JOURNAL OF AMERICAN COLLEGE HEALTH, VOL. 62, NO. 8

Major Article

Patterns of Compensatory Behaviors and Disordered Eating in College Students Katherine Schaumberg, PhD; Lisa M. Anderson, BA; Erin Reilly, MA; Drew A. Anderson, PhD

Abstract. Objective: The current study investigated rates of endorsement of eating-related compensatory behaviors within a college sample. Participants: This sample included male and female students (N D 1,158). Methods: Participants completed the Eating Disorder Examination Questionnaire (EDE-Q). The study defined 3 groups of students: those who did not endorse purging behaviors, those who endorsed only exercise, and those who endorsed laxative use or vomiting. Rates of related eating disorder risk variables were compared across the 3 groups. Results: Almost half of college students reported utilizing exercise as a compensatory strategy over the past 28 days. Those reporting compensatory exercise did not differ from other community and college samples on EDE-Q subscales. Conclusions: Findings suggest that college students report significant rates of compensatory exercise, and those who report exercise as their only compensatory behavior also report relatively low levels of eating disorder risk.

behaviors, such as laxative use, self-induced vomiting, and exercise with intent to influence one’s body shape or weight, are often observed as clinically significant features of eating disorders. Research suggests that engaging in purging (ie, self-induced vomiting or laxative use) and nonpurging (ie, exercising, fasting) compensatory behaviors are consistently associated with elevated eating disorder symptomatology and general psychopathology reported within clinical samples.5–7 For instance, engagement in compensatory behaviors also relates to poorer treatment outcomes and faster time to relapse for individuals with disordered eating.8–10 In addition, laxative use, driven exercise, and subjective bulimic episodes predicted elevated psychological distress within a community-based sample of obese young women.11 Thus, it follows that individuals who engage in compensatory behaviors for the sake of influencing shape or weight are a high-risk group for developing eating disorders and related psychological difficulties.6 Further investigations have indicated that the use of multiple compensatory methods, as well as the frequency with which one engages in such behaviors, may be associated with greater eating disorder risk and symptom severity.12 One study found that treatment-seeking youth reporting multiple methods of compensatory behaviors had significantly greater eating disorder and general psychopathology than those who reported using only 1 or no compensatory behavior methods. In another investigation, adults who endorsed multiple methods of compensatory behaviors had significantly more severe eating disorder symptoms and elevated general psychopathology as compared with individuals who engaged in a single compensatory behavior type.13 Overall, individuals who endorse multiple methods of compensatory behaviors appear to show significantly worse eating disorder symptom severity and elevated general psychopathology,

Keywords: eating disorders, mental health, nutrition

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ecent studies indicate that eating disorder prevalence rates are high among college students.1 Furthermore, college may also be a sensitive period for weight gain, placing individuals at risk for obesity.2 In response, there has been recent interest in developing and implementing effective eating disorder and obesity prevention programs within college populations.3,4 As college health researchers and professionals work to develop efficacious intervention programs, one important consideration includes establishing an understanding of the prevalence and impact of specific eating and exercise patterns in college students. Behaviors that are particularly relevant in disordered eating include compensatory behaviors. Compensatory Dr Schaumberg, Ms Anderson, Ms Reilly, and Dr Anderson are with the Department of Psychology at the University at Albany, State University of New York, in Albany, New York. Copyright Ó 2014 Taylor & Francis Group, LLC 526

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suggesting that differences in compensatory behavior patterns can impact the severity of risk. Some evidence also suggests that specific compensatory behaviors may be associated with different eating disorder risk profiles. In particular, differences in symptom severity and psychopathology risk may also be associated with the character of compensatory behaviors used. For instance, one study found that self-induced vomiting evidenced stronger associations with severe eating disorder and general psychopathology than other compensatory behaviors.8 Although some researchers have examined the difference between bulimia nervosa (BN) binge-purge and nonpurge subtypes, a review of such studies deemed the current literature inconclusive.14 Thus, the nature of the relationship between nonpurging compensatory behaviors and elevated psychopathology is not definitive. One compensatory behavior that is common in college students and may also represent a differential risk profile for the development of eating disorders is exercise. One recent study, for instance, reported a 25% prevalence rate of eating disorders within female college athletes, with a majority of individuals endorsing use of exercise as a means for controlling body weight over and above any other form of eating-disordered behavior, including fasting, vomiting, and use of laxatives or diuretics.15 Although this sample was drawn from athletes, it reflects an interesting trend that has also been noted in studies looking at nonathletic samples—frequent exercise appears to be positively associated with eating disorder symptoms among college students.1 Furthermore, studies that have examined the profile of eating disorders not otherwise specified (ED-NOS) in college students indicate that college women with this diagnosis often engage in daily exercise.16,17 Notably, one study examining ED-NOS found that exercise for weight control was the only compensatory behavior to be endorsed by women without clinically significant eating problems, although it was endorsed at a lower rate for those who were not seeking counseling and those without eating problems as compared with women who were seeking counseling.17 Exercise differs from other compensatory behaviors, such as vomiting and laxative use, as moderate amounts of exercise are generally considered part of a healthy lifestyle.18 Exercise is recommended to maintain physical health,19 and is associated with positive mental health outcomes.20,21 In addition, previous studies of the relationship between exercise and eating pathology in college students indicate that this relationship is complex.22, 23 One study, for instance, found that exercise might not indicate the presence of eating and body image concerns in college students in the absence of negative affect–related motivation for this exercise.22 Another examination of college students found that, for men, exercise was only related to positive affect. In women, however, exercise related to positive outcomes for individuals who did not endorse eating problems, but negative outcomes for women who did endorse other eating problems.23 In another sample of college-aged women, researchers found that women who engaged in substantial VOL 62, NOVEMBER/DECEMBER 2014

amounts of obligatory exercise generally fell into 2 groups: one group that showed signs of eating disorders and psychological distress and another group that evidenced very low levels of eating disturbance and psychological distress.24 In this study, individuals who exercised at high rates and evidenced high risk for eating disorders were also more likely to score high on an Exercise Fixation subscale of the Obligatory Exercise Questionnaire.24 Altogether, results from such studies indicate that some, but not all, collegeaged individuals who engage in high levels of exercise are at risk for the development of pathological eating patterns. In addition to exercise’s complex relationship with problematic eating patterns in college students, recent studies also purport that exercise relates to other problematic health behaviors, namely, alcohol consumption, in college populations.25 This relationship between weight control behavior and problematic drinking patterns includes the use of weight control behaviors to compensate or prepare for calories ingested through alcohol. Findings from investigations of this phenomenon indicated that strength training and vigorous intensity exercise related to increased odds of binge drinking, whereas moderate exercise related to reduced odds of binge drinking. Other compensatory behaviors, including using laxatives or vomiting, also related to binge drinking, and did so at a much higher rate as compared with exercise. Furthermore, the relationship between problematic eating and exercise patterns may depend on gender.26 Altogether, further investigation of the relationship between self-defined excessive exercise and problematic eating patterns could be of use for an understanding of multiple college health issues. Also of interest, college students may be likely to endorse greater levels of compensatory behaviors on selfreport measures. Many studies, for instance, find that individuals are likely to report greater amounts of problematic eating patterns on the Eating Disorder Examination Questionnaire (EDE-Q) compared with the Eating Disorder Examination (EDE) interview.27–29 No studies have currently examined whether a college sample may be particularly prone to overreporting exercise as a compensatory behavior on an eating disorder screening measure such as the EDE-Q, although this seems possible, as high levels of exercise are generally culturally sanctioned. Because compensatory behaviors are often considered to be clinically distinguishing factors for individuals with eating pathology, evaluating the relationship between severity of eating pathology and compensatory behavior type in nonclinical samples can inform the specific risk profiles for developing an eating disorder. For instance, it remains unclear whether differences in the nature of compensatory behaviors (exercise versus purging behaviors) place individuals at different risk for developing and maintaining disordered eating pathology. Furthermore, researchers have identified young adulthood, particularly for those who attend college, as time when individuals are at risk for weight gain.2 In response, there has been much interest in reducing risk for obesity during college,30 and interventions 527

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that aim to prevent or treat obesity typically promote exercise.31 Thus, it is important to examine whether the promotion of exercise for weight management in college students could inadvertently lead to problematic patterns of exercise, and whether increasing levels of exercise may put individuals at risk for eating pathology. Because college students represent a group with elevated eating pathology risk, the current study sought to establish whether the presence of compensatory behaviors, particularly regarding the presence of exercise only versus purging behaviors, would reflect differences in eating disorder risk profiles within a sample of male and female college students. METHODS Participants and Procedure Data were collected from 1,158 undergraduate male and female (57.1%) participants. Data were compiled from 4 studies conducted at a large northeastern university in the United States between 2009 and 2012. In all studies, participants attended a single appointment in which they completed an informed consent procedure and, immediately thereafter, completed a series of survey measures, including the EDE-Q. All studies were approved by the university’s institutional review board. Mean EDE-Q score did not differ depending on which study participants completed.

Measures Eating Disorder Examination Questionnaire Self-reported binge eating and compensatory behaviors were measured by the EDE-Q,32 a 28-item self-report questionnaire that was developed from the “gold standard” EDE interview.33 The EDE-Q is similar to the EDE interview in that it uses almost identical language and rating scales to assess eating behaviors and attitudes over a 4-week timeframe. The questionnaire is composed of 4 subscales that assess the same constructs as the EDE interview: Dietary Restraint, Shape Concern, Weight Concern, and Eating Concern. Examples of questions from each subscale include “Have you been consciously trying to restrict the amount of food you eat to influence your shape or weight?” (Dietary Restraint), “Has your shape influenced how you think about (judge) yourself as a person?” (Shape Concern), “How dissatisfied have you felt about your weight?” (Weight Concern), and “Has thinking about food, eating or calories made it very difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)?” (Eating Concern). Questions from these subscales are rated on a Likert scale from either 0 (not at all) to 6 (markedly) or 0 (no days over the past 28) to 6 (every day in the past 28 days), whichever is appropriate to the question. In questions that are rated from no days to every day, other options for answers represent a number of days over the past 28 days that the participant has engaged in this behavior. To obtain subscale scores, the ratings for 528

relevant items are added together and divided by the sum of items that form the subscale. Subscales, thus, represent continuous variables. In addition to the 4 subscales, the measure inquires about the presence of binge episodes or use of compensatory behaviors over the past 28 days. The EDE-Q also asks individuals to self-report height, weight, and, for females, recent menstrual status. Scores for the EDE-Q have evidenced good internal consistency for each of the 4 subscales in both community and clinical samples of women.34–36, In the current study, the internal consistency for the subscales was very good (Shape Concern: a D .91; Weight Concern: a D .85; Eating Concern: a D .81; Dietary Restraint: a D .85). Adequate concurrent validity for the EDE-Q has been established across clinical and community-based samples, with generally strong agreement between the questionnaire and its predecessor, the EDE interview.32,37 Additionally, the EDE-Q has demonstrated good predictive validity, accurately distinguishing between individuals with and without eating disorder psychopathology.33,35

Data Analysis For analysis, participants were divided into 3 groups based on self-report of compensatory behavior usage in the past 28 days: individuals who did not endorse any compensatory behaviors (n D 612), individuals who endorsed exercise as their only compensatory behavior (n D 425), and individuals who endorsed laxative use or vomiting (n D 121). Exercise appears to be the most frequent compensatory behavior strategy endorsed by college students.1,15,25 Furthermore, exercise differs from other compensatory behaviors in that it is associated with both positive and negative outcomes.22,23 The 3 groups were chosen in the current study in order to determine if individuals who only endorsed excessive exercise as a compensatory behavior differed in body mass index (BMI) and eating disorder risk as compared with those who endorsed other types of compensatory behaviors or those who endorsed no compensatory behaviors. First, we examined differences in self-reported BMI in the 3 groups utilizing an analysis of variance (ANOVA) approach in order to examine whether individuals who only engaged in exercise as compensatory behavior differed in other areas of eating disorder risk from individuals who did not engage in any compensatory behaviors and those who reported laxative use and vomiting over the past 28 days. Additionally, 3 groups’ mean scores on the 4 subscales of the EDE-Q were compared utilizing an ANCOVA approach, which included gender and weight status as covariates. Significant differences between these 3 groups were followed up by contrasting individuals who reported compensatory behaviors and those who did not through independent-samples t tests. We also investigated whether individuals who endorsed only exercise differed from individuals who endorsed other compensatory behaviors JOURNAL OF AMERICAN COLLEGE HEALTH

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TABLE 1. Means and Standard Deviations From the Eating Disorder Examination Questionnaire Binge episodes Sample

n

No purging 612 Exercise only 425 Laxative or diuretic 121 use/vomiting Overall sample 1,158 Comparison samples 723 Undergraduate womena Undergraduate menb 404 Community womenc 235 935 Eating-disordered womenc

Female (%)

M

SD

52.5 59.6 71.1

1.43 2.67 4.95

3.36 4.03 6.05

57.1

2.26

4.11

BMI M

SD

EC M

WC SD

M

SD

SC M

Dietary Restraint SD

EDE-Q Avg

M

SD

M

SD

22.03 3.86 0.28 0.62 1.18 1.38 1.38 1.43 23.71 4.03 0.76 0.99 2.15 1.59 2.53 1.60 23.06 4.44 1.66 1.43 2.78 1.68 3.11 1.74

0.64 1.66 2.27

1.05 1.40 1.69

0.85 1.77 2.46

0.98 1.24 1.51

22.78 4.06 0.60 0.97 1.71 1.61 1.99 1.67

1.19

1.40

1.35

1.28

100

1.11 1.11 1.97 1.56 2.27 1.54

1.62

1.54

1.74

1.30

0.0 100 100

0.43 0.77 1.29 1.27 1.59 1.38

1.04

1.19

1.09 0.93 4.02

1.00 0.86 1.28

Note. BMI D body mass index; EC D Eating Concern; WC D Weight Concern; SC D Shape Concern; EDE-Q Avg D average score from the Eating Disorder Examination Questionnaire. All scores reported from the EDE-Q. a Luce et al.39 b Lavender et al.40 c Aardoom et al.41

utilizing t tests. Evaluation of differences between groups on these subscales was the primary analysis of the current investigation. In addition to examining whether these 3 groups differed from one another, we also examined whether frequency of excessive exercise predicted scores on each of the EDE-Q subscales within the excessive exercise only group by evaluating the bivariate correlations between exercise frequency and subscale scores. Means and standard deviations for eating disorder risk variables in each group are presented in Table 1. As groups displayed unequal variances and variables were positively skewed, variables were inverse transformed prior to analyses. Lastly, scores garnered from previous studies that provided EDE-Q normative values for clinical and nonclinical samples were compared with results from the current sample RESULTS Level of Compensatory Behavior Endorsement Overall, nearly half of participants (47.8%) in this sample of undergraduate men and women indicated that they had engaged in a compensatory behavior at least once over the past 28 days. This is slightly higher than previously reported rates of compensatory exercise from within other college samples.36 Of the individuals who had engaged in compensatory behaviors, 79.3% reported exercise as their only compensatory behavior. In this group of individuals who reported exercise as their only compensatory behavior, the median number of days over the last 28 days that individuals reported this behavior was 7, with a mean of 9.27 § 7.67 days. Based on the frequency of compensatory behaviors, 68.8% self-reported compensatory exercisers in this VOL 62, NOVEMBER/DECEMBER 2014

sample would meet a key criterion for a diagnosis of BN— an average use of compensatory behavior strategies of at least once per week.38

BMI and Gender Overall, the groups showed significant differences on level of BMI along with the percentage of individuals in each category who were classified as overweight. According to self-report, 15.3% of individuals who did not report compensatory behaviors were also overweight, compared with 28.9% of participants who reported exercise as their only compensatory strategy and 24% of individuals who reported laxative use or vomiting. This represented a significant difference between the 3 groups, x2(2, 1158) D 28.53, p < .001, Cramer’s V D .16. Individuals who reported any compensatory behaviors over the previous 28 days were more likely to be overweight than those who did not report compensatory behavior use, t(1158) D 2.66, p D .004, d D .16, although individuals who endorsed exercise as their only compensatory did not differ in their BMI from those who reported other compensatory behaviors. Within the group of individuals who reported excessive exercise as their only compensatory behavior, frequency of excessive exercise was unrelated to BMI, r D .004, p D .95. Weight status for each participant was dichotomized as healthy weight (BMI < 25.00) or overweight (BMI  25.00) and was entered as a covariate in additional analyses. Gender also varied across the 3 groups, x2(2, 1158) D 14.90, p D .001, Cramer’s V D .11. Individuals who reported compensatory behaviors, particularly those who reported purging through vomiting and laxative use, were more likely to be female. Because women report higher 529

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levels of eating disorder risk,31 gender was entered as a covariate in subsequent analyses.

Frequency of Binge Eating In examining between group differences on eating pathology variables, we first examined the reported frequency of binge eating among participants. Overall, there was a relationship between use of compensatory behaviors and binge eating, F(2, 1149) D 37.04, p < .001, h 2p D .06. Contrasts indicate that individuals who reported compensatory behaviors of any kind also reported more frequent episodes of binge eating than those who did not report compensatory behaviors, t(1153) D 7.34, p < .001, d D .43. In addition, individuals who reported laxative use and vomiting evidenced a greater average number of binge eating episodes than individuals who only reported compensatory exercise, t(543) D 4.71, p < .001, d D .40. Within the group of individuals who reported excessive exercise as their only compensatory behavior, frequency of excessive exercise was unrelated to frequency of binge eating, r D .09, p D .07.

Shape Concern Individuals also varied in their level of shape concern across compensatory behavior group, F(2, 1152) D 89.65, p < .001, h 2p D .13. Follow-up contrasts indicated that individuals who engaged in compensatory behaviors reported more shape concern than those who did not, t(1156) D 14.16, p < .001, d D .83, and those who reported laxative use and vomiting also reported significantly more shape concern than those who reported only exercising as a compensatory behavior, t(544) D 3.46, p D .001, d D .29. Within the group of individuals who reported excessive exercise as their only compensatory behavior, frequency of excessive exercise was unrelated to shape concern, r D .04, p D .41.

Weight Concern With regards to weight concern, the 3 groups again differed, F(2, 1152) D 68.46, p < .001, h 2p D .11. In addition, individuals who reported engaging in compensatory behaviors also reported more weight concern than those who did not, t(1156) D 12.56 p < .001, d D .74, and individuals who reported laxative use and/or vomiting reported more weight concern than those who only engaged in exercise as a compensatory behavior, t(545) D 3.67, p < .001, d D .31. Within the group of individuals who reported excessive exercise as their only compensatory behavior, frequency of excessive exercise did not relate to weight concern, r D .06, p D .22. 530

Eating Concern With regards to eating concern, again, groups classified by compensatory behavior use differed from one another, F (2, 1140) D 118.56, p < .001, h 2p D .17. Individuals who engaged in compensatory behaviors showed higher eating concern than those who did not, t(1144) D 12.58, p < .001, d D .74, and those who engaged in laxative use and vomiting displayed higher levels of eating concern than those who only reported exercise, t(538) D 7.78, p < .001, d D .67. Within the group of individuals who reported excessive exercise as their only compensatory behavior, frequency of excessive exercise did not relate to eating concern, r D .06, p D .26.

Dietary Restraint The expected pattern of results persisted for dietary restraint, with the 3 compensatory behavior groups again differing from one another, F(2, 1145) D 110.32, p < .001, h 2p D .16, and compensatory behavior users showing greater restraint than those who had not used compensatory behaviors, t(1148) D 15.30, p < .001, d D .90. Again, those who reported laxative use and/or vomiting reporting more dietary restraint than those who only reported exercise, t(539) D 3.92, p < .001, d D .34. Within the group of individuals who reported excessive exercise as their only compensatory behavior, frequency of excessive exercise was correlated with dietary restraint, r D .24, p < .001.

Comparison of Group Means With Community and Clinical Norms Table 1 also presents EDE-Q means from samples of community women, undergraduate men and women, and a clinical sample of individuals with eating disorders. Altogether, the current sample of individuals reported similar levels of eating pathology to a sample of community women along with undergraduate samples.39,40 Furthermore, the overall sample along with all subgroups evidenced lower scores on the EDE-Q than women with eating disorders.41 With regards to subgroups, individuals who did not engage in compensatory behaviors had a lower average EDE-Q global score than other undergraduate samples.39–41 Individuals who engaged in only exercise as a method of purging evidenced similar EDE-Q global scores as compared with undergraduate women, and participants who engaged in purging through laxative use and/or vomiting reported slightly higher EDE-Q global scores as compared with undergraduate men and women,39–40 although this subsample, as noted, reported lower scores than a clinical sample of individuals with eating disorders.41 Next, we examined the clinical significance of differences between the current sample and previously reported EDE-Q means. Differences between samples were considered clinically meaningful if the average EDE-Q global JOURNAL OF AMERICAN COLLEGE HEALTH

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scores from each subgroup in the current study exceeded 1 standard deviation from the other sample means. In regards to individuals who reported only engaging in exercise, mean scores from this sample for the EDE-Q were within 1 standard deviation of comparison undergraduate samples composed of women and men, and a comparison sample of community women.39–41 Thus, individuals reporting exercise as their only compensatory strategy evidence similar rates of disordered eating as other undergraduate and community samples. In addition, the EDE-Q average for this sample remained well below 1 standard deviation from the EDE-Q average for a clinical sample of eating-disordered women. Therefore, it may be concluded that clinically significant differences exist between levels of eating pathology in individuals who report exercise as their only compensatory strategy and clinical samples of individuals with eating disorders. Individuals who endorsed laxative use or vomiting evidenced scores on the EDE-Q that were within 1 standard deviation of scores from a sample of college women, although they evidenced scores that were greater than a sample of college men and a sample of community women. Individuals in this study who endorsed laxative use or vomiting also reported scores that were, on average, greater than 1 standard deviation below the EDEQ average for a clinical sample of individuals with eating disorders. Overall, a comparison of the current sample with previous reports indicates that individuals who were engaging in exercise as their only compensatory behavior reported similar levels of eating pathology with other nonclinical samples, whereas individuals reporting laxative use or vomiting appear at higher risk than some subsets of the general population, but with lower levels of eating pathology as compared with a clinical sample. COMMENT Participants in the current study reported significant levels of compensatory exercise. The rates of compensatory exercise in this sample of college individuals appear alarming at first glance; however, it is possible that some individuals who reported engaging in this compensatory behavior strategy may not be at high risk for developing full-syndrome eating pathology. Overall, individuals in this sample who reported compensatory behaviors reported higher levels of eating disorder risk as compared with individuals who did not engage in compensatory behaviors. Furthermore, the distinction of individuals who utilized exercise as compared with vomiting and laxative use was useful in that the latter group reported the highest scores on the EDE-Q. Individuals who reported compensatory exercise appeared to score similarly on the EDE-Q to other nonclinical undergraduate samples, despite the fact that many of these individuals reported rates of compensatory behaviors that would meet qualifications for the diagnosis of BN, particularly as the number of bulimic episodes required per week to meet diagnostic criteria has been reduced to once per week in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.38 Furthermore, within the group of VOL 62, NOVEMBER/DECEMBER 2014

individuals who reported exercise as their only compensatory method, frequency of exercise was not related to eating shape concern, weight concern, eating concern, frequency of binge eating, or BMI. Frequency of exercise was somewhat related to dietary restraint. The fact that presence, but not frequency, of engaging in exercise as a compensatory behavior related to level of eating disorder risk is an interesting finding. This suggests that qualities of individuals who choose to engage in exercise as a compensatory strategy may be more important in predicting eating disorder risk as compared with the compensatory exercise itself. As interventions that aim to reduce obesity risk include exercise as a key component,20 it is important to evaluate whether encouraging physical activity for weight management in college students is likely to lead to problematic patterns of exercise, and whether increasing levels of exercise may put individuals at risk for eating pathology. Notably, exercisers in our sample reported higher, not lower, BMI than those who did not engage in compensatory exercise. This correlation could relate to many factors, including increased muscle mass, greater motivation for exercise among overweight individuals, or the failure of exercise as a compensatory strategy, and should be examined prospectively.

Limitations The current study has several limitations due to the crosssectional design. As such, findings have multiple interpretations that must be evaluated in future research. With regards to the rates of exercise reported in the current study, it is possible that individuals overreported exercise as a compensatory behavior on the EDE-Q. Whereas vomiting and laxative use may be underreported on questionnaire measures,42 exercising represents a more culturally sanctioned method of weight control. Thus, individuals may be more likely to engage in this compensatory behavior and also more likely to report this behavior. It is possible that, due to self-presentation bias, exercise may even be overreported, although current research on the relationship between social desirability and self-reports of exercise indicate minimal relationship between these constructs.43 In addition, individuals may be confused about the wording of this particular question on the EDE-Q. The specific question asks, “Over the past 28 days, how many times have you exercised in a “driven” or “compulsive” way as a means of controlling your weight, shape or amount of fat, or to burn off calories?” It is possible that individuals who are engaging in exercise for weight management may endorse this question, regardless of the intensity and duration in which they exercise. Comparing responses on this specific question to an interview version may be beneficial to aid in determining whether individuals are accurately reporting problematic exercise on the EDE-Q. As an alternative interpretation of the current results, the rates reported by individuals in the current study may be accurate, in 531

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which case many college-aged individuals appear to be at risk for engaging in problematic patterns of exercise.

FUNDING No funding was used to support this research and/or the preparation of the manuscript.

Conclusions College students reported utilizing exercise as a compensatory behavior at high rates in the current study. Overall, these individuals also reported low levels of eating pathology. As such, it follows that the utilization of exercise as a compensatory strategy does not always promote other forms of eating pathology in college students. Studies find that individuals have a variety of motivations for engaging in exercise, some relating to positive and others relating to negative psychological health.21 One recent study, for instance, found that vigorous physical activity relates to positive mental health and lower perceived stress in college students.44 In addition, exercise differs from other compensatory behaviors in that moderate amounts of exercise produce physical and mental health benefits. Future research should attempt to differentiate healthy from unhealthy patterns of and motives for exercise in college students in a concise manner in order to identify individuals who may be at risk for eating pathology and other health issues. Altogether, this investigation provides an exploration into the relationship between self-reports of compensatory behaviors and eating disorder risk in college students. Nearly half of college individuals in a large sample reported compensatory exercise. Given the complicated nature of exercise and general acceptance of moderate to more extreme physical activity as a method for weight and general health maintenance, these results should not necessarily function as an alarm, but, rather, a signal towards the need for future research. Furthermore, college health professionals should consider exercise as a behavior that could have both healthy and unhealthy correlates. As such, individualized evaluation of eating disorder risk associated with utilizing exercise as a weight maintenance strategy seems prudent. In the current study, those who engage in compensatory exercise appear, overall, to be at moderate risk for eating pathology, but less so than individuals reporting other compensatory strategies. The current study highlights the value of considering exercise as a distinct compensatory behavior and prompts future investigations to continue to clarify what constitutes healthy versus unhealthy patterns of exercise in college students. In sum, college students may be at high risk of engaging compensatory exercise behaviors. Increased awareness of the potential relationships with compensatory exercise may enable college counselors and health providers to design college programming to promote adaptive collegiate lifestyle choices. Additionally, gaining a more nuanced perspective of which college students may be at risk for engaging in maladaptive behaviors as well as how various risk factors interact should impact college programming efforts.

CONFLICT OF INTEREST DISCLOSURE

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The authors have no conflicts of interest to report. The authors confirm that the research presented in this article met the ethical guidelines, including adherence to the legal requirements, of the United States and received approval from the Institutional Review Board of the University at Albany, State University of New York. NOTE For comments and further information, address correspondence to Katherine Schaumberg, Department of Psychology, University at Albany, State University of New York, 1400 Washington Avenue, Albany, NY 12222, USA (e-mail: [email protected]). REFERENCES 1. Eisenberg D, Nicklett EJ, Roeder K, Kirz NE. Eating disorder symptoms among college students: prevalence, persistence, correlates, and treatment-seeking. J Am Coll Health. 2011;59:700–707. 2. Delinsky SS, Wilson GT. Weight gain, dietary restraint, and disordered eating in the freshman year of college. Eat Behav. 2008;9:82–90. 3. Jones M, Kass AE, Trockel M, Glass AI, Wilfley DE, Taylor CB. A population-wide screening and tailored intervention platform for eating disorders on college campuses: the healthy body image program. J Am Coll Health. 2014;62:351–356. 4. Stice E, Rohde P, Shaw H, Marti CN. Efficacy trial of a selective prevention program targeting both eating disorders and obesity among female college students: 1- and 2-year follow-up effects. J Consult Clin Psychol. 2013;81:183–189. 5. Mond JJ, Hay PJ, Rodgers B, Owen C, Mitchell J. Correlates of the use of purging and non-purging methods of weight control in a community sample of women. Aust N Z J Psychiatry. 2006;40:136–142. 6. Abebe DS, Lien L, Torgersen L, von Soest T. Binge eating, purging and non-purging compensatory behaviours decrease from adolescence to adulthood: a population-based, longitudinal study. BMC Public Health. 2012;12:Article 32. 7. Ghaderi A. Structural modeling analysis of prospective risk factors for eating disorder. Eat Behav. 2003;3:387–396. 8. Dalle Grave R, Calugi S, Marchesini G. Self-induced vomiting in eating disorders: associated features and treatment outcome. Behav Res Ther. 2009;47:680–684. 9. Olmsted MP, Kaplan AS, Rockert W. Rate and prediction of relapse in bulimia nervosa. Am J Psychiatry. 1994;151:738– 743. 10. Støving RK, Andries A, Brixen KT, Bilenberg N, Lichtenstein MB, Hørder K. Purging behavior in anorexia nervosa and eating disorder not otherwise specified: a retrospective cohort study. Psychiatry Res. 2012;198:253–258. 11. Mond JM, Rodgers B, Hay PJ, et al. Obesity and impairment in psychosocial functioning in women: the mediating role of eating disorder features. Obesity. 2007;15:2769–2779. 12. Stiles C, Shields E, Labuschagne Z, Goldschmidt AB, Doyle AC, Grange DL. The use of multiple methods of compensatory behaviors as an indicator of eating disorder severity in treatment-seeking youth. Int J Eat Disord. 2012;45:704–710. JOURNAL OF AMERICAN COLLEGE HEALTH

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Received: 5 November 2013 Revised: 15 April 2014 Accepted: 22 May 2014

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