EMPIRICAL ARTICLE
Eating-Disordered Behavior in Adolescent Boys: Eating Disorder Examination Questionnaire Norms Jonathan Mond, PhD, MPH1,2* Ashleigh Hall, BSc (Hons)3 Caroline Bentley, BSc (Hons)1 Carmel Harrison, BPsych (Hons)1 Kassandra Gratwick-Sarll, BA (Hons)1 Vivienne Lewis, BPsych, DPsych3
ABSTRACT Objective: We sought to provide normative data for the Eating Disorder Examination Questionnaire (EDE-Q) for adolescent boys. Method: The EDE-Q was completed by 531 boys aged 12–18 years recruited from a number of schools in the Australian Capital Territory (ACT) region of Australia. Data for 1,135 female adolescents, recruited as part of the same research project, are provided for comparative purposes. Results: Scores on each the EDE-Q subscales and, with the exception of excessive exercise, the prevalence of each of the eating disorder behaviors assessed, were substantially higher among girls than among boys. Still, 6.0% of boys reported regular episodes of objective binge eating, 8.3% reported regular episodes of loss of control eating, 5.3% reported regular excessive exercise and 4.9% reported overvaluation of weight or shape. Eating-disordered behavior was
Introduction The Eating Disorder Examination Questionnaire (EDE-Q), developed by Fairburn and Beglin in the early 1990s,1 is currently the most widely used selfreport measure of disordered eating.2,3 It provides a detailed assessment of attitudinal and behavioral eating disorder features in a relatively brief (36item) format. It is used extensively for both research and clinical purposes and normative data are available for various study populations, including adolescent girls,4 young adult women,5 and male6 and female7 college students. Accepted 3 December 2013 *Correspondence to: Jonathan Mond, PhD, MPH, Research School of Psychology, the Australian National University, Canberra ACT 0200, Australia. E-mail: [email protected] 1 Research School of Psychology, Australian National University, Canberra, Australia 2 Department of Psychology, Macquarie University, Sydney, Australia 3 Centre for Applied Psychology, University of Canberra, Canberra, Australia Published online 13 December 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/eat.22237 C 2013 Wiley Periodicals, Inc. V
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more common among older adolescents than among younger adolescents and this was the case for both boys and girls. Reliability coefficients for the EDE-Q subscales were marginally lower in boys (0.70–0.94) than in girls (0.84–0.97). Conclusions: The EDE-Q appears to be suitable for use in adolescent boys, with the qualification that eating and weight/ shape control behaviors that are largely confined to males may not be adequately assessed. The lack of assessment of subjective binge eating episodes may also be problematic. There is a need for research addressing whether and to what extent different features are associated with distress and disability in boys as well as the validity of the EDE-Q assessment of these features when compared C 2013 Wiley with interview assessment. V Periodicals, Inc. Keywords: EDE-Q; norms; boys (Int J Eat Disord 2014; 47:335-341)
Despite this, normative EDE-Q data for adolescent males are lacking. Reas et al.8 reported EDE-Q for a mixed sample of male high school and college students. However, the mean age of participants in this study was 19.7 years and the sample size (n 5 250) did not permit reporting of data for adolescents in isolation or for younger and older subgroups of adolescents. While there is good evidence that the prevalence of eating disorder symptoms increases from early to late adolescence in females,9–11 evidence bearing on the prevalence of eating disorder symptoms in younger versus older boys is limited.9–11 Normative, population-based EDE-Q data for adolescent males would be particularly welcome in light of reported increases in the numbers of young men with eating disorders receiving specialist treatment12 and the possibility that this reflects change at the population level.13 Available evidence9–11,14–16 suggests that eating-disordered behavior remains comparatively uncommon in adolescent boys, with the possible exception of excessive exercise,17,18 although there is a lack of recent, population-based research using a 335
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comprehensive assessment of eating disorder features and including both boys and girls.11 The primary goal of this study was, therefore, to provide normative EDE-Q data for a populationbased sample of adolescent males. Secondary aims of the study were to compare the prevalence of eating disorder features between male and female adolescents and between younger and older adolescents. Consistent with the available evidence, it was hypothesized that the prevalence of most, if not all, eating disorder features would be higher in female than in male adolescents and higher in older than in younger adolescents for both males and females.
Method Study Design and Participants Participants were recruited as part of the Australian Capital Territory (ACT) Schools Mental Health Literacy Survey, a cross-sectional study of eating-disordered behavior among male and female secondary school students attending schools in the ACT region of Australia (population of 375,000 in 2012), which includes the city of Canberra.19 Of the 45 secondary schools in the ACT region, all but five were invited, via their principals, to participate in the study. Twelve schools (30.0% of all schools approached), which varied in terms of type (Government, Independent, Catholic) and students numbers, agreed to participate. Government schools were somewhat under-represented among participating schools when compared with all ACT schools (50.0% vs. 62.8%), whereas Independent schools were somewhat over-represented (33.3% vs. 23.3%) (Catholic schools: 16.3% vs. 14.0%).20 Total enrolments at participating schools ranged from 589 to 1482, whereas the number of participants at these schools ranged from 18 to 418 (mean 5 147.5, SD 5 37.5). The sample was also diverse in terms of the geographical locations of participating schools. Among schools that chose not to participate, the main reasons given for this were commitments to other research projects, lack of intra-curricular time and concerns relating to student workload. Within participating schools, recruitment methods were driven primarily by logistical considerations and were therefore variable. In some cases, principals gave permission for the whole of their high school (years 7–10) or “college” (years 11–12) students to participate. In other cases, permission was given to contact the heads of specific faculties (e.g., health, physical education, psychology). The decision was then made by the faculty head as to which of their classes would participate. All students in classes selected for participation who attended class on the day(s) assigned for data collection
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were invited to complete a printed, self-report questionnaire, in their classrooms, during school hours and under the supervision of a teacher and one or more members of the research team. The questionnaire included, in addition to the EDE-Q, measures of general psychological distress and quality of life, and basic socio-demographic information, namely, age, sex, country of birth, first language, and residential post-code. Body mass index (BMI) (kg/m2) was calculated from self-reported height and weight.9 A separate, detachable section of the survey included contact details of the researchers and of potentially helpful sources of information for students who might be experiencing an eating or other mental health problem. Pilot testing, conducted in a sample of 46 male and 71 female students recruited from a single school, ensured that the survey material was appropriate for participants’ reading/comprehension level and that there were no items for which unacceptably high rates of missing data would be likely. The total time for survey administration, including debriefing, was 40 min. The study was presented as an opportunity for schools to promote eating disorders “mental health literacy" among their students and no remuneration was provided. Both students and their parents were informed, in advance, as to the study aims and methods and of their right to decline participation. An “opt-out” consent process was employed for parents whereas an “opt-in” process was employed for students. That is, parental consent was assumed unless parents indicated that they did not wish for their child to participate whereas students were required to confirm in writing their willingness to participate. The study design and methods were approved by the Australian National University Human Research Ethics Committee (2011/573), the ACT Department of Education and Training (2011/00468-8) and the Catholic Education Office (R106903). Completed questionnaire were received from 1,749 students, a participation rate (number of students completing questionnaires divided by number of students approached to complete questionnaires) of 78.7%. Data for nine participants who were less than 12 years of age or greater than 18 years and for a further 70 participants (4.0%) who were found to have unacceptably high levels of missing or corrupt data were excluded. The final sample therefore comprised 1,670 students aged 12–18 years. Of these, 1,135 (68.0%) were female, 531 were male, and 4 did not indicate their gender. The overrepresentation of female students, which reflected greater perceived relevance of the study material among the principals of all girls schools and/or among the heads of faculties (e.g., psychology) in which female students were over-represented, was anticipated and was considered advantageous in addressing study aims that dictated relatively large numbers of participants with eating disorder symptoms.21 International Journal of Eating Disorders 47:4 335–341 2014
EDE-Q IN ADOLESCENT BOYS
The sample comprised 3.6% of all male secondary school students in the ACT in 2012 and 7.8% of all female secondary school students.20 The proportion of male study participants who were in high school (years 7–10) (as opposed to college: years 11–12) was somewhat higher than the proportion of all ACT male secondary school students in high school (77.5% vs. 66.1%), whereas the proportion of female participants in high school was similar to that of all ACT female secondary school students in high school (67.3% vs. 66.2%) (total sample: 70.6% vs. 66.2%).19 Reflecting the demographic profile of the ACT region,22 the vast majority of participants were born in Australia (88.3%) and had English as a first language (90.4%). The mean (SD) ages of male and female participants were, respectively, 14.85 (1.70) years and 15.51 (1.63) years. The mean (SD) BMI of the 481 male participants (90.6% of the total sample) who provided details of height and weight was 20.52 (3.58), whereas the mean (SD) BMI of the 1007 female participants (88.7% of the total sample) who provided details of height and weight was 20.68 (3.57).
Study Measures Eating Disorder Examination Questionnaire (EDE-Q). The EDE-Q is a 36-item self-report measure that assesses the occurrence and frequency of eating disorder features during the past 28 days.1,23 Scores on each of four subscales, as well as a global score, may be derived from 22 items assessing core attitudinal features, namely, restraint, eating concern, weight concern, and shape concern. Scores on these items (and subscales) range from “0” to “6”, with higher scores indicating higher symptom levels. Items comprising the EDE-Q subscales have been found to have very good internal consistency, test–retest reliability and convergent validity in clinical and general population samples.2,3 As in previous studies,4,24 minor changes to the wording of some questions were made in order to ensure the suitability of the instrument for an adolescent population. Also as in previous research,25,26 very high rankorder correlations were observed between scores on the Weight and Shape Concern subscales and this was the case in both male (r 5 0.92) and female (r 5 0.92) participants (total sample: r 5 0.95). Hence, items of these subscales were combined to form a single, Weight/Shape Concern scale. However, for the purpose of comparison with previous research, data for the individual subscales are also reported. Cronbach alphas in the present study sample ranged from 0.70 (Eating Concern) to 0.94 (global score) for male participants and from 0.84 (Eating Concern) to 0.97 (global score) for female participants. Remaining items of the EDE-Q assess the occurrence and frequency of specific eating disorder behaviors, namely, binge eating, and the use of self-induced vomitInternational Journal of Eating Disorders 47:4 335–341 2014
ing, laxative misuse, and excessive exercise, as a means of controlling weight or shape. For this study, additional items were included to assess the occurrence and frequency of subjective binge eating episodes, namely, episodes of perceived overeating in which a loss of control is experienced but the amount of food consumed is not unusually large, and the use of diet pills.9,27,28 “Loss of control” eating, defined as the occurrence of either objective or subjective binge eating episodes, was also considered.28 For binge (and loss of control) eating, self-induced vomiting, laxative misuse and misuse of diet pills, “regular occurrence” was defined as at least weekly.29 In the absence of any agreed-upon operational definitions of the nonpurging weight-control behaviors, regular extreme dietary restriction was defined, using an item of the EDE-Q Restraint subscale, as “going for long periods of time (for example, 8 h or more in the daytime) without eating anything at all to control your weight or shape” on average at least three times per week, whereas regular excessive exercise was defined as “exercising really hard or in a driven or compulsive way as a means of controlling your weight or shape” on average at least five times per week. These definitions have been used in previous, population-based studies of young men and women.5,7,8 The “overvaluation of weight or shape” was defined as a score of 5 on either (or both) of the (Importance of Weight and Importance of Shape) items assessing this construct.30,31
Statistical Analysis Data, primarily descriptive, are presented as mean (SD) scores on the EDE-Q subscales and the percentage (%) frequency of any and regular occurrence of eating disorder behaviors, for male and female participants and for younger and older participants. “Younger” and “older” participants were defined, respectively, as participants aged 12–15 years and those aged 16–18 years.14 For the EDE-Q subscales, percentile ranks were provided for male participants. In order to examine the effects of age and sex on EDE-Q subscale scores, a series of 2 x 2 analyses of variance was conducted with age and sex as the independent variables and the EDE-Q subscales as the dependent variables. In order to examine the effects of age and sex on the occurrence of eating disorder behaviors, a series of (Mantel-Haenszel) linear-by-linear chisquare tests was conducted to test the hypothesis that the frequency of occurrence of each behavior increased in a linear fashion across the four sex-age subgroups, i.e., from younger boys to older boys to younger girls to older girls. These analyses were repeated using an alternative operational definition of “younger” and “older” based on school year, rather than age, as outlined previously. Since the findings were unchanged, only results of the original
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MOND ET AL. Means and standard deviations for EDE-Q subscales by sex and age groupa
TABLE 1.
Boys Younger (n 5 374) Mean (SD)
Older (n 5 156) Mean (SD)
Total (n 5 530) Mean (SD)
Younger (n 5 647) Mean (SD)
Older (n 5 487) Mean (SD)
Total (n 5 1,134) Mean (SD)
0.48 (0.92) 0.41 (0.73) 0.63 (1.05) 0.74 (1.19) 0.73 (1.15) 0.57 (0.86)
0.69 (1.07) 0.40 (0.69) 0.76 (1.04) 0.95 (1.14) 0.92 (1.12) 0.70 (0.87)
0.54 (0.97) 0.40 (0.72) 0.67 (1.05) 0.81 (1.18) 0.79 (1.15) 0.61 (0.86)
1.28 (1.47) 1.11 (1.34) 1.94 (1.78) 2.14 (1.85) 2.14 (1.84) 1.62 (1.50)
1.74 (1.67) 1.35 (1.43) 2.54 (1.81) 2.86 (1.83) 2.85 (1.82) 2.12 (1.55)
1.48 (1.57) 1.21 (1.38) 2.20 (1.82) 2.45 (1.88) 2.45 (1.86) 1.84 (1.54)
Restraint Eating Concern Weight Concern Shape Concern Weight/shape Concern Global score a
Girls
“Younger”: 12–15 years; “Older”: 16–18 years.
TABLE 2. Percentile ranks for EDE-Q subscale scores for adolescent boys (n 5 531)
Percentile
Restraint
Eating Concern
Weight Concern
Shape Concern
Weight/ Shape Concern
Global score
0.00 0.00 0.00 0.00 0.00 0.20 0.40 1.00 1.80
0.00 0.00 0.00 0.00 0.00 0.20 0.40 0.60 1.20
0.00 0.00 0.13 0.25 0.29 0.50 0.75 1.25 2.38
0.00 0.00 0.00 0.00 0.20 0.40 0.60 1.20 2.20
0.00 0.00 0.08 0.17 0.33 0.50 0.78 1.25 2.42
0.00 0.05 0.10 0.18 0.28 0.41 0.61 0.86 1.73
10 20 30 40 50 60 70 80 90
analyses, which were deemed to be more suitable for an international audience, are reported here. A significance (alpha) level of 0.05 was employed for all tests, all tests were two-tailed, and all analysis was conducted using SPSS version 21.0.
Results One male and one female participant, both in year 9, did not report their age, hence data are presented for 530 males and 1,134 females. Mean scores for the EDE-Q subscales by sex and age group are shown in Table 1, whereas percentile ranks for the EDE-Q subscales for male participants are shown in Table 2. Analysis of variance confirmed that, for all EDE-Q subscales (and the global score), females had higher scores than males and older participants had higher scores than younger participants (all p < .01), with the exception that the main effect of age for the Eating Concern subscale did not reach statistical significance (p 5 .08). For the Weight and Shape (and Weight/ Shape) Concern subscales and the global score, there was a significant interaction between sex and age (all p < .05), whereas this interaction approached significance for the Eating Concern (p 5 .06) and Restraint (p 5 .12) subscales. In all cases, differences between younger and older par338
ticipants were more pronounced for females than for males. Data for the occurrence of specific eating disorder behaviors, also stratified by sex and age, are shown in Table 3. As can be seen, objective and subjective binge eating, extreme dietary restriction, and excessive exercise were the most common behaviors in this sample, whereas self-induced vomiting and the misuse of laxatives or diet pills were comparatively uncommon. As is also apparent in Table 3, the likelihood of occurrence of eating disorder behaviors was lowest in younger boys and highest in older girls. Linear-by-linear v2 tests confirmed that the likelihood of both any and regular occurrence of eating disorder behaviors increased linearly from younger boys to older boys to younger girls to older girls and that this was the case for all eating disorder behaviors (all p < .05) with the exception of regular excessive exercise (p 5 .53). Of the 32 male participants who reported regular objective binge eating episodes, 6 (18.8%) also reported regular subjective binge eating episodes; of the 18 males participants who reported regular subjective binge eating episodes, 6 (33.3%) also reported regular objective binge eating episodes (v 5 19.80, p < .01). Of the 188 female participants who reported regular objective binge eating episodes, 48 (25.5%) also reported regular subjective binge eating episodes; of the 141 female participants who reported regular subjective binge eating episodes, 48 (34.0%) also reported regular objective binge eating episodes (v 5 34.16, p < .01).
Discussion We reported EDE-Q data for 531 adolescent boys recruited from schools in an urbanized region of Australia. Data for 1135 female adolescents, recruited as part of the same research project, were included for comparative purposes. As expected, EDE-Q subscale scores and, with the exception of International Journal of Eating Disorders 47:4 335–341 2014
EDE-Q IN ADOLESCENT BOYS TABLE 3.
Occurrence of eating disorder features by sex and age groupa Boys
Objective binge eating Any Regularb Subjective binge eating Any Regularb Loss of control eating Any Regularb Self-induced vomiting Any Regularb Laxative misuse Any Regularb Misuse of diet pills Any Regularb Extreme dietary restriction Any Regularc Excessive exercise Any Regulard Overvaluation of weight/shape
Girls
Younger (n 5 374) %
Older (n 5 156) %
Total (n 5 530) %
Younger (n 5 647) %
Older (n 5 487) %
Total (n 5 1,134) %
9.6 4.8
13.5 9.0
10.8 6.0
24.1 16.4
28.1 16.8
25.8 16.6
3.7 2.4
7.1 5.8
4.7 3.4
12.4 10.0
17.2 15.4
14.5 12.3
12.0 6.7
17.3 12.2
13.6 8.3
29.7 21.5
39.0 29.0
33.7 24.7
1.9 0.8
1.3 0.6
1.7 0.8
4.3 2.0
9.2 4.9
6.4 3.3
0.3 0.3
0.0 0.0
0.2 0.2
1.5 0.5
2.9 2.1
2.1 1.1
0.5 0.5
1.3 0.0
0.8 0.4
1.7 1.2
3.9 3.5
2.6 2.2
11.8 2.4
10.3 1.9
11.3 2.3
27.7 8.5
37.8 15.4
32.0 11.5
18.4 4.5 4.5
21.8 7.1 5.8
19.4 5.3 4.9
27.5 4.9 19.8
32.0 6.0 30.0
29.5 5.4 24.2
a
Younger: 12–15 years; Older: 16–18 years. Occurrence of these behaviors, on average, at least once per week during the past 4 weeks. c “Going for long periods of time (for example, 8 h or more in the daytime) without eating anything at all to control your weight or shape” on average at least three times per week during the past 4 weeks. d “Exercising really hard or in a driven or compulsive way as a means of controlling your weight or shape” on average at least five times per week during the past 4 weeks. b
excessive exercise, the prevalence of each of the eating disorder features assessed, was substantially higher among girls than among boys. Still, 6.0% of boys reported regular episodes of objective binge eating, 8.3% reported regular episodes of loss of control eating, 5.3% reported regular excessive exercise, and 4.9% reported overvaluation of weight or shape. Also as expected, eating-disordered behavior was more common among older adolescents than among younger adolescents and this was the case for both boys and girls. Reliability coefficients for the EDE-Q subscales were marginally lower in boys (0.70–0.94) than in girls (0.84–0.97). The finding that eating disorder features were more common in late adolescence than in early adolescence in both boys and girls is notable because, thus far, evidence for this difference has been largely confined to females.9–11 In particular, the current findings suggest that loss of control eating may be nearly twice as common in older boys as in younger boys. Boys’ concerns about their weight or shape also appear to increase substantially from early to late adolescence, the overvaluation of weight or shape being reported by 5.8% of International Journal of Eating Disorders 47:4 335–341 2014
older boys in the current study. Hence, in boys, as in girls, early adolescence appears to be a key point for intervention.9 Whether overvaluation has the same significance in males as in females is, however, unclear.13,32 It might also be noted that levels of eating disorder psychopathology among older adolescent boys in this study were lower than those reported by Lavender and colleagues in male college students in the USA. Thus, the mean EDE-Q global score in Lavender et al.’s study was 1.09, compared with 0.61 in this study. Although these findings raise the possibility of further increases in eating disorder psychopathology, i.e., from late adolescence to early adulthood [e.g., Ref. 33], methodological differences between studies, in particular the recruitment of participants from a college campus in Lavender et al.’s study, render such inferences tentative. The finding that excessive exercise was as common in boys (5.3%) as in girls (5.4%) might have been expected, given the current EDE-Q definition of excessive exercise (exercising really hard or in a driven or compulsive way as a means of controlling your weight or shape) and given that the 339
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prevalence of “compulsive” exercise has been found to be similar in male and female adolescents.11,18 Studies employing the EDE-Q in general population samples of adults have also found the prevalence of excessive exercise to be similar in men and women.34 Nevertheless this is, to our knowledge, the first study to examine sex differences in the prevalence of excessive exercise—as assessed by the EDE-Q—in adolescents. In adolescents, as in adults, there remains no agreed-upon operational definition of either excessive exercise or extreme dietary restriction.32 The definitions of these terms employed in the current study have been used in previous community-based studies of young men and women but their validity in adolescents is unclear. The very low prevalence of purging behaviors among boys in the current study is consistent with findings from previous epidemiological studies in adolescent populations.9,11,15 Notwithstanding its widespread use, the EDE-Q has limitations. Most notably, in the context of the current study, it was designed for use in female populations and may therefore not be sensitive to those eating and weight/shape control behaviors, such as behaviors intended to increase muscle mass, that are largely confined to males.13,17,35 The issue of whether and how the EDE-Q might be modified to better capture eating disorder attitudes and behaviors as these present in males warrants further consideration.35,36 In the meantime, it would seem prudent for both researchers and clinicians to administer an appropriate supplementary measure, such as the Drive for Muscularity Scale,37 when assessing eating disorder psychopathology in males. Other concerns about the EDE-Q, in its current form, relate to the extensive overlap between items of the weight and shape Concern subscales3,26 and the lack of assessment of subjective binge eating episodes.27,32 Concerning the assessment of subjective binge eating, items assessing this behavior were included in earlier versions of the EDE-Q but have since been removed, presumably because the assessment of subjective binge eating has been found to be unreliable.2,27,38 In the absence of any alternative assessment, however, our view is that it is preferable to retain assessment of this construct for the time being. The current findings suggest that in boys, as in girls, subjective binge eating may be nearly as common as—and overlap relatively little with—objective binge eating. As with the other features assessed by the EDE-Q, research will be needed to determine whether and to what extent subjective binge eating is associated with distress and disability in young men, as it is in young women.27,32,39 Research will also be needed to 340
determine the validity of the EDE-Q assessment of attitudinal and behavioral features when compared with interview assessment, as has occurred in both clinical and general population samples of young women2,3 but not, to our knowledge, in young men. At least two limitations of the current research should be noted. First, only one third of the schools approached to participate did in fact participate. However, participating schools were diverse in terms of their type and geographic location and endorsement of the study by School Principals and/or Faculty heads was such that participation rates within participating schools were high. Further, EDE-Q subscale scores for female participants were strikingly similar to those reported by Carter and Fairburn in their study of girls in the UK4 and in a 2007 study of female adolescents recruited from a different region of Australia.24 Hence, we are confident that participants were representative of the total population of secondary school students in the ACT region. On the other hand, it should be reiterated that the ACT is a highly urbanized, relatively affluent and relatively homogeneous region, such that the generalizability of the findings to other, more diverse populations is unclear. A second limitation of the current study was that the number of older male participants was relatively small. Hence, findings relating to the prevalence of disordered eating in this subgroup may need to be interpreted with caution. In sum, the current findings suggest the prevalence of most, if not all, eating disorder features remains substantially higher in girls than in boys and that, in both boys and girls, eating-disordered behavior is more prevalent in late adolescence than in early adolescence. The EDE-Q appears to be suitable for use in adolescent boys, with the qualification that eating and weight/shape control behaviors that are largely confined to males may not be adequately assessed. The lack of assessment of subjective binge eating may also be problematic. There is a need for research addressing whether and to what extent different eating disorder features are associated with distress and disability in boys as well as the validity of the EDE-Q assessment of these features when compared with interview assessment.
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EDE-Q IN ADOLESCENT BOYS 3. Berg KC, Peterson CB, Frazier P, Crow SJ. Psychometric evaluation of the eating disorder examination and eating disorder examination-questionnaire: A systematic review of the literature. Int J Eat Disord 2012;45:428–438. 4. Carter JC, Stewart DA, Fairburn CG. Eating Disorder Examination Questionnaire: Norms for young adolescent girls. Behav Res Ther 2001;39:625–632. 5. Mond JM, Hay PJ, Rodgers B, Owen C. Eating Disorder Examination Questionnaire (EDE-Q): Norms for young adult women. Behav Res Ther 2006;44: 53–62. 6. Luce K, Crowther J, Pole M. Eating disorder examination questionnaire (EDE-Q): Norms for undergraduate women. Int J Eat Disord 2008;41:273– 276. 7. Lavender JM., De Young KP, Anderson DA. Eating Disorder Examination Questionnaire (EDE-Q): Norms for undergraduate men. Eat Behav 2010;11: 119–121. 8. Reas DL, Overas M, Oyvind R. Norms for the Eating Disorder Examination Questionnaire (EDE-Q) among high school and university men. Eat Disord J Treat Prev 2012;20:437–443. 9. Neumark-Sztainer D, Wall M, Eisenberg ME, Story M, Hannan PJ. Overweight status and weight control behaviors in adolescents: Longitudinal and secular trends from 1999 to 2004. Prev Med 2006;43:52–59. 10. Abebe DS, Lien L, Von Soest R. The development of bulimic symptoms from adolescence to young adulthood in females and males: A population-based longitudinal cohort study. Int J Eat Disord 2012;45:737–745. 11. Allen KL, Crosby RD, Oddy WH, Byrne SM. Eating disorder symptom trajectories in adolescence: Effects of time, participant sex, and early adolescent depressive symptoms. J Eat Disord 2013;1:32. 12. Darcy AM, Doyle AC, Lock J, Peebles R, Doyle P, Le Grange D. The Eating Disorders Examination in adolescent males with anorexia nervosa: How does it compare to adolescent females? Int J Eat Disord 2012;45:110–114. 13. Mond JM, Mitchison D, Hay PJ. Eating disordered behavior in men: Prevalence, impairment in quality of life, and implications for prevention and health promotion. In: Cohn L, Lemberg R, editors. Current Findings on Males with Eating Disorders. London: Routledge, 2013, pp. 195–208. 14. O’Dea JA. Studies of obesity, body image and related health issues among Australian adolescents: How can programs in schools interact with and complement each other? J Student Wellbeing 2010;4:3–16. 15. Haines J, Ziyadeh NJ, Franko DL, Mond JM, Austin SB. Screening high school students for eating disorders: Validity of brief behavioral and attitudinal measures. J School Health 2011;81:530–535. 16. Sonneville KR, Horton NJ, Micali N, Crosby RD, Swanson SA, Solmi F, et al. Longitudinal associations between binge eating and overeating and adverse outcomes among adolescents and young adults. JAMA Pediatrics 2013;167: 149–155. 17. Anderson CB, Bulik CM. Gender differences in compensatory behaviors, weight and shape salience, and drive for thinness. Eat Behav 2004;1–11. 18. Goodwin H, Haycraft E, Meyer C. The relationship between compulsive exercise and emotion regulation in adolescents. Br J Health Psych 2012;17:699– 710. 19. Australian Bureau of Statistics. Population by Age and Sex, Regions of Australia, 2012 (cat. no. 3235.0). Canberra, ACT: ABS, 2013. 20. Education and Training Directorate, ACT Government. ACT School Census Feb 2012. Canberra, ACT: ACT Government, 2012. 21. Mond JM, Hay PJ, Rodgers B, Owen C. Eating disorders “mental health literacy”: What do women with bulimic eating disorders think and know about bulimia nervosa and its treatment? J Mental Health 2008;17:565–575.
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22. Australian Bureau of Statistics. In fACT - Statistical Information on the ACT and Region, Feb 2011 (cat. no. 1308.8). Canberra, ACT: ABS, 2011. 23. Fairburn CG, Beglin S. Eating Disorder Examination Questionnaire (EDE-Q 6.0). In: Fairburn CG, editor. Cognitive Behaviour Therapy and Eating Disorders. New York: Guildford Press, 2008, pp. 309–313. 24. Mond JM, Marks P, Hay PJ, Rodgers B, Kelly C, Owen C, Paxton SJ. Mental health literacy and eating-disordered behavior: Beliefs of adolescent girls concerning the treatment of and treatment-seeking for bulimia nervosa. J Youth Adolesc 2007;36:753–762. 25. Mond JM, Rodgers B, Hay PJ, Owen C. Obesity and impairment in psychosocial functioning: The mediating role of eating-disordered behaviour. Obesity 2007;15:2769–2779. 26. White HJ, Haycraft E, Goodwin H, Meyer C. Eating Disorder Examination Questionnaire: Factor structure for adolescent girls and boys. Int J Eat Disord (in press). 27. Mond JM, Latner JE, Hay PJ, Owen C, Rodgers B. Subjective vs objective bulimic episodes: Another nail in the coffin of a problematic distinction. Behav Res Ther 2010;48:661–669. 28. Matheson BE, Tanofsky-Kraff M, Shafer-Berger S, Sedaka NM, Mooreville M, Reina SA, et al. Eating patterns in youth with and without loss of control eating. Int J Eat Disord 2012;45:957–961. 29. American Psychiatric Association (APA). (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5). Washington, DC: American Psychiatric Association. 30. Mond JM, Hay PJ, Rodgers B, Owen C. Binge eating with and without the “undue influence of weight or shape on self-evaluation”: Implications for the diagnosis of binge eating disorder. Behav Res Ther 2007;45:929–938. 31. Grilo CM, Masheb RM, White MA. Significance of overvaluation of shape/ weight in binge-eating disorder: Comparative study with overweight and bulimia nervosa. Obesity 2010;18:499–504. 32. Mond JM. Classification of bulimic-type eating disorders: From DSM-IV to DSM-V. J Eat Disord 2013;1:33. 33. Neumark-Sztainer D, Wall M, Larson NI, Eisenberg ME, Loth K. Dieting and disordered eating behaviors from adolescence to young adulthood: Findings from a 10-year longitudinal study. J Am Diet Assoc 2011;111:1004–1011. 34. Hilbert AM, de Zwaan M., Braehler E. How frequent are eating disturbances in the population? Norms of the Eating Disorder Examination-Questionnaire. PLoS ONE 2012;7:e29125. 35. Murray SB, Rieger E, Hildebrandt T, Karlov L, Russell J, Boon E, et al. A comparison of eating, exercise, shape, and weight related symptomatology in males with muscle dysmorphia and anorexia nervosa. Body Image 2012;9: 193–200. 36. Griffiths S, Murray SB, Touyz S. Disordered eating and the muscular ideal. J Eat Disord 2013;1:15. 37. McCreary DR, Sasse DK, Saucier DM, Dorsch KD. Measuring the drive for muscularity: Factorial validity of the Drive for Muscularity Scale in men and women. Psychol Men Masculinity 2004;5:49–58. 38. Mond JM, Rodgers B, Hay PJ, Owen C, Beumont PJV. Temporal stability of the Eating Disorders Examination Questionnaire (EDE-Q). Int J Eat Disord 2004;36:195–203. 39. Mond JM, Rodgers B, Hay PJ, Owen C. Mental health impairment associated with eating-disordered behaviour in a community sample of women. J Mental Health 2011;20:456–466.
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Eating-Disordered Behavior in Adolescent Boys: Eating Disorder Examination Questionnaire Norms Jonathan Mond, PhD, MPH1,2* Ashleigh Hall, BSc (Hons)3 Caroline Bentley, BSc (Hons)1 Carmel Harrison, BPsych (Hons)1 Kassandra Gratwick-Sarll, BA (Hons)1 Vivienne Lewis, BPsych, DPsych3
ABSTRACT Objective: We sought to provide normative data for the Eating Disorder Examination Questionnaire (EDE-Q) for adolescent boys. Method: The EDE-Q was completed by 531 boys aged 12–18 years recruited from a number of schools in the Australian Capital Territory (ACT) region of Australia. Data for 1,135 female adolescents, recruited as part of the same research project, are provided for comparative purposes. Results: Scores on each the EDE-Q subscales and, with the exception of excessive exercise, the prevalence of each of the eating disorder behaviors assessed, were substantially higher among girls than among boys. Still, 6.0% of boys reported regular episodes of objective binge eating, 8.3% reported regular episodes of loss of control eating, 5.3% reported regular excessive exercise and 4.9% reported overvaluation of weight or shape. Eating-disordered behavior was
Introduction The Eating Disorder Examination Questionnaire (EDE-Q), developed by Fairburn and Beglin in the early 1990s,1 is currently the most widely used selfreport measure of disordered eating.2,3 It provides a detailed assessment of attitudinal and behavioral eating disorder features in a relatively brief (36item) format. It is used extensively for both research and clinical purposes and normative data are available for various study populations, including adolescent girls,4 young adult women,5 and male6 and female7 college students. Accepted 3 December 2013 *Correspondence to: Jonathan Mond, PhD, MPH, Research School of Psychology, the Australian National University, Canberra ACT 0200, Australia. E-mail: [email protected] 1 Research School of Psychology, Australian National University, Canberra, Australia 2 Department of Psychology, Macquarie University, Sydney, Australia 3 Centre for Applied Psychology, University of Canberra, Canberra, Australia Published online 13 December 2013 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/eat.22237 C 2013 Wiley Periodicals, Inc. V
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more common among older adolescents than among younger adolescents and this was the case for both boys and girls. Reliability coefficients for the EDE-Q subscales were marginally lower in boys (0.70–0.94) than in girls (0.84–0.97). Conclusions: The EDE-Q appears to be suitable for use in adolescent boys, with the qualification that eating and weight/ shape control behaviors that are largely confined to males may not be adequately assessed. The lack of assessment of subjective binge eating episodes may also be problematic. There is a need for research addressing whether and to what extent different features are associated with distress and disability in boys as well as the validity of the EDE-Q assessment of these features when compared C 2013 Wiley with interview assessment. V Periodicals, Inc. Keywords: EDE-Q; norms; boys (Int J Eat Disord 2014; 47:335-341)
Despite this, normative EDE-Q data for adolescent males are lacking. Reas et al.8 reported EDE-Q for a mixed sample of male high school and college students. However, the mean age of participants in this study was 19.7 years and the sample size (n 5 250) did not permit reporting of data for adolescents in isolation or for younger and older subgroups of adolescents. While there is good evidence that the prevalence of eating disorder symptoms increases from early to late adolescence in females,9–11 evidence bearing on the prevalence of eating disorder symptoms in younger versus older boys is limited.9–11 Normative, population-based EDE-Q data for adolescent males would be particularly welcome in light of reported increases in the numbers of young men with eating disorders receiving specialist treatment12 and the possibility that this reflects change at the population level.13 Available evidence9–11,14–16 suggests that eating-disordered behavior remains comparatively uncommon in adolescent boys, with the possible exception of excessive exercise,17,18 although there is a lack of recent, population-based research using a 335
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comprehensive assessment of eating disorder features and including both boys and girls.11 The primary goal of this study was, therefore, to provide normative EDE-Q data for a populationbased sample of adolescent males. Secondary aims of the study were to compare the prevalence of eating disorder features between male and female adolescents and between younger and older adolescents. Consistent with the available evidence, it was hypothesized that the prevalence of most, if not all, eating disorder features would be higher in female than in male adolescents and higher in older than in younger adolescents for both males and females.
Method Study Design and Participants Participants were recruited as part of the Australian Capital Territory (ACT) Schools Mental Health Literacy Survey, a cross-sectional study of eating-disordered behavior among male and female secondary school students attending schools in the ACT region of Australia (population of 375,000 in 2012), which includes the city of Canberra.19 Of the 45 secondary schools in the ACT region, all but five were invited, via their principals, to participate in the study. Twelve schools (30.0% of all schools approached), which varied in terms of type (Government, Independent, Catholic) and students numbers, agreed to participate. Government schools were somewhat under-represented among participating schools when compared with all ACT schools (50.0% vs. 62.8%), whereas Independent schools were somewhat over-represented (33.3% vs. 23.3%) (Catholic schools: 16.3% vs. 14.0%).20 Total enrolments at participating schools ranged from 589 to 1482, whereas the number of participants at these schools ranged from 18 to 418 (mean 5 147.5, SD 5 37.5). The sample was also diverse in terms of the geographical locations of participating schools. Among schools that chose not to participate, the main reasons given for this were commitments to other research projects, lack of intra-curricular time and concerns relating to student workload. Within participating schools, recruitment methods were driven primarily by logistical considerations and were therefore variable. In some cases, principals gave permission for the whole of their high school (years 7–10) or “college” (years 11–12) students to participate. In other cases, permission was given to contact the heads of specific faculties (e.g., health, physical education, psychology). The decision was then made by the faculty head as to which of their classes would participate. All students in classes selected for participation who attended class on the day(s) assigned for data collection
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were invited to complete a printed, self-report questionnaire, in their classrooms, during school hours and under the supervision of a teacher and one or more members of the research team. The questionnaire included, in addition to the EDE-Q, measures of general psychological distress and quality of life, and basic socio-demographic information, namely, age, sex, country of birth, first language, and residential post-code. Body mass index (BMI) (kg/m2) was calculated from self-reported height and weight.9 A separate, detachable section of the survey included contact details of the researchers and of potentially helpful sources of information for students who might be experiencing an eating or other mental health problem. Pilot testing, conducted in a sample of 46 male and 71 female students recruited from a single school, ensured that the survey material was appropriate for participants’ reading/comprehension level and that there were no items for which unacceptably high rates of missing data would be likely. The total time for survey administration, including debriefing, was 40 min. The study was presented as an opportunity for schools to promote eating disorders “mental health literacy" among their students and no remuneration was provided. Both students and their parents were informed, in advance, as to the study aims and methods and of their right to decline participation. An “opt-out” consent process was employed for parents whereas an “opt-in” process was employed for students. That is, parental consent was assumed unless parents indicated that they did not wish for their child to participate whereas students were required to confirm in writing their willingness to participate. The study design and methods were approved by the Australian National University Human Research Ethics Committee (2011/573), the ACT Department of Education and Training (2011/00468-8) and the Catholic Education Office (R106903). Completed questionnaire were received from 1,749 students, a participation rate (number of students completing questionnaires divided by number of students approached to complete questionnaires) of 78.7%. Data for nine participants who were less than 12 years of age or greater than 18 years and for a further 70 participants (4.0%) who were found to have unacceptably high levels of missing or corrupt data were excluded. The final sample therefore comprised 1,670 students aged 12–18 years. Of these, 1,135 (68.0%) were female, 531 were male, and 4 did not indicate their gender. The overrepresentation of female students, which reflected greater perceived relevance of the study material among the principals of all girls schools and/or among the heads of faculties (e.g., psychology) in which female students were over-represented, was anticipated and was considered advantageous in addressing study aims that dictated relatively large numbers of participants with eating disorder symptoms.21 International Journal of Eating Disorders 47:4 335–341 2014
EDE-Q IN ADOLESCENT BOYS
The sample comprised 3.6% of all male secondary school students in the ACT in 2012 and 7.8% of all female secondary school students.20 The proportion of male study participants who were in high school (years 7–10) (as opposed to college: years 11–12) was somewhat higher than the proportion of all ACT male secondary school students in high school (77.5% vs. 66.1%), whereas the proportion of female participants in high school was similar to that of all ACT female secondary school students in high school (67.3% vs. 66.2%) (total sample: 70.6% vs. 66.2%).19 Reflecting the demographic profile of the ACT region,22 the vast majority of participants were born in Australia (88.3%) and had English as a first language (90.4%). The mean (SD) ages of male and female participants were, respectively, 14.85 (1.70) years and 15.51 (1.63) years. The mean (SD) BMI of the 481 male participants (90.6% of the total sample) who provided details of height and weight was 20.52 (3.58), whereas the mean (SD) BMI of the 1007 female participants (88.7% of the total sample) who provided details of height and weight was 20.68 (3.57).
Study Measures Eating Disorder Examination Questionnaire (EDE-Q). The EDE-Q is a 36-item self-report measure that assesses the occurrence and frequency of eating disorder features during the past 28 days.1,23 Scores on each of four subscales, as well as a global score, may be derived from 22 items assessing core attitudinal features, namely, restraint, eating concern, weight concern, and shape concern. Scores on these items (and subscales) range from “0” to “6”, with higher scores indicating higher symptom levels. Items comprising the EDE-Q subscales have been found to have very good internal consistency, test–retest reliability and convergent validity in clinical and general population samples.2,3 As in previous studies,4,24 minor changes to the wording of some questions were made in order to ensure the suitability of the instrument for an adolescent population. Also as in previous research,25,26 very high rankorder correlations were observed between scores on the Weight and Shape Concern subscales and this was the case in both male (r 5 0.92) and female (r 5 0.92) participants (total sample: r 5 0.95). Hence, items of these subscales were combined to form a single, Weight/Shape Concern scale. However, for the purpose of comparison with previous research, data for the individual subscales are also reported. Cronbach alphas in the present study sample ranged from 0.70 (Eating Concern) to 0.94 (global score) for male participants and from 0.84 (Eating Concern) to 0.97 (global score) for female participants. Remaining items of the EDE-Q assess the occurrence and frequency of specific eating disorder behaviors, namely, binge eating, and the use of self-induced vomitInternational Journal of Eating Disorders 47:4 335–341 2014
ing, laxative misuse, and excessive exercise, as a means of controlling weight or shape. For this study, additional items were included to assess the occurrence and frequency of subjective binge eating episodes, namely, episodes of perceived overeating in which a loss of control is experienced but the amount of food consumed is not unusually large, and the use of diet pills.9,27,28 “Loss of control” eating, defined as the occurrence of either objective or subjective binge eating episodes, was also considered.28 For binge (and loss of control) eating, self-induced vomiting, laxative misuse and misuse of diet pills, “regular occurrence” was defined as at least weekly.29 In the absence of any agreed-upon operational definitions of the nonpurging weight-control behaviors, regular extreme dietary restriction was defined, using an item of the EDE-Q Restraint subscale, as “going for long periods of time (for example, 8 h or more in the daytime) without eating anything at all to control your weight or shape” on average at least three times per week, whereas regular excessive exercise was defined as “exercising really hard or in a driven or compulsive way as a means of controlling your weight or shape” on average at least five times per week. These definitions have been used in previous, population-based studies of young men and women.5,7,8 The “overvaluation of weight or shape” was defined as a score of 5 on either (or both) of the (Importance of Weight and Importance of Shape) items assessing this construct.30,31
Statistical Analysis Data, primarily descriptive, are presented as mean (SD) scores on the EDE-Q subscales and the percentage (%) frequency of any and regular occurrence of eating disorder behaviors, for male and female participants and for younger and older participants. “Younger” and “older” participants were defined, respectively, as participants aged 12–15 years and those aged 16–18 years.14 For the EDE-Q subscales, percentile ranks were provided for male participants. In order to examine the effects of age and sex on EDE-Q subscale scores, a series of 2 x 2 analyses of variance was conducted with age and sex as the independent variables and the EDE-Q subscales as the dependent variables. In order to examine the effects of age and sex on the occurrence of eating disorder behaviors, a series of (Mantel-Haenszel) linear-by-linear chisquare tests was conducted to test the hypothesis that the frequency of occurrence of each behavior increased in a linear fashion across the four sex-age subgroups, i.e., from younger boys to older boys to younger girls to older girls. These analyses were repeated using an alternative operational definition of “younger” and “older” based on school year, rather than age, as outlined previously. Since the findings were unchanged, only results of the original
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MOND ET AL. Means and standard deviations for EDE-Q subscales by sex and age groupa
TABLE 1.
Boys Younger (n 5 374) Mean (SD)
Older (n 5 156) Mean (SD)
Total (n 5 530) Mean (SD)
Younger (n 5 647) Mean (SD)
Older (n 5 487) Mean (SD)
Total (n 5 1,134) Mean (SD)
0.48 (0.92) 0.41 (0.73) 0.63 (1.05) 0.74 (1.19) 0.73 (1.15) 0.57 (0.86)
0.69 (1.07) 0.40 (0.69) 0.76 (1.04) 0.95 (1.14) 0.92 (1.12) 0.70 (0.87)
0.54 (0.97) 0.40 (0.72) 0.67 (1.05) 0.81 (1.18) 0.79 (1.15) 0.61 (0.86)
1.28 (1.47) 1.11 (1.34) 1.94 (1.78) 2.14 (1.85) 2.14 (1.84) 1.62 (1.50)
1.74 (1.67) 1.35 (1.43) 2.54 (1.81) 2.86 (1.83) 2.85 (1.82) 2.12 (1.55)
1.48 (1.57) 1.21 (1.38) 2.20 (1.82) 2.45 (1.88) 2.45 (1.86) 1.84 (1.54)
Restraint Eating Concern Weight Concern Shape Concern Weight/shape Concern Global score a
Girls
“Younger”: 12–15 years; “Older”: 16–18 years.
TABLE 2. Percentile ranks for EDE-Q subscale scores for adolescent boys (n 5 531)
Percentile
Restraint
Eating Concern
Weight Concern
Shape Concern
Weight/ Shape Concern
Global score
0.00 0.00 0.00 0.00 0.00 0.20 0.40 1.00 1.80
0.00 0.00 0.00 0.00 0.00 0.20 0.40 0.60 1.20
0.00 0.00 0.13 0.25 0.29 0.50 0.75 1.25 2.38
0.00 0.00 0.00 0.00 0.20 0.40 0.60 1.20 2.20
0.00 0.00 0.08 0.17 0.33 0.50 0.78 1.25 2.42
0.00 0.05 0.10 0.18 0.28 0.41 0.61 0.86 1.73
10 20 30 40 50 60 70 80 90
analyses, which were deemed to be more suitable for an international audience, are reported here. A significance (alpha) level of 0.05 was employed for all tests, all tests were two-tailed, and all analysis was conducted using SPSS version 21.0.
Results One male and one female participant, both in year 9, did not report their age, hence data are presented for 530 males and 1,134 females. Mean scores for the EDE-Q subscales by sex and age group are shown in Table 1, whereas percentile ranks for the EDE-Q subscales for male participants are shown in Table 2. Analysis of variance confirmed that, for all EDE-Q subscales (and the global score), females had higher scores than males and older participants had higher scores than younger participants (all p < .01), with the exception that the main effect of age for the Eating Concern subscale did not reach statistical significance (p 5 .08). For the Weight and Shape (and Weight/ Shape) Concern subscales and the global score, there was a significant interaction between sex and age (all p < .05), whereas this interaction approached significance for the Eating Concern (p 5 .06) and Restraint (p 5 .12) subscales. In all cases, differences between younger and older par338
ticipants were more pronounced for females than for males. Data for the occurrence of specific eating disorder behaviors, also stratified by sex and age, are shown in Table 3. As can be seen, objective and subjective binge eating, extreme dietary restriction, and excessive exercise were the most common behaviors in this sample, whereas self-induced vomiting and the misuse of laxatives or diet pills were comparatively uncommon. As is also apparent in Table 3, the likelihood of occurrence of eating disorder behaviors was lowest in younger boys and highest in older girls. Linear-by-linear v2 tests confirmed that the likelihood of both any and regular occurrence of eating disorder behaviors increased linearly from younger boys to older boys to younger girls to older girls and that this was the case for all eating disorder behaviors (all p < .05) with the exception of regular excessive exercise (p 5 .53). Of the 32 male participants who reported regular objective binge eating episodes, 6 (18.8%) also reported regular subjective binge eating episodes; of the 18 males participants who reported regular subjective binge eating episodes, 6 (33.3%) also reported regular objective binge eating episodes (v 5 19.80, p < .01). Of the 188 female participants who reported regular objective binge eating episodes, 48 (25.5%) also reported regular subjective binge eating episodes; of the 141 female participants who reported regular subjective binge eating episodes, 48 (34.0%) also reported regular objective binge eating episodes (v 5 34.16, p < .01).
Discussion We reported EDE-Q data for 531 adolescent boys recruited from schools in an urbanized region of Australia. Data for 1135 female adolescents, recruited as part of the same research project, were included for comparative purposes. As expected, EDE-Q subscale scores and, with the exception of International Journal of Eating Disorders 47:4 335–341 2014
EDE-Q IN ADOLESCENT BOYS TABLE 3.
Occurrence of eating disorder features by sex and age groupa Boys
Objective binge eating Any Regularb Subjective binge eating Any Regularb Loss of control eating Any Regularb Self-induced vomiting Any Regularb Laxative misuse Any Regularb Misuse of diet pills Any Regularb Extreme dietary restriction Any Regularc Excessive exercise Any Regulard Overvaluation of weight/shape
Girls
Younger (n 5 374) %
Older (n 5 156) %
Total (n 5 530) %
Younger (n 5 647) %
Older (n 5 487) %
Total (n 5 1,134) %
9.6 4.8
13.5 9.0
10.8 6.0
24.1 16.4
28.1 16.8
25.8 16.6
3.7 2.4
7.1 5.8
4.7 3.4
12.4 10.0
17.2 15.4
14.5 12.3
12.0 6.7
17.3 12.2
13.6 8.3
29.7 21.5
39.0 29.0
33.7 24.7
1.9 0.8
1.3 0.6
1.7 0.8
4.3 2.0
9.2 4.9
6.4 3.3
0.3 0.3
0.0 0.0
0.2 0.2
1.5 0.5
2.9 2.1
2.1 1.1
0.5 0.5
1.3 0.0
0.8 0.4
1.7 1.2
3.9 3.5
2.6 2.2
11.8 2.4
10.3 1.9
11.3 2.3
27.7 8.5
37.8 15.4
32.0 11.5
18.4 4.5 4.5
21.8 7.1 5.8
19.4 5.3 4.9
27.5 4.9 19.8
32.0 6.0 30.0
29.5 5.4 24.2
a
Younger: 12–15 years; Older: 16–18 years. Occurrence of these behaviors, on average, at least once per week during the past 4 weeks. c “Going for long periods of time (for example, 8 h or more in the daytime) without eating anything at all to control your weight or shape” on average at least three times per week during the past 4 weeks. d “Exercising really hard or in a driven or compulsive way as a means of controlling your weight or shape” on average at least five times per week during the past 4 weeks. b
excessive exercise, the prevalence of each of the eating disorder features assessed, was substantially higher among girls than among boys. Still, 6.0% of boys reported regular episodes of objective binge eating, 8.3% reported regular episodes of loss of control eating, 5.3% reported regular excessive exercise, and 4.9% reported overvaluation of weight or shape. Also as expected, eating-disordered behavior was more common among older adolescents than among younger adolescents and this was the case for both boys and girls. Reliability coefficients for the EDE-Q subscales were marginally lower in boys (0.70–0.94) than in girls (0.84–0.97). The finding that eating disorder features were more common in late adolescence than in early adolescence in both boys and girls is notable because, thus far, evidence for this difference has been largely confined to females.9–11 In particular, the current findings suggest that loss of control eating may be nearly twice as common in older boys as in younger boys. Boys’ concerns about their weight or shape also appear to increase substantially from early to late adolescence, the overvaluation of weight or shape being reported by 5.8% of International Journal of Eating Disorders 47:4 335–341 2014
older boys in the current study. Hence, in boys, as in girls, early adolescence appears to be a key point for intervention.9 Whether overvaluation has the same significance in males as in females is, however, unclear.13,32 It might also be noted that levels of eating disorder psychopathology among older adolescent boys in this study were lower than those reported by Lavender and colleagues in male college students in the USA. Thus, the mean EDE-Q global score in Lavender et al.’s study was 1.09, compared with 0.61 in this study. Although these findings raise the possibility of further increases in eating disorder psychopathology, i.e., from late adolescence to early adulthood [e.g., Ref. 33], methodological differences between studies, in particular the recruitment of participants from a college campus in Lavender et al.’s study, render such inferences tentative. The finding that excessive exercise was as common in boys (5.3%) as in girls (5.4%) might have been expected, given the current EDE-Q definition of excessive exercise (exercising really hard or in a driven or compulsive way as a means of controlling your weight or shape) and given that the 339
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prevalence of “compulsive” exercise has been found to be similar in male and female adolescents.11,18 Studies employing the EDE-Q in general population samples of adults have also found the prevalence of excessive exercise to be similar in men and women.34 Nevertheless this is, to our knowledge, the first study to examine sex differences in the prevalence of excessive exercise—as assessed by the EDE-Q—in adolescents. In adolescents, as in adults, there remains no agreed-upon operational definition of either excessive exercise or extreme dietary restriction.32 The definitions of these terms employed in the current study have been used in previous community-based studies of young men and women but their validity in adolescents is unclear. The very low prevalence of purging behaviors among boys in the current study is consistent with findings from previous epidemiological studies in adolescent populations.9,11,15 Notwithstanding its widespread use, the EDE-Q has limitations. Most notably, in the context of the current study, it was designed for use in female populations and may therefore not be sensitive to those eating and weight/shape control behaviors, such as behaviors intended to increase muscle mass, that are largely confined to males.13,17,35 The issue of whether and how the EDE-Q might be modified to better capture eating disorder attitudes and behaviors as these present in males warrants further consideration.35,36 In the meantime, it would seem prudent for both researchers and clinicians to administer an appropriate supplementary measure, such as the Drive for Muscularity Scale,37 when assessing eating disorder psychopathology in males. Other concerns about the EDE-Q, in its current form, relate to the extensive overlap between items of the weight and shape Concern subscales3,26 and the lack of assessment of subjective binge eating episodes.27,32 Concerning the assessment of subjective binge eating, items assessing this behavior were included in earlier versions of the EDE-Q but have since been removed, presumably because the assessment of subjective binge eating has been found to be unreliable.2,27,38 In the absence of any alternative assessment, however, our view is that it is preferable to retain assessment of this construct for the time being. The current findings suggest that in boys, as in girls, subjective binge eating may be nearly as common as—and overlap relatively little with—objective binge eating. As with the other features assessed by the EDE-Q, research will be needed to determine whether and to what extent subjective binge eating is associated with distress and disability in young men, as it is in young women.27,32,39 Research will also be needed to 340
determine the validity of the EDE-Q assessment of attitudinal and behavioral features when compared with interview assessment, as has occurred in both clinical and general population samples of young women2,3 but not, to our knowledge, in young men. At least two limitations of the current research should be noted. First, only one third of the schools approached to participate did in fact participate. However, participating schools were diverse in terms of their type and geographic location and endorsement of the study by School Principals and/or Faculty heads was such that participation rates within participating schools were high. Further, EDE-Q subscale scores for female participants were strikingly similar to those reported by Carter and Fairburn in their study of girls in the UK4 and in a 2007 study of female adolescents recruited from a different region of Australia.24 Hence, we are confident that participants were representative of the total population of secondary school students in the ACT region. On the other hand, it should be reiterated that the ACT is a highly urbanized, relatively affluent and relatively homogeneous region, such that the generalizability of the findings to other, more diverse populations is unclear. A second limitation of the current study was that the number of older male participants was relatively small. Hence, findings relating to the prevalence of disordered eating in this subgroup may need to be interpreted with caution. In sum, the current findings suggest the prevalence of most, if not all, eating disorder features remains substantially higher in girls than in boys and that, in both boys and girls, eating-disordered behavior is more prevalent in late adolescence than in early adolescence. The EDE-Q appears to be suitable for use in adolescent boys, with the qualification that eating and weight/shape control behaviors that are largely confined to males may not be adequately assessed. The lack of assessment of subjective binge eating may also be problematic. There is a need for research addressing whether and to what extent different eating disorder features are associated with distress and disability in boys as well as the validity of the EDE-Q assessment of these features when compared with interview assessment.
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