Eating Disorders, Weight Perception, And Dieting In Adolescence

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Rasmus Isomaa The present dissertation states that eating disorders are common among adolescent females. As many as one in ten females have suffered from a clinically significant eating disorder during their development towards adulthood. However, the most prevalent eating disorders among adolescents are unspecified, which may lead to an underestimation of the prevalence of these disorders. Eating Disorders, Weight Perception, and Dieting in Adolescence Eating disorders are psychosomatic problems, which evolve around a strong fear of weight gain, restrictive eating patterns, and a strong preoccupation with body shape. An eating disorder can be defined as a persistent disturbance of eating behaviour or behaviour to control weight, which significantly impairs physical health or psychosocial functioning. Eating Disorders, Weight Perception, and Dieting in Adolescence A broader awareness of eating disorders is needed to facilitate prevention and to ensure early detection and intervention. 2011 ISBN 978-952-12-2521-5 ISBN 978-952-12-2522-2 (digital) Rasmus Isomaa

Eating Disorders, Weight Perception, and Dieting in Adolescence Rasmus Isomaa Vasa 2011

ISBN 978-952-12-2521-5 ISBN 978-952-12-2522-2 (digital) UNIPRINT Åbo 2011

Eating disorders, weight perception, and dieting in adolescence Table of Contents Abstract . 4 Acknowledgements . 5 List of Original Publications . 7 1 Introduction . 8 1.1 Eating Disorders . 9 1.1.1 Diagnostic Criteria . 10 1.1.2 Prevalence and Incidence. 12 1.1.3 Outcome. 14 1.1.4 Weight Perception and Dieting in Relation to Eating Disorders . 14 1.2 Summary of the Literature Reviewed . 16 1.3 Aims . 17 2 Method . 19 2.1 Participants and Procedure . 19 2.2 Measures . 21 2.2.1 Eating disorders and dieting . 21 2.2.2 Weight and weight perception . 22 2.2.3 Depressive symptoms . 23 2.2.4 Social anxiety . 23 2.2.5 Self-esteem . 23 2.3 Statistical analyses . 24 2.4 Ethical considerations . 25 3 Results . 26 3.1 Prevalence and Incidence of Eating Disorders . 26 3.2 Outcome of Eating Disorders . 27 3.3 Weight Perception . 28 3.4 Dieting. 30 4 Discussion . 32 4.1 Results . 32 4.2 Methods. 35 4.3 Implications. 37 4.3.1 Implications for research . 37 4.3.2 Implications for prevention and treatment . 38 4.4 Summary . 39 References . 41 Original publications I-IV . 51 Samanfattning

Eating disorders, weight perception, and dieting in adolescence Abstract Background: Eating disorders are serious psychiatric disorders, which usually have their onset in adolescence. Body dissatisfaction and dieting, both common among adolescents, are recognised risk factors for eating disorders. The aim of the present study was to assess the prevalence of eating disorders in the general adolescent population, assess the risk of developing eating disorders in subgroups of dieters, and analyse longitudinal concomitants of incorrect weight perception. Method: A prospective follow-up study on 595 adolescents, aged 15 at baseline, was conducted in western Finland. The study comprised questionnaires directed at the whole study population and subsequent personal interviews with adolescents found to be screen-positive for eating disorders, at both baseline and three-year follow-up. Results: The lifetime prevalence rates for 18 year old females were 2.6 % for anorexia nervosa, 0.4 for bulimia nervosa, and 9.0 % for eating disorder not otherwise specified (EDNOS). No prevalent case of DSM-IV eating disorders was found among the male participants. Eating disorders, as well as depressive symptoms, social anxiety, and low self-esteem, was more prevalent among females who perceived themselves as being overweight, despite being normal or underweight, when compared to females with a correct weight perception. An incorrect weight perception was associated in males with social anxiety. Female adolescents dieting due to psychological distress, rather than vanity or overweight, had a fifteen-fold risk of developing an eating disorder. Conclusions: Eating disorders are common among female adolescents, and adolescents choosing to diet due to psychological distress show a markedly increased risk of developing an eating disorder. Promotion of general well-being as well as the prevention of body dissatisfaction and misdirected dieting, accompanied by early detection and proper treatment of eating disorders, is needed to reduce the incidence of and facilitate recovery in adolescents suffering from eating disorders.

Eating disorders, weight perception, and dieting in adolescence Acknowledgements During my early teenage years I remember considering a vocational education to become a chef. I can’t remember how serious this ambition was, but I do recall that my parents thought that an academic education would better fit my endowments. I am now at a point in my career where I can entitle myself an expert, not in food, but in eating and more particularly in disordered eating. The process leading up to the present dissertation started already in the winter of 2004 and many individuals and associations have been helpful along the way. I would like to express my gratitude to those who have been directly involved in the research process. My research partner and mother Anne Isomaa for surprisingly smooth and efficient cooperation. Professor Riittakerttu Kaltiala-Heino, Professor Mauri Marttunen and all others from Adolescent Mental Health Cohort research group for insightful comments and support during the whole process. Professor Kaj Björkqvist, my supervisor for the present dissertation and professor already from the start of my academic inquiries into developmental psychology. I also wish to thank my pre-reviewers Nina Lindberg and Helen Cowie for useful comments on the manuscript. I appreciate all the time and effort invested by everyone involved in the process, which have resulted in the present doctoral dissertation. I would like to thank all colleagues at Åbo Akademi University who have either directly or indirectly been involved in the process. A special thanks to my corridor neighbour Klas for sometimes in-depth and sometimes relievingly shallow discussion on research related and personal issues. Thanks also to Peter Ahlroos at Tritonia EduLab for help with the cover of the dissertation. I would also like to acknowledge the personnel working clinically with eating disorders in Jakobstad for their interest in and positive attitude towards research, and of course all adolescents who participated in the study. I would also like to thank my wife Tove and my children Knut and Ylva for emotional support and for providing a research free environment at home, making it possible to work efficiently during the days and to avoid working in the evenings.

Eating disorders, weight perception, and dieting in adolescence Thanks to my father Bo for giving me my first insights into the world of academic research and SPSS, and my brothers Björn, Anders and Ludvig for encouragement and aptly varying interest in my research. For financial support, which made this research possible I express my gratitude to Signe and Ane Gyllenberg Foundation, the Otto A. Malm Foundation, Stiftelsen för Åbo Akademi and Svenska kulturfonden. Finally I wish to thank Åbo Akademi University and the Department of Social and Health Care in Jakobstad for employing me, thus making my life as a young researcher more convenient.

Eating disorders, weight perception, and dieting in adolescence List of Original Publications I. Isomaa, A-L., Isomaa, R., Marttunen, M., & Kaltiala-Heino, R. (2010). Obesity and eating disturbances are common in 15-year old adolescents. A two-step interview study. Nordic Journal of Psychiatry, 64, 123-129. II. Isomaa, R., Isomaa, A-L., Marttunen, M., Kaltiala-Heino, R., & Björkqvist, K. (2009). The prevalence, incidence, and development of eating disorders in Finnish adolescents – a two-step three-year followup study. European Eating Disorders Review, 17, 199-207. III. Isomaa, R., Isomaa, A-L., Marttunen, M., Kaltiala-Heino, R., & Björkqvist, K. (2010). Psychological distress and risk for eating disorders in subgroups of dieters. European Eating Disorders Review, 18, 296-303. IV. Isomaa, R., Isomaa, A-L., Marttunen, M., Kaltiala-Heino, R., & Björkqvist, K. (2011). Longitudinal concomitants of incorrect weight perception in female and male adolescents. Body Image, 8, 58-63.

Introduction 8 1 Introduction Adolescence can be defined as the period between beginning of puberty and adulthood. Adolescence is a unique and distinct developmental period, which comprises both psychological and physiological processes of change. During adolescence significant changes occur in brain development, endocrinology, emotions, cognition, behaviour, and interpersonal relationships (Evans & Seligman, 2005). A large part of the developmental process involves adapting, with increased cognitive capacity and social understanding, to a changing body (Erikson, 1980). A large part of mental health disorders have their onset in adolescence and many carry over into adulthood. Aside from disorders, many health habits, which influence adult behaviour, have their foundation in adolescence (Evans & Seligman, 2005). Development conceptualised by contemporary developmental science is made up by reciprocal interactions of the individual and context. This dynamic system encompasses all levels of organisation ranging from the biological, psychological, and social actions to the societal, cultural, and physical environment embedded in historical context (Lerner & Castellino, 2002). Developmental psychopathology can therefore be defined as “the study of the origins and course of individual patterns of behavioral maladaptation” (Sroufe & Rutter, 1984, p. 18). When development is conceptualised from a developmental science perspective, the search for the one crucial cause of a disorder is not of particular interest, since such a factor does not by definition exist. Of higher relevance to research stemming from a developmental psychopathology viewpoint are, apart from the actual disorders, subclinical functioning and individuals at a high risk of psychopathology who do not develop a disorder (Cicchetti & Rogosch, 2002). In contemporary Western society, two contrary trends regarding body weight are present. On the one hand, a rising prevalence of overweight and obese children and, on the other, an increasing drive for thinness and an unhealthy preoccupation with body shape and weight (Cole, Bellizzi, Flegal, & Dietz, 2000; Konstanski & Gullone, 1998; Levine & Smolak, 2002). These contradicting trends result in a situation whereby an increasing number of people are dissatisfied with their actual body size

Introduction 9 and shape. Adolescents, faced with the important developmental task of coming to terms with a changing body, may be particularly sensitive to the discrepancy between real and ideal bodies (Levine & Smolak, 2002). The consequential body dissatisfaction accompanied by dieting is one of the most common predecessors of eating disorders (Keel, Baxter, Heatherton, & Joiner, 2007; Paxton & Heinicke, 2008), which constitutes the main focus of the present thesis. 1.1 Eating Disorders Eating disorders are serious psychiatric disorders which alter cognitive function, judgement, emotional stability and restrict the life activities of sufferers. Eating disorders and anorexia nervosa in particular are among the deadliest psychiatric disorders (Klump, Bulik, Kaye, Treasure, & Tyson, 2009). Increased public and medical awareness during the past decades might give the impression that eating disorders are phenomena of contemporary Western society. However, eating disorders and self-starvation have followed mankind throughout history (Bemporad, 1996). The term anorexia nervosa, which literally means loss of appetite, was coined in 1874 by Sir William Gull, but the medical condition was described already at the end of the 17th century by Richard Morton. Although reports of overeating and vomiting have been present in medical records from the 19th century, the term bulimia nervosa was not coined until 1979 (Vandereycken, 2002). The understanding of eating disorders has grown substantively during the latter half of the 20th century. A large part of this growth in knowledge can be attributed to the pioneering work of Hilde Bruch, whose view of eating disorders focused on the patient’s struggle for autonomy, control, lack of self-esteem, and distorted body image (Skårderud, 2009; Vandereycken, 2002). Eating disorders are psychosomatic problems, which evolve around a strong fear of weight gain, restrictive eating patterns, and a strong preoccupation with body shape (Norring & Clinton, 2002). Eating disorders in a current view can be defined as “a persistent disturbance of eating behavior or behavior to control weight, which significantly impairs physical health or psychosocial functioning” (Fairburn & Walsh, 2002, p. 171).

Introduction 10 1.1.1 Diagnostic Criteria Criteria for diagnosing eating disorders are found in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) published by the American Psychiatric Association (American Psychiatric Association, 1994) and in the International Classification of Diseases (ICD-10) by the World Health Organization (World Health Organization, 2007). Although the diagnostic criteria for anorexia nervosa and bulimia nervosa are similar in the two classification systems, the “eating disorder not otherwise specified” category in DSM-IV corresponds to the diagnoses for atypical anorexia nervosa, atypical bulimia nervosa, and eating disorder, unspecified, in the ICD-10. In the present thesis, eating disorders are conceptualised according to the diagnostic criteria in the DSM-IV. The DSM-IV uses a multiaxial system for classification. The five axes comprise clinical syndromes, developmental disorders and personality disorders, physical conditions, severity of psychosocial stressors, and highest level of functioning. All diagnoses are based on a proposed definition of a mental disorder, which states that a mental disorder is a clinically significant behavioural or psychological syndrome associated with distress or disability that is not an expectable and culturally sanctioned response to a particular event or a manifestation of conflicts between the individual and society (American Psychiatric Association, 1994). In 2000 the American Psychiatric Association published a text revision of the manual, DSM-IV-TR (American Psychiatric Association, 2000), but no changes were made to the diagnostic criteria for eating disorders. The DSM-IV contains three diagnoses for eating disorders: anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified (EDNOS). The diagnostic criteria of anorexia nervosa concern an intense preoccupation with weight and shape, pursuit of thinness, and physical consequences of the disorder. A diagnosis of bulimia nervosa is based on episodes of binge eating and recurrent inappropriate compensatory behaviours. The EDNOS category is a residual category for disorders of eating that do not meet the criteria for anorexia nervosa or bulimia nervosa. Most EDNOS cases resemble anorexia nervosa or bulimia nervosa, but lack one of the diagnostic criteria sufficient for diagnosis (Fairburn & Walsh, 2002). Complete descriptions of diagnostic criteria for eating disorders in the DSM-IV are presented in Tables 1 to 3.

Introduction 11 Table 1 Diagnostic criteria for Anorexia nervosa (307.1) in DSM-IV A. Refusal to maintain body weight at or above a minimally normal weight for age and height (e.g., weight loss or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected). B. Intense fear of gaining weight or becoming fat, even though under weight. C. Disturbance in the way one's body weight or shape are experienced, undue influence of body weight or shape on self evaluation, or denial of the seriousness of the current low body weight. D. In postmenarcheal females, amenorrhea, i.e., the absence of at least three consecutive menstrual cycles. A woman is considered to have amenorrhea if her periods occur only following hormone administration e.g. oestrogen. Specify type: Restricting type: During the current episode of anorexia nervosa, the person has not regularly engaged in binge-eating or purging behaviour (i.e., self-induced vomiting or misuse of laxatives, diuretics, or enemas). Binge-eating–purging type: During the current episode of anorexia nervosa, the person has regularly engaged in binge-eating or purging behaviour. Table 2 Diagnostic criteria for Bulimia nervosa (307.51) in DSM-IV A. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: 1. Eating, in a discrete period of time, an amount of food that is definitely larger than most 2. A sense of lack of control over eating during the episode (e.g., a feeling that one cannot people would eat during a similar period of time and under similar circumstances. stop eating or control what or how much one is eating). B. Recurrent inappropriate compensatory behaviour in order to prevent weight gain, such as selfinduced vomiting; misuse of laxatives, diuretics, enemas, or other medications; fasting; or excessive exercise. C. The binge eating and inappropriate compensatory behaviour both occur, on average, at least twice a week for 3 months. D. Self evaluation is unduly influenced by body shape and weight. E. The disturbance does not occur exclusively during episodes of anorexia nervosa. Specify type: Purging type: During the current episode of bulimia nervosa, the person has regularly engaged in self-induced vomiting or the misuse of laxatives, diuretics, or enemas. Nonpurging type: During the current episode of bulimia nervosa, the person has used inappropriate compensatory behaviour but has not regularly engaged in self-induced vomiting or misused laxatives, diuretics, or enemas.

Introduction 12 Table 3 Diagnostic criteria for EDNOS (307.50) in DSM-IV The Eating Disorder Not Otherwise Specified category is for eating disorders that do not meet the criteria for any specific eating disorder. Examples include 1. For females, all of the criteria for anorexia nervosa are met except that the patient has regular menses. 2. All of the criteria for anorexia nervosa are met except that, despite significant weight loss, the patient's current weight is in the normal range. 3. All of the criteria for bulimia nervosa are met except that the binge eating and inappropriate compensatory mechanisms occur at a frequency of less than twice a week or for a duration of less than 3 months. 4. The regular use of inappropriate compensatory behaviour by an individual of normal body weight after eating small amounts of food (e.g., self-induced vomiting after the consumption of two cookies). 5. Repeatedly chewing and spitting out, but not swallowing, large amounts of food. 6. Binge-eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviours characteristic of bulimia nervosa. 1.1.2 Prevalence and Incidence Two commonly used measures in descriptive epidemiology are prevalence and incidence. Prevalence estimates provides the proportion of cases in a given population at a specific point in time, point prevalence, or during a specified period, for example lifetime prevalence. The number of new cases in relation to the total number of individuals at risk during a specified period is expressed as incidence. To facilitate comparison between studies the incidence of eating disorders is often expressed as new cases per 100 000 person-years (Keski-Rahkonen, Raevuori, & Hoek, 2008). The American Psychiatric Association stated in 2006 that the true incidence and prevalence of eating disorders is still unclear and that results vary depending on the sampling and assessment methods (American Psychiatric Association, 2006). In a much cited review of the prevalence and incidence of eating disorders Hoek and van Hoeken (2003) reported an average prevalence for anorexia nervosa of 0.3 % and of 1.0 % for bulimia nervosa in young females. Recent methodologically sound largescale studies on the lifetime prevalence of DSM-IV anorexia nervosa in Finland (Keski-Rahkonen et al., 2007), Sweden (Bulik, Sullivan, Tozzi, Furberg,

Introduction 13 Lichtenstein, & Pedersen, 2006), Australia (Wade, Bergin, Tiggemann, Bulik, & Fairburn, 2006), and the United States (Hudson, Hiripi, Pope, & Kessler, 2007) have reported figures ranging from 0.9 to 2.2 % for women and from 0.1 to 0.3 for men (Keski-Rahkonen, et al., 2008). Recent prevalence estimates for DSM-IV bulimia nervosa resemble those for anorexia nervosa; 1.7 % in Finland (Keski-Rahkonen et al., 2009) and 1.5 % in the United States (Hudson et al., 2007). A review of studies on bulimia nervosa found the lifetime prevalence to be between 1-2 % for women and 0.5 % for men (KeskiRahkonen et al., 2008). Sub-threshold cases of anorexia nervosa or bulimia nervosa are the most common forms of eating disorders in the community and fall into the category of eating disorders not otherwise specified (EDNOS) (American Psychiatric Association, 1994; Machado, Machado, Goncalves, & Hoek, 2007). In outpatient settings, EDNOS accounts for 60 % of all cases, but this category has often been overlooked by researchers (Fairburn & Bohn, 2005). Cases fulfilling all but one criterion for anorexia nervosa (Bulik et al., 2006; Keski-Rahkonen et al., 2007; Wade et al., 2006) or bulimia nervosa (Keski-Rahkonen et al., 2009) have been as common as full syndrome cases in population-based studies. The prevalence of DSM-IV EDNOS has ranged from 2.4 % to 4.9 % in recent studies of young women (Keski-Rahkonen et al., 2008). The prevalence of binge-eating disorder, a subtype of EDNOS, was 3.5 % among women and 2.0 % among men in the United States (Hudson et al., 2007). Studies on the incidence of eating disorders have usually been conducted in clinical settings leading to an underestimation of the true incidence, since far from all cases are detected by the health care system (Hoek & van Hoeken, 2003). Community based studies on the incidence of eating disorders have reported figures of 270 per 100 000 person-years for anorexia nervosa and 210 per 100 000 person-years for bulimia nervosa in female adolescents (Keski-Rahkonen et al., 2009; KeskiRahkonen et al., 2007). Anorexia nervosa usually has its onset earlier than bulimia nervosa. Peak-years of incidence are 15-19 years for anorexia nervosa and 20-24 years for bulimia nervosa (Hoek & van Hoeken, 2003; Keski-Rahkonen et al., 2008).

Introduction 14 Estimates of the incidence of EDNOS in adolescents and young adult females have ranged from 960 to 2800 per 100 000 person-years (Ghaderi & Scott, 2001; Lahortiga-Ramos, De Irala-Estevez, Cano-Prous, Gual-Garcia, Martinez-Gonzalez, & Cervera-Enguix, 2005). Based on the above mentioned studies on the incidence and prevalence of eating disorders between one in twenty and one in ten young women suffer from eating disorders during their lifetime and between one and three percent develop an eating disorder every year during peak years of incidence. 1.1.3 Outcome Important parameters of outcome in eating disorders are remission and mortality. Anorexia nervosa usually has its onset during the mid-teenage years. In some cases the disorder is short-lived, but in some unremitting (Fairburn & Harrison, 2003). Studies of the outcome of eating disorders have shown anorexia nervosa to have the least favourable outcome with regard to both remission and mortality. Moreover, studies of outcome, with a follow-up time over five years, have reported remission in 48-84 % of cases with anorexia nervosa, 70-72 % of cases with bulimia nervosa, and 75 % of cases with EDNOS. Mortality figures have ranged from 1-8 % of cases with anorexia nervosa and 0-2 % of cases with bulimia nervosa (Keel & Brown, 2010). In Finland, Keski-Rahkonen and colleagues reported clinical recovery in two-thirds of women suffering from anorexia nervosa and half of women suffering from bulimia nervosa within five years. After reaching clinical recovery, many still suffer from psychological problems for several years (Keski-Rahkonen et al., 2009; KeskiRahkonen et al., 2007). 1.1.4 Weight Perception and Dieting in Relation to Eating Disorders Body image is a multidimensional concept which encompasses both self-perceptions and self-attitudes (Cash, 2004) and is related to the sociocultural norms and ideals, more specifically to the ideal of thinness in females and of muscularity in males (Smolak, 2004). Weight perception is the subjective interpretation of an individual’s weight status and perceiving oneself as overweight or underweight is related to low self-esteem and other mental health problems in both male and female adolescents

Introduction 15 (Al Mamun, Cramb, McDermott, O'Callaghan, Najman, & Williams, 2007; Perrin, Boone-Heinonen, Field, Coyne-Beasley, & Gordon-Larsen, 2010). In childhood, boys and girls have similar body compositions, but during puberty the fat percentage increases in females and decreases in males (Moelgaard & Michaelsen, 1998). Adapting to the physical changes during puberty is a timeconsuming and challenging process, and body dissatisfaction usually increases in adolescence. Among female adolescents the decrease in body satisfaction generally ends in middle-adolescence, but among male adolescents, the process continues into young adulthood. Still, males express markedly less body dissatisfaction than females during this developmental period (Eisenberg, Neumark-Sztainer, & Paxton, 2006; Paxton & Heinicke, 2008). Some degree of body dissatisfaction may be regarded as normative in adolescent females, and this dissatisfaction usually concerns excess fat on hips, buttocks, stomach, and thighs. Adolescent males also strive to avoid being fat, but instead of pursuing thinness, they seek to gain weight in the form of muscles (Levine & Smolak, 2002). The drive for thinness as well as the drive for muscularity is associated with negative psychological outcomes (Kelley, Neufeld, & MusherEizenman, 2010). A logical consequence of perceiving oneself as being overweight or unfit is dieting. Dieting is a widely recognized risk factor for eating disorders in adolescence and can be defined as the intentional and sustained restriction of caloric intake for the purposes of weight loss or weight maintenance (Abraham, 2003; Patton, JohnsonSabine, Wood, Mann, & Wakeling, 1990; Patton, Selzer, Coffey, Carlin, & Wolfe, 1999; Stice, Burton, Lowe, & Butryn, 2007). Dieting has effects on both physical and mental health. In a review of the consequences of weight loss, French and Jeffrey (1994) found dieting-induced weight cycling to be associated with alterations in metabolic rate and an increased risk for future weight gain. The psychological effects of die

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