RESEARCH UPDATE REVIEW

This series of10-yearupdates in child and adolescent psychiatry began in July 1996. Topics areselected in
consultation with the AACAP Committee on Recertification, bothfor the importanceofnew research and
its clinical or developmentalsignificance. The authors have been asked to place an asterisk before thejive
or six most seminal references.
M.KD.

Anorexia Nervosa and Bulimia Nervosa in

Children and Adolescents: A Review of the Past 10 Years
HANS STEINER, M.D., AND JAMES LOCK, PH.D., M.D.

ABSTRACT
Objective: To critically review the research in juvenile anorexia nervosa and bulimia nervosa over the past 10 years and
highlight recent advances in normal development as it pertains to these disorders and their diagnosis, prevention, and
treatment. Method: Computerized search methods were combined with manual searches of the literature. A detailed
review of the most salient articles is provided. Preference was given to studies involving children and adolescents that
approached the subject from a developmental perspective. Results: The information from these studies is presented in
a developmental framework. Research in eating disorders has progressed, but definitive longitudinal data are still absent
from the literature. Research specific to treatment of child and adolescent eating disorders remains rare. Conclusions:
Data approaching eating disorders from a developmental perspective are available in only a few studies. Research is
needed addressing normative data on the development of eating behavior and specific risk and resilience factors for
pathology in specific developmental periods. Especially lacking are studies regarding the continuities and discontinuities
of eating disturbances across the life span. Best documented are epidemiological studies of prevalence and incidence,
long-term outcome in anorexia nervosa, and short-term treatment response in bulimia. J. Am. Acad. Child Adolesc.
Psychiatry, 1998, 37(4): 352-359. KeyWords: eating disorders, anorexia nervosa, bulimia, developmental trajectories.

Classic eating disorders (anorexia nervosa [AN] and
bulimia [BULD represent relatively common and signifi-
cant disturbances that require carefully coordinated,
comprehensive intervention. There is evidence that
treatment can be successful, but even with treatment, it
is unclear whether significant risks and vulnerabilities for
recurrence ever completely resolve (Herzog et al., 1993).
In eating disorders, we observe the co-occurrence of
pathological thoughts and emotions concerning appear-
ance, eating, and food, as well as eating behavior that is
Accepted August 14, 1997.
Dr. Steiner is Professor of Psychiatry and Dr. Lock is Assistant Profi'ssor of
Psychiatry. Deportment of Psychiatry and Behavioral Sciences, Stanford
University School ofMedicine, Stanford, 01.
Dr. Steiners effirt on this manuscript was supported by a grant from the
Eucalyptus Foundation.
Reprint requests to Dr. Steiner, 401 Quarry Road. Stanford, G4 95305-5540.
0890-8567/98/.~704-0352/$03.0010©1996 by the American Academy
of Child and Adolescent Psychiatry.
deviant, leading to alterations in body composition and
functioning that are the direct result of these symptoms.
These disorders are classic "psychosomatic" syndromes
in the sense that psychological and somatic functioning
are inextricably intertwined (Heebink et al., 1995).
Eating disorders are often conceptualized as devel-
opmental disorders. However, few prospective studies
examine normative and pathological phenomena in
populations at risk (Steiner et al., 1995). Only a few
studies have used longitudinal designs (Attie and
Brooks-Gunn, 1989; Killen et al., 1994; Marchi and
Cohen, 1990). However, in the past decade a sizable
subporrion of the literature has directly addressed
problems in youth, culminating in a special volume
(Steinhausen, 1995).
We review here the changes in the DSM, recent
epidemiological data, studies of risk factors, and treat-
ment effectiveness studies in children and adolescents.

352 J. AM. ACAD. CHILD ADOl.ESC. PSYCHIATRY. 37:4. APRIL 1998


Diagnostic Issues
Changes in diagnostic categories for eating disorders
are present in DSM-/V (American Psychiatric Associ-
ation, 1994). Both AN and BUL have been moved to a
separate section called "Eating Disorders." For both dis-
orders , body image disturbance may now be expressed
in different ways as either distortion of the experience
itself or as the denial of the seriousness of weight loss.
The subtyping of AN now indicates the presence of
binge-eating/purging versus restricting behaviors. The
presence of both binge eating and purging occurring
exclusively in the context of AN is now diagnosed as a
subtype of AN. A corresponding exclusion criterion is
added to the diagnosis of BUL. Descriptions of binges
are operationalized. Some recent research suggests cur-
rent diagnostic criteria are too restrictive (Garfinkel
et al., 1995, 1996). In addition, binge-eating disorder
research criteria are included in DSM-/V.
Epidemiology
There has been significant progress in our epidemio-
logical database (Flament et aI., 1995; Lucas et al.,
199 I) . Newer studies are population-based, specifically
target juveniles, and use state-of-the-art, two-phase
screening designs. From these studies, it appears that
the prevalence of eating disorders in adolescence has
increased during the past 50 years (Lucas et aI., 1991).
While eating disorders continue to be more prevalent in
the Western industrialized nations of white ethniciry
and in middle- and upper-class females, there is an
increasing diversity of ethnic and socioeconomic groups
(Lacey and Dolan, 1988; Pumariega, 1986).
Lucas et al. (1991) performed a population-based
incidence study of AN in Rochester, Minnesota, over a
50-year span (1935-1984). The incidence rate for
females decreased from 16.6 per 100,000 person-years
in 1935-1939 to 7 in 1950-1954 and increased to 26.3
in 1980-1984. The incidence rates for women over 20
years of age remained constant, but there was a sig-
nificant increase for females 15 through 24 years old.
The overall age-adjusted incidence rate for females was
14.6 and for males, 1.8. Lucas and colleagues suggest
that the increase in the 15- through 24-year-old group
mirrors times in history in which the media portray
thinner models. The more severe and unremitting form
of AN has remained constant, but teenagers may be
more vulnerable to cultural pressures and may develop a
milder form of illness in response to such pressures.
] . AM . A CAD. CHIl.D ADOLESC. PSYCHIATRY..17:4. APRIL 1998
EATIN G DISORDERS : A REVIEW
Flament et al. (1995) reported the results of a two-
stage (survey followed up by interviews) screening for
BUL in France in 3,527 unselecred secondary school
students. Girls self-reported high rates of overconcern
with body weight and shape, dieting, bulimic binges,
self-induced vomiting, use of laxatives, and use of diet
pills compared with boys. On the basis of their data,
Flament et al. estimated that BUL has a prevalence rate
of about 1.1% in girls and 0.2% in boys. BUL seems to
be less frequent in this age group than in adult women,
and these findings support the clinical observation that
most patients with BUL become ill in the latter half of
adolescence.
Most epidemiological studies report mild eating dis-
turbances in their subjects that would qualify for an
eating disorder not otherwise specified (Flament et aI.,
1995; Killen et al., 1986; Lucas et al., 1991). Between
40% and 60% of high school girls in the United States
diet to lose weight, although the meaning of "dieting"
varies greatly (Field et al., 1993). According to Killen
et al. (1986), about 13% induce vomiting or use diet
pills, laxatives, or diuretics. About 30% to 40% of
junior high girls also admit to concerns about weight
(Childress et al., 1993). Eating disorder not otherwise
specified is probably more common than classic eating
disorders in juveniles.
The systematic study of males with eating disorders is
significantly impaired by the relatively small numbers
involved. Most studies exclude male patients. Males
more commonly suffer from BUL but are still out-
numbered by females by approximately 5: 1 (Flament
ct al., 1995).
Psychiatric Comorbidity
Psychiatric comorbidity has been the focus of much
research. Most eating disorder patients who are in-
cluded in research projects come from specialized eating
disorder clinics (Braun et al., 1994), and there may be
an overrepresentation of more seriously compromised
individuals. Herzog et al. (1992b) studied a large clinic
sample of adults and adolescents and found that about
63% of all eating disorder patients had a lifetime
affective disorder. This comorbidity was especially high
in patients with mixed anorectic and bulimic features.
Depression and AN show independent familial trans-
mission (Strober and Katz, 1988), but this may not be
the case in BUL (Keck et al., 1990). Smith et al. (1993)
have shown a high level of anxiety disorders in AN on
353
STEIN ER AND LOCK
6-year follow-up, occurring separately from and together
with persistent eating disorders. Rastam (1992) found
35% of anorectic patients also suffer from comorbid
obsessive-compulsive disorder. Alcohol and drug abuse is
commonly diagnosed in adults with eating disorders bur
has not been studied in juveniles (Katz, 1992). Specific
studies document a high prevalence of substance abuse
among patients with BUL (Laessle et a!" 1989). A mod-
erate degree of overlap between avoidant personality and
AN and borderline personality and BUL has been shown
in adult patients (Herzog et a!', 1992a).
Risk Factors
A review of the many studies of risk factors for AN
and BUL is structured here in terms of the major devel-
opmental phases of childhood and adolescence.
Preschool. Charoor (1989) suggests a developmental
model for the emergence of eating problems in the pre-
school age group that awaits empirical testing. Demo-
graphics of early feeding problems suggest discontinuity,
because boys are at greater risk of eating disorders in
early childhood, whereas in adolescence, girls become so.
Marchi and Cohen (1990), using a lagged design ,
studied two different, overlapping (ages 0 through 10
and 9 through 18) cohorts, following them prospec-
tively for 2.5 years. They studied six eating behaviors at
three time po ints by maternal interview and found that
maladaptive early cating patterns increased the likeli-
hood of later problems. Picky eating and digestive prob-
lems predate anorectic behavior, whereas pica and meals
in childhood characterized by fighting (indicating prob-
lems in the self-regulation of eating and eating-related
family struggles) predict BUL. Numbers of subjects fol-
lowed were too small to capture the onset of AN, so pre-
syndromal definitions of illness were accepted. Other
salient features of eating disorders were not studied.
In a retrospective study of eat ing disorder patients
and controls, Steiner et a!. (1991) found that mothers of
eat ing disorder patients report reliance on scheduled
feeding and prematurel y introduced solids more
frequently than controls. Although these practices were
independent of the patient's primary diagnosis (AN or
BUL) , the y were also used with siblings who were not
ill, suggesting that other factors are likely involved in
pathogenesis.
School-Age. In elementary school, children want to be
thinner than they are (up to 4 5%) (Maloney et a!' ,
1989). Thirty-seven percent try some form of weight
354
loss, and 6.9 % score in the pathological range on an
ada pted version of the Eating Attitude Test. There are
few significant differences betwe en boys and girls. Body
image di stortions in this group are associated with
dieting and weight concerns (Childress et a!', 1993).
Food refusal, ritualistic beh avior during meals, phobic
beh avior, and elevated Internalizing scale scores on the
Child Behavior Checklist are described in school-age
children (Singer er a!' , 1992).
Prepuberty and Adolescence. In a short-term prospec-
tive stu dy, Attie and Brooks-Gunn (1989), following
193 girls from 7th through 10th grade for 2 years, tested
the hypothesis that the development of eating problems
represents an accommodation to puberty. Multiple
regressions confirmed that eating problems emerged in
respon se to pubertal change. Girls who felt most neg-
atively about their bodies at pub erty were at highest risk
for the development of eating difficulties, after initial
eating problem scores were taken into account.
Several cross-sectional stu dies identify associations
betw een disturbed eating and problems with body satis-
faction in prepuberty. Altmann et al. (1998) identified a
significant association between anxious attachment and
eating concerns. Other studies implicate deficient self-
regulation (Steiner, 1990; Strob er, 1991), affective labil-
ity and pubertal status (Killen er al., 1992), and concerns
abou t current sha pe (Fab ian and Thompson, 1989;
Levine et a!', 1994).
Contextu al risk factors in this developmental phase
include teasing by peers (Fabian and Thompson, 1989),
discomfort in discussing problems with parents (Larson,
1991), maternal preoccupation with diets (Hill et a!',
1990), and acculturation to Western values in immi-
grants (Pumariega, 1986; Steinhausen, 1995).
Age of Onset. The relationship between the age of
onset and outcome in AN and BUL is still unclear,
mo stly because of methodological problems (Fichter
and QuadAieg, 1995).
Other Risk Factors. A variety of risk factors not asso-
ciated with specific developmental phases have been
identified. Being of female gend er, having a pear-shaped
bod y, and having a body mass index high in fat are
identified as constituting risk (Radke-Sharpe et a!' ,
1990). In some stud ies, a high incidence of sexual abuse
has been reported by women with d iagno sed eating dis-
ord ers (Palmer er a!', 1990; Rorty et a!', 1994) . The rates
of abuse seem higher in BUL than AN (Waller, 1991).
The issue is insufficiently explored in juveniles.
J. AM . AC AD , CHILD ADOL ESC. PSYC H IAT RY. .H:4. APRI L 1998

There continues to be evidence for the familial
clustering of eating disorders (Kendler et al., 1991;
Strober, 1990) and eating attitudes (Rutherford et aI.,
1993) suggesting a role for heritable causation, but there
are no adequate longitudinal stud ies controlling shared
and nonshared environments . On the other hand,
studies of families find distinct characteristics by both
self-report and observational methods (Steiger et al.,
1992) . Families of anorectic patients appear more con-
trolled and organized, while families of bulimic patients
are more chaotic, conflicted, and critical. Differences are
also apparent in observer-rated transactions (Humphrey,
1989). However, the addition of other psychopatho-
logical contrast groups and nonclinical families
sometimes obscures these differences (Thienemann and
Steiner, 1993).
The study of the neurobiology of eating disorders has
demonstrated impressive hormonal and neurohormonal
systems differences in adult and late-adolescent patients
who are acutely ill (Laue et al., 1991; Pirke and Platte ,
1995). It is not clear whether any of these changes can be
generalized to non-ehronically ill adolescent populations,
represent specific risk factors , are brought on by star-
vation and perpetuate illness, or are simpl y the result of
bodily changes due to starvation and sernistarvation. In
most cases, hormone levels return to normal after
refeeding.
Personality differences have been repeatedly found by
multiple methods and from a variety of theoretical
backgrounds (temperament, personality, ego psychol-
ogy), showing anorectic girls to be anxious, inhibited,
and controlled, while bulimic patients tend to be more
affectively labile, undercontrolled, and active (Casper
et al., 1992; Leon et al., 1992; Shaw and Steiner, 1997;
Steiner, 1990) .
Assessment Instruments
Assessing eating disorders remains a complex area of
clinical activity because the disorders present with a mix
of disturbances in multiple domains. Specific structured
interviews (e.g., the Eating Disorder Examination)
(Cooper and Fairburn, 1987) are available, as are screen-
ing instruments in parent and child versions (Slade
et al., 1990). Clinical self-reports are available also: The
Eating Disorder Inventory has normative data down to
age 14 years (Shore and Porter, 1990), the Eating
Attitude Test has a version applicable to school-age chil-
dren (Maloney et aI. , 1988), and the Kids Eating
J. AM . ACAD. C H I L D ADOLES C. P SYCHIATRY, 37:4, APRIL 1998
EATI N G DI SORDERS: A REVIEW
Disorder Survey is applicable to middle school children
(Childress et aI., 1993).
Naturalistic Course And Prognosis
AN The course of AN is variable. Some patients
recover completely after the index episode. Others
develop a fluctuating course of weight gains and losses.
Still others remain in a chronically deteriorating course.
More than a third have recurrent affective illnesses, and
suicide has been reported in up to 5% of patients with
chronic AN. Although vocational and academic func-
tioning may be good, psychological and social impair-
ment persists even after weight restoration. Studies
indicate a mortality rate from 3% to 10% (Herzog
et al., 1993; Sullivan, 1995).
The short- and long-term medical complications of
AN in adolescents are known (Fisher et al., 1995; Palla
and Lin, 1988). Changes in growth hormone, hypo-
thalamic hypogonadism , bone marrow hypoplasia,
structural abnormalities of the brain, cardiac dysfunc-
tion , and gastrointestinal difficulties are all common.
Recent studies continue to document that the most
significant medical problems for adolescents differing
from adults are the potential for significant growth
retardation, pubertal dela y or interruption, and peak
bone mass reduction. Risks of death as a result of
complications of AN are estimated at 6% to 15%
(Steinhausen et al., 1991, 1993) . Half the deaths result
from suicide.
BUL. Patients with BUL have a variable course. The
majority follow a chronic fluctuation of binge/purge
behavior. In a recent study, at 3-year follow-up approx-
imately one third of patients remained in the index
episode; of those who recovered from the index episode,
two thirds relapsed within a year and a half, and of
those who recovered from this second episode, half
relapsed (Keller et aI., 1992).
BUL usually begins in late adolescence or early adult-
hood. Binge eating typically begins in the context of an
episode of dieting. Once identified, patients are able to
seek treatment and they appear motivated, but once
purging begins and is reinforced, it can be surprisingly
resistant to change. Although patients experience vari-
ations in weight, they rarely approach the low weights
associated with AN . Other medical complications, such
as hypokalemia, esophageal tears, gastric disturbances,
dehydration, and orthostatic blood pressure changes, may
require intermittent hospitalization (Kreipe et al., 1995).
355
ST EINER AND l.OCK
Patients often have a history of impulsive behaviors such
as alcohol use and shoplifting. Preoccupation with food
can impair social, school, and work functioning.
Treatment and Outcomes
Treatment of AN requires that individual, familial,
medical , and nutritional aspects of the disease be
addressed . Guidelines for the psychiatric and medical
treatment of AN are published (Kreipe et al., 1995; Yager
et al., 1993). Overall results of all types of treatment are
modest to moderate (Kreipe and Uphoff, 1992).
An initial goal for most patients with AN is the
restoration of physical health. A series of weight goals
may be calculated for each patient. This is best done by
a nutritionist with experience in the evaluation of
patients with eating disorders. The body mass index
(weight [kilograms)/height [meters]") is a more preci se
estimate of healthy targets ( Beu rno n r et al ., 1988 ).
Normative ranges by age are listed in available tables
(H ammer et al., 1991 ). If growth failure has occurred,
an ideal body weight based on expected height for age
may provide a more medically appropriate standard.
The role of hospitalization for AN has changed dra-
matically over the past 10 years, at least in the United
States. Currently, hospitalization in the United States is
limited to brief, acute weight restoration and refeeding.
Low discharge weight confers unnecessary risk for relapse
and poor prognosis (Baran et al., 1995) . Inpatient treat-
m ent stud ies of young adults suggest a continued role
for this modality for severe cases (Eckert et aI., 1995).
Studies of intensive day treatment programs also are
suggestive, but specific studies of youth in such settings
are lacking (Kaye et al., 1996) .
A large variety of outpatient approaches to individ-
ual, family, and group therapy are used in the treatment
of AN. Specific research in adolescent AN has found
the mo st promising results in th e treatment effectiveness
of famil y therapy. Russell treat ed adolescent patients
(~1 8 years old and with an illness duration of less than
3 years) with fam ily therapy for 1 year. In his model , the
famil y is encouraged to take charge of the patient's
eating. This therapy was co m pa red with individual
therapy that emphasized su p p o rt, education, and
problem-solving. Outcomes at I- year follow-up were
d ecidedl y su pe rio r for the yo u nge r patients who
received famil y therapy a nd su pe rio r for the older
patients who received individual th erapy (Russell et al.,
1987 ). Follow-up data (Eisler et al., in press) suggest
356
th at these results continue to hold up 5 years after treat-
ment. Others have had sim ilar findings using different
methodologies (Robin et al., 1994).
Psychopharmacological interventions for AN have
been examined in adult sam ples, but the role of these
agents in adolescents is relatively unexplored (Garfinkel
and Garner, 1987). During periods of acute medical
co m p ro m ise, psychopharmacological agents are of
lim ited use. Among adults, medications that have been
most frequently used include antidepressants and low-
dose neuroleptics. Low-dose neuroleptics are used to
add ress severe obsessional thinking, anxiety, and psy-
chotic-like thinking, but they cause problems with
binge induction and there is little evidence of other
benefit compared with controls. Multiple older small
stu d ies have demonstrated few sign ificant improve-
ments in patients as a result of psychopharmacological
intervention (e.g., C risp et al ., 1987). More recent
studies have explored the role of sero to n in reuptake
inh ibitors in the treatment of AN in terms of relap se
prevention, but systematic stu d ies are not yet available
(Gwirtzman et al., 1990 ).
A variety of studies have looked at the short-, inter-
rnediate-, and long-term outcome of patients with AN
after treatment. Most of these studies are of adult popu-
lat ion s, although many of the patients in these studies
presumably had AN as teen agers. Studies have generally
demonstr ated th at half have good outcomes, a qu arter
have intermediate outcomes, and a quarter do poorly
(Ratnasuriya et al., 1991; Smith et al., 1993; Steinhausen
et al., 1991, 1993; van der-ham et al., 1994). Recovery
in these studies has been generally confined to measures
of weight and nutritional rehabilitation, but some
stu d ies indicate that other psychiatric and social aspects
of the illness may persist. Herzog er al. (1996) reported
recent findings that the bulimic sub type of AN had a
high er recover y short term than the restricting subtype.
Treatment compliance and person ality variables ma y be
important mediators of improved treatment outcome
(Steiner et aI., 1990 ). Higher levels of general psycho-
pathology increase the risk of poorer treatment out-
comes, though depression itself was of no predictive
value in adolescent samples (Herpertz-Dahlmann et al.,
1996 ).
Studies indicate that approximately 44% of patients
followed up for at least 4 years after onset ind icate a
"goo d" outcome, defined as reach ing at least up to 15%
of ideal weight, while 29% indicate an "intermediate
J. A M , AC A D, CHILD ADOL ESC. PSYCH I AT RY, .' 7 :4 , APRIL 199 8

outcome" and 24% a "poo r" outcome. Fewer than 5%
of the patients died (Yager er al., 1993), but higher rates
have been reported (Ratnasuriya et al., 1991). Treat-
ment studies of BUL compared with AN studies are
more ad vanced. Still, th e focu s of the majority of these
stud ies is on young adult populations. T he most prom-
ising studies for adolescents with BUL, as with AN , sug-
gest a role for fam ily th erapy. A study of 49 adolescent
eating disord er patients and their fam ilies found th at
mother's criti cal co mme nts explained 28% to 34% of
the variance in out come in patients and that th is rating
was the best ourcome predictor (van Furth et al., 1996).
Two recent stu d ies of family environments of bulimic
patients identified physic al punishment as contributing
to overall outco me difficulties and as indi cative of worse
family fun ct ion ing (Fallo n et al., 1994; Rorty er al.,
1995 ). Fin ally, a pilot study found th at treatment of
female s (aged 14 through 17 years) with bri ef fam ily
th erapy resulted in significa n t decreases in bulimic
behaviors at 1 year (Dodge, 1995). Interp ersonal therapy
has not been systematically studied in youth.
Studies of other treatment modaliti es report mostly
on adults, bur some of th eir findin gs may apply to
younger patients. Some stu d ies suggest th at cognitive-
beh avioral therapeutic ap p roaches are useful (Agras
et al., 1989). Blouin et al. (1994) found that cogni tive
change was an important bur nor necessary factor in
relation to beh avioral cha nges, su ch as binge-purge
reduction . T hey found t ha t the effec t ive ness o f
cognitive-behavioral th erapy was mediat ed by a variety
of famili al and symptoma tic characteristics of pati ents,
including less controlling families, lower weight, and
less likelih ood of using laxatives or diuretics. Another
behavioral treatment, exposure and respon se preven-
tion , requ ires that the pat ient eat feared foods in front
of the th erapi st witho ut th e option of purging later.
This is usually used in controlled settings, i.e., ho spit als
or day program s. It is uncl ear whethe r this method is
more effective than cogni tive-behav io ral ap p roac hes
(Agras et al., 1989).
Drug th erapy has been implemente d more often in
the treatment of BUL but has not been fou nd to be as
effect ive as cognit ive-behav io ral app ro aches (Agr as
et al., 1992 ). Man y an tide pressants have been found to
be more effective than placebo in con tro lled, short- term
treatment of binge eatin g. Longer-term stu dies have not
been conducted (G oldstein er al., 199 5). No specific
stu dies of drug therapy for ado lescents are available.
J. A M . AC A D . C II I I. D A !H )I. ES C . l' S YCIII AT RY. .17 :4 . A l' R I I. 1')')H
EAT I N G DI SO R D ER S : A R EVI EW
In su m mary, recent stud ies of treatment for BUL
have demonstrated, at least in adults, that cognitive-
beha vioral interventions and antidepressants, especially
selective seroto nin reuptake inhibitors, are potentially
effective. Ca ut ion about the appli cation of the se find -
ings to adolescent populat ion s is warrant ed. Other data
cont inue to suggest th at there is an importa nt role for
famil y therapy and for intensive treatment modaliti es.
Conclus ion
To esta blish risks and causal m odels, an y d evel-
opmental model of eating disorders mu st account for
the normal development of complex facto rs in multiple
domains and their inte raction, but as it currently sta nds,
we ha ve man y defici en cie s in our k now led ge base.
Availabl e dat a suppo rt a mult id imen sion al model of
eating d isorders, en compassing cult ural, social, psy-
chol ogical, and biologi cal variabl es as important in th e
pathogenesis, diagn osis, and treatment. T his is a co n-
servative model th at may reflect our igno rance. More is
known abo ut risk, very little about protective facto rs.
Continuities and discontinuities between risks and d is-
turban ces have not been well do cumented acro ss all
developmental phase s.
Ten years ago, treatment outcom e stu d ies were rare,
esp eciall y those applying standard ized in struments:
clearl y, thi s has cha nged. There are som e persistent
methodological problem s: Most stu d ies involve mixed
samples of ad ults and juveniles, and age at onset of ill-
ness and duration of illness are rarely con trolled for and
thus may confound treatment result s. Studies address-
ing this issue from a d evelopmental perspective are
needed. This may requ ire a tailoring of treatment to
developmental stage-so me thing th at has been done
infrequentl y to date.
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Low Levels of Physical Activity in 5-Year-Old Children. Arline D . Salbe, PhD , Anne Marie Fonrvieille, PhD, In geborg T
Harper. BS. Eric Ravussin , PhD
As the prevalence of obes ity in Western soc ieties has increased to disturbing levels. interest in the role of physical ina ctivity in
promoting this trend has incre ased . We assessed physi cal activity encrgy expenditure (AEE) in 127 S-year-old children. 43 of
whom were white ch ild ren and 84 Pima Indian children ; the latter group represents a population with an extremely high
prevalence of obe sity. Total energy expenditure (T EE) and resting metabolic rate (RM R) were measured by the doubly labeled
water method and ind irect calor imetry. respect ively. From these mea sured value s. different indexes of ph ysical act ivity were
calcul ated . including AEE = T EE - (RM R + 0.1 X TE E) and ph ysical activity level (PAL = TEE/RMR). By the age of 5 years,
Pima Indian children were signifi cantly heavier (23 .0 ± 5.3 kg vs 19.1 + 2 .6 kg) and fatt er (30 ± 7% vs 21 ± 5% body fat) than
white ch ild ren (p < 0 .000 I ). whereas TEE (59 96 ± 1005 kJ/day vs 56 90 ± 760 kJlday) and RMR (443 1 ± 625 kj/day vs 4 236 ±
53 4 kJ/day) were sim ilar in the 2 groups in both ab solute value s and after adjustment for far-free mass. fat mass. and sex. Both
white and Pima Indian children had physical activity levels 20% to 30% lower (PAL = 1.35 ± 0 .13) than currently recommended
by the World Health Organization (1.7 to 2.0) . However, the different calculated indexes of physical activity were comparable in
the two racial groups. Differences in TEE or AEE are unlikely to explain the obe sity seen in Pima Indian children at a later age,
suggesting that excess food intake is likely to playa ma jor role in the cause of obes ity in th is obe sity -prone population. However.
both wh ite and Pim a Indian children have su rp risingly low levels of ph ysical acti vity. a cond ition that portends poorly for the
prevention of ob esity in adulthood. J Pediatr 1997; 131:4 23-429

J. AM . ACAD. C H I l. D ADOL ESc:. PSYCHIATRY . .~7 :4. APRIL 19 98 359