Disturbed Eating Severity Scale (DESS) places disturbed eating risk on a continuum

Appetite 59 (2012) 168–176

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Research report

Disturbed Eating Severity Scale (DESS) places disturbed eating risk on a continuum q Virginia M. Quick a,⇑,1, Carol Byrd-Bredbenner b a b

Division of Epidemiology and Community Health, School of Public Health, University of Minnesota, 1300 South Second Street, Suite 300, Minneapolis, MN 55454, USA Department of Nutritional Sciences, Rutgers University, 26 Nichol Avenue, New Brunswick, NJ 08901, USA

a r t i c l e

i n f o

Article history: Received 27 January 2012 Received in revised form 31 March 2012 Accepted 3 April 2012 Available online 12 April 2012 Keywords: Disturbed eating Eating behaviors Young adults

a b s t r a c t The purpose of this study was to develop a tool for assessing the severity of disturbed eating, use the tool to place disturbed eating behavior severity on a continuum, and to investigate how demographic and psychographic characteristics associated with disturbed eating differ across this continuum. Young adults (n = 2438; 58% White; 63% female) from three north coast universities completed an online survey (fall 2009 to summer 2010) assessing eating behaviors and psychographic characteristics. Eating behavior scores were used to calculate the Disturbed Eating Severity Score (DESS), which placed participants along a continuum of four disturbed eating severity (non- disturbed to highly-disturbed) categories. Analysis of covariance and post hoc tests revealed significant differences among DESS categories on all eating behavior scales and nearly all psychographic characteristics. Thus, the DESS scale may help health care practitioners identify patients with varying degrees of disturbed eating behaviors and offer early interventions that could halt progress toward an eating disorder. Published by Elsevier Ltd.

Introduction Eating disorders are defined as a ‘‘clinically meaningful behavioral or psychological pattern having to do with eating or weight that is associated with distress, disability, or with substantially increased risk of morbidity or mortality (Grilo, 2006)’’. On the other hand, disturbed eating behaviors are abnormal behaviors associated with eating disorders, but do not warrant a psychiatric diagnosis of an eating disorder defined by the Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) (Diagnostic and Statistical Manual of Psychiatric Disorders, 2000). Examples of disturbed eating behaviors are restraint eating, emotional eating, disinhibited eating, night eating, binge eating, weight concerns, shape concerns, eating concerns, strict dieting, night eating, and controlling one’s body weight and shape through inappropriate compensatory behaviors (e.g., purging). Eating disorders arise from a multifactorial and complex model in which various factors (e.g., psychological, biological, and sociocultural domains) interact with each other directly or indirectly to affect eating behaviors (Striegel-Moore, 1997). Identification of the risk factors for eating disorders is still evolving, and frequently includes eating and weight management q Financial Disclosure: Kappa Omicron Nu Research Fellowship. Conflict of Interest: The authors have no conflict of interest. ⇑ Corresponding author. E-mail address: [email protected] (V.M. Quick). 1 Conducted this study while at Rutgers University.

0195-6663/$ - see front matter Published by Elsevier Ltd. http://dx.doi.org/10.1016/j.appet.2012.04.001

practices that may begin when a ‘‘healthy’’ concern for one’s weight devolves into an ‘‘unhealthy’’ concern (Grilo, 2006; Tanofsky-Kraff & Yanovski, 2004; Van Strien, Engels, Leeuwe, & Snoek, 2005). Eating disorder risk factors also include body image disturbances, mental disorders associated with disturbed eating (e.g., depression, anxiety), intrapersonal characteristics (e.g., low self-esteem, poor coping skills), and sociocultural environment features (e.g., pressures from the media or at family mealtimes) (Ball & Lee, 2000; Blokstra, Burns, & Seidell, 1999; Blond, 2008; Bulik, 2002; Haines, Neumark-Sztainer, Eisenberg, & Hannan, 2006; Herzog & Eddy, 2007; Hesse-Biber, Leavy, Quinn, & Zoino, 2006; van den Berg et al., 2007; Worobey, 2002). The lifetime prevalence estimates of anorexia nervosa, bulimia nervosa, and binge eating disorder among women are 0.9%, 1.5%, and 3.5%, respectively, whereas among men these conditions occur at a rate of 0.3%, 0.5%, and 2.0% (Hudson, Hiripi, Pope, & Kessler, 2007). Disturbed eating behaviors, which are early markers of a potential eating disorder diagnosis, are generally thought to be much higher than the current lifetime prevalence rates for psychiatric diagnosis of eating disorders (Grilo, 2006), but actual prevalence rates are unknown. In addition, few easy-to-use, reliable tools are available to help health care practitioners identify patients with disturbed eating behaviors that could escalate to a more serious diagnosis of an eating disorder. Currently, eating disorder risk assessments are limited in the following ways: narrow scope of disturbed eating behaviors evaluated, instruments tend to be targeted to female audiences, instrument reliabilities are modest (especially for certain racial/

V.M. Quick, C. Byrd-Bredbenner / Appetite 59 (2012) 168–176

ethnic groups), and/or instruments were developed and used only in clinical settings thereby limiting their generalizability to the general population (Kashubeck-West, Mintz, & Saunders, 2001; Mitchell & Peterson, 2005; Olmsted, McFarlane, Carter, & Trottier, 2007; Reas & Grilo, 2004). Thus, a reliable assessment tool that more comprehensively evaluates disturbed eating practices in a diverse non-clinical population is needed to fill this gap. Therefore, the purposes of this study was to develop a tool for assessing the prevalence and severity of a broader array of disturbed eating behaviors, and use the tool to place disturbed eating behavior severity on a continuum from non-disturbed to highly disturbed. A second purpose was to determine how demographic and psychographic characteristics associated with disturbed eating differed among the varying levels of disturbed eating severity in a large, diverse, free-living population of young adults. Methods This study was approved by the Institutional Review Board at the authors’ university. Participants completed an online survey that included demographic questions and assessed disturbed eating behaviors and related psychographic characteristics. Demographic information included self-reported age, gender, race, height, weight, current health status, eating disorder history, and number of mentally and physically unhealthy days per month. Disturbed eating behaviors and related psychographic characteristics were evaluated using carefully selected extant instruments adapted for the purpose of developing and evaluating the tool developed in this study; that is, the Disturbed Eating Severity Scale (DESS). An extensive literature search to identify salient eating behaviors and psychographic characteristics that affect eating behaviors as well as to identify existing valid, reliable, brief self-report measures for assessing the DESS was conducted. A panel of experts (n = 9) in nutrition, eating disorder treatment, psychology, and public health also reviewed the eating behaviors and psychographic characteristic measures to ensure comprehensiveness and contextual value of the measures to the study’s purpose. Thus, the validity and reliability of most instruments used in the survey were already established as good to excellent. The instructions for completing the scales preceded scale items. Eating behaviors Nine eating behavior scales were included in the survey and used to develop the DESS. These include scales from the Eating Disorder Examination Questionnaire (EDE-Q), 16th edition, Three Factor Eating Questionnaire-18 (TEFQ), and Night Eating Questionnaire, which are described below. Four EDE-Q Likert scales (Restraint, and Eating, Weight, and Shape Concerns) were used to assess frequency of attitudinal and behavioral features of eating disorders experienced in the last 28 days (Fairburn, Cooper, & O’Connor, 2008). The Restraint scale measures attempts to restrict food so as to influence one’s body weight and shape, and to gain a sense of control over food intake. The Eating Concerns scale assesses preoccupation with and feelings towards eating. The Weight Concerns scale evaluates feelings toward weight and the Shape Concerns scale measures feelings about body shape and size. Individual scores for each scale and a composite score that included all four scales (i.e., Global score) were computed using standard procedures (Fairburn, Cooper, & O’Connor, 2008). Higher scores indicate more eating disorder symptomatology and greater eating disorder risk. The EDE-Q’s Binge Eating Disorder Module was used to assess how often one engaged in binge eating and inappropriate

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compensatory behaviors (i.e., self-induced vomiting, medication misuse, and excessive exercise) (Fairburn, Cooper, & O’Connor, 2008). Binge eating, self-induced vomiting, or misusing medicine are of clinical importance when they occur four or more times in 28 days (Lavender, De Young, & Anderson, 2010; Luce, Crowther, & Pole, 2008). Exercising excessively is of clinical importance if it occurs 20 or more times in 28 days (Lavender et al., 2010; Luce et al., 2008). Therefore, binge eating, self-induced vomiting, and medication misuse items were assigned a score of 0, 1, 2, 3, 4, 5, 6 for no times, one time, two times, three times, four times, five times, and six or more times, respectively. The exercising excessively item was scored as 0 for no times, 1, 2, 3, 4, 5, and 6 equaled exercising excessively for 1 to 5, 6 to 10, 11 to 15, 16 to 20, 21 to 25, or more than 25 times in the past 28 days, respectively. This scoring method was used because a score of 4 for any of these inappropriate behaviors is slightly above the scale mid-point and allows for higher scores reflecting more frequent occurrences (i.e., greater severity). Unless otherwise indicated, scores for all other scales used in this study were computed using the procedures provided by the original scale developer (i.e., averaging the responses to items in the scale). Emotional and Disinhibited Eating were appraised using the Three Factor Eating Questionnaire-18 (Karlsson, Persson, Sjostrom, & Sullivan, 2000). The Emotional Eating scale evaluates how emotions influence an individual’s urge to eat and the Disinhibited Eating scale assesses uncontrolled eating behaviors (Karlsson et al., 2000). The Disinhibited Eating scale was shortened to reduce participant burden by including items with the strongest factor loadings reported previously (Karlsson et al., 2000). Higher scores indicated greater emotional eating behaviors and/or a greater loss of control over eating. Items with the most pertinent features of night eating syndrome (i.e., nocturnal eating) from the Night Eating Questionnaire were used (Allison et al., 2008). Participants were judged to be a night eater if they reported getting up in the middle of the night and eating at least half or more of their daily food intake after suppertime. Scale scores for night-eaters equaled the mean of the six scale items and non-night eaters received a score of 0. Higher scores indicate greater night eating severity.

Psychographic characteristics associated with disturbed eating Body image attributes were evaluated using the Appearance Schema Inventory-Revised (ASI-R) and a Body Image Distortion measure. The ASI-R’s Self-Evaluative Salience scale measures the extent to which one equates self-worth to physical appearance. The ASI-R’s Motivational Salience scale evaluates investment in one’s appearance (Cash & Labarge, 1996). Higher scores on the ASI-R scales indicate greater importance of physical appearance in one’s self-worth assessment and greater investment in one’s physical appearance. Both of these scales were reduced in length to lower participant burden by eliminating repetition and overlap with other measures assessed. Body Image Distortion is a comparison of actual body mass index (BMI) weight category (i.e., underweight [BMI < 18.5], normal weight [BMI = 18.5–24.9], overweight [BMI P 25], scored 1, 2 and 3, respectively) with perceived current body weight (i.e., very thin/thin, average, slightly heavy/overweight, scored 1, 2 and 3, respectively). The Body Image Distortion score was calculated by subtracting actual BMI weight category score from perceived current body weight. Possible score ranges are from 2 to 2. Scores closer to zero indicate accurate body image perception. Positive scores indicate individuals perceive they are heavier than they actually are (increased body image distortion), whereas negative values indicate that individuals perceive they

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are thinner than they actually are (decreased body image distortion). The mental disorders associated with disturbed eating measures were depression, anxiety, and obsessive compulsive disorder (OCD). The Patient Health Questionnaire was used to assess severity of depression (Kroenke, Spitzer, & Williams, 2001) and the Generalized Anxiety Disorder instrument measured anxiety severity, both of which are based on DSM-IV criteria (Spitzer, Kroenke, Williams, & Lowe, 2006). OCD severity was evaluated using the Florida Obsessive Compulsive Inventory (Storch et al., 2007). Higher scale scores indicate greater depression, anxiety and OCD severity. Intrapersonal characteristics examined were self-esteem, coping strategies, dichotomous thinking with regard to eating, and regulation of emotions. Self-esteem was assessed using four items with high factor loadings from the Rosenberg Self Esteem scale (Martin-Albo, Nunez, Navarro, & Grijalvo, 2007; Rosenberg, 1965). The original Likert scale was altered from a 4- to a 5-point scale (strongly disagree = 1, disagree = 2, neither agree nor disagree = 3, agree = 4, strongly agree = 5) to increase consistency with the other survey items and provide a broader range of answer choices. Higher scores indicate greater self-esteem. Health value (i.e., the importance placed on personal health) was assessed using the Health Motivation scale (Seeman & Seeman, 1983). Higher scores indicate greater emphasis placed on one’s health. The Coping Inventory for Stressful Situations instrument appraised coping strategies using three scales (Task-Oriented Coping, Emotion-Oriented Coping, and Social Diversion Coping) (Endler & Parker, 1990). The Task-Oriented Coping scale evaluates extent to which purposeful efforts aimed at solving problems and cognitively restructuring/altering problems were used. The Emotion-Oriented Coping scale judges the degree to which emotional reactions were used to cope. The Social Diversion scale, adapted from the Avoidant Coping scale, measures how much individuals divert themselves by socializing with friends when faced with a difficult situation. These scales were shortened to reduce repetition and to minimize participant burden by using items with the highest factor loadings (Calsbeek, Rijken, van Berge, Henegouwen, & Dekker, 2003). Lower scores on all three scales indicate negative coping abilities. The Eating scale from the Dichotomous Thinking in Eating Disorders Scale (Byrne, Allen, Dove, Watt, & Nathan, 2008) assesses the presence of a rigid, ‘‘black-and-white’’ cognitive thinking style. This scale established, for those who dieted, the degree to which they thought food was either ‘‘good’’ or ‘‘bad’’. Higher mean scores indicated greater eating dichotomous thinking. The Regulation of Emotions scale from the Wong & Law Emotional Intelligence Scale was used to evaluate an individual’s ability to regulate his or her own emotions (Wong & Law, 2002). Higher overall sum scores indicate greater regulation ability (i.e., emotional intelligence). Sociocultural environmental factors examined included media influences, use of media that are body image intense, and family mealtime environment. Items with the highest factor loadings (Thompson, van den Berg, Roehrig, Guarda, & Heinberg, 2004) from the Sociocultural Attitudes Towards Appearance Questionnaire were used to evaluate media influences in the environment on body image and eating disturbances. The Internalization-General scale assesses the influence of generic media (e.g., TV, magazines). The Pressures-Media scale measures perceived pressure from the media and the Information-Media scale evaluates awareness of societal appearance norms conveyed by the media (e.g., movies, TV, magazines). Higher scores for these scales named above indicate more frequent comparisons of one’s body to those of people in the media, greater feelings of pressure to obtain the physical appearance standard set by the media, and

greater awareness of the societal appearance norms set by the media. The Body Image Intense Media scale developed for this study asked participants to name their two favorite television shows, magazines, and websites. Each response was coded as being either body image intense or not, based on how a focus group of young adults (n = 5) categorized the TV shows, magazines, and websites named by participants. A score of 1 was designated for each body image intense TV show, magazine, and website named, and a score of 0 was designated for non-body image intense media. Scores for this measure were computed by summing all responses, so a possible score ranged from 0 to 6, with higher scores reflecting greater preference for body image intense media. The Childhood Family Mealtime Questionnaire scales assesse the family eating environment experienced as a child (Miller, McCluskey-Fawcett, & Irving, 1993). For this study, scale items were retained based on their relevance and the results of univariate analysis (Miller et al., 1993). The Mealtime Communication Based-Stress, Mealtime Structure, Appearance Weight Control, and Emphasis on Mother’s Weight scales assessed the following: stress felt during family mealtimes, family mealtime pressures to eat, the importance of weight management, and how one felt with respect to the emphasis placed on his or her mother’s weight as a child, respectively. Higher scores on the scales indicated greater mealtime stress, mealtime structure, importance placed on weight control, and emphasis placed on mother’s weight as a child, respectively. Sample & recruitment Young adults, ages 18–26 years old, were recruited to participate in this study because they represent a high risk group for disturbed eating and eating disorders (Bell & Lee, 2006; Lewis et al., 2000). Participants from universities (n = 3) on the east coast of the U.S. were invited to complete an online survey about eating practices via notices (e.g., posters on campus, emails to listservs, announcements made in large general education classes). Recruitment notices included a website link for the informed consent document and survey. As an incentive, participants were offered a chance to win 1 of 10 $25 cash prizes and in some instances professors of participants who were recruited from several large general education courses (n = 14) also offered extra credit to students for completing the survey. Data analysis The DESS score was developed for this study to provide a summary of how severely disturbed participants’ eating behaviors and weight and shape concerns were. The DESS is a composite score computed using individual scores from the nine Eating Behavior scales. Thus, this score takes into account behaviors typically used to assess eating disorders as well as other disturbed eating behaviors not considered in scales used to assess the presence of eating disorders (e.g., EDI (Garner, 1991; Garner, Olmsted, & Polivy, 1983) and EAT-26 (Garner & Garfinkel, 1979)), namely night eating, emotional eating, and disinhibited eating. These additional scales were included because the behaviors they assess are often identified as precursors to eating disorders (Cash & Pruzinsky, 2002; Fairburn & Brownell, 2002). The first step in computing the DESS score was to calculate the scores for each of the nine Eating Behavior scales. The second step was to determine the percentiles (i.e., 75th, 90th) for the scores of each Eating Behavior scale and assign each participant a percentile ranking for each scale. Scale scores below the 75th percentile were considered ‘‘normal’’ and were ranked as 0. Scores from the 75th to less than the 90th percentiles were considered above normal and

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were ranked as 1. Scores at or above the 90th percentile were considered well above normal and were ranked as 2. Using percentile rankings permitted even weighting across the nine Eating Behavior scales. The third step in calculating the DESS score was to sum the percentile ranking scores of the nine Eating Behavior scales to create the composite score (possible score range of 0–18) and determine the percentiles (i.e., 75th, 90th) of the summed ranking scores. The final step was to assign participants to a disturbed eating severity category (i.e., not disturbed, mildly disturbed, disturbed, and highly disturbed). Those categorized as ‘‘not disturbed’’ had a summed ranking score of 0. Those categorized as ‘‘mildly disturbed’’ had a score above 0 and below the 75th percentile (score >0 and <5). Those categorized as ‘‘disturbed’’ scored at or above the 75th percentile and below the 90th percentile (score P5 and <10). Those categorized as ‘‘highly disturbed’’ scored at or above the 90th percentile (score P10). The cut-offs for disturbed eating severity categories were based on previous research (Fairburn et al., 2008; Lavender et al., 2010; Luce et al., 2008) as well as typical percentile categories used in psychological measurements (e.g., a percentile greater than 75 is considered above normal) (Mond, Hay, Rodgers, Owen, & Beumont, 2004a; Wechsler, 1944). Internal consistency scores (i.e., Cronbach’s-a) were calculated for all survey instruments to assess reliability. Descriptive statistics for each of the disturbed eating severity categories were then generated for all demographic data, eating behavior measures, and psychographic instruments. Analysis of variance (ANOVA) for demographics and ANCOVA (covariates BMI and gender) with Bonferroni post hoc tests were conducted to examine significant differences between disturbed eating severity groups of all variables measured. Pearson correlation coefficients for the nine eating behavior scales, DESS score, Global EDE-Q score, and eating disorder history, along with calculating the percent that each eating behavior scale contributed to the DESS, were performed to determine whether the eating behavior scales used to generate the DESS score contributed significantly to disturbed eating severity. Significance was set at P < 0.05. All analyses were conducted on PASW Statistics 19.0 SPSS.

Results After eliminating participants who were not in the age range of 18 to 26 years (n = 99), had a chronic health condition (n = 176), were non-college students (n = 21), or who omitted key demographic information (i.e., height, weight, or gender; n = 6), the total sample size was 2438 participants. The sample was diverse with 58% of participants classifying themselves as White. Participants were mostly female (63%) and either first or second year (64%) college students in their late teens/early twenties (mean age 19.66 ± 1.48SD years). Participants also were mostly (68%) at a healthy weight (BMI P 18.5 to <25). Additionally, 2% of participants reported being diagnosed at some point in their life with an eating disorder, with significantly higher rates in females (3.0%) than males (0.3%). Table 1 shows scores at the 75th and 90th percentile for each of the nine eating behavior scales used to create the DESS score. Table 2 reports mean DESS scores by category (i.e., non-disturbed, mildly disturbed, disturbed, and highly disturbed). Mean DESS scores (3.46 ± 3.84 SD) were at the lower end of the possible score range (i.e., 0–18). However, only 29% were categorized as non-disturbed. Mean DESS scores increased significantly among the DESS categories. ANOVA revealed significant main effects among DESS categories on most demographic characteristics (except for age and race

Table 1 Score percentiles of scales used to derive the Disturbed Eating Severity Score (n = 2438). Characteristic (possible score range)

75th Percentile

Eating Disorder Examination Questionnaire Binge eating (0–6) 1.00 Restraint (0–6) 2.00 Eating concerns (0–6) 1.00 Shape concerns (0–6) 3.13 Weight concerns (0–6) 2.60 Compensatory Behaviors Score (0–6) 0.33 Three-Factor Eating Questionnaire-18 Emotional Eating (1–4) 2.67 Disinhibited Eating (1–4) 2.67 Night Eating Severity (0–30) >0.00a Disturbed Eating Severity Score (0–18) 5.00

90th Percentile 5.00 3.20 2.20 4.50 4.00 1.33 3.00 3.00 11.00 10.00

a Night Eating Severity scores >0 occurred at the 85.5th percentile. Thus, in the case of this scale, a score of 1 was assigned for scores between the 85.5th and <90th percentile.

[non-white vs. white]), and post hoc analyses indicated that all or most pairs of DESS categories differed significantly (Table 3). For instance, higher BMIs were significantly associated with greater disturbed eating severity. Self-rated health status declined and the number of mentally and physically unhealthy days in the past month rose significantly as DESS score increased. Additionally, the incidence of eating disorder history increased significantly as disturbed eating severity rose. ANCOVA, controlling for BMI and gender, revealed a main effect for each of the nine eating behavior scales comprising the DESS that were significantly different among disturbed eating severity categories (see Table 3). Post-hoc analyses indicated all pairs of disturbed eating severity categories were significantly different, with eating behavior scale scores increasing as severity category increased. ANCOVA, controlling for BMI and gender, also revealed significant main effects on DESS categories on all measures of psychographic characteristics related to disturbed eating, except Mealtime Structure (see Table 3). Post-hoc analyses indicated that all or most pairs of DESS categories tended to differ significantly. Thus, Self-Evaluative and Motivational Salience, Body Image Distortion, Depression, Anxiety, OCD, Emotion-Oriented Coping, Dichotomous Thinking, Pressures-Media, Internalization-General, Information-Media, Body Image Intense Media, Mealtime Communication-Based Stress, Appearance Weight Control, and Emphasis on Mother’s Weight as a Child scores increased significantly as disturbed eating became more severe. On the other hand, Self-Esteem, Health Value, Task-Oriented Coping, and Regulation of Emotion scores significantly decreased as disturbed eating severity increased. Pearson correlation coefficients of the eating behavior scales that form the DESS score and the Global EDE-Q score are reported in Table 4. All eating behavior scales correlated significantly with the DESS score as anticipated and also correlated significantly with the Global EDE-Q score. In addition, eating disorder history correlated significantly with the DESS score and the Global EDE-Q score. All eating behavior scales, except Disinhibited Eating and Night Eating, were significantly correlated with eating disorder history. As shown in Table 5, all of the eating behavior scales contributed to the DESS score of all disturbed eaters with the percentages contributed by each scale being significantly different as disturbed eating severity increased. Restraint, Binge Eating and Eating, Shape, and Weight Concerns scores increased as disturbed eating severity increased whereas Inappropriate Compensatory Behaviors and Emotional, Disinhibited, and Night Eating scores decreased.

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Table 2 Frequencies of Disturbed Eating Severity Score (DESS) categories by gender. Disturbed Eating Severity Category*

Non-disturbed (ND) Mildly-disturbed (MD) Disturbed (D) Highly-disturbed (HD)

All participants (N = 2438)

Female participants (N = 1525)

Male participants (N = 913)

N (%)

Mean DESS ± SD

N (%)

Mean DESS ± SD

N (%)

Mean DESS ± SD

695 (28.5) 1019 (41.8) 486 (19.9) 238 (9.8)

0.00 ± 0.00 2.21 ± 1.07 6.57 ± 1.39 12.12 ± 1.85

382 607 346 190

0.00 ± 0.00 2.31 ± 1.01 A 6.66 ± 1.42B 12.14 ± 1.88

313 (34.3)a 412 (45.1)b 140 (15.3)a 48 (5.3)a

0.00 ± 0.00 2.07 ± 1.01A 6.35 ± 1.30B 12.06 ± 1.71

(25.0)àa (39.8)b (22.7)a (12.5)a

*

Groups were categorized from cut-off values of Disturbed Eating Severity Score (DESS) percentiles (ND=0, MD<75th percentile, 75th P D<90th percentile, HD P 90th percentile). Numbers followed by the same lowercase superscript in a row are significantly different using Chi-square analyses. a p<0.001. b p<0.01.   Numbers followed by the same uppercase superscript in a row are significantly different using independent samples t-tests. A p<0.001. B p<0.05. à

Discussion The DESS created in this study yields scores that permit health researchers and practitioners to describe the severity of disturbed eating behaviors and place them along a continuum ranging from non-disturbed to highly disturbed. That is, DESS scores indicate that 29%, 42%, 20% and 10% of young adults were categorized as non-disturbed, mildly disturbed, disturbed, and highly disturbed eaters, respectively. The DESS incorporates nine instruments with good validity and reliability, all of which measure key attributes associated with disordered eating (Allison et al., 2008; Fairburn et al., 2008; Mitchell & Peterson, 2005), but some of which typically are not included when evaluating patients’ eating disorder risk (Mitchell & Peterson, 2005). The scoring method developed for the DESS recognized the potential contribution of each disturbed eating practice by equally weighting the scales. Findings from this study revealed that mean Weight and Shape Concerns scale scores for participants categorized as highly disturbed eaters reached the level considered clinically significant by the EDE-Q (i.e., mean scale scores P4 indicating increased eating disorder symptomatology) (Fairburn et al., 2008; Mond et al., 2004a). However, mean Restraint and Eating Concern scores for highly disturbed eaters did reach this cut-off (i.e., mean scale score P4) (Fairburn & Beglin, 1994; Fairburn et al., 2008). A mean Global EDE-Q score of P4, is the cut-off used to identify those at eating disorder risk (Fairburn & Beglin, 1994; Fairburn et al., 2008). The highly disturbed category achieved a mean Global EDE-Q score near four, which suggests that the DESS scoring method and categorization of disturbed eating severity rankings yields valid results. It is important to note that the highly disturbed group did not fully reach the Global EDE-Q cut-off score. A comparison of results from the self-report EDE-Q (which was used in this study) with the semi-structured interview EDE indicated that those who were found to have an eating disorder using the interview EDE did not reach the clinically significance level for diagnosis of an eating disorder with the self-report EDE-Q (Mond, Hay, Rodgers, Owen, & Beumont, 2004b). Thus, the clinical significance level set for the self-report EDE-Q may be too high. Participants categorized as highly disturbed eaters also performed one or more compensatory behavior (i.e., excessive exercise, medicine misuse, self-inducted vomiting) and/or binge ate at levels of clinical significance (Lavender et al., 2010; Luce et al., 2008). That is, they either exercised excessively for P20 or more days, and/or misused medicine, self-induced vomiting, and/or binge ate P4 times in the past 28 days. Additionally, approximately 17% of night eaters were categorized as highly disturbed eaters, which indicated the prevalence of this behavior, and confirmed that it is important to consider night eating behaviors when examining disturbed eating behaviors.

Scores for all body image attributes (i.e., Self-Evaluative Salience, Motivational Salience, Body Image Distortion) and the sociocultural media environment (i.e., Pressures-Media, Internalization-General, Information-Media, Body Image Intense Media), which are influencers of disturbed body image and eating (Hesse-Biber et al., 2006; Striegel-Moore, 1997), increased significantly as disturbed eating severity rose. This finding lends further support to the usefulness of the DESS because these body image attributes and sociocultural media environment influencers reflect internalization of the thin ideal (Brown & Dittmar, 2005; Durken & Paxton, 2002; Keery, van den Berg, & Thompson, 2004; Stice & Shaw, 2002), which is positively associated with disturbed eating and eating disorders in females and males (Karazsia & Crowther, 2008). That is, individuals who place a greater emphasis on physical appearances and subscribe to societal norms of unrealistic body sizes are at increased risk for disturbed eating (Hesse-Biber et al., 2006). The Social Comparison Theory and Gerber’s Cultivation Theory posit that exposure to the mass media portrayal of the thin ideal of females can have adverse effects on body image (Festinger, 1954; Gerber, Gross, Morgan, Signorielli, & Shanahan, 1994; Poran, 2002). Females who compare themselves to idealized images of beauty (i.e., upward social comparisons) that are unachievable, are more susceptible to feelings of body dissatisfaction and likely to engage in unhealthy weight control behaviors (Gerber et al., 1994; Martin & Gentry, 1997; Martin & Kennedy, 1993). Furthermore, Gerber’s Cultivation Theory posits that the more media people are exposed to, the more they will begin to view the mass media images as realistic (Gerber et al., 1994). Research is limited in males’ responsiveness to the portrayal of the male ideal muscular masculine physique (i.e., V-shaped, muscular, low body fat) (Anderson, 2002). However, results from this study provide support for the Social Comparison Theory and Cultivation Theory in that increased exposure to body image intense media (i.e., TV, magazines, websites) was associated with increased DESS scores in females and males. Anxiety, Depression, and OCD severity scores increased as DESS scores rose. This finding further demonstrates the robustness of the DESS score because anxiety, depression, and OCD are well recognized co-morbidities of eating disorders (Bulik, Sullivan, Fear, & Joyce, 1997; Herzog, Keller, Sacks, Yeh, & Lavori, 1992; Hsu, Kaye, & Weltzin, 1993; Wonderlich, 2002). For instance, negative mood and stress, as it relates to anxiety and depression, are the most frequently cited precipitants of binge eating (Herman & Mack, 1975; Ruderman, 1986). Study findings related to intrapersonal characteristics (i.e., individual processes) associated with disturbed eating (i.e., Self-Esteem, Health Value, Stress and Coping, Regulation of Emotion, and Dichotomous Thinking) are congruent with those

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V.M. Quick, C. Byrd-Bredbenner / Appetite 59 (2012) 168–176 Table 3 Demographics, eating behaviors and related-psychographic characteristics of young adults by disturbed eating severity. Characteristic (possible score range) Demographics Age BMI Current health status Mentally unhealthy days (0–30) Physically unhealthy days (0–30) History of an eating disorder [N (% yes)] Eating Behaviors Global EDE-Q scoreB (0–6) RestraintE (0–6) Eating ConcernsE (0–6) Shape ConcernsE (0–6) Weight ConcernsE (0–6) Binge EatingE (0–6) Inappropriate compensatory behaviors ScoreE (0–6) Emotional EatingF (1–4) Disinhibited EatingF (1–4) Night Eating SeverityG (0–30) Disturbed Eating Severity Score (0–18) Body image attributes Self-Evaluative SalienceH (1–5) Motivational SalienceH (1–5) Body Image DistortionI ( 2 to 2) Mental disorders DepressionJ (0–24) AnxietyK (0–21) FOCI L (0–20)C Intrapersonal characteristics Self-EsteemM (1–5) Health ValueN (1–5) Task-Oriented CopingO (1–5) Emotion-Oriented CopingO (1–5) Social DiversionO (1–5) Dichotomous Eating ScaleP (1–4)D Regulation of EmotionQ (7–28) Sociocultural Media Environment Pressures-MediaR (1–5) Internalization-GeneralR (1–5) Information-MediaR (1–5) Body Image Intense Media ScoreS (0–6) Family Mealtime Communication-Based StressT Mealtime StructureT (1–5) Appearance Weight ControlT (1–5) Emphasis on Mother’s WeightT (1–5) *

Cronbach’s a

ND* (N = 695) Mean ± SD*

MD* (N = 1019) Mean ± SD

D* (N = 486) Mean ± SD

HD* (N = 238) Mean ± SD

FA

p-value

n/a n/a

19.73 ± 1.52 22.31 ± 3.46 3.87 ± 0.83 3.89 ± 6.46 2.14 ± 4.33 6 (0.86)

19.68 ± 1.49 23.21 ± 3.81 3.71 ± 0.83 4.98 ± 6.97 2.95 ± 5.31 13 (1.28)

19.54 ± 1.41 24.43 ± 4.52 3.52 ± 0.88 7.42 ± 8.47 3.70 ± 5.67 13 (2.67)

19.70 ± 1.44 24.71 ± 4.24 3.22 ± 0.95 13.87 ± 10.35 5.33 ± 7.54 17 (7.14)

1.64 38.66abcde 40.11à 116.42à 23.29bcef 31.89ce

0.177 <0.001 <0.001 <0.001 <0.001 <0.001

0.50 0.84 0.74 0.78 n/a

0.43 ± 0.42 0.28 ± 0.47 0.11 ± 0.18 0.79 ± 0.76 0.53 ± 0.64 0.00 ± 0.00 0.00 ± 0.00 1.53 ± 0.49 1.73 ± 0.43 0.00 ± 0.00 0.00 ± 0.00

1.05 ± 0.72 0.93 ± 1.04 0.38 ± 0.44 1.63 ± 1.14 1.26 ± 1.06 0.13 ± 0.41 0.25 ± 0.55 1.95 ± 0.67 2.17 ± 0.62 1.96 ± 4.85 2.21 ± 1.07

2.31 ± 0.91 2.06 ± 1.32 1.21 ± 0.86 3.23 ± 1.30 2.76 ± 1.28 0.56 ± 0.89 0.74 ± 1.08 2.38 ± 0.76 2.46 ± 0.66 3.73 ± 6.63 6.57 ± 1.39

3.76 ± 0.84 3.36 ± 1.44 2.80 ± 1.13 4.63 ± 0.96 4.23 ± 0.98 1.70 ± 1.59 1.32 ± 1.47 2.89 ± 0.71 2.89 ± 0.60 4.64 ± 7.70 12.12 ± 1.85

1494.89à 591.71à 1256.95à 900.64à 924.77à 408.97à 242.20à 348.97à 287.81à 92.66à 8201.57à

<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001

0.85 0.71 n/a

2.84 ± 0.67 3.39 ± 0.69 0.12 ± 0.54

3.16 ± 0.65 3.59 ± 0.66 0.26 ± 0.56

3.61 ± 0.61 3.81 ± 0.68 0.03 ± 0.55

4.04 ± 0.60 4.00 ± 0.66 0.12 ± 0.54

228.86à 64.11à 40.52bcdef

<0.001 <0.001 <0.001

0.87 0.90 0.91

3.49 ± 3.68 3.55 ± 3.81 4.50 ± 2.90

4.90 ± 3.86 4.98 ± 4.13 4.86 ± 2.89

7.48 ± 4.73 7.39 ± 4.83 6.20 ± 3.32

11.69 ± 5.65 10.77 ± 5.29 7.62 ± 3.98

254.33à 189.64à 43.28bcdef

<0.001 <0.001 <0.001

0.85 0.60 0.80 0.76

4.10 ± 0.77 3.27 ± 0.73 4.05 ± 0.70 2.45 ± 0.91 2.37 ± 0.92 2.45 ± 0.54 21.63 ± 4.11

3.83 ± 0.81 3.24 ± 0.68 4.00 ± 0.69 2.77 ± 0.94 2.58 ± 0.97 2.73 ± 0.53 20.60 ± 4.31

3.44 ± 0.85 3.17 ± 0.68 3.86 ± 0.72 3.08 ± 0.90 2.80 ± 1.02 2.99 ± 0.58 19.84 ± 4.34

2.75 ± 0.89 3.08 ± 0.66 3.63 ± 0.76 3.53 ± 0.94 2.92 ± 1.00 3.29 ± 0.52 18.17 ± 4.89

174.75à 9.09bce 25.47bcdef 92.91à 26.41abcde 62.56à 38.12à

<0.001 0.001 0.001 <0.001 0.011 <0.001 <0.001

0.87 n/a

2.52 ± 0.93 2.47 ± 1.13 2.58 ± 0.92 1.55 ± 1.21

2.97 ± 0.97 2.88 ± 1.16 2.87 ± 0.90 1.88 ± 1.26

3.64 ± 0.90 3.50 ± 1.06 3.25 ± 0.86 2.25 ± 1.30

4.08 ± 0.80 4.08 ± 0.91 3.43 ± 0.85 2.34 ± 1.35

182.37à 150.00à 75.52abcde 27.61abcde

<0.001 <0.001 <0.001 <0.001

0.73 0.81 0.86 0.72

1.52 ± 0.52 3.28 ± 1.05 1.56 ± 0.62 1.73 ± 0.72

1.62 ± 0.59 3.31 ± 1.07 1.86 ± 0.80 1.94 ± 0.83

1.83 ± 0.69 3.32 ± 1.09 2.38 ± 1.00 2.27 ± 0.92

1.97 ± 0.74 3.42 ± 1.03 2.82 ± 1.06 2.53 ± 1.02

51.44à 1.83 134.57à 60.88à

<0.001 0.140 <0.001 <0.001

   

n/a n/a 0.83 0.80 0.88 0.83  

 

0.73 0.87 0.88  

ND = non-disturbed, MD = mildly disturbed, D = disturbed, HD = highly disturbed; SD = standard deviation. Cronbach’s-a cannot be computed for 1-item scales. Bonferroni follow-up procedures revealed that all pairs (ND and MD, ND and D, ND and HD, MD and D, MD and HD, D and HD) are significantly different (p < 0.05), except where otherwise noted in superscript letters: aND and MD; bND and D; cND and HD; dMD and D; eMD and HD; and fD and HD are significantly different (p < 0.05). A ANOVA for demographic characteristics and ANCOVA (covariates BMI and gender) for all other characteristics were performed. B Global EDE-Q is a composite mean score of Restraint, and Eating-, Shape- and Weight-Concerns scales. C Except for FOCI (N = 230 for ND, N = 477 for MD, N = 268 for D, N = 162 for HD). D Except for participants who reported dieting (N = 111 for ND, N = 343 for MD, N = 258 for D, N = 192 for HD). E EDE-Q (Eating Disorders Examination Questionnaire, 16th edition), 7-point frequency or Likert scales that describe how often individuals engaged in restraint or felt concerns about eating and body weight and shape (Fairburn et al., 2008). F TFEQ-18 (Three Factor Eating Questionnaire, 4-point Likert scale (definitely false to definitely true)) (Karlsson et al., 2000). G Night Eating Questionnaire, 5-point semantic-differential scale (e.g., never to always) (Allison et al., 2008). H Appearance Schema Inventory-Revised, 5-point Likert scale (strongly disagree to strongly agree) (Cash & Labarge, 1996). I Body Image Distortion (developed by authors). J Patient Health Questionnaire-8, 4-point Likert scale (not at all to nearly every day), score ranges from 0 to 4 indicated no depression severity, 5 to 9 mild depression severity, 10 to14 moderate depression severity, 15 to 19 moderately severe depression (Kroenke et al., 2001). K Generalized Anxiety Disorder-7, 4-point Likert scale (not at all to nearly every day), score ranges for Anxiety severity indicate 0 to 4 is minimal, 5 to 9 is mild, 10 to 14 is moderate, and 15 to 21 is severe (Spitzer et al., 2006). L Florida Obsessive Compulsive Inventory, 5-point semantic Likert scale (e.g., no avoidance to extreme avoidance) (Storch et al., 2007). M Rosenberg Self-Esteem, 5-point Likert scale (strongly disagree to strongly agree) (Rosenberg, 1965). N Health Motivation, 5-point Likert scale (strongly disagree to strongly agree) (Seeman & Seeman, 1983). O Coping Inventory for Stressful Situations, 5-point Likert scale (strong disagree to strongly agree) (Endler & Parker, 1990). P Dichotomous Thinking in Eating Disorders Scale, 4-point Likert scale (definitely false to definitely true) (Byrne et al., 2008). Q Wong & Law Emotional Intelligence Scale (Regulation of Emotions subscale), 7-point Likert scale (strongly disagree to strongly agree) (Wong & Law, 2002). R Sociocultural Attitudes Towards Appearance Questionnaire, 5-point Likert scale (strongly disagree to strongly agree) (Thompson et al., 2004). S Body Image Intense Media Score (developed by authors). T Childhood Family Mealtime Questionnaire, 5-point Likert scale (never to always) (Miller et al., 1993).   à

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Table 4 Bivariate correlations of the Disturbed Eating Severity Scores (DESS), Eating Behaviors, Global EDE-Q score, and History of an Eating Disorder (N = 2438). Predictor 1. DESS 2. Restraint Eating 3. Eating Concerns 4. Shape Concerns 5. Weight Concerns 6. Binge Eating 7. Inappropriate Compensatory Behaviors 8. Emotional Eating 9. Disinhibited Eating 10. Night Eating Severity 11. Global EDE-Q score 12. History of an Eating Disorder *

1 –

2

3 *

0.70 –

4 *

0.82 0.63* –

5 *

0.77 0.67* 0.72* –

6 *

0.78 0.66* 0.75* 0.91* –

7 *

0.59 0.33* 0.51* 0.37* 0.37* –

8 *

0.51 0.41* 0.40* 0.30* 0.31* 0.38* –

9 *

0.56 0.28* 0.41* 0.41* 0.41* 0.26* 0.11* –

10 *

0.53 0.22* 0.33* 0.29* 0.29* 0.33* 0.13* 0.49* –

11 *

0.31 0.04 0.15* 0.05* 0.09* 0.14* 0.21* 0.10* 0.14* –

12 *

0.85 0.83* 0.85* 0.94* 0.94* 0.43* 0.39* 0.42* 0.31* 0.09* –

0.14* 0.12* 0.19* 0.11* 0.12* 0.11* 0.08* 0.09* 0.05 0.02 0.14* –

Pearson correlation coefficients are statistically significant at p < 0.05.

Table 5 Percent of Disturbed Eating Severity Scores (DESS) contributed By each Eating Behavior Scale. Eating Behavior Scale

Restraint Eating Concerns Shape Concerns Weight Concerns Binge Eating Inappropriate Compensatory Behaviors Emotional Eating Disinhibited Eating Night Eating Severity Total (%)

Mean Percent Scale Score Contributed to DESS Score ND* (N = 695)

MD* (N = 1019)

D* (N = 486)

HD* (N = 238)

F

p-value

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0

9.7 4.8 4.1 6.8 10.2 17.9 13.7 21.2 11.6 100

10.8 10.7 11.3 11.4 11.2 12.6 12.4 12.4 7.2 100

11.5 14.1 13.2 13.5 12.0 9.7 10.8 10.9 4.3 100

65.34abc 136.22à 161.47abcde 98.09abcde 67.55abc 95.06abcde 71.59abc 115.46abcde 48.62à –

<0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 <0.001 –

*

ND = non-disturbed, MD = mildly disturbed, D = disturbed, HD = highly disturbed. ANOVA with Bonferroni follow-up procedures revealed that all pairs (ND and MD, ND and D, ND and HD, MD and D, MD and HD, D and HD) are significantly different (p < 0.05), except where otherwise noted with superscript letters: aND and MD; bND and D; cND and HD; dMD and D; eMD and HD; and fD and HD are significantly different (p < 0.05). à

reported in the literature (Ball & Lee, 2000; Butow, Beumont, & Touyz, 1993; Button, Loai, Davies, & Sonuga-Barke, 1997; Zysberg & Rubanov, 2010). For instance, participants with lower levels of self-esteem had significantly higher DESS scores, and these same participants reported more mentally and physically unhealthy days than participants with higher self-esteem. It is reasonable to expect that, as an individual’s mental and physical health declines, their quality of life and overall self-esteem levels suffer (Thompson, Coover, Richards, Johnson, & Cattarin, 1995). However, it is unclear if the decrease in quality of life and self-esteem are antecedent or subsequent factors of disturbed eating. Coping is defined as an attempt to manage demands that are perceived as stressful, as well as emotions generated (Carver & Scheier, 1989). Having appropriate coping skills to deal with stress and being able to regulate emotions (i.e., emotional intelligence) are thought to play a protective role in preventing disturbed eating behaviors (Spoor, Bekker, Van Strien, & van Heck, 2007). The significantly lower reliance on task-oriented coping (i.e., a positive coping mechanism that addresses the problem causing distress), lower regulation of emotion (i.e., ability to carry out accurate reasoning about emotions and ability to use emotions and emotional knowledge to enhance thought), and higher reliance on emotion-oriented coping (i.e., a negative coping mechanism dependent on emotions) as disturbed eating severity increased, supports previous investigations reporting increased emotion-oriented coping and decreased task-oriented coping and regulation of emotions as dieting, bingeing, disordered eating attitudes, and disturbed eating increased (Ball & Lee, 2002; Denisoff & Endler, 2000; Freeman & Gil, 2004; Troop, Holbrey, Trowler, & Treasure, 1994; Zysberg & Rubanov, 2010).

Additionally, the presence of dichotomous thinking (i.e., presence of rigid ‘‘black and white’’ or ‘‘good and bad’’ cognitive thinking) was elevated in those who were highly disturbed eaters. Findings related to this trait support published research reporting a positive association between rigid thinking and disturbed eating and eating disorders (Butow et al., 1993; Lingswiler, Crowther, & Stephens, 1989; Steiger, Goldstein, Mongrain, & Van der Feen, 1990). All family environment characteristic scores (i.e., Mealtime Communication-Based Stress, Appearance Weight Control, Emphasis on Mother’s Weight) that assessed recalled mealtime experiences as a child increased as DESS score increased, except for Mealtime Structure (i.e., pressures to eat during family mealtimes as a child). Thus, negative family mealtime environments appear to be yet another key influencer of disturbed eating (Miller et al., 1993). The findings from this study suggest that the newly developed DESS categorization of those with disturbed eating compares favorably with other measures. The DESS correlated significantly with the Global EDE-Q score, a highly respected measure for assessing eating disorder risk (Mitchell & Peterson, 2005; Mond et al., 2004b; Olmsted et al., 2007). Eating disorder history also correlated significantly with the DESS score, Global EDE-Q score, and all eating behavior scales, except Disinhibited Eating and Night Eating. Even though Disinhibited Eating and Night Eating behaviors scores were not significantly correlated with eating disorder history, they are important features of disturbed eating as seen by their contributions to DESS scores. Because it was not ascertained whether those reporting an eating disorder history were active cases or the type of eating disorder that had been

V.M. Quick, C. Byrd-Bredbenner / Appetite 59 (2012) 168–176

diagnosed, future research should examine this new scale with a sample of individuals who have various types of eating disorders to explore its usefulness. Importantly, all nine eating behavior scales contributed significantly to the DESS score and differed significantly as disturbed eating severity rose (non-disturbed to highly disturbed). The decline in the proportion of Inappropriate Compensatory Behaviors and Emotional, Disinhibited, and Night Eating scores contributed to disturbed eating as severity increased seems counter to what was expected. However, this appears to indicate that as disturbed eating severity increases, a broader array of disturbed eating behaviors occur, thereby causing a relative ‘‘dilution’’ of the contribution of these scores to the overall DESS. The DESS scale does appear promising in its ability to help health care practitioners identify patients with varying degrees of disturbed eating behaviors and offer early interventions that could prevent progress toward more profound eating disturbances and, possibly, an eating disorder. It is important to address the limitations of this study. First, the sample was limited to young adults in college and may not be generalizable to the young adult population as a whole. However, participants were from a non-clinical setting and were racially diverse. Additionally, the proportion of White to non-White participants in this study is similar to national data for the 20 to 24 years age group (National Center for Health Statistics (NCHC), National Health and Nutrition Examination Questionnaire III), so this sample likely reflects the young adult college-age population in the United States. Another limitation is self-reported height and weight; however, previous research has shown high correlations between self-reported height and weight in young people (Strauss, 1999). The cross-sectional design of this survey limits assignment of temporality; however, it is valuable for hypothesis generating research and provides the basis for more prospective designs. Despite these limitations, there are strengths. First, this study included a large sample of young adults who completed the survey online. The online survey administration made it easy and convenient for participants. This method of survey administration also permitted participants to complete it privately, which may have generated more honest responses; thereby, resulting in a higher rate of highly disturbed eaters than the rates typically reported for eating disorders (Hudson et al., 2007) because participants were less concerned about self-disclosure (Evers, 2006; Strecher, 2007; Wright, 2005). Second, the instruments used in this study were valid, reliable measures and had good to excellent reliabilities. Third, the DESS defined disturbed eating more comprehensively than has been done previously by incorporating factors related to eating disorders that typically have not been included when assessing disturbed eating severity. The score generated by this scale is strongly associated with other known disordered eating risk factors indicating excellent construct validity. Also, nearly all psychographic instruments used in this study known to be associated with disordered eating, differed significantly in synchrony with DESS categories, thereby further supporting the construct validity of the DESS score. The true value of the DESS is in its potential to shift the focus from diagnosis of an eating disorder (after the fact) to identifying precursor behaviors (risk factors) and severity. Identification of these precursor behaviors may enable health professionals to intervene earlier, when treatment is more effective (DeSocio, O’Toole, Nemirow, Lukach, & Magee, 2007). In conclusion, this study calls attention the need to screen and monitor disturbed eating behaviors in young adults, especially given that nearly one-third of the young adults in this study were either disturbed or highly disturbed eaters. Disturbed eating behaviors can be detrimental to overall quality of life and strain society’s medical costs (Rosen, 2010). Early screening for indicators of disturbed eating, using a tool like the DESS, offers the potential

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