). Disordered eating and substance use in high school students: Results from the Youth Risk Behavior Surveillance System

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1 Wesleyan University From the SelectedWorks of Ruth Striegel Weissman 2008 ). Disordered eating and substance use in high school students: Results from the Youth Risk Behavior Surveillance System Ruth Striegel Weissman Available at:

2 SPECIAL SECTION ARTICLE Disordered Eating and Substance Use in High-School Students: Results from the Youth Risk Behavior Surveillance System Emily M. Pisetsky, BA Y. May Chao, MA Lisa C. Dierker, PhD Alexis M. May, BA Ruth H. Striegel-Moore, PhD* ABSTRACT Objective: To examine the association between disordered eating (fasting, diet product use, and vomiting or laxative use) and use of 10 substances (cigarettes, alcohol, marijuana, cocaine, inhalants, heroin, methamphetamines, ecstasy, steroids, and hallucinogens) in a nationally representative adolescent sample. Method: Participants were 13,917 U.S. high-school students participating in the 2005 Youth Risk Behavior Surveillance System. Results: Disordered eating was significantly associated with the use of each substance. Using effect size estimates that take base rates into consideration, for female students, associations between substance use and disordered eating were weak for all but three forms of substance use: current smoking, binge drinking, and inhalants. Among male students, strong (marijuana, steroids, and inhalants) or moderate effects (all other substances) were observed. Conclusion: Future research needs to focus on inhalant use and methamphetamine use in males. Increased medical attention should be directed toward adolescents who practice disordered eating behaviors because they are also at elevated risk for using cigarettes, alcohol, inhalants, methamphetamines, and steroids. VC 2008 by Wiley Periodicals, Inc. Keywords: eating disorders; substance use; comorbidity; bulimic behaviors; adolescents (Int J Eat Disord 2008; 41: ) Introduction The comorbidity of eating disorders and substance abuse has been widely demonstrated. It is estimated that about 12 18% of people with anorexia nervosa and 30 70% of individuals with bulimia nervosa abuse alcohol, tobacco, or other drugs (for a review, see Holderness et al. 1 ). This research, conducted mostly with adult women, has shown that more women with bulimia nervosa or the binge/purge subtype anorexia nervosa exhibit substance abuse than women with restricting anorexia nervosa or women with no eating disorder. 2 4 A few studies have included adolescent samples and, as is the case for adults, found elevated use of tobacco, illicit substances, and alcohol (the consumption of which, until age 21 years, is illegal in the United States), especially Accepted 16 December 2007 *Correspondence to: Ruth H. Striegel-Moore, PhD, Department of Psychology, Wesleyan University, 207 High Street, Middletown, CT rstriegel@wesleyan.edu Department of Psychology, Wesleyan University, Middletown, Connecticut Published online 17 March 2008 in Wiley InterScience ( DOI: /eat VC 2008 Wiley Periodicals, Inc. among those participants with bulimic spectrum symptoms. 5 7 Adolescence is the typical time of onset for eating disorders as well as substance use, and therefore this age group warrants further investigation. 8 The Youth Risk Behavior Surveillance System (YRBSS), with a sample size of over 13,000 adolescents and data on a wide variety of disordered eating behaviors and substance use, provides important information about this area. Alcoholhasbeenthemostcommonlystudied substance; consistently, elevated levels of alcohol use have been found among individuals who engage in binge eating. 1,5,6,9 Significant associations have also been reported between eating disorder symptoms, cigarette use, and nicotine dependence. 10,11 One study showed a relationship between binge eating and marijuana use. 6 With few exceptions, 2 studies of illicit drug use and eating disorders have not disaggregated specific substances but rather reported on any substance use. 12 Certain illicit substances may be particularly likely to be consumed by individuals with eating disorder or body image concerns because of their anorexic properties (e.g., methamphetamines, cocaine) or because they are specifically used to alter body shape and size (e.g., steroids). 13 Piran and 464 International Journal of Eating Disorders 41:

3 DISORDERED EATING Robinson 5 examined the widest range of illicit drugs and found an association between dieting and central nervous system stimulants as well as between binge eating or dieting and prescription medication use in a sample of 526 college students. Herzog et al. 2 also examined a wide range of illicit substances among a sample of 268 women with eating disorder diagnoses, and found amphetamines, cocaine, and marijuana to be the commonly used substances prior to entry in the study. Neither of these studies included men or involved large enough sample sizes to test for associations of disordered eating and use of low prevalence substances. Given the YRBSS large sample size, including both male and female adolescents, even low prevalence substances can be examined. Studies on the comorbidity of eating disorders and substance use have varied in how they define eating pathology, ranging from using DSM-IV diagnostic criteria for eating disorders to using scales of symptomatology. The YRBSS includes questions about fasting, diet product use, and purging but does not ask about binge eating or overvaluation of weight or shape. Unhealthy weight control behaviors, such as fasting, diet product use, and purging, can be indicative of pathology and cause health concerns. Adolescents exhibiting these behaviors may be at the early stage of a full-syndrome eating disorder and therefore even the behavior alone is noteworthy. Self-reported purging behaviors have also been shown to be predictive of bulimia nervosa and, when used as a screening measure, purging has shown relatively good sensitivity (.88) and specificity (.93). 14 Therefore, the present study focused on fasting, diet product use, and purging behaviors. The present study capitalized upon the availability of data from a large, nationally representative sample of female and male high-school students in the United States to examine the association between disordered eating (fasting, diet product use, or purging) and use of 10 substances (cigarettes, alcohol, marijuana, cocaine, inhalants, heroin, methamphetamines, ecstasy, steroids, and hallucinogens). Research has consistently found significant higher prevalence of full-syndrome eating disorders and weight control behaviors among adolescent females than males 4,15 18 ; substance use, on the other hand, has been documented to be much more prevalent in adolescent males. 19 Because of these marked gender differences, we examined comorbidity separately for females and males. Method Participants The YRBSS has been conducted by the Centers for Disease Control and Prevention (CDC) biennially since 1991 and is designed to provide a cross-sectional assessment of health risk behaviors among U.S. youth. Each YRBSS used a three-stage cluster sample design to obtain a nationally representative sample of 9th to 12th grade students in public and private high schools in the United States. In the first stage of sampling, counties were separated into primary sampling units (PSUs), with a county, a subarea of a larger county, or several smaller adjacent counties forming one PSU. The PSUs were divided into 16 strata based on the degree of urbanization and percentage of Black and Hispanic students. PSUs were selected from each strata with the probability of a PSU being selected proportional to the total number of students enrolled in that PSU. In the second stage of sampling, schools with at least one of the grades 9 to 12 were selected, once again with the probability of a school being selected proportional to the total number of students enrolled. Schools with higher percentages of Black and Hispanic/Latino students were over sampled. In the third stage of sampling, one or two intact classes of either a required subject (e.g., English) or a required period (e.g., first period) were randomly selected from each grade in each school. No substitutes were made for schools that refused to participate. Further details about the YRBSS sampling method have been described previously. 20 The school response rate for the 2005 YRBSS was 78% (159 schools) and the student response rate was 86% for an overall response rate of 67%. A total of 13,917 usable questionnaires were received from 7,193 female and 6,664 male students. Instrument and Procedure An institutional review board at the CDC approved each YRBSS, and parental consent was obtained before survey administration. Participation was voluntary and anonymous. Surveys were administered by trained data collectors in classrooms without the presence of teachers. Variables of interest to this report included demographic variables, disordered eating, and tobacco, alcohol, and drug use. Disordered Eating. Disordered eating was defined as a positive response to one or more of three questions about engaging in inappropriate behaviors for weight control during the past 30 days. Students were asked whether they had engaged in any of the following behaviors in order to lose weight or to keep from gaining weight : (1) fasting, defined as going without eating for 24 h or more; (2) taking diet pills, powders, or liquids without a doctor s advice; or (3) purging, defined as vomiting or taking laxatives. International Journal of Eating Disorders 41:

4 PISETSKY ET AL. TABLE 1. Prevalence estimates of unhealthy weight control behaviors practiced during the past 30 days, by gender Females (%) Males (%) Odds Ratio 95% Confidence Interval Fasting 1,142 (16.5) 509 (8.1) 2.493* Diet products 545 (7.7) 314 (4.8) 1.838* Purging 442 (6.2) 191 (2.9) 2.297* Any unhealthy weight control behavior 1,571 (21.8) 748 (11.2) 2.444* All three unhealthy weight control behaviors 101 (1.5) 63 (1.0) 1.543** Notes: Fasting 5 going without eating for 24 h or more in the past 30 days to lose weight or keep from gaining; Diet products 5 taking diet pills, powders, or liquids without a doctor s advice in the past 30 days to lose weight or keep from gaining; Purging 5 vomiting or taking laxatives in the past 30 days to lose weight or keep from gaining. *p \.0001, **p \.05. Substance Use Variables. Use of 10 types of substances was measured as follows: similar to other reports using the YRBSS, 21,22 cigarette use was defined as current if the student endorsed smoking on at least 1 day in the past 30 days, and frequent if the student endorsed smoking on 20 or more days in the past 30 days. Adolescents were considered exhibiting alcohol abuse if they engaged in binge drinking, having five or more drinks of alcohol in a row, that is, within a couple of hours, one or more times in the past 30 days. Marijuana use and cocaine use were both defined as using the substance one or more times in the past 30 days. Inhalants, methamphetamines, ecstasy, steroid, and hallucinogen use were only measured for lifetime use, and therefore were each defined as any lifetime use. Inhalant use was considered answering once or more to the question During your life, how many times have you sniffed glue, breathed the contents of aerosol spray cans, or inhaled any paints or sprays to get high? Statistical Analyses Logistic regression models were used to determine the presence of any gender differences in the prevalence of each of the three disordered eating behaviors and use of the 10 substances. Next, separate logistic regressions were conducted for females and males to establish differences in use of each of the 10 substances between adolescents who did versus did not report disordered eating. Sample weights were used in each individual analysis to correct for differences in the probability of selection and to adjust for nonresponse. Adjustments for the design effects were incorporated into the estimation process implemented by SAS (Version 9.1) survey procedures to generate accurate standard errors. The effect size reported was Number Needed to Take (NNT). NNT is the answer to the question: How many cases do you have to see to find one more failure than if you had observed their matched controls? In this study, failure refers to reporting use of a particular substance. NNT has been recommended because it takes into account the base rates of each of the conditions of interest. 23,24 Following Kraemer and Kupfer, a NNT less than 4 was considered a strong effect; a NNT between 4 and 9 was considered a moderate effect; and an NNT over 9 was considered a weak effect. 24 NNT analyses were derived by taking the reciprocal of the difference between the estimated probability of having use of each substance given disordered eating and the probability of having use of each substance given no disordered eating: 1/[Pr(Substance DE)2 Pr(Substance No DE)]. Results Prevalence of Fasting, Use of Diet Products, or Purging As shown in Table 1, fasting was the most common disordered eating behavior for both females and males (n 5 1,659, 12.5%), followed by diet product use (n 5 862, 6.3%) and purging (n 5 639, 4.7%). A total 1,571 female (21.8%) and 748 male (11.2%) adolescents exhibited at least one disordered eating behavior in the past 30 days. Although 1 in 5 females and 1 in 10 males exhibited at least one of these behaviors, only 101 females (1.5%) and 63 males (1.0%) reported engaging in all three. More females than males reported each of these behaviors. Disordered eating did not vary by grade in school: 9th grade, 16.7%; 10th grade, 16.3%; 11th grade, 17.2%; and 12th grade, 16.8%. Prevalence of Substance Use As shown in Table 2, of the substances measured for use in the past month, binge drinking and current cigarette use had the highest prevalence: over 20% of the population reported binge drinking or smoking a cigarette. Cocaine was the substance used by the fewest students: less than 5% reported any cocaine use in the past month. Inhalants were the most prevalent of the substances measured for lifetime use: over 10% of the students reported that they ever used an inhalant. Use of methamphetamine or heroin was the least common, each with prevalence estimates of around 2%. Substance use prevalence estimates differed across grade level for some (e.g., binge drinking increased for every grade level) but not all 466 International Journal of Eating Disorders 41:

5 DISORDERED EATING TABLE 2. Prevalence estimates of substance use by gender Substance Females (%) Males (%) Odds Ratio 95% Confidence Interval Current use (once or more in past 30 days) Current cigarette 1,366 (19.7) 1,490 (23.7) Frequent cigarette (20 or more days) 501 (7.2) 589 (9.4) Binge drinking 1,562 (22.0) 1,792 (27.7) 0.810* Marijuana 1,282 (18.0) 1,577 (24.4) 0.785* Cocaine 195 (2.8) 304 (4.8) 0.688** Lifetime use (once or more in lifetime) Inhalants 847 (12.0) 726 (11.2) 1.235** Heroin 97 (1.4) 318 (3.4) 0.414* Methamphetamines 115 (1.6) 167 (2.5) 0.686*** Ecstasy 351 (4.9) 485 (7.4) 0.720** Steroids 177 (2.5) 319 (4.8) 0.652** Hallucinogens 330 (5.4) 560 (9.9) 0.637* *p \.0001, **p \.01, ***p \.05. TABLE 3. Prevalence, odds ratios, and number needed to take (NNT) for substance use among females who do or do not report disordered eating Logistic Regression Substance Disordered Eating (%) No Disordered Eating (%) Odds Ratios 95% Confidence Interval NNT Current cigarette 517 (35.0) 849 (15.6) 3.1* Frequent cigarette 193 (13.1) 308 (5.7) 2.6* Binge drinking 556 (36.2) 1006 (18.1) 2.7* Marijuana 308 (18.5) 1413 (23.1) 2.2* Cocaine 73 (9.0) 122 (2.0) 3.4* Inhalants 211 (25.5) 589 (9.7) 3.5* Heroin 41 (5.0) 56 (0.9) 3.7* Methamphetamines 42 (5.0) 73 (1.2) 3.3* Ecstasy 113 (13.7) 236 (3.7) 3.6* Steroids 69 (8.2) 108 (1.7) 3.5* Hallucinogens 110 (15.0) 220 (4.1) 3.5* *p \ TABLE 4. Prevalence, odds ratios, and number needed to take (NNT) for substance use among males who do or do not report disordered eating Logistic Regression Substance Disordered Eating (%) No Disordered Eating (%) Odds Ratios 95% Confidence Interval NNT Current cigarette 276 (42.2) 1214 (21.5) 3.1* Frequent cigarette 127 (19.4) 462 (8.2) 3.0** Binge drinking 292 (42.2) 1500 (25.9) 2.2* Marijuana 164 (44.8) 1059 (17.8) 2.3* Cocaine 66 (18.3) 238 (4.0) 5.5* Inhalants 137 (34.6) 145 (2.4) 3.7* Heroin 93 (23.2) 125 (2.1) 11.6* Methamphetamines 70 (17.1) 97 (1.6) 12.9* Ecstasy 122 (29.8) 363 (5.9) 5.0* Steroids 116 (28.1) 203 (2.3) 8.1* Hallucinogens 107 (31.5) 453 (8.6) 4.2* *p \.0001, **p \.01. substances (e.g., prevalence of cocaine and ecstasy use did not vary across any grade level), as reported in detail by the Centers for Disease Control. 25 Use of each substance, except cigarettes and inhalants, was more prevalent in males than in females. Comorbidity of Disordered Eating and Substance Use Female Students As presented in Table 3, disordered eating was significantly associated with use of each substance. Associations between disordered eating International Journal of Eating Disorders 41:

6 PISETSKY ET AL. and (any) current cigarette use, current binge drinking, and lifetime use of inhalants all had a moderate effect size. Weak associations were observed for the association between disordered eating and frequent current cigarette use, as well as lifetime use of marijuana, cocaine, heroin, methamphetamines, ecstasy, steroids, or hallucinogens. Male Students. As shown in Table 4, all associations between disordered eating and use of each specific substance were statistically significant. Associations between disordered eating and current marijuana use and lifetime inhalant and steroid use each had a strong effect size, and the associations for each of the remaining substances had a moderate effect size. Conclusion This study explored the relationship between disordered eating and substance use in a nationally representative sample of U.S. adolescents. All associations between disordered eating and use of substances were statistically significant for both female and male students. As has been well documented in the literature, 18 more female students than male students reported disordered eating behaviors. Except for smoking, where female and males students had comparable prevalence estimates, and inhalant use, where female students had a higher usage rate, use of illicit substances or binge drinking was significantly more common among male students. Using effect size estimates (NNT) that take base rates into consideration, for female students, associations between substance use and disordered eating were weak for all but three forms of substance use: current smoking, binge drinking, and inhalants. Among male students, strong (marijuana, steroids, and inhalants) or moderate effects (all other substances) were observed. Several explanations have been offered for comorbidity between disordered eating and substance use behaviors: use of a substance specifically to alter body weight or shape or decrease appetite and eating; use of substances (including food) as a means to escape awareness from aversive emotional experiences 26 ; and use of substances as a clinical correlate of impulsivity. 27 These are not mutually exclusive explanations, and given the cross-sectional nature of the YRBSS, we caution that the data cannot be used to infer causal relationships. Rather, our findings may be useful for generating hypotheses. Prospective studies are needed to further explore the associations between and the potential mediating mechanisms underlying substance use and disordered eating. Several substances have been shown to suppress appetite, eating, or weight. Our finding of a moderately strong association between smoking and disordered eating is consistent with previous reports that adolescent girls smoke in efforts to lose weight or keep from gaining weight. 25 Cigarette companies often advertize to women for the effect of weight loss (e.g., Virginia Slims). 26 It is of note that the association between smoking and disordered eating also was observed among male students. Health promotion campaigns encouraging smoking prevention or cessation should educate both female and male adolescents about healthy approaches to control weight. In males but not females, lifetime steroid use was considerably more common among those reporting disordered eating. Given that illegal steroid use among young healthy males often occurs in combination with weight lifting activity with its purpose being to dramatically change body weight and shape, the link between steroids and disordered eating behaviors is likely more direct. 28 Cocaine is also known for its appetite suppressant quality, and previous research found that many female cocaine users name weight control as an important motivation for use of the substance. 2,13 This study found that among females, current cocaine use only weakly (though statistically significantly) predicted disordered eating. In males, the association was moderately strong. It is possible that higher frequency use (rather than any use ) would be required to detect a clinically significant association between cocaine use and disordered eating in female adolescents. Marijuana is known to stimulate appetite, and in a previous study of male and female adolescents, marijuana use was shown to be associated with binge eating but not with fasting, diet product use, or purging. 6 Consistent with this earlier study, findings from the YRBSS suggest that among female students, marijuana use is only weakly (albeit significantly) associated with inappropriate weight control behaviors. Binge drinking was found to moderately strongly predict disordered eating in female and male adolescents. In addition to alcohol being used as an appetite suppression, 13 it has been proposed that individuals use alcohol to self-medicate, to cope with strong negative emotions arising from eating and body image problems or associated depression, anxiety, or other comorbid psychopathologies. Binge drinking may reflect impulsivity. 468 International Journal of Eating Disorders 41:

7 DISORDERED EATING Inhalant use has been shown to cause loss of appetite as well as nausea, and therefore could be used as a method of weight control. 29 Similar to binge drinking, inhalant use also may be reflecting impulsivity. Inhaling the substances contained in easily accessible household products such as aerosol cans involves less premeditation (i.e., may reflect a spur of the moment behavior) than obtaining an illicit substance. Although research on impulsivity in eating disorders and substance use literature has focused on females, 30,31 we hypothesize that males who engage in disordered eating and abuse substances may also engage in impulsive behaviors which could account for the appeal of inhalants. Our report relied on preexisting survey data that did not allow us to adequately address the issue of impulsivity. The YRBSS does include some questions on risky sexual behaviors, seat-belt usage, and other behaviors which could be considered impulsive. Exploratory analyses (data not shown) showed that as measured, impulsivity did not confound the associations presented. Future research should address issues of impulsivity in males and motivations for use of particular substances. Several limitations need to be noted including the cross-sectional design, possible errors in selfreport, and incomplete assessment of key variables such as binge eating, impulsivity, or depression. Longitudinal data would have indicated the temporal order of the adoption of disordered eating, substance use, depression, and impulsive characteristics. Furthermore, frequency of disordered eating was not assessed in the YRBSS. A person who purged once in the past month, for example, may be clinically different than a person who purged at a higher frequency, and the same logic applies to people who use substances. Notwithstanding these limitations, this study utilized data from a large, nationally representative sample to explore in detail the relationship between use of a wide variety of illicit substances and eating pathology. Previous research has focused almost exclusively on female populations, and the YRBSS data provide new information on disordered eating and substance use in male adolescents. The moderate or strong associations between disordered eating and use of each substance is cause for concern, and should inform clinicians, researchers, and prevention specialists alike. Moreover, use of inhalants and steroids rarely has been studied among those with eating disorders, yet our findings point to the need for increased attention to these hazardous substances. Finally, our exploration of the strength of the association between disordered eating and each of the 10 substances examined in this report, taking into consideration the base rate of these behaviors in an adolescent population, help focus attention on those substances most likely to be used or abused by individuals experiencing weight or eating concerns. Clinicians working with adolescent populations need to be mindful that weight control efforts may signal substance use and vice versa, especially among male adolescents because use of all substances is higher for males with disordered eating behaviors. Future research should further investigate the relationship between eating pathology, substance use, and gender. References 1. Holderness CC, Brooks-Gunn J, Warren MP. Co-morbidity of eating disorders and substance abuse review of the literature. Int J Eating Disord 1994;16: Herzog DB, Franko DL, Dorer DJ, Keel PK, Jackson S, Manzo MP. Drug abuse in women with eating disorders. 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