Eating-style and weight-concerns in young females1

In this study, attitudes towards eating among adolescent school-girls were compared to those among fashion models and eating disorder patients. The results clearly demonstrate a preoccupation with body weight, even in school-girls. A majority of the girls indicated a wish to lose weight, even when the current Body Mass Index was between 20 and 25. Eating disorder patients more commonly reported premorbid overweight. Furthermore, fashion models tended to have an eating-style that was comparable to that of patients with eating disorders. The finding that the mean current body weight of all girls was lower than before suggests that many girls developed a restrained eating style. Vomiting, the use of anorectic drugs and laxatives, eating alone, and counting calories were reported by a substantial proportion of the adolescent girls. Moreover, a substantial proportion of the girls experienced a loss of control over eating. The combination of this eating-style and being overweight, can be considered as risk factor for the development of eating disorders. Introduction

The culture of slimming in Western societies creates an important and

increasing discrepancy between the real shape and the ideal shape (Garner,

Garfinkel, Schwartz, & Thompson, 1980). Preoccupation with body weight

and excessive concerns about body shape may induce eating patterns that

are similar to those of patients with eating disorders. It remains to be

demonstrated under which conditions such eating patterns develop into

eating disorders.

Dissatisfaction with body weight and shape are very common among

preadolescent and adolescent girls. It is particularly concerning that girls

who show relatively unhealthy baseline eating attitudes are more likely to

fit in the category of the partial syndrome of eating disorders (PSED) at

follow-up (Button & Whitehouse, 1981). While PSED is not inevitably

associated with the development of anorexia or bulimia nervosa, it can, at

the least, be regarded as similar to the first stage of Slade's (1987)

1 Vervaet, M., & van Heeringen, C. (2000). Eating Style and Weight Concerns in Young

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developmental model of eating disorders. The danger exists that any girl

who has reached this stage is prone to see low body weight and control as

rewarding, and that she will then go on to develop a more robust disorder as

a consequence.

Thus, cultural factors may be a necessary condition in the

development of eating disorders, or at least act as a facilitating factor,

especially as Western cultures also suggest that success and the approval of

others are solutions for problems (Wooley & Wooley, 1985). To be slim is

a symbol of beauty, sexual attractiveness, and success. Weight control is

considered synonymous with discipline, personal strength and willpower

(Noordenbos, 1990). Contemporary values such as perfectionism and

control and pressure on females to enhance their appearance induce social

stresses. The question remains: To what extent does such an internalisation

process remain adaptive, or proceed beyond a certain limit and develop into

psychopathology? Knowledge of psychological factors contributing to the

development of pathological eating behaviors is indispensable for the

identification of diagnostic criteria of the eating disorders.

This study compared eating styles and weight concerns among

schoolgirls, fashion models, and patients diagnosed as suffering from eating

disorders. The groups were chosen in order to assess the association

between eating behaviour, weight concerns, and eating disorders.

Method

Girls attending the fifth year of two large secondary schools participated in

this study (n=333). Questionnaires were filled in collectively. The

Females. Eating Disorders: The Journal of Treatment and Prevention, 8: 233-240.

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questionnaire was also sent to 20 fashion models of a national agency and to

40 patients with eating disorders (ED) admitted to the Department of Eating

Disorders (University Hospital Gent) in 1993 (31.0% anorectics in

treatment, n = 10; 62.5% bulimics of normal weight, n = 20; 6.3%

overweight (BMI > 25) bulimics, n = 2). Items in the questionnaire covered

age, weight, desired weight, educational level, presence of a boyfriend, use

of anorectic drugs and laxatives, weight and eating problems (defined as

self-criticism on weight and eating patterns, perceived excessive

bodyweight, or lack of control over eating), vomiting, eating-patterns,

thinking about eating (i.e. extent of preoccupation), eating alone (eating in

secret), counting calories, preference for sweet or salty foods, loss of

control, and the frequency (exceptional, sometimes, daily) and severity

(<500Kcal, 1000-2000 Kcal, >2000 Kcal) of this loss of control. Moreover,

the participants were asked to fill in the Dutch Eating Behaviour

Questionnaire (DEBQ; Van Strien, 1986) which consists of the following

subscales: emotional eating (eating elicited by emotional stimuli), restrained

eating (the tendency to eat to lose weight), and external eating (eating

elicited by external stimuli).

Statistical analysis was performed using SPSS 9.0, and included a

comparison of the characteristics between the schoolgirls, models and ED

patients, by means of chi-square analysis for nominal variables and non-

parametric tests for continuous variables.

Results

Questionnaires were returned by 333 schoolgirls (100 %), 11 fashion

models (55 %), and 32 ED-patients (80%). Table 1 shows mean values for

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age, weight, and body mass index (BMI= weight/length x length) in the

three groups.

Table 1: A Comparison of the Mean Values and Standard Deviation for Age, Weight and BMI Among Schoolgirls, Fashion Models, and ED-patients.

Schoolgirls Models ED n = 333 n = 11 n = 32 Mean (SD) Mean (SD) Mean (SD)

_____________________________________________________________ Age (years)1 16.8 (0.8)ab 19 (0.9)ac 24 (5.2)bc

Weight (kg)2 56 (6.4) 57 (3.5) 54 (12.6) BMI3 20 (1.9) 18 (1.O) 19 (4.1) 1One-way ANOVA, F = 262.8; (df = 2); p < .0001 post-hoc comparison (Bonferroni) a p < .000; b p < .000; c p < .000 2One-way ANOVA, F = .765; (df = 2); p = .466 3One-way ANOVA, F = 1.5444; (df = 2); p = .215

There was a significant difference between the three groups in mean age,

but not in mean weight and BMI.

Mean reported former weight was higher than mean current weight

in all three groups (Table 2).

Table 2: A comparison of the Mean and Standard Deviation in Highest Weight, Desired Weight, and Desired BMI among Schoolgirls, Models and ED-patients.

Schoolgirls Models ED n = 333 n = 11 n = 32 _____________________________________________________________ Highest weight1 58 (6.9)ab 61 (5.6)ac 66 (16.5)bc

Desired weight2 54 (5.5) 55 (1.9) 52 (7.7) Desired BMI3 19 (1.5) 18 (0.7) 19 (2.2)

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1One-way ANOVA, F = 12.9; (df = 2); p < .000 post-hoc comparison (Bonferroni) a p = .445; b p = .000 c p = .528 2One-way ANOVA, F = .1.2; (df = 2); p = .297 3One-way ANOVA, F = 2.5; (df = 2); p = .083

On the contrary, girls in the three groups indicated a desired weight that was

lower than the ideal BMI (63,5% of the schoolgirls want to lose weight, n =

212 versus 8,1% who want to gain weight, n = 27; 81,8% of the fashion

models want to lose weight, n = 9 versus 9,1% who want to gain weight, n =

1; 62,5% of the eating disorder group want to lose weight, n = 20 versus

21,9% who want to gain weight, n = 7). Mean reported highest weight was

significantly higher in ED patients than for the other groups. In the eating

disorder group 40.6% (n = 13) reported a premorbid overweight, in contrast

to 1,2% (n = 4) among the schoolgirls and 0% among the fashion models.

Significant differences between the three groups were found for

educational level and for reported weight and eating-problems (Table 3).

Table 3: A comparison of the frequency (%) of the Highest School Level, Relationship, Weight Problems, and Eating Problems Among Schoolgirls, Models and ED Patients. Schoolgirls Models ED X2 p-value _____________________________________________________________ Highest 74.4 27.3 62.5 20.120 0.000 school level Relationship 27.9 54.5 21.9 4.460 0.108 Weight 21.6 27.3 78.1 47.619 0.000 problems Eating 18.3 45.5 90.6 83.060 0.000 problems

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Fashion models had a lower educational level when compared to the other

two groups. Although the mean weight of attending schoolgirls was ideal,

nearly one in four indicated problems with their body weight. One in two

fashion models and one in five schoolgirls experienced eating problems.

No significant association was found between having a boyfriend and

belonging to one of the study groups. It is noteworthy that approximately

10% of the ED patients denied having eating problems.

Table 4 shows the results regarding the use of more drastic methods

to reduce body weight, i.e. anorectic drugs, vomiting, or laxatives. It was

found that 16 % of the schoolgirls used laxatives, compared to 36 % of the

models. Five percent of the schoolgirls used anorectic drugs, while 4 %

reported vomiting.

Table 4: A comparison of the Use of Anorectic Drugs, Vomiting and Laxatives Among Schoolgirls, Models, and ED patients. Schoolgirls Models ED X2 p-value % % % ___________________________________________________________ Drugs 4.8 0 15.6 6.500 0.100 Vomiting 3.9 0 37.5 52.34 0.000 Laxatives 15.9 36.4 46.9 20.83 0.000

Eating patterns also were compared between the three groups. As

shown in Table 5, no significant differences in 'skipping breakfast' and

'experienced loss of control over eating' were found.

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Table 5: Comparison of Eating Pattern Among Schoolgirls, Models and, ED Patients school-girls

% Models

% ED %

X2-test p-value

Skipping breakfast

10.2 18.2 21.9 4.419 0.100

Skipping lunch

2.1 9.1 9.4 6.936 0.030

Skipping dinner

1.2 9.1 9.4 14.67 0.001

Never eating between meals

13.2 27.3 34.4 0.000

Eating alone

23 90.9 62.5 44.03 0.000

Thinking about food

38.9 72.7 90.3 34.13 0.000

Counting calories

12 27.3 50 33.93 0.000

Loss of control

63 72.7 71.9 1.403 0.500

once a day (frequency)

6.3 12.5 30.4 9.885

0.007

>2000Kcal (amount)

21.1 42.9 47.8 6.636

0.030

However, the severity and especially the frequency of loss of control

differed significantly between the groups. ED patients showed more

frequent loss of control over eating and reported the ingestion of larger

amounts of food (in terms of Kcal). The significant character of the

differences regarding the other items was mainly due to a lower frequency

of disturbed eating patterns among the schoolgirls. However, even 12% of

the schoolgirls counted calories, 40% thought about food during the day,

and 23 % reported frequent eating while being alone.

Mean scores on the items of the Dutch Eating Questionnaire are

shown in Table 6.

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Table 6: Comparison of the Mean Scores and Their Standard Deviation on the Dutch Eating Questionnaire Among Schoolgirls, Models, and eating ED Patients. School-girls Models ED _____________________________________________________________ Restrained eating1 2.6 (0.9)ab 3.4 (1.0) ac 3.6 (0.9) bc Diffuse emotions2 2.8 (0.8) ab 3.4 (0.7) ac 3.3 (1.2) bc Clear emotions3 2.1 (0.7) ab 2.1 (0.7) ac 2.7 (1.2) bc Total emotions4 2.3 (0.7) ab 2.5 (0.4) ac 2.8 (1.1) bc External eating5 2.9 (0.5) ab 2.9 (0.5) ac 2.5 (0.7) bc 1One-way ANOVA, F = 16,1; (df = 2); p = .000 post-hoc comparison (Bonferroni) a p = .028; b p =.000; c p =1.000

2 F = .7,8; (df = 2); p = .000 a p = .058; b p =.003 c p =1.000

3 F = 8,7; (df = 2); p = .000 a p = 1.000; b p =.000; c p =.101

4 F = 16,1; (df = 2); p = .001 a p = 1.000; b p =.001; c p =.595

5;F = 16,1; (df = 2); p = .001 a p = 1.000; b p =.001; c p =.265 Significant differences (p = 0.001) in the occurrence of ‘restrained eating’,

‘emotional eating’ and ‘external eating’ were found between schoolgirls

and ED patients, but no significant differences were found between models

and ED patients. The mean score for ‘restrained eating’ was significant

lower for schoolgirls than that of the fashion models.

Discussion and conclusion

This study in a large group of young women suggests a substantial

preoccupation with body weight, not only in patients diagnosed with eating

disorders, but also in fashion models and in schoolgirls. The means of

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desired weight are lower in all three groups so we may hypothesize that a

majority of girls in this study wanted to lose weight, even when their

current BMI could be regarded as ideal. The eating pattern of fashion

models appears to resemble that of eating disordered patients. Schoolgirls

express severe concerns about their body weight, and one in four indicates

problems related to their body weight, although this apparently is not the

case in view of girls’ normal BMIs. The perceived problems induce

counting calories and a restrained eating style, albeit to a lesser extent than

in fashion models and eating disordered patients. The results also show that

fashion models do not report to suffer from an eating disorder in spite of the

fact that their eating patterns closely resemble those of eating disordered

patients. However, even one in ten ED patients does not report to suffer

from a disorder although she is currently being treated. In order to lose

weight models commonly report the use of laxatives while patients

additionally report vomiting. Finally, the results indicate that the highest

ever mean body weight was reported by the patients suffering from an

eating disorder. The finding of a premorbid overweight in eating disordered

patients is in keeping with the results from previous studies.

Two methodological aspects of this study should be addressed. First, the

schools were not randomly selected. Therefore, participating subjects

cannot be considered to be representative of the general population, and

may actually have an increased risk of developing an eating disorder as the

schools were only attended by girls who belonged to higher social classes,

who were obliged to wear uniforms, and who were confronted with a very

competitive spirit. Second, some questionnaires were not returned by the

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fashion models and the patients, so some results may be due to a selection

bias. The low response rate in the model group may be due to distrust or

lack of interest. The higher weight in models in comparison with the

schoolgirls may be due to the significant difference in mean age between

schoolgirls and fashion models. Finally, a number of schoolgirls and

models may have actually been suffering from an eating disorder.

Keeping these methodological limitations in mind, the findings from

this study indicate that the mean body weight in schoolgirls can be regarded

as ideal, as far as the body mass index is a correct index of body weight in

this age group. In any case, the results demonstrate that there are no severe

problems regarding body weight in this group of young females. However,

restrained eating, vomiting, and the use of anorectic drugs or laxatives

appear to be known as weight reducing strategies even among schoolgirls

and nearly one in five schoolgirls reports subjective problems with their

body weight and eating. Moreover, eating alone, thinking about food during

the day, counting calories and experiencing of a loss of control over eating

are commonly experienced. In view of a demonstrated association between

binge eating and psychopathology (Telch and Agras, 1994), the finding that

almost two-thirds of the schoolgirls report a loss of control over eating is

important. Six percent of the schoolgirls even report loss of control to occur

once a day, involving the ingestion of more than 2000 Kcal in more than

20%.

Equally important are the demonstrated similarities between patients

and fashion models, suggesting that the stronger the perceived pressure on

body weight, the higher the risk of developing an eating disorder might be.

The fact that the models do not consider themselves as suffering from a

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disorder may reflect the appreciation associated with their appearance, but

might also be due to a denial of the negative consequences of their job. In

view of the strong impact of pictures of models in fashion magazines (Field

et al., 1999) our current findings indicate the necessity of providing

information about potential negative consequences of a restrained eating

style to become underweight in terms of developing psychopathology. As a

conclusion, the results of this study suggest that being overweight during

adolescence is a risk factor for developing identity related problems in a

Western society with a slimming culture.

During the months following this study, 10 of the participating

schoolgirls attended the outpatient Department of Eating Disorders. Their

symptoms fitted the criteria for an eating disorder according to DSM-IV.

Thus, this study not only resulted in the detection of potential risk factors

for eating disorders among schoolgirls, but also may have lowered the

threshold for seeking treatment.

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References

American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, DC: APA. Button, E.J., Withouse, A.(1981). Subclinical anorexia nervosa. Psychological Medicine, 11, 509-516. Field, A.E., Cheung, L., Wolf, A.M., Herzog, D.B., Gortmaker, S.L., Colditz, G.A.(1999). Exposure to the Mass Media and Weight Concerns Among Girls. Pediatrics, Vol. 103, (3), 36-45. Garner, D.M., Garfinkel, P.E., & Olmsted, M.P.(1983). An overview of sociocultural factors in the development of anorexia nervosa. In: Darby, P.L., Garfinkel, P.E., Garner, D.M., & Coscina, D.V.(Eds.). Anorexia Nervosa. Recent Developments in Research (pp. 65-82). New York: Alan R. Liss. Garner, D.M., Garfinkel, P.E., Schwartz, D., Thompson, M. (1980). Cultural expectations of thinness in women. Psychological Reports, 47, 483-491. Noordenbos, G. (1990). Looking for the hidden identity behind a secret disorder. The recovery process of anorexia and bulimia nervosa. In: Petherson, G., Essed, Ph., & Richardson, D. (Eds.), Between Selfhelp and Professionalism ( pp.197-212). Amsterdam: The Moon Foundation The International Congress on Menthal Health Care for Women. Slade, P.D.(1987). Early recognition and prevention: Is it possible to screen people at risk of developing an eating disorder? In: D.Hardoff & E.Chigier (Eds). Eating Disorders in Adolescents and Young Adults. London: Freund. Telch, C.F., Agras, W.S.(1994). Obesity, Binge Eating and Psychopathology: Are They Related? International Journal of Eating Disorders, 15(1), 53-61. Van Strien, T., Frijters, J., Roosen, R., Knuiman-Mijl D., Defares, P.(1986). Eating behavior, personality traits and body mass in women. Wageningen, The Netherlands: Agricultural University . Wooley, S.C., & Wooley, O.W.(1985). Intensive outpatient and residential treatment for bulimia. In: Garner D.M. & Garfinkel P.E.(Eds.). Handbook of psychotherapy for anorexia nervosa and bulimia (p. 391). New York/London: Guilford Press.