Journal of the American College of Nutrition
ISSN: 0731-5724 (Print) 1541-1087 (Online) Journal homepage: http://www.tandfonline.com/loi/uacn20
Eating Disorders and Psychopathological Traits in Obese Preadolescents and Adolescents Viviana Finistrella PsyD, Melania Manco MD, PhD, FACN, Nicola Corciulo MD, Beatrice Sances PsyD, Mario Di Pietro MD, Raffaella Di Gregorio PsyD, Fosca Di SanteMarsili PsyD, Perla Maria Fiumani PsyD, Fabio Presaghi PsyD PhD & Amalia Maria Ambruzzi MD, FACN To cite this article: Viviana Finistrella PsyD, Melania Manco MD, PhD, FACN, Nicola Corciulo MD, Beatrice Sances PsyD, Mario Di Pietro MD, Raffaella Di Gregorio PsyD, Fosca Di SanteMarsili PsyD, Perla Maria Fiumani PsyD, Fabio Presaghi PsyD PhD & Amalia Maria Ambruzzi MD, FACN (2015) Eating Disorders and Psychopathological Traits in Obese Preadolescents and Adolescents, Journal of the American College of Nutrition, 34:2, 142-149, DOI: 10.1080/07315724.2014.938182 To link to this article: http://dx.doi.org/10.1080/07315724.2014.938182
Published online: 09 Mar 2015.
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Date: 21 September 2015, At: 09:31
Original Research
Eating Disorders and Psychopathological Traits in Obese Preadolescents and Adolescents
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Viviana Finistrella, PsyD, Melania Manco, MD, PhD, FACN, Nicola Corciulo, MD, Beatrice Sances, PsyD, Mario Di Pietro, MD, Raffaella Di Gregorio, PsyD, Fosca Di SanteMarsili, PsyD, Perla Maria Fiumani, PsyD, Fabio Presaghi, PsyD, PhD, Amalia Maria Ambruzzi, MD, FACN Research Unit for Multifactorial Diseases, Obesity and Diabetes, Ospedale Pediatrico 10 Bambino Ges u IRCCS, Rome, ITALY (V.F., M.M., A.M.A.); Centro di Prevenzione Diagnosi e 11 Cura dell’ Obesit a in et a evolutiva-U.O. Pediatria, P.O. Gallipoli, Lecce, ITALY (N.C., B.S.); 12 Unit a di Pediatria, Ospedale S. Liberatore, Atri, Teramo, ITALY (M.D.P., R.D.G., F.D.S.M.); 13 Seconda Universit a degli Studi di Napoli, Napoli, ITALY (P.M.F.); Facolt a di Medicina e 14 Psicologia, Universit a “La Sapienza,” Rome, ITALY (F.P.) Key words: childhood and adolescent obesity, eating disorders, psychopathological symptoms Objective: to investigate the presence of eating disorders (ED) and psychopathological traits in obese preadolescents and adolescents compared to normal-weight peers. Design: Overweight/obese patients aged 11 to 14 y and normal-weight peers’ data collected by means of self-report questionnaires administered to parents and children. Setting: Clinical Nutrition Units in the Municipalities of Rome, Naples, Gallipoli and Atri, Italy. Subjects: 376 preadolescents and adolescents. Patients were 187 (93 boys, BMID27.9 §;4.1; 94 girls, BMID28.1 §4.5); normal-weight controls were 189 subjects (94 boys, BMID19.4 §1.4; 95 girls, BMID19.5 §1.5). Measures of outcome: eating disorder behaviors, psychopathological traits and symptoms estimated by means of the eating disorders scales (EDI-2) and psychopathological scales (CBCL 4–18). Results: Patients reached higher scores than controls in most of the eating disorders scales and psychopathological scales. Twenty-one (11.2%) patients were considered at risk of developing an eating disorder and 75 (40%) presented social problems. With regard to weight status, age-group and gender, main significant interaction effects were seen in social problems (FD 6.50; p 65.
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Eating Disorder Assessment The EDI-2 is a self-report measure, widely used to detect the presence of significant markers of EDs. It has been standardized and validated in the Italian version [16], reaching a good level of reliability (Cronbach’s a between 0.78 and 0.84). EDI-2 includes 91 items, divided into 11 subscales. The first 3 subscales describe symptomatic behaviors: (1) drive for thinness (DT), which measures excessive preoccupation regarding dieting, body weight and weight gain; (2) bulimia (BU), regarding the presence of thoughts or actual episodes of excessive and uncontrolled food intake; and (3) body dissatisfaction (BD), which measures dissatisfaction for some body parts. The other 8 subscales measure the presence of personality traits more commonly associated with EDs: (4) ineffectiveness, which evaluates the presence of general feelings of insecurity and helplessness; (5) perfectionism, which measures the presence of thoughts or beliefs that only exceptional results are acceptable; (6) interpersonal distrust, regarding the presence of a general feeling of alienation and distrust toward others; (7) enteroceptive awareness, which evaluates the presence of confusion and uncertainty in perception and response to emotions and physiological stimuli; (8) maturity fears, which measures the presence of a regressive desire to return to childhood; (9) asceticism, which evaluates the tendency to find self-worth through discipline, sacrifice, control over body functions, and spiritual ideals; (10) impulse regulation, which measures the tendency for impulsiveness and destructiveness in relationships; and (11) social insecurity, which measures the tendency to believe that social relationships are difficult and unsuccessful. The evaluation of the theoretical risk of EDs in the sample of obese participants was achieved by comparing their results with the mean scores obtained by subjects with a confirmed diagnosis of ED and the cutoffs present in the Italian version of the 3 clinical symptoms scales (DT, BU, BD).
Psychological Assessment The CBCL 4–18 is a self-report measure that evaluates the presence of psychopathological symptoms and behaviors. It has been validated and standardized in the Italian population with good reliability (Cronbach’s a between 0.66 and 0.91) [17]. The CBCL 4–18 includes 11 subscales, the first 8 of which refer to psychopathological problems: (1) withdrawn (W); (2) somatic complaints; (3) anxious/depressed; (4) social problems; (5) thought problems; (6) attention problems; (7) delinquent behavior; and (8) aggressive behavior. The last 3
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Data Analysis Continuous data were reported as mean § SD, with categorical data as counts and percentages. Comparisons between the patient group and control group were performed by means of a 2-way analysis of variance test. p < 0.05 was considered statistically significant. SPSS statistical software (Ver. 12.0, SPSS Inc., Chicago, IL) was used.
RESULTS Sample Characteristics Thirteen subjects (6.5%, 6 boys) dropped out of the enrolled patient sample because they did not complete at least 90% of the items. Eleven subjects (5.9%, 5 boys) dropped out of the enrolled control sample: 5 did not complete at least 90% of the items and 6 were not present on the day the test was administered. These subjects did not differ from the rest of the patient and control groups with regards to mother and child age and BMI and mother education and occupation (data not shown). The final total sample included 376 children. The patient group included 93 overweight/obese boys (24.7%; BMI D 27.9 § 4.1 kg/m2, age D 12.4 § 1.8 years) and 94 overweight/obese girls (25%; BMI D 28.1 § 4.5 kg/m2, age D 12.9 § 1.8 years). The control group included 94 normal-weight boys (25%, BMI D 19.4 § 1.4, age D 12.3 § 1.3 years) and 95 normal-weight girls (25.3%, BMI D 19.5 § 1.5 kg/m2, age D 12.7 § 1.5 years).
EDI-2 and CBCL Overweight and obese patients reached higher scores than normal-weight controls in many EDI-2 subscales (drive for thinness, bulimia, body dissatisfaction, externalizing syndrome, maturity fears, asceticism; p < 0.05 for interpersonal distrust and p < 0.0001 for all others) and all CBCL scales (p < 0.0001 for all except attention problems and aggressive behaviors, whose statistical significance was p < 0.001). Mean values and standard deviations for each subscale are reported separately for gender and age group (Table 1). Preadolescent and adolescent patients reached higher scores than controls on most of the EDI-2 subscales (statistical significance p < 0.001 for drive for thinness, bulimia, body dissatisfaction, internalizing syndrome, enteroceptive awareness, maturity fears, and ascetism; p < 0.05 for interpersonal
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Eating Disorders in Obese Children Table 1. Descriptive Statistics of CBCL and EDI-2 Subscales for the Main Effects of Gender, Age, and Weight Groups
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Obese M § SD
Control M § SD
Boys M § SD
W Som AD Soc Th Att Del Aggr Int Ext Tot
4.01 3.01 6.03 4.9 0.92 5.27 2.84 8.64 12.84 11.91 42.42
§ 2.6 § 2.5 § 4.5 § 2.6 § 1.4 § 3.6 §2 § 5.5 § 7.9 § 6.9 § 21.7
2.99 2.00 3.9 2.39 0.42 4.05 2.04 7.02 8.16 9.01 27.88
§ 2.5 § 2.1 § 3.63 § 2.3 § 1.1 § 3.5 § 2.4 § 5.6 § 6.7 § 7.5 § 21.1
3.65 2.26 4.92 3.76 0.66 5.1 2.44 7.99 10.32 10.95 35.51
DT BU BD IN P ID E M ASC IR SI
9.86 3.07 14.68 5.9 7.49 5.23 5.84 8.99 5.01 4.92 4.7
§ 5.7 § 3.6 § 8.6 § 5.1 § 6.3 § 3.9 § 5.3 § 5.4 § 3.6 § 5.6 § 4.1
3.62 1.63 4.94 3.76 6.35 4.41 3.47 6.96 2.91 4.14 4.33
§4 § 2.9 § 5.7 § 4.0 § 5.4 § 3.8 § 3.4 § 3.9 § 2.6 § 5.0 § 3.7
6.22 2.29 9.09 4.29 7.21 4.85 4.52 8.11 3.88 4.23 4.69
CBCL § 2.7 § 2.1 § 4.1 § 2.6 § 1.2 § 3.6 § 2.1 § 5.6 § 7.4 § 7.4 § 21.1 EDI-2 § 5.9 § 2.9 § 8.8 § 4.5 § 5.9 § 4.1 § 4.3 § 4.8 § 3.2 § 4.4 § 4.3
Girls M § SD
Preadolescents M § SD
Adolescents M § SD
3.35 2.74 5.00 3.51 0.68 4.22 2.44 7.66 10.66 9.95 34.72
§ 2.5 § 2.6 § 4.3 § 2.9 § 1.3 § 3.5 § 2.4 § 5.6 § 7.9 § 7.3 § 23.8
3.22 2.26 4.79 3.79 0.8 4.56 2.43 7.74 9.89 10.28 35.23
§ 2.5 § 2.1 § 4.1 § 2.9 § 1.4 § 3.6 § 2.0 § 5.7 § 7.2 § 7.2 § 23
3.75 2.71 5.11 3.5 0.56 4.75 2.45 7.89 11.02 10.6 35.01
§ 2.6 § 2.5 § 4.3 § 2.7 § 1.1 § 3.6 § 2.4 § 5.5 §8 § 7.6 § 22
7.22 2.4 10.48 5.35 6.62 4.78 4.78 7.83 4.03 4.82 4.34
§ 5.7 § 3.7 § 8.7 § 4.9 § 5.9 § 3.6 § 4.9 § 4.8 § 3.5 § 6.1 § 3.5
7.09 2.68 10.16 4.92 7.2 4.8 4.69 8.49 3.97 5.41 4.64
§ 6.1 § 3.6 § 8.2 § 4.6 § 5.4 § 3.8 § 4.3 § 4.8 § 3.2 § 5.5 § 4.0
6.41 2.06 9.45 4.74 6.66 4.84 4.62 7.51 3.94 3.75 4.40
§ 5.5 § 3.1 § 9.3 § 4.9 § 6.3 § 3.9 § 4.8 § 4.7 § 3.4 § 5.0 § 3.9
CBCL D Child Behavior Checklist, EDI-2 D Eating Disorder Inventory–2, W D withdrawn, Som D somatic complaints, AD D anxious-depressed, Soc D social problems, Th D thought problems, Att D attention problems, Del D delinquent behavior, Aggr D aggressive behavior, Int D internalizing syndrome, Ext D externalizing syndrome, Tot D total problems. DT D drive for thinness, BU D bulimia, BD D body dissatisfaction, IN D ineffectiveness, P D perfectionism, ID D interpersonal distrust, E D enteroceptive awareness, M D maturity fears, ASC D asceticism, IR D impulse regulation, SI D social insecurity.
distrust) and CBCL 4–18 subscales (statistical significance p < 0.001 for withdrawn, somatic complaints, anxiousdepressed, social depressed, thought problems, delinquent behaviors, internalizing syndrome, externalizing syndrome; p < 0.001 for attention problems and aggressive behaviors). Obese/overweight preadolescent boys, with respect to gender and age groups, reached higher scores than normal-weight, age-matched individuals on the EDI-2 subscales drive for thinness, body dissatisfaction (p < 0.0001 for both), enteroceptive awareness, maturity fears, and ascetism (p < 0.05). Obese adolescents reached higher scores in drive for thinness, body dissatisfaction, enteroceptive awareness, ascetism (p < 0.0001 for all), and maturity fears (p < 0.05). We found higher scores in obese preadolescent girls on EDI-2 subscales for drive for thinness, body dissatisfaction, ineffectiveness (p < 0.0001 for all), enteroceptive awareness, maturity fears (p < 0.001), interpersonal distrust, and ascetism (p < 0.05). The scores related to obese adolescent girls were higher for subscales such as drive for thinness, body dissatisfaction (p < 0.0001), ascetism (p < 0.001), bulimia, and ineffectiveness (p < 0.0001). Obese/overweight preadolescent boys reached higher scores with regards to the CBCL subscales than normal-weight age-matched individuals in somatic complaints, social
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
problems, thought problems, internalizing syndrome, total problems (p < 0.0001 for all), anxious-depressed, attention problems, delinquent behaviors, externalizing problems (p < 0.001), and withdrawn (p < 0.05). Higher scores were found in obese adolescent boys in social problems, internalizing syndrome (p < 0.0001 for both), anxious-depressed, externalizing syndrome, total problems (p < 0.001), thought problems, and delinquent and aggressive behaviors (p < 0.05). Higher CBCL scores were found in obese preadolescent girls on subscales for social problems, delinquent behaviors, total problems (p < 0.0001), somatic complaints, attention problems, aggressive behaviors, internalizing and externalizing syndromes (p < 0.001), anxious-depressed, and thought problems (p < 0.05). In obese adolescent girls, higher CBCL scores were found on subscales for social problems (p < 0.001) and internalizing syndrome (p < 0.05). Table 2 reports statistical significance of differences in EDI-2 and CBCL subscale scores between patients and normal-weight controls. Table 3 reports interaction effects among scores. The main significant interaction effects were seen in social problems, F D 6.50, p < 0.05, and ineffectiveness, F D 4.15, p < 0.05, with regard to weight status, age group, and gender.
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Eating Disorders in Obese Children Table 2. Descriptive Statistics of CBCL and EDI-2 Subscales in Age Groups Preadolescents
Adolescents
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Boys
Girls
Boys
Girls
Obese
Control
Obese
Control
Obese
Control
Obese
Control
M § SD
M § SD
M § SD
M § SD
M § SD
M § SD
M § SD
M § SD
W Som AD Soc Th Att Del Aggr Int Ext Tot
4.07 2.58 6.11 4.82 1.24 6.02 3.11 9.11 12.33 12.89 45.29
§ 2.6 § 2.1 § 4.3 § 2.5 § 1.7 §4 § 2.3 § 6.6 § 6.9 § 7.7 § 22.3
2.7 1.32 3.59 2.61 0.3 4 1.77 6.84 6.73 8.75 25.73
§ 2.5 § 1.2 § 3.3 § 2.5 § 0.8 § 3.1 § 1.5 § 4.6 § 5.1 § 6.4 § 16.8
3.52 3.25 5.82 5.59 1.16 5.18 3.11 9.02 12.7 11.67 44.23
§ 2.4 § 2.7 § 4.7 § 2.8 § 1.8 § 3.7 § 1.9 § 5.8 § 8.2 § 6.5 § 24.6
2.56 1.88 3.58 2.07 0.47 2.95 1.7 5.93 7.7 7.72 25.23
DT BU BD IN P ID E M ASC IR SI
9.29 2.84 13.78 4.56 6.93 4.53 5.24 9.29 5 4.98 4.62
§ 6.2 § 3.4 § 8.4 § 3.9 § 5.4 § 3.8 § 4.4 § 4.6 § 3.6 §5 § 4.1
3.43 2.02 5.41 4.25 7.36 5 3.32 7.07 3.48 4.48 5.14
§4 §3 § 5.8 § 4.4 § 5.7 § 4.7 § 3.2 § 4.1 § 2.7 § 4.5 § 4.6
10.93 4.36 15.41 7.39 7.86 5.52 6.41 10.43 4.52 7.32 5.14
§ 6.0 § 4.5 § 6.9 § 5.4 § 5.6 § 3.2 § 5.1 § 5.7 § 3.4 § 6.3 § 4.1
4.58 1.44 5.88 3.47 6.65 4.12 3.74 7.12 2.84 4.86 3.65
CBCL § 2.3 § 1.8 § 3.2 § 2.1 § 1.0 §3 § 1.9 § 5.1 § 6.4 § 6.7 § 19.5 EDI-2 § 4.7 § 2.9 §6 § 3.6 § 5.2 § 3.2 § 3.7 §4 § 2.5 §6 § 3.0
4.31 2.9 6.35 5.25 0.81 5.67 2.88 9.19 13.62 13.1 42.52
§ 2.8 § 1.9 § 4.8 § 2.3 § 1.3 § 3.4 § 1.5 § 5.3 § 8.5 § 7.1 § 19.3
3.48 2.2 3.64 2.4 0.32 4.7 2.02 6.84 8.5 9.06 28.58
§ 2.5 § 2.5 § 2.9 § 1.9 § 0.8 § 3.7 § 2.6 § 5.5 § 6.2 § 7.3 § 20.1
4.1 3.28 5.82 4.02 0.52 4.28 2.34 7.34 12.68 10.1 38.16
§ 2.6 § 3.0 § 4.3 § 2.7 § 0.8 § 3.1 §2 § 4.1 § 7.8 § 6.0 § 20.6
3.13 2.48 4.69 2.44 0.6 4.38 2.58 8.25 9.42 10.23 31.23
9.6 2.5 13.44 5.38 8.12 5.83 6.5 9.21 5.02 3.54 4.44
§ 5.6 § 2.9 § 10.3 § 5.1 § 6.9 § 3.8 § 5.3 § 5.7 § 3.4 § 3.8 § 4.1
2.66 1.84 3.92 3.06 6.44 4.06 3.02 6.9 2.12 4 4.6
§ 3.7 § 2.6 § 4.8 § 4.3 § 5.5 § 4.1 § 2.9 § 4.3 § 1.9 § 4.4 § 4.5
9.68 2.68 16.06 6.32 7.04 5.02 5.24 7.24 5.44 4.08 4.64
§ 5.2 § 3.6 § 8.4 § 5.7 § 7.2 § 4.6 § 6.1 §5 § 4.2 § 6.4 § 4.3
3.9 1.25 4.73 4.25 5.15 4.48 3.81 6.79 3.25 3.38 3.94
§ 2.6 § 2.4 § 4.7 § 2.7 § 1.4 §4 § 3.2 § 6.8 § 8.1 § 9.1 § 26.16 § 3.3 §3 § 6.3 § 3.7 § 5.1 § 2.9 § 3.8 § 4.5 §4 § 5.1 § 2.3
CBCL D Child Behavior Checklist, EDI-2 D Eating Disorder Inventory–2, W D withdrawn, Som D somatic complaints, AD D anxious-depressed, Soc D social problems, Th D thought problems, Att D attention problems, Del D delinquent behavior, Aggr D aggressive behavior, Int D internalizing syndrome, Ext D externalizing syndrome, Tot D total problems. DT D drive for thinness, BU D bulimia, BD D body dissatisfaction, IN D ineffectiveness, P D perfectionism, ID D interpersonal distrust, E D enteroceptive awareness, M D maturity fears, ASC D asceticism, IR D impulse regulation, SI D social insecurity.
We carried out the evaluation of the ED-related risk on the basis of the EDI-2 cutoff criteria, which pointed out that 11.2% of the subjects in the clinical sample were at risk of developing an ED (N D 21; 9 boys, 12 girls). Seventy-five patients (40%) presented social problems.
DISCUSSION The findings of this study show how, in preadolescence and adolescence, obesity is significantly associated to some traits and aspects typical of eating disorders but also to psychological problems in general. Ineffectiveness, among the former aspects, and social problems, among the latter behaviors, are constantly found in obese participants of both genders and age groups (Tables 2 and 3). Other traits related to eating disorders and aspects associated with psychological problems may become more evident in one sex or age group. The cross-sectional design of the present investigation, unfortunately, does
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not allow any conclusion to be drawn on the age- and sexdependent dynamic shaping of emotional eating and relationships among eating disorders symptoms, specific personality traits and internalizing and externalizing symptoms in obese young patients. Nevertheless, the higher scores of EDI-2 subscales that were found in obese patients confirm the pivotal association of emotional dysregulation and obesity. Obese patients in our study generally presented more symptomatic behaviors and psychological traits than their normalweight peers, denoting a significant alteration not only in eating behaviors and food intake but also an increased tendency to express anxious thoughts and excessive expectation with relation to body thinness and dieting. Anxiety in obese children referred for treatment might develop with regards to clinical intervention due to the occurrence of nonrealistic expectations and goals (e.g., extra-thin body), as pointed out by the evidently higher than normal mean scores in the Drive for Thinness and Body Dissatisfaction scales of the EDI-2. Based on probability, we estimated theoretically that 11.3% of the total obese sample had an increased risk for developing
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Eating Disorders in Obese Children Table 3. Main and Interaction Effects of Weight Group (Obese vs Control), Gender (boys vs girls), and Age Group (Preadolescents vs Adolescents) on CBCL and EDI-2 Measures CBCL
df Weight group Gender Age group Weight group * Gender Weight group * Age group Gender * Age group Weight group * Gender * Age group
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Som
AD
Soc
Th
Att
Del
Aggr
Int
Ext
Tot
F
F
F
F
F
F
F
F
F
F
F
1, 368 14.01*** 18.03*** 25.18*** 98.72*** 14.77*** 11.18*** 60.55*** 7.98** 38.71*** 15.15*** 43.31*** 1, 368 1.33 4.00* 0.04 1.03 0.01 5.93* 0.00 0.33 0.20 1.74 0.13 * * 1, 368 4.26 3.71 0.69 0.95 3.10 0.37 0.02 0.10 2.49 0.24 0.00 1, 368 0.05 0.04 1.37 0.01 2.78 0.48 1.51 1.46 0.72 2.48 0.87 1, 368 0.25 1.42 0.29 1.67 5.62* 5.43* 5.46* 2.95 0.55 1.95 4.00* 1, 368 0.01 0.36 0.24 1.92 0.04 0.02 0.01 0.06 0.20 0.02 0.00 1, 368 0.25 0.00 0.59 6.50* 0.37 0.77 1.63 3.17 0.18 1.77 0.53 EDI-2
df Weight group Gender Age group Weight group * Gender Weight group * Age group Gender * Age group Weight group * Gender * Age group
W
DT F
BU F
BD F
IN F
1, 368 151.10*** 18.38*** 167.10*** 20.63*** 1, 368 3.90* 0.09 3.40 4.98* 1, 368 1.38 3.18 0.60 0.12 1, 368 0.14 4.28* 1.01 2.73 1, 368 0.06 1.52 0.96 0.01 1, 368 0.52 1.00 0.19 0.00 1, 368 0.67 0.98 0.05 4.15*
P F
ID F
3.52 0.93 0.73 0.57 1.31 1.13 0.35
4.25* 0.03 0.02 0.09 0.73 0.09 3.77
E F
M F
ASC F
IR F
26.52*** 17.84*** 41.75*** 2.08 0.32 0.33 0.23 1.19 0.00 9.31** 0.01 3.83* 0.62 0.24 0.22 1.99 0.03 2.09 2.08 1.57 1.24 2.86 4.19* 1.66 2.28 2.34 0.45 0.14
SI F 0.74 0.75 0.32 2.92 0.07 0.10 0.49
CBCL D Child Behavior Checklist, EDI-2 D Eating Disorder Inventory–2, W D withdrawn, Som D somatic complaints, AD D anxious-depressed, Soc D social problems, Th D thought problems, Att D attention problems, Del D delinquent behavior, Aggr D aggressive behavior, Int D internalizing syndrome, Ext D externalizing syndrome, Tot D total problems. DT D drive for thinness, BU D bulimia, BD D body dissatisfaction, IN D ineffectiveness, P D perfectionism, ID D interpersonal distrust, E D enteroceptive awareness, M D maturity fears, ASC D asceticism, IR D impulse regulation, SI D social insecurity. *p < 0.05. **p < 0.01. ***p < 0.001.
an eating disorder. Although we have no follow-up data, the chosen cutoffs for the clinical EDI-2 subscales are all very high and comparable to scores obtained by subjects with a confirmed diagnosis of eating disorders, and this allows us to reduce the risk of having included false-positive cases. Moreover, the percentage of 11.3% is in line with estimates from other studies that estimated a risk as high as 9% in obese subjects [18]. Nine of 21 of the patients found to be at risk for ED were boys. This assessed finding is an interesting one and has been explained by other researchers as the effect of social changes [19]. The association of obesity with psychological problems was very strong in our sample of obese preadolescents, as shown by the significant differences in all of the CBCL mean scores compared to normal peers. Moreover, there is an interesting finding with relation to gender. Obese boys reached significantly higher scores in all 11 dimensions of the CBCL. This finding supports the presence of general psychological distress associated with their condition, whereas obese girls presented higher scores, compared to normal-weight girls, within the internalizing domain, thus suggesting a greater tendency toward developing anxiousdepressed and somatic symptoms.
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Another relevant finding is that 40% of the obese preadolescents and adolescents in our study reach clinical scores in the Social Problems area of the CBCL. This result confirms observations from other studies claiming that obese children may experience difficulty in achieving positive and stable friendships [20]. Indeed, they can more easily become targets for peer verbal/physical aggression and are frequently isolated from social networks [21]. Thirty-five percent of obese subjects in our study scored well over the clinical cutoffs in the Internalizing Syndrome scale, and this could mean, in line with research data available, that the psychopathological dimension more closely associated to obesity is the anxious-depressive syndrome and more generally all problems directed to self (i.e., somatic complaints) [22,23]. A relevant, although not as high, clinical risk was found in the externalizing scale results, because 27% of obese children scored over the clinical cutoffs, thus showing the presence of aggressive and antisocial behaviors. That said, we may mention that bullying behaviors are increasingly evident in peer interactions in children and adolescents. Jansenn et al.’s study [24] showed that obese children who are victims of bullying at
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Eating Disorders in Obese Children a young age become more openly aggressive and active in joining bullying behaviors when they are teenagers. We would like to highlight that 40% of obese children in our study were at clinical risk on the Total Problems scale, thus showing a high degree of psychological distress related to their condition. We believe that obesity is not related to a specific psychopathology but may contribute to bringing about a general sense of distress that touches many different psychoaffective dimensions of personal and social life.
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CONCLUSIONS Our study presents new evidence of the relationship between obesity in preadolescence and adolescence, a crucial time for psychosomatic changes, and the development of eating disorders and psychopathological traits, thus highlighting the complex and multifaceted nature of this medical condition. Our data confirm the primary role for emotional eating in the dynamic interplay among traits, symptoms, and conducts associated with obesity. Our study has shown that obese preadolescents display behaviors, thoughts, and personality traits that may significantly differ from nonobese peers and that are nearer to those presented by ED subjects. They can also present a broad range of psychopathological problems, different in quality and intensity but clinically significant. An effective assessment of dysfunctional traits with relation to food intake, self and body image, and relationship with others should take place in the preadolescent years. The EDI-2 has shown to be an effective and adequate tool for screening, but other, more specific screening tools, especially for bulimia and BED, may be recommended. Evaluation of obese preadolescents and adolescents must also include an assessment of psychopathological problems, which cannot go undetected or left untreated, because they are highly prevalent in this population and harmful for the patient’s well-being. We acknowledge limitations in the study, such as the impossibility of determining the direction of causality in the above-mentioned relationships and the absence of a follow-up study, which would have effectively assessed how many of the at-risk children had in fact developed an eating disorder and of what type. Our future research will be aimed at a better understanding of the many factors involved in adaptive and maladaptive eating development, in order to render more visible the complex dynamics underlying obesity as a medical and psychosocial condition and in order to identify effective clinical interventions.
ACKNOWLEDGMENTS We are grateful to Paula Lavis at the Mental Health Institute, London, and Paolo Varricchio, Assistant Professor at Rutgers New Jersey Medical School, Newark, New Jersey, for careful editing of the article.
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Received December 16, 2013; accepted June 19, 2014.
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21. Midei AJ, Matthews KA: Interpersonal violence in childhood as a risk factor for obesity: a systematic review of the literature and proposed pathways. Obes Rev 12:e159–e172, 2011. 22. Cortese S, Cuzzolaro M, Maffeis C, Piccolo F, Ferrucci G, Tato L, Pajno-Ferrara F, Dalla Bernardina B: Depressive symptoms and low self-esteem in obese children and adolescent. Minerva Pediatr 57:65–71, 2005. 23. Erickson SJ, Robinson TN, Haydel KF, Killen JD: Are overweight children unhappy? Body mass index, depressive symptoms, and
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ISSN: 0731-5724 (Print) 1541-1087 (Online) Journal homepage: http://www.tandfonline.com/loi/uacn20
Eating Disorders and Psychopathological Traits in Obese Preadolescents and Adolescents Viviana Finistrella PsyD, Melania Manco MD, PhD, FACN, Nicola Corciulo MD, Beatrice Sances PsyD, Mario Di Pietro MD, Raffaella Di Gregorio PsyD, Fosca Di SanteMarsili PsyD, Perla Maria Fiumani PsyD, Fabio Presaghi PsyD PhD & Amalia Maria Ambruzzi MD, FACN To cite this article: Viviana Finistrella PsyD, Melania Manco MD, PhD, FACN, Nicola Corciulo MD, Beatrice Sances PsyD, Mario Di Pietro MD, Raffaella Di Gregorio PsyD, Fosca Di SanteMarsili PsyD, Perla Maria Fiumani PsyD, Fabio Presaghi PsyD PhD & Amalia Maria Ambruzzi MD, FACN (2015) Eating Disorders and Psychopathological Traits in Obese Preadolescents and Adolescents, Journal of the American College of Nutrition, 34:2, 142-149, DOI: 10.1080/07315724.2014.938182 To link to this article: http://dx.doi.org/10.1080/07315724.2014.938182
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Date: 21 September 2015, At: 09:31
Original Research
Eating Disorders and Psychopathological Traits in Obese Preadolescents and Adolescents
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Viviana Finistrella, PsyD, Melania Manco, MD, PhD, FACN, Nicola Corciulo, MD, Beatrice Sances, PsyD, Mario Di Pietro, MD, Raffaella Di Gregorio, PsyD, Fosca Di SanteMarsili, PsyD, Perla Maria Fiumani, PsyD, Fabio Presaghi, PsyD, PhD, Amalia Maria Ambruzzi, MD, FACN Research Unit for Multifactorial Diseases, Obesity and Diabetes, Ospedale Pediatrico 10 Bambino Ges u IRCCS, Rome, ITALY (V.F., M.M., A.M.A.); Centro di Prevenzione Diagnosi e 11 Cura dell’ Obesit a in et a evolutiva-U.O. Pediatria, P.O. Gallipoli, Lecce, ITALY (N.C., B.S.); 12 Unit a di Pediatria, Ospedale S. Liberatore, Atri, Teramo, ITALY (M.D.P., R.D.G., F.D.S.M.); 13 Seconda Universit a degli Studi di Napoli, Napoli, ITALY (P.M.F.); Facolt a di Medicina e 14 Psicologia, Universit a “La Sapienza,” Rome, ITALY (F.P.) Key words: childhood and adolescent obesity, eating disorders, psychopathological symptoms Objective: to investigate the presence of eating disorders (ED) and psychopathological traits in obese preadolescents and adolescents compared to normal-weight peers. Design: Overweight/obese patients aged 11 to 14 y and normal-weight peers’ data collected by means of self-report questionnaires administered to parents and children. Setting: Clinical Nutrition Units in the Municipalities of Rome, Naples, Gallipoli and Atri, Italy. Subjects: 376 preadolescents and adolescents. Patients were 187 (93 boys, BMID27.9 §;4.1; 94 girls, BMID28.1 §4.5); normal-weight controls were 189 subjects (94 boys, BMID19.4 §1.4; 95 girls, BMID19.5 §1.5). Measures of outcome: eating disorder behaviors, psychopathological traits and symptoms estimated by means of the eating disorders scales (EDI-2) and psychopathological scales (CBCL 4–18). Results: Patients reached higher scores than controls in most of the eating disorders scales and psychopathological scales. Twenty-one (11.2%) patients were considered at risk of developing an eating disorder and 75 (40%) presented social problems. With regard to weight status, age-group and gender, main significant interaction effects were seen in social problems (FD 6.50; p 65.
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Eating Disorder Assessment The EDI-2 is a self-report measure, widely used to detect the presence of significant markers of EDs. It has been standardized and validated in the Italian version [16], reaching a good level of reliability (Cronbach’s a between 0.78 and 0.84). EDI-2 includes 91 items, divided into 11 subscales. The first 3 subscales describe symptomatic behaviors: (1) drive for thinness (DT), which measures excessive preoccupation regarding dieting, body weight and weight gain; (2) bulimia (BU), regarding the presence of thoughts or actual episodes of excessive and uncontrolled food intake; and (3) body dissatisfaction (BD), which measures dissatisfaction for some body parts. The other 8 subscales measure the presence of personality traits more commonly associated with EDs: (4) ineffectiveness, which evaluates the presence of general feelings of insecurity and helplessness; (5) perfectionism, which measures the presence of thoughts or beliefs that only exceptional results are acceptable; (6) interpersonal distrust, regarding the presence of a general feeling of alienation and distrust toward others; (7) enteroceptive awareness, which evaluates the presence of confusion and uncertainty in perception and response to emotions and physiological stimuli; (8) maturity fears, which measures the presence of a regressive desire to return to childhood; (9) asceticism, which evaluates the tendency to find self-worth through discipline, sacrifice, control over body functions, and spiritual ideals; (10) impulse regulation, which measures the tendency for impulsiveness and destructiveness in relationships; and (11) social insecurity, which measures the tendency to believe that social relationships are difficult and unsuccessful. The evaluation of the theoretical risk of EDs in the sample of obese participants was achieved by comparing their results with the mean scores obtained by subjects with a confirmed diagnosis of ED and the cutoffs present in the Italian version of the 3 clinical symptoms scales (DT, BU, BD).
Psychological Assessment The CBCL 4–18 is a self-report measure that evaluates the presence of psychopathological symptoms and behaviors. It has been validated and standardized in the Italian population with good reliability (Cronbach’s a between 0.66 and 0.91) [17]. The CBCL 4–18 includes 11 subscales, the first 8 of which refer to psychopathological problems: (1) withdrawn (W); (2) somatic complaints; (3) anxious/depressed; (4) social problems; (5) thought problems; (6) attention problems; (7) delinquent behavior; and (8) aggressive behavior. The last 3
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Data Analysis Continuous data were reported as mean § SD, with categorical data as counts and percentages. Comparisons between the patient group and control group were performed by means of a 2-way analysis of variance test. p < 0.05 was considered statistically significant. SPSS statistical software (Ver. 12.0, SPSS Inc., Chicago, IL) was used.
RESULTS Sample Characteristics Thirteen subjects (6.5%, 6 boys) dropped out of the enrolled patient sample because they did not complete at least 90% of the items. Eleven subjects (5.9%, 5 boys) dropped out of the enrolled control sample: 5 did not complete at least 90% of the items and 6 were not present on the day the test was administered. These subjects did not differ from the rest of the patient and control groups with regards to mother and child age and BMI and mother education and occupation (data not shown). The final total sample included 376 children. The patient group included 93 overweight/obese boys (24.7%; BMI D 27.9 § 4.1 kg/m2, age D 12.4 § 1.8 years) and 94 overweight/obese girls (25%; BMI D 28.1 § 4.5 kg/m2, age D 12.9 § 1.8 years). The control group included 94 normal-weight boys (25%, BMI D 19.4 § 1.4, age D 12.3 § 1.3 years) and 95 normal-weight girls (25.3%, BMI D 19.5 § 1.5 kg/m2, age D 12.7 § 1.5 years).
EDI-2 and CBCL Overweight and obese patients reached higher scores than normal-weight controls in many EDI-2 subscales (drive for thinness, bulimia, body dissatisfaction, externalizing syndrome, maturity fears, asceticism; p < 0.05 for interpersonal distrust and p < 0.0001 for all others) and all CBCL scales (p < 0.0001 for all except attention problems and aggressive behaviors, whose statistical significance was p < 0.001). Mean values and standard deviations for each subscale are reported separately for gender and age group (Table 1). Preadolescent and adolescent patients reached higher scores than controls on most of the EDI-2 subscales (statistical significance p < 0.001 for drive for thinness, bulimia, body dissatisfaction, internalizing syndrome, enteroceptive awareness, maturity fears, and ascetism; p < 0.05 for interpersonal
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Eating Disorders in Obese Children Table 1. Descriptive Statistics of CBCL and EDI-2 Subscales for the Main Effects of Gender, Age, and Weight Groups
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Obese M § SD
Control M § SD
Boys M § SD
W Som AD Soc Th Att Del Aggr Int Ext Tot
4.01 3.01 6.03 4.9 0.92 5.27 2.84 8.64 12.84 11.91 42.42
§ 2.6 § 2.5 § 4.5 § 2.6 § 1.4 § 3.6 §2 § 5.5 § 7.9 § 6.9 § 21.7
2.99 2.00 3.9 2.39 0.42 4.05 2.04 7.02 8.16 9.01 27.88
§ 2.5 § 2.1 § 3.63 § 2.3 § 1.1 § 3.5 § 2.4 § 5.6 § 6.7 § 7.5 § 21.1
3.65 2.26 4.92 3.76 0.66 5.1 2.44 7.99 10.32 10.95 35.51
DT BU BD IN P ID E M ASC IR SI
9.86 3.07 14.68 5.9 7.49 5.23 5.84 8.99 5.01 4.92 4.7
§ 5.7 § 3.6 § 8.6 § 5.1 § 6.3 § 3.9 § 5.3 § 5.4 § 3.6 § 5.6 § 4.1
3.62 1.63 4.94 3.76 6.35 4.41 3.47 6.96 2.91 4.14 4.33
§4 § 2.9 § 5.7 § 4.0 § 5.4 § 3.8 § 3.4 § 3.9 § 2.6 § 5.0 § 3.7
6.22 2.29 9.09 4.29 7.21 4.85 4.52 8.11 3.88 4.23 4.69
CBCL § 2.7 § 2.1 § 4.1 § 2.6 § 1.2 § 3.6 § 2.1 § 5.6 § 7.4 § 7.4 § 21.1 EDI-2 § 5.9 § 2.9 § 8.8 § 4.5 § 5.9 § 4.1 § 4.3 § 4.8 § 3.2 § 4.4 § 4.3
Girls M § SD
Preadolescents M § SD
Adolescents M § SD
3.35 2.74 5.00 3.51 0.68 4.22 2.44 7.66 10.66 9.95 34.72
§ 2.5 § 2.6 § 4.3 § 2.9 § 1.3 § 3.5 § 2.4 § 5.6 § 7.9 § 7.3 § 23.8
3.22 2.26 4.79 3.79 0.8 4.56 2.43 7.74 9.89 10.28 35.23
§ 2.5 § 2.1 § 4.1 § 2.9 § 1.4 § 3.6 § 2.0 § 5.7 § 7.2 § 7.2 § 23
3.75 2.71 5.11 3.5 0.56 4.75 2.45 7.89 11.02 10.6 35.01
§ 2.6 § 2.5 § 4.3 § 2.7 § 1.1 § 3.6 § 2.4 § 5.5 §8 § 7.6 § 22
7.22 2.4 10.48 5.35 6.62 4.78 4.78 7.83 4.03 4.82 4.34
§ 5.7 § 3.7 § 8.7 § 4.9 § 5.9 § 3.6 § 4.9 § 4.8 § 3.5 § 6.1 § 3.5
7.09 2.68 10.16 4.92 7.2 4.8 4.69 8.49 3.97 5.41 4.64
§ 6.1 § 3.6 § 8.2 § 4.6 § 5.4 § 3.8 § 4.3 § 4.8 § 3.2 § 5.5 § 4.0
6.41 2.06 9.45 4.74 6.66 4.84 4.62 7.51 3.94 3.75 4.40
§ 5.5 § 3.1 § 9.3 § 4.9 § 6.3 § 3.9 § 4.8 § 4.7 § 3.4 § 5.0 § 3.9
CBCL D Child Behavior Checklist, EDI-2 D Eating Disorder Inventory–2, W D withdrawn, Som D somatic complaints, AD D anxious-depressed, Soc D social problems, Th D thought problems, Att D attention problems, Del D delinquent behavior, Aggr D aggressive behavior, Int D internalizing syndrome, Ext D externalizing syndrome, Tot D total problems. DT D drive for thinness, BU D bulimia, BD D body dissatisfaction, IN D ineffectiveness, P D perfectionism, ID D interpersonal distrust, E D enteroceptive awareness, M D maturity fears, ASC D asceticism, IR D impulse regulation, SI D social insecurity.
distrust) and CBCL 4–18 subscales (statistical significance p < 0.001 for withdrawn, somatic complaints, anxiousdepressed, social depressed, thought problems, delinquent behaviors, internalizing syndrome, externalizing syndrome; p < 0.001 for attention problems and aggressive behaviors). Obese/overweight preadolescent boys, with respect to gender and age groups, reached higher scores than normal-weight, age-matched individuals on the EDI-2 subscales drive for thinness, body dissatisfaction (p < 0.0001 for both), enteroceptive awareness, maturity fears, and ascetism (p < 0.05). Obese adolescents reached higher scores in drive for thinness, body dissatisfaction, enteroceptive awareness, ascetism (p < 0.0001 for all), and maturity fears (p < 0.05). We found higher scores in obese preadolescent girls on EDI-2 subscales for drive for thinness, body dissatisfaction, ineffectiveness (p < 0.0001 for all), enteroceptive awareness, maturity fears (p < 0.001), interpersonal distrust, and ascetism (p < 0.05). The scores related to obese adolescent girls were higher for subscales such as drive for thinness, body dissatisfaction (p < 0.0001), ascetism (p < 0.001), bulimia, and ineffectiveness (p < 0.0001). Obese/overweight preadolescent boys reached higher scores with regards to the CBCL subscales than normal-weight age-matched individuals in somatic complaints, social
JOURNAL OF THE AMERICAN COLLEGE OF NUTRITION
problems, thought problems, internalizing syndrome, total problems (p < 0.0001 for all), anxious-depressed, attention problems, delinquent behaviors, externalizing problems (p < 0.001), and withdrawn (p < 0.05). Higher scores were found in obese adolescent boys in social problems, internalizing syndrome (p < 0.0001 for both), anxious-depressed, externalizing syndrome, total problems (p < 0.001), thought problems, and delinquent and aggressive behaviors (p < 0.05). Higher CBCL scores were found in obese preadolescent girls on subscales for social problems, delinquent behaviors, total problems (p < 0.0001), somatic complaints, attention problems, aggressive behaviors, internalizing and externalizing syndromes (p < 0.001), anxious-depressed, and thought problems (p < 0.05). In obese adolescent girls, higher CBCL scores were found on subscales for social problems (p < 0.001) and internalizing syndrome (p < 0.05). Table 2 reports statistical significance of differences in EDI-2 and CBCL subscale scores between patients and normal-weight controls. Table 3 reports interaction effects among scores. The main significant interaction effects were seen in social problems, F D 6.50, p < 0.05, and ineffectiveness, F D 4.15, p < 0.05, with regard to weight status, age group, and gender.
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Eating Disorders in Obese Children Table 2. Descriptive Statistics of CBCL and EDI-2 Subscales in Age Groups Preadolescents
Adolescents
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Boys
Girls
Boys
Girls
Obese
Control
Obese
Control
Obese
Control
Obese
Control
M § SD
M § SD
M § SD
M § SD
M § SD
M § SD
M § SD
M § SD
W Som AD Soc Th Att Del Aggr Int Ext Tot
4.07 2.58 6.11 4.82 1.24 6.02 3.11 9.11 12.33 12.89 45.29
§ 2.6 § 2.1 § 4.3 § 2.5 § 1.7 §4 § 2.3 § 6.6 § 6.9 § 7.7 § 22.3
2.7 1.32 3.59 2.61 0.3 4 1.77 6.84 6.73 8.75 25.73
§ 2.5 § 1.2 § 3.3 § 2.5 § 0.8 § 3.1 § 1.5 § 4.6 § 5.1 § 6.4 § 16.8
3.52 3.25 5.82 5.59 1.16 5.18 3.11 9.02 12.7 11.67 44.23
§ 2.4 § 2.7 § 4.7 § 2.8 § 1.8 § 3.7 § 1.9 § 5.8 § 8.2 § 6.5 § 24.6
2.56 1.88 3.58 2.07 0.47 2.95 1.7 5.93 7.7 7.72 25.23
DT BU BD IN P ID E M ASC IR SI
9.29 2.84 13.78 4.56 6.93 4.53 5.24 9.29 5 4.98 4.62
§ 6.2 § 3.4 § 8.4 § 3.9 § 5.4 § 3.8 § 4.4 § 4.6 § 3.6 §5 § 4.1
3.43 2.02 5.41 4.25 7.36 5 3.32 7.07 3.48 4.48 5.14
§4 §3 § 5.8 § 4.4 § 5.7 § 4.7 § 3.2 § 4.1 § 2.7 § 4.5 § 4.6
10.93 4.36 15.41 7.39 7.86 5.52 6.41 10.43 4.52 7.32 5.14
§ 6.0 § 4.5 § 6.9 § 5.4 § 5.6 § 3.2 § 5.1 § 5.7 § 3.4 § 6.3 § 4.1
4.58 1.44 5.88 3.47 6.65 4.12 3.74 7.12 2.84 4.86 3.65
CBCL § 2.3 § 1.8 § 3.2 § 2.1 § 1.0 §3 § 1.9 § 5.1 § 6.4 § 6.7 § 19.5 EDI-2 § 4.7 § 2.9 §6 § 3.6 § 5.2 § 3.2 § 3.7 §4 § 2.5 §6 § 3.0
4.31 2.9 6.35 5.25 0.81 5.67 2.88 9.19 13.62 13.1 42.52
§ 2.8 § 1.9 § 4.8 § 2.3 § 1.3 § 3.4 § 1.5 § 5.3 § 8.5 § 7.1 § 19.3
3.48 2.2 3.64 2.4 0.32 4.7 2.02 6.84 8.5 9.06 28.58
§ 2.5 § 2.5 § 2.9 § 1.9 § 0.8 § 3.7 § 2.6 § 5.5 § 6.2 § 7.3 § 20.1
4.1 3.28 5.82 4.02 0.52 4.28 2.34 7.34 12.68 10.1 38.16
§ 2.6 § 3.0 § 4.3 § 2.7 § 0.8 § 3.1 §2 § 4.1 § 7.8 § 6.0 § 20.6
3.13 2.48 4.69 2.44 0.6 4.38 2.58 8.25 9.42 10.23 31.23
9.6 2.5 13.44 5.38 8.12 5.83 6.5 9.21 5.02 3.54 4.44
§ 5.6 § 2.9 § 10.3 § 5.1 § 6.9 § 3.8 § 5.3 § 5.7 § 3.4 § 3.8 § 4.1
2.66 1.84 3.92 3.06 6.44 4.06 3.02 6.9 2.12 4 4.6
§ 3.7 § 2.6 § 4.8 § 4.3 § 5.5 § 4.1 § 2.9 § 4.3 § 1.9 § 4.4 § 4.5
9.68 2.68 16.06 6.32 7.04 5.02 5.24 7.24 5.44 4.08 4.64
§ 5.2 § 3.6 § 8.4 § 5.7 § 7.2 § 4.6 § 6.1 §5 § 4.2 § 6.4 § 4.3
3.9 1.25 4.73 4.25 5.15 4.48 3.81 6.79 3.25 3.38 3.94
§ 2.6 § 2.4 § 4.7 § 2.7 § 1.4 §4 § 3.2 § 6.8 § 8.1 § 9.1 § 26.16 § 3.3 §3 § 6.3 § 3.7 § 5.1 § 2.9 § 3.8 § 4.5 §4 § 5.1 § 2.3
CBCL D Child Behavior Checklist, EDI-2 D Eating Disorder Inventory–2, W D withdrawn, Som D somatic complaints, AD D anxious-depressed, Soc D social problems, Th D thought problems, Att D attention problems, Del D delinquent behavior, Aggr D aggressive behavior, Int D internalizing syndrome, Ext D externalizing syndrome, Tot D total problems. DT D drive for thinness, BU D bulimia, BD D body dissatisfaction, IN D ineffectiveness, P D perfectionism, ID D interpersonal distrust, E D enteroceptive awareness, M D maturity fears, ASC D asceticism, IR D impulse regulation, SI D social insecurity.
We carried out the evaluation of the ED-related risk on the basis of the EDI-2 cutoff criteria, which pointed out that 11.2% of the subjects in the clinical sample were at risk of developing an ED (N D 21; 9 boys, 12 girls). Seventy-five patients (40%) presented social problems.
DISCUSSION The findings of this study show how, in preadolescence and adolescence, obesity is significantly associated to some traits and aspects typical of eating disorders but also to psychological problems in general. Ineffectiveness, among the former aspects, and social problems, among the latter behaviors, are constantly found in obese participants of both genders and age groups (Tables 2 and 3). Other traits related to eating disorders and aspects associated with psychological problems may become more evident in one sex or age group. The cross-sectional design of the present investigation, unfortunately, does
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not allow any conclusion to be drawn on the age- and sexdependent dynamic shaping of emotional eating and relationships among eating disorders symptoms, specific personality traits and internalizing and externalizing symptoms in obese young patients. Nevertheless, the higher scores of EDI-2 subscales that were found in obese patients confirm the pivotal association of emotional dysregulation and obesity. Obese patients in our study generally presented more symptomatic behaviors and psychological traits than their normalweight peers, denoting a significant alteration not only in eating behaviors and food intake but also an increased tendency to express anxious thoughts and excessive expectation with relation to body thinness and dieting. Anxiety in obese children referred for treatment might develop with regards to clinical intervention due to the occurrence of nonrealistic expectations and goals (e.g., extra-thin body), as pointed out by the evidently higher than normal mean scores in the Drive for Thinness and Body Dissatisfaction scales of the EDI-2. Based on probability, we estimated theoretically that 11.3% of the total obese sample had an increased risk for developing
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Eating Disorders in Obese Children Table 3. Main and Interaction Effects of Weight Group (Obese vs Control), Gender (boys vs girls), and Age Group (Preadolescents vs Adolescents) on CBCL and EDI-2 Measures CBCL
df Weight group Gender Age group Weight group * Gender Weight group * Age group Gender * Age group Weight group * Gender * Age group
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Som
AD
Soc
Th
Att
Del
Aggr
Int
Ext
Tot
F
F
F
F
F
F
F
F
F
F
F
1, 368 14.01*** 18.03*** 25.18*** 98.72*** 14.77*** 11.18*** 60.55*** 7.98** 38.71*** 15.15*** 43.31*** 1, 368 1.33 4.00* 0.04 1.03 0.01 5.93* 0.00 0.33 0.20 1.74 0.13 * * 1, 368 4.26 3.71 0.69 0.95 3.10 0.37 0.02 0.10 2.49 0.24 0.00 1, 368 0.05 0.04 1.37 0.01 2.78 0.48 1.51 1.46 0.72 2.48 0.87 1, 368 0.25 1.42 0.29 1.67 5.62* 5.43* 5.46* 2.95 0.55 1.95 4.00* 1, 368 0.01 0.36 0.24 1.92 0.04 0.02 0.01 0.06 0.20 0.02 0.00 1, 368 0.25 0.00 0.59 6.50* 0.37 0.77 1.63 3.17 0.18 1.77 0.53 EDI-2
df Weight group Gender Age group Weight group * Gender Weight group * Age group Gender * Age group Weight group * Gender * Age group
W
DT F
BU F
BD F
IN F
1, 368 151.10*** 18.38*** 167.10*** 20.63*** 1, 368 3.90* 0.09 3.40 4.98* 1, 368 1.38 3.18 0.60 0.12 1, 368 0.14 4.28* 1.01 2.73 1, 368 0.06 1.52 0.96 0.01 1, 368 0.52 1.00 0.19 0.00 1, 368 0.67 0.98 0.05 4.15*
P F
ID F
3.52 0.93 0.73 0.57 1.31 1.13 0.35
4.25* 0.03 0.02 0.09 0.73 0.09 3.77
E F
M F
ASC F
IR F
26.52*** 17.84*** 41.75*** 2.08 0.32 0.33 0.23 1.19 0.00 9.31** 0.01 3.83* 0.62 0.24 0.22 1.99 0.03 2.09 2.08 1.57 1.24 2.86 4.19* 1.66 2.28 2.34 0.45 0.14
SI F 0.74 0.75 0.32 2.92 0.07 0.10 0.49
CBCL D Child Behavior Checklist, EDI-2 D Eating Disorder Inventory–2, W D withdrawn, Som D somatic complaints, AD D anxious-depressed, Soc D social problems, Th D thought problems, Att D attention problems, Del D delinquent behavior, Aggr D aggressive behavior, Int D internalizing syndrome, Ext D externalizing syndrome, Tot D total problems. DT D drive for thinness, BU D bulimia, BD D body dissatisfaction, IN D ineffectiveness, P D perfectionism, ID D interpersonal distrust, E D enteroceptive awareness, M D maturity fears, ASC D asceticism, IR D impulse regulation, SI D social insecurity. *p < 0.05. **p < 0.01. ***p < 0.001.
an eating disorder. Although we have no follow-up data, the chosen cutoffs for the clinical EDI-2 subscales are all very high and comparable to scores obtained by subjects with a confirmed diagnosis of eating disorders, and this allows us to reduce the risk of having included false-positive cases. Moreover, the percentage of 11.3% is in line with estimates from other studies that estimated a risk as high as 9% in obese subjects [18]. Nine of 21 of the patients found to be at risk for ED were boys. This assessed finding is an interesting one and has been explained by other researchers as the effect of social changes [19]. The association of obesity with psychological problems was very strong in our sample of obese preadolescents, as shown by the significant differences in all of the CBCL mean scores compared to normal peers. Moreover, there is an interesting finding with relation to gender. Obese boys reached significantly higher scores in all 11 dimensions of the CBCL. This finding supports the presence of general psychological distress associated with their condition, whereas obese girls presented higher scores, compared to normal-weight girls, within the internalizing domain, thus suggesting a greater tendency toward developing anxiousdepressed and somatic symptoms.
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Another relevant finding is that 40% of the obese preadolescents and adolescents in our study reach clinical scores in the Social Problems area of the CBCL. This result confirms observations from other studies claiming that obese children may experience difficulty in achieving positive and stable friendships [20]. Indeed, they can more easily become targets for peer verbal/physical aggression and are frequently isolated from social networks [21]. Thirty-five percent of obese subjects in our study scored well over the clinical cutoffs in the Internalizing Syndrome scale, and this could mean, in line with research data available, that the psychopathological dimension more closely associated to obesity is the anxious-depressive syndrome and more generally all problems directed to self (i.e., somatic complaints) [22,23]. A relevant, although not as high, clinical risk was found in the externalizing scale results, because 27% of obese children scored over the clinical cutoffs, thus showing the presence of aggressive and antisocial behaviors. That said, we may mention that bullying behaviors are increasingly evident in peer interactions in children and adolescents. Jansenn et al.’s study [24] showed that obese children who are victims of bullying at
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Eating Disorders in Obese Children a young age become more openly aggressive and active in joining bullying behaviors when they are teenagers. We would like to highlight that 40% of obese children in our study were at clinical risk on the Total Problems scale, thus showing a high degree of psychological distress related to their condition. We believe that obesity is not related to a specific psychopathology but may contribute to bringing about a general sense of distress that touches many different psychoaffective dimensions of personal and social life.
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CONCLUSIONS Our study presents new evidence of the relationship between obesity in preadolescence and adolescence, a crucial time for psychosomatic changes, and the development of eating disorders and psychopathological traits, thus highlighting the complex and multifaceted nature of this medical condition. Our data confirm the primary role for emotional eating in the dynamic interplay among traits, symptoms, and conducts associated with obesity. Our study has shown that obese preadolescents display behaviors, thoughts, and personality traits that may significantly differ from nonobese peers and that are nearer to those presented by ED subjects. They can also present a broad range of psychopathological problems, different in quality and intensity but clinically significant. An effective assessment of dysfunctional traits with relation to food intake, self and body image, and relationship with others should take place in the preadolescent years. The EDI-2 has shown to be an effective and adequate tool for screening, but other, more specific screening tools, especially for bulimia and BED, may be recommended. Evaluation of obese preadolescents and adolescents must also include an assessment of psychopathological problems, which cannot go undetected or left untreated, because they are highly prevalent in this population and harmful for the patient’s well-being. We acknowledge limitations in the study, such as the impossibility of determining the direction of causality in the above-mentioned relationships and the absence of a follow-up study, which would have effectively assessed how many of the at-risk children had in fact developed an eating disorder and of what type. Our future research will be aimed at a better understanding of the many factors involved in adaptive and maladaptive eating development, in order to render more visible the complex dynamics underlying obesity as a medical and psychosocial condition and in order to identify effective clinical interventions.
ACKNOWLEDGMENTS We are grateful to Paula Lavis at the Mental Health Institute, London, and Paolo Varricchio, Assistant Professor at Rutgers New Jersey Medical School, Newark, New Jersey, for careful editing of the article.
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Received December 16, 2013; accepted June 19, 2014.
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