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The prevalence of compulsive eating and exercise among college students: An exploratory study
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Psychiatry Research 165 (2009) 154 – 162 www.elsevier.com/locate/psychres
The prevalence of compulsive eating and exercise among college students: An exploratory study Jenny Guidi a,b,⁎, Maribeth Pender b , Steven D. Hollon c , Sidney Zisook d , Faye H. Schwartz b , Paola Pedrelli b , Amy Farabaugh b , Maurizio Fava b , Timothy J. Petersen b b
a Department of Psychology, University of Bologna, Bologna, Italy Depression Clinical & Research Program, Massachusetts General Hospital, Boston, MA, USA c Vanderbilt University, Nashville, TN, USA d University of California, San Diego, CA, USA
Received 26 October 2006; received in revised form 9 July 2007; accepted 9 October 2007
Abstract Eating disturbances continue to grow among college students, and researchers have begun to investigate factors that may lead to abnormal eating behaviors in this population. Recent research has also suggested that excessive exercise can become a compulsive behavior that may affect psychological health. The aim of this exploratory study was to evaluate the relationships between both compulsive eating and exercise, and demographic and clinical variables in a college population. Participants were 589 undergraduates (mean age 20 years) recruited during a mental health screening at two different campuses. Participants completed a screening package of measures including a questionnaire about socio-demographic data, the Beck Depression Inventory (BDI), the Beck Hopelessness Scale (BHS), the Consumptive Habits Questionnaire (CHQ), the Modified Overt Aggression Scale—Self-rated version (MOAS), and the Quality of Life Enjoyment and Satisfaction Questionnaire—Short version (QLESQ). A prevalence rate of 7.2% was found for compulsive eating and 18.1% for compulsive exercise, as measured by the CHQ. Only 11 participants (1.9%) reported both compulsive eating and exercise. There was no significant relationship between compulsive eating and compulsive exercise. The results suggest that college students may represent a group at high risk of developing abnormal eating behaviors and compulsive exercise. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Prevention; Depression; Risk factors
1. Introduction Eating disturbances continue to grow among college students (Mulholland and Mintz, 2001; Kurth et al., 1995), and researchers have begun to investigate factors that may ⁎ Corresponding author. Department of Psychology, University of Bologna, Viale Berti Pichat 5, 40127 Bologna, Italy. Tel.: +39 051 2091339; fax: +39 051 243086. E-mail address: [email protected] (J. Guidi).
lead to abnormal eating behaviors in this population, including both personal factors and environmental variables (Allison and Park, 2004; Raffi et al., 2000). Previous studies showed that partial-syndrome eating disorders are two to five times more common than diagnosable eating disorders in adolescent females (Dancyger and Garfinkel, 1995), affecting 4%–16% of the population (Killen et al., 1994; Shisslak et al., 1987). Subthreshold eating disturbances (i.e. those that have some symptoms but no actual disorder) affect a significant portion of young
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people, and compulsive eating may be viewed as a specific form of subthreshold eating disturbance. Binge-eating disorder (defined by DSM-IV-TR as a specific eating disorder characterized by the presence of recurrent binge-eating episodes in the absence of inappropriate compensatory behaviors) has also become a significant clinical concern because of its positive relationship with psychological distress, and in particular with depression (Bulik et al., 2002; Smith et al., 1998; Telch and Stice, 1998; Mussell et al., 1995). Yanovski et al. (1993) found that participants with binge-eating disorder (BED) were more likely to have a lifetime diagnosis of an Axis I disorder, primarily major depressive disorder, than controls without BED. Further, a recent study on BED and psychological distress in college students found a direct association between depression, anxiety, alexithymia, and binge eating (Mitchell and Mazzeo, 2004). Research also indicates that individuals with eating disorders tend to engage in excessive exercise. Traditionally, physical activity has been associated with numerous health benefits (Francis, 1999; Scully et al., 1998). However, recent research suggests that excessive exercise can become a compulsive behavior, which also may limit its effectiveness in enhancing psychological states and cause a significant impairment in social and occupational functioning of individuals (Thome and Espelage, 2004). While some observers may view these persons as just extremely dedicated or motivated, many of them may be obsessed with exercise. They need to significantly increase the frequency or intensity of their exercise behavior and experience psychological withdrawal symptoms when they are unable to exercise for a while, losing control of their exercise behavior (Zmijewski and Howard, 2003). De Coverley Veale (1987) was the first to hypothesize the existence of “exercise dependence” and proposed a specific set of diagnostic criteria to assess symptoms of exercise dependence adapting DSM-IV-TR (American Psychiatric Association [APA], 2000) criteria for substance dependence disorder. The notion of exercise dependence has been shown not to be limited to professional athletes, and some experts believe that it is a far more serious condition than many clinicians currently recognize. Exercise dependence can pose health risks, both physical and psychological. For example, people with exercise dependence tend to continue exercising despite minor injuries. Similarly, excessive exercise may affect psychological health, by being associated with mood disturbance and with abnormal eating behaviors (Yates, 1996; Wolf and Akamatsu, 1994). Psychological withdrawal symptoms might follow a period of
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abstinence from exercise, which may be responded to by re-engaging in further exercise. In individuals with primary exercise dependence, “the exercise is an end in itself and the dieting and weight loss are used to improve performance” (De Coverley Veale, 1987). On the other hand, individuals with secondary exercise dependence, having a primary diagnosis of eating disorder, might be exercising excessively to lose weight or compensate for binge eating. Zmijewski and Howard (2003) found that the number of exercise-dependence symptoms was significantly associated with problematic attitudes toward eating. A recent study by Thome and Espelage (2004) examined gender differences in the association between exercise and psychological health among a sample of university students. Male and female participants were found to exercise for different reasons. In males, exercise was associated with greater life satisfaction and lower level of depression whereas in females it was associated with eating disorders. Despite the increased prevalence of these clinical issues on college campuses (American College Health Association, 2004), mental health services are often unequipped to handle them. Warning signs and symptoms of psychological distress in college students might be rapid changes in mood, depression, sleep disorders, substance abuse, anxiety disorders, eating disorders, impulsive behaviors and, potentially, suicidal behaviors (Kadison and DiGeronimo, 2004; Kessler and Walters, 1998). The present study was a part of a multi-site collaborative university-based program for the prevention of youth suicide, assessing the prevalence of depression and other risk factors for suicide in a college population. The aim of this exploratory study was to evaluate the relationships between both compulsive eating and exercise, and demographic and clinical variables such as depression, aggression, and quality of life. 2. Methods 2.1. Participants Participants were 589 undergraduate students. The sample was approximately evenly divided with regard to gender, and the majority of students were Caucasian. Out of the total sample of 589 students, 669 responded to either the question regarding compulsive eating or the question regarding compulsive exercise, and 564 responded to both questions. Since analyses were performed separately for these two questions, analyses included all participants with non-missing data for the
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relevant outcomes. Sample demographics are presented in Table 1.
voucher for use at campus dining and/or retail outlets in addition to a list of on- and off-campus mental health resources.
2.2. Procedures 2.3. Measures The present study was a part of a larger program for the prevention of youth suicide that was carried out at two different universities located in the Southern United States (University A and University B). Participants were recruited during a mental health screening that took place at the two campuses. At each site, screening sessions were conducted in a public and prominent location and occurred during peak student traffic periods. A table was set up, staffed with licensed mental health professionals and research assistants. Students interested in participation who approached the table were told about the study and then given a brief written consent form along with the package of screening questionnaires. Participants who obtained a score of ≥ 13 on the Beck Depression Inventory and/or positively endorsed a screening question about suicidal ideation (BDI item #9 ≥ 1) were asked to be interviewed by a clinician. Those who completed the screening assessments received a $10.00
For the current study we considered the measures included in the screening package: - Questionnaire about socio-demographic data. A fourpage questionnaire covering several demographic domains including: age, gender, school year, ethnicity, current living situation and satisfaction with living situation. - Beck Depression Inventory (BDI; Beck et al., 1961). This 21-item measure of depression assesses both psychological symptoms and physical symptoms. Each item is scored from 0 to 3, with higher scores indicative of greater severity of depression. - Beck Hopelessness Scale (BHS; Beck et al., 1974). The BHS asks a respondent to answer true or false to a series of 20 statements reflecting attitudes regarding the future. Higher scores indicate higher levels of hopelessness.
Table 1 Demographic variables by presence or absence of compulsive eating Demographics a
University A B Gender Females Males
Living situation On campus Off campus Ethnicity White Asian Other
School year Satisfaction with living situation a N = 564–569. ⁎ P b 0.05. ⁎⁎ P b 0.01. ⁎⁎⁎ P b 0.001.
Total sample (N = 569)
No compulsive eating (N = 525)
Compulsive eating (N = 41)
Test of difference between groups
Adjusted for site, gender and depression severity
Frequency (%)
Frequency (%)
Frequency (%)
χ2
P
Odds ratio
P
10.32
0.001⁎⁎⁎
3.41
0.003⁎⁎
322 (56.6) 247 (43.4)
287 (89.69) 238 (96.75)
33 (10.31) 8 (3.25) 9.49
0.002⁎⁎
2.30
0.03⁎
299 (52.5) 270 (47.5)
266 (89.56) 259 (96.28)
31 (10.44) 10 (3.72)
Frequency (%)
Frequency (%)
Frequency (%)
P
LR χ2
P
4.49
0.03⁎
0.02
0.88
10.27
0.14
3.35
0.18
t
P
LR χ2
P
0.04⁎ 0.49
2.53 0.02
0.11 0.88
341 (59.9) 227 (39.9)
308 (90.86) 216 (95.58)
31 (9.14) 10 (4.42)
318 (55.9) 143 (25.1) 106 (18.6)
287 (90.82) 135 (95.07) 101 (95.28)
29 (9.18) 7 (4.93) 5 (4.72)
Mean ± S.D.
Mean ± S.D.
Mean ± S.D.
2.78 ± 1.47 4.74 ± 1.04
2.82 ± 1.47 4.75 ± 1.03
2.34 ± 1.53 4.63 ± 1.04
χ2
2.02 0.68
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- Consumptive Habits Questionnaire (CHQ; unpublished). This is a brief questionnaire used to obtain information about the responders' current consumption levels of alcohol, caffeine, street drugs and prescription drugs. Moreover, this questionnaire assesses characteristics of participants' compulsive behaviors, including eating, exercise, gambling, sexual activities, spending, risk taking and other compulsive activities (see Appendix for more details). For the current study, we focused on the presence or absence of compulsive eating and exercise. No explicit summary score was used from the CHQ. Number of times per week/month reported by respondents was considered as descriptive results. - Modified Overt Aggression Scale — Self-Rated Version (MOAS; Yudofsky et al., 1986). The MOAS investigates four different aspects related to aggressive behavior: verbal aggression, violence against property, self-aggression and physical aggression. Response options are 0 to 4 on a 5-point Likerttype scale. Higher scores indicate a greater level of aggression. - Quality of Life Enjoyment and Satisfaction Questionnaire—Short Form (QLESQ; Endicott et al., 1993). This questionnaire includes 16 items related to physical health, mood, work satisfaction, enjoyment in leisure activities, ability to function in daily life and overall satisfaction with life. Participants are asked to consider the past week and to rate their answers on a 5point Likert-type scale (from 1 = very poor through 5 = very good). A quality of life index score is calculated by averaging the scores of all items. 2.4. Data analyses Data were entered in SPSS, after which descriptive statistics were calculated. Chi-square tests were performed to assess the differences between the two groups (presence or absence of compulsive behavior) on dichotomous demographic variables. Similarly, two-sample t-tests were used to test for differences in average score on continuous demographic and clinical measures between participants who did or did not endorse compulsive behaviors. The t-tests and chi-square tests examined compulsive eating and compulsive exercise separately. Logistic regressions were used to supplement the univariate significance tests by looking at the effect of each demographic and clinical variable, controlling for the effects of variables identified by previous research as important predictors. To identify variables whose relationships with compulsive behaviors can be generalized
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to populations of college students other than at the two universities included in this study, one of the variables we also controlled for was study site. The dependent variable for the logistic regressions was the presence or absence of self-reported compulsive behaviors. Likelihood ratio chi-square tests were used to compare regression models controlling for a fixed set of important predictors with and without the demographic or clinical factor being tested. 3. Results Of the 569 participants who answered either the compulsive eating or compulsive exercise questions on the CHQ, 41 (7.2%) reported compulsive eating, and 103 (18.1%) reported compulsive exercise; only 11 (1.9%) reported both compulsive eating and compulsive exercise. There was not a statistically significant relationship between compulsive eating and compulsive exercise (N = 564, χ2(1) = 2.82, P = 0.093). 3.1. Compulsive eating Compulsive eating was found to have a significantly different prevalence between the two university campuses (P = 0.001), genders (P = 0.002), living situations (P = 0.03) and years in school (P = 0.04) (Table 1). A greater proportion of participants reporting compulsive eating attended University A, were female, lived on campus and were in their initial years in school. Table 2 shows mean scores on self-report clinical measures, comparing participants who reported compulsive eating with those who did not. Statistically significant differences between the two groups were found for BDI total score (P b 0.0005), MOAS selfaggression subscale (P = 0.0098) and QLESQ score (P = 0.0052). Results showed that participants who reported compulsive eating, compared with those who did not, had higher levels of depression and selfaggression and less satisfaction with their lives. Using logistic regression, we adjusted the compulsive eating univariate findings to control for the effect of study site as well as factors suggested as important by previous research such as gender, comorbid depression, and self-aggression. However, the MOAS self-aggression item did not improve the prediction of the presence of compulsive eating using a logistic regression once controlling for site, gender, and depression severity (as measured by the total BDI score) (χ2 = 1.06; P = 0.304) and therefore could be omitted from further logistic regressions. The univariate comparisons in Tables 1 and 2 were therefore supple-
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Table 2 Clinical measures by the presence or absence of compulsive eating Clinical measures a
BDI
BHS MOAS MOAS self-aggression QLESQ
No compulsive eating (N = 525)
Compulsive eating (N = 41)
Test of difference between groups
Adjusted for site, gender and depression severity
Mean ± S.D.
Mean ± S.D.
t
P
Odds ratio
P
1.08
0.001⁎⁎⁎
LR χ2
P
0.23 0.10 1.06 0.64
0.63 0.75 0.30 0.42
5.63 ± 5.58
9.48 ± 7.81
− 4.12
b0.0005⁎⁎⁎
Mean ± S.D.
Mean ± S.D.
t
P
2.97 ± 2.74 0.65 ± 1.27 0.12 ± 0.39 3.73 ± 0.54
3.12 ± 3.11 0.65 ± 1.00 0.30 ± 0.72 3.48 ± 0.63
− 0.33 0.01 − 2.60 2.80
0.74 0.99 0.0098⁎⁎ 0.0052⁎⁎
a N = 550–569. ⁎⁎ P b 0.01. ⁎⁎⁎ P b 0.001.
mented by P values that were adjusted by controlling for site, gender, and depression severity, showing that living situation (P = 0.88), year in school (P = 0.11), selfaggression (P = 0.30), and quality of life (P = 0.42) were no longer statistically significant predictors of compulsive eating. A logistic regression controlling for depression severity and gender showed that participants at University A were 3.4 times more likely than those at University B to report compulsive eating (P = 0.003; 95% confidence interval for odds ratio: 1.5–7.7). Adjusting for depression severity and site, females were 2.3 times more likely than males to report compulsive eating (P = 0.030; 95% confidence interval for odds ratio: 1.1– 4.9). After controlling for site and gender, an increase in total BDI score of one point increased the odds of compulsive eating by a factor of 1.1 (P = 0.001; 95% confidence interval for odds ratio: 1.03–1.13); equivalently, in this sample a subject with a BDI 5 points higher than another of the same gender at the same university was 1.6 times more likely to have compulsive eating. Participants were also asked to report how many times per week compulsive eating occurred. For those who responded to this question (N = 26), the average of current weekly frequency of compulsive eating was 3.54 (S.D. = 2.39) and was 4.23 (S.D. = 3.63; N = 17) for past weekly frequency. More than 73% of respondents reported current compulsive eating behavior at least twice a week. 3.2. Compulsive exercise Compulsive exercise was reported by a significantly higher proportion of males (23.4%) than females (13.4%; χ2 = 9.50; P = 0.002). In addition, a significantly
lower proportion of Asians (9.8%) in respect to Caucasians (22.2%) and other races including Blacks and Hispanics (17%) reported compulsive exercise (χ2 = 10.27; P = 0.006) (Table 3). Participants who reported compulsive exercise were not statistically significantly different on any of the clinical measures compared with those who did not. The average current frequency of compulsive exercise reported by respondents (N = 85) was equal to
Table 3 Demographic variables by presence or absence of compulsive exercise Demographics a
No compulsive Compulsive exercise exercise (N = 464) (N = 103)
Test of difference between groups
Frequency (%) Frequency (%) χ2 University A B Gender Females Males Living situation On campus Off campus Ethnicity White Asian Other
262 (81.37) 202 (82.45)
60 (18.63) 43 (17.55)
258 (86.58) 206 (76.58)
40 (13.42) 63 (23.42)
281 (82.65) 182 (80.53)
59 (17.35) 44 (19.47)
246 (77.85) 129 (90.21) 88 (83.02)
70 (22.15) 14 (9.79) 18 (16.98)
Mean ± S.D.
Mean ± S.D.
9.50 0.002**
0.41 0.52
10.27 0.006**
School year 2.81 ± 1.47 Satisfaction with 4.75 ± 1.06 living situation a
P
0.11 0.74
N = 565–569. ** P b 0.01.
2.7 ± 1.51 4.74 ± 0.94
t
P 0.68 0.50 0.02 0.98
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4.61 (S.D. = 1.94) times per week and was nominally higher in the past (μ = 5.27, S.D. = 2.12; N = 62). The most prevalent activities were running, weight lifting and swimming. 4. Discussion Epidemiologic research on BED has a relatively short history. The phenomenon of binge eating in the absence of inappropriate compensatory behaviors that define bulimia nervosa (BN) attracted relatively little scientific interest until the introduction of BED in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders as a specific Eating Disorder Not Otherwise Specified (EDNOS). Even though compulsive eating and binge eating are not necessarily the same construct, they may have some overlapping clinical aspects, since binge eating is defined as the consumption of an unusually large amount of food with a subjective sense of loss of control over the eating. The prevalence of compulsive eating in our sample (52.5% female, 44% minorities, mean age 20 years) was 7.2%. Mitchell and Mazzeo (2004) examined the relationship between eating disorders and psychological distress among college students and found a prevalence rate of BED equal to 2.6% (assessed by the diagnostic composite of the Eating Disorder Diagnostic Scale). However, 13.3% of their sample met cutoff scores for moderate to severe binge eating (as measured by the Binge Eating Scale). In the past decade Spitzer and colleagues conducted BED field trials among several community and patient samples, and found that among college students (79% female, 26% minorities, mean age 22 years) 2.8% of women and 1.9% of men met criteria for BED (Spitzer et al., 1993). Gender differences in the prevalence of BED did not reach statistical significance. A rapidly growing literature has investigated demographic variables correlated with BED and fixed markers, such as gender and ethnicity, to identify highrisk groups in the population. Consistent with previous studies, which have found significant differences in rates of abnormal eating behaviors between males and females, we found that females were 2.3 times more likely than males to report compulsive eating (P = 0.030). However, these findings are inconsistent with two recent studies, which have found equal (Smith et al., 1998) or higher (Johnson et al., 2002) rates of binge eating among males in a general population. Lewinsohn et al. (2002) also found that among
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young adults (mean age 25 years) men (28%) were more likely than women (14%) to report that they had experienced episodes of overeating. Nonetheless, gender differences regarding compensatory behaviors and distress about binge eating suggest that men might be at lower risk for full-syndrome eating disorders than women. No statistically significant differences were found among diverse ethnic groups in our sample on compulsive eating. These findings were consistent with Mitchell and Mazzeo's (2004) study of binge eating among Caucasian and African American college students. However, few studies have examined eating disorders in general, and BED in particular, among diverse ethnic groups; therefore, any conclusions regarding ethnicity are premature. Further research is needed to assess the prevalence of BED in additional ethnic groups. With respect to compulsive exercise, a prevalence rate as high as 18.1% was found in our sample, and the average frequency of current exercise reported by respondents (N = 85) was equal to 4.61 (S.D. = 1.94) times per week. In a recent study of exercise dependence among college students (Zmijewski and Howard 2003), participants averaged 5.2 h (S.D. = 4.4, range 30 min to 25 h) of exercise per week, and a majority of them (66%, N = 237) were found to engage in exercise one to four times per week, whereas 7.9% exercised seven or more times each week. Another study on occurrence of exercise dependence in a college-aged population (Garman et al., 2004), which evaluated through self-report measures the amount of activity per week, found that 21.8% of participants in the sample exercised 360 or more minutes per week and demonstrated an obligatory or pathological nature of their activity pattern. In our study males were significantly more likely than females to report compulsive exercise. A recent study (Hausenblas and Symons Downs, 2002) on exercise dependence among college students also found that the male participants reported more exercise-dependence symptoms compared with the female participants, as measured by the Exercise Dependence Scale (Hausenblas and Symons Downs, 2001). Conversely, Thome and Espelage (2004) found that males and females did not differ in the amount of exercise they reported during the past week or in a typical week. Moreover, they found that exercise was associated with better psychological health (as greater positive affects, satisfaction with life and lower levels of depression and anxiety) in male college students. Zmijewski and Howard (2003) also found a higher prevalence
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of exercise-dependence withdrawal symptoms among college women than men and that women reported using exercise to prevent negative affect states significantly more often than did men. This study examined compulsive eating and compulsive exercise separately. Only 11 participants (1.9%) reported both compulsive eating and exercise, and no statistically significant relationships between the two variables were found in our sample. These findings support the clinical significance of abnormal eating behaviors in the absence of certain inappropriate compensatory behaviors (such as excessive exercise) among college students, and draw attention to exercise-dependence symptoms as a relevant clinical concern in this population. Our investigation has several strengths, including the nature of the sample. Very few studies have examined compulsive eating in a college population despite the fact that college students may represent a group at high risk of developing eating disorders. Furthermore, this study included both males and females as well as diverse ethnic groups, while many studies of eating disorders have included exclusively female and primarily Caucasian clinical samples. However, certain limitations should be noted. Both compulsive eating and exercise were assessed using a self-report measure of consumptive habits (CHQ) and no explicit definitions of “compulsive” behaviors, as well as “current” or “past” frequency were given to the responders. A number of studies have compared interview and self-report methods of assessing the core features of eating disorders, with mixed results (Black and
Wilson, 1996; Fairburn and Beglin, 1994; Loeb et al., 1994; Wilfley et al., 1997). Interviews allow investigators to define key terms such as binge eating and to use detailed guidelines for rating complex concepts. Such precision is difficult to achieve using self-report instruments, as data obtained with this method are dependent on the participants' willingness to report accurate information (Carter et al., 2001; Grilo et al., 2001). The self-selected sample could inflate the prevalence rates observed in this study, as participants in this mental health screening may be more likely to have psychological distress than other students who did not agree to cooperate. In addition, participants of this study were university students at two specific campuses, which limits the generalizability of our findings. Consequently, when we analyzed data on compulsive eating, we adjusted for the effect of study site, as well as for depression severity and gender. In summary, college students may represent a group at high risk of developing abnormal eating behaviors and compulsive exercise, as evidenced by our findings. Further research is needed to explore both demographic and psychological correlates of compulsive eating and compulsive exercise in this population. Acknowledgements This study was supported by a grant from the Jed Foundation. We would like to thank all college students for participating in this program. Additionally, we would like to thank investigators, clinicians and research assistants for their support.
Appendix A. Consumptive Habits Questionnaire (CHQ) Do you currently consume alcohol? Yes _____ No _____ ______# 12 ounce beer or wine coolers per day ______# 4–6 ounce glasses wine per day ______# ounce distilled spirits per day Do you currently consume any caffeine? Yes _____ No _____ ______# cups of tea per day ______# cups of coffee per day ______# 12 ounce colas per day Have you ever engaged in the past or currently in other addictive behaviors? Yes _____ No _____
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Compulsive use of street drugs Compulsive use of prescription drugs Compulsive use of alcohol Compulsive use of caffeine Compulsive exercise Compulsive eating Gambling Compulsive sexual activities Compulsive buying or spending Risk taking behaviors Other compulsive Activities
Current frequency (fill in if current)
Past frequency (if part history, record freq at highest point
Y/N
_____#/week _____#/month
_____#/week _____#/month
Y/N
_____#/week _____#/month
_____#/week _____#/month
Y/N
⁎noted above⁎
_____#/week _____#/month
Y/N
⁎noted above⁎
_____#/week _____#/month
Y/N Y/N Y/N Y/N
_____#/week _____#/month _____#/week _____#/month _____#/week _____#/month _____#/week _____#/month
_____#/week _____#/month _____#/week _____#/month _____#/week _____#/month _____#/week _____#/month
Y/N
_____#/week _____#/month
_____#/week _____#/month
Y/N Y/N
_____#/week _____#/month _____#/week _____#/month
_____#/week _____#/month _____#/week _____#/month
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Types (specify)
©Massachusetts General Hospital, Depression Clinical and Research Program.
References Allison, K.C., Park, C.L., 2004. A prospective study of disordered eating among sorority and nonsorority women. International Journal of Eating Disorders 35, 354–358. American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorder, (4th ed.). Author (text-revision), Washington, DC. American College Health Association, 2004. National College Health Assessment: reference group report. Author, Baltimore, Md. Beck, A.T., Ward, C.H., Mendelson, M., Mock, J., Erbaugh, J., 1961. An inventory for measuring depression. Archives of General Psychiatry 4, 561–571. Beck, A.T., Weissman, A., Lester, D., Trexler, L., 1974. The measurement of pessimism: the hopelessness scale. Journal of Consulting & Clinical Psychology 42 (6), 861–865. Black, C.M.D., Wilson, G.T., 1996. Assessment of eating disorders: interview versus questionnaire. International Journal of Eating Disorders 20, 43–50. Bulik, C.M., Sullivan, P.F., Kendler, K.S., 2002. Medical and psychiatric morbidity in obese women with and without binge eating. International Journal of Eating Disorders 32, 72–78. Carter, J., Aimé, A., Mills, J., 2001. Assessment of bulimia nervosa: a comparison of interview and self-report questionnaire methods. International Journal of Eating Disorders 30, 187–192. Dancyger, I.F., Garfinkel, P.E., 1995. The relationship of partial syndrome eating disorders to anorexia nervosa and bulimia nervosa. Psychological Medicine 25, 1019–1025. De Coverley Veale, D.M.W., 1987. Exercise dependence. British Journal of Addiction 82, 735–740. Endicott, J., Nee, J., Harrison, W., Blumenthal, R., 1993. Quality of life enjoyment and satisfaction questionnaire: a new measure. Psychopharmacology Bulletin 29 (2), 321–326.
Fairburn, C.G., Beglin, S.A., 1994. Assessment of eating disorder pathology: interview or self-report questionnaire? International Journal of Eating Disorders 16, 363–370. Francis, K.T., 1999. Status of the year 2000 health goals for physical activity and fitness. Physical Therapy 79, 405. Garman, J.F., Hayduk, D.M., Crider, D.A., Hodel, M.M., 2004. Occurrence of exercise dependence in a college-aged population. Journal of American College Health 52 (5), 221–228. Grilo, C.M., Masheb, R.M., Wilson, G.T., 2001. A comparison of different methods for assessing the features of eating disorders in patients with binge eating disorder. Journal of Consulting and Clinical Psychology 69, 317–322. Hausenblas, H.A., Symons Downs, D., 2001. The Exercise Dependence Scale Manual. Unpublished test manual. University of Florida, Gainesville. Hausenblas, H.A., Symons Downs, D., 2002. Relationship among sex, imagery, and exercise dependence symptoms. Psychology of Addictive Behaviors 16 (2), 169–172. Johnson, W.G., Rohan, K.J., Kirk, A.A., 2002. Prevalence and correlates of binge eating in White and African American adolescents. Eating Behaviors 3, 179–189. Kadison, R., DiGeronimo, T., 2004. College of the Overwhelmed: The Campus Mental Health Crisis and What To Do About It. JosseyBass, San Francisco, CA. Kessler, R.C., Walters, E.E., 1998. Epidemiology of DSM-III-R major depression and minor depression among adolescents and young adults in the National Comorbidity Survey. Depression and Anxiety 7, 3–14. Killen, J.D., Taylor, C.B., Hayward, C., Wilson, D.M., Haydel, K.F., Robinson, T.N., Litt, I., Simmonds, B.A., Varady, A., Kraemer, H., 1994. Pursuit of thinness and onset of eating disorder symptoms in a community sample of adolescent girls: a threeyear prospective analysis. International Journal of Eating Disorders 16, 227–238.
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Kurth, C.L., Krahn, D.D., Nairn, K., Drewnowski, A., 1995. The severity of dieting and bingeing behaviors in college women: interview and validation of survey data. Journal of Psychiatric Research 29, 211–225. Lewinsohn, P.M., Seeley, J.R., Moerk, K.C., Striegel-Moore, R.H., 2002. Gender differences in eating disorder symptoms in young adults. International Journal of Eating Disorders 32, 426–440. Loeb, K.L., Pike, K.M., Walsh, B.T., Wilson, G.T., 1994. Assessment of diagnostic features of bulimia nervosa: interview versus selfreport format. International Journal of Eating Disorders 16, 75–81. Mitchell, K.S., Mazzeo, S.E., 2004. Binge eating and psychological distress in ethnically diverse undergraduate men and women. Eating Behaviors 5, 157–169. Mulholland, A.M., Mintz, L.B., 2001. Prevalence of eating disorders among African American women. Journal of Counseling Psychology 48 (1), 111–116. Mussell, M.P., Mitchell, J.E., Weller, C.L., Raymond, N.C., Crow, S.J., Crosby, R.D., 1995. Onset of binge eating, dieting, obesity, and mood disorders among subjects seeking treatment for binge eating disorder. International Journal of Eating Disorders 17, 395–401. Raffi, A.R., Rondini, M., Grandi, S., Fava, G.A., 2000. Life events and prodromal symptoms in bulimia nervosa. Psychological Medicine 30, 727–731. Scully, D., Kremer, J., Meade, M.M., Graham, R., Dedgeon, K., 1998. Physical exercise and psychological well-being: a critical review. British Journal of Sports Medicine 32, 111–120. Shisslak, C.M., Crago, M., Neal, M.E., 1987. Prevention of eating disorders among adolescents. Journal of Consulting and Clinical Psychology 55, 660–667. Smith, D.E., Marcus, M.D., Lewis, C.E., Fitzgibbon, M., Schreiner, P., 1998. Prevalence of binge eating disorder, obesity, and depression in a biracial cohort of young adults. Annals of Behavioral Medicine 20, 227–232.
Spitzer, R.L., Yanowski, S., Wadden, T., Wing, R., Marcus, M.D., Stunkard, A., Devlin, M., Mitchell, J., Hasin, D., Horne, R.L., 1993. Binge eating disorder: its further validation in a multi-site study. International Journal of Eating Disorders 13, 137–154. Telch, C., Stice, E., 1998. Psychiatric comorbidity in women with binge eating disorder: prevalence rates from a non-treatmentseeking sample. Journal of Consulting and Clinical Psychology 66 (5), 768–776. Thome, J., Espelage, D.L., 2004. Relations among exercise, coping, disordered eating, and psychological health among college students. Eating Behaviors 5, 37–351. Wilfley, D.E., Schwartz, M.B., Spurrell, E.B., Fairburn, C.G., 1997. Assessing the specific psychopathology of binge eating disorder patients: interview or self-report? Behaviour Research and Therapy 35, 1151–1159. Wolf, E.M., Akamatsu, T.J., 1994. Exercise involvement and eatingdisordered characteristics in college students. Eating Disorders 2 (4), 308–318. Yanovski, S.Z., Nelson, J.E., Dubbert, B.K., Spitzer, R.L., 1993. Association of binge eating disorder and psychiatric comorbidity in obese subjects. American Journal of Psychiatry 150, 1472–1479. Yates, A., 1996. Athletes, eating disorders, and overtraining syndrome. In: Epling, W.F., Pierce, D. (Eds.), Activity anorexia: Theory, research, and treatment. Erlbaum, Mahwah, pp. 179–188. Yudofsky, S.C., Silver, J.M., Jackson, W., Endicott, J., Williams, D., 1986. The overt aggression Scale for the objective rating of verbal and physical aggression. American Journal of Psychiatry 143 (1), 35–39. Zmijewski, C.F., Howard, M.O., 2003. Exercise dependence and attitudes toward eating among young adults. Eating Behaviors 4, 181–195.
Psychiatry Research 165 (2009) 154 – 162 www.elsevier.com/locate/psychres
The prevalence of compulsive eating and exercise among college students: An exploratory study Jenny Guidi a,b,⁎, Maribeth Pender b , Steven D. Hollon c , Sidney Zisook d , Faye H. Schwartz b , Paola Pedrelli b , Amy Farabaugh b , Maurizio Fava b , Timothy J. Petersen b b
a Department of Psychology, University of Bologna, Bologna, Italy Depression Clinical & Research Program, Massachusetts General Hospital, Boston, MA, USA c Vanderbilt University, Nashville, TN, USA d University of California, San Diego, CA, USA
Received 26 October 2006; received in revised form 9 July 2007; accepted 9 October 2007
Abstract Eating disturbances continue to grow among college students, and researchers have begun to investigate factors that may lead to abnormal eating behaviors in this population. Recent research has also suggested that excessive exercise can become a compulsive behavior that may affect psychological health. The aim of this exploratory study was to evaluate the relationships between both compulsive eating and exercise, and demographic and clinical variables in a college population. Participants were 589 undergraduates (mean age 20 years) recruited during a mental health screening at two different campuses. Participants completed a screening package of measures including a questionnaire about socio-demographic data, the Beck Depression Inventory (BDI), the Beck Hopelessness Scale (BHS), the Consumptive Habits Questionnaire (CHQ), the Modified Overt Aggression Scale—Self-rated version (MOAS), and the Quality of Life Enjoyment and Satisfaction Questionnaire—Short version (QLESQ). A prevalence rate of 7.2% was found for compulsive eating and 18.1% for compulsive exercise, as measured by the CHQ. Only 11 participants (1.9%) reported both compulsive eating and exercise. There was no significant relationship between compulsive eating and compulsive exercise. The results suggest that college students may represent a group at high risk of developing abnormal eating behaviors and compulsive exercise. © 2007 Elsevier Ireland Ltd. All rights reserved. Keywords: Prevention; Depression; Risk factors
1. Introduction Eating disturbances continue to grow among college students (Mulholland and Mintz, 2001; Kurth et al., 1995), and researchers have begun to investigate factors that may ⁎ Corresponding author. Department of Psychology, University of Bologna, Viale Berti Pichat 5, 40127 Bologna, Italy. Tel.: +39 051 2091339; fax: +39 051 243086. E-mail address: [email protected] (J. Guidi).
lead to abnormal eating behaviors in this population, including both personal factors and environmental variables (Allison and Park, 2004; Raffi et al., 2000). Previous studies showed that partial-syndrome eating disorders are two to five times more common than diagnosable eating disorders in adolescent females (Dancyger and Garfinkel, 1995), affecting 4%–16% of the population (Killen et al., 1994; Shisslak et al., 1987). Subthreshold eating disturbances (i.e. those that have some symptoms but no actual disorder) affect a significant portion of young
0165-1781/$ - see front matter © 2007 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.psychres.2007.10.005
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people, and compulsive eating may be viewed as a specific form of subthreshold eating disturbance. Binge-eating disorder (defined by DSM-IV-TR as a specific eating disorder characterized by the presence of recurrent binge-eating episodes in the absence of inappropriate compensatory behaviors) has also become a significant clinical concern because of its positive relationship with psychological distress, and in particular with depression (Bulik et al., 2002; Smith et al., 1998; Telch and Stice, 1998; Mussell et al., 1995). Yanovski et al. (1993) found that participants with binge-eating disorder (BED) were more likely to have a lifetime diagnosis of an Axis I disorder, primarily major depressive disorder, than controls without BED. Further, a recent study on BED and psychological distress in college students found a direct association between depression, anxiety, alexithymia, and binge eating (Mitchell and Mazzeo, 2004). Research also indicates that individuals with eating disorders tend to engage in excessive exercise. Traditionally, physical activity has been associated with numerous health benefits (Francis, 1999; Scully et al., 1998). However, recent research suggests that excessive exercise can become a compulsive behavior, which also may limit its effectiveness in enhancing psychological states and cause a significant impairment in social and occupational functioning of individuals (Thome and Espelage, 2004). While some observers may view these persons as just extremely dedicated or motivated, many of them may be obsessed with exercise. They need to significantly increase the frequency or intensity of their exercise behavior and experience psychological withdrawal symptoms when they are unable to exercise for a while, losing control of their exercise behavior (Zmijewski and Howard, 2003). De Coverley Veale (1987) was the first to hypothesize the existence of “exercise dependence” and proposed a specific set of diagnostic criteria to assess symptoms of exercise dependence adapting DSM-IV-TR (American Psychiatric Association [APA], 2000) criteria for substance dependence disorder. The notion of exercise dependence has been shown not to be limited to professional athletes, and some experts believe that it is a far more serious condition than many clinicians currently recognize. Exercise dependence can pose health risks, both physical and psychological. For example, people with exercise dependence tend to continue exercising despite minor injuries. Similarly, excessive exercise may affect psychological health, by being associated with mood disturbance and with abnormal eating behaviors (Yates, 1996; Wolf and Akamatsu, 1994). Psychological withdrawal symptoms might follow a period of
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abstinence from exercise, which may be responded to by re-engaging in further exercise. In individuals with primary exercise dependence, “the exercise is an end in itself and the dieting and weight loss are used to improve performance” (De Coverley Veale, 1987). On the other hand, individuals with secondary exercise dependence, having a primary diagnosis of eating disorder, might be exercising excessively to lose weight or compensate for binge eating. Zmijewski and Howard (2003) found that the number of exercise-dependence symptoms was significantly associated with problematic attitudes toward eating. A recent study by Thome and Espelage (2004) examined gender differences in the association between exercise and psychological health among a sample of university students. Male and female participants were found to exercise for different reasons. In males, exercise was associated with greater life satisfaction and lower level of depression whereas in females it was associated with eating disorders. Despite the increased prevalence of these clinical issues on college campuses (American College Health Association, 2004), mental health services are often unequipped to handle them. Warning signs and symptoms of psychological distress in college students might be rapid changes in mood, depression, sleep disorders, substance abuse, anxiety disorders, eating disorders, impulsive behaviors and, potentially, suicidal behaviors (Kadison and DiGeronimo, 2004; Kessler and Walters, 1998). The present study was a part of a multi-site collaborative university-based program for the prevention of youth suicide, assessing the prevalence of depression and other risk factors for suicide in a college population. The aim of this exploratory study was to evaluate the relationships between both compulsive eating and exercise, and demographic and clinical variables such as depression, aggression, and quality of life. 2. Methods 2.1. Participants Participants were 589 undergraduate students. The sample was approximately evenly divided with regard to gender, and the majority of students were Caucasian. Out of the total sample of 589 students, 669 responded to either the question regarding compulsive eating or the question regarding compulsive exercise, and 564 responded to both questions. Since analyses were performed separately for these two questions, analyses included all participants with non-missing data for the
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relevant outcomes. Sample demographics are presented in Table 1.
voucher for use at campus dining and/or retail outlets in addition to a list of on- and off-campus mental health resources.
2.2. Procedures 2.3. Measures The present study was a part of a larger program for the prevention of youth suicide that was carried out at two different universities located in the Southern United States (University A and University B). Participants were recruited during a mental health screening that took place at the two campuses. At each site, screening sessions were conducted in a public and prominent location and occurred during peak student traffic periods. A table was set up, staffed with licensed mental health professionals and research assistants. Students interested in participation who approached the table were told about the study and then given a brief written consent form along with the package of screening questionnaires. Participants who obtained a score of ≥ 13 on the Beck Depression Inventory and/or positively endorsed a screening question about suicidal ideation (BDI item #9 ≥ 1) were asked to be interviewed by a clinician. Those who completed the screening assessments received a $10.00
For the current study we considered the measures included in the screening package: - Questionnaire about socio-demographic data. A fourpage questionnaire covering several demographic domains including: age, gender, school year, ethnicity, current living situation and satisfaction with living situation. - Beck Depression Inventory (BDI; Beck et al., 1961). This 21-item measure of depression assesses both psychological symptoms and physical symptoms. Each item is scored from 0 to 3, with higher scores indicative of greater severity of depression. - Beck Hopelessness Scale (BHS; Beck et al., 1974). The BHS asks a respondent to answer true or false to a series of 20 statements reflecting attitudes regarding the future. Higher scores indicate higher levels of hopelessness.
Table 1 Demographic variables by presence or absence of compulsive eating Demographics a
University A B Gender Females Males
Living situation On campus Off campus Ethnicity White Asian Other
School year Satisfaction with living situation a N = 564–569. ⁎ P b 0.05. ⁎⁎ P b 0.01. ⁎⁎⁎ P b 0.001.
Total sample (N = 569)
No compulsive eating (N = 525)
Compulsive eating (N = 41)
Test of difference between groups
Adjusted for site, gender and depression severity
Frequency (%)
Frequency (%)
Frequency (%)
χ2
P
Odds ratio
P
10.32
0.001⁎⁎⁎
3.41
0.003⁎⁎
322 (56.6) 247 (43.4)
287 (89.69) 238 (96.75)
33 (10.31) 8 (3.25) 9.49
0.002⁎⁎
2.30
0.03⁎
299 (52.5) 270 (47.5)
266 (89.56) 259 (96.28)
31 (10.44) 10 (3.72)
Frequency (%)
Frequency (%)
Frequency (%)
P
LR χ2
P
4.49
0.03⁎
0.02
0.88
10.27
0.14
3.35
0.18
t
P
LR χ2
P
0.04⁎ 0.49
2.53 0.02
0.11 0.88
341 (59.9) 227 (39.9)
308 (90.86) 216 (95.58)
31 (9.14) 10 (4.42)
318 (55.9) 143 (25.1) 106 (18.6)
287 (90.82) 135 (95.07) 101 (95.28)
29 (9.18) 7 (4.93) 5 (4.72)
Mean ± S.D.
Mean ± S.D.
Mean ± S.D.
2.78 ± 1.47 4.74 ± 1.04
2.82 ± 1.47 4.75 ± 1.03
2.34 ± 1.53 4.63 ± 1.04
χ2
2.02 0.68
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- Consumptive Habits Questionnaire (CHQ; unpublished). This is a brief questionnaire used to obtain information about the responders' current consumption levels of alcohol, caffeine, street drugs and prescription drugs. Moreover, this questionnaire assesses characteristics of participants' compulsive behaviors, including eating, exercise, gambling, sexual activities, spending, risk taking and other compulsive activities (see Appendix for more details). For the current study, we focused on the presence or absence of compulsive eating and exercise. No explicit summary score was used from the CHQ. Number of times per week/month reported by respondents was considered as descriptive results. - Modified Overt Aggression Scale — Self-Rated Version (MOAS; Yudofsky et al., 1986). The MOAS investigates four different aspects related to aggressive behavior: verbal aggression, violence against property, self-aggression and physical aggression. Response options are 0 to 4 on a 5-point Likerttype scale. Higher scores indicate a greater level of aggression. - Quality of Life Enjoyment and Satisfaction Questionnaire—Short Form (QLESQ; Endicott et al., 1993). This questionnaire includes 16 items related to physical health, mood, work satisfaction, enjoyment in leisure activities, ability to function in daily life and overall satisfaction with life. Participants are asked to consider the past week and to rate their answers on a 5point Likert-type scale (from 1 = very poor through 5 = very good). A quality of life index score is calculated by averaging the scores of all items. 2.4. Data analyses Data were entered in SPSS, after which descriptive statistics were calculated. Chi-square tests were performed to assess the differences between the two groups (presence or absence of compulsive behavior) on dichotomous demographic variables. Similarly, two-sample t-tests were used to test for differences in average score on continuous demographic and clinical measures between participants who did or did not endorse compulsive behaviors. The t-tests and chi-square tests examined compulsive eating and compulsive exercise separately. Logistic regressions were used to supplement the univariate significance tests by looking at the effect of each demographic and clinical variable, controlling for the effects of variables identified by previous research as important predictors. To identify variables whose relationships with compulsive behaviors can be generalized
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to populations of college students other than at the two universities included in this study, one of the variables we also controlled for was study site. The dependent variable for the logistic regressions was the presence or absence of self-reported compulsive behaviors. Likelihood ratio chi-square tests were used to compare regression models controlling for a fixed set of important predictors with and without the demographic or clinical factor being tested. 3. Results Of the 569 participants who answered either the compulsive eating or compulsive exercise questions on the CHQ, 41 (7.2%) reported compulsive eating, and 103 (18.1%) reported compulsive exercise; only 11 (1.9%) reported both compulsive eating and compulsive exercise. There was not a statistically significant relationship between compulsive eating and compulsive exercise (N = 564, χ2(1) = 2.82, P = 0.093). 3.1. Compulsive eating Compulsive eating was found to have a significantly different prevalence between the two university campuses (P = 0.001), genders (P = 0.002), living situations (P = 0.03) and years in school (P = 0.04) (Table 1). A greater proportion of participants reporting compulsive eating attended University A, were female, lived on campus and were in their initial years in school. Table 2 shows mean scores on self-report clinical measures, comparing participants who reported compulsive eating with those who did not. Statistically significant differences between the two groups were found for BDI total score (P b 0.0005), MOAS selfaggression subscale (P = 0.0098) and QLESQ score (P = 0.0052). Results showed that participants who reported compulsive eating, compared with those who did not, had higher levels of depression and selfaggression and less satisfaction with their lives. Using logistic regression, we adjusted the compulsive eating univariate findings to control for the effect of study site as well as factors suggested as important by previous research such as gender, comorbid depression, and self-aggression. However, the MOAS self-aggression item did not improve the prediction of the presence of compulsive eating using a logistic regression once controlling for site, gender, and depression severity (as measured by the total BDI score) (χ2 = 1.06; P = 0.304) and therefore could be omitted from further logistic regressions. The univariate comparisons in Tables 1 and 2 were therefore supple-
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Table 2 Clinical measures by the presence or absence of compulsive eating Clinical measures a
BDI
BHS MOAS MOAS self-aggression QLESQ
No compulsive eating (N = 525)
Compulsive eating (N = 41)
Test of difference between groups
Adjusted for site, gender and depression severity
Mean ± S.D.
Mean ± S.D.
t
P
Odds ratio
P
1.08
0.001⁎⁎⁎
LR χ2
P
0.23 0.10 1.06 0.64
0.63 0.75 0.30 0.42
5.63 ± 5.58
9.48 ± 7.81
− 4.12
b0.0005⁎⁎⁎
Mean ± S.D.
Mean ± S.D.
t
P
2.97 ± 2.74 0.65 ± 1.27 0.12 ± 0.39 3.73 ± 0.54
3.12 ± 3.11 0.65 ± 1.00 0.30 ± 0.72 3.48 ± 0.63
− 0.33 0.01 − 2.60 2.80
0.74 0.99 0.0098⁎⁎ 0.0052⁎⁎
a N = 550–569. ⁎⁎ P b 0.01. ⁎⁎⁎ P b 0.001.
mented by P values that were adjusted by controlling for site, gender, and depression severity, showing that living situation (P = 0.88), year in school (P = 0.11), selfaggression (P = 0.30), and quality of life (P = 0.42) were no longer statistically significant predictors of compulsive eating. A logistic regression controlling for depression severity and gender showed that participants at University A were 3.4 times more likely than those at University B to report compulsive eating (P = 0.003; 95% confidence interval for odds ratio: 1.5–7.7). Adjusting for depression severity and site, females were 2.3 times more likely than males to report compulsive eating (P = 0.030; 95% confidence interval for odds ratio: 1.1– 4.9). After controlling for site and gender, an increase in total BDI score of one point increased the odds of compulsive eating by a factor of 1.1 (P = 0.001; 95% confidence interval for odds ratio: 1.03–1.13); equivalently, in this sample a subject with a BDI 5 points higher than another of the same gender at the same university was 1.6 times more likely to have compulsive eating. Participants were also asked to report how many times per week compulsive eating occurred. For those who responded to this question (N = 26), the average of current weekly frequency of compulsive eating was 3.54 (S.D. = 2.39) and was 4.23 (S.D. = 3.63; N = 17) for past weekly frequency. More than 73% of respondents reported current compulsive eating behavior at least twice a week. 3.2. Compulsive exercise Compulsive exercise was reported by a significantly higher proportion of males (23.4%) than females (13.4%; χ2 = 9.50; P = 0.002). In addition, a significantly
lower proportion of Asians (9.8%) in respect to Caucasians (22.2%) and other races including Blacks and Hispanics (17%) reported compulsive exercise (χ2 = 10.27; P = 0.006) (Table 3). Participants who reported compulsive exercise were not statistically significantly different on any of the clinical measures compared with those who did not. The average current frequency of compulsive exercise reported by respondents (N = 85) was equal to
Table 3 Demographic variables by presence or absence of compulsive exercise Demographics a
No compulsive Compulsive exercise exercise (N = 464) (N = 103)
Test of difference between groups
Frequency (%) Frequency (%) χ2 University A B Gender Females Males Living situation On campus Off campus Ethnicity White Asian Other
262 (81.37) 202 (82.45)
60 (18.63) 43 (17.55)
258 (86.58) 206 (76.58)
40 (13.42) 63 (23.42)
281 (82.65) 182 (80.53)
59 (17.35) 44 (19.47)
246 (77.85) 129 (90.21) 88 (83.02)
70 (22.15) 14 (9.79) 18 (16.98)
Mean ± S.D.
Mean ± S.D.
9.50 0.002**
0.41 0.52
10.27 0.006**
School year 2.81 ± 1.47 Satisfaction with 4.75 ± 1.06 living situation a
P
0.11 0.74
N = 565–569. ** P b 0.01.
2.7 ± 1.51 4.74 ± 0.94
t
P 0.68 0.50 0.02 0.98
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4.61 (S.D. = 1.94) times per week and was nominally higher in the past (μ = 5.27, S.D. = 2.12; N = 62). The most prevalent activities were running, weight lifting and swimming. 4. Discussion Epidemiologic research on BED has a relatively short history. The phenomenon of binge eating in the absence of inappropriate compensatory behaviors that define bulimia nervosa (BN) attracted relatively little scientific interest until the introduction of BED in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders as a specific Eating Disorder Not Otherwise Specified (EDNOS). Even though compulsive eating and binge eating are not necessarily the same construct, they may have some overlapping clinical aspects, since binge eating is defined as the consumption of an unusually large amount of food with a subjective sense of loss of control over the eating. The prevalence of compulsive eating in our sample (52.5% female, 44% minorities, mean age 20 years) was 7.2%. Mitchell and Mazzeo (2004) examined the relationship between eating disorders and psychological distress among college students and found a prevalence rate of BED equal to 2.6% (assessed by the diagnostic composite of the Eating Disorder Diagnostic Scale). However, 13.3% of their sample met cutoff scores for moderate to severe binge eating (as measured by the Binge Eating Scale). In the past decade Spitzer and colleagues conducted BED field trials among several community and patient samples, and found that among college students (79% female, 26% minorities, mean age 22 years) 2.8% of women and 1.9% of men met criteria for BED (Spitzer et al., 1993). Gender differences in the prevalence of BED did not reach statistical significance. A rapidly growing literature has investigated demographic variables correlated with BED and fixed markers, such as gender and ethnicity, to identify highrisk groups in the population. Consistent with previous studies, which have found significant differences in rates of abnormal eating behaviors between males and females, we found that females were 2.3 times more likely than males to report compulsive eating (P = 0.030). However, these findings are inconsistent with two recent studies, which have found equal (Smith et al., 1998) or higher (Johnson et al., 2002) rates of binge eating among males in a general population. Lewinsohn et al. (2002) also found that among
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young adults (mean age 25 years) men (28%) were more likely than women (14%) to report that they had experienced episodes of overeating. Nonetheless, gender differences regarding compensatory behaviors and distress about binge eating suggest that men might be at lower risk for full-syndrome eating disorders than women. No statistically significant differences were found among diverse ethnic groups in our sample on compulsive eating. These findings were consistent with Mitchell and Mazzeo's (2004) study of binge eating among Caucasian and African American college students. However, few studies have examined eating disorders in general, and BED in particular, among diverse ethnic groups; therefore, any conclusions regarding ethnicity are premature. Further research is needed to assess the prevalence of BED in additional ethnic groups. With respect to compulsive exercise, a prevalence rate as high as 18.1% was found in our sample, and the average frequency of current exercise reported by respondents (N = 85) was equal to 4.61 (S.D. = 1.94) times per week. In a recent study of exercise dependence among college students (Zmijewski and Howard 2003), participants averaged 5.2 h (S.D. = 4.4, range 30 min to 25 h) of exercise per week, and a majority of them (66%, N = 237) were found to engage in exercise one to four times per week, whereas 7.9% exercised seven or more times each week. Another study on occurrence of exercise dependence in a college-aged population (Garman et al., 2004), which evaluated through self-report measures the amount of activity per week, found that 21.8% of participants in the sample exercised 360 or more minutes per week and demonstrated an obligatory or pathological nature of their activity pattern. In our study males were significantly more likely than females to report compulsive exercise. A recent study (Hausenblas and Symons Downs, 2002) on exercise dependence among college students also found that the male participants reported more exercise-dependence symptoms compared with the female participants, as measured by the Exercise Dependence Scale (Hausenblas and Symons Downs, 2001). Conversely, Thome and Espelage (2004) found that males and females did not differ in the amount of exercise they reported during the past week or in a typical week. Moreover, they found that exercise was associated with better psychological health (as greater positive affects, satisfaction with life and lower levels of depression and anxiety) in male college students. Zmijewski and Howard (2003) also found a higher prevalence
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of exercise-dependence withdrawal symptoms among college women than men and that women reported using exercise to prevent negative affect states significantly more often than did men. This study examined compulsive eating and compulsive exercise separately. Only 11 participants (1.9%) reported both compulsive eating and exercise, and no statistically significant relationships between the two variables were found in our sample. These findings support the clinical significance of abnormal eating behaviors in the absence of certain inappropriate compensatory behaviors (such as excessive exercise) among college students, and draw attention to exercise-dependence symptoms as a relevant clinical concern in this population. Our investigation has several strengths, including the nature of the sample. Very few studies have examined compulsive eating in a college population despite the fact that college students may represent a group at high risk of developing eating disorders. Furthermore, this study included both males and females as well as diverse ethnic groups, while many studies of eating disorders have included exclusively female and primarily Caucasian clinical samples. However, certain limitations should be noted. Both compulsive eating and exercise were assessed using a self-report measure of consumptive habits (CHQ) and no explicit definitions of “compulsive” behaviors, as well as “current” or “past” frequency were given to the responders. A number of studies have compared interview and self-report methods of assessing the core features of eating disorders, with mixed results (Black and
Wilson, 1996; Fairburn and Beglin, 1994; Loeb et al., 1994; Wilfley et al., 1997). Interviews allow investigators to define key terms such as binge eating and to use detailed guidelines for rating complex concepts. Such precision is difficult to achieve using self-report instruments, as data obtained with this method are dependent on the participants' willingness to report accurate information (Carter et al., 2001; Grilo et al., 2001). The self-selected sample could inflate the prevalence rates observed in this study, as participants in this mental health screening may be more likely to have psychological distress than other students who did not agree to cooperate. In addition, participants of this study were university students at two specific campuses, which limits the generalizability of our findings. Consequently, when we analyzed data on compulsive eating, we adjusted for the effect of study site, as well as for depression severity and gender. In summary, college students may represent a group at high risk of developing abnormal eating behaviors and compulsive exercise, as evidenced by our findings. Further research is needed to explore both demographic and psychological correlates of compulsive eating and compulsive exercise in this population. Acknowledgements This study was supported by a grant from the Jed Foundation. We would like to thank all college students for participating in this program. Additionally, we would like to thank investigators, clinicians and research assistants for their support.
Appendix A. Consumptive Habits Questionnaire (CHQ) Do you currently consume alcohol? Yes _____ No _____ ______# 12 ounce beer or wine coolers per day ______# 4–6 ounce glasses wine per day ______# ounce distilled spirits per day Do you currently consume any caffeine? Yes _____ No _____ ______# cups of tea per day ______# cups of coffee per day ______# 12 ounce colas per day Have you ever engaged in the past or currently in other addictive behaviors? Yes _____ No _____
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Compulsive use of street drugs Compulsive use of prescription drugs Compulsive use of alcohol Compulsive use of caffeine Compulsive exercise Compulsive eating Gambling Compulsive sexual activities Compulsive buying or spending Risk taking behaviors Other compulsive Activities
Current frequency (fill in if current)
Past frequency (if part history, record freq at highest point
Y/N
_____#/week _____#/month
_____#/week _____#/month
Y/N
_____#/week _____#/month
_____#/week _____#/month
Y/N
⁎noted above⁎
_____#/week _____#/month
Y/N
⁎noted above⁎
_____#/week _____#/month
Y/N Y/N Y/N Y/N
_____#/week _____#/month _____#/week _____#/month _____#/week _____#/month _____#/week _____#/month
_____#/week _____#/month _____#/week _____#/month _____#/week _____#/month _____#/week _____#/month
Y/N
_____#/week _____#/month
_____#/week _____#/month
Y/N Y/N
_____#/week _____#/month _____#/week _____#/month
_____#/week _____#/month _____#/week _____#/month
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Types (specify)
©Massachusetts General Hospital, Depression Clinical and Research Program.
References Allison, K.C., Park, C.L., 2004. A prospective study of disordered eating among sorority and nonsorority women. International Journal of Eating Disorders 35, 354–358. American Psychiatric Association, 2000. Diagnostic and Statistical Manual of Mental Disorder, (4th ed.). Author (text-revision), Washington, DC. American College Health Association, 2004. National College Health Assessment: reference group report. Author, Baltimore, Md. Beck, A.T., Ward, C.H., Mendelson, M., Mock, J., Erbaugh, J., 1961. An inventory for measuring depression. Archives of General Psychiatry 4, 561–571. Beck, A.T., Weissman, A., Lester, D., Trexler, L., 1974. The measurement of pessimism: the hopelessness scale. Journal of Consulting & Clinical Psychology 42 (6), 861–865. Black, C.M.D., Wilson, G.T., 1996. Assessment of eating disorders: interview versus questionnaire. International Journal of Eating Disorders 20, 43–50. Bulik, C.M., Sullivan, P.F., Kendler, K.S., 2002. Medical and psychiatric morbidity in obese women with and without binge eating. International Journal of Eating Disorders 32, 72–78. Carter, J., Aimé, A., Mills, J., 2001. Assessment of bulimia nervosa: a comparison of interview and self-report questionnaire methods. International Journal of Eating Disorders 30, 187–192. Dancyger, I.F., Garfinkel, P.E., 1995. The relationship of partial syndrome eating disorders to anorexia nervosa and bulimia nervosa. Psychological Medicine 25, 1019–1025. De Coverley Veale, D.M.W., 1987. Exercise dependence. British Journal of Addiction 82, 735–740. Endicott, J., Nee, J., Harrison, W., Blumenthal, R., 1993. Quality of life enjoyment and satisfaction questionnaire: a new measure. Psychopharmacology Bulletin 29 (2), 321–326.
Fairburn, C.G., Beglin, S.A., 1994. Assessment of eating disorder pathology: interview or self-report questionnaire? International Journal of Eating Disorders 16, 363–370. Francis, K.T., 1999. Status of the year 2000 health goals for physical activity and fitness. Physical Therapy 79, 405. Garman, J.F., Hayduk, D.M., Crider, D.A., Hodel, M.M., 2004. Occurrence of exercise dependence in a college-aged population. Journal of American College Health 52 (5), 221–228. Grilo, C.M., Masheb, R.M., Wilson, G.T., 2001. A comparison of different methods for assessing the features of eating disorders in patients with binge eating disorder. Journal of Consulting and Clinical Psychology 69, 317–322. Hausenblas, H.A., Symons Downs, D., 2001. The Exercise Dependence Scale Manual. Unpublished test manual. University of Florida, Gainesville. Hausenblas, H.A., Symons Downs, D., 2002. Relationship among sex, imagery, and exercise dependence symptoms. Psychology of Addictive Behaviors 16 (2), 169–172. Johnson, W.G., Rohan, K.J., Kirk, A.A., 2002. Prevalence and correlates of binge eating in White and African American adolescents. Eating Behaviors 3, 179–189. Kadison, R., DiGeronimo, T., 2004. College of the Overwhelmed: The Campus Mental Health Crisis and What To Do About It. JosseyBass, San Francisco, CA. Kessler, R.C., Walters, E.E., 1998. Epidemiology of DSM-III-R major depression and minor depression among adolescents and young adults in the National Comorbidity Survey. Depression and Anxiety 7, 3–14. Killen, J.D., Taylor, C.B., Hayward, C., Wilson, D.M., Haydel, K.F., Robinson, T.N., Litt, I., Simmonds, B.A., Varady, A., Kraemer, H., 1994. Pursuit of thinness and onset of eating disorder symptoms in a community sample of adolescent girls: a threeyear prospective analysis. International Journal of Eating Disorders 16, 227–238.
162
J. Guidi et al. / Psychiatry Research 165 (2009) 154–162
Kurth, C.L., Krahn, D.D., Nairn, K., Drewnowski, A., 1995. The severity of dieting and bingeing behaviors in college women: interview and validation of survey data. Journal of Psychiatric Research 29, 211–225. Lewinsohn, P.M., Seeley, J.R., Moerk, K.C., Striegel-Moore, R.H., 2002. Gender differences in eating disorder symptoms in young adults. International Journal of Eating Disorders 32, 426–440. Loeb, K.L., Pike, K.M., Walsh, B.T., Wilson, G.T., 1994. Assessment of diagnostic features of bulimia nervosa: interview versus selfreport format. International Journal of Eating Disorders 16, 75–81. Mitchell, K.S., Mazzeo, S.E., 2004. Binge eating and psychological distress in ethnically diverse undergraduate men and women. Eating Behaviors 5, 157–169. Mulholland, A.M., Mintz, L.B., 2001. Prevalence of eating disorders among African American women. Journal of Counseling Psychology 48 (1), 111–116. Mussell, M.P., Mitchell, J.E., Weller, C.L., Raymond, N.C., Crow, S.J., Crosby, R.D., 1995. Onset of binge eating, dieting, obesity, and mood disorders among subjects seeking treatment for binge eating disorder. International Journal of Eating Disorders 17, 395–401. Raffi, A.R., Rondini, M., Grandi, S., Fava, G.A., 2000. Life events and prodromal symptoms in bulimia nervosa. Psychological Medicine 30, 727–731. Scully, D., Kremer, J., Meade, M.M., Graham, R., Dedgeon, K., 1998. Physical exercise and psychological well-being: a critical review. British Journal of Sports Medicine 32, 111–120. Shisslak, C.M., Crago, M., Neal, M.E., 1987. Prevention of eating disorders among adolescents. Journal of Consulting and Clinical Psychology 55, 660–667. Smith, D.E., Marcus, M.D., Lewis, C.E., Fitzgibbon, M., Schreiner, P., 1998. Prevalence of binge eating disorder, obesity, and depression in a biracial cohort of young adults. Annals of Behavioral Medicine 20, 227–232.
Spitzer, R.L., Yanowski, S., Wadden, T., Wing, R., Marcus, M.D., Stunkard, A., Devlin, M., Mitchell, J., Hasin, D., Horne, R.L., 1993. Binge eating disorder: its further validation in a multi-site study. International Journal of Eating Disorders 13, 137–154. Telch, C., Stice, E., 1998. Psychiatric comorbidity in women with binge eating disorder: prevalence rates from a non-treatmentseeking sample. Journal of Consulting and Clinical Psychology 66 (5), 768–776. Thome, J., Espelage, D.L., 2004. Relations among exercise, coping, disordered eating, and psychological health among college students. Eating Behaviors 5, 37–351. Wilfley, D.E., Schwartz, M.B., Spurrell, E.B., Fairburn, C.G., 1997. Assessing the specific psychopathology of binge eating disorder patients: interview or self-report? Behaviour Research and Therapy 35, 1151–1159. Wolf, E.M., Akamatsu, T.J., 1994. Exercise involvement and eatingdisordered characteristics in college students. Eating Disorders 2 (4), 308–318. Yanovski, S.Z., Nelson, J.E., Dubbert, B.K., Spitzer, R.L., 1993. Association of binge eating disorder and psychiatric comorbidity in obese subjects. American Journal of Psychiatry 150, 1472–1479. Yates, A., 1996. Athletes, eating disorders, and overtraining syndrome. In: Epling, W.F., Pierce, D. (Eds.), Activity anorexia: Theory, research, and treatment. Erlbaum, Mahwah, pp. 179–188. Yudofsky, S.C., Silver, J.M., Jackson, W., Endicott, J., Williams, D., 1986. The overt aggression Scale for the objective rating of verbal and physical aggression. American Journal of Psychiatry 143 (1), 35–39. Zmijewski, C.F., Howard, M.O., 2003. Exercise dependence and attitudes toward eating among young adults. Eating Behaviors 4, 181–195.