescents: a prospective study and five
year follow-up. J. Psychiatr. Res., 19, 509-514, 1985.
10. Rosenvinge J.H., Mouland S.O.: Outcome and progno-
sis of anorexia nervosa. A retrospective study of 41
subjects. Br. J. Psychiatry, 156, 92-97, 1990.
11. Tanaka H., Kiriike N., Nagata T., Riku K.: Outcome of
severe anorexia nervosa patients receiving inpatient
treatment in Japan: an 8-year fol low-up study.
Psychiatry Clin. Neurosci., 55, 389-96, 2001.
12. Holliday J., Uher R., Landau S., Collier D., Treasure J.:
Personality pathology among individuals with a life-
time history of anorexia nervosa. J. Pers. Disord., 20,
417-30, 2006.
13. Kaye W.: Neurobiology of anorexia and bulimia ner-
vosa. Physiol. Behav., 94, 121-35, 2008.
14. Lilenfeld L.R., Wonderlich S., Riso L.P., Crosby R.,
Mitchell J.: Eating disorders and personality: a
methodological and empirical review. Clin. Psychol.
Rev., 26, 299-320, 2006.
15. Anderluh M.B., Tchanturia K., Rabe-Hesketh S.,
Treasure J.: Childhood obsessive-compulsive personal-
ity traits in adult women with eating disorders: defin-
ing a broader eating disorder phenotype. Am. J.
Psychiatry, 160, 242-247, 2003.
16. Bulik C.M., Sullivan P.F., Fear J.L., Pickering A.:
Outcome of anorexia nervosa: eating attitudes, person-
ality, and parental bonding. Int. J. Eat. Disord., 28, 139-
147, 2000.
17. Crane A.M., Roberts M.E., Treasure J.: Are obsessive-
compulsive personality traits associated with a poor
outcome in anorexia nervosa? A systematic review of
randomized controlled trials and naturalistic outcome
studies. Int. J. Eat. Disord., 40, 581-588, 2007.
18. Fairburn C.G., Cooper Z., Doll H.A., Welch S.L.: Risk
factors for anorexia nervosa: three integrated case-
control comparisons. Arch. Gen. Psychiatry, 56, 468-
476, 1999.
19. Fassino S., Piero A., Gramaglia C., Abbate-Daga G:
Clinical, psychopathological and personality corre-
lates of interoceptive awareness in anorexia nervosa,
bulimia nervosa and obesity. Psychopathology, 37,
168-174, 2004.
20. Halmi K.A., Agras W.S., Crow S., Mitchell J., Wilson
G.T., Bryson S.W., Kraemer H.C.: Predictors of treat-
ment acceptance and completion in anorexia nervosa:
implications for future study designs. Arch. Gen.
Psychiatry, 62, 776-781, 2005.
21. Heiman N., Stallings M.C., Young S.E., Hewitt J.K.:
Investigating the genetic and environmental structure
of Cloninger's personality dimensions in adolescence.
Twin Res., 7, 462-470, 2004.
22. Jonnal A.H., Gardner C.O., Prescott C.A., Kendler K.S.:
Obsessive and compulsive symptoms in a general pop-
ulation sample of female twins. Am. J. Med. Genet., 96,
791-796, 2000.
23. Tozzi F., Aggen S.H., Neale B.M., Anderson C.B.,
Mazzeo S.E., Neale M.C., Bulik C.M.: The structure of
perfectionism: a twin study. Behav. Genet., 34, 483-494,
2004.
24. Bulik C.M., Slof-Op't Landt M.C., van Furth E.F.,
Sullivan P.F.: The genetics of anorexia nervosa. Annu.
Rev. Nutr., 27, 263-275, 2007.
25. Bulik C.M., Sullivan P.F., Tozzi F., Furberg H.,
Lichtenstein P., Pedersen N.L.: Prevalence, heritability,
and prospective risk factors for anorexia nervosa.
Arch. Gen. Psychiatry, 63, 305-312, 2006.
26. Dancyger I.F., Sunday S.R., Eckert E.D., Halmi K.A.: A
comparative analysis of Minnesota Multiphasic
Personality Inventory profiles of anorexia nervosa at
hospital admission, discharge, and 10-year follow-up.
Compr. Psychiatry, 38, 185-191, 1997.
27. Gundersen J.H.: Psychometric features related to the
acute phase and final outcome of anorexia nervosa.
Scand. J. Psychol., 30, 81-89, 1989.
28. Schork E.J., Eckert E.D., Halmi K.A.: The relationship
between psychopathology, eating disorder diagnosis,
and clinical outcome at 10-year follow-up in anorexia
nervosa. Compr. Psychiatry, 35, 113-123, 1994.
29. Edwin D., Andersen A.E., Rosell F.: Outcome predic-
tion by MMPI in subtypes of anorexia nervosa.
Psychosomatics, 29, 273-282, 1988.
30. Klump K.L., Strober M., Bulik C.M., Thornton L.,
Johnson C., Devlin B., Fichter M.M., Halmi K.A.,
Kaplan A.S., Woodside D.B., Crow S., Mitchell J.,
Rotondo A., Keel P.K., Berrettini W.H., Plotnicov K.,
Pollice C., Lilenfeld L.R., Kaye W.H.: Personality char-
acteristics of women before and after recovery from
an eating disorder. Psychol. Med., 34, 1407-1418, 2004.
31. Srinivasagam N.M., Kaye W.H., Plotnicov K.H.,
Greeno C., Weltzin T.E., Rao R.: Persistent perfection-
ism, symmetry, and exactness after long-term recovery
from anorexia nervosa. Am. J. Psychiatry, 152, 1630-
1634, 1995.
32. Wentz E., Gillberg C., Gillberg I.C., Rastam M.: Ten-
year follow-up of adolescent-onset anorexia nervosa:
psychiatric disorders and overall functioning scales. J.
Child Psychol. Psychiatry, 42, 613-622, 2001.
33. Laessle R.G., Schweiger U., Pirke K.M.: Depression as
a correlate of starvation in patients with eating disor-
ders. Biol. Psychiatry, 23, 719-725, 1988
34. Casper R.C.: How useful are pharmacological treat-
ments in eating disorders?. Psychopharmacol. Bull.,
36, 88-104, 2002.
35. Costa P.T. Jr., Bagby R.M., Herbst J.H., McCrae R.R.:
Personality self-reports are concurrently reliable and
valid during acute depressive episodes. J. Affect.
Disord., 89, 45-55, 2005.
36. Claes L., Vandereycken W., Luyten P., Soenens B.,
Pieters G., Vertommen H.: Personality prototypes in
eating disorders based on the Big Five model. J. Pers.
Disord., 20, 401-416, 2006.
37. Podar I., Hannus A., Allik J.: Personality and affectivity
characteristics associated with eating disorders: a
comparison of eating disordered, weight-preoccupied,
and normal samples. J. Pers. Assess., 73, 133-147, 1999.
38. Beato-Fernandez L., Rodriguez-Cano T.: Gender dif-
ferences regarding psychopathological, family and
social characteristics in adolescents with abnormal
eating behavior. Eat. Behav., 6, 337-344, 2005.
39. Kramer M.D., Krueger R.F., Hicks B.M.: The role of
internalizing and externalizing liability factors in
accounting for gender differences in the prevalence of
common psychopathological syndromes. Psychol.
Med., 38, 51-61, 2008.
40. Hebebrand J., Casper R., Treasure J., Schweiger U.:
The need to revise the diagnostic criteria for anorexia
nervosa. J. Neural Transm., 111, 827-840, 2004.
41. Wilfley D.E., Bishop M.E., Wilson G.T., Agras W.S.:
Classification of eating disorders: toward DSM-V. Int.
J. Eat. Disord., 40 Suppl, S123-S129, 2007.
42. Howell D.C.: Statistical Methods for Psychology.
Boston, PWS-Kent Publishing Company, 1992.
43. Kachele H.: [A multicenter study of expenditure and
success in psychodynamic therapy of eating disorders.
Study design and initial resul ts]. Psychother.
Psychosom. Med. Psychol., 49, 100-108, 1999.
44. Baran S.A., Weltzin T.E., Kaye W.H.: Low discharge
weight and outcome in anorexia nervosa. Am. J.
Psychiatry, 152, 1070-1072, 1995.
45. Howard W.T., Evans K.K., Quintero-Howard C.V.,
Bowers W.A., Andersen A.E.: Predictors of success or
failure of transition to day hospital treatment for inpa-
tients with anorexia nervosa. Am. J. Psychiatry, 156,
1697-1702, 1999.
46. Guarda A.S.: Treatment of anorexia nervosa: insights
and obstacles. Physiol. Behav., 94, 113-120, 2008.
47. Wilksch S., Wade T.D.: Differences between women
with anorexia nervosa and restrained eaters on shape
and weight concerns, self-esteem, and depression.
Int. J. Eat. Disord., 35, 571-578, 2004.
48. Silverstone P.H.: Low self-esteem in eating disordered
patients in the absence of depression. Psychol. Rep.,
67, 276-278, 1990.
49. Silverstone P.H.: Is chronic low self-esteem the cause
of eating disorders? Med. Hypotheses, 39, 311-5, 1992.
50. Connan F., Troop N., Landau S., Campbell I.C.,
Treasure J.: Poor social comparison and the tendency
to submissive behavior in anorexia nervosa. Int. J. Eat.
Disord., 40, 733-739, 2007.
51. Troop N.A., Allan S., Treasure J.L., Katzman M.: Social
comparison and submissive behaviour in eating disor-
der patients. Psychol. Psychother., 76, 237-249, 2003.
52. Fairburn C.G.: Evidence-based treatment of anorexia
nervosa. Int. J. Eat. Disord., 37 Suppl, S26-S30; discus-
sion S41-S42, 2005.
53. Karpowicz E., Skrster I., Nevonen L.: Self-esteem in
patients treated for anorexia nervosa. Int. J. Ment.
Health Nurs., 18, 318-325, 2009.
54. Stein K.F., Corte C.: The identity impairment model: a
longitudinal study of self-schemas as predictors of dis-
ordered eating behaviors. Nurs. Res., 57: 182-190,
2008.
55. Sassaroli S., Gallucci M., Ruggiero G.M.: Low percep-
tion of control as a cognitive factor of eating disorders.
Its independent effects on measures of eating disor-
ders and its interactive effects with perfectionism and
self-esteem. J. Behav. Ther. Exp. Psychiatry, 39, 467-
488, 2008.
56. Bjrck C., Clinton D., Sohlberg S., Norring C.: Negative
self-image and outcome in eating disorders: results at
3-year follow-up. Eat. Behav., 8, 398-406, 2007.
57. Miller J.L., Schmidt L.A., Vaillancourt T., McDougall P.,
Laliberte M.: Neuroticism and introversion: a risky
combination for disordered eating among a non-clini-
cal sample of undergraduate women. Eat. Behav., 7,
69-78, 2006.
58. Casper R.C.: Personality features of women with good
outcome from restricting anorexia nervosa.
Psychosom. Med., 52, 156-170, 1990.
ORIGINAL
RESEARCH
PAPER
Key words:
Eating disorders,
eating attitudes, dietetics,
university students, nutrition.
Correspondence to:
Fragiskos Gonidakis,
1
st
Psychiatric Department,
Athens University Medical
School, Vas Sofias 74,
11528 Athens, Greece.
E-mail: fragoni@yahoo.com
Accepted: January 15, 2009
A study of eating attitudes and related
factors in a sample of first-year female
Nutrition and Dietetics students of
Harokopion University in Athens,
Greece
INTRODUCTION
Although anorexia nervosa and bulimia
nervosa are quite rare mental disorders (1,
2), they tend to be found more often in
female adolescents and young adults (2, 3).
According to the above findings a consider-
able percentage of patients will experience
eating disorder symptomatology during
their studies in college or university.
Therefore, eating disorders and disor-
dered eating attitudes have been extensive-
ly studied in college and university students
(4). In three studies investigating the preva-
lence of eating disorders among students it
was reported that 1-2.2% of the students
were diagnosed as suffering from an eating
disorder (5-7).
As expected the percentage of female stu-
dents that are reporting disordered eating
attitudes is much higher than the actual
prevalence of eating disorders in the overall
population of university and collage stu-
dents. Prouty et al. (8) and Makino et al. (9)
reported that 17% and 5.1% of the female
students, respectively, had disordered eat-
ing attitudes. Special attention has been
given to female health students (10). Szweda
and Thorne (11) reported that 20% of the
female applicants for a university nurse
training course and 19% of first-year med-
ical students were found to have disordered
eating patterns. Also Babar et al. (12)
reported that 21.7% of medical and nursing
students had anorexic behavior.
Dieting or the desire to lose weight is
quite common among university students
although only a small percentage of them
are overweight (8-11%) or obese (0.8-1%)
(13-15). It is interesting that dieting and
especially fat-avoidance in female college
students has been associated with lower
levels of self-esteem and higher scores on
the Eating Attitudes Test (EAT) (16). Al-
though the relation between dieting and
eating disorders has been extensively
examined (17, 18), the prevalence of eating
disorders among health professionals con-
cerned with diet and nutrition has not
been sufficientl y investigated. To our
knowledge there is only one report in the
literature of a small study conducted by
F. Gonidakis
1,2
, A. Sigala
2
, E. Varsou
1
, and G. Papadimitriou
1
1
1
st
Psychiatric Department, Athens University Medical School,
2
Health Visitors School, Athens Technological
Institution, Athens, Greece
ABSTRACT. OBJECTIVE: To investigate eating attitudes and related factors in a sample of
first-year female students of Harokopion University, Nutrition and Dietetics (ND) School.
METHOD: The Eating Attitudes Test (EAT-26), a set of 12 male and female figures, and two
questionnaires for demographic, clinical and nutritional data were administered to 53 ND
students and 54 first-year female students of Athens Technological Institution Health Visitors
(HV) School. RESULTS: The ND group scored higher in EAT-26 total score (p=0.05) and
Diet subscale (p=0.02) than the HV group. EAT-26 score in the ND group correlated signifi-
cantly with dinner avoidance (correlation coefficient: 0.3, p=0.02). Logistic regression analy-
sis showed that avoidance of dinner (p=0.03), choosing leaner ideal women figures (p=0.005)
and larger self images (p=0.01) were the three factors that could predict high EAT-26 scores
in the ND group (EAT-2620). CONCLUSIONS: First-year ND students might have more
often disordered eating attitudes as opposed to students from other university programs.

e121
F. Gonidakis, A. Sigala, E. Varsou, et al.
Kinzl et al. (19) on the prevalence of orthorex-
ia nervova in dietitians. The authors conclud-
ed not only that orthorexia nervosa was
very frequent among dietitians but in addition
that some women take up dietetics because of
an existing eating disorder and their hope of
coping with it (19).
The primary aim of the present study was to
investigate whether first-year female students
who chose to become dietitians have more dis-
ordered eating attitudes than students in the
control group. Health Visitor (HV) students
were chosen as control group because provid-
ing public education on issues of nutrition is
among their professional interests. A sec-
ondary aim of the study was to identify factors
that may be related to disordered eating atti-
tudes in first-year female Nutrition and Dietet-
ics (ND) university students. To our knowledge
this is the first study that focuses on the issue
of eating attitudes in female students that are
studying ND.
MATERIAL AND METHOD
Study design
The study was conducted during the first
trimester of two subsequent academic years
(2005-2006). All first-year female students of
Harokopion University, Department of ND and
Athens Technological Institution, HV School,
were approached after class and asked to par-
ticipate in the study. The students that partici-
pated in the study were recruited from two
schools only because in the area of Athens, cap-
ital of Greece, these two schools are the only
ones that provide university level education on
ND and HV. All students had to pass a national
level examination after concluding their high
school education in order to be admitted in the
university school of their choice. Each student
was administered the EAT-26, a set of 12 male
and female figures and two questionnaires for
demographic, clinical and nutritional data.
Finally a member of the research team (AS)
measured the height and weight of each student
and the body mass index (BMI) was calculated
accordingly.
The study protocol was reviewed and
approved by the administration boards and rel-
evant scientific committees of Harokopion Uni-
versity, Department of ND and Athens Techno-
logical Institution, HV School. Each participat-
ing student provided written informed consent
in order to be included in the study. The inclu-
sion criteria were female gender, age between
18 and 25 years and adequate knowledge (read
and write) of the Greek language.
Measurements
a) Data concerning age, parents social and
economical status, marital status, type of res-
idence and university school preference as
well as data concerning dieting during the
last six months; minimum, maximum and
ideal adult weight were collected by ques-
tionnaire. The fathers profession was used
as an indicator of the familys socio-econom-
ic status. The students were grouped accord-
ingly into three major categories: lower
(farmers, labourers and blue collar workers),
medium (technicians, self-employed persons,
medium employees, small and medium sized
shop owners) and upper class (scientists,
businessmen, high ranking corporate
employees) (20).
b) A second questionnaire that evaluated the
frequency of meals was also administered.
The students were asked how often they had
breakfast, snack, lunch and dinner during
the last month. Each question had 5 possible
answers in a Likert-like scale (every day, 5
times/week, 3 times/week, once per week,
and never). The score for each question var-
ied from 1 (every day) to 5 (never).
c) The EAT-26, consisting of 26 items with 5
possible answers in a Likert-like scale (21).
Each answer score varies from 0 to 3 pro-
viding a total score of 0-78. This test has
been translated in Greek and validated by
Simos (1996, doctoral thesis) on a popula-
tion of Greek students. The EAT-26 consists
of three subscales: Diet, Bulimia and Oral
control. According to the Greek edition of
the scale, respondents scoring equal or over
20 are considered at risk for an eating dis-
order. In isolation, the scale does not yield a
specific diagnosis for an eating disorder;
however it is consistently used as an effec-
tive screening instrument and it has been
found to be effective with clinical and sub-
clinical populations (22).
d) All students were asked to observe a series
of 12 male and 12 female human figures and
select the one that they considered to be an
ideal male and female body (23). Additional-
ly, the students were asked to select the fig-
ure that in their mind better represented
their own body (23). The male and female
figures were presented and scored in a hier-
archical order starting from the most lean
(score of 1) and ending with the most
obese (score of 12).
Students t-test and
2
were used to compare
scale and nominal variables respectively.
Kendalls tau-b was used to investigate possible
correlations between the EAT-26 total score
and scale and ordinal variables. Finally, a step-
Eating attitudes of female Dietetics students
wise logistic regression analysis was used to
investigate factors that could predict high score
in the EAT-26 scale (EAT-2620).
RESULTS
Of the 85 ND students that were enrolled and
attended classes, 14 were excluded because
they were older than 25 years of age, and 18
refused participating in the study. Overall, 53
ND students were included in the study. Of the
84 HV students that were enrolled and attend-
ed classes, 11 were excluded because they were
older that 25 years of age, and 19 refused par-
ticipating. Overall, 54 HV students were includ-
ed in the study.
Comparison between the two groups of
students
Demographic data
The two groups did not differ significantly in
age (ND: 18.20.5, HV: 18.30.6, t=1.1, df=105,
p=0.3), parental socio-economical status or
type of residency (Table 1). All students were
single. Concerning the students university
school preference it was found that studying
ND was the first choice for 71.7% of the stu-
dents while studying to become a HV was the
first choice only for 5.6% of the students. The
above di fference was hi ghl y si gnifi cant
(p=0.001) (Table 1).
Data concerning weight, dieting and eating
disorders
The two groups did not differ significantly in
their replies concerning their minimum, maxi-
mum and ideal BMI (after the age of 17) (Table
2), or whether they regarded themselves as
overweight or not [ND: 24 (45.3%) vs HV: 25
(46.3%),
2
=0.01, df=1, p=0.9]. Also, the two
groups did not differ in the percentage of stu-
dents who reported that they were dieting dur-
ing the last 6 months [ND: 8 (15.1%) vs HV: 7
(13.1%),
2
=0.1, df=1, p=0.8]. It is interesting
that while in both groups the mean BMI was
between 21 and 22, close to half of the students
(45-46%) regarded themselves as overweight.
Frequency of meals
Due to the small number of replies in the cat-
egori es once per week or never, the
answers were recoded to the following three
categories: always, 3-5 times per week, and
less than 3 times per week. The main differ-
ence between the two groups was that more
ND students reported that they were having
breakfast regularly during the week (p=0.001)
as compared to the HV students (Table 3).
Also, it is noteworthy that more than one third
of both student groups (34% in the ND and
35.2% in the HV group) reported that they
Variables ND group HV group
2
N % N %
2
df sig.
Age
Socio- Lowew 6 11.3 10 18.5
economic Middle 36 67.9 38 70.4 2.5 2 0.3
status Upper 11 20.8 6 11.1
Residency Family 24 45.3 32 59.3 2.1 1 0.2
Alone/ 29 54.7 22 40.7
roommate
Marital status (single) 53 100% 54 100%
University school 38 71.7% 3 5.6% 49 1 0.001
preference (1
st
choice)
N: number of students; df: degrees of freedom; sig.: significance.
TABLE 1
Comparison between the Nutrition and Dietetics (ND) and the
Health Visitor (HV) group. Demographic variables.
2
ND group HV group t-test
N % N %
2
df sig. Mean SD Mean SD t df p
Score Score
BMI (measured) 21.8 2.5 21.8 3.5 0.03 105 0.9
Min BMI 19.5 2.3 19.7 3.2 0.3 105 0.8
Max BMI 22.5 2.6 23 4 0.7 105 0.4
Ideal BMI 19.8 1.4 20 1.7 0.8 105 0.4
Overweight (yes) 24 45.3 25 46.3 0.01 1 0.9
Dieting (yes) 8 15.1 7 13.1 0.1 1 0.8
N: number of students; d: degrees of freedom; sig.: significance; SD: standard deviation; BMI: body mass index.
TABLE 2
Comparison between the Nutrition and Dietetics (ND) and the Health Visitor (HV) group. Data concerning weight,
dieting and eating disorders.
were having dinner less that 3 times per week
(Table 3).
Clinical measurements
The ND students scored higher than the HV
students in the EAT-26 (p=0.05) and EAT-26
Diet subscale (p=0.02) (Table 4). In addition the
percentage of students at greater risk for an
eating disorder (EAT-2620) was higher in the
ND group [ND: 16 (30.2%), HV: 6 (11.1%),
2
=6,
df=1, p=0.02]. There was no other significant
difference between the two groups (Table 4).
Kendalls tau-b correlation test for scale and
ordinal variables showed that ND students
EAT-26 total score correlated positively with
skipping dinner often (correlation coefficient:
0.3, p=0.02) and negatively with skipping lunch
often (correlation coefficient: -0.2, p=0.04).
Variables ND group HV group t-test
Mean SD Mean SD t df p
score score
EAT-26 total 14.3 9.0 10.8 8.5 2.0 105 0.05
EAT-26 diet 8.4 6.9 5.4 6.2 2.3 105 0.02
EAT-26 bulimia 2 2.6 2 2.3 0.1 105 0.9
EAT-26 oral control 3.9 3.1 3.3 3.1 1.1 105 0.3
Ideal female figure 5.1 1.1 5.3 0.9 0.7 105 0.5
Ideal male figure 5.8 1.1 5.7 1.2 0.5 105 0.6
Self figure 6.3 1 5.9 1.6 1.4 105 0.2
df: degrees of freedom; SD: standard deviation; EAT-26: 26 item Eating Attitudes Test.
TABLE 4
Health Visitor (HV) group. Clinical measurements.
2
N % N %
2
df sig.
Breakfast Everyday 32 60.4 14 25.9 18.1 2 0.001
5 days/week 9 17 6 11.1
<3 days/week 12 22.6 34 63
Lunch Everyday 44 83 37 68.5 3.1 2 0.2
5 days/week 6 11.3 11 20.4
<3 days/week 3 5.7 6 11.1
Dinner Everyday 21 39.6 22 40.7 0.1 2 0.9
5 days/week 14 26.4 13 24.1
<3 days/week 18 34 19 35.2
Snack Everyday 25 47.2 25 46.3 3.3 2 0.2
5 days/week 12 22.6 6 11.1
<3 days/week 16 30.2 23 42.6
TABLE 3
Health Visitor (HV) group. Meals frequency.
Variables EAT20 EAT<20 X
2
EAT20 EAT<20 t-test
N % N % X
2
df sig. Mean SD Mean SD t df p
score score
Age 18.3 0.5 18.2 0.5 0.5 51 0.6
BMI 22.3 2 21.5 2.6 1 51 0.3
Min BMI 19.1 2 19.7 2.4 0.8 51 0.4
Max BMI 22.9 2.3 22.3 2.8 0.8 51 0.4
Ideal BMI 19.7 1.3 19.9 1.5 0.4 51 0.6
Ideal female figure 4.9 1 5.2 1.1 0.9 51 0.4
Ideal male figure 5.6 1.3 5.8 1 0.6 51 0.6
Self figure 6.4 0.9 6.2 1 0.8 51 0.4
Socio- Lower 1 6.3 5 13.5 0.7 2 0.7
economical Middle 11 68.8 25 67.9
status Upper 4 25 7 20.8
Residency Family 3 18.8 21 56.8 6.5 1 0.01
Alone/ 13 81.3 16 43.21
room-mate
University school
preference (1
st
choice) 10 62.5 28 75.7 1 1 0.3
Overweight (yes) 12 75 12 32.4 8.2 1 0.004
Dieting (yes) 5 31.3 3 8.1 4.7 1 0.03
N: number of students; df: degrees of freedom; sig.: significance; SD: standard deviation; BMI: body mass index.
TABLE 5A
Comparison between Eating Attitudes Test (EAT) high (20) and low (<20) scorers in the Nutrition and Dietetics group.
Factors related with disordered eating
attitudes in first-year female university
students of Nutrition and Dietetics
(Table 5A and B)
The subgroup of ND students who scored high
(20) on EAT-26 reported more often than the
group of students who scored low on the EAT-26
that they were living away from home (their
parental families; p=0.01), dieting during the last
6 months (p=0.03), and that they believed that
they were overweight (p=0.004). Considering
meal frequency, the group of high EAT-26
scorers reported more often that they were skip-
ping dinner (p=0.03).
Stepwise logistic regression analysis showed
that avoidance of dinner (p=0.03), choosing
leaner ideal women figures (p=0.005) and larger
self-images (p=0.001) were the three factors that
could predict a high score in the EAT-26 (EAT-
2620). R
2
Nagelkerkle was calculated at 0.224,
thus indicating that the above three factors
could account for 22.4% of EAT-26 variance.
The Hosmer-Lemeshow test did not reach sta-
tistical significance (p=0,8) thus indicating that
the model produced by logistic regression
analysis has goodness of fit (Table 6).
DISCUSSION
Overall 74.5% (53 out of 71 students) of the
ND and 74% (54 out of 73 students) of the HV
students approached and eligible to be includ-
ed in the study agreed to participate. The main
objection of the students who refused partici-
pating in the study was that they did not want
to be weighed in front of the researcher
although the measurement was conducted, pri-
vately, between classes, inside vacant lecture
rooms. The rest of the students who refused
participating in the study replied that they were
in a hurry or that they just were not in the
mood of filling questionnaires. The interview-
ers estimation was that the group of students
who refused to participate did not seem to dif-
fer in their physical characteristics from the
group of students who agreed to participate (ie
slimmer or larger body size, differences in their
physical appearance etc.).
As mentioned previously, the first aim of
our study was to investigate the possibility
that young women who chose to study ND
have more disordered eating attitudes than
students in the control group. Our hypothesis,
based on the results of Kinzl et al. (19), was
confirmed by the study results. Although the
two groups were quite similar considering
demographic data, body measurements, body
size estimation and frequency of meals, the
ND group had higher EAT-26 measurements
especially in the Diet subscale. Furthermore
the percentage of students that scored higher
or equal than 20 in the EAT-26 was signifi-
cantly higher in the ND group. While the per-
centage of high EAT-26 scorers in the HV
group (11.1%) is similar to the ones reported
in the literature for university students (6, 7,
24), the percentage of high EAT-26 scorers in
the ND group is remarkably higher, around
three times more, than in the HV group. The
above results lead us to the conclusion that
first-year ND female students have more dis-
ordered eating attitudes than students in the
control group. This result is in accordance
with the study by Kinzl et al. (19) on ortho -
rexia nervosa in dietitians.
The only other difference found between the
two groups was that the ND students reported
more often that they were having breakfast on
a regular basis than HV students. The frequen-
cy with which students consume breakfast was
not related to the presence of disordered eating
attitudes. In discrepancy to our result Montero
Bravo et al. (25) reported that there was no
major difference in the dietary habits between
ND students and students of Nursing, Pharma-
cy and Podology.
Variables EAT20 EAT<20
2
N % N %
2
df sig.
Breakfast Everyday 10 62.5 22 59.5 0.3 2 0.8
5 days/week 2 12.5 7 18.9
<3 days/week 4 25 8 21.6
Lunch Everyday 15 93.8 29 78.4 2.1 2 0.3
5 days/week 1 6.3 5 13.5
<3 days/week 0 0 3 8.1
Dinner Everyday 3 18.8 18 48.6 7.4 2 0.03
5 days/week 8 50 6 16.2
<3 days/week 5 31.3 13 35.1
Snack Everyday 6 37.5 19 51.4 1.2 2 0.6
5 days/week 5 31.3 7 18.9
<3 days/week 5 31.3 29.7 29.7
TABLE 5B
Comparison between Eating Attitudes test (EAT) high (20) and low
(<20) scorers in the Nutrition and Dietetics group. Meals frequency.
Variables in the equation B SE df sig.
Dinner frequency -0.4 0.2 1 0.03
Ideal female figure 0.7 0.3 1 0.003
Self-figure -0.6 0.2 1 0.001
SE: standard error; df: degrees of freedom; sig.: significance.
TABLE 6
Factors related to Eating Attitudes Test (EAT) high (20) score in the
Nutrition and Dietetics group. Forward stepwise logistic regression.
REFERENCES
1. Bulik C.M., Sullivan P.F., Tozzi F., Furberg H.,
Lichtenstein P., Pedersen N.L.: Prevalence, heritability,
and prospective risk factors for anorexia nervosa.
2. Hoek H.W., van Hoeken D.: Review of the prevalence
and incidence of eating disorders. Int. J. Eat. Disord.,
34, 383-396, 2003.
3. Keski-Rahkonen A., Hoek H.W., Susser E.S., Linna
M.S., Sihvola E., Raevuori A., Bulik C.M., Kaprio J.,
Rissanen A.: Epidemiology and course of anorexia ner-
vosa in the community. Am. J. Psychiatry, 164, 1259-
1265, 2007.
4. Phillips E.L., Pratt H.D.: Eating disorders in college.
Pediatr. Clin. North Am., 52, 85-96, 2005.
5. Kugu N., Akyuz G., Dogan O., Ersan E., Izgic F.: The
prevalence of eating disorders among university stu-
dents and the relationship with some individual char-
acteristics. Aust. N. Z. J. Psychiatry, 40, 129-135, 2006.
6. Uzun O., Gulec N., Ozsahin A., Doruk A., Ozdemir B.,
Caliskan U.: Screening disordered eating attitudes and
eating disorders in a sample of Turkish female college
students. Compr. Psychiatry, 47, 123-126, 2006.
7. Mancilla-Diaz J.M., Franco-Paredes K., Vazquez-Arevalo
R., Lopez-Aguilar X., Alvarez-Rayon G.L., Tellez-Giron
M.T.: A two-stage epidemiological study on prevalence
of eating disorders in female university students in
Mexico. Eur. Eat. Disord. Rev., 5, 463-470, 2007.
8. Prouty A.M., Protinsky H.O., Canady D.: College
women: eating behaviors and help-seeking prefer-
ences. Adolescence, 37, 353-363, 2002.
9. Makino M., Hashizume M., Yasushi M., Tsuboi K.,
Dennerstein L.: Factors associated with abnormal eat-
ing attitudes among female college students in Japan.
Arch. Womens Ment. Health, 9, 203-208, 2006.
10. Herzog D.B., Pepose M., Norman D.K., Rigotti N.A.:
Eating disorders and social maladjustment in female
medical students. J. Nerv. Ment. Dis., 173, 734-737, 1985.
11. Szweda S., Thorne P.: The prevalence of eating disor-
The second aim of our study was to examine
factors that might be related to high scores on
the EAT-26 in the ND students group. The first
factor that was found to be related with high
scores on the EAT-26 was disordered eating
patterns and especially skipping dinner. Also
high EAT-26 scorers reported more often than
EAT-26 low scorers that they were dieting in
the last six months prior to the investigation.
Irregular meal habits have been reported in the
literature to be associated with high EAT-26
scores in female college students (9). Reducing
the number of daily meals seems to be one of
the methods used by female dieters to achieve
the desired weight reduction (15). Furthermore
dieting behavior in female university students
has been related, as in our study, with EAT-26
higher scores and especially with the Diet sub-
scale (16).
The second factor that was found to be relat-
ed with high scores on the EAT-26 was body
dissatisfaction expressed through the choice of
a leaner ideal and a larger self body figure. It
should be noted that the mean BMI between
the two ND groups did not differ significantly
and was between normal limits. Similar results
have also been reported in the literature for
university students (14, 15).
It is interesting that high EAT-26 scorers in
the ND group reported more often than low
EAT-26 scores in the same group that they
were living alone or with roommates. Living
away from home has been related to the devel-
opment of more undesirable eating habits in
Greek students (26). Furthermore, difficulties in
separation from family and individuation have
been linked to eating disorder symptomatology
in university students (27).
The two main limitations of the present study
were the difficulty to generalize the results of
the study and the lack of a diagnostic instru-
ment for eating disorders. The study results
can serve only as an indication of ND students'
eating attitudes since the student sample was
small and drawn from only one ND school. The
above limitation was due to the small number
of new female students that are admitted and
attend classes every year in the ND School and
the inability of the research team to extend the
data collection time period beyond the original
two years or to extend the research to universi-
ties outside the area of Athens. Disordered eat-
ing attitudes, as measured by EAT-26, are far
more often in the university female population
than are actually diagnosed, via the Diagnostic
and Statistical Manual of Mental Disorders -
Fourth Edition (DSM-IV), eating disorders (6, 7,
28). The small size of the sample combined with
the low prevalence of eating disorders prevent-
ed us from using a diagnostic instrument for
eating disorders. Finally a third limitation of
the study is that is has been restricted to first-
year students. It would have been extremely
interesting to investigate the impact of four
years study in ND on a group of students who
were found to be quite worried about their diet
and body size.
In conclusion first-year ND students might
have more often disordered eating attitudes as
opposed to students from other university pro-
grams. Avoiding dinner and body dissatisfac-
tion expressed though the choice of a leaner
ideal and a larger self body figure seem to be
related with disordered eating attitudes in the
ND group. The hypothesis that Nutrition and
Dietics might be chosen as a professional sci-
entific field for studies by a larger number of
young women with disordered eating attitudes
and its possible consequences is quite intrigu-
ing but needs further investigation.
ders in female health care students. Occup. Med.
(Lond.), 52, 113-119, 2002.
12. Babar N., Alam M., Ali S.S., Ansari A., Atiq M., Awais
A., Amin F., Israr S.M.: Anorexic behaviour and atti-
tudes among female medical and nursing students at a
private university hospital. J. Pak. Med. Assoc., 52,
272-276, 2002.
13. Cilliers J., Senekal M., Kunneke E.: The association
between the body mass index of first-year female uni-
versity students and their weight-related perceptions
and practices, psychological health, physical activity
and other physical health indicators. Public Health
Nutr., 9, 234-243, 2006.
14. Navia B., Ortega R.M., Requejo A.M., Mena M.C.,
Perea J.M., Lopez-Sobaler A.M.: Influence of the desire
to lose weight on food habits, and knowledge of the
characteristics of a balanced diet, in a group of Madrid
university students. Eur. J. Clin. Nutr., 57 Suppl 1, S90-
93, 2003.
15. Bellisle F., Monneuse M.O., Steptoe A., Wardle J.:
Weight concerns and eating patterns: a survey of uni-
versity students in Europe. Int. J. Obes. Relat. Metab.
Disord., 19, 723-730, 1995.
16. Liebman M., Cameron B.A., Carson D.K., Brown D.M.,
Meyer S.S.: Dietary fat reduction behaviors in college
students: relationship to dieting status, gender and key
psychosocial variables. Appetite, 36, 51-56, 2001.
17. Neumark-Sztainer D., Wall M., Guo J., Story M.,
Haines J., Eisenberg M.: Obesity, disordered eating,
and eating disorders in a longitudinal study of adoles-
cents: how do dieters fare 5 years later? J. Am. Diet.
Assoc., 106, 559-568, 2006.
18. Butryn M.L., Wadden T.A.: Treatment of overweight
in children and adolescents: does dieting increase the
risk of eating disorders? Int. J. Eat. Disord., 37, 285-
29, 2005.
19. Kinzl J.F., Hauer K., Traweger C., Kiefer I.: Orthorexia
nervosa in dieticians. Psychother. Psychosom., 75, 395-
396, 2006.
20. Madianos M., Zarnari O.: Indicator of socio-economic
status. In: Madianos M., Zarnari O. (Eds.), Health and
Greek society. Athens, National Center of Social
Research, 1988, pp. 28-30.
21. Garner D.M., Olmsted M.P., Bohr Y., Garfinkel P.E.:
The eating attitudes test: psychometric features and
clinical correlates. Psychol. Med., 12, 871-878, 1982.
22. Koslowsky M., Scheinberg Z., Bleich A., Mark M.,
Apter A., Danon Y., Solomon Z.: The factor structure
and criterion validity of the short form of the Eating
Attitudes Test. J. Pers. Assess., 58, 27-35, 1992.
23. Furnham A., Baguma P.: Cross-cultural differences in
the evaluation of male and female body shapes. Int. J.
Eat. Disord., 15, 81-89, 1994.
24. Tamim H., Tamim R., Almawi W., Rahi A., Shamseddeen
W., Ghazi A., Taha A., Musharrafieh U.: Risky weight
control among university students. Int. J. Eat. Disord.,
39, 80-83, 2006.
25. Montero Bravo A., Ubeda Martin N., Garcia Gonzalez
A.: [Evaluation of dietary habits of a population of uni-
versity students in relation with their nutritional
knowledge]. Nutr. Hosp., 21, 466-473, 2006.
26. Papadaki A., Hondros G., A. Scott J., Kapsokefalou M.:
Eating habits of university students living at, or away
from home in Greece. Appetite, 49, 169-176, 2007.
27. Marsden P., Meyer C., Fuller M., Waller G.: The rela-
tionship between eating psychopathology and separa-
tion-individuation in young nonclinical women. J.
Nerv. Ment. Dis., 190, 710-713, 2002.
28. Tlgyes T., Nemessury J.: Epidemiological studies on
adverse dieting behaviors and eating disorders among
young people in Hungary. Soc. Psychiatry Psychiatr.
Epidemiol., 39, 647-654, 2004.
ORIGINAL
RESEARCH
PAPER
Key words:
Body image, body image
distortion, body size
estimation, anorexia nervosa,
children and adolescents.
Correspondence to:
Nora Schneider,
Department of Child and
Adolescent Psychiatry,
Psychosomatics and
Psychotherapy, Charit
Universittsmedizin Berlin,
Campus Virchow Klinikum,
Augustenburgen Platz 1,
13353 Berlin, Germany.
E-mail:
nora.schneider@charite.de
The assessment of body image
distortion in female adolescents with
anorexia nervosa: The development of
a Test for Body Image Distortion in
Children and Adolescents (BID-CA)
INTRODUCTION
In addition to a low body weight, amen-
orrhea and the fear of gaining weight, the
diagnosis of anorexia nervosa (AN)
requires symptoms of a disturbance in the
way in which ones body weight or shape is
experienced, undue influence of body
weight or shape on self-evaluation, or
denial of the seriousness of the current low
body weight (1, p. 545) also referred to as
body image distortion. Body image distor-
tion is considered a multidimensional phe-
nomenon, which consists of perceptual,
cognitive-affective and behavioral compo-
nents. According to most authors the per-
ceptual component of body image distor-
tion refers to the overestimation of ones
own body size. The cognitive-affective com-
ponent reflects thoughts and feelings about
ones own body, while the behavioral com-
ponent refers to social aspects including
hiding ones body from others, e.g. by
wearing oversized clothes, or the assump-
tion that others may judge oneself in a cer-
tain way (2). Neuropsychological studies
have found evidence for neural substrates
that underlie body image distortion. They
reveal hemispherical differences in body
image (3) and an activation of the brains
fear network (4, p. 25) in AN patients,
which includes the amygdala, the gyrus
fusiformis and the brainstem region. The
amygdala is known to be involved in emo-
tional processes. Thus, an important rela-
tionship seems to exist between affects of
eating disorders and the overestimation of
eating disordered participants (5, 6). These
findings underline the interaction between
neurological and behavioral factors of eat-
ing disorders.
In the literature we find considerable con-
troversy regarding the specificity of body
image distortion to AN. As a diagnostic cri-
terion it is stated in the Diagnostic and Sta-
tistical Manual of Mental Disorders - Fourth
Edition (DSM-IV) for AN, but not for other
forms of eating disorders. Yet, empirical
findings also suggest overestimation of
actual as well as perceived body size in
bulimia nervosa patients (2), obesity
patients (7) and ballet/gymnastics pupils (8).
N. Schneider
1
, P. Martus
2
, S. Ehrlich
1
, E. Pfeiffer
1
, U. Lehmkuhl
1
,
and H. Salbach-Andrae
1
1
Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, and
2
Department of
Biostatistics and Epidemiology, Charit Universittsmedizin Berlin, Germany
ABSTRACT. The purpose of this study was to develop an instrument (Test for Body Image
Distortion in Children and Adolescents, BID-CA) suitable for adolescents to detect and quan-
tify body image distortion. Participants were patients with anorexia nervosa (AN; N=75),
healthy age-matched control participants (N=268) and age-matched thin female athletes
(N=50) with a mean age of 15.2 (standard deviation =2.0) years. We assessed body image dis-
tortion (arm, waist, and thigh) using the BID-CA and two scales of the Eating Disorder
Inventory-2 (EDI-2; Drive for Thinness, Body Dissatisfaction). Diagnostic validity of the BID-
CA was analyzed with receiver operating characteristic (ROC) curves. Additional regression
analyses revealed the variables BID-CA thigh and EDI-2 Drive for Thinness to be the best at
predicting body image distortion among AN patients. In conclusion, the BID-CA showed
good diagnostic validity. It is efficient, language independent, time-saving and seems appro-
priate for children and adolescents.

e128
Assessment of body image distortion in anorexia
To the contrary, Probst et al. (9) found a more
accurate body size estimation by obese than
non-obese children using the video distortion
method. These findings suggest a general over-
estimation of ones own body parts exists.
Therefore, the degree to which AN patients
overestimate their body size may have more
relevance for the distortion criterion than
merely overestimation itself.
The method used to assess body image dis-
tortion seems to be a relevant factor as well.
Meermann (8), for exampl e, observed an
under- or overestimation in female AN patients
depending on the method used (Video Distor-
tion, Image Marking Procedure and Body
Image Screening Scale). Thus, methodological
factors may explain the above mentioned
inconsistencies. Techniques and instruments
for body image distortion are usually projective
methods, figural and questionnaire formats
using photo distortion, clinical interviews or
the estimation of body size. Slade and Russell
(10), for example, studied the perceptual com-
ponent of body image by using a visual size
estimation technique. Participants were asked
to picture their body masses on a wall using
light projection. The authors used the ratio of
estimated size to actual size x 100 as a measure.
This study showed overestimation of body
parts in AN patients, but could not be consis-
tently replicated. To detect perceptual deficits
in eating disordered patients, Shafran and Fair-
burn (11) used body-part- and whole-body-
techniques, respectively. Although several dif-
ferent methods to assess body image distortion
already exist, most of these methods are time-
consuming and/or require special equipment.
Moreover, psychometric properties and norm
values are often not provided for children and
adolescents.
AN is a disorder with prevalence rates
between 0.5 and 0.7% among teenage girls. It
usually manifests during adolescence which is
reflected by a well replicated peak incidence
rate in females between 10 and 19 years old (12,
13). Therefore, the diagnosis of AN represents
a frequent problem for pediatricians, psychia-
trists and psychologists who work with chil-
dren and adolescents. As mentioned, body
image distortion is one of the key criteria for
AN requiring reliable and valid assessment.
Even though some instruments for the percep-
tual as well as cognitive-affective assessment of
body image distortion exist, there is a need for
efficient, time-saving and valid tests suitable for
children and adolescents with AN.
In summary, body image distortion as a mul-
tidimensional phenomenon, while difficult to
assess, is extremely important for patients with
AN. The necessity of reliably assessing body
image distortion in clinical settings and the lack
of norm values for instruments assessing such
distortion in children and adolescents have led
us to establish a new body image distortion test
suitable for that age group. The aim of the pre-
sent and ongoing study is to develop an effec-
tive, efficient and valid instrument for the
assessment of body image distortion that is
quantifiable and appropriate for children and
adolescents. The main goal is to obtain appro-
priate norm values. However, at this point of
research, we want to present first results: we
have tested for group differences, sensitivity,
specificity and diagnostic validity of the Test
for Body Image Distortion in Children and
Adolescents (BID-CA).
METHOD
Participants
Three samples consisting of 393 participants
in total were included in our study: AN patients
(N=75), (healthy) control participants (N=268)
and female athletes (n=50). Mean age was 15.2
[standard deviation (SD)=2.0; range 10.9-20.6].
The AN patient group consisted of in- and out-
patients treated at a Child and Adolescent Psy-
chiatric Department. All AN patients met the
criteria outlined in the DSM-IV (1) and were
diagnosed using a structured interview for
anorectic and bulimic disorders (SIAB) (14).
Out of the 75 AN patients 52 (69.3%) were iden-
tified as the restrictive type and 23 (30.7%) as
the purging type. They were measured at base-
line, i.e. before treatment. Their mean age was
15.6 (SD=1.7, range 11.5-20.6). The control
group was recruited from local high schools
and was tested during class. It consisted of
high school girls whose mean age was 15.1
(SD=2.1, range 10.9-19.6). The female athletes
were considered as a second control group as
it may be of more interest for clinical applica-
tion to differentiate between AN patients and
persons with a small body mass index (BMI)
due to sports: the group consisted of elite
rhythmic gymnasts with a BMI lower than that
of the control participants and were thus
assumed to be better comparable to the BMI of
AN patients. They were contacted through
gymnastic clubs and were tested during train-
ing sessions at Olympic base camps. Their
mean age was 14.8 (SD=2.1, range 11.0-18.9).
All athletes trained at least 8 hours per week.
Amenorrhea (diagnostic criteria for AN indi-
cating endocrine dysfunction) was reported by
all AN patients, six (12.0%) female athletes (>15
years) and ten (3.7%) control participants (>15
N. Schneider, P. Martus, S. Ehrlich, et al.
TABLE 1
General characteristics, Eating Disorder Inventory-2 (EDI-2) and Test
for Body Image Distortion in Children and Adolescents (BID-CA) results.
years). Table 1 summarizes the general charac-
teristics of each group as well as the results of
the Eating disorder inventory-2 (EDI-2) ques-
tionnaire and the BID-CA.
This study was approved by the institutional
review board. Written informed consent was
obtained from the participants and their
guardians. Anonymity of participants was
maintained.
Procedure and materials
For each subject body height (m) and body
weight (kg) were determined objectively by
research assistants to calculate a BMI (kg/m
2
).
The control group and the female athlete group
were assessed once, while the AN patients
were asked to repeat the BID-CA a week after
the first assessment as well as at the end of
their treatment. The following assessment was
administered with varying order across partici-
pants in order to avoid sequence effects:
- BID-CA. This instrument (German version: Test
zur Erfassung der Krperbildstrung bei
Kindern und Jugendlichen = TEK-KJ) has been
designed to assess body image distortion (see
Appendix). Using a string (length: 180 cm,
approx. 71 inches; diameter: 0.6 cm, approx.
inches) participants were asked to estimate the
size of their upper arm at the level of their
armpit, their waist at the level of their belly but-
ton and their thigh at the level of their crotch.
The initial string is presented on a table in no
specific manner (Fig. 1, step 1) with the instruc-
tion to form a circle that represents the per-
ceived circumference of the above named body
parts. Participants were asked to form a closed
circle with one end of the string connecting to
the rest of the string (Fig. 1, step 2) to represent
the perceived circumference. Using the string
first in order to avoid a falsification effect due to
the string own thickness, and a tape-measure
subsequently, the actual circumferences were
determined (Fig. 1, steps 3 and 4). The raw data
were then converted into three Body Image
Distortion Indices (BID-I) for upper arm, waist
and thigh, each calculated as follows:
circumference
perceived
BID-I
arm/waist/thigh
= ____________________ 100.
circumference
actual
Ultimately, a mean BID-I (BID-I
mean
) was calcu-
lated:
BID-I
arm
+BID-I
waist
+BID-I
thigh
BID-I
mean
= ______________________________ .
3
- EDI-2. This instrument (German version: 15) is
a self-report questionnaire, which assesses
attitudinal and behavioral aspects of eating
disorders. For our study, we only included the
two most relevant subscales for the assess-
ment of body image distortion into our analy-
Mean (SD)
AN patients Female athletes Control participants
N=75 N=50 N=268
Age (years) 15.6 (1.7) 14.8 (2.1) 15.1 (2.1)
Body height (m) 1.64 (.1) 1.61 (1.0) 1.66 (.1)
Body weight (kg) 42.1 (5.6) 48.0 (9.4) 57.1 (11.3)
BMI (kg/m
2
) 15.6 (1.5) 18.3 (2.1) 20.7 (3.5)
EDI-DT (raw data) 29.8 (10.0) 19.8 (8.1) 20.2 (9.3)
EDI-BD (raw data) 38.7 (12.3) 27.9 (10.7) 32.5 (12.7)
BID-I
arm
128.6 (29.5) 118.2 (17.4) 117.2 (22.0)
BID-I
waist
132.8 (19.6) 126.0 (16.8) 117.5 (17.7)
BID-I
thigh
129.3 (22.2) 115.3 (16.2) 108.9 (16.0)
BID-I
mean
130.2 (20.3) 119.8 (12.3) 114.5 (13.7)
SD: standard deviation; AN: anorexia nervosa; BMI: body mass index; EDI: Eating
Disorder Inventory; DT: Drive for Thinness; BD: Body Dissatisfaction; BID-I: Body
Image Distortion Index.
FIGURE 1
Procedure of the Test for Body Image Distortion in Children and Adolescents (BID-CA)
exemplified by the estimation of the thigh circumference.
sis: Drive for Thinness (DT) and Body Dissat-
isfaction (BD). These scales tap into attitudes
and behaviors concerning eating, weight and
body shape. Norm values exist for children
and adolescents between 10 and 20 years of
age and the subscales DT (Cronbachs =0.92
for female eating disordered patients, =0.86
for healthy female participants) and BD
(Cronbachs =0.94 for female eating disor-
dered sample, =0.93 for female non-patient
sample) show good internal consistency.
Statistical methods
Analysis of variance (ANOVA) was conduct-
ed for each variable of the BID-CA (BID-I
arm
,
BID-I
waist
, BID-I
thigh
) to determine group differ-
ences in the estimation of body parts. Pairwise
group comparisons were realized subsequently
by t-tests. Test-retest reliability regarding the
one-week follow-up was determined by intra-
class correlation (ICC) coefficients.
Diagnostic validity of the BID-CA was ana-
lyzed by receiver operating characteristic (ROC)
curves, and the area under these curves (AUC)
including standard errors (SE). The ROC curves
were generated by using each value measured
in our sample as a potential cut-off. Concrete
examples of cut-off points are presented for
specificities of BID-I
arm/waist/thigh
at 70, 80 and
90%. For further explanation on the method see
the paragraph on ROC analyses below. The
combined diagnostic validity (i.e. the combina-
tion of several quantitative measurements in one
score) was assessed by calculating diagnostic
scores using multiple logistic regression analy-
sis. Variable selection and the leaving-one-out
method were applied. In this analysis the true
status of a person is the dependent variable. The
probability for disease p depending on the value
BID-I
arm/waist/thigh
(BID) is given by
p
In
_____
=
0
+
1
BID.
( 1-p )
The level of significance was 0.05 (two-sided)
for all statistical tests. A power analysis had
been conducted beforehand. The following
effect sizes (difference of means in both groups
divided by the pooled standard deviation) could
be detected with a power of 0.80: control par-
ticipants versus AN patients: 0.37, female ath-
letes versus AN patients: 0.52, control partici-
pants versus female athletes: 0.44. Commercial-
ly available software (SPSS for Windows,
release 12.0.1; nquery, release 6.0) was used.
ROC analysis
For diagnostic tests measured on continuous
or ordinal scales, cut-off values, which separate
pathological from normal results, have to be
defined. Determination of the sensitivity (the
fraction of subjects with pathological values
among diseased subjects = hit rate) and the
specificity (the fraction of subjects with normal
values among undiseased subjects) of the test
are dependent on these cut-off values. However,
if a diagnostic test is still in the phase of scientif-
ic evaluation, it is valuable to compare the per-
formance of the test using several cut-off values.
Each cut-off determines a pair of sensitivity and
specificity. ROC analysis provides a graphical
display of all possible pairs with 1-specificity
(fraction of subjects with pathological values
among undiseased subjects = false alarm rate)
on the x-axis and sensitivity on the y-axis. Thus
the optimal combination (sensitivity = specificity
= 1 = 100%) corresponds to the upper left corner
of the display with x=0. The closer the curve
approaches this point, the better the test. The
AUC quantifies how well the test behaves. For a
perfect test this area is 100%, for a test without
any diagnostic value it is 50%. The comparison
of several diagnostic tests may be seen by show-
ing several ROC curves in one display.
If a diagnostic test consists of several sub-
tests, the results of these subtests are usually
added up to obtain a total score. If the subtests
have different diagnostic value or if they are
measured on non-comparable scales the score
can be improved by weighing the subscales dif-
ferently. Logistic regression analysis is a statis-
tical tool, which provides weights for the sub-
scales. ROC analysis can be applied to the sub-
tests as well as to the total score.
RESULTS
Normal range, frequency of
overestimation and group differences
BID-CA group means (Table 1) indicate the
following overestimation scores: arm = 17.2%
(control group), 18.2% (athletes), 28.6% (AN);
waist = 17.5% (control group), 26.0% (athletes),
32.8% (AN); thigh = 8.9% (control group),
18.2% (athletes), 28.6% (AN). According to our
population-based control group the normal
range (mean1 SD) for body image distortion
lies between BID-I
arm
=95.2 and 139.2, BID-I
waist
= 99.8 and 135.2, BID-I
thigh
=92.9 and 124.9,
which constitutes the systematic deviation.
According to results of the ANOVA, the three
groups differed significantly for each BID-CA
variable (p<0.001). Differences between control
participants and AN patients were significant
for each of the three variables (BID-I
arm
: T=3.1,
df=98, p=0. 002; BID-I
waist
: T=6. 6, df=341,
p<0.001; BID-I
thigh
: T=8.9, df=341, p<0.001).
TABLE 2
General cut-off points, sensitivities and specificities for the Body Image
Distortion Indices (BID-I).
Athletes and AN patients differed significantly
in all three BID-CA variables as well (BID-I
arm
:
T=2.2, df=123, p=0.026; BID-I
waist
: T=2.0, df=123,
p=0.048; BID-I
thigh
: T=3.8, df=123, p<0.001). Dif-
ferences between athletes and control partici-
pants were significant for BID-I
thigh
(T=-2.6,
df=316, p=0.010) and BID-I
waist
(T=-3.2, df=315,
p=0.002), but not for BID-I
arm
(T=-0.3, df=316,
p=0.761).
Reliability BID-CA
Test-retest reliability of the BID-CA was calcu-
lated using ICC. At this point of the study, these
data can only be provided for the AN group
(N=18). ICC were determined by correlations
between baseline scores and scores of one week
later: ICC
arm
=0.81; ICC
thigh
=0.74; ICC
waist
=0.62.
ROC analysis for the BID-CA
and logistic regression
To assess the quality of the discriminatory
power of the BID-CA between AN patients and
control participants, ROC curves for BID-I
arm
,
BID-I
waist
and BID-I
thigh
were used (Fig. 2). The
AUC were as following: AUC
arm
=0.63 [95% con-
fidence interval (CI)=(0.55-0.70)]; AUC
waist
=0.73
[CI=(0.66-0.79)]; AUC
thigh
=0.79 [CI=(0.73-0.84)].
The BID-CA variables were then entered into a
stepwise logistic regression analysis (forward
selection). In the first step BID-I
thigh
was selected
(=-0.06; SE=0.01; p<0.001). In the second step
BID-I
waist
was added (=-0.02; SE =0.01; p=0.013).
ROC curves were also used to assess the qual-
ity of the discriminatory power between AN
patients and female athletes (Fig. 2): AUC
arm
=0.61 [CI=(0.51-0.71)]; AUC
waist
=0.61 [CI=(0.51-
0.71)]; AUC
thigh
=0.71 [CI=(0.61-0.80)]. A stepwise
logistic regression again revealed BID-I
thigh
as
the best variable predicting body image distor-
tion (=-0.04; SE=0.01; p<0.001).
Cut-off points, sensitivities and specificities
for the BID-I are shown in Table 2.
FIGURE 2
Receiver operating characteristic (ROC) curves for Test for Body Image
Distortion in Children and Adolescents (BID-CA). A) Anorexia nervosa
(AN) patients vs. control participants (AUC
arm
: 0.63; AUC
waist
: 0.73;
AUC
thigh
: 0.79). B) AN patients vs. female athletes (AUC
arm
: 0.61;
AUC
waist
: 0.61; AUC
thigh
: 0.71). AUC: area under the curve; BID-I: Body
Image Distortion Indices.
1.0
0.8
0.6
0.4
0.2
0.0
S
e
n
s
i
t
i
v
i
t
y
0.0 0.2 0.4 0.6 0.8 1.0
1 - Specificity
BID-I
arm
BID-I
thigh
BID-I
waist
ROC curve
1.0
0.8
0.6
0.4
0.2
0.0
S
e
n
s
i
t
i
v
i
t
y
0.0 0.2 0.4 0.6 0.8 1.0
1 - Specificity
BID-I
arm
BID-I
thigh
BID-I
waist
ROC curve
A
B
BID-I Specificity (%) Sensitivity (%) Cut-off point
AN patients vs. Arm 70 51 124.6
control participants 80 45 129.6
90 16 144.5
Thigh 70 69 118.3
80 59 123.5
90 44 132.0
Waist 70 59 127.0
80 53 132.9
90 31 141.2
AN patients vs. Arm 70 45 128.5
female athletes 80 44 131.5
90 23 140.5
Thigh 70 63 122.5
80 51 126.0
90 44 132.0
Waist 70 53 132.0
80 37 136.5
90 21 147.0
AN: anorexia nervosa.
1.0
0.8
0.6
0.4
0.2
0.0
S
e
n
s
i
t
i
v
i
t
y
0.0 0.2 0.4 0.6 0.8 1.0
1 - Specificity
BID-I
thigh
and
BID-I
waist
DT and BD
BID-I
thigh
BID-I
waist
DT and BD
ROC curve
1.0
0.8
0.6
0.4
0.2
0.0
S
e
n
s
i
t
i
v
i
t
y
0.0 0.2 0.4 0.6 0.8 1.0
1 - Specificity
ROC curve
BID-I
thigh
and
BID-I
waist
DT and BD
BID-I
thigh
BID-I
waist
DT and BD
A
B
ROC analyses for the EDI-2 scales
Drive for Thinness and Body
Dissatisfaction and logistic regression
As a means of comparison, we also used
ROC curves to assess the discriminatory power
of the EDI-2 scales DT and BD between AN
patients and control participants [AUC
DT
=0.75
with CI=(0.70-0.82); AUC
BD
=0.63 with CI=(0.56-
0.70)] and between AN patients and female ath-
letes [AUC
DT
=0.78 with CI=(0.70-0. 86);
AUC
BD
=0.73 with CI=(0.64-0.82)].
Afterwards, a stepwise logistic regression
(forward selection) was conducted, which
yielded DT for both AN patients versus control
participants (=-0.10; SE=0.02; p<0.001) as well
as AN patients versus female athletes (=-0.11;
SE=0.02; p<0.001) as the best predictor for
body image distortion. For AN patients versus
control participants BD was added in the sec-
ond step (=0.65; SE=0.02; p=0.001).
Multivariate analysis for BID-CA
variables and DT/BD combined
Diagnostic validity was furthermore tested
for the BID-CA variables (BID-I
arm
, BID-I
thigh
and BID-I
waist
) and the EDI-2 scales DT and BD
combined. As the variable BID-I
arm
did not pro-
vide any information, it was removed from
multivariate analyses. The remaining variables
were included into the model regardless of
their significance. ROC anal yses (Fig. 3)
revealed an AUC=0.84 [CI=(0.79-0.89)] for AN
patients versus control participants and an
AUC=0.75 [CI=(0.66-0.84)] for AN patients ver-
sus female athletes.
A stepwise logistic regression (forward selec-
tion) yielded thigh (=-0.06; SE=0.01; p<0.001)
in a first step, DT (=-0.08; SE=0.02; p<0.001) in
a second step and BD (=0.08; SE=0.02;
p<0.001) in a third step as the best predictors
for body image distortion in AN patients versus
control participants. For AN patients versus
female athletes DT (first step; =-0.11; SE=0.02;
p<0.001) and thigh (second step; =-0.10;
SE=0.02; p<0.001) were the best predictors.
Pre-/post-tests for AN patients before and
after psychotherapy
To see if in-patient psychotherapy, which
includes body-oriented therapy, affects the
results of the BID-CA, we conducted t-tests for
paired samples on 28 AN inpatients (for the rest
of the AN patients no post-test data was avail-
able). The data were assessed before in-patient
psychotherapy (t
0
; two days after admission to
our clinic) and after in-patient psychotherapy
(t
1
). Significant changes were found for BID-I
arm
(p=0.001), BID-I
waist
(p=0.001) and BID-I
thigh
(p<0.001). This is not to exclude the possibility
that patients without therapy would have shown
a comparable change over time.
DISCUSSION
The purpose of our study is to develop an
efficient and valid instrument for body image
distortion which is appropriate for children
and adolescents and can easily be applied in a
FIGURE 3
Multivariate analysis: receiver operating characteristic (ROC) curves for
Test for Body Image Distortion in Children and Adolescents (BID-CA) and
Eating Disorder Inventory-2 (EDI-2) subscales [Drive for Thinness (DT)
and Body Dissatisfaction (BD)]. A) Anorexia nervosa (AN) patients
vs. control participants. B) AN patients vs. female athletes.
clinical setting, the BID-CA. In the present
study, we think that two comparisons are use-
ful: 1) AN patients versus population-based
control participants as a proof of concept, and
2) AN patients versus female athletes that are
thinner than the population-based control sam-
ple due to their sporting activity. The latter
comparison may be of more interest for clinical
application. Our results show significant differ-
ences between all groups in estimating the size
of their body parts with the athletes having an
intermediate position between AN patients and
control participants. We, furthermore, found
good test-retest reliability and good discrimi-
natory qualities of the BID-CA between AN
patients and control participants.
The BID-CA variable best predicting body
image distortion was thigh, underlining that
the self-evaluation of the circumference of the
thigh is essential for AN patients. It discrimi-
nated more effectively between AN patients
and both groups of control participants than
the circumference of the waist. Rosen and
Ramirez (16) support these results. They found
more appearance concerns for thighs/legs
(62.2%) in 45 eating disorder patients than for
stomach/waist (44.4%). Examining healthy
undergraduate students (18-24 years old)
Thompson et al. (17, p. 510) showed a more
pronounced overestimation of the thigh com-
pared to the waist i f the students were
instructed to estimate their body size on an
emotional level (referring to inner feeling
regardless of the facts). For the female athletes
participating in our study, however, a compar-
ison to control participants revealed that the
waist plays the most important role. This vari-
able discriminated best between these two
groups. Using the AUC as an effect size indica-
tor for the group differences in body size esti-
mation, our results show a less strong effect
for the AN patients versus athletes comparison
than for the AN patients vs. control partici-
pants comparison.
In general, we found an overestimation of
body parts in all examined groups. Our results
for AN patients and control participants as
well as for female athletes are in line with pre-
vious studies (8, 11). The general overestima-
tion of body size in healthy female adolescents
that we found indicates a variance due to sys-
tematic deviation and is congruent with find-
ings by Thompson et al. (17), who reported
the same for young female adults. Incorrect
body image was moreover found in both nor-
mal weight and overweight children and ado-
lescents (N=255, 6-18 years old) by Ohtaharaet
al. (18).
Our results suggest no specificity of body
image distortion for AN. Body image distortion
exists in all groups with different levels of
occurrence, yet AN patients display the highest
level of overestimation. The BID-CA is able to
discriminate moderately between AN patients
and young active female athletes who may
share physical characteristics such as low body
weight. This effect is comparable to the result
achieved by using the EDI-2 scales DT and BD.
However, these scal es are not explicitly
designed for the assessment of body image dis-
tortion. Our data suggest an effective combina-
tion of the BID-CA and the two EDI-2 subscales
DT and BD for detecting a body image distor-
tion. Therefore, both instruments appear to
complement one another, which could be help-
ful if a more complex and detailed diagnostic
investigation is required.
First and foremost in a diagnostic phase it is
helpful to support a clinical impression with a
time-saving diagnostic instrument. Consider-
ing our research we believe the BID-CA to pro-
vide a good body image distortion measure.
Moreover, we see an absolute advantage espe-
cially for children and adolescents due to easy
instructions and good comprehension rates. In
contrast to a questionnaire (e.g. EDI-2), the
BID-CA is language independent, which may
be of advantage.
Despite the contributions of this initial study
to the assessment and understanding of body
image distortion in adolescent AN patients,
there are some limitations. Because we vali-
dated the BID-CA with a young female sample
of adolescents, our results cannot be general-
ized to males, to children younger than 11
years, to adults older than 20 years, or to
other clinical populations. It is furthermore
important to mention that eating disorders
cannot fully be excluded, as participants were
only screened using the EDI-2. Thus, we have
to acknowledge the possibility that AN patient
group i ndi vi dual s and i ndi vi dual s of the
female athlete sample and/or individuals of the
control group sample may share overlapping
characteristics with regard to eating disor-
ders. For future research, a structured diag-
nostic interview would be desirable for all
groups. The assignment of other instruments
assessing body image distortion in terms of
body-part- and whole-body-techniques would
be necessary to determine convergent validity
of the BID-CA. Moreover, we have to state
that the AUC values found in our study can
only be considered moderate (0.63-0.79 for AN
versus control participants; 0.61-0.71 for AN
versus athletes). A further limitation of our
study is the lack of external criteria to test for
general deficits in estimating circumferences.
Such general deficits most likely interact with
the estimation of ones own body parts; there-
fore, we recently added external criteria to the
BID-CA. To date we do not have enough data
on these external criteria to be reported here.
In a larger sample of eating disorder patients,
bulimia nervosa patients should be included
and separate analyses for subtypes of AN
(restrictive type, binge purging type) should
be conducted. Furthermore, a differentiation
of inpatients and outpatients could be quite
informative. Our study is ongoing and aims to
standardize the BID-CA for children and ado-
lescents suffering from AN.
To conclude, the BID-CA is a diagnostic
instrument for the assessment of body image
distortion. This study shows the diagnostic
validity of the BID-CA. The thigh and waist
measures of the BID-CA discriminate well
between the AN patients and the control par-
ticipants. The test showed good sensitivity
and specificity. Moreover, it is a simple and
time efficient instrument that is language
i ndependent. The BID-CA appears to be
appropriate for diagnosing body image dis-
tortion. We see an absolute advantage in the
BID-CA, especially for children and adoles-
cents.
APPENDIX 1
REFERENCES
tistical manual of mental disorders (4
th
ed.).
Washington, DC, APA, 1994.
2. Vocks S., Legenbauer T., Rddel H., Troje N.F.: Static
and dynamic body image in bulimia nervosa: mental
representation of body dimensions and biological
motion patterns. Int. J. Eat. Disord., 39, 1-8, 2006.
3. Smeets M.A.M., Kosslyn S.M.: Hemispheric differ-
ences in body image in anorexia nervosa. Int. J. Eat.
Disord., 29, 409-416, 2001.
4. Seeger G., Braus D.F., Ruf M., Goldberger U., Schmidt
M.H.: Body image distortion reveals amygdala activa-
tion in patients with anorexia nervosa a functional
magnetic resonance imaging study. Neurosci. Lett.,
326, 25-28, 2002.
5. Gardner R.M., Bokenkamp E.D.: The role of sensory
and nonsensory factors in body size estimations of
eating disorder subjects. J. Clin. Psychol., 52, 3-15,
1996.
6. Fernndez-Aranda F., Dahme B., Meermann R.: Body
image in eating disorders and analysis of its relevance:
a preliminary study. J. Psychosom. Res., 47, 419-428,
1999.
7. Sorbara M., Geliebter A.: Body image disturbance in
obese outpatients before and after weight loss in rela-
tion to race, gender, binge eating, and age of onset of
obesity. Int. J. Eat. Disord., 31, 416-423, 2002.
8. Meermann R.: Experimental investigation of distur-
bance in body image estimation in anorexia nervosa
patients, and ballet and gymnastics pupils. Int. J. Eat.
Disord., 2, 91-100, 1983.
9. Probst M., Braet C., Vandereycken W., De Vos P., Van
Coppenolle H., Verhofstadt-Deneve L.: Body size esti-
mation in obese children: a controlled study with the
video distortion method. Int. J. Obes. Relat. Metab.
Disord., 19, 820-824, 1995.
10. Slade P.D., Russell G.F.M.: Awareness of body dimen-
sions in anorexia nervosa: cross-sectional and longitu-
dinal studies. Psychol. Med., 3, 188-199, 1973.
11. Shafran R., Fairburn C.G.: A new ecologically valid
method to assess body size estimation and body size
dissatisfaction. Int. J. Eat. Disord., 32, 458-465, 2002.
12. Brunner R., Resch F.: Ess-Strungen ein
zunehmendes Problem bei Kindern und Jugendlichen?
Therapeutische Umschau, 63, 545-549, 2006.
13. Herzog W., Friederich H.C., Wild B., Lwe B., Zipfel
S.: Magersucht. Ther. Umsch., 63, 539-543, 2006.
14. Fichter M., Quadflieg N.: Strukturiertes Inventar fr
Anorektische und Bulimische Essstrungen nach
DSM-IV und ICD-10. Gttingen, Hogrefe, 1999.
15. Rathner G., Waldherr K.: Eating Disorder Inventory-2:
Eine deutschsprachige Validierung mit Normen fr
weibliche und mnnliche Jugendliche. Z. Klin. Psychol.
Psychiatr. Psychother., 45, 157-182, 1997.
16. Rosen J.C., Ramirez E.: A comparison of eating disor-
ders and body dysmorphic disorder on body image
and psychological adjustment. J. Psychosom. Res., 44,
441-449, 1998.
17. Thompson K.J., Dolce J.J., Spana R.E., Register A.:
Emotionally versus intellectually based estimates of
body size. Int. J. Eat. Disord., 6, 507-513, 1987.
18. Ohtahara H., Ohzeki T., Hanaki K., Motozumi H.
Shiraki K.: Abnormal perception of body weight is not
solely observed in pubertal girls: incorrect body image
in children and its relationship to body weight. Acta
Psychiatr. Scand., 87, 218-222, 1992.
19. Skrzypek S., Wehmeier P.M., Remschmidt H.: Body
image assessment using body size estimation in recent
studies on anorexia nervosa. A brief review. Eur. Child
Adolesc. Psychiatry, 10, 215-221, 1992.
e137
CASE
REPORT
Key words:
Topiramate, taste, smell,
sensory, epilepsy.
Correspondence to:
A. Ghanizadeh,
Department of Psychiatry,
Research Center
for Psychiatry and
Behavioural Sciences,
Hafez Hospital, Shiraz, Iran.
E-mail:
ghanizad@sina.tums.ac.ir
Loss of taste and smell during
treatment with topiramate
INTRODUCTION
Topiramate (TPM) is a sulfamate-substi-
tuted monosaccharide. As in adults, TPM
plasma concentration in children is linear
and proportionally increased with dose and
unaffected by food. Its plasma clearance is
about 50% higher in children in compari-
son with adults. Therefore, children gener-
ally need higher mg/kg dosage than adults
to achieve the same TPM plasma concentra-
tions. TPM has a dual route of elimination.
Its renal clearance predominates in the
absence of enzyme induction (1).
TPM modifies several receptor-gated and
voltage-sensitive ion channels, including
voltage-activated Na
+
and Ca
2+
channels
and non-N-methyl D-aspartate (NMDA),
involved in the pathophysiology of epilepsy
and migraine. The drug interacts with both
glutamate receptors and -aminobutyric
acid-A (GABA-A) receptors, inhibiting
some different glutamate-receptor subtypes
[-amino-3-hydroxy-5-methyl-4-isoxazole
propionic acid (AMPA)/kainate receptors]
and increasing the frequency of single
GABA-A receptors channel opening medi-
ated chloride currents (2).
TPM facilitates GABA function through a
non-benzodiazepine site on the GABA-A
receptor. So, it decreases extracellular
release of dopamine in the midbrain, and
antagonizes glutamate activity (3).
TPM suppresses the appetite and causes
weight loss (4, 5). TPM was suggested for
treatment of olfactory hallucinations (6),
visual hallucination (7) and treatment of
glossodynia (8).
This is a report of one patient who had
lost his ability to detect taste and odor dur-
ing treatment with TPM and regained these
senses after discontinuation of TPM.
CASE REPORT
The patient is a three and half-year-old
boy with idiopathic generalized tonic clonic
epilepsy. TPM was administered and titrat-
ed up to 25 mg/day. His mother reported
that he refused to take the tablet. He took
the tablet without any resistance after about
5 days from the first administration day. He
took it for about 6 months and the dosage
was titrated up to 125 mg/day. His mother
reported that he could not feel taste of
foods because he did not reject unfavorable
taste of foods which he had refused before
administration of TPM.
In addition, according to his mothers
report, he had enjoyed the smell of flowers
before administration of TPM but after some
days (about 1 to 2 weeks) he did not enjoy
that smell anymore and never complained
about any unfavorable smell he had disliked
before prescription of the medication. His
physician decided to taper it because the
seizure attacks were not improved complete-
ly. So, TPM was discontinued after about 3
weeks. Then, he reported that he was able to
express taste of foods about 4 to 6 days after
discontinuation of TPM. In addition, his
mother said that his child complained about
an intolerable smell coming in from outside.
It was the first complaint of unfavorable
smell during the last 7 months. He was also
able to enjoy the smell of flowers some days
after discontinuation of TPM. Tolerability
A. Ghanizadeh
1,2
1
Research Center for Psychiatry and Behavioral Sciences, Shiraz University of Medical Sciences, Hafez Hos-
pital, Shiraz, Iran,
2
The Academic Child Psychiatry Unit, Department of Paediatrics, Royal Childrens Hospital,
The University of Melbourne, Melbourne, Australia
ABSTRACT. Topiramate has already been suggested for treatment of olfactory halluciana-
tion. This is a report of a three and a half-year-old boy with idiopathic generalized tonic
colonic epilepsy. He had lost his ability to detect and recognize taste and odor during treat-
ment with topiramate. Those abilities improved after discontinuation of topiramate.

EWD_09_e05_Ghanizadeh*.qxp:EWD_e 4-11-2009 10:15 Pagina 138
A. Ghanizadeh
was very good. Besides the complaints, no
adverse drug reactions such as lacrimation,
headache, nausea, photophobia, insomnia, eye-
lid edema, conjunctival and nasal congestion
were observed.
No pathological finding was found in physi-
cal examination. Blood pressure was normal.
Neurological examination was unremarkable
and prior diagnostic work-up included a brain
computed tomography scan, brain magnetic
resonance imaging, renal and liver function
tests, and electroencephalogram was normal.
Blood and urine laboratory examinations were
normal. No concomitant psychiatric disorder
was found. Oral consent was given for publica-
tion of this report.
DISCUSSION
To the Authors knowledge, this is the first
report of possible loss of ability to detect and rec-
ognize taste and smell during treatment with
TPM in children. The temporal sequence of the
disability and medication administration, cessa-
tion of anosemia and inability to detect and rec-
ognize taste after discontinuation of TPM, lack of
other medication, and lack of any known medical
cause are suggestive of a possible causal effect of
TPM. Of course, it is a single cross sectional-case
study and it is impossible to definitely link TPM
with the impairment in this report. Moreover,
this report is based on the mothers report of the
child. Therefore, the reliability and validity of the
evaluation of the perception of taste and smell
senses might be a concern. In addition, the
patient also suffered from epilepsy. However, the
Author conducted deep interviews with the
mother in three separate sessions and concluded
that this report has enough reliability and validi-
ty. The pathophysiology of possible TPM-
induced impairment is unclear. Clinicians should
be aware of this possible side-effect and it should
be discussed with parents and children before
taking TPM because it might be disturbing.
Further researches are necessary to determine
if there is any possible association. This concern
about safety emphasizes the need for further
controlled trial evidence in longer-term studies.
REFERENCES
1. Wu W.N., Heebner J.B., Streeter A.J., Moyer M.D.,
Takacs A.R., Doose R.D. Ferraiolo B.L.: Evaluation of
the absorption, excretion, pharmacokinetics and
metabolism of the anticonvulsant, topiramate in
healthy men. Pharm. Res., 11, Suppl., S336, 1994.
2. Faught E., Wilder B.J., Ramsay R.E., Reife R.A.,
Kramer L.D., Pledger G.W.: Topiramate placebocon-
trolled dose-ranging trial in refractory partial epilepsy
using 200-, 400-, and 600-mg daily dosages.
Topiramate YD Study Group. Neurology, 46, 1684-
1690, 1996.
3. Langtry H.D., Gillis J.C., Davis R.: Topiramate a
review of its pharmacodynamic and pharmacokinetic
properties and clinical efficacy in the management of
epilepsy. Drugs, 54, 752-972, 1997.
4. Van Ameringen M., Mancini C., Pipe B., Campbell M.,
Oakman J.: Topiramate treatment for SSRI-induced
weight gain in anxiety disorders. J. Clin. Psychiatry,
63, 981-984, 2002.
5. Dursun S.M., Devarajan S.: Clozapine weight gain,
plus topiramate weight loss [letter]. Can. J. Psychiatry,
45, 198, 2000.
6. Johnson J., Bourgeois J.A., Quanbeck C.: Treatment of
olfactory hallucinations with topiramate. J. Clin.
Psychopharmacol., 26, 340-341, 2006.
7. Anghelescu I., Klawe C., Himmerich H., Szegedi A.:
Topiramate in venlafaxine-induced visual hallucinations
in an obese patient with a posterior cerebral artery
infarction. J. Clin. Psychopharmacol., 21, 462-464, 2001.
8. Siniscalchi A., Gallelli L., Marigliano N.M., Orlando P.,
De Sarro G.: Use of topiramate for glossodynia. Pain
Med., 8, 531-534, 2007.
EWD_09_e05_Ghanizadeh*.qxp:EWD_e 4-11-2009 10:15 Pagina 139
e139
CASE
REPORT
Key words:
Eating disorders, anorexia
nervosa, psychosis,
teratment, case report.
Correspondence to:
Sonia Sarr,
Psychiatrist, MD, Universitat
Central de Barcelona,
Day Hospital,
Eating Disorders Department,
ABB Eating Disorders Centre,
Barcelona.
E-mail: 31554ssa@comb.cat
Transient psychosis in anorexia
nervosa: Review and case report
PSYCHOSES IN EATING
DISORDERS: REVIEW
AND UPDATE
Eating disorders are a common mental
health problem in Western culture influ-
enced countries, with long-term treatment
requirements, a risk to chronicity, and
therefore both disabling consequences for
the patient and high economic charges for
the mental health system (1). Usually
unveiled in early adolescence, it is not
uncommon to see patients maintaining the
disorder when reaching adult age and even
after motherhood, with the subsequent risk
for the child. The original diagnosis may
change upon time, restrictive-type cases
evolving to purging or binge-eating ones,
and alternating distorted eating patterns
from time to time. Personality disorders
abound in these patients as well as among
their relatives (2), although in pubertal and
adolescent ages it is more accurate to con-
sider previous traits rather than an estab-
lished abnormal personality.
Psychotic episodes are reported in 10-15%
of eating disordered patients (3); most of
them are transient, although 1-3% will
obtain a schizophrenia diagnosis (4-7). In
our two-year series we have found an inci-
dence of 5% (3 transient psychoses - two in
restrictive anorexia plus one in binge-eating
disorder, 1 paranoid schizophrenia and
restrictive anorexia; all women, N=80).
Patients with anorexia nervosa are more
prone to psychotic accesses, especially
restrictive-type ones, which share neurocog-
nitive deficits with schizophrenics: difficul-
ties in shifting attention, overestimation of
detail, and weak central coherence (8). Psy-
chosis in bulimia is rare and mainly limited
to case reports (9). Extreme malnutrition
with low body mass index (BMI), a highly
obsessive state, concurrent affective disor-
ders, electrolytic or hormonal misbalances,
substance abuse and iatrogenic effects have
been proposed as pathological mechanisms
leading to psychosis in eating disorders,
through hyperactivation of the dopaminer-
gic system. Somatic delusions and hallucina-
tions are the most prevalent features, fol-
lowed by paranoid contents. Pharmacologi-
cal treatment comprises neuroleptic agents,
benzodiazepines and antidepressants with
an anti-obsessive spectrum, always carefully
monitored, as low weight and purging
behaviours become specific risk factors for
side-effects in this population. In severe mal-
nutrition tricyclics are better avoided, sertra-
line being a safer option. Neuroleptics must
be administered at the minimal effective
dosage; atypical agents with a sedative and
orexigen effect like olanzapine or quetiapine
can be a good choice (10-12).
S. Sarr
Day Hospital, Eating Disorders Department, ABB Eating Disorders Centre, Barcelona, Spain
ABSTRACT. Psychotic symptoms are a key feature in eating disorders. Restrictive-type
anorectics are more prone to suffer them, coherent with recent neurocognitive findings
reporting attentional and processing deficits in restrictive anorexia partially common to
schizophrenia. Psychotic crises urge psychiatrists to make an accurate differential diagnosis
with endogenous psychoses and carefully judge treatment options. If attentively attended,
such crises can give us clues to understand the patients functioning and consider new strate-
gies. We report two transient psychotic episodes in restrictive-type anorectic female patients,
one with a previous experience. Onset of psychotic symptoms was related to severe malnu-
trition only in one of them (body mass index <15). We discuss risk factors, clinical presenta-
tion and treatment, focusing on the emotional disturbances maintained after recovery. Caus-
es for psychotic features in these patients are reviewed and treatment individually tailored.
An integrative understanding of eating disorders as a unique meeting point between psy-
chosis and neurosis is encouraged.

Psychosis in anorexia nervosa
Written informed consent was obtained from
both patients for publication of these case
reports. A copy of the written consents is avail-
able for review. Names have been altered in
order to preserve confidentiality.
CASE REPORT 1
Paula, 23 years old, is the youngest and only
girl of four brothers. She underwent early
nefrectomy and tonsil removal. Her grand-
mother has a bipolar disorder. Her mother had
always a strong drive to healthy meals, avoid-
ing sweets, pastry and fried foods. As a child
Paula had frequent night fears and separation
anxiety, occasional unreality feelings and suici-
dal thoughts, starting psychiatric and psycho-
logical treatment she has maintained ever
since. She was an insecure child, deeply
attached to her mother and vice versa , hav-
ing difficulties to manage stressful events, and
highly pessimistic from adolescence on. At
school she always obtained good records, and
even improved at college. At 15 with healthy
weight she started to complain about her looks,
went on a diet and became amenorrheic; after
medical advice she slightly increased food
income, but soon restricted again, even liquid
income. For a brief period she smoked
cannabis and drank, not heavily. At 21, feeling
increasingly frustrated, she took a paroxetine
overdose. At 22 she had again amenorrhea,
spent the day studying, complained of attention
problems, neglected friends and became
increasingly nervous, sad, bad-tempered and
agitated when tried to be pushed to eat by her
worried family. She underwent aesthetic
abdominal surgery but still complained of
being too fat, intensely avoided eating, exer-
cised and briefly vomited.
When she entered our day hospital BMI was
14.75 kg/m
2
, she was severely constipated, low
heart-rated, hypothermic, had global osteope-
nia and tooth enamel loose, blood analyses
revealing high androgenic levels and low folli-
cle-stimulating hormone (FSH). She was on
reboxetine 60 mg plus lorazepam 1 mg daily.
She felt extremely nervous and overactive, had
frequent panic attacks, was obsessed with food,
body and weight gain fear and had severe self-
image distortion, considering herself clearly
overweighed. She suffered insomnia and body
disintegration nightmares. Her conscience was
occasionally blurred. She complained of hear-
ing voices impelling her not to eat, not to give
in, mocking of her for being fat and repulsive.
Sometimes she believed her parents would
attack her, though judging it unlikely in the end
she feared of becoming mad and felt in a big
despair. She tried to injury herself in several
occasions as punishment for eating and often
had to be stopped, becoming frequently agitat-
ed; once she took an overdose. All this hap-
pened especially around mealtimes, when fear
to loose control or being defeated became
unbearable. She had cenaesthesical hallucina-
tions concerning food altering her body, run-
ning through it and feeling her stomach rip-
ping, which only sometimes and partially criti-
cised. Her speech was reiterative, focused on
food, weight and meals, being hard to distract
her from looking and checking her body. Mil-
lon test rated over 70 in dependent (107), com-
pulsive (98) and schizoid (72) items.
Treatment was urgently started, carefully
increasing dosages up to 15 mg olanzapine, 200
mg sertraline (low heart rate proscribed tri-
cyclics) and 15 mg lorazepam daily. With
strong environmental control and daily psy-
chotherapy, Paula slowly improved and psy-
chotic features remitted, even if for some
weeks she occasionally heard voices when con-
fronting stressful events. Individual, group and
family therapy were at first stage addressed at
awareness of illness and controlling eating
behaviour, later on recognising and managing
distorted beliefs and underlying personal diffi-
culties, and family attitudes towards the patient
and food. She progressively restored social
relations and restarted college, maintaining
high self-exigency and low self-esteem, difficul-
ties to cope with stress and poor interpersonal
implication, though managing the day trough.
Eighteen months after internment she decided
to leave treatment to concentrate in college and
continue with her former therapist. BMI had
remained stable at 20-21 kg/m
2
.
CASE REPORT 2
Angela, 22 years old, entered day hospital
from ambulatory treatment due to a one-month
progressive weight loss with added psychotic
symptoms. At check-in her BMI was 18.96
kg/m
2
and she had one month amenorrhea, was
avoiding food, overactive, and had a strong
drive for thinness. She had recently completed
her middle formative period and remembered
feeling empty and frustrated, with no objec-
tive in life, confused and disappointed. To cope
with these feelings she determined herself to
give more as a daughter and girlfriend and
started restricting food. Gradually she began to
hear a loud, dark and dim masculine voice,
resembling her fathers, commanding her to
stop eating and expressing aggressive contents
S. Sarr
towards her parents, who were pressing on her
to eat. This voice was intermittent, appearing
mainly when she felt divided, half of her for
one thing and the other for the contrary. This
often happened confronting her anxieties at
mealtimes: she knew she had to eat to recover,
yet she felt it as a menace; then the voice grew
and even shouted (eat no more, its far
enough), and she was scared. She regarded it
as a strange voice, different from her own
thinking, although when it became louder she
felt it difficult to distinguish her own voice.
Sometimes she could impose and make it dimin-
ish. She became gradually sad and frightened;
obsessive circular thinking on food and weight
led to ritualised behaviours on personal care
and order; she began to suffer insomnia. She
was taking no pharmacological treatment at the
moment. She was suspicious, mentally over-
activated, highly anxious yet notoriously alex-
ithymic and hypomimic, and had severely dis-
torted self-image perception. No concrete delu-
sions or speech disorders were detected. She
made a self-punitive attribution of her relapse,
with partial awareness of illness: she acknowl-
edged having felt over-self-demanding, and
remembered at first noticing some internal
warnings she finally eluded.
Angela is the younger of two brothers. She is
allergic to penicillin, does not take drugs or
alcohol, no previous illnesses other than a frac-
ture and the eating disorder. She is described
as a shy, introspective, responsible and perse-
verant girl. She tends to rigid, ruminative and
pessimistic style of thinking, having difficulties
in coping with stress and frustrations. Her
father, described as severe and demanding,
suffered an early loss which imprinted him
deeply. Her mother is considered a passive and
dependent wife. Both have always placed high
expectations on Angela.
At 14, when menstruation started, BMI 19.7
kg/m
2
, Angela began to isolate and increase
study hours, progressively avoided food, exer-
cised, lost 15 kg and became amenorrheic for
the next 3 years, densitometry revealing
osteopenia. She was diagnosed anorexia ner-
vosa, restrictive-type. She underwent several
hospitalisations in order to restore weight. At
16 she was referred to a neurologist for sudden
episodes of blurred conscience, fainting, hyper-
ventilation, muscular rigidity, tongue biting
and convulsive movements; epileptic origin
was discarded. She had also frequent panic
attacks by this time. At 19 years, BMI 18.5
kg/m
2
, in day hospital regime yet secretly tak-
ing dieting pills, she once reported hearing
threatening voices compelling her to kill herself
during psychomotor agitation after lowering
ansiolytic dosage; yet, she was more concerned
with weight gain fear than with the voices. She
was re-interned and treated on risperidone 3
mg daily, maprotiline 75 mg daily, sertraline
150 mg daily, oxcarbamazepine 1200 mg daily,
clonazepam 6 mg daily and diazepam 30 mg
daily. A month later, feeling anxious with
paresthesias, voices appeared again and effec-
tively remitted with a single alprazolam dose.
She was discharged to follow external treat-
ment with group and family therapy.
During the next 2 years medication was pro-
gressively lowered, maintaining on sertraline
100 mg daily, diazepam 5 mg daily and
lormetazepam 2 mg daily. At 20 she had a sud-
den anxiety attack with depersonalisation,
derealisation and fear to become mad, which
reversed in a week without further medication.
She stayed well for the next 7 months, and
treatment was finally stopped. Nine months
later she started the present episode.
Her psychological profile at 19 years shows
both psychoneurotic traits, with Millon test
highest rates in phobic (110), schizoid, schizo-
typal, psychotic thinking, compulsive (all 109),
self-destructive (104) and major depression
(103) scales (14 rating over 75).
Clinical course and follow-up
She restarted under intensive individual and
group therapy. Pharmacological treatment was
restored and raised to sertraline 150 mg, olan-
zapine 5 mg and diazepam 15 mg daily. Voices
lowered and discontinued. Parental expecta-
tions continued to focus on Angela, though
therapists repeatedly encouraged the couple
private life and interests. Therapy focused in
expressing negative emotions, recognising
relapse warnings and acting in consequence,
with partial success. During the following
months she maintained weight and clinical sta-
bility (BMI 19-20 kg/m
2
), gradually restarted
previous activities and academic life. Her eating
behaviour and thinking style (symptomatic and
cognitive levels) improved at first, but personal-
ity traits: perfectionism, dichotomist thinking,
over-self-exigency (emotional and inner value
levels) did not change much. A month later she
restricted again, having not abandoned phar-
macological treatment; but this time for a
great novelty she did ask for help. Voices did
not reappear. Medication was increased, hospi-
tal attendance briefly intensified and re-facing
autonomy and college encouraged. Yet back in
campus she once again felt incapable of lower-
ing or adapting her goals, avoided friends,
restricted and even purged, without psychotic
symptoms (BMI 19.6 kg/m
2
). At last she decided
to abandon college and started a simple job,
Psychosis in anorexia nervosa
which she has managed to maintain; being this
a new and self-chosen area, parental schemes
have become somehow useless. Angela under-
stands that a key to her recovery lies in her abil-
ity to accept personal weaknesses, taking
options and risks, and permitting failure and
imperfection that is, changing inner values
; yet it is hard for her to emotionally accept it,
as it opposes family values being for so long her
own; restriction and obsessions appear as con-
trol defences, leading her to dissociation and
hence to psychosis.
At present a more neutral, supporting and
non-directive approach is being tried while she
works on her autonomy. She follows individual
psychiatric therapy, and she has been pro-
posed a cognitive remediation module (CRT).
She maintains on sertraline, olanzapine and
diazepam. Her weight fragile a trend to
restriction persists but menstruation present,
a new Millon rates over 75 only in dysthimic
(82), depressive (77) and compulsive (75) items,
and she is taking some important decisions in
her life, though with no little anxiety. Her two
halves try to converge; the question is if she
will resist the challenge to her former internal-
ized values.
DISCUSSION
Both patients are anorexia nervosa cases,
restrictive-type. Both have negative prognostic
features: rigidity and former obsessive person-
ality traits, extended duration of illness, several
previous treatment options, family resistance,
plus early adaptation problems, affective disor-
der and low BMI in the first case. Both were
turning to purging-type day hospitalisation may
have prevented, a usual fact in the natural evolu-
tion of anorexia (as usual, clinical findings pre-
cede theoretical update, and dynamic diagnostic
criteria are still to be devised). The fact that psy-
chosis is rare in bulimia and relatively common
in anorexia, and that by our present knowledge
only restrictive-type patients seem to share cog-
nitive impairments with schizophrenia (8, 13)
raises the question of how does this psychotic
basis and its suspected neurological substrate
develop in patients starting as pure restrictors
when they evolve to purging, binge and bulimia
or to unspecified disorder. Long-term follow-up
studies with neuropsychological exam are need-
ed to test this point. Fasting per se, proposed to
promote dopaminergic hyperactivity, may acti-
vate psychotic experiences (14), yet this pro-
vides a partial answer, suggesting only one of
various triggers, as shows our second case
report with preserved BMI.
Depersonalisation and derealisation phenom-
ena are often found as pre-dissociative warn-
ing signals ready to evolve to a psychotic dis-
closure in eating-disordered patients. Typical
of psychotic disorders as well as severe neurot-
ic ones (obsessive-compulsive, panic attacks),
in eating disorders these symptoms always
enfold an emotional disturbance, a profound
yet subconscious contradiction between
though and actions. And emotions are sup-
posed to involve a different neuro-anatomical
substrate, in the right hemisphere. Bulimics
can also suffer dissociation sometimes linked
to previous trauma and be intensely obsess-
ed, yet psychosis is rare in them. So rigidity
and introversion seemingly constitute trigger-
ing factors acting as pre-psychotic conditions
in restrictive-type anorexia. In this sense, in
both reported cases onset of psychosis was
preceded by a long period of self-punishment
and self-denial experiences; and in Angela,
with greater previous awareness of illness, it
was also related to contradictory/double mes-
sages. Distinctive rigid, concrete, dichotomous
(all-or-nothing) and ruminative thinking style,
aided by fasting and malnutrition, would make
restrictors more prone to dissociative experi-
ences and so to psychosis. Both girls showed
also a highly obsessive state and self-image
perceptual distortion typical of severely
impaired cases; both had an intense drive to
thinness, and both had become amenorrheic.
Paula had a serious and lasting psychotic
episode with brief but clear paranoid delusions,
verbal and somatic hallucinations. Paranoid
delusional ideas have often been described in
restrictive-type anorexia, linked to low BMI,
usually with minor analytical alterations (5).
Moreover, Paulas mother shows traits of an
orthorexic disorder. In severely underweight
patients like her, mental impairment is to be
expected, although blood analyses be relatively
preserved. Yet this was not the case in Angelas
psychotic onset, with discretely low BMI;
though, she had a widely pathological personal-
ity profile, potential hysterical and conversive
elements in her past crises, and panic attacks
which further add to depersonalisation, dissoci-
ation and psychosis risk. Both girls are severely
alexithymic, a key trait supporting dissociation
(15). At short-term follow-up after discharge
Paulas weight had slightly decreased (600 mg),
psychosis not reappearing. But she had not
deeply changed, retaining her former image-
focused values, and so a relapse may be expect-
ed. Angela maintained weight and voices did
not reappear, maybe due to medication, yet she
has suffered several relapses. Her evolution is
slow, but she has managed some progresses
S. Sarr
like being aware of certain relapse warnings
and seeking help when they arise, understand-
ing if not wanting. In both these patients matu-
rity and separation anxieties join with previous
obsessive traits, reflected in fear from loosing
control, channelled at first by academic accom-
plishments and later through the eating disor-
der. Nevertheless, especially regarding Angela,
it becomes clear that the disorder reaches a
wider and deeper emotional dimension far
beyond the cognitive, easier to modify, one.
As for treatment goals, attention must be
drawn on partial and step-by-step accomplish-
ments, insisting on the idea that whenever
weight and nutritional status permit thera-
pists must be patient and work for hope and
involvement, as long as the patient is willing to
engage and work for change. We must try hard
with families and significant relations; we must
be humble and reconsider treatment whenever
necessary. About therapeutical steps, begin
controlling eating behaviours, then teaching
symptom-managing and emotional strategies
(social abilities, tolerance to stress, cognitive
approach to distorted thinking, rebuilding
communication and social networks), to finally
challenge the core values and assumptions that
underlie eating disorders as their ultimate trig-
gers. Patients should gradually learn to know
and accept themselves, with virtues and weak-
nesses alike. If this last and deepest level is not
reached and modified, relapse may once more
appear. On the contrary, if the patient does
succeed at moving this last stage, he/she has a
strong chance to overcome the eating disorder.
2. Blinder B.J., Cumella E.J., Sanathara V.A.: Psychiatric
comorbidities of female inpatients with eating disor-
ders. Psychosom. Med., 68, 454-462, 2006.
3. Hudson J.I., Pope H.G., Jonas J.M.: Psychosis in
anorexia nervosa and bulimia. Br. J. Psychiatr., 145,
420-423, 1994.
4. Escande M., Gayral L., Girard M.: tats psychotiques
et organisation psychotique au cours de lanorexie
mentale. Ann. Med. Psychol. (Paris), 2, 382-392, 1975.
5. Grounds A.: Transient psychoses in anorexia nervosa:
a report of 7 cases. Psychol. Med., 12, 107-113, 1982.
6. Joos A., Steinert T.: Komorbiditt von Schizophrenie
und bulimischer Anorexie: Ein Fall mit forensischer
Relevanz. Nervenarzt., 68, 417-420, 1977.
7. Nagata T., Ono K., Nakayama K.: Anorexia nervosa
with chronic episodes for more than 30 years in a
patient with a comorbid schizotypal personality disor-
der. Psychiatr. Clin. Neurosci., 61, 434-436, 2007.
8. Roberts M., Tchanturia K., Stahl D., Southgate L.,
Treasure J.: A systematic review and meta-analysis of
set-shifting ability in eating disorders. Psychological.
Med., 37, 1075-84, 2007.
9. Deckelman M.C., Dixon L.B., Conley R.R.: Comorbid
bulimia nervosa and schizophrenia. Int. J. Eat. Dis., 22,
101-105, 1997.
10. Mehler-Wex C., Romanos M., Kirchheiner J., Schulze
U.M.: Atypical antipsychotics in severe anorexia ner-
vosa in children and adolescents: review and case-
reports. Eur. Eat. Dis. Rev., 16, 100-108, 2008.
11. Powers P.S., Bannon Y., Eubanks R., McCormick T.:
Quetiapine in anorexia nervosa patients: an open label
outpatient pilot study. Int. J. Eat. Dis., 40, 21-26, 2007.
12. Aragona M.: Tolerability and efficacy of aripiprazole in
a case of psychotic anorexia nervosa comorbid with
epilepsy and chronic renal failure. Eat. Weight. Dis.,
12, e54-e57, 2007.
13. Kerbeshian J., Burd L.: Is anorexia nervosa a neu-
ropsychiatric developmental disorder? An illustrative
case-report. World. J. Biol. Psychiatry, 19, 1-10, 2008.
14. Mavrogiorgou P., Juckel G., Bauer M.: Rezidivierende
paranoid-halluzinatorische Psychose nach Beginn
einer Hungerkur bei einer Patientin mit Anorexia ner-
vosa. Fortschr. Neurol. Psychiatr., 69, 211-214, 2001.
15. Iancu I., Cohen E., Yehuda Y.B., Kotler M.: Treatment
of eating disorders improves eating symptoms but not
alexithymia and dissociation proneness. Compr.
Psychiatry, 47, 189-193, 2006.
REFERENCES
1. Crow S.J., Nyman J.A.: The cost-effectiveness of
anorexia nervosa treatment. Int. J. Eat. Disord., 35,
155-160, 2004.
e144
BRIEF
REPORT
Key words:
Gender, mass media
influence, loneliness,
disordered eating,
college students.
Correspondence to:
Mary E. Pritchard,
1910 University Dr., Boise,
ID 83725-1715, Idaho, USA.
E-mail:
marypritchard@boisestate.edu
An examination of the relation of
gender, mass media influence,
and loneliness to disordered eating
among college students
INTRODUCTION
Disordered eating behaviors (e.g.,
unhealthy eating behaviors such as restrict-
ing caloric intake, over-exercising, or purg-
ing) are becoming increasingly common in
U.S. adolescents (1, 2) and adults (2-4). Not
only are individuals who exhibit disordered
eating attitudes and behaviors at a greater
risk for developing clinical eating disorders
(5, 6), disordered eating has also been asso-
ciated with serious physical and mental
health risks (5, 7, 8). For these reasons, it is
important to examine factors that influence
disordered eating. The present study will
focus on three of these factors: gender,
media influence, and loneliness. Extant
research findings on each factor will be
described in the paragraphs that follow.
GENDER
Although researchers used to believe that
disordered eating affected only women (9),
more recent research indicates that this may
no longer be the case. Men and women both
believe that being overweight is undesirable
(10). Nevertheless, both genders have differ-
ent views when it comes to ideal body image
and both are susceptible to disordered eat-
ing patterns. In western and westernized
countries, thinness is a trait of female attrac-
tiveness, especially the hips, thighs and bot-
tom areas (11, 12). On the other hand, male
attractiveness is characterized by muscle
definition in the chest and arm muscles (11-
13). When comparing themselves to socially
approved ideal images, women are more
likely to judge themselves as overweight
whereas men tend to judge themselves as
underweight. As a result, Furnham et al. (11)
found that 73% of males and 22% of females
desired to increase their upper body size,
whereas 63% of females and 41% of males
wanted to decrease their lower body size.
Not surprisingly, societal messages are
affecting individuals at increasingly
younger ages. For example, females after
menarche reported feelings of body dissat-
isfaction and wanted to reduce their
weight, whereas males during puberty
wanted to increase body mass and believed
that appearance was an important aspect of
their sex appeal (14). These feelings of body
dissatisfaction have been linked to disor-
dered eating. In fact, males and females
who disliked themselves at age 13 were
more likely to engage in disordered eating
patterns during early adulthood (15). In
addition, ODea and Abraham (16) found
that between 9 and 12% of college men
reported feelings of unhappiness with their
body image, felt fat, and were determined
A. Wright, and M.E. Pritchard
Department of Psychology, Boise State University, Idaho, USA
ABSTRACT. Previous research has found that mass media influence and loneliness relate to
disordered eating behaviors in women, but little is known about this relation in men. The
present study examined the relations among disordered eating patterns, gender, mass media
influence, and loneliness in male and female college students. Results of a stepwise regres-
sion revealed that disordered eating attitudes and behaviors (as measured by the Eating Atti-
tudes Test-26) were predicted by mass media influence, gender, and loneliness, respectively.
In the present study both male and female college students appear susceptible to developing
disordered eating patterns. Clinicians may wish to address unrealistic comparisons to media
and client interpersonal skills when designing treatment plans.

to lose weight. In addition, between 11 and
30% of male adolescents and 45 and 62% of
female adolescents reported feelings of body
dissatisfaction after binge eating according to
Felker and Stivers (17). Furthermore, men are
less likely than women to seek treatment for
their disordered eating behaviors. ODea and
Abraham (16) found that 9% of their male par-
ticipants reported having an eating disorder,
but none of them sought treatment because
they believed that eating disorders only affect-
ed women.
MEDIA INFLUENCE
Television and magazines present air-
brushed, artificial images as real; thus people
associate themselves to what media portray
and in turn may develop patterns of disordered
eating to attain the ideal image (13). In addition,
over the past 40 years the dominant body
shape as portrayed in magazines and Miss
America Pageant winners has changed from a
full hourglass shape to a thin tubular shape
(18). According to Park (19), when people are
subjected to media influence, they often change
their attitudes or behavior accordingly. Thus it
is perhaps not surprising that media consump-
tion significantly predicted womens eating dis-
orders (20, 21). In addition, the use of beauty
and fashion magazines increases the desire to
be thin among female adolescent girls and col-
lege students (19, 21). Males are now being tar-
geted as well. GI Joe action figures have
become increasingly muscular over the last 30
years. Media exposure has been shown to pre-
dict mens attitudes in favor of personal thin-
ness and dieting (20) In addition, males who
were exposed to ideal image advertisements
reported strong feelings of muscle dissatisfac-
tion (13). Thus the ideal body image becomes
unattainable yet desirable to reach for both
males and females (9, 13).
LONELINESS
Peer acceptance, perceived social support, and
friendship intimacy may contribute to negative
body images, concerns over eating, and dieting
(22, 23). In fact, perceived social problems and
low levels of attachment with peers have been
linked to body image dissatisfaction and disor-
dered eating behaviors in adolescent girls and
college students (24, 25). In addition, Rotenberg
and Flood (26) reported that feelings of loneli-
ness among male and female college students
increase as food consumption increases.
PRESENT STUDY
Previous studies have shown that media
influence and loneliness relate to disordered
eating behaviors, especially in women (13, 19,
21, 22-26). However, few studies have exam-
ined the relations among media influence, lone-
liness, and disordered eating in both men and
women. The purpose of this study is to examine
the relations among disordered eating pat-
terns, gender, media influence, and loneliness
in male and female college students. It was
hypothesized that disordered eating behaviors
would be more common in women, those with
high levels of media influence, and those with
high levels of perceived loneliness. In addition,
to ascertain which of the three factors (gender,
mass media, or loneliness), best predicted dis-
ordered eating scores, we conducted a step-
wise regression. No predictions were made as
to which factor would be more important as
this analysis was exploratory in nature.
METHOD
Participants
Two hundred seventy-three undergraduates
(153 men, 120 women) at state university in the
Rocky Mountain Region of the United States par-
ticipated in this study. They were all students in
Introduction to Psychology courses and received
course credit for their participation in this study.
Participants were given a packet of question-
naires to answer in a 30-minute session. The
Institutional Review Board approved all proce-
dures before data collection commenced. As the
survey was anonymous, consent was implied.
Measures
Disordered eating
The Eating Attitudes Test-26 (EAT-26) (27)
was used to assess the disordered eating atti-
tudes and behaviors. Although the EAT-26 is
composed of three subscales (Dieting, Bulimic
symptoms and Food preoccupation, and Oral
control), to be consistent with previous
research (20, 21) the present study utilized the
sum total EAT-26 scores (=0.75). Individuals
scoring 20 or higher on the EAT-26 are consid-
ered at risk for eating disorders. None of the
men in the study scored at or above the cutoff;
however, 9 (7.5%) of the women did.
Loneliness
The UCLA Loneliness Scale is a 20-item ques-
tionnaire measuring global loneliness (28). Items
were scored on a 4-point scale (I have never felt
this way, I have felt this way rarely, I have felt
TABLE 1
Summary of stepwise regression analysis for variables predicting dis-
ordered eating behaviors in undergraduates (N=271).
Disordered eating and media influence
this way sometimes, I have felt this way often).
The sum of all 20 items with a few items in
reverse code determines the score of loneliness.
Higher total scores indicate higher levels of
loneliness. The measure was highly reliable with
regards to internal consistency with coefficient
alpha ranging from .89 to 0.94 and test-retest
reliability is r=0.73 for a 1-year period (28).
Media influence
The influence of the media on body image was
assessed by the Mass Media Influence Subscale
of the Socialization Factors Questionnaire (29).
The scale was measured on a 5-point scale
(never/rarely, sometimes, often, usually, always).
RESULTS
As might be expected, women had higher
EAT-26 scores [mean (M)=7.08, standard devia-
tion (SD)=6.93] than did men (M=4.17, SD=3.73).
To ascertain which of the three factors (gender,
mass media influence, or loneliness) best pre-
dicted disordered eating scores, we regressed
each of these factors onto EAT-26 sum scores
utilizing a stepwise regression. As displayed in
Table 1, mass media influence was the primary
variable relating to disordered eating behav-
iors, Model F (1, 270)=44.95, p<0.001, R
2
=0.14.
Once mass media influence had been entered
into the equation, gender was the next variable
that significantly impacted disordered eating,
Model F (2, 269)=32.10, p<0.001, R
2
=0.19. Final-
ly, once mass media influence and gender had
been entered into the equation, loneliness also
significantly predicted disordered eating behav-
iors, Model F (3, 268)=25.42, p<0.001, R
2
=0.22.
DISCUSSION
The purpose of this study was to examine
whether gender, media influence, and loneliness
were related to disordered eating patterns in
male and female undergraduates; and if so,
which variable was most important in predicting
disordered eating. As hypothesized and similar
to previous research with female undergraduates
(13, 19), mass media influence did relate to diet-
ing or disordered eating patterns in male and
female undergraduates and in fact, according to
the stepwise regression, was the most significant
factor associated with disordered eating.
Although none of the men in our study
scored above the cutoff on the EAT-26, the
mean EAT-26 score for men was 7.08, indicat-
ing that men were reporting some disordered
eating behaviors. Thus, similar to previous
research, both men and women seem suscepti-
ble to developing disordered eating patterns in
order to achieve the desired body (11-13).
Finally, as predicted, the present study sug-
gested there was a relation between loneliness
and disordered eating. Thus, similar to Schutz
and Paxtons (22) study of adolescent girls, the
present study suggests that having low levels of
attachment to peers may be linked with disor-
dered eating patterns in male and female col-
lege students.
Limitations
Several limitations were present throughout
this study. The population sample was limited to
only introductory psychology students. Thus,
future studies may wish to investigate these
behaviors in older adults and adolescents. In
addition, the majority of the population sample
was Caucasian. Thus, future research may wish
to examine disordered eating in a more racially
and ethnically diverse sample. The present study
only examined general media influence. Future
research may wish to examine the type of infor-
mation the media is presenting to viewers or dif-
ferent types of exposure modalities (e.g., TV vs.
magazines), as well as frequency and duration of
exposure. Oral control and bulimic symptoms
were relatively uncommon in our sample (the
highest score for both subscales was 9.00). It is
unclear whether the measure just did not tap into
the most common disordered eating behaviors
or whether our sample was relatively healthy.
Future studies may wish to use a more diverse
sample in terms of disordered eating behaviors
and may wish to utilize a scale that measures
more common aspects of disordered eating, such
as body dissatisfaction. Finally, as the present
study was correlational in nature, it is unclear
whether individuals prone to developing disor-
Variable B SE B
Disordered eating behaviors
Step 1
Mass media 3.09 0.46 0.38***
Step 2
Mass media 2.91 0.45 0.36***
Gender 2.52 0.62 0.23***
Step 3
Mass media 2.75 0.45 0.34***
Gender 2.56 0.61 0.23***
Loneliness 0.10 0.03 0.17**
**p<0.01, ***p<0.001.
dered eating behaviors tend to be lonely or have
a great deal of media exposure or whether indi-
viduals with those characteristics tend to develop
disordered eating patterns later in life. Future
studies may wish to examine these issues longi-
tudinally to better answer this question.
CONCLUSION
Although dieting and bulimic symptoms
were more common in women in the present
study, both male and female college students
appear susceptible to developing disordered
eating patterns. Clinicians may wish to consid-
er gender, media exposure and influence, and
loneliness when developing treatment plans for
their clients. Helping clients develop interper-
sonal skills and minimizing their exposure to
mass media may also help curtail development
of disordered eating patterns or help diminish
symptomology.
11. Furnham A., Badmin N., Sneade I.: Body image dissat-
isfaction: Gender differences in eating attitudes, self-
esteem, and reasons for exercise. J. Psychol., 136, 581-
596, 2002.
12. Jung J., Peterson M.: Body dissatisfaction and patterns
of media use among preadolescent children. Fam.
Consum. Sc. Res. J., 36, 40-54, 2007.
13. Agliata D., Tantleff-Dunn S.: The impact of media
exposure on males body image. J. Soc. Clin. Psychol.,
23, 7-22, 2004.
14. ODea J.A., Abraham S.: Onset of disordered eating
attitudes and behaviors in early adolescence: interplay
of pubertal status, gender, weight, and age.
Adolescence, 34, 671-679, 1999.
15. Sischo L., Taylor J., Martin P.Y.: Carrying the weight
of self-derogation? Disordered eating practices as
social deviance in young adults. Deviant Behav., 27,
1-30, 2006.
16. ODea J.A., Abraham S.: Eating and exercise disorders
among young college men. J. Am. Coll. Health, 50, 273-
278, 2002.
17. Felker K., Stivers C.: The relationship of gender and
family environment to eating disorder risk in adoles-
cents. Adolescence, 29, 821-834, 1994.
18. Pavelo M.: How drive for thinness moderates the influ-
ence of media on female body image. J. Under -
graduate. Psychol. Res., 1, 22-26, 2006.
19. Park S.: The influence of presumed media influence on
womens desire to be thin. Commun. Res., 32, 594-614,
2005.
20. Harrison K., Cantor J.: The relationship between media
consumption and eating disorders. J. Commun., 47,
40-67, 1997.
21. Martnez-Gonzlez M., Gual P., Lahortiga F., Alonso
Y., de Irala-Estvez J., Cervera S.: Parental factors,
mass media influences, and the onset of eating disor-
ders in a prospective population-based cohort.
Pediatrics, 111, 315-320, 2003.
22. Gerner B., Wilson P.H.: The relationship between
friendship factors and adolescent girls body image
concern, body dissatisfaction, and restrained eating.
Int. J. Eat. Dis., 37, 313-320, 2005.
23. Giles M.S., Helme D., Krcmar M.: Predicting disor-
dered eating intentions among incoming college fresh-
man: An analysis of social norms and body esteem.
Commun. Stud., 54, 395-410, 2007.
24. Schutz H.K., Paxton S.J.: Friendship quality, body dis-
satisfaction, dieting and disordered eating in adoles-
cent girls. Brit. J. Clin. Psychol., 46, 67-83, 2007.
25. Pritchard M., Yalch K.L.: Relationships among loneli-
ness, interpersonal dependency, and disordered eating
in young adults. Pers. Indiv. Diff., 46, 341-346, 2009.
26. Rotenberg K.J., Flood D.: Loneliness, dysphoria,
dietary restraint, and eating behavior. Int. J. Eat. Dis.,
25, 55-61, 1998.
27. Garner D.M., Garfinkel P.E.: The Eating Attitudes Test:
An index of the symptoms of anorexia nervosa.
Psychol. Med. 9, 273279, 1979.
28. Russell D.W.: UCLA Loneliness Scale (Version 3): relia-
bility, validity, and factor structure. J. Pers. Assess., 66,
20-40, 1996.
29. Vartanian L.R., Giant C.L., Passino R.M.: Ally McBeal
vs. Arnold Schwarzenegger: comparing mass media,
interpersonal feedback and gender as predictors of
satisfaction with body thinness and muscularity. Soc.
Behav. Personal., 711-723, 2001.
REFERENCES
1. Cook-Cottone C.P., Phelps L.: Adolescent eating disor-
ders. In: Bear G., Minke K., Thomas A. (Eds. ),
Childrens needs III: understanding and addressing.
The developmental needs of children. Bethesda, MD,
National Association of School Psychol ogists
Publications, 2006, pp. 977-988.
2. Polivy J., Herman C.P.: Diagnosis and treatment of nor-
mal eating. J. Consult. Clin. Psychol., 55, 635-644, 1987.
3. French S.A., Jeffrey R.W., Murray D.: Is dieting good
for you? Prevalence, duration and associated weight
and behaviour changes for specific weight loss strate-
gies over four year in US adults. Int. J. Behav. Nutr.
Phys. Act., 23, 320-327, 1999.
4. Neumark-Sztainer D., Sherwood N.E., French S.A.,
Jeffrey R.W.: Weight control behaviors among adult
men and women: cause for concern? Obes. Res., 7,
179-188, 1999.
5. Fredrickson B., Roberts T.: Objectification theory.
Psychol. Women. Q., 21, 173-206, 1997.
6. Warner C., Warner C., Matuszak T., Rachal J.: Disor -
dered eating in entry-level military personnel. Mil.
Med., 172, 147-151, 2007.
7. Lock J., Reisel B., Steiner H. Associated health risks of
adolescents with disordered eating: how different are
they from their peers? Results from a high school sur-
vey. Child. Psychiatry Hum. Dev., 31, 249-265, 2001.
8. Hautala L., Junnila J., Helenius H., Vnnen A.,
Liuksila P., Rih H., Vlimki M., Saarijrvi S.:
Towards understanding gender differences in disor-
dered eating among adolescents. J. Clin. Nurs., 17,
1803-1813, 2008.
9. McCreary D.R., Sasse D.K.: An exploration of the drive
for muscularity in adolescent boys and girls. J. Am.
Coll. Health, 48, 297-304, 2000.
10. Varnado-Sullivan P.J., Horton R., Savoy S.: Differences
for gender, weight and exercise in body image distur-
bance and eating disorder symptoms. Eat. Weight Dis.,
11, 118-125, 2006.
e148
BRIEF
REPORT
Key words:
Randomized controlled trial
(RCT), overweight, obesity,
physical activity, physical
fitness, picoeconomics,
hyperbolic discounting,
intertemporal bargaining
theory, motivational
interviewing, cognitive
behavioral therapy.
Correspondence to:
Anthony J. Mascola, MD,
Department of Psychiatry
& Behavioral Sciences,
Stanford University
School of Medicine,
401 Quarry Road, Stanford,
CA 94305-5722, USA.
E-mail:
amascola@stanford.edu
Framing physical activity as a distinct
and uniquely valuable behavior
independent of weight management:
A pilot randomized controlled trial
for overweight and obese sedentary
persons
INTRODUCTION
Traditional interventions for over-
weight/obese persons are complex, multi-
component efforts (1). Physical activity is
often included as a subcomponent to
increase the probability of successful weight-
management. Such interventions have
demonstrated limited long-term success with
disappointingly high relapse rates (2).
Several large epidemiologic trials reveal
an inverse relationship between physical fit-
ness and all-cause-mortality in over-
weight/obese persons. Modestly fit over-
weight persons appear to be at lower risk
for all-cause-mortality relative to similarly
overweight and even thin but unfit persons.
Significantly less activity may be needed to
produce these benefits than is necessary to
achieve weight loss. Thus it may be possible
to be fit but fat (3). Promoting modest
increases in physical activity independent of
weight-management has not been well stud-
ied as a main outcome of intervention for
overweight/obese persons, yet this may
offer long-term public health advantages
relative to usual weight-focused efforts.
Recent behavioral-economic research
suggests a promising theoretical frame-
work for modeling health-behavior choices
and promoting change. Intertemporal bar-
gaining theory (IBT) (4, p. 258) proposes
that enduring behavior change is hampered
by a fundamentally steep psychological dis-
counting rate of valuation of reward (5).
Small immediately available temptations
(i.e. indulging in dietary lapses, skipping
planned exercise sessions to enjoy the com-
forts of the sofa) often have a surprisingly
powerful ability to seduce a person away
A.J. Mascola, T.A. Yiaslas, R.L. Meir, S.M. McGee, N.L. Downing, K.M. Beaver,
L.B. Crane, and S. Agras
Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine, Stanford University
School of Medicine, Stanford, CA, USA
ABSTRACT. PURPOSE: Promoting benefits of physical activity independent of weight-
management may help overweight/obese persons. DESIGN: Pilot randomized-controlled-
trial. SUBJECTS: Twenty-six sedentary, overweight/obese persons receiving health-care at
Stanford Medical Center, no contraindications for exercise. CONTROL/INTERVENTION
GROUPS: Usual medical care and community weight-management/fitness resources versus
same plus a brief intervention derived from behavioral-economic and evolutionary psycho-
logical theory highlighting benefits of activity independent of weight-management. ANALY-
SIS: Intent-to-treat. Cohens d effect-sizes and 95% confidence intervals (95%CI) for changes
in moderate-intensity-equivalent physical activity/week, cardiorespiratory fitness, and
depression at 3 months relative to baseline. RESULTS: Intervention group participants
demonstrated 3.76 hour/week of increased physical activity at study endpoint, controls only
0.7 hours/week (Cohens d=0.74, 95% CI -0.06 to +1.5). They also improved cardiorespiratory
fitness (Cohens d=0.51, 95% CI -0.3 to +1.3) and reduced depression relative to controls
(Cohens d=0.66, 95% CI -0.1 to +1.4). CONCLUSION: Promoting activity independent of
weight-management appears promising for further study.

A.J. Mascola, T.A. Yiaslas, R.L. Meir, et al.
from enjoying the larger, but delayed, proba-
bilistic rewards resulting from prolonged
health-maintenance efforts. The IBT model pro-
poses that the discounting rate of valuation of
reward can shift dynamically between being
fundamentally steeply discounted (favoring
temptations) to meta-stable states favoring
longer-term rewards. This change occurs
when: 1) individual choices are perceived as
being bundled together in a category of related
choices (choosing according to personal rules,
values, and principles), and 2) ones confidence
in consistently defending the bundled choices
against future temptations is high. The rate
reverts back to being steeply discounted in the
opposite conditions. Such biases toward steep
discounting of rewards resulting in weight gain
in todays environment are consistent with evo-
lutionary psychological models of fitness which
describe natural selection of survival-enhanc-
ing behavioral biases as having occurred for
most of human history in very different envi-
ronmental contexts (6).
We aimed to create an intervention utilizing
these theoretical principles to promote sus-
tained selection of long-term, health-enhancing
behavioral choices despite the temptations
lurking in todays nutrient-dense, labor-sparing
environment. First, our intervention focused on
promoting physical activity as the primary out-
come of interest. Participants were free and
encouraged to pursue weight-loss if desired.
However we encouraged participants to care-
fully consider the possible advantages of con-
structing separate mental accounts (4, p. 101)
for keeping track of their physical activity and
weight-management efforts. This subtle change
in mental accounting was promoted with the
aim of preserving physical activity despite laps-
es and failures in weight-management which
were anticipated to be probable given the pub-
lished literature to date (7). Second, we sought
to foster the development of wise personal
rules/values: firm enough to overcome tempta-
tion while flexible enough to allow acceptance
of occasi onal l apses and spontanei ty to
enhance long-term sustainability (4, pp. 148-
149). Third, we encouraged participants to
consider activities they found intrinsically
enjoyable which offered incremental increases
in challenge as skill improved to maintain
uncertai nty i n accessi ng the awards of
achievement thus preventing premature satia-
tion and boredom (4, p. 164; 8, p. 74). Fourth,
we encouraged careful evaluation of personal
environment to decrease the density of choices
between temptations and long term rewards
(i.e. placing the TV remote control in an incon-
venient location) (4, p. 74). We conducted a
small pilot study to assess whether such an
approach would show sufficient promise in
increasing physical activity to justify a larger
randomized trial.
METHODS
Participants
Participants were recruited between 2004-
2005 by clinician referral and self-initiated
response to advertisements displayed in the
outpatient Medical and Psychiatric clinics at
Stanford Medical Center and Palo Alto Medical
Foundation. Patients were eligible if: they were
being seen by a primary health-care provider;
were 18-65 years old; had a body mass index
(BMI) between 25-45 kg/m
2
; were not regularly
physically active in the past 6 months as per a
physical activity staging algorithm (9), and
were in American Heart Association risk class-
es A1-A3 (apparently healthy with no evidence
of increased cardiovascular risk with unsuper-
vised physical activity and no known coronary
artery disease) (10). Patients were otherwise
excluded. Patients with bulimia, dementia, a
psychotic disorder, and those appointed a legal
guardian/conservator were excluded.
Control and intervention
Participants were assigned to either: 1) a
usual health-care control condition in which
they were encouraged to select their own per-
sonal health goals and use resources available
in their health-care plan and community (con-
sultation with their health professionals, gym
memberships, weight-loss centers, etc.) to
achieve their goals, or 2) the same plus a brief
intervention delivered at the medical center
derived from IBT framing physical activity
independently of weight-management. At the
end of the wait list period, control participants
were provided the experimental intervention.
The intervention was designed to encourage a
wisely flexible behavior management style
derived from IBT (4) incorporating separate
mental accounts for physical activity and
weight-maintenance as described above. It was
delivered in a counseling style adapted from the
motivational interviewing (MI) model (11) with
procedures adapted from a cognitive behavioral
therapy model of enhancing self-regulation (12).
Participants were provided individualized feed-
back from a health assessment conveying the
importance of physical activity independent of
weight status. Participants in the experimental
condition were offered as many as 3 in-person
consultation meetings with a non-specialist
health consultant trained in MI (pre-professional
Promoting activity independent of weight
student volunteers with limited clinical experi-
ence) followed by up to 4 brief telephone con-
tacts in the 3 months following baseline assess-
ment. Participants were asked only to commit to
attending the assessment appointments neces-
sary for data collection. Participants were pro-
vided a workbook and access to a website that
contained self-help resources and links that rein-
forced the content of the intervention.
Objectives
We hypothesized that intervention group par-
ticipants would be more likely to demonstrate
increased physical activity at the end of the
study period than would usual care participants.
Measures
The main outcome measure was self-reported
physical activity assessed by the Stanford Seven
Day Physical Activity Recall (13). We converted
minutes of physical activity into minutes of mod-
erate-equivalent activity by combining the sum
of minutes of moderate activity with the sum of
minutes of vigorous activity weighted by a fac-
tor of 2.5 reflecting the weightings in current
guidelines. Secondary outcome measures
included cardiorespiratory fitness assessed by a
submaximal exercise step protocol, the Modified
Canadian Aerobic Fitness Test (mCAFT) (14).
Depression was measured with the Beck
Depression Inventory (BDI) (15). Each
patient/health-counselor interaction that
occurred was video or audio recorded. One ses-
sion from each participant was randomly select-
ed and assessed for treatment integrity using an
adaptation of the Motivational Interviewing
Treatment Integrity coding system (MITI) (16).
Sample size
As this was an unfunded pilot study, we
attempted to recruit approximately 30 patients
for the purposes of assessing feasibility and
obtaining a rough estimate of the effect-size
and confidence-interval of the intervention.
Randomization
Participants were randomly assigned via a
double-blinded, centralized, allocation method
ensuring concealment of sequence to those
enrolling patients and concealment of identity
and patient characteristics to the independent
person allocating treatment assignment. The
random sequence was generated by drawing
cards from an opaque container using block
randomization with a block size of ten.
Blinding
Those assessing outcomes were blinded to
group assignment.
Statistical methods
Analyses were performed using SPSS 13.0
and ESCI delta. Standardized effect-sizes and
confidence-intervals were calculated for
between-groups changes in moderate-equiva-
lent intensity physical activity per week, car-
diorespiratory fitness, and depression.
RESULTS
Participant flow and numbers analyzed
Two hundred forty-eight patients were
assessed for eligibility, 26 met criterion and
were enrolled. Fourteen were randomized to the
intervention and twelve to control. All 26 sub-
jects were included in the analyses which were
performed by intention-to-treat. Missing data
were conservatively imputed utilizing baseline-
observation-carried-forward.
Baseline data
Participants were predominately female (N=
24, 92%), white (N=20, 77%), married (N=15,
58%), and well-educated (median education:
college degree). The mean age was 43.8 years
[standard deviation (SD) =9]; mean BMI was 35
(SD=7.4); mean hours of moderate-equivalent
physical activity/week were 1.27 (SD=1.25). The
majority (N=15, 58%) were employed full-time
(median category of hours worked/week: 40-
50); median household income: $100,000-
125,000. A large percentage of patients had self-
reported Axis I Psychiatric conditions (N=11,
42%) including major depressive disorder (N=6,
23%), bipolar disorder (N=4, 15%), and obses-
sive compulsive disorder (N=1, 4%). Many
patients suffered from chronic pain (N=6, 23%).
Table 1 shows the baseline characteristics of
participants in each group. Frequencies are
reported for categorical variables. Means SD
are reported for continuous measures.
Outcomes and estimation
The i nterventi on group parti ci pants
increased moderate-equivalent-physical-activi-
ty by 3.76 hours/week while the 12 controls
increased only 0.7 hours per week (Cohens
d=0.74; 95% CI -0.06 to 1.5). This corresponds
to a moderate to large effect-size by Cohens
conventions and is quite significant with respect
to current guidelines for physical activity.
Cardiorespiratory fitness scores for interven-
tion participants improved by 3.6 points on the
mCAFT while controls worsened by 4.5 points.
(Cohens d=0.51, 95% CI: -0.3 to +1.3). Depres-
sion scores (BDI) for the intervention group
improved 1.2 points while controls worsened
by 2.4 points. (Cohens d=0.66, 95% CI: -0.1 to
A.J. Mascola, T.A. Yiaslas, R.L. Meir, et al.
+1.4). No significant adverse effects of the
intervention were reported.
Adherence to the desired style of delivery of
the content of the intervention as assessed by
the MITI was high [mean global empathy: 5.8
(SD=0.4); mean global spirit: 5.4 (SD=0.7)]. Few
counselor behaviors non-adherent to the pro-
tocol were noted (5/667 codes assigned). Inter-
rater-reliability in assessing adherence was
good to excellent (intraclass correlation coeffi-
cients for empathy and spirit 0.91 and 0.74
respectively). Validity of adherence assessment
appeared strong. Mean Pearson product corre-
lation coefficients from each individual rater
against gold standard tapes produced by the
University of New Mexico (UNM) ranged from
r=0.83 to r=0.97 (p<0.05 for each rater). The
overall mean Pearson correlation coefficient for
our coders against the ratings provided by
UNM was r=0.91 (SD=0.09).
DISCUSSION
Summary
Adding a brief experimental intervention to
usual health-care and community resources for
health promotion resulted in a moderate to
large standardized effect-size increase in physi-
cal activity at 3 months which was quite signifi-
cant by current physical activity guidelines.
Moderately sized, beneficial effect-sizes were
also observed in favor of the intervention for
cardiorespiratory fitness and depression.
Limitations
The findings of this research are promising
but preliminary. Limitations include small sam-
TABLE 1
Baseline characteristics of participants.
Characteristic Control Intervention
(N=12) (N=14)
Sex (N of subjects)
Male 1 1
Female 11 13
Race or ethnicity (N of subjects)
White 8 12
Black 1 0
Hispanic 1 2
Other/declined to state 2 0
Age (years) 45.89.0 42.19.0
Weight (kg) 97.526.8 94.516.6
(Detecto Digital Scale model 6800)
Height (cm) 164.15.6 166.47.2
(Seca Height-Rite Stadiometer model 225)
Body mass index (kg/m
2
) 36.09.1 34.25.8
Abdominal circumference (cm) 105.819.4 99.913.6
% Body fat (Bioelectric Impedence 41.35.5 39.64.3
Omron HBF-306 Body Fat Analyzer)
mCAFT score 269.359.0 294.047.9
(Submaximal Step Fitness Test)
Hours of moderate activity/week (7 Day PAR) 1.71.4 0.90.86
Hours of hard activity/week (7 Day PAR) 0.210.40 0.03.13
Hours of very hard activity/week (7 Day PAR) 00 00
Hours of moderate-equivalent activity/week 2.191.9 1.00.8
(7 Day PAR)
Fasting glucose (mg/dl) (Cholestech LDX) 96.810.7 95.111.0
Total cholesterol (mg/dl) (Cholestech LDX) 195.839.0 219.652.6
LDL (mg/dl) (Cholestech LDX) 121.936.8 132.942.8
HDL (mg/dl) (Cholestech LDX) 46.112.5 53.917.7
Triglycerides (mg/dl) (Cholestech LDX) 138.654.5
231.2319.1
Systolic blood pressure (mmHg) (Omron 130.115.8 128.214.4
HEM-711automated sphygmomanometer)
Diastolic blood pressure (mm Hg) (Omron 86.611.9 86.09.4
HEM-711automated sphygmomanometer)
Beck Depression Inventory 11.07.0 11.77.3
Axis I psychiatric siagnosis? (N of subjects) 6 5
Taking psychotropic medication? (N of subjects) 6 6
Chronic pain diagnosis? (N of subjects) 3 3
Taking pain medication? (N of subjects) 3 3
Either Axis I psychiatric or pain diagnosis? 8 6
(N of Subjects)
Taking psychotropic or pain medication? 7 6
(N of subjects)
Smoker (N of subjects) 1 1
4
3.5
3
2.5
2
1.5
1
0.5
0
C
h
a
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n
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r
a
t
e
e
q
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l
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Group
Control Intervention
FIGURE 1
Change in moderate-equivalent physical activity at 3 months relative
to baseline. Overweight sedentary persons exposed to the intervention
demonstrated 3.76 hours/week of increased activity at study end-
point compared to 0.7 hours/week for controls (Cohens d=0.74,
95% confidence interval 0.06 to +1.5).
Promoting activity independent of weight
ple size, lack of longer-term follow-up compar-
isons and limited resources to conduct more
sophisticated objective assessments of physical
activity and cardiorespiratory fitness. The two
groups were intentionally asymmetric with
respect to contact hours with a clinician to
assess whether the addition of brief resources
to usual care would result in a clinically mean-
ingful effect. The contact time alone, regardless
of theory, could, of course, account for differ-
ences between the two groups. The sample was
predominately female, highly educated and
white. Participants were recruited based upon
self-initiative in following up on clinicians rec-
ommendations or advertisements. As in any
study in which participants are recruited by
nonrandom means, selection biases could influ-
ence the generalizability of the findings.
Significance
This study provides preliminary support for
an inexpensive, theoretically promising
approach to a significant public health problem.
Most treatment interventions for over-
weight/obesity are complex and result in mod-
est, poorly sustained changes. A simpler
approach may be more practical, achievable
and sustainable resulting in significant public
health benefits. Brief exposure to an IBT
derived intervention framing physical activity as
a behavior independent of weight-management
is worthy of further study and consideration.
successfully control their weight? Findings of a three
year community-based study of men and women. Int.
J. Obes. Relat. Metab. Disord., 24, 1107-1110, 2000.
3. LaMonte M.J., Blair S.N.: Physical activity, cardiores-
piratory fitness, and adiposity: contributions to dis-
ease risk. Curr. Opin. Clin. Nutr. Metab. Care., 9,
540-546, 2006.
4. Ainslie G.: Breakdown of will. Cambridge - New York,
Cambridge University Press, 2001, xi.
5. Green L., Myerson J.: A discounting framework for
choice with delayed and probabilistic rewards.
Psychol. Bull., 130, 769-792, 2004.
6. Haselton M.G., Nettle D.: The paranoid optimist: an
integrative evolutionary model of cognitive biases.
Pers. Soc. Psychol. Rev., 10, 47-66, 2006.
7. Marlatt G.A., Donovan D.M.: Relapse prevention:
maintenance strategies in the treatment of addictive
behaviors. 2
nd
ed. New York, Guilford Press, 2005,
xiv, p. 416.
8. Csikszentmihalyi M.: Flow: The psychology of optimal
experience. New York, Harper Perennial, 1990, p. 303.
9. Norman G.: Examining three exercise staging algo-
rithms in two samples. Ann. Behav. Med., 20, S211,
1998.
10. Balady G.J.: Recommendations for cardiovascular
screening, staffing, and emergency policies at
Health/Fitness Facilities. Circulation, 97, 2283-2293, 1998.
11. Miller W.R., Rollnick S.: Motivational interviewing :
preparing people for change. 2
nd
ed. New York,
Guilford Press, 2002 xx, p. 428.
12. Burns D.D.: The feeling good handbook. New York,
Penguin Group, 1999.
13. Pereira M.A.: A collection of physical activity question-
naires for health-related research. Med. Sci. Sports.
Exerc., 29, S1-205, 1997.
14. Weller I.M.: A study to validate the modified Canadian
Aerobic Fitness Test. Can. J. Appl. Physiol., 20, 211-
221, 1995.
15. Beck A.T.: An inventory for measuring depression.
16. Moyers T.B.: Assessing competence in the use of
motivational interviewing. J. Subst. Abuse Treat., 28,
19-26, 2005.
REFERENCES
1. Brownell K.D.:The LEARN Program for Weight
Management 2000. Dallas, Texas, American Health
Publishing Company, 2000, p. 312.
2. Crawford D., Jeffery R.W., French S.A.: Can anyone
e153
BRIEF
REPORT
Key words:
Obesity, weight bias,
stigmatization, free-response,
stereotypes.
Correspondence to:
Geri Hosburgh-McLeod,
Cancer Society of New
Zealand, Social &
Behavioural Research Unit,
Department of Preventive
& Social Medicine,
University of Otago,
Dunedin, New Zealand.
E-mail:
henge312@student.otago.ac.nz
Received: February 14, 2008
Unprompted generation of obesity
stereotypes
INTRODUCTION
Recent reviews suggest that prejudice
against overweight and obesity is common
(1), harmful (2), and increasing (3). Typical-
ly, obese people are described as physically
lazy, gluttonous, unattractive, and are less
likely to be selected for a relationship or as
a friend (4). However, this research has
almost exclusively used methods (both qual-
itative and quantitative) that prompt partici-
pants to describe or rate their attitudes and
beliefs about obese people, often guided by
researcher prescribed stereotypes and
characterization. Such approaches can limit
the scope of responses, and due to their less
than covert approach, are subject to
response bias (5). Studies using more sub-
tle, and arguably more accurate, free-
response formats are rare (6). However,
such studies are required if researchers are
to better characterize, understand, and
address the growing problem of prejudice
towards obese people.
A common problem encountered when
examining explicit attitudes toward stigma-
tized groups is socially desirable respond-
ing (7). Recently, researchers have begun to
employ implicit measures of prejudice (8). A
relatively new, but popular, measure of
implicit prejudice is the Implicit Association
Test (IAT). The IAT bypasses the problem of
socially desirable responding by instead
measuring the strength of the automatic
associations that one holds in memory
between certain attributes (e.g., positive
and negative attitudes and beliefs), and spe-
cific objects or targets (e.g., obese individu-
als). However, these types of measures also
appear to suffer from validity issues, and
are constrained in terms of the depth and
descriptive quality of the attitude informa-
tion they yield (9).
One study that has used a more covert
and naturalistic free-response methodology
asked participants to write a story about a
drawing of a woman who was presented as
either obese or normal-weight (6). Respons-
es were coded specifically for the affective
valence of the story, rather than analyzing
freely generated beliefs, characteristics, or
behaviors attributed to the obese or nor-
mal-weight target. The study found that
respondents spontaneously generated sig-
nificantly more gloomy and unpleasant sto-
ries, indicating more negative valence, for
the obese target relative to the normal-
weight target (6). This free response
approach has proven similarly effective in
research on other stereotyped groups. For
example, Macrae et al., (10) asked partici-
pants to write about a typical day in the
G. Horsburgh-McLeod
1
, J.D. Latner
2
, and K.S. OBrien
3
1
Cancer Society of New Zealand, Social & Behavioural Research Unit, Department of Preventive & Social
Medicine, University of Otago, Dunedin, New Zealand,
2
Department of Psychology, University of Hawaii at
Manoa, Honolulu, Hawaii,
3
School of Psychological Sciences, University of Manchester, Manchester, UK
ABSTRACT. Prejudice towards obese people is widespread and has negative conse-
quences for individuals with obesity. The present study covertly examined whether partici-
pants spontaneously generate different written transcript content (i.e., more negative
stereotypes) when presented with a picture of an obese person or a normal-weight person.
Two pictures of young women were computer generated to appear identical in all features
except for body shape, which was either obese or normal-weight. Forty-nine women blind
to the nature of the study were randomized to receive either the obese or normal-weight
picture and asked to write a free-response description of a typical day in the life of the
woman depicted. Independent coding of the transcripts revealed more frequent negative
stereotypes and more negative valence generated by participants asked to describe a typical
day of the obese target. These differences are consistent with the prevalent negative stereo-
types of obese individuals.

Unprompted generation of obesity stereotypes
FIGURE 1
Computer generated pictures of the normal-weight
and obese target stimuli.
life of a Skinhead. The resulting descriptions
allowed a more detailed analysis of the nega-
tive stereotypes, characteristics, and behaviors
attributed to that target group.
The present study sought to use this more
covert, naturalistic, and less constrained
method to investigate free-response descrip-
tions of a typical day in the life of either an
obese or a normal-weight woman. Specifically,
we examined differences in the content and
valence of written descriptions of an obese or
normal-weight target stimulus. Because obese
individuals have previously been stereotyped
as physically inactive, less liked as friends and
partners, unattractive, and having different eat-
ing patterns, it was hypothesized that these
four types of stereotypes would be sponta-
neously produced more frequently for obese
than for normal-weight targets. It was also
hypothesized that obese targets would be
described with greater negative valence than
normal-weight targets.
METHODS
Participants
Forty-nine Caucasian women aged 18-45
years, from Christchurch, New Zealand, partici-
pated in this study. Participants were blind to
the purpose of the study and were told the study
was designed to examine writing abilities.
Materials and procedure
An Internet computer program (www.
myvirtualmodel.com) was used to create full-
page black and white figures of an obese and
normal-weight Caucasian female target. The
height and weight entered for each figure was
160 cm and 113 kg for the obese target and 160
cm and 60 kg for the normal-weight target. The
www.myvirtualmodel.com website does not
allow specific age assignment, instead offering
a younger vs. older model. The authors chose
to use the younger model option, which was
judged (authors consensus) to appear approxi-
mately 25 years old. Aside from weight status,
the target stimuli were identical in all aspects of
appearance [i.e. , clothing, hairstyl e, age
(younger model), and facial features] (Fig. 1).
Upon arrival, participants were randomized
to receive either the obese (N=24) or normal-
weight (N=25) target picture. Each participant
received one of the two target stimuli along
with a blank writing booklet. Participants were
asked to write open-ended descriptions about
the obese or normal-weight target stimulus,
using the following instructions: Please look at
the picture supplied to you. Please spend the
next 5 minutes writing a description of what
you think would be a typical Sunday for the
person portrayed. There are no right or wrong
answers to this task; we are just interested in
your thoughts about how this person may
spend their day.
A post-study question sheet, asking partici-
pants to write what they thought was the true
purpose of the study, confirmed that the partic-
ipants were unaware of the true nature of the
study. This study was approved by the Univer-
sity of Canterbury Ethics Board.
Content analysis
Two independent female coders, blind to the
aim and experimental conditions employed in
the study, were asked to code the participant
transcripts and record counts of four common
stereotypes identified in the obesity prejudice
literature (1). Specifically, coders were asked to
identify the occurrence of common stereotypes
in the transcripts where the following four
domains were mentioned: 1) Activities, 2)
Attractiveness/Appearance, 3) Relationships,
and 4) Eating behaviors. When a single state-
ment contained references to more than one
stereotype domain (e.g., she and her boyfriend
may go out for a light meal, the statement was
coded as containing a description in each rele-
G. Horsburgh-McLeod, J.D. Latner, and K.S. OBrien
TABLE 1
Frequency of the categories mentioned within the domains
of Activities, Relationships,
Appearance/Attractiveness, and Eating behaviors.
vant domain (e.g., the Relationships and the
Eating domain). Coders were also asked to
identify specific sub-themes within each of the
four broad stereotype domains. Sub-themes
identified more than once within a single tran-
script were recorded as one count, so that tran-
script counts measure the occurrence/non-
occurrence of the stereotype for each partici-
pant. Where differences occurred between
coders, the relevant passage was discussed by
the coders until agreement was reached.
Affective valence
To assess the affective valence (negative or
positive tone) of participants written respons-
es, the technique described by Hiller (6) was
used. Here, two different independent coders
rated the valence of each complete written
description of targets provided by participants
on a Likert scale (1=extremely negative tone
and 7=extremely positive tone). These coders
were also blind to the aim and experimental
conditions employed in the study. The coders
valence scores for the participants transcripts
were averaged to give a single score for each
transcript.
RESULTS
Content analysis
Chi-square tests for independence were per-
formed to examine differences between obese
and normal-weight targets regarding the
domains of Activities, Attractiveness/Ap-
pearance, Relationship, and Eating behaviors.
All descriptors that occurred fit into one of
these four domains. The coders agreed 90% of
the time about the occurrence of descriptions
in the obese condition, and 84% of the time
about the occurrence of specific descriptions
in the normal-weight condition. Following dis-
cussion and resolution of differences, agree-
ment between coders reached 100% for both
targets.
Activities
Four consistent sub-theme descriptions
emerged related to activities (Table 1). The
obese target was less likely than the normal-
weight target to be described as sleeping late in
the morning and going shopping, and more
likely to be described as having relaxed at
home. Although there was no significant differ-
ence in the frequency of descriptions of the
obese and the normal-weight target stimulus
regarding doing chores/housework, this activi-
ty was described more frequently for the obese
target stimulus.
Relationships
The existence of a boyfriend or romantic part-
ner was mentioned significantly less often for the
obese target, despite a more frequent description
of the obese target having children. Although
friends were mentioned more frequently for the
normal-weight target than for the obese target,
this difference only approached significance.
Appearance/Attractiveness
The obese target stimulus received signifi-
cantly fewer descriptions about enhancing
their attractiveness through personal grooming
than the normal-weight target stimulus.
Eating behaviors
The normal-weight target was more frequent-
ly described as having eaten out in cafs or
restaurants than the obese target. There were
no significant differences in the frequency of
descriptions of eating at home and being a non-
healthy eater, although the obese target stimulus
was given each of these descriptions more fre-
quently (4 vs. 2 counts). The obese weight target
was described more often as cooking for others,
which was also not significant.
Affective valence
The inter-rater reliability of the coders for
affective tone was r=0.66, p<0.01 for the nor-
Domain Normal-weight Obese woman
2
woman (N=24) (N=25)
Activities
Sleeping late 10 14 3.95*
Relax/read 11 19 3.47*
Chores/housework 12 17 1.64
Go shopping 14 5 7.58*
Relationships
Children 3 10 4.75*
Boyfriend/partner 11 1 6.65*
Friends 17 11 3.68
Appearance/Attractiveness
Personal grooming 10 2 7.51*
Eating behaviors
Eat at home 11 19 1.14
Eat out 15 4 11.15*
Cooking for others 4 9 1.37
*p<0.05.
Unprompted generation of obesity stereotypes
mal-weight picture and r=0.49, p<0.05 for the
obese picture. An independent-samples t-test
compared the coders mean valence ratings of
the descriptions of obese and normal-weight
targets. Ratings of affective tone were lower,
indicating a more negative tone, for the obese
target than for the normal-weight target [t(47)
=4.86, p<0.001; means=2.98 vs. 4.68].
DISCUSSION
Respondents painted significantly different
portraits of the lives of the obese and normal-
weight target stimuli. Obese women were more
often characterized as resting at home and hav-
ing children and less often characterized as
shopping, sleeping late, having a romantic part-
ner, grooming themselves, or eating out. Addi-
tionally, descriptions of the obese target were
rated as being significantly more negatively
valanced than those of the normal-weight tar-
get. The present results are consistent with past
findings that obese people are viewed as having
less pleasant and rewarding lives (6). Important-
ly, the emergence of significant differences in
participants descriptions of the obese vs. nor-
mal-weight targets is striking given that figures
were identical in all aspects of appearance
except weight. For example, while participants
described the normal-weight target as having
spent time getting dressed and doing her hair
(with product) and being tidy, well presented
and fashionable including hairstyle, they
viewed the obese target as someone who does
not spend long on her appearance, i.e. clothes
are not important to her. Thus, using a free-
response method where participants were not
prompted to generate stereotypes and were
unaware of the purpose of the study, typically
negative stereotypes about activities, attractive-
ness, relationships, and eating behaviors,
emerged for obese targets regardless.
These results are consistent with previous
findings that individuals judged as attractive are
ascribed more positive qualities (11) and more
favorable impressions and judgments (12).
Given the inverse correlation between body
weight and judgments of attractiveness (13, 14)
people may believe that obese individuals do
not participate in rewarding relationships or
activities (e.g., dining out, shopping). Further-
more, obese women have been labeled as being
both less desirable and less capable in intimate
relationships (15). Unfortunately, such percep-
tions may be based on reality; for example,
obese adolescent girls are less likely to have
dated than their normal-weight peers (16). Even
though the obese targets in the present study
were less often described as having a romantic
partner, they were more often described as hav-
ing children, suggesting that they may perhaps
have been perceived as being somewhat older
than the matched but normal-weight target.
The present work links well with and supports
past research where stigmatized individuals have
described coping with the rejection and margin-
alization that results from being overweight or
obese (17). For example, obese individuals may
use the coping strategies of avoidance, with-
drawal, and eating. Avoidance and withdrawal
may be implicit in the characterization of the
obese woman as spending more time staying at
home and less time going out shopping. Dysfunc-
tional eating habits are another coping strategy
that obese individuals use in response to stigma
and discrimination (18). Though the present
study did not find any descriptions of disordered
eating, the obese target was described signifi-
cantly less often as eating in public, which may
suggest avoidance behavior or secretive eating.
The present study represents preliminary
work aimed at exploring more novel method-
ological approaches to the studying of anti-fat
attitudes and as such has some limitations.
Notably, the study was comprised of a relatively
small sample of exclusively Caucasian women.
Additionally, height and weight data, and
accordingly, body mass index of the partici-
pants was not gathered or calculated. Those
with a lower body weight may have generated
more negative stereotypes, which has been
reported in the literature in the past (19). How-
ever, despite these limitations, particularly in
regards the small sample size, meaningful
effects were found. It is also possible that a
broader range of categories and sub-themes
could emerge in a larger and more diverse sam-
ple. For example, the present methodology
might yield quite different sub-themes in a sam-
ple of health professionals, with likely more
mention around the eating behaviors and health
status for obese targets. Future research should
explore the use of free-response methods in
more diverse samples and examine the effects
of ethnicity, sex, age, and weight on obesity
stereotypes. The present study illustrates the
utility of free-response designs in examining the
domains most affected by the widespread prej-
udice against obese individuals.
ACKNOWLEDGEMENTS
We acknowledge our colleagues Dr. Lucy Johnston,
University of Canterbury, and Mr. Andrew Gray, Uni-
versity of Otago, for their advice and support on this
project.
G. Horsburgh-McLeod, J.D. Latner, and K.S. OBrien
10. Macrae C.N., Bodenhausen G.V., Milne A.B., Jetten J.:
Out of mind but back in sight: Stereotypes on the
rebound. J. Pers. Soc. Psychol., 67, 808-817, 1994.
11. Eagly A.H., Makhijani G., Ashmore D., Longo LC.:
What is beautiful is good, but: a meta-analytic
review of the physical attractiveness stereotype.
Psychol. Bul., 110, 109-128, 1991.
12. Jackson A., Hunter J.E., Hodge C.N.: Physical attrac-
tiveness and intellectual competence: a meta-analytic
review. Soc. Psychol. Q., 58, 108-122, 1995.
13. Galper R.E., Weiss E.: Attribution of behavioral inten-
tions to obese and normal-weight stimulus persons.
Eur. J. Soc. Psychol., 5, 425-440, 1975.
14. Clayson D.E., Klassen M.L.: Perception of attractive-
ness by obesity and hair color. Percep. Mot. Skills., 68,
199-202, 1989.
15. Reagan P.C.: Sexual outcasts: The perceived impact of
body weight and gender on sexuality. J. App. Soc.
Psychol., 26, 1803-1815, 1996.
16. Pearce M., Boergers J., Prinstein M.J.: Adolescent obe-
sity, overt and relational peer victimization, and
romantic relationships. Obes. Res., 10, 386-393, 2002.
17. Puhl R., Brownell K.D.: Ways of coping with obesity
stigma: review and conceptual analysis. Eat. Behav., 4,
53-78, 2003.
18. Puhl R. , Moss-Racusin C.A., Schwartz M.B.:
Internalization of weight bias: Implications for binge
eating and emotional well-being. Obesity, 15, 19-23,
2007.
19. Schwartz, M.B., Vartanian, L., Nosek, B., Brownell, K.D.:
The influence of ones own body weight on implicit and
explicit anti-fat bias. Obesity, 14, 440-447, 2006.
REFERENCES
1. Puhl R., Brownell K.D.: Bias, discrimination, and obesi-
ty. Obes. Res., 9, 788-805, 2001.
2. Puhl R.M., Latner J.D.: Stigma, obesity, and the health
of the nations children. Psychol. Bul., 133, 557-580,
2007.
3. Latner J.D., Stunkard A.J., Wilson G.T.: Stigmatized
students: age, gender, and ethnicity effects in the
stigmatization of obesity. Obes. Res., 13, 1226-1231,
2005.
4. Brownell K.D., Puhl R.B., Schwartz M.B., Rudd L.C.:
Weight bias: nature, consequences, and remedies.
New York, Guilford, 2005.
5. Jarvie G.J., Lahey B.B., Graziana W., Farmer E.:
Childhood obesity and social stigma: what we know
and what we dont know. Dev. Rev., 3, 237-273, 1983.
6. Hiller D.V.: The salience of overweight in personality
characterization. J. Psychol., 108, 233-240, 1981.
7. Paulhus, D.L.: Measurement and control of response
bias. In: Robinson J.P., Shaver P.R., Wrightsman L.S.
(Eds.), Measures of personality and social psychologi-
cal attitudes. New York, Academic Press, 1991, pp. 17-
59.
8. Greenwald A.G., McGhee D.E., Schwartz J.L.: Mea sur -
ing individual differences in implicit cognition: the
implicit association test. J. Pers. Soc. Psychol., 74,
1464-1480, 1998.
9. OBrien K.S., Halberstadt J., Latner J., Hunter J.A.,
Caputi P.: Do anti-fat attitudes predict anti-fat behav-
iours. A novel approach to getting the truth. Obesity,
16, Suppl. 2, S87-S92, 2008.
e158
BRIEF
REPORT
Key words:
Obesity, motivation,
readiness, lifestyle
modification, weight loss.
Correspondence to:
Prof. Carlo Maria Rotella,
Sezione Malattie del
Metabolismo e Diabetologia,
Dipartimento di
Fisiopatologia Clinica,
Universit degli Studi di
Firenze, Viale Pieraccini 6,
50139 Firenze, Italy.
E-mail: c.rotella@dfc.unifi.it
Received: September 23, 2008
Motivational readiness to change
in lifestyle modification programs
INTRODUCTION
Despite substantial progress in the last
years, weight management programs still
remain a great challenge. Drop out rates
undoubtedly represent a growing problem.
The average data increased from about 11%
in 1974 to about 21% in 1986 (1) and appear
to have stabilized at about 20% in the follow-
ing 10-15 years (2). On the other hand, more
recent data (3), including our own experi-
ence (4), show an 8 month-1 year drop-out
rate of more than 70% (individual program)
but less than 30% (group program).
It might be therefore necessary to revisit
the initial treatment phase. Better defining
the importance of the characteristics of this
initial phase (e.g., definition of success, rate
and amount of weight loss) and all the
information gathered during it or even
before participants start may prove to be
associated with long-term outcomes (5).
Reviewing the literature published until
now, another major point comes forth: usu-
ally the methods applied and the instru-
ments used do not meet at all the needs of
the population enrolled. Therefore, match-
ing interventions to patients, saving
resources, and increasing program efficacy
could be potential targets of adopting readi-
ness-profiling approaches
LIFESTYLE INTERVENTIONS
Major health threats associated with
overweight and obesity include all the char-
acteristics of metabolic syndrome such as
hypertension, dyslipidemia, type 2 diabetes,
and cardiovascular diseases. Therefore, a
great number of trials designed to really
affect lifestyle in order to prevent the devel-
opment of diabetes, could represent a good
tool to understand how difficult, expensive
and often ineffective such an intervention
could be.
Recent randomized, controlled studies
have shown that diabetes can be prevented
or delayed in high-risk individuals by inten-
sive lifestyle modification programs. For
example, the Diabetes Prevention Program
(DPP) demonstrated that weight loss and
B. Cresci, and C.M. Rotella
Section of Metabolic Diseases and Diabetes, Department of Clinical Pathophisiology, University of Florence,
Florence, Italy
ABSTRACT. Weight management programs still remain a great challenge as drop out rates
represent a growing problem. It is essential to try and identify the predictors of success, in
order to make a proposal really custom-tailored to the patients. Among the most valuable
applications of valid weight loss prediction models is the early identification of individuals
with the least estimated probability of success, who should be directed to alternative thera-
pies. Equally important are improvements in the matching between treatments and partici-
pants, which are dependent on the measurement of relevant pre-treatment variables. In the
treatment of obesity and in many other pathologies and dependencies, the motivation to
change has an important role both in the period of the weight loss and in the phase of the
maintenance of the result. Therefore, if the patient is considered to be ready to lose weight,
weight loss therapy should be initiated, if not, the immediate goal will be to prevent further
weight gain and explore barriers to weight reduction. Many papers have been published
regarding the measurement of the degree/level of motivation of the patient towards a specific
treatment. Unfortunately, most of these questionnaires have been created and then applied to
different areas; in particular they have been used before starting specific therapies for addic-
tion. Unfortunately, a validated and easy-to-use questionnaire assessing at the meantime
treatment motivation and readiness with adequate predictive capacity for weight loss actually
is not available in most languages, so that empiric non-objective methods continue to be
used. (Eating Weight Disord. 14: e158-e162, 2009).

B. Cresci and C.M. Rotella
moderate physical activity can delay or prevent
the development of diabetes by 58% in high-risk
people. The DPP reported such a reduction in
the incidence of diabetes over almost 3 years in
subjects treated with an intensive lifestyle inter-
vention (ILS), involving changes in diet and
physical activity compared with participants
treated with standard cure/placebo (6, 7). The
DPP enrolled 3234 participants with impaired
glucose tolerance (IGT) and body mass index
(BMI) 24 kg/m
2
. The primary outcome was to
achieve and maintain at least a 7% weight
reduction through a combination of diet and
moderate-intensity physical activity. The pro-
gram included a one-on-one, 16-lesson core
curriculum, followed by monthly maintenance
visits that included both group sessions and
one-on-one visits with case managers. Control
participants received standard lifestyle recom-
mendations through an annual 30-min educa-
tion session. The lifestyle intervention reduced
the incidence by 58% and standard cure plus
metformin by 31%, as compared with control
alone; the lifestyle intervention was therefore
significantly more effective than metformin (8).
An arm including lifestyle intervention plus met-
formin could have undoubtedly provided useful
information on this topic. Unfortunately, the
DPP lifestyle intervention is really a cost-effec-
tive strategy to prevent type 2 diabetes. With
respect to this point, a recent study tried to ana-
lyze the cost-effectiveness of this program using
the Archimedes simulation model. This model
suggests that the DPP intervention costs more
per quality-adjusted life-year saved than previ-
ously estimated, and might be too expensive for
health plans or a national program to be imple-
mented. Nevertheless, lifestyle modification is
likely to have important effects on the morbidity
and mortality of diabetes and should be recom-
mended to all high-risk people. Less expensive
methods are therefore needed to achieve the
degree of weight loss seen in the DPP (9).
Moreover, the key contribution of the recent
studies of ILS and the economic modelling
results (10) is that ILS should clearly be among
the set of treatment options considered for
obese individuals with a discrete number of
high-risk factors. From these and other studies,
designed with the same aims and regarding
lifestyle interventions like the one used in the
DPP, we can learn that it is more important
than ever to plan, evaluate and target every
program using an accurate pre-treatment
screening.
However, further investigations will be
important regarding at least three other issues.
First, no single treatment option is likely to be
the best for all individuals. Therefore, a broad-
er understanding of the incremental cost-effec-
tiveness of different treatments for different
subgroups of high-risk individuals is definitely
desirable. Second, the fact that certain treat-
ments are cost-effective for high-risk individu-
als does not answer the question of the cost-
effectiveness of the same interventions for
lower risk obese individuals, whose treatment
benefits may also be worth the cost. More indi-
vidualized programs have the potential for
higher cost-effectiveness and improved overall
success rates, by targeting specific areas of
concern in selected participants or homoge-
neous groups (11). Third, most of these treat-
ments aimed at the modification of lifestyle
habits are usually imposed more than proposed
and little time is spent in motivating patients to
start such a program.
It is therefore essential to address the research
in this field to try and identify the predictors of
success in weight loss programs, in order to
make a proposal really custom-tailored to the
patients.
PREDICTING LIFESTYLE
CHANGE PROGRAM
SUCCESS/FAILURE
Predicting weight loss outcomes from infor-
mation collected from subjects before they start
weight management programs is a long-stand-
ing desire (12).
Among the most valuable applications of
valid weight loss prediction models is the early
identification of individuals with the least esti-
mated probability of success in a given treat-
ment, who could (and perhaps should) be
directed to alternative therapies. Research
specifically aimed at studying these over-
weight/obese persons, who are more resistant
to current forms of treatment, would be partic-
ularly relevant. Equally important are improve-
ments in the matching between treatments and
participants, which are dependent on the mea-
surement of relevant pre-treatment variables.
Unfortunately, this kind of observations are
essentially based on theoric, and therefore
arbitrary, assumptions rather than on realistic
evaluations.
However, some evidence has shown that indi-
vidual weight change cannot be accurately pre-
dicted, with only a few variables showing posi-
tive results (13, 14). Nevertheless, advances in
theoretical formulations regarding the process
of weight control (15) improved research
methodologies (16), and an increasing number
of variables tested as potential predictors (17)
suggest that further progress is possible.
Motivation and readiness in obesity
A relatively recent review, in fact, points out
that results from original studies published
since 1995 show that fewer previous weight
loss attempts and an autonomous, self-moti-
vated cognitive style are the best prospective
predictors of successful weight management.
In the most obese samples, higher initial BMI
may also be correlated with larger absolute
weight losses. Several variables, including
binge eating, eating disinhibition and restraint,
and depression/mood clearly do not predict
treatment outcomes, when assessed before
treatment. Importantly, for a considerable
number of psychosocial constructs (e.g. eating
self-efficacy, body image, self-esteem, outcome
expectancies, weight-specific quality of life and
several variables related to exercise), evidence
is suggestive, but insufficient for a definitive
conclusion to be drawn (18).
MOTIVATION AND READINESS
Motivation represents the wants, needs and
beliefs that drive a character; the push of the
mental forces to accomplish an action; the feel-
ings that drive someone toward the effort to
achieve a particular goal. The concept of readi-
ness is very close, complementary, but slightly
different and implies the idea of time, i.e. the
time needed to obtain a certain result. In other
words, it is the state of having been made
ready or prepared for use or action, the state of
prompt willingness. .
The concept of motivation to the change or
motivational readiness interests many prob-
lems related to health, like weight control. In
the treatment of obesity and in many other
pathologies and dependencies, the motivation
to change has an important role both in the
period of the weight loss and in the phase of
the maintenance of the result, often of difficult
management. Obesity therapy, to be effective,
must aim at important changes in the lifestyle;
all this demands much time and active involve-
ment of the patient. Sometimes an apparent
motivation to face the treatment is found, but
later on insufficient collaboration during the
therapeutic program together with low grade
flexibility and resistances to the change can
emerge. On the other hand, if a patient intro-
duces obvious difficulties of motivation to the
cure already in the diagnostic phase, it is
mandatory to deepen the problem and deal
with it in order to reinforce the therapeutic
alliance. The insufficient motivation always rep-
resents an obstacle for the success of the treat-
ment, so that the therapist will need to work on
the importance of the motivation, helping the
patient to find advantages and disadvantages
in the process of change. The goals of the ther-
apist should be to promote the development of
the motivation to change if not present, to
maintain a good level of motivation during the
therapeutic iter, to reinforce the motivation of
the patient in the most critical moments or in
case of lapse/relapse. Indeed, it is particularly
important that the degree of motivation of the
subject could be estimated at the very begin-
ning of the program, discussing with the
patient if he really wants to change. During the
treatment, the patient needs to feel he can
maintain and follow the program, being able to
make decisions with serenity, managing to
identify the situations that could act as obsta-
cles to change.
Summarizing, in the treatment of a patient
motivation represents a nodal aspect. A good
motivation to change is essentially based on:
decisional ability (decisional balance), confi-
dence in ones own abilities (self-efficacy), criti-
cal knowledge of at risk situations (situational
temptations) but also critical knowledge of ill-
ness and risk factors related to excessive weight
gain. Time availability undoubtedly represents
an important factor to be pointed out, but time
management strictly depends on most of the fac-
tors previously listed (decisional balance, self-
efficacy, but also social/environmental support).
Other factors that can negatively affect moti-
vation to change could be identified in the age
of the patients entering the program. While
intensive lifestyle programs have been reported
to have positive clinical outcomes in adults, few
studies have reported successful interventions
in children and adolescents. Treatment modali-
ties for children present a unique challenge as
nutrition education, physical activity, and
behavior modification must be presented to
both the parent or caregiver and child, with the
parent or caregiver being the major agent of
change in the family, so that the background
becomes rather different. Talking about factors
affecting motivational readiness we should not
forget the previous lifestyle of the patient,
including both dietary intake and exercise, but
also less previous dieting and fewer weight loss
attempts. We also have to mention their habit
to pay attention to their own body and to spend
some time for themselves, which is tightly
linked to what surrounds them (family, job,
money, etc.), and particularly in the low self-
esteem, in their quality of life and outcome
evaluation (19). Last but not least, the patients
work, the social and family environment should
be considered in deciding if it is a good time to
implement weight loss therapy.
In a few words, good candidates for treat-
B. Cresci and C.M. Rotella
ment are patients who decide they want to lose
weight for appropriate reasons, are not cur-
rently experiencing major life stressors, do not
have psychiatric or medical illnesses that pre-
vent effective weight loss, and are willing to
devote the time needed to make lifestyle
changes. If the patient is considered to be
ready to lose weight, weight loss therapy
should be initiated. If the patient is not ready to
lose weight, the immediate goal will be to pre-
vent further weight gain and explore barriers
to weight reduction (20).
HOW TO ASSESS MOTIVATION
AND READINESS
In the treatment of a patient the motivational
readiness to the cure cannot be misregarded
anymore.
However, dealing with obese people trying to
enter a lifestyle modification program, many
methods have been used to assess patients
readiness/motivation to change. Moreover, the
scenario is quite different if we look at studies
performed not only in primary care/general
practitioners or in specialized clinical settings
but also it strictly depends on the number of
patients enrolled in the study. Therefore we can
find motivation and readiness assessed with a
simple linear ladder, which has the clear limita-
tion of being rather subjective, or using the
Transtheoretical Stages of Change Model cre-
ated by Prochaska and Di Clemente (21) in the
original version or in one of the various
attempts to make it measurable (22).
Many papers have been published regarding
the degree/level of motivation of the patient
towards a specific treatment. Unfortunately,
most of these questionnaires have been creat-
ed and then applied to different areas; in par-
ticular they have been used before starting
speci fi c therapies for addicti on. (smok-
ing/alcohol abuse or drug addiction), and only
quite recently for change in lifestyle in general
(weight-loss, physical activity, treatment for
chronic pathologies such as asthma and dia-
betes, or eating behavior disorders) (23-30).
This is the story, among the others, of one of
the most historic questionnaires, the Deci-
sional Balance Inventory (DBI), consisting of
20 items (10 pro and 10 cons) and of 6 items in
a shorter form, which was firstly used for
smoke dependence based on the concept of
decision making (30, 31) and only afterwards
adapted to the evaluation of the motivation to
lose weight using the combination of the deci-
sional balance and stages of change models
(32). Anyway, this questionnaire has not yet
been validated in most languages, included
Italian.
Another important aspect that should be
investigated before starting the treatment is the
readiness of the patient. The most famous test
used for this purpose was created by Brownell
(33), which is specifically targeted to a patient
entering a weight loss program. This question-
naire has also been translated into Italian, but
this version has not actually been validated (34).
LEAVING THE CRYSTAL
BALL BEHIND: NEED FOR AN
APPROPRIATE VALIDATED TOOL
Undoubtedly, the development of a valid and
comprehensive questionnaire evaluating moti-
vation/readiness and its use as a screening tool
in obesity treatment may represent additional
outcomes in this field (33). Although the study
of readiness for weight loss has been frequent-
l y recommended over the past 20 years,
including more recently in the National Insti-
tutes of Healths The Practical Guide to the
Identification, Evaluation, and Treatment of
Overweight and Obesity in Adults (20), and in
many evidence-based clinical practice guide-
lines regarding the assessment and treatment
of obesity and overweight in adults, a validated
and easy-to-use questionnaire assessing at the
meantime treatment motivation and readiness
with adequate predictive capacity for weight
loss is actually not available in most languages,
so that often empiric non-objective methods
continue to be used.
REFERENCES
1. Brownell K.D., Kramer M.: Behavioral management of
obesity. Med. Clin. North Am., 73, 185-201, 1989.
2. Wadden T.A., Foster G.D.: Behavioral treatment of
obesity. Med. Clin. North. Am., 84, 441-461, 2000.
3. Inelmen E.M., Toffanello E.D., Enzi G., Gasparini G.,
Miotto F., Sergi G., Busetto L.: Predictors of drop out
in overweight and obese outpatients. Int. J. Obes., 29,
122-128, 2005.
4. Cresci B., Tesi F., La Ferlita T., Ricca V., Ravaldi C.,
Rotella C.M., Mannucci E.: Group versus individual
cognitive-behavioral treatment for obesity: results after
36 months. Eat. Weight Disord., 12, 147-153, 2007.
5. Astrup A., Rossner S.: Lessons from obesity manage-
ment programs: greater initial weight loss improves
long-term maintenance. Obes. Rev., 1, 17-19, 2000.
6. Knowler W.C., Barrett-Connor E., Fowle S.E.,
Hamman R.F., Lachin J.M., Walker E.A., Nathan D.M.,
for the Diabetes Prevention Program Group:
Reduction in the incidence of type 2 diabetes with
lifestyle intervention or metformine. N. Engl. J. Med.,
346, 393-403, 2002.
7. Hamman R.F., Wing R.R., Edelstein S.L., Lachin J.M.,
Motivation and readiness in obesity
Bray G.A., Delahanty L.A., Hoskin M., Kriska A.M.,
Mayer-Davis E., Pi-Sunyer X., Regensteiner J., Venditti
B., Wylie-Rosett J., for the Diabetes Prevention
Program Research Group: Effect of weight loss with
lifestyle intervention on risk of diabetes. Diabetes Care,
29, 21022107, 2006.
8. The Diabetes Prevention Program Research Group:
The Diabetes Prevention Program (DPP): description of
lifestyle intervention. Diabetes Care, 25, 2165-2171,
2002.
9. Eddy D.M., Schlessinger L., Khan R.: Clinical outcomes
and cost-effectiveness of strategies for managing peo-
ple at high risk of diabetes. Ann. Int. Med.,143, 251-
264, 2005.
10. Avenell A., Broom J., Brown T.J., Poobalan A., Aucott
L., Stearns S.C., Smith W.C.S., Jung R.T., Campbell
M.K., Grant A.M.: Systematic review of the long-term
effects and economic consequences of treatments for
obesity and implications for health improvement.
Health Technol. Assess., 8, n. 21, iii-iv, 2004.
11. Brownell K.D., Wadden T.A.: The heterogeneity of
obesity: fitting treatments to individuals. Behav. Ther.,
22, 153-177, 1991.
12. Weiss A.R.: Characteristics of successful weight reduc-
ers: a brief review of predictor variables. Addict.
Behav., 2, 193-201, 1977.
13. Wadden T.A., Letizia K.A.: Predictors of attrition and
weight loss in patients treated by moderate to severe
caloric restriction. In: Wadden T.A., Van-Itallie T.B.
(Eds.), Treatment of the seriously obese patient. New
York, NY, The Guilford Press, 1992, pp. 383-4104.
14. Wilson G.T.: Behavioral and psychological predictors
of treatment outcome in obesity. In: Allison D.A., Pi-
Sunyer F.X. (Eds.), Obesity treatment: establishing
goals, improving outcomes, and reviewing the
research agenda. New York, Plenum Press, 1995, pp.
183-189.
15. Cooper Z., Fairburn C.G.: On the other hand, a new
cognitive behavioural approach to the treatment of
obesity. Behav. Res. Ther., 39, 499-511, 2001.
16. Kraemer H.C., Wilson G.T., Fairburn C.G., Agras
W.S.: Mediators and moderators of treatment effects
in randomized clinical trials. Arch. Gen. Psychiatry, 59,
877-883, 2002.
17. Teixeira P.J., Going S.B., Houtkooper L.B., Cussler
E.C., Martin C.J., Metcalfe L.L., Finkenthal N.R., Blew
R.M., Sardinha L.B., Lohman T.G.: Weight loss readi-
ness in middle-aged women: psychosocial predictors
of success for behavioral weight reduction. J. Behav.
Med., 25, 499-523, 2002.
18. Teixeira P.J., Going S.B., Sardinha L.B., Lohman T.G.:
A review of psychosocial pre-treatment predictors of
weight control. Obes. Rev., 6, 4365, 2005.
19. Texeira P.J., Palmeira A.L., Branco T.L., Martins S.S.,
Minderico C.S., Barata J.T., Silva A.M., Sardinha L.B.:
Who wil lose weight? A reexamination of predictors of
weight loss in women. Int. J. Behav. Nutr. Phys. Act., 1,
12, 2004.
20. NHLBI Obesity Education Initiative and North
American Association for the Study of Obesity. The
practical guide. Identification, evaluation, and treat-
ment of overweight and obesity in adults. NIH publica-
tion n. 00-4084, October 2000.
21. Prochaska J.O., Di Clemente C.C.: Stages and process-
es of self-change of smoking: Toward an integrative
model of change. J. Consult. Clin. Psychol., 51, 390-
395, 1983.
22. Derisley J., Reynolds S.: Evaluation of the stages of
change scales to measure client readiness for treat-
ment in a mental health sample. Behav. Cogn.
Psychother., 30, 217222, 2002.
23. McConnaughy B.A., Prochaska J.O., Velicer W.F.:
Stages of change in psychotherapy Measurement and
sample profiles. Psychotherapy: Theory, Research, and
Practice, 20, 368-375, 1983.
24. Geller J., Drab D.L.: The readiness and motivation
interview: a symptom-specific measure of readiness
for change in the eating disorders. Eur. Eat. Disord.
Rev., 7, 259-278, 1999.
25. Miller W.R., Tonigan J.S.: Assessing drinkers motiva-
tion for change: The Stages of Change Readiness and
Treatment Eagerness Scale (SOCRATES). Psychol.
Addict. Behav., 10, 81-89, 1996.
26. Spiller V., Zavan V., Guelfi G.P.: Assessing motivation
for change in subjects with alcohol problems: the
MAC2-A questionnaire. Alcohol Alcohol, 41, 616-623,
2006.
27. Dishman R.K., Ickes W.: Self-motivation and adher-
ence to therapeutic exercise. J. Behav. Med., 4, 421-
438, 1981.
28. Velicer W.F., Di Clemente C.C., Prochaska J.O.,
Brandenburg N.: Decisional balance measure for
assessing and predicting smoking status. J. Pers. Soc.
Psychol., 48, 1279-1289, 1985.
29. Fava J.L., Rossi J.S., Velicer W.F., Prochaska J.O.:
Structural confirmation of short form instruments for
the transtheoretical model. Paper presented at the 99th
Annual Meeting of the American Psychological
Association, San Francisco, CA, 1991.
30. Ward R.M., Velicer W.F., Rossi J.S., Fava J.L.,
Prochaska J.O.: Factorial Invariance and Internal
Consistency for the Decisional Balance Inventory -
Short Form. Addict. Behav., 29, 953-958, 2004.
31. Velicer W.F., DiClemente C.C., Prochaska J.O. ,
Brandenburg N.: Decisional balance measure for
assessing and predicting smoking status. J. Pers. Soc.
Psychol., 48, 1279-1289, 1985.
32. O'Connell D., Velicer W.F.: A decisional balance mea-
sure and the stages of change model for weight loss.
Int. J. Addict., 23, 729-750, 1988.
33. Brownell K.D..: Dieting readiness. Weight Control
Dig., 1, 5-10, 1990.
34. Dalle Grave R.: Sono pronto a perdere peso. In: Il peso
ragionevole settimana per settimana. Verona, Positive
Press, 1997, pp. 25-29.
35. Fontaine K.R., Cheskin L.J., Allison D.B.: Predicting
treatment attendance and weight loss: assessing the
psychometric properties and predictive validity of the
Dieting Readiness Test. J. Pers. Assess., 68, 173-183,
1997.
e163
BRIEF
REPORT
Key words:
Anorexia nervosa, trait
anxiety, social anxiety, eating
disorder psychopathology.
Correspondence to:
Dr. Ulrike M.E. Schulze,
Department of Child
and Adolescent
Psychiatry/Psychotherapy,
University of Ulm,
Steinhvelstrasse 5,
D-89075 Ulm, Germany.
e-mail:
ulrike.schulze@uniklinik-ulm.de
Trait anxiety in children and
adolescents with anorexia nervosa
INTRODUCTION
In various ways, anxiety is a major feature
of anorexia nervosa (AN). First, the core
psychopathological feature is the dread of
fatness which has been called also weight
phobia or fear of becoming fat. In addition,
anxiety is present at various stages of the
disorder. Many patients already show pre-
morbid symptoms of anxiety (1, 2). Prior to
the manifestation of the eating disorder a
sizeable number of patients have difficulties
in separating from their caregivers (3).
Moreover, there are correlations of pre-
morbid anxiety with an early onset of the
eating disorder (3).
Furthermore, comorbid anxiety symp-
toms and disorders are quite common in AN
(1, 4-7). A large proportion of patients is suf-
fering from maturity fears (8) and up to
some 50% of the patients fulfil criteria for
social phobia (SP) (4, 9, 10). Life-time preva-
lence for generalized anxiety disorder (GAD)
has been reported to range between 24 and
31% (4, 11). About two thirds of all patients
with AN tend to show at least one lifetime
anxiety disorder, most often before the first
onset of a major depressive episode (12).
In addition, recent aetiological studies
point to anxiety as a contributing factor to
AN. Genetic studies have provided some
evidence of a shared transmission of anxi-
ety and eating disorder symptoms (13). It
has also been hypothesized that in addition
to certain temperamental features and per-
sonality traits fear conditioning plays a
major role in females with AN (14-16)
Finally, long-term outcome studies of AN
show that both affective disorders and anxi-
ety disorders are the most common long-
term other psychiatric disorders (17). Thus,
anxiety serves as a vulnerability factor both
for the development and the maintenance
of AN (1, 18).
Most of the current knowledge on the
association of anxiety and AN stems from
studies in adult patients, little is known
about anxiety as a personality feature and a
comorbid condition in children and adoles-
cents suffering from AN. Therefore, the
present pilot study assessed trait and state
anxiety in a series of children and adoles-
cents suffering from AN. Within this per-
spective, the association between severity
of AN as reflected by the body mass index
(BMI), eating disorder psychopathology,
and anxiety was also studied.
METHOD
Sample
We investigated a sample of 23 female
inpatients aged 10 to 18 years [mean=14.69;
U.M.E. Schulze
1
, S. Calame
2
, F. Keller
3
, and C. Mehler-Wex
4
Departments of Child and Adolescent Psychiatry and Psychotherapy, Universities of
1
Ulm and
2
Wrzburg,
Germany
ABSTRACT. In this study of trait anxiety in children and adolescents with anorexia nervosa,
a consecutive series of 23 newly admitted children and adolescents with anorexia nervosa
was studied by use of the State-Trait-Anxiety-Inventory, the Eating Disorders Inventory
(EDI), the Social Phobia and Anxiety Inventory for Children (SPAI-C), and a structured psy-
chiatric interview (DIPS: Diagnostisches Interview bei psychischen Strungen). In addition,
clinical diagnoses were taken from the files. Trait anxiety was significantly increased at the
time of admission and social phobia was present in a large proportion of the patients. Specif-
ic eating disorder psychopathology as measured by the EDI was significantly associated with
trait anxiety. There were no clinical diagnoses (according to the International Classification of
Diseases - Tenth Revision) of anxiety disorders. Features of anxiety are very common in
young patients with anorexia nervosa and closely linked to specific psychopathology. Anxi-
ety disorders need careful evaluation in these patients.

Anxiety in anorexia nervosa
standard deviation (SD)=1.54] who were con-
secutively admitted for the first time at the
Department of Child and Adolescent Psychiatry
and Psychotherapy, University of Wrzburg,
Germany. Treatment lasted for 14-202 days
(mean=84.93, SD=44.35). All patients fulfilled
International Classification of Diseases - Tenth
Revision (ICD-10) diagnostic criteria for AN.
Mean BMI of the patients was 14.70 kg/m
2
(SD=1.58) and mean intelligence quotient (IQ)
was 105.97 (SD=10.02, range=89-124).
Procedure
Eating disorder psychopathology and severity
Self assessment of eating disorder psy-
chopathology was based on the German ver-
sion of the Eating Disorder Inventory (EDI) (19-
22). The 8 subscales of the EDI are called: drive
for thinness, bulimia, body dissatisfaction, inef-
fectiveness, perfectionism, interpersonal dis-
trust, interoceptive awareness and maturity
fears. Validation of the original version was
carried out using a sample of 113 anorexic
patients and 577 female controls. As an indica-
tor of severity of the eating disorder, the BMI
at the time of admission was assessed.
Trait anxiety
Trait anxiety was studied by use of the Ger-
man adaptation (23) of the State-Trait-Anxiety
Inventory (STAI) (24-27). This questionnaire
contains two scales for the assessment of anxi-
ety as a state and as a trait and provides norms
only for trait anxiety because of varying condi-
tions for state anxiety. German norms were
based on a sample of 2385 subjects. There are
three gender-specific subgroups with the
youngest group aged 15 to 29 years. The total
scores of the trait subscale range from 20 to 80.
Assessment of co-existing symptoms
Social phobic symptoms were studied by use
of the German version (28, 29) of the Social
Phobia and Anxiety Inventory for Children
(SPAI-C) (30, 31). A cut-off of 20 allows for the
differentiation between social phobic and
healthy subjects. German norms are available
for children and adolescents aged 8 to 16 years.
Eight of our patients were aged 17 to 18 years.
Norms for 16 year olds were used also for these
patients. The standardization of the German
version of the SPAI-C is based on a sample of
1197 students (normative sample) and 145 chil-
dren and adolescents with a psychiatric disor-
der (e.g. anxiety disorders, eating disorders,
attention deficit hyperactivity disorder, conduct
disorder). The mean age of these patients was
13.29 years (2.86). In addition, both parents
were interviewed for their childs history of
anxiety disorders and personal losses based on
a structured interview (DIPS) (32).
All statistical computations were based on
SPSS version 11.0 and the SAS program. Pear-
son correlations and t-tests were calculated.
Because of multiple comparisons Bonferroni
correction of the level of significance was car-
ried out and resulted in an adjusted level of
p0.0002.
RESULTS
In this sample, 18 patients (75%) scored
above the 50th percentile for trait anxiety. A
comparison of the present sample with the nor-
mative group revealed that the patients with
AN had significantly higher scores on both
anxiety scales (Table 1).
According to SPAI-C criteria, 8 of the
patients fulfilled criteria for SP and 14 of the
patients scored above the 50
th
percentile. The
AN sample (mean-17.4, SD=9.7) had signifi-
cantly higher scores than the controls
(mean=12.51, SD=7.87; t=2.53, df=1212,
p=0.006) but did not differ from the clinical
sample (mean=16.52, SD=10.77; t=0.32; df=160,
NS). History findings based on the structured
psychiatric interview (DIPS: Diagnostisches
Interview bei psychischen Strungen) showed
that early separation anxiety had been present
in 12 patients (44.4%). According to the criteria
of this interview, and except for one girl, all of
them turned out to fulfil criteria for social pho-
bia at the time of parents questioning. Loss of
a friendship or grandparent was reported in 6
of the cases (22.2%).
Clinical diagnoses in addition to the eating
disorder as documented in the files were dys-
thymia (6.9%), depressive episode (24.1%),
organic depression (3.5%) and obsessive-com-
pulsive disorder (3.5%). In 52% of the patients
there was no comorbid psychiatric diagnosis
TABLE 1
State-Trait-Anxiety Inventory (STAI) findings in anorexia nervosa
(AN) patients and controls.
AN (N=23) Controls (N=342) t (df) p
Trait anxiety
Mean (SD) 43,30 (13,2) 35,65 (9,8) 2,73 (23) 0,012
State anxiety
Mean (SD) 46,00 (14,5) 36,95 (10,3) 2.94 (23) 0,007
AN: study group; controls: normative sample; SD: standard deviation.
U.M.E. Schulze, S. Calame, F. Keller, et al.
and there was not a single case with a comor-
bid anxiety disorder.
There were no significant correlations of BMI
at admission to the number of anxiety symptoms
(state anxiety: r=0.14, trait anxiety: r=0.23, social
phobia: r=-.19). In contrast, there were signifi-
cant correlations between trait anxiety and
social phobic symptoms (r=0.64; p<0.01) and
between trait and state anxiety (r=0.78; p<0.002).
As Table 2 shows, state anxiety was signifi-
cantly associated with drive for thinness,
body dissatisfaction, ineffectiveness, per-
fectionism, interpersonal distrust, and inte-
roceptive awareness. In addition, trait anxiety
significantly correlated with scores measuring
drive for thinness, bulimia, body dissatis-
faction, ineffectiveness, perfectionism,
interpersonal distrust and interoceptive
awareness of the EDI, whereas there was no
significant correlation with maturity fears. All
correlations indicate that there is a positive
association between trait anxiety and eating
disorder psychopathology.
DISCUSSION
The present study based on a clinical sample
of rather young patients suffering from AN
provides evidence that trait anxiety is signifi-
cantly elevated at the time of admission.
In addition, dimensional criteria for the pres-
ence of SP are fulfilled in a large proportion of
these patients. However, the latter finding is
not specific to AN because there were no sig-
nificant differences between this sample and
the clinical sample as assessed by Melfsen et al.
(33) (even though some significance levels in
Table 2 do not fulfil the strict Bonferroni crite-
ria, they do fulfil conventional criteria). Fur-
thermore, in patients suffering from AN these
social phobic symptoms should not be mistak-
en as an expression of alexithymia as Turk et al.
(34) have pointed out.
Findings on trait anxiety could reflect an
early form of existential anxiety in anorexic
patients, which is defined as a characteristic
reaction to a lack of meaning and becomes
manifest in a disorder specific psychopatholo-
gy (35). Trait anxiety is defined as a disposition
to unspecific fear responses without time limi-
tation. Considering developmental aspects, it is
conceivable, that in younger individuals, safety
behaviours and cognitive avoidance strategies
suggested as potential mechanisms linking
anxiety and eating disorders (36) are to a
greater or lesser extent unconsciously used to
cope with an omnipresent fearfulness. This is
in accordance with the results of Fox and
Leung (35), who revealed significant relation-
ships between eating disorder symptoms and
existential well-being only up to an age of 31
years (the older of two adult anorexia groups).
In this context, it is also noteworthy that we
didnt find a significant correlation between the
trait anxiety of our patients and their maturity
fears (EDI). Other important links between
(trait) anxiety and AN are presumably trait
related and also heritable psychobiological
alterations, most notably pertaining to the
brain serotonin (5-HT) function (2, 37-40).
In the present study, structured psychiatric
interviews revealed that premorbid separation
anxiety disorders (SAD) were quite common
and that almost all of these patients showed
social phobia (SP) in addition to AN at the time
of admission. The increased rate of SP is very
much in accordance with findings from other
studies based on adolescent and adult patients
(1, 5, 41). In addition, further studies point to a
rather strong association of AN with other anx-
iety disorders. In a study based on adult
patients by Milos et al. (6), anxiety disorders
were the most common Axis I diagnoses,
whereas cluster C (anxious-fearful) was the
most common Axis II diagnosis. In another
study based on adult females with eating disor-
ders, Bulik et al. (3) also found a high rate of
separation anxiety disorders in childhood
(17.7%). However, in contrast to the strong
TABLE 2
Correlations between Eating Disorders Inventory (EDI) subscales
and anxiety scales.
State anxiety Trait anxiety SPAI-C-D
(N=23) (N=23) (N=17)
EDI 1
drive for thinness 0.41* 0.73*** -0.15
EDI 2
bulimia 0.36 0.59** 0.63
EDI 3
body dissatisfaction 0.49* 0.68** 0.06
EDI 4
ineffectiveness 0.72*** 0.72*** 0.56*
EDI 5
perfectionism 0.62** 0.66** 0.48
EDI 6
interpersonal distrust 0.69*** 0.76*** 0.80***
EDI 7
interoceptive awareness 0.80*** 0.87*** 0.43
EDI 8
maturity fears 0.22 0.29 0.15
*p<0.05; **p<0.01; ***p<0.0002.
SPAI-C-D: Social Phobia and Anxiety Inventory for Children.
association of SAD and SP in the present study
only one third of the sample of the study by
Bulik et al. (3) developed social phobic symp-
toms after a mean interval of 9 years. SAD was
assessed only retrospectively in both studies
and differences in age and informants may well
account for the different findings of the two
studies.
Unfortunately, comorbid SP was not diag-
nosed in a single case based on unstructured
clinical interviews so that an important clinical
phenomenon was not sufficiently recognized.
This clinical neglect may have several serious
consequences. First, these obviously unrecog-
nized symptoms could have acted as a treat-
ment barrier as has been shown in a study by
Goodwin and Fitzgibbon (42). Furthermore,
there is evidence that symptoms of anxiety may
lead to parasuicidal behaviour in eating disor-
der patients as shown in the study by Wildman
et al. (43). The latter study also found that the
anxiety disorder in most cases preceded the
onset of the eating disorder. Finally, there may
be an association to substance abuse disorders.
In a multi-center study of comorbid alcohol use
disorders and eating disorders it was found
that anxiety is part of a phenotypic profile that
includes also perfectionistic traits and impul-
sive, dramatic dispositions (44).
When the association of state and trait anxi-
ety with clinical features of anorexia nervosa
was studied, there was no significant correla-
tion with BMI. In contrast, most of the EDI
scales measuring specific eating disorder psy-
chopathology were significantly associated
with trait anxiety indicating a close positive link
between these features. Similar findings have
been obtained also in more than half of a large
sample of adult eating disordered patients stud-
ied by Milos et al. (6). In the latter sample, 5 out
of the 8 EDI subscales showed strong associa-
tions with comorbid Axis I diagnoses. Changes
in trait and state anxiety may also be relevant
during recovery from AN. In a small series of 8
adolescent patients significant improvements of
STAI scores and the EDI subscale measuring
interoceptive awareness were observed in par-
allel to weight restoration (45). Furthermore,
drive for thinness was predicted by heightened
social anxiety even in a sample of non-clinical
women (46). Finally, there is some evidence that
anxiety and malnutrition contribute to a syn-
drome-specific vicious cycle (47).
Limitations of the present study include the
relatively small sample size and the absence of
a structured interview for eating or anxiety dis-
order. Concerning the available reference data
for the used instruments, the age spectrum of
our sample was broad (48). The existing Ger-
man version of the State Trait Anxiety Invento-
ry for Children (STAI-C) (49), which is validated
(N=219) for the age span from 8 to 16, is not
commercially available. Therefore we used the
STAI (23), and results must be interpreted care-
fully. Nevertheless, the questions were compre-
hensible also for the younger adolescents.
In conclusion, features of anxiety are very
common in patients with AN of all ages. In the
present sample of young patients, these symp-
toms and diagnoses did not receive sufficient
consideration in routine clinical examination.
However, there is a close association to a broad
range of eating disorder specific psychopathol-
ogy and there is sufficient evidence that the
course and outcome of AN is strongly influ-
enced by anxiety (7). Thus, anxiety needs to be
addressed in the process of both assessment
and treatment of AN.
ACKNOWLEDGEMENTS
We want to express our gratitude to Prof. Dr. A.
Warnke and Prof. Dr.Dr. H.-C. Steinhausen for their
helpful support and advice.
REFERENCES
1. Kaye W.H., Bulik C.M., Thornton L., Barbarich N.,
Masters K.: Comorbidity of anxiety disorders with
anorexia and bulimia nervosa. Am. J. Psychiatry, 161,
2215-2221, 2004.
2. Raney T.J., Thornton L.M., Berrettini W., Brandt H.,
Crawford S., Fichter M.M., Halmi K.A., Johnson C.,
Kaplan A.S., LaVia M., Mitchell J., Rotondo A., Strober
M., Woodside D.B., Kaye W.H., Bulik C.M.: Influence
of overanxious disorder of childhood on the expres-
sion of anorexia nervosa. Int. J. Eat. Disord., 41, 326-
332, 2008.
3. Bulik C.M., Sullivan P.F., Fear J.L., Joyce P.R.: Eating
disorders and antecedent anxiety disorders: a con-
trolled study. Acta Psychiatr. Scand., 96, 101-107, 1997.
4. Godart N.T., Flament M.F., Lecrubier Y., Jeammet P.:
Anxiety disorders in anorexia nervosa and bulimia
nervosa: co-morbidity and chronology of appearance.
Eur. Psychiatry, 15, 38-45, 2000.
5. Hinrichsen H., Waller G., Emanuelli F.: Social anxiety
and coping strategies in the eating disorders. Eat.
Behav., 4, 117-126, 2003.
6. Milos G.A., Spindler U., Schnyder U.: Psychiatric
comorbidity and Eating Disorder Inventory (EDI) pro-
files in eating disorder patients. Can. J. Psychiatry, 49,
179-184, 2004.
7. Salbach-Andrae H., Lenz K., Simmendinger N.,
Klinkowski N., Lehmkuhl U., Pfeiffer E.: Psychiatric
comorbidities among female adolescents with anorexia
nervosa. Child Psychiatry Hum. Dev., 39, 261-272, 2008.
8. Atkins D.M., Silber T.J.: Clinical spectrum of anorexia
nervosa in children. J. Dev. Behav. Pediatr., 14, 211-
216, 1993.
9. Lucka I.: Anxiety disorders in children suffering from
anorexia nervosa. Psychiatr. Pol., 40, 83-97, 2006.
U.M.E. Schulze, S. Calame, F. Keller, et al.
10. Godart N., Perdereau F., Curt F., Rein Z., Lang F.,
Venisse J.L., Halfon O., Bizouard P., Loas G., Corcus
M., Jeammet P., Flament M.F.: Comorbidity of anxiety
with eating disorders and OCD. Am. J. Psychiatry, 163,
326; author reply 327-329, 2006.
11. Lilenfeld L.R., Kaye W.H., Greeno C.G., Merikangas
K.R., Plotnicov K., Pollice C., Rao R., Strober M., Nagy
L.: A controlled family study of anorexia nervosa and
bulimia nervosa: psychiatric disorders in first-degree
relatives and effects of proband comorbidity. Arch.
Gen. Psychiatry, 55, 603-10, 1998.
12. Godart N.T., Perdereau F., Curt F., Rein Z., Lang F.,
Venisse J.L., Halfon O., Bizouard P., Loas G., Corcus
M., Jeammet P., Flament M.F.: Is major depressive
episode related to anxiety disorders in anorexics and
bulimics? Compr. Psychiatry, 47, 91-98, 2006.
13. Keel P.K., Klump K., Miller K.B., McGue M., Iacono
W.G.: Shared transmission of eating disorders and
anxiety disorders. Int. J. Eat. Disord., 38, 99-105, 2005.
14. Lilenfeld L.R., Wonderlich S., Riso L.P., Crosby R.,
Mitchell J.: Eating disorders and personality: a
methodological and empirical review. Clin. Psychol.
Rev., 26, 299-320, 2006.
15. Strober M.: Pathologic fear conditioning and anorexia
nervosa: on the search for novel paradigms. Int J Eat
Disord., 35, 504-508, 2004.
16. Strober M., Freeman R., Lampert C., Diamond J.,
Teplinsky C., DeAntonio M.: Are there gender differ-
ences in core symptoms, temperament, and short-term
prospective outcome in anorexia nervosa? Int. J. Eat.
Disord., 39, 570-575, 2006.
17. Steinhausen H.C.: The outcome of anorexia nervosa in
the 20th century. Am. J. Psychiatry, 159, 1284-1293, 2002.
18. Yackobovitch-Gavan M., Golan M., Valevski A.,
Kreitler S., Bachar E., Lieblich A., Mitrani E., Weizman
A., Stein D.: An integrative quantitative model of fac-
tors influencing the course of anorexia nervosa over
time. Int. J. Eat. Disord., 42, 306-317, 2009.
19. Thiel A., Paul T.: Entwicklung einer deutschsprachigen
Version des Eating-Disorder-Inventory (EDI).
Zeitschrift fr Differentiel le und Diagnostische
Psychologie, 9, 267-278, 1988.
20. Garner D.M., Olmsted M.P., Polivy J., Garfinkel P.E.:
Comparison between weight-preoccupied women and
anorexia nervosa. Psychosom. Med., 46, 255-266, 1984.
21. Rathner G., Rumpold G.: Convergent validity of the
eating disorder inventory and the anorexia nervosa
inventory for self-rating in an Austrian nonclinical
population. Int. J. Eat. Disord., 16, 381-393, 1994.
22. Garner D.M., Olmstedt M.P., Polivy J.: Development
and validation of a multidimensional Eating Disorder
Inventory for Anorexia and Bulimia. Int. J. Eat.
Disord., 2, 14-34, 1983.
23. Laux L., Glanzmann P., Schaffner P., Spielberger C.D.:
Das State-Trait-Angstinventar. Theoretische Grund-
lagen und Handanweisungen. Wienheim, Beltz-
Testgesellschaft, 1981.
24. Auerbach S.M., Spielberger C.D.: The assessment of
state and trait anxiety with the Rorschach test. J. Pers.
Assess., 36, 314-335, 1972.
25. Blankstein K.R.: Relationships between Spielberger
trait anxiety and Lykken social and physical trait anxi-
ety. J. Clin. Psychol., 32, 781-782, 1976.
26. Papay J.P., Spielberger C.D.: Assessment of anxiety
and achievement in kindergarten and first- and sec-
ond-grade children. J. Abnorm. Child Psychol., 14,
279-286, 1986.
27. Spielberger C.D., Gorsuch R.L., Lushene R.E.: Manual
for the State-Trait-Anxiety Inventory. Palo Alto,
California, Consulting Psychologist Press, 1970.
28. Melfsen S., Florin I., Walter H.-J.: Die deutsche
Fassung des Social Phobia and Anxiety Inventory for
Children (SPAI-C-D): Psychometrische Eigenschaften
und Normierung. Diagnostica, 45, 95-103, 1999.
29. Melfsen S., Florin I., Warnke A.: SPAIK. Sozialphobie
und angstinventar fr Kinder. Gttingen, Hogrefe,
2001.
30. Morris T.L., Masia C.L.: Psychometric evaluation of the
social phobia and anxiety inventory for children: con-
current validity and normative data. J. Clin. Child
Psychol., 1998, 27, 452-458.
31. Beidel D.C., Turner S.M., Morris T.L.: Social Phobia
and Anxiety Inventory for Children. Toronto, Multi
Health Systems, 1998.
32. Unnewehr S., Schneider S., Margraf J.: Kinder-DIPS,
Diagnostisches Interview bei psychischen Strungen
im Kindes- und Jugendalter. Berlin, Springer-Verlag,
1995.
33. Melfsen S., Walitza S., Warnke A.: The extent of social
anxiety in combination with mental disorders. Eur.
Child Adolesc. Psychiatry, 15, 111-117, 2006.
34. Turk C.L., Heimberg R.G., Luterek J.A., Mennin D.S.,
Fresco D.M.: Emotion dysregulation in generalized
anxiety disorder: a comparison with social anxiety dis-
order. Cogn. Ther. Res., 29, 89-106, 2005.
35. Fox A.P., Leung N.: Existential well-being in younger
and older people with anorexia nervosa--a preliminary
investigation. Eur. Eat. Disord. Rev., 17, 24-30, 2009.
36. Pallister E., Waller G.: Anxiety in the eating disorders:
understanding the overlap. Clin. Psychol. Rev., 28, 366-
386, 2008.
37. Bailer U.F., Frank G.K., Henry S.E., Price J.C., Meltzer
C.C., Weissfeld L., Mathis C.A., Drevets W.C., Wagner
A., Hoge J., Ziolko S.K., McConaha C.W., Kaye W.H.:
Altered brain serotonin 5-HT1A receptor binding after
recovery from anorexia nervosa measured by positron
emission tomography and [carbonyl11C]WAY-100635.
38. Silberg, J.L., Bulik, C.M.: The developmental associa-
tion between eating disorders symptoms and symp-
toms of depression and anxiety in juvenile twin girls. J.
Child Psychol. Psychiatry, 46, 1317-1326, 2005.
39. Jacobs M.J., Roesch S., Wonderlich S.A., Crosby R.,
Thornton L., Wilfley D.E., Berrettini W.H., Brandt H.,
Crawford S., Fichter M.M., Halmi K.A., Johnson C.,
Kaplan A.S., Lavia M., Mitchell J.E., Rotondo A.,
Strober M., Woodside D.B., Kaye W.H., Bulik C.M.:
Anorexia nervosa trios: behavioral profiles of individu-
als with anorexia nervosa and their parents. Psychol.
Med., 26, 1-11, 2008.
40. Kaye, W.: Neurobiology of anorexia and bulimia ner-
vosa. Physiol. Behav., 94, 121-135, 2008.
41. Godart N.T., Perdereau F., Curt F., Lang F., Venisse
J.L., Halfon O., Bizouard P., Loas G., Corcos M.,
Jeammet P., Flament M.F.: Predictive factors of social
disability in anorexic and bulimic patients. Eat. Weight
Disord., 9, 249-257, 2004.
42. Goodwin R.D., Fitzgibbon M.L.: Social anxiety as a
barrier to treatment for eating disorders. Int. J. Eat.
Disord., 32, 103-106, 2002.
43. Wildman P., Lilenfeld L.R.R., Marcua M.D.: Axis I
comorbidity onset and parasuicide in women with eat-
ing disorders. Int. J. Eat. Disord., 35, 190-197, 2004.
44. Bulik C.M., Klump K., Thornton L., Kaplan A., Devlin
B., Fichter M.M, Halmi K., Strober M., Woodside
D.B., Crow S., Mitchell J.E., Rotondo A., Mauri M.,
Cassano G.B., Keel P.K., Berrettini W.H., Kaye W.H.:
Alcohol use disorder comorbidity in eating disorders:
a multicenter study. J. Clin. Psychiatry, 65, 1000-1006,
2004.
45. Matsumoto, R., Kitabayashi Y., Narumoto J., Wada Y.,
Okamoto A., Ushijima Y., Yokoyama C., Yamashita T.,
Takahashi H., Yasuno F., Suhara T., Fukui K.: Regional
cerebral blood flow changes associated with interocep-
tive awareness in the recovery process of anorexia ner-
vosa. Prog. Neuropsychopharmacol. Biol. Psychiatry,
30, 1265-1270, 2006.
46. Gilbert N., Meyer C.: Social anxiety and social compar-
ison: differential links with restrictive and bulimic atti-
tudes among nonclinical women. Eat. Behav., 4, 257-
264, 2003.
47. Pollice C., Kaye W.H., Greeno C.G., Weltzin T.E.:
Relationship of depression, anxiety, and obsessionality
to state of illness in anorexia nervosa. Int. J. Eat.
Disord., 21, 367-376, 1997.
48. Oskis A., Loveday C., Hucklebridge F., Thorn L., Clow
A.: Diurnal patterns of salivary cortisol across the ado-
lescent period in healthy females. Psychoneuro-
endocrinology, 34, 307-316, 2009.
49. Unnewehr S., Joormann J., Schneider S., Margraf J.:
Deutsche bersetzung des State-Trait-Anxiety Inventory
for Children. Unverffentlichtes Manuskript. 1992.

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