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Eating Disorder Behaviors Are Increasing- Findings from

Eating Disorder Behaviors Are Increasing- Findings from

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Eating Disorder Behaviors Are Increasing: Findings fromTwo Sequential Community Surveys in South Australia
Phillipa J. Hay
, Jonathan Mond
, Petra Buttner
, Anita Darby
School of Medicine, University of Western Sydney, Sydney, Australia,
School of Psychological Science, La Trobe University, Melbourne, Victoria,Australia,
School Public Health, Tropical Medicine and Rehabilitation Science, James Cook University, Townsville, Queensland, Australia,
Disciplineof Psychiatry, School of Medicine, James Cook University, Townsville, Queensland, Australia
Evidence for an increase in the prevalence of eating disorders is inconsistent. Our aim was to determine changein the population point prevalence of eating disorder behaviors over a 10-year period.
Methodology/Principal Findings.
Eating disorder behaviors were assessed in consecutive general population surveys of men and women conducted in 1995(n=3001, 72% respondents) and 2005 (n=3047, 63.1% respondents). Participants were randomly sampled from households inrural and metropolitan South Australia. There was a significant (all p
0.01) and over two-fold increase in the prevalence of binge eating, purging (self-induced vomiting and/or laxative or diuretic misuse) and strict dieting or fasting for weight orshape control among both genders. The most common diagnosis in 2005 was either binge eating disorder or other ‘‘eatingdisorders not otherwise specified’’ (EDNOS; n=119, 4.2%).
In this population sample the pointprevalence of eating disorder behaviors increased over the past decade. Cases of anorexia nervosa and bulimia nervosa, ascurrently defined, remain uncommon.
Citation: Hay PJ, Mond J, Buttner P, Darby A (2008) Eating Disorder Behaviors Are Increasing: Findings from Two Sequential Community Surveys inSouth Australia. PLoS ONE 3(2): e1541. doi:10.1371/journal.pone.0001541
There is continued debate over the question of whether theprevalence of eating disorders is increasing. Estimates of theprevalence of psychiatric disorders rest on accurate recognitionand delineation of disorders in classification schemes, and thedevelopment of methods for community-based epidemiologicalstudies, such as the Epidemiologic Catchment Areas study in 1980[1]. While anorexia nervosa was the first eating disorder to berecognised,withthe 19
centuryreports ofGull[2] and Lesague[3],bulimia nervosa, and binge eating disorder were not described untilnearlyacenturylater[4–6].Itisnowagreedthatthefirstestimatesof general population point prevalence of eating disorders likelyoverestimated bulimia nervosa and the ‘second generation’ ofstudies(for example that of Bushnell
et al 
[7]) had been consistent in finding bulimia nervosa to occur in around 1% of young western womenand that partial eating disorder syndromes or eating disorder nototherwise specified (EDNOS), [6] occur in between 2 and 5% of  young women [8]. In contrast anorexia nervosa likely occurs in lessthan 0.5% of young women and is uncommon in the generalpopulation, for example as found by Aalto-Setala and colleagues [9]. Accurate incidence studies have been more difficult to completebut cohort and clinical incidence studies [7,10] have supported anincrease in the incidence of bulimia nervosa over the 10 years (i.e.the 1980s) following its recognition, with one study suggesting thishas since reached a peak [11]. Sequential population surveys havebeen problematic and variable in regard to case definition andascertainment, but those that have been done have not reportedan increase since the late 1980s [12]. In contrast to bulimia nervosa,clinical incidence studies of anorexia nervosa have accessed likelycases more through medical records of patients presenting with itsphysical complications, such as infertility, and unexplained weightloss[13,14]. A systematicreview[15]of cumulative incidencestudiesreported an estimated mean yearly incidence in the generalpopulation of 8 cases per 100,000 with a likely increase in theincidenceofanorexia nervosa inyoung women inthe lastcentury upto the 1970s. The estimated incidence of bulimia nervosa was 12cases per 100,000 per year [15].Most recently a study of time trends in general practice databasesin the UK [16] reported an initial increase and then decrease inbulimia nervosa incidence. A similar study of time trends in primarycare from the Netherlands [17] found a decrease in incidence of bulimia nervosa. In addition, a US study involving consecutivesurveys of college students [18] from 1982, 1992, and 2002, suggestthat incidence and/or prevalence of bulimia nervosa and relateddisorders may be decreasing over the 20 year period. Findings fromnational surveys indicate that the 12-month or current prevalence of eatingdisordersinrecentcommunitysurveysinNorthAmerica[19],New Zealand [20] and Europe [21] may vary by more than fourfold, and in North America Hudson and colleagues [19] foundcohort effects supporting a putative increase in prevalence of eating disorders over time and comparatively high rates (2.1%) of bingeeatinginbothmen(1.7%)andwomen(2.5%).Thepresentstudywasplanned to investigate changes, if any, in the community prevalenceof eating disorder behaviors over a 10 year period in South Australiaand to compare the findings with these international studiesconducted over the past decade.
Two independent cross-sectional single stage interview basedsurveys were conducted a decade apart. Both surveys wereembedded in the respective year Health Omnibus Survey, under
Academic Editor:
R. Srinivasa Murthy, Office of the WHO Representative in Sudan,Sudan
July 30, 2007;
January 2, 2008;
February 6, 2008
2008 Hay et al. This is an open-access article distributed under theterms of the Creative Commons Attribution License, which permits unrestricteduse, distribution, and reproduction in any medium, provided the original authorand source are credited.
The study was supported by an establishment grant to Professor Hayfrom the Office of the Vice-Chancellor James Cook University.
Competing Interests:
The authors have declared that no competing interestsexist.
* To whom correspondence should be addressed.
E-mail: p.hay@uws.edu.au
PLoS ONE | www.plosone.org 1 February 2008 | Issue 2 | e1541
the auspices of the South Australian Health Commission. Theinterviews were conducted by Harrison Health Research [8,22].
Sample selection and interview procedures
The sample selection and interview procedures were the same foreach survey. Samples were selected from both metropolitan andrural areas. For the metropolitan sample in 1995 320, and in 2005386 ‘‘collectors’ districts’’ were selected from those used by the Australian Bureau of Statistics in the 1991 and 2001 censusrespectively. For the country samples, all towns of 10,000 or morein population size and a selection of towns of at least 1,000 peoplewere surveyed. The collectors’ districts were chosen according totheir probability of selection proportional to size. Within eachcollector’s district a starting point was randomly selected. Fromthis starting point, using a pre-determined process based on a‘‘skip’’ pattern of every fourth household, 10 dwellings werechosen. Only one interview was conducted per household ordwelling, and, where more than one resident was aged over15 years, the respondent was the person whose birthday was last.The sample was a non-replacement sample, and up to six separate visits were made to interview the person chosen to take part.The interview was piloted during February 1995 and August2005, with 50 interviews. No formal reliability study was done, but5% in 1995 and 10% in 2005 of each interviewer’s work wasselected at random, and the respondents re-contacted and anumber of questions were asked of them, to ensure they had beeninterviewed as reported. Interviews were conducted from Marchuntil the second week of May 1995 and September through to 31
December 2005.
The interview
The structured, respondent-based interview, comprised a range of health-related and demographic questions, including presentheight and weight. The eating disorder behavior questions werewritten by the first author (PH), and were modelled on relatedquestions used in the investigator-based interview, the Eating Disorder Examination (EDE; 23). (The EDE, is however a muchmore detailed and comprehensive assessment of symptoms,particularly binge eating.) The questions were embedded towardsthe end of the interview. Three eating disorder behaviors wereassessed, namely binge eating, purging and strict dieting or fasting.Current regular use of these behaviors was defined as the behavioroccurring at least weekly over the three months prior to theinterview. In order to assess diagnostic criteria for bulimia nervosaand related EDNOS and an estimate of burden, in 2005 twoadditional questions were added, namely one assessing importanceof weight and shape and one assessing ‘days out of role’ [24]. Theformer was modeled on the Importance of Weight andImportance of Shape questions employed in the EDE. Becausethese questions were not asked in the 1995 survey, it was possibleto consider 1) change in the prevalence of eating disorderbehaviors over time and 2) prevalence of diagnoses in 2005, butnot change in prevalence of diagnoses over time. Body mass index(BMI; kg/m
 ) was calculated from self-reported weight and height.The specific questions relating to eating disorders in the surveywere: (i)
I would now like to ask you about episodes of overeating that you mayhave had recently. By overeating, or binge eating, I mean eating an unusuallylarge amount of food in one go and at the time feeling that your eating was out of control, [that is you could not prevent yourself from overeating, or that youcould not stop eating once you had started]. Over the past three months how often have you overeaten in the way I have described? 
Responses were madefrom a 4-point list of ‘not at all’, ‘less than weekly’, ‘once a week’and ‘two or more times a week’; (ii)
The next questions are about various weight-control methods some people use. Over the past three months have youregularly used, that is at least ONCE A WEEK, used any of the following: laxatives, diuretics (water tablets), made yourself sick, in order to control your shape or weight? 
Responses were either ‘yes’ or ‘no’; (iii)
Over the past three months have you regularly e.g. at least once weekly, or recurrently during the three months, done any of the following: gone on a very strict diet, or eatenhardly anything at all for a time, in order to control your shape or weight? 
Responses were either ‘yes’ or ‘no’; (iv)
In the past three months has your weight and/or your shape influenced how you think about (judge) yourself as a  person? E.g. has it been a really important issue to you/to your self-confidence? 
Responses were on a 6-point scale from ‘not at all’ to ‘extremely(the most important thing for you)’ with a cut-off of 
4 to indicateat least moderate importance; and (v)
During the past four weeks, onhow many days (approximately), if any, were you unable to complete your work, study or household responsibilities because of any problem with your  physical or emotional health? 
The number of days between 0 and 28was recorded.
Data were weighted by the inverse of the individual’s probabilityof selection, then re-weighted to benchmarks derived from theEstimated Resident Populations at 30th June 1994, by age, sex andLocal Government Area, from the Australian Bureau of Statistics(Catalogue No 3204.4). The stratified cluster sampling approachwas taken into account during the entire statistical analysis.Numerical data were presented as mean values and standarddeviations (SD). T-tests and chi–squared tests as appropriate wereused to test for bivariate differences between the 1995 and 2005surveys. Estimated prevalence of eating disorders were accompa-nied by 95%-confidence intervals (95%-CI). Multivariable logisticregression analyses were conducted to determine the odds of reporting each eating disorder behavior as a function of the year of study (1995 and 2005) controlling for the baseline values of potential confounders, namely, age, gender, body mass index,country of birth, marital status, level of education, and income.Multivariate analyses were stratified by gender. Results of multivariate analyses are presented as odds-ratios and 95%-confidence intervals. A significance level of 0.05 was employed forall tests. Analyses were conducted using the SPSS for Windows version 14 and the survey commands of STATA release 8.
 All subjects in the study gave verbal informed consent to theirparticipation and the study was approved as ethical by theGovernment of South Australia Department of Health. Allparticipants received written information about the survey priorto consent being obtained. Written consent was deemedimpractical in this large low risk survey by the Department, verbal consent was obtained by the interviewers and audited bythe Department, and the oral informed consent process wasapproved by the research ethics committee of the Department.
The samples
Demographic and other details of the sample and respondents areshown in Table 1. There was a decrease in the overall responserate, with numbers of refusals to participate increasing.Significant differences between the samples were observed withrespect to age (p=0.002), BMI (p
0.001), annual householdincome (p
0.001) and educational attainment (p
0.001). Therewere no significant differences on any of the other socio-demographic variables assessed.
Increasing Eating Disorders?PLoS ONE | www.plosone.org 2 February 2008 | Issue 2 | e1541
Prevalence of eating disorder behaviors
Results of multivariable logistic regression analyses showed thatthere were significant increases in the current regular use of allthree eating disorder behaviors in both men and women (Table 2).In comparison to 1995, participants were 2.4 times more likely toreport binge eating in 2005 (p
0.001). Age increased not only from one cross-section to the next, butalso, as shown on Table 3 in the subgroups of individuals reporting purging (p=0.025) and strict dieting or fasting (p
0.001).Similarly, amongst the participants who reported strict dieting orfasting behavior mean body mass index increased from 25.2 (SD7.1) in 1995 to 28.4 (7.0) in 2005 (p=0.011). Within the sub-groups of participants with reported eating disorder behaviors thepercentage of participants living in metropolitan areas did notchange between 1995 and 2005 (binge eating: p=0.955; purging:p=0.241; strict dieting or fasting: p=0.940).
Table 1.
Comparative demographic and socio-economic datafor the 1995 and 2005 surveys.......................................................................
1995 survey(n=3001)2005 survey(n=3047) p-value
% Response rate 71.5% 60.9%
0.001% Reasons for non-response (n=1199) (n=1953)Refusal 45.4% 51.8%Failure to establish contact 33.4% 28.8%Vacant house 11.3% 8.9%Lack of fluency in English 4.8% 3.6%Not at home during survey period 4.1% 3.3%Illness or other incapacity 1.2% 3.7%Mean age (SD) [years] 43.4 (19.2) 45.1 (24.5) 0.002Mean body mass index (SD) [kg/m
] 25.1 (5.6)(n=2765)26.0 (6.1)(n=2802)
0.001% Female 50.8% 51.0% 0.902% Metropolitan based 69.3% 70.1% 0.775% Born in Australia 76.5% 77.6% 0.418% Married or de-facto 62.0% 62.4% 0.804% With highest educational attainmentgraduate diploma or degree or higher20.7% 27.1%
0.001% With yearly household incomegreater than $AUD 50,00020.0%(n=2669)50.0%(n=2698)
0.001Excepting response rates, all results were adjusted for cluster sampling.SD=standard deviationdoi:10.1371/journal.pone.0001541.t001
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Table 2.
Comparative distribution over time of regularcurrent
eating disorder behaviors.......................................................................
1995 survey 2005 surveyOdds-ratio95%-CI
 All participants
(n=3001) (n=3047)Binge eating
96 (3.1%) 205 (7.2%) 2.4 [1.6, 3.7]
24 (0.7%) 54 (1.5%) 2.9 [1.4, 5.8] =0.003Strict dieting or fasting
48 (1.6%) 129 (4.6%) 2.6 [1.7, 3.9]
Male participants
(n=1216) (n=1290)Binge eating 36 (3.1%) 77 (7.8%) 2.1 [1.2, 3.5] =0.007Purging 0 (0%) 14 (1.0%) NA
0.001Strict dieting or fasting 8 (0.6%) 44 (3.9%) 5.1 [2.1, 12.0]
Female participants
(n=1785) (n=1757)Binge eating 60 (3.2%) 128 (7.5%) 2.5 [1.6, 3.9]
0.001Purging 24 (1.3%) 40 (2.1%) 1.5 [0.85, 2.8] =0.152Strict dieting or fasting 40 (2.5%) 85 (5.2%) 2.0 [1.3, 3.2] =0.002All results were adjusted for the cluster sampling approach.
Current regular use of these behaviors was defined as the behavior occurringat least weekly over the three months prior to the interview;
Binge eating was described as episodes of overeating, namely eating anunusually large amount of food in one go and at the time feeling that theeating was out of control, (i.e. it could not be prevented or stopped);
Purging was described as a weight control method comprising the use of laxatives, diuretics (water tablets), or self-induced vomiting;
Strict dieting was described as ‘‘going on a very strict diet’’, and fasting as‘‘eating hardly anything at all for a time’’, both for the purpose of weight orshape control;
Multivariate adjusted odds ratio and 95%-confidence interval; adjusted for age,gender, BMI, country of birth, education and income level as relevant;
Because of zero frequency of purging in 1995 males an adjusted odds ratiocould not be calculated, and a bivariate chi-squared test adjusted for clustersampling was conducted.doi:10.1371/journal.pone.0001541.t002
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Table 3.
Age distributions of participants with regular current
eating disorder behaviours...................................................................................................................................................
Binge eating
Strict dieting or fasting
Age (years) 1995 (n=96) 2005 (n=205) 1995 (n=24) 2005 (n=54) 1995 (n=48) 2005 (n=129)
1524 21.9% 29.3% 19.8% 13.6% 45.2% 20.0%2534 34.3% 21.3% 13.5% 9.0% 29.2% 26.5%3544 21.7% 18.4% 43.9% 21.2% 15.2% 17.1%4554 18.0% 17.4% 11.0% 28.6% 8.7% 21.4%5564 1.7% 7.4% 6.7% 7.5% 0% 9.7%
=65 2.3% 6.2% 5.2% 20.1% 1.7% 5.3%Mean (SD)
34.4 (13.1) 36.4 (19.8) 38.5 (14.6) 48.0 (21.7) 27.9 (10.7) 38.6 (19.8)p-value P=0.265 P=0.025 P
0.001All results were adjusted for the cluster sampling approach.
Current regular use of these behaviors was defined as the behavior occurring at least weekly over the three months prior to the interview.
Binge eating was described as episodes of overeating, namely eating an unusually large amount of food in one go and at the time feeling that the eating was out of control, (i.e. it could not be prevented or stopped).
Purging was described as a weight control method comprising the use of laxatives, diuretics (water tablets), or self-induced vomiting.
Strict dieting was described as ‘‘going on a very strict diet’’, and fasting as ‘‘eating hardly anything at all for a time’’, both for the purpose of weight or shape control.
SD=standard deviationdoi:10.1371/journal.pone.0001541.t003
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Increasing Eating Disorders?PLoS ONE | www.plosone.org 3 February 2008 | Issue 2 | e1541

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