Eating Disorder Symptoms: Differences among Ethnic Groups

Dr. David Herzog, Emeritus Professor of Psychiatry at Harvard Medical School, is an internationally renowned expert on eating disorders.  He founded and directed the Harvard Eating Disorders Center, which later became the Harris Center for Education and Advocacy in Eating Disorders at Massachusetts General Hospital.

Detection of high-risk attitudes and behaviors is critical in the goal of preventing eating disorders. In 1996, the National Eating Disorders Screening Program (NEDSP) was launched on 409 college campuses across the United States. The NEDSP reached a diverse student population and used a self-report screening questionnaire to identify those at risk for eating disorders.  NEDSP participants were offered an opportunity to meet with an on-site counselor to review their responses to the questionnaire in order to receive a recommendation for what, if any, further clinical evaluation would be necessary.

Dr. Herzog and his team analyzed data from 5,435 NEDSP questionnaires for a study of ethnic differences in the prevalence of eating disorder symptoms and related distress. Questionnaire items assessed the presence and frequency of restrictive eating, amenorrhea, binge eating, self-induced vomiting, use of laxatives and diuretics, and potentially problematic exercise behaviors. Three questions were used to measure distress related to the reported symptoms. Participants were asked to select the best response on 4-point scales ranging from ‘‘never’’ to ‘‘all of the time’’ reflecting the degree to which eating and weight concerns (a) caused a great deal of distress, (b) interfered with relationships, and (c) interfered with academic/work performance.

The frequency of binge eating, restrictive eating, vomiting, and amenorrhea

did not differ significantly across ethnic groups.  However, significant between-group differences were found with respect to modes of purging. Binge correlates (such as eating until uncomfortably full) were significantly more frequent among Caucasian than African American participants. Binge eating was the best predictor of distress among Caucasians, African Americans, and Latinos, whereas vomiting was the best predictor of distress among Asians. Asian participants who used laxatives were significantly less likely to receive a recommendation for further evaluation than non-Asian participants.

The findings suggest there may be some important differences among ethnic groups in regard to eating disorder symptoms, symptom-related distress, and likelihood for referral that merit further investigation. Clinician recognition of this

potential diversity may enhance culturally competent care for eating disorders.

Pregnancy and Eating Disorders

Dr. David Herzog was the first Endowed Professor of Psychiatry in the Field of Eating Disorders at Harvard Medical School. He is board certified in pediatrics, child and adolescent psychiatry and general psychiatry and has treated over 3,000 individuals with anorexia nervosa, bulimia nervosa, and associated diagnoses. Dr. Herzog founded and directed the Harvard Eating Disorders Center, which later became the Harris Center for Education and Advocacy in Eating Disorders at Massachusetts General Hospital. 

In 1987, Dr Herzog initiated his National Institute of Mental Health-funded Longitudinal Study of Anorexia and Bulimia Nervosa, mapping the course and outcome in 246 women followed at frequent intervals. The Longitudinal Study – the largest and most extensive of its kind – has provided a better understanding of how anorexia and bulimia progress, including rates of recovery and relapse, medical consequences, associated psychiatric illnesses, the quality of patients’ relationships, and functioning at school or at work.

As part of the Longitudinal Study, Dr. Herzog and his team examined the course of pregnancy and neonatal status for babies born to women with eating disorders. Forty-nine live births were included.  The participants were interviewed by trained assistants and completed a brief self-report questionnaire that assessed both birth statistics and birth-related complications. Medical records and/or self-report data describing the babies’ birth status were obtained.

The researchers found that women with eating disorders who regain their health prior to conception and remain nutritionally stable throughout pregnancy are not more prone to obstetrical problems than those who have never had an eating disorder. However, engaging in abnormal weight control behaviors during pregnancy can increase the risk of complications such as miscarriage, premature delivery, Cesarean delivery, low-birth-weight babies, and postpartum depression.

The results of this study emphasized the importance of viewing pregnant women with past or current eating disorders as high risk and monitoring them closely both during and after pregnancy to optimize maternal and fetal outcomes.

Weight Suppression and Bulimia Nervosa

Dr. David Herzog, Emeritus Professor of Psychiatry at Harvard Medical School, is a renowned expert on eating disorders.  He is a distinguished researcher, teacher, clinician and advocate and is the recipient of many honors and awards. Dr. Herzog was the first Endowed Professor of Psychiatry in the Field of Eating Disorders at Harvard Medical School. In 1994, he founded the Harvard Eating Disorders Center, which later became the Harris Center for Education and Advocacy in Eating Disorders at Massachusetts General Hospital.

Dr. Herzog collaborated with researchers at Drexel University in Philadelphia to investigate the role of weight suppression in predicting recovery or relapse in bulimia nervosa.  Weight suppression is defined as the difference between a patient’s past highest weight and her weight at entry into the study. The participants were 110 women with bulimia nervosa from Dr. Herzog’s National Institute of Mental Health-funded Longitudinal Study.  At study entry, these 110 participants were, on average, 25 years old and had been ill for an average of 6 years. The researchers collected data by interviewing the women at 6-12 month intervals over 8 years about their eating behaviors, mood symptoms, and general life functioning.

Weight suppression was significantly associated with time to first full remission, indicating that women who were more weight-suppressed at study entry took longer to recover. These results support previous research suggesting that high weight suppression may fuel binge eating and make weight gain more likely. Future research is needed to explore methods of improving treatment outcome for highly weight-suppressed individuals with bulimia nervosa.

Anorexia Nervosa and Stigma

Dr. David Herzog, Emeritus Professor of Psychiatry at Harvard Medical School, is an internationally respected scholar on eating disorders credited with over 280 publications.  He is board certified in pediatrics, child and adolescent psychiatry, and general psychiatry and has treated over 3,000 individuals with eating disorders such as anorexia and bulimia nervosa. He founded and directed the Harris Center for Education and Advocacy in Eating Disorders at Massachusetts General Hospital and, prior to that, the Harvard Eating Disorders Center.

Dr. David Herzog and his staff collaborated with Boston University to explore public stigma associated with eating disorders. In 2010, 173 college students were shown one of three videos describing anorexia as a product of either biology, culture, or an interaction between the two. 

Each video ran about 5 minutes and consisted of two parts. All three videos opened with the same two-minute segment, in which an average-weight actress portrays a young woman who has recovered from anorexia. She describes her descent into the disorder and the suffering she experienced while actively ill, including her self-loathing, impaired concentration, physical consequences, obsessionality, and social isolation. She also discusses her attempts to appear fine to the outside world while feeling miserable inside.

The second part of each video varied by condition, but each consisted of a three-minute segment in which a middle-aged actor portrays a doctor who is an expert on anorexia nervosa. In all conditions, the basic structure of the segment was the same, though specific content varied. First, the doctor describes the seriousness of anorexia. Next, he indicates that much debate surrounds the etiology of anorexia but that a great deal of evidence points to the role of (biological/sociocultural/both biological and sociocultural) factors in the development of the disorder. Then, he elaborates the research evidence supporting the roles of (biology/society/an interaction between biology and society) in the development of the disorder.

Finally, in each video, the expert states that anorexia can be treated but often requires a team of doctors and sometimes occurs in the context of hospitalization. He also says that "adequate insurance coverage and other supports for those with this disease are very much needed."

After watching the videos, the participants completed a questionnaire designed to measure which explanation evoked the least stigmatizing attitudes. Those who viewed the interaction video demonstrated less stigma than those who viewed the sociocultural video but more than those who viewed the biology video. The stigma against anorexia tended to be blame-based, meaning that the disorder was seen as the patient’s own doing.  Both the biological and the interaction groups showed more intention to engage in helping behavior than the sociocultural group.

The preponderance of empirical evidence points to anorexia as a product of an interaction between both biology and culture.  More research is needed to learn how to accurately portray the etiology of the disorder while, at the same time, trying to reduce stigma.

 

Alcohol Use Disorder and Eating Disorders

Dr. David Herzog – Emeritus Professor of Psychiatry at Harvard Medical School – has devoted much of his career to improving the lives of individuals with eating disorders.  He founded and directed the Harris Center for Education and Advocacy in Eating Disorders at Massachusetts General Hospital and was the first Endowed Professor of Psychiatry in the Field of Eating Disorders at Harvard Medical School. 

Dr. Herzog’s Longitudinal Study of Anorexia and Bulimia Nervosa is internationally recognized as the largest and most extensive of its kind.  Beginning in 1987, he and his staff followed 246 women with anorexia and bulimia, trying to determine how patients fare over time.  Who gets better and how?  What factors lead to a better or worse outcome?  Data was collected by interviewing the women every 6-12 months about their eating behaviors, physical and emotional health, employment and relationships. The study has provided key knowledge about how eating disorders and alcohol use disorder influence each other. 

Over one fourth of the sample reported a lifetime history of alcohol use disorder. Ten percent of the study subjects developed alcohol use disorder over the course of the study. Alcohol use disorder did not influence recovery from eating disorder symptoms; however, a number of eating disorder symptoms predicted both the onset and recovery from an episode of alcohol use disorder. Poor psychosocial functioning and history of substance use predicted prospective onset of an episode of alcohol use disorder for both anorexia and bulimia. Unique predictors for alcohol use disorder for women with anorexia were depression, overconcern with body image, and vomiting.  For the women with anorexia nervosa, group therapy and hospitalization were useful for recovery from an alcohol use episode.  For the women with bulimia nervosa, individual therapy and exercise shortened recovery time from an alcohol use episode.

Dr. Herzog and his team concluded from their study that serious problems with alcohol are not uncommon in patients with anorexia or bulimia, and alcohol intake should be monitored in all patients with eating disorders, regardless of specific diagnosis.  A substantial number of patients who initially present with an eating disorder develop alcohol problems over the course of time, suggesting that the risk is an ongoing one. 

Future research is needed to determine the best combination of treatment modalities when eating disorders and alcohol use disorder co-exist and to address what works best for whom.

 

Drug Abuse in Women with Eating Disorders

Dr. David Herzog, Emeritus Professor of Psychiatry at Harvard Medical School, founded and directed the Harvard Eating Disorders Center, which later became the Harris Center for Education and Advocacy in Eating Disorders at Massachusetts General Hospital.  Dr. Herzog’s Longitudinal Study of Anorexia and Bulimia Nervosa is internationally recognized as the largest and most extensive of its kind. Beginning in 1987, he and his staff followed 246 women with anorexia and bulimia to gain a better understanding of what happens to patients over time. They collected data by interviewing participants every 6-12 months about their eating behaviors, physical and emotional health, work and relationships. The study provided valuable information about the relationship between drug use disorder and eating disorders.

Forty-two (17.1%) of the 246 Longitudinal Study participants reported a lifetime history of drug use disorder. Of these 42 women, 22 (52.3%) had anorexia nervosa at intake and 20 (47.7%) had bulimia at intake. Of the 22 women with anorexia with a lifetime history of drug use disorder, 17 had a history of drug use disorder at entry into the study and of these, 4 had a prospective onset during the study. Five participants with anorexia developed a first episode of drug use disorder over the course of the study. Of the 20 participants with bulimia with a lifetime diagnosis of drug use disorder, 14 had a history of drug use disorder at intake into the study, and of these, 4 had a prospective onset during the course of the study, whereas 6 developed a new onset during the study. 

Dr. Herzog and his staff examined the degree to which participants who had a prospective onset of drug use disorder during the study also carried a diagnosis of affective disorder or alcohol use disorder during that same period. The data indicated that 12 of 19 participants (63.2%) had a co-occurring major depressive disorder episode and 6 of 19 participants (31.6%) had a diagnosis of hypomania during the drug use disorder episode. Seven of 19 participants (36.8%) had a co-occurring diagnosis of alcohol use disorder. 

The most commonly abused illicit drugs were amphetamines and cocaine (both of which have appetite suppressant effects) and marijuana.  Rates of drug use disorder did not differ between intake diagnoses of anorexia and bulimia. The finding that 5 of 22 participants with anorexia and 6 of 20 participants with bulimia were diagnosed with drug use disorder for the first time over the 9-year course of the study suggests that the risk for drug use disorder in women with eating disorders continues over time.

Dr. Herzog and his staff concluded from the study that drug abuse in women with eating disorders is an area of clinical concern and should be monitored routinely throughout the treatment process.