Eating Disorder Pathology in a Culinary Arts School

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1 Eating Disorder Pathology in a Culinary Arts School ELIZABETH L. HODGES Department of Psychiatry Behavioral Sciences, Medical University of South Carolina, Charleston, South Carolina, USA EILEEN J. STELLEFSON Department of Professional and Community Education, Medical University of South Carolina, Charleston, South Carolina, USA MARK P. JARRELL Private practice, Charleston, South Carolina, USA CAROLYNE. COCHRANE and TIMOTHY D. BREWERTON Institute of Psychiatry, Medical University of South Carolina, Charleston, South Carolina, USA Eating disorders (ED) have been reported to occur more frequently in a.ssociation with certain occupations, such as dancing and modeling, but no data exist regarding ED frequency in the culinary arts profession. We therefore administered two diagnostic ED instruments (the Diagnostic Survey of Eating Disorders [C. Johnson, 1987] and the Eating Disorders Inventory [D. M. Garner, 1983]) to 411 students in a culinary arts school in Charleston, South Carolina. Eighteen percent had a lifetime ED diagnosis per DSM-III-R or DSM-IV Options Book criteria. Of 146 women, 5% had bulimia nervosa (BN), 21.2% had an ED not otherwise specified (EDNOS), and 4.1% had binge eating disorder (BED). Of265 men, 1.5% had BN, 7.2% had EDNOS, and 1.9% had BED. The mean body mass index (BM!) was 24 for women and 27.6 for men. Men with an ED were heavier (BM!= 29.9±6.0) than men without This material was presented at the Seventh International Conference on Eating Disorders, New York, April 1996, and at Eating Disorders '93, London. Address correspondence to Elizabeth L. Hodges, M.S.W., Institute of Psychiatry, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC Eatln& Dlaordero, 7:43-.50, 1999 Copyrl&hl C 1999 Brunner/l\fazel, Inc /99 $

44 E. L. Hodges et al an ED (BM! = 25.3±4, p ~.0001). There was no significant difference in BM! of women with and without an ED. Twentynine percent of the students were overweight (BM! > 27).

2 44 E. L. Hodges et al an ED (BM! = 25.3±4, p ~.0001). There was no significant difference in BM! of women with and without an ED. Twentynine percent of the students were overweight (BM! > 27). An ED diagnosis was found in 21% of those who were overweight. Student specialty choice (culinary vs. hospitality/ management) did not predict the presence of an ED. These findings suggest the need for student counseling programs to be aware of the presence of EDs in culinary school applicants and students. The eating disorders-anorexia nervosa (AN) and bulimia nervosa (BN)-are psychiatric illnesses with severe medical, psychological, and interpersonal consequences. Several studies have examined the prevalence of disturbed eating patterns in particular professions that impose weight criteria: dancing (Druss & Silverman, 1979; Garner & Garfinkel, 1980); modeling; and competitive athletics, such as wrestling (Enns, Drewnowski, & Grinker, 1987; Hsu, 1990). Although the culinary arts profession does not impose weight or shape criteria for professional affiliation, the emphasis on food (i.e., its handling, preparation, appearance, availab.ility, etc.) may either (a) predispose individuals prone to eating disorder (ED) pathology to develop serious clinical or subclinical EDs or (b) attract individuals already manifesting symptoms of these illnesses. In their famous work on the effects of starvation on mental functioning, Keys, Brozek, Henschel, Mickelson, and Taylor (1950) noted that starved individuals become more obsessed with food in a variety of ways, including an increased interest in the preparation of food. The impetus for the present study of culinary student eating attitudes and behaviors was the self-referral to the Medical University of South Carolina Institute of Psychiatry, Eating Disorders Program of two culinary students attending a local culinary arts university. Because we could find no studies in the literature that examined the eating patterns of individuals in the culinary profession, we decided to investigate this area. PARTICIPANTS AND METHODS The student body of a culinary university in Charleston, South Carolina was the target population for this study. This institution offers degrees in culinary arts as well as hotel or restaurant management/hospitality. Students at this institution are high school graduates, 17 years of age or older, both male and female. Seven hundred eleven students were enrolled in 1992, when this study was conducted. A total of 411 students (265 men and 146 women) participated in the study. The students who did not participate were either at another campus site during the study or elected not to participate.

Eating Di.sorders in a Culinary Arts School 45 The students were asked to participate in the survey of eating attitudes and behavior on a voluntary basis.

3 Eating Di.sorders in a Culinary Arts School 45 The students were asked to participate in the survey of eating attitudes and behavior on a voluntary basis. This involved the completion of two paperand-pencil self-report instruments: the Diagnostic Survey of Eating Disorders (DSED; Johnson 1987) and the Eating Disorder Inventory (EDI; Garner et al., 1983). Because of the time constraints involved in having students complete two paper-and-pencil instruments, we shortened the DSED by eliminating items relating to comorbid conditions such as substance abuse, anxiety, and affective disorders. Confidentiality was assured because no identifying information was required on the surveys. Each survey was numbered so that if a student wished to contact one of the investigators for feedback or referral regarding his or her questionnaires, it was possible to do so. Diagnoses based on Diagnostic and Stati.stical Manual of Mental Disorders (third edition, revised (DSM-III-R], American Psychiatric Association, 1987) criteria were made for AN, BN, and ED not otherwise specified (EDNOS) and on DSM-IV (American Psychiatric Association, 1994) Options Book criteria for binge eating disorder (BED) by evaluating information on the DSED. Overweight (high body mass index [BMI] was defined as a BMI of greater than 27.3 for women and greater than 27.8 for men (Kuczmarski et al., 1997). To make the findings more relevant to current ED classifications, we have adopted DSM-IV nomenclature in the discussion of findings as well as in the tables. RESULTS Analysis of data was completed for 411 respondents. The mean student age was 22.3 years (SD= 5.01). Thirty-five and a half percent of the respondents were women, and 64.5% were male. Racial breakdown was 85.4% Caucasian, 11.7% African American, 0.5% Asian, and 2.2% other. Of the 146 women, 45 (30.8%) had a diagnosable ED. None of the women had a diagnosis of AN alone; however, 1 woman (0.7%) met criteria for AN, binge-purge subtype. Seven women (5%) had a diagnosis of BN, 31 (21.2%) had a diagnosis of EDNOS, 6 ( 4.1 % ) had a diagnosis of BED, and 32 (22%) were overweight. The mean BMI for women without an ED (25.3±4.6) did not significantly differ from the mean BMI for women with an ED (24.3±5.7). Of the 265 men surveyed, 29 (10.9%) met criteria for an ED. None of the men had AN alone, but 1 (0.4%) met criteria for AN, binge-purge subtype. Four men (1.5%) had a diagnosis of BN, 19 (7.2%) had a diagnosis of EDNOS, 5 (1.9%) met criteria for BED, and 86 (32%) were overweight. The mean BMI for men with an ED (29.9 ± 6.0) was significantly higher than for men without an ED (25.3 ± 4.6) (p :s;;;.0001). For breakdown of ED by gender see Table 1. Table 2 shows percentages of ED diagnosis by gender.

4 46 E. L. Hodges et al. TABLE 1 Rates of Specific Diagnoses by Gender Diagnosis Female Male % n % n No diagnosis BN AN, Binge-purge subtype ED NOS BED Note. BN 2 bulimia nervosa; AN 2 anorexia nervosa; EDNOS s eating disorder not otherwi e pecified; BED ~ Binge eating disorder. Diagnosis TABLE 2 Percentages of All Diagnoses by Gender Female Male % n % n No diagnosis All ED Note. ED = eating disorder. An analysis of individual items on the DSED revealed the following results. Male participants were slightly older than female participants (mean age for men= 22.8±5.5, mean age for women = 21.3±4.7). Women endorsed vomiting beginning at an earlier age than did men (age = 15.7±2.2 for women and 18.0±5.6 for men). A breakdown of the results by gender revealed a trend toward women endorsing fasting more than men did, whereas men more often endorsed skipping meals as a way to lose weight. Women endorsed significantly more anxiety after a binge than men (p <.00001; women also endorsed binge eating in private more than men did. They also endorsed vomiting significantly more frequently than men (p <.00001). Men endorsed eating more rapidly during a binge (p <.00001) and endorsed weighing and measuring their bodies more frequently than women did (p ~.03). Further analysis of data revealed that culinary students, both men and women, were heavier than hospitality students. There was a trend toward more weight fluctuation in the culinary students. There was also a trend toward both male and female culinary students endorsing more fasting, eating rapidly during a binge, feeling miserable after a binge, and having uncontrollable urges to binge. Male culinary students endorsed bingeing at an earlier age than female students, whereas male hospitality students endorsed using laxatives at an earlier age. Male culinary students en dors~d

Eating Disorders in a Culinary Arts School 47 30 * eo. eo+ 25 20-16 10-5 0 - I Females Mates FIGURE 1. Mean body mass index (BMI) by gender and diagnosis.

5 Eating Disorders in a Culinary Arts School * eo. eo I Females Mates FIGURE 1. Mean body mass index (BMI) by gender and diagnosis. Eatingdisordered men were significantly heavier than non-eating-disordered men (* p ~.0001, rmpaired t test), although there was no significant difference in mean BMI between the female groups. more discomfort with their binge eating behavior, more dieting, more laxative use, and feeling out of control during a binge than male hospitality students did. Female culinary students endorsed vomiting at an earlier age (14.8±2.04 years) and endorsed more, and earlier, laxative use than female hospitality students (16.6±1.9 years). Differences in the choice of student subspecialty-that is, culinary versus hospitality I management-was examined with chi square and was not found to be related to the presence of either an ED or high BMI (> 27.3 for women and 27.8 for men). The prevalence of overweight (high BMI) students was 27.8%. Eighty-six male students (32%) were overweight, and 179 (68%) were not. Thirty-two women (22%) were overweight, whereas 114 (78%) were not (x, p <.03). For mean BMI by gender and ED diagnosis, see Figure 1. An analysis of EDI subscale means revealed that female culinary students scored significantly higher than male culinary students on the Bulimia,.

6 48 E. L. Hodges et al TABLE 3 EDI Suhscale Means Type of respondent Drive for BuJ Body In eff Perfectionism 'fhinneh Die Women Culinary school (N = 146) Normal (N = 205) Men Culinary school (N = 265) Normal (N = 101) p S.01, unpaired t 1e1t: culinary 1tudent1 venue controlt by gender... P S.001, unpaired t tell: culinary students venue controls by gender. Nou. EDI Eating Disordcn lnveotory-2; Bui Bulimia; Body Dit Body Diuati1faction; Ineff lneffectiveneu; lotp Di1t lnterpenonal Dl1mm; IA lnteroeeptive Awarenen; Mat Fean Maturity Fean lntp la Mat Diet Fears *'" Ineffectiveness, and lnteroceptive Awareness subscales (p ~.001), whereas male culinary students scored significantly higher on the Interpersonal Distrust and Maturity Fears subscales than female culinary students (p ~.001). These findings are consistent with scores of male and female nonpatient college samples (Garner, 1991). Further analysis of EDI subscale means revealed that female culinary students scored significantly higher on the Bulimia, Ineffectiveness, lnterpersonal Distrust, and lnteroceptive Awareness subscales than female normal controls (p -=::;.001). Female culinary students also scored higher on the Maturity Fears subscale than female controls (p ~.01). Male culinary students scored higher on the Bulimia, Body Dissatisfaction, Ineffectiveness, Interpersonal Distrust, lnteroceptive Awareness, and Maturity Fears subscales than male normal controls (p ~.001). For a complete breakdown of EDI subscale means of culinary students by sex compared to normal controls, see Table 3. SUMMARY AND DISCUSSION Nineteen percent of 411 students participating in this study of eating attitudes and behavior had a DSM-IVED. Women (31%) were more likely to have an ED than men were (11 % ). Men with an ED were significantly heavier than men without an ED (x, p <.030). Twenty-nine percent of the students surveyed were overweight, and 21 % of those overweight students had an ED diagnosis. The most prevalent ED diagnosis was ED NOS, comprising 51 students. We decided to separate out the diagnosis of BED from other EDNOS diagnoses, for several reasons. Given the constant focus on and availability of food in a culinary school, we postulated that the incidence of bingeing would be significantly higher among these students compared to other

Eating Disorders in a Culinary Arts School 49 college student groups. We wanted to evaluate the prevalence of BED in this population separately from the EDNOS category.

7 Eating Disorders in a Culinary Arts School 49 college student groups. We wanted to evaluate the prevalence of BED in this population separately from the EDNOS category. Furthermore, we felt that the category of EDNOS was not descriptive enough to distinguish between lower weight individuals or overweight bingers, or low-weight purgers who did not meet criteria for AN or BN. Students who endorsed subclinical symptoms of an ED or who reported a resolved history of an ED were not included in the ED percentage. In addition, many students who were obese and who binged did not meet the diagnostic criteria for BED because they did not view either their weight or their binge eating as problematic. The data also do not capture the number of students who turned in blank surveys or declined to participate in the study. It is well known that EDs are secretive in nature, and many of these students may have been symptomatic and reluctant to reveal their problems in a survey in their school setting. Our finding that 5% of female students surveyed had BN is higher than other studies, which have shown the prevalence of BN in the general population to be 2.3% (Fairburn & Beglin, 1990; Dansky et al., in press). The proportion of women to men with an ED was found to be higher than Andersen's (1990) description of the breakdown in the general population of females to males being 10:1, although his work focused primarily on the diagnoses of AN and BN and did not look at the BED category. Our study showed the breakdown of EDs to be 30.8% in women versus 10.9% in men. The National Women's Study revealed a prevalence rate of 2.4% for BN and 1.0% for BED (Dansky et al., 1998); this study looked at women only, with no data for prevalence rates for men. The prevalence of BED in our study ( 4% for women, 1.9% for men) correlates with other prevalence studies for this diagnostic group (Dansky et al., 1998; Spitzer et al., 1992). Our study revealed that the rate of high BMis (> 27.8) in the male student group as a whole (both culinary and hospitality students) was consistent with that reported in the general population. In the general population, 31. 7% of men between the ages of 20 and 7 4 are overweight (Kuczmarski et al., 1997). In our study, 32% of male students were overweight. The prevalence of women with high BMI (> 27.3) in the general population (34.9%; Kuczmarski et al., 1997) is greater than that of our female culinary respondents; in our study, 22% of female students were overweight. The culinary student population appears to be a group at risk for the existence or development of eating pathology and diagnosable EDs. Further studies would be helpful not only to ascertain the prevalence of eating pathology in other culinary student groups but also to determine the relationship between this symptomatology and the presence of substance abuse and affective or anxiety disorders, which we did not examine in this population. Our study alone may not be adequate to suggest that individuals who are vulnerable to EDs are drawn to the culinary field, or whether the field.

8 50 E. L. Hodges et al. itself tends to promote EDs through its natural focus on food. There is a clear finding, however, of increased prevalence of lifetime EDs in this student group, beginning before entry into culinary school. Examining the mean age of onset of the ED compared to the mean age of starting school, which is 17th in this case, this study can shed some light on which came first: the ED or entry into culinary school. In our study, the onset of the ED occurred first. It is important to recognize ED pathology in the culinary school student group because of the impact on a chef in terms of his or her occupational adjustment and job satisfaction. ED awareness and counseling programs should be a primary component of student counseling and recruitment programs in all culinary schools. REFERENCES American Psychiatric Association. (1987). Diagnostic and stalislical manual of mental disorders (3rd ed., rev.). Washington, DC: Author. American Psychiatric Association. (1994 ). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Crisp, A. H., Bums, T. (1990). Eating disorders in males: Critical questions in controlling eating disorders with facts, advice, and resources. In A. E. Andersen (Ed.). Males with Eating Disorders (p. 77). Philadelphia: Brunner/Maze! Publishers. Dansky, B. S., Brewerton, T. D.,.Kilpatrick, D. G., O'Neil, P. M., Resnick, H. S., Best, C. L., & Saunders, B. E. (1998). Tiie nature and prevalence of binge eating disorder in a national sample of women. In DSM-!J' Sourcebook. Volume 4, pp Washington, DC: American Psychiatric Press. Druss, R. G., & Silverman, J. A. (1979). Body image and perfectionism of ballerinas: comparison and contrast with anorexia nervosa. General Hospital Psychiatry, 2, Enns, M. P., Drewnowski, A., & Grinker, J. A. (1987). Body composition, body size estimation and attitudes toward eating in male college athletes. Psychosomatic Medicine, 49, Fairburn, C. G., & Beglin, J. J. (1990). Studies of the epidemiology of bulimia nervosa. American Journal of Psychiatry, 147, Garner, D. M. (1983). Eating Disorders Inventory. Odessa, FL: Psychological Assessment Resources. Gamer, D. M. (1991 ). Eating Disorders Inventory-2 professional manual. Odessa, FL: Psychological Assessment Resources. Gamer, D. M., & Garfinkel, P. E. (1980). Socio-cultural factors in the development of anoreria nervosa. Psychological Medicine, 10, Hsu, G. L. K. (1990). Eating disorders. New York: Guilford Press. Johnson, C. {1984). The initial consultation for patients with bulimia and anorexia nervosa. In DM Gamer and PE Garfinkel (Eds.) Handbook of Psychotherapy for Anorexia Nervosa and Bulimia (pp ). New York: Guiliord Press. Keys, A., Brozek, J., Henschel, A., Mickelson, 0., Taylor, H. L. (1950). The biology of human starvation. Minneapolis: University of Minnesota Press. Spitzer, R. L., Devlin, M., Walsh, B. T., Hasin, D., Wing, R., Marcus, M., Stunkard, A., Wadden, T., Yanovski, S., Agras, S., Mitchell, J., & Nonas, C. (1992). Binge eating disorder: A multisite field trial of the diagnostic criteria. International Journal of Eating Disorders, 11,

Eating Disorders. Anorexia Nervosa. DSM 5:Eating Disorders. DSM 5: Feeding and Eating Disorders 9/24/2015

Eating Disorders. Anorexia Nervosa. DSM 5:Eating Disorders. DSM 5: Feeding and Eating Disorders 9/24/2015 DSM 5: Feeding and Eating Disorders Eating Disorders Marsha D. Marcus, PhD The North American Menopause Society October 3, 2015 Feeding and Eating Disorders are characterized by a persistent disturbance