Binge Eating in Overweight Treatment-Seeking Adolescents

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1 Binge Eting in Overweight Tretment-Seeking Adolescents Deorh R. Glsofer, 1,2 MA, Mrin Tnofsky-Krff, 1 PHD, Kmryn T. Eddy, 3,4 MA, Susn Z. Ynovski, 5 MD, Kelly R. Theim, 1 BA, Mrgret C. Mirch, 1 BS, Smreh Ghorni, 1,6 BS, Lis M. Rnzenhofer, 1,6 BS, Dvid Hg, 2 PHD, nd Jck A. Ynovski, 1 MD, PHD 1 Unit on Growth nd Oesity, Developmentl Endocrinology Brnch, Ntionl Institute of Child Helth nd Humn Development, 2 Deprtment of Psychology, Americn University, 3 Center for Anxiety nd Relted Disorders, Boston University, 4 Optiml Weight for Life Clinic, Children s Hospitl, 5 Division of Digestive Diseses nd Nutrition, nd 6 Division of Nutrition Reserch Coordintion, Ntionl Institute of Dietes nd Digestive Kidney Diseses, Ntionl Institutes of Helth, DHHS Ojective To exmine the frequency nd recency of inge eting in reltion to psychopthology in overweight, tretment-seeking dolescents. Methods We investigted psychologicl correltes of the frequency nd recency of reported loss of control (LOC) eting episodes in 160 overweight (ody mss index [BMI]: 40.7 ± 8.8 kg/m 2 ) dolescents. On the sis of the responses to the eting disorder exmintion (EDE), prticipnts were ctegorized into one of four groups: full-syndrome inge eting disorder (BED); recent ut infrequent inge eting (episodes within the 3 months efore interview; RECENT-BINGE); remote nd infrequent LOC eting (episodes occurring >3 months efore ssessment; PAST-LOC), or no history of LOC episodes (NE). Results The BED group reported higher EDE scores (glol, p <.01), nd more negtive mood nd nxiety thn ll other groups (p s <.01). Compred with NE, RECENT-BINGE lso reported more nxiety nd higher EDE scores (p s <.01). Conclusions Overweight, tretment-seeking dolescents with BED re clerly distinguishle from teens without the disorder on mesures of eting-relted psychopthology, mood, nd nxiety. RECENT-BINGE, ut not PAST-LOC, is lso ssocited with significntly greter eting-relted nd generl psychopthology. Key words dolescents; inge eting; inge eting disorder; oesity. Binge eting disorder (BED), provisionl dignostic ctegory in DSM-IV-TR (Americn Psychitric Assocition [APA], 2000), is chrcterized y recurrent inge eting episodes in the sence of inpproprite compenstory ehviors nd is often ssocited with oesity (de Zwn et l., 1994). When compred with non-ingeeting dults, those with BED suffer from greter etingdisordered cognitions (Crow, Stewrt Agrs, Hlmi, Mitchell, & Kremer, 2002; Mshe & Grilo, 2000; Striegel- Moore et l., 2001; Wilfley, Schwrtz, Spurrell, & Firurn, 2000), incresed generl psychopthology (Mussell et l., 1996; Wilfley, Friedmn, et l., 2000; Ynovski, Nelson, Duert, & Spitzer, 1993), nd more helth prolems (Johnson, Spitzer, & Willims, 2001; de Zwn et l., 2002). The DSM-IV-TR description of BED identifies frequency nd durtion criteri tht must e met to receive dignosis. The frequency criterion is inge eting (eting n ojectively lrge quntity of food during which loss of control [LOC] is experienced) on verge t lest twice per week; the durtion criterion is tht inge eting occurs consistently over 6-month period (APA, 2000). All correspondence concerning this rticle should e ddressed to Mrin Tnofsky-Krff, PhD, Unit on Growth nd Oesity, DEB, NICHD, NIH, 10 Center Drive, CRC, Room MSC 1103, Bethesd, Mrylnd E-mil: tnofskm@mil.nih.gov. Journl of Peditric Psychology 32(1) pp , 2007 doi: /jpepsy/jsl012 Advnce Access puliction June 25, 2006 Journl of Peditric Psychology vol. 32 no. 1 Pulished y Oxford University Press on ehlf of the Society of Peditric Psychology 2006

2 96 Glsofer et l. However, there re few dt demonstrting these thresholds identify the mjority of individuls hving significnt difficulties with inge eting. Investigtions compring dults with BED to those with suthreshold BED (chrcterized y recurrent episodes of inge eting with n verge frequency of once per week during the pst 6 months) hve found few differences etween groups on mesures of psychitric distress, ody weight, dieting, weight history, or ody imge disturnce (Striegel-Moore et l., 2000; Striegel-Moore, Wilson, Wilfley, Elder, & Brownell, 1998). A study employing n even less stringent frequency criterion for suthreshold BED (inge eting t lest once per month during the pst 6 months) lso found few differences on mesures of eting-relted nd generl psychopthology etween women with dignostic nd suthreshold BED (Crow et l., 2002). These dt suggest tht inge eting, even t lower frequencies, is cliniclly significnt prolem. Moreover, the significnce of ojectively lrge overeting s n importnt chrcteristic of BED in dults hs een questioned, suggesting tht the experience of LOC my e the most slient fctor ssocited with emotionl distress (Niego, Prtt, & Agrs, 1997; Prtt, Niego, & Agrs, 1998). Although few dolescents meet the criteri for fullsyndrome BED (Johnson, Grieve, Adms, & Sndy, 1999; Stice, Killen, Hywrd, & Tylor, 1998; Stice, Presnell, & Bermn, 2001), the prevlence of suthreshold inge eting, prticulrly mong overweight dolescents, ppers to e sustntil (Johnson, Rohn, & Kirk, 2002), with estimtes rnging from 20% (Isnrd et l., 2003) to 30% (Decluwe, Bret, & Firurn, 2003) in weight loss tretment-seeking smples. Consistent with the dult literture (Striegel-Moore et l., 1998, 2000), studies in dolescents seeking weight loss tretment hve found tht those who report suthreshold inge eting hve greter eting-relted distress nd depressive symptomtology thn those who do not report ny inge eting (Berkowitz, Stunkrd, & Stllings, 1993; Decluwe et l., 2003; Isnrd et l., 2003; Johnson et l., 1999). Nevertheless, the implictions of suthreshold inge eting s compred with full-syndrome BED in dolescents re uncler. In community smple of 10- to 18-yer-olds, Johnson et l. (1999) found tht children meeting full dignostic criteri for BED y questionnire reported significntly more depressive symptomtology nd greter distured eting-relted cognitions thn children descriing suthreshold inge eting. By contrst, nother study of middle nd high school students with BED nd suthreshold BED found no sustntil differences in depressed mood, self-esteem, or ody disstisfction (Ackrd, Neumrk- Sztiner, Story, & Perry, 2003). Although full-syndrome BED in childhood is rre, children reporting LOC episodes regrdless of the mount of food eten hve greter diposity nd psychologicl distress thn those with no LOC episodes (Morgn et l., 2002; Tnofsky- Krff et l., 2004). In study using structured clinicl interviews, overweight children (6 13 yers) who endorsed experiencing s few s one episode of LOC eting in their lifetime reported greter eting-disordered nd generl psychopthology compred with overweight children who reported no such episodes (Tnofsky-Krff, Fden, Ynovski, Wilfley, & Ynovski, 2005). A notle limittion of most prior studies exmining inge eting mong dolescents is the lck of interview methodology to ssess eting-disordered ehviors nd cognitions (Ackrd et l., 2003; Decluwe et l., 2003; Isnrd et l., 2003; Johnson et l., 1999; Morgn et l., 2002). To investigte the potentil ssocition of frequency nd recency of inge eting episodes with eting-relted cognitions nd generl psychopthology, we used n interview method to ssess eting-disordered pthology in cohort of overweight, tretment-seeking dolescents. We posited tht the frequency nd recency of inge eting would e relted to higher levels of depressive nd nxious symptomtology. Specificlly, we hypothesized tht () teens meeting DSM-IV-TR criteri for BED (high frequency nd high recency) would report the highest levels of eting-relted nd generl psychopthology nd tht () prticipnts endorsing recent suthreshold inge eting in the 3 months efore ssessment (low frequency ut high recency) would report more emotionl disturnce thn dolescents who reportedly hd never experienced inge or LOC eting. Given the findings of Tnofsky-Krff et l. (2005), we lso expected dolescents who reported the experience of LOC eting ever in the pst (low frequency nd low recency) would report higher levels of etingrelted, depressive nd nxious symptomtology thn dolescents who reportedly hd never experienced inge or LOC eting. Methods Prticipnts We studied smple of 160 overweight dolescents seeking weight loss tretment. Teens were 14.1 ± 1.4 yers old, with BMI of 40.7 ± 8.8 kg/m 2. The smple ws composed of 87 Africn Americn teens (54.4%), 71 Cucsin teens (44.4%), nd 2 Hispnic teens (1.3%). Ninety-three (58.1%) were femles. Dt were collected

3 Binge Eting in Adolescents 97 from two sites. One hundred nd twenty-nine prticipnts were recruited through newspper dvertisements nd letters to physicins prcticing within 60 miles of Bethesd, MD, for weight loss study involving mediction. Inclusion criteri for the tretment were ges yers t study entry, meeting the ntionl criterion for overweight in youth with BMI greter thn the NHANES II 95th percentile for ge nd sex (Must, Dlll, & Dietz, 1991), nd the presence of t lest one quntifile oesity-relted comoridity, including hypertension, type 2 dietes or impired glucose tolernce, hyperinsulinemi (insulin 15 μu/l), hyperlipidemi (totl triglyceride 200 mg/dl, totl cholesterol >200 mg dl 1, or totl LDL cholesterol 130 mg/dl), heptic stetosis, or sleep pne documented y forml sleep study. Individuls were excluded if they hd mjor pulmonry, heptic, crdic, or musculoskeletl disorder unrelted to oesity, history of sustnce use or other psychitric disorder tht would impir complince with the study protocol, used n norexint in the pst 6 months, or recently lost significnt weight ( 5% of ody weight). For complete description of study requirements, see McDuffie et l. (2002). Thirtyone dolescents seeking weight loss tretment t Boston, MA, hospitl-sed clinic, which used ehvior modifiction nd dherence to low glycemic index dietry recommendtions, were lso included in the current study. Inclusion criteri t this clinic were ges yers, overweight defined s BMI greter thn the NHANES II 95th percentile for ge nd sex, nd English conversnt. Exclusion criteri included severe cognitive impirment or psychotic disorder. Procedure Institutionl review ords of oth institutions pproved the protocols. Ech dolescent gve written ssent, nd prent or gurdin gve written consent for protocol prticiption. Sixty-one percent of those screened in Bethesd, MD, met eligiility requirements nd prticipted in ll ssessments. All dolescents seeking tretment t the Boston, MA, clinic were informed of the study y mil (n = 140). Ninety fmilies with dolescents were successfully reched y telephone nd provided dditionl informtion out the study. Of these, 45 (50%) declined prticiption. Of the interested fmilies (n = 45), six did not meet eligiility criteri, nd eight were unle to e scheduled. Thus, 31 dolescents prticipted in the present study (representing 34% of those contcted y telephone nd 22% of dolescents receiving tretment t the clinic). There were no differences in ptient demogrphics etween those prticipting nd those not prticipting in the study. All dt were collected t seline, efore inititing tretment. To mesure eting-relted ehviors nd cognitions, sujects completed the Eting Disorder Exmintion version 12OD/C.2 (EDE) (Firurn & Cooper, 1993), which contins 21 items tht ssess disordered ttitudes nd ehviors relted to eting, ody shpe, nd weight nd 13 items designed to dignose specific DSM-IV-TR eting disorders (APA, 2000). Responses re coded vi four suscles: restrint (cognitive nd ehviorl restriction), eting concern, shpe concern, nd weight concern. The glol score represents the men of the four suscle scores. The EDE identifies three types of eting episodes: ojective inge episodes (OBE, overeting with LOC), sujective inge episodes (SBE, LOC without ojective overeting s ssessed y the interviewer ut viewed s excessive y the interviewee), nd ojective overeting (overeting without LOC). The EDE hs excellent internl consistency (Cooper, Cooper, & Firurn, 1989), test retest reliility (Rizvi, Peterson, Crow, & Agrs, 2000), nd oth discriminnt nd concurrent vlidity (Firurn & Cooper, 1993; Willimson et l., 1995). The EDE ws dministered to prticipnts 15 yers. The child version of the EDE (ChEDE) (Brynt-Wugh, Cooper, Tylor, & Lsk, 1996) ws dministered to prticipnts <15 yers (n = 60) s recommended y the uthors of the mesure. The ChEDE differs from the dult version only in tht its script hs een edited to mke it more ccessile to children ges 8 14 yers nd tht two items tht ssess the criticl overevlution of shpe nd weight hve een supplemented with sort tsk. The ChEDE queries out inge episodes in the 3 months efore ssessment; therefore, interviewers reviewed DSM-IV-TR BED criteri for prticipnts ged <15 yers who endorsed OBEs (APA, 2000). Following the overeting section of the EDE nd ChEDE, n dditionl question ssessing LOC eting history ws included (for the complete series of questions, see Tnofsky-Krff et l., 2005). Prticipnts were sked whether they hd ever experienced LOC (regrdless of mount of food eten) efore the 6 months ssessed y the EDE. Teens who endorsed n LOC experience efore ut not within the pst 6 months were not sked to descrie the specific eting episode in detil, ut rther whether they reclled experiencing LOC while eting. Interviewers were grdute clinicl psychology students nd post-undergrdute reserch ssocites who ttended hr of trining. Before conducting interviews, ech interviewer ws trined y listening to

4 98 Glsofer et l. udiotpes of smple interviews, conducting prctice EDE, oserving the triner conducting n EDE, nd then conducting n EDE while the triner oserved. Trining ws continued until t lest 95% greement etween triner nd trinee rtings ws demonstrted. To ensure qulity, ll interviews were tped, nd weekly meetings were held to review every interview throughout dt collection. At the weekly meetings, responses tht were difficult to code (e.g., presence or sence of LOC experience) nd the coding of eting episode sizes were determined y consensus. To exmine wht constitutes lrge mount of food for dolescents, we sked ll prticipnts, whether or not they descried disordered eting, to descrie the lrgest mount eten in the lst 28 dys. Using this informtion, tem memers discussed the mount eten nd cme to unnimous consensus regrding whether the mount ws unmiguously lrge or sujectively lrge given the circumstnces for the child s ge nd sex. Interrter reliility ws otined on 15.5% (20 interviews) of rndomly selected EDE tpes from the Bethesd smple. EDE interrter reliility nlyses reveled tht rters chieved very good reliility, with intrclss correltions rnging from.87 to.98 on the suscle nd totl scores (ll ps <.01). Prticipnts were ctegorized into one of four groups: full-syndrome BED; recent ut infrequent inge eting (episodes of overeting during which LOC is experienced within the 3 months efore interview; RECENT-BINGE); remote nd infrequent LOC eting (episodes of eting, regrdless of the mount of food consumed during which LOC is experienced, occurring >3 months efore ssessment; PAST-LOC), or no history of LOC episodes (NE). Becuse previous studies hve shown no differences etween children with no eting psychopthology nd those who endorse ojective overeting without LOC (Morgn et l., 2002; Tnofsky-Krff et l., 2004), the current study included children who reported ojective overeting into the NE group. The Children s Depression Inventory (CDI) (Kovcs, 1982) ws used to ssess cognitive, ffective, nd ehviorl signs of depression. The CDI genertes five suscles negtive mood, interpersonl prolems, ineffectiveness, nhedoni, nd negtive self-esteem nd totl score. The CDI hs demonstrted dequte internl consistency, test retest reliility, nd discriminnt vlidity (Costello & Angold, 1988; Curry & Crighed, 1993). The Stte-Trit Anxiety Inventory for Children (STAIC) (Spielerger, 1973) ws used s mesure of trit nxiety. The STAIC hs een shown to hve high internl consistency, stility for trit nxiety, nd dequte vlidity (Spielerger, Gorsuch, & Lushene, 1970). The Child Behvior Checklist (CBCL) (Achench & Elderrook, 1991) ssesses child ehviorl/emotionl prolems s reported y prents/gurdins nd genertes internlizing nd externlizing prolems suscles. The CBCL is well-vlidted screen for child nd dolescent psychopthology (Connor et l., 2003). Items querying prents current occuptions re included in the CBCL. Responses to these items were coded ccording to the Hollingshed Socioeconomic Sttus (SES), which is widely used mesure of socil nd economic level sed on creer nd eduction sttus (Hollingshed, 1975). Physicl Mesures For the Bethesd, MD, cohort, weight ws otined to the nerest 0.1 kg using clirted digitl scle (Scle- Tronix, Wheton, IL), nd height ws otined in triplicte to the nerest 1 mm using stdiometer clirted efore ech set of mesurements (Holtin Ltd., Crymmych, Wles). BMI (kg/m 2 ) ws clculted. All prticipnts underwent medicl history nd physicl exmintion performed y n endocrinologist or trined nurse prctitioner. Brest nd puertl hir development were ssigned ccording to the stges of Tnner (Mrshll & Tnner, 1969, 1970), nd testiculr volumes were mesured (in cc) ccording to Prder (Tnner, 1981). Puertl stge nd testiculr volume indicte neurocognitive nd physicl mturity (Mrshll & Tnner, 1969, 1970). Prticipnts t the Boston, MA, clinic were weighed on clirted nondigitl lnce em scle (Detecto, We City, MO), nd height ws otined to the nerest 1 mm using clirted stdiometer. With the exception of three prticipnts who self-reported Tnner stge, puertl stge ws ssessed y n endocrinologist or nurse prctitioner during physicl exmintion. Anlyses On the sis of prior studies tht found the dignosis of BED to e reltively rre mong overweight dolescents (Johnson et l., 1999; Stice et l., 1998, 2001), we nticipted tht only 6% of our study smple would meet the EDE criteri for BED. Therefore, to ensure cell size 10 for the group dignosed with BED, which we estimted would give 80% power to detect 0.5 point differences in EDE suscle scores etween groups (with lph set t.05), we sought to recruit 160 dolescents to the study. Comprisons etween groups were performed using one-wy nlysis of vrince (ANOVA) with Bonferroni Hocherg s correction, conservtive test ccounting for multiple comprisons pplied to ech fmily of post hoc

5 Binge Eting in Adolescents 99 mens. A z score (Frisncho, 1990) stndrdized for ge, sex, nd rce ws used for BMI (BMI-SD). Age, sex, BMI-SD, SES, nd puertl stge were considered relevnt covrites for ANOVA models, ecuse these vriles hve een identified s potentilly confounding fctors of outcome in studies of ody weight nd growth mong youth (Johnson, Figuero-Colon, Hung, Dwyer, & Gorn, 2005; Sun et l., 2001). Since differences were identified etween the Bethesd nd Boston smples, clinic site (Bethesd or Boston) ws lso considered s potentil covrite. Mens djusted for covrites re reported for these nlyses. Mens ± SD re reported, nd nominl proility vlues re shown. Differences nd ssocitions etween groups were considered significnt when p-vlues fter correction for multiple comprisons were.05, nd ll tests were two-tiled. Regression ws used to evlute the ssocition etween log of LOC/inge eting frequency nd scores on mesures of psychopthology. Becuse the log-trnsformtion required recoding for those with no LOC or inge episodes within the lst 3 months, teens in the NE group were ritrrily coded to hve hd 0.05 episodes. Becuse teens in the PAST-LOC group generlly reported single episode within the pst yer, they were coded s hving hd 0.25 LOC/inge episodes in the pst 3 months. For the RECENT-BINGE nd BED groups, the totl numer of inge episodes in the 3 months efore ssessment ws used. The numer of inge eting episodes ws log-trnsformed for nlyses. Results Sixty-seven mle nd 93 femle dolescents prticipted (Tle I). Teens from Bethesd (14.3 ± 1.5 yers, 41.7 ± 9.2 kg/m 2 ) were significntly older nd hevier thn Tle I. Smple Demogrphics NE [n = 88 (55.0%)] PAST-LOC [n = 24 (15.0%)] teens in the Boston group (13.4 ± 1.1 yers, 36.6 ± 5.5 kg/m 2 ; ps <.01); however, there were no significnt differences etween smples in BMI-SD score (t = 1.9, p =.06). Groups did not significntly differ in SES (t = 1.1, p =.20) nd puertl stge (t = 1.8, p =.08), or sex (c 2 = 1.5, p =.22); however, there were significnt differences in rce etween smples (c 2 = 14.3, p <.01). In the Bethesd smple, 59.7% of teens were Africn Americn nd 40.3% were Cucsin. In the Boston group, 32.3% of prticipnts were Africn Americn, 61.3% were Cucsin, nd 6.5% were Hispnic. Teens in the Boston group reported significntly greter depressive symptomtology (CDI totl scores, ± 14.42) thn those in the Bethesd group (6.46 ± 5.61, t = 5.50, p <.01). In the Boston group, prticipnts lso reported significntly more eting-relted psychopthology on the EDE glol score (t = 3.54, p <.01) nd ll suscles (p s <.05), with the exception of the EDE weight concern suscle, thn teens in the Bethesd smple. CBCL scores did not differ y group. Eting Behviors nd Relted Cognitions On the sis of EDE interviews, 10 prticipnts (6.3%) met the criteri for BED, with the numer of inge dys rnging from 23 to 80 (men ± SD: 35.0 ± 18.48) over the pst 6 months. Thirty-eight dolescents (23.8%) were clssified s RECENT-BINGE, with the numer of inge dys rnging from 1 to 13 (men ± SD: 3.7 ± 3.3) over the lst 3 months. Twenty-four dolescents (15.0%) reported PAST-LOC; 88 prticipnts (55.0%) hd NE. Groups did not differ with regrd to ny mesured demogrphic or physicl vrile (Tle I). Anlyses of the EDE glol score controlled for clinic site. SES nd clinic site were covrites for the EDE eting RECENT-BINGE [n = 38 (23.8%)] BED [n = 10 (6.3%)] Rnge Age (yers) 14.0 ± ± ± ± Sex Mle 36 (40.9%) 8 (33.3%) 20 (52.6%) 3 (30%) Rce Africn Americn 49 (55.7%) 12 (50%) 23 (60.5%) 3 (30%) Cucsin 38 (43.2%) 12 (50%) 14 (36.8%) 7 (70%) Hispnic 1 (0.01%) 1 (2.6%) SES (Mdn) Puertl stge 3.4 ± ± ± ± BMI (kg/m 2 ) 40.6 ± ± ± ± Child BMI-SD 5.6 ± ± ± ± BED, inge eting disorder; BMI, ody mss index; NE, no episode; PAST-LOC, loss of control eting in the pst; RECENT-BINGE, inge eting in the pst 3 months; SES, socioeconomic sttus. For Children s Depression Inventory, N = 155. For Child Behvior Checklist, N = 158 nd for the current occuption questions of this mesure, from which SES ws derived, N = 147. For the Stte-Trit Anxiety Inventory for Children, N = 124.

6 100 Glsofer et l. concern suscle. SES ws lso covrite for the EDE restrint suscle. Prticipnts with BED hd significntly higher EDE eting (overll F = 23.8, p <.01), shpe (overll F = 19.4, p <.01), nd weight concern (overll F = 13.3, p <.01) suscle scores nd glol scores (overll F = 19.0, p <.01) compred with prticipnts in the RECENT-BINGE, PAST-LOC, nd NE groups (Fig. 1A). Compred with the NE group, the RECENT-BINGE group hd higher scores on the eting, shpe, nd weight concern suscles nd glol scores. Teens in the RECENT-BINGE group lso reported significntly more shpe nd concern thn those in the PAST-LOC group. No significnt differences were detected etween groups on the EDE restrint suscle. Generl Psychopthology For the CDI, prticipnts in the BED group hd significntly higher negtive mood scores compred with individuls in the other three groups fter controlling for clinic site (overll F = 10.2, p <.01, Fig. 1B). Prticipnts with BED hd significntly higher totl CDI scores thn the NE group fter controlling for clinic site (overll F = 4.7, p <.01). A significnt min effect ws EDE Suscle Scores CDI Suscle Scores A B NE PAST-LOC c lso reveled etween groups on the mesure of trit nxiety (F = 9.49, p <.01, Fig. 2A). Adolescents with BED reported significntly higher trit nxiety compred with prticipnts in ll other groups. In ddition, prticipnts with recent inge eting reported significntly higher trit nxiety scores thn those in the NE group. Significnt differences were detected on the internlizing suscle (F = 5.66, p <.01) nd externlizing suscle of the CBCL, for which BMI-SD served s covrite (F = 6.34, p <.01; Fig. 2B). Prents of teens with BED nd recent inge eting reported significntly higher internlizing nd externlizing ehviors in their children compred with prents of prticipnts in the NE group. Frequency of LOC nd inge eting dys ws positively ssocited with eting-relted psychopthology, nxiety, nd depressive symptomtology (Fig. 3). There ws significnt positive ssocition etween the numer of LOC nd inge eting episodes nd scores on the EDE restrint (r 2 =.05, p <.01), eting concern (r 2 =.29, p <.01), shpe concern (r 2 =.27, p <.01), nd weight concern (r 2 =.18, p <.01) suscles nd glol score (r 2 =.29, p <.01). Frequency of LOC nd inge eting episodes RECENT-BINGE BED Restrint Eting Concern Shpe Concern Weight Concern Neg Mood Interpersonl Ineffectiveness Anhedoni Neg Self-Esteem c c Figure 1. (A) Eting Disorder Exmintion (EDE) suscle scores of prticipnts endorsing no episode (NE), loss of control eting in the pst (PAST- LOC), inge eting in the pst 3 months (RECENT-BINGE), nd inge eting disorder (BED). Socioeconomic sttus (SES) ws significnt covrite for the EDE restrint suscle. For the EDE eting concern suscle, SES nd site served s covrites. (B) Children s Depression Inventory (CDI) suscle scores. For the CDI negtive mood, interpersonl, nd nhedoni suscles, site served s covrite. Site nd ge were covrites for the CDI negtive self-esteem suscle. Brs differing in letters re significntly different.

7 Binge Eting in Adolescents 101 Trit Anxiety Score CBCL t-score B A Figure 2. (A) STAIC trit nxiety scores nd (B) Child Behvior Checklist (CBCL) internlizing nd externlizing t-scores of prticipnts endorsing no episode (NE), loss of control eting in the pst (PAST- LOC), inge eting in the pst 3 months (RECENT-BINGE), nd inge eting disorder (BED). Body mss index (BMI-SD) ws covrite for the CBCL externlizing suscle. Brs differing in letters re significntly different. ws lso significntly ssocited with ll CDI scles; negtive mood (r 2 =.13, p <.01), interpersonl (r 2 =.03, p <.05), ineffectiveness (r 2 =.05, p <.01), nhedoni (r 2 =.08, p <.01), nd negtive self-esteem (r 2 =.09, p <.01) suscle scores nd CDI totl scores (r 2 =.10, p <.01), s well s STAIC trit nxiety scores (r 2 =.16, p <.01). The numer of LOC nd inge eting episodes ws not significntly ssocited with CBCL suscle or totl scores. Discussion NE PAST-LOC RECENT-BINGE BED NE PAST-LOC RECENT-BINGE BED Internlizing In this study of inge eting in overweight, tretmentseeking dolescents, 45% of teens reported they hd engged in inge or LOC eting t some time in their lives. Individuls dignosed with full-syndrome BED were distinguishle from those reporting suthreshold levels of inge eting or no inge eting in tht they experienced higher emotionl distress nd distured eting cognitions, equivlent to tht experienced y dults with BED (Wilfley, Schwrtz et l., 2000). However, individuls who endorsed recent suthreshold inge Externlizing c eting in the lst 3 months were lso distinguishle from those who reported no LOC eting whtsoever, with the former group reporting higher levels of distured eting cognitions nd nxiety nd their prents reporting more child ehvior prolems. In generl, the numer of inge episodes endorsed y dolescents ws positively ssocited with mesures of psychopthology. In contrst to dult studies (Crow et l., 2002; Striegel- Moore et l., 1998, 2000), ut consistent with one prior dolescent study (Johnson et l., 1999), prticipnts with BED experienced significntly higher levels of eting-disordered ttitudes, more negtive mood, nd nxiety compred to those with recent suthreshold inge eting in the lst 3 months. This finding my e due to differences in the suthreshold criteri employed in dult studies. To e ctegorized in the RECENT-BINGE group, prticipnts in our smple needed only to endorse engging in single inge eting episode in the pst 3 months. In dult studies, the requirement for suthreshold BED rnges from once per week (Striegel- Moore et l., 1998, 2000) to once per month (Crow et l., 2002). A threshold less thn once per month, ut greter thn one episode in 3 months, my wrrnt study to determine t wht limit inge episodes ecome indictive of greter psychopthology in dolescents. Despite lower scores on the EDE scles compred with the BED group, those with infrequent ut recent inge eting episodes hd significntly higher scores on the eting, shpe nd weight concern suscles, the glol EDE scle, nd trit nxiety thn their overweight counterprts who did not report inge or LOC eting in the pst. These findings support prior reserch tht children nd dolescents who engge in inge eting t ny frequency in recent period preceding ssessment suffer from more distured eting cognitions nd nxiety thn those without history of inge or LOC eting (Decluwe et l., 2003; Johnson et l., 1999; Morgn et l., 2002; Tnofsky-Krff et l., 2004). This study found log-liner reltionship etween inge frequency nd scores from the EDE, STAIC, nd CDI, suggesting continuous reltionship etween inge or LOC eting nd psychopthology mong teens in our smple. The higher weight concern scores of dolescents in the RECENT-BINGE group re prticulrly trouling ecuse weight concern is elieved to e risk fctor for the development of n eting disorder in helthy weight smples (Killen et l., 1994, 1996; Stice et l., 1998; Stice, Presnell, & Spngler, 2002). Although the Killen studies did not use the EDE suscle to mesure concern, the two mesures rodly cpture worries nd preoccuption with one s ody weight. In ddition to weight

8 102 Glsofer et l. EDE Shpe Concern STAIC Trit Anxiety Score A LOC/Binge Episodes in Pst 3 mo C LOC/Binge Episodes in Pst 3 mo Figure 3. Numer of loss of control (LOC)/inge eting episodes in the pst 3 months versus (A) Eting Disorder Exmintion (EDE) shpe concern suscle scores: r 2 =.27, p <.01; (B) EDE weight concern suscle scores: r 2 =.18, p <.01; (C) STAIC trit nxiety scores: r 2 =.16, p <.01; nd (D) CDI totl scores: r 2 =.10, p <.01. Numer of LOC or inge eting episodes ws log-trnsformed for nlysis, with those hving no episodes coded s hving 0.05 episodes per 3 months nd those with LOC eting in the pst coded s hving 0.25 episodes per 3 months. concern, thin ody preoccuption is prospective predictor of eting disorders (McKnight Investigtors, 2003), suggesting tht roder construct of distured eting cognitions my predict future eting disorders. Although it is uncler whether increses in eting nd shpe concern my lso serve s risk fctors for fullsyndrome eting disorders mong overweight teens, it is notle tht in the current study, teens in the RECENT- BINGE group reported more shpe concern thn those in oth lower threshold groups. In ddition to the potentil risk of eting disorder development, prticipnts who inge et my e t risk for excessive weight gin. Binge eting hs een ssocited with dditionl weight gin in three longitudinl studies of primrily helthy weight dolescents (Field et l., 2003; Stice, Cmeron, Killen, Hywrd, & Tylor, 1999; Stice et l., 2002). In three-yer longitudinl study of younger children t risk for dult oesity, inge eting hs lso een shown to predict weight nd ft gin (Tnofsky-Krff et l., 2006). Therefore, prticipnts EDE Weight Concern CDI Totl Score B 50 D LOC/Binge Episodes in Pst 3 mo LOC/Binge Episodes in Pst 3 mo with BED or recent ut infrequent inge eting my e t risk for excessive weight gin compred with teens endorsing pst LOC or never experiencing LOC eting. Future reserch is needed to determine whether inge eting is risk fctor for further weight gin in severely overweight tretment-seeking dolescents. Our finding tht lmost hlf of the prticipnts experienced inge or LOC eting, either presently or t some point in their lifetime, supports prior studies of overweight tretment-seeking dolescents (Decluwe et l., 2003; Isnrd et l., 2003) nd suggests higher frequency of inge eting mong this popultion thn those found in overweight nd norml weight nontretment-seeking youth. Among nontretment-seeking overweight youth, prevlence estimtes for LOC/inge eting re lower, from 14.6% (Tnofsky-Krff et l., 2004) to 33.1% (Morgn et l., 2002) in children nd 18.5% in dolescents (Johnson et l., 2002). Binge eting estimtes mong norml weight non-tretment-seeking youth re lower thn those reported y their overweight

9 Binge Eting in Adolescents 103 counterprts (Tnofsky-Krff et l., 2004). Our results suggest tht inge or LOC eting is n experience shred y sustntil proportion of overweight tretmentseeking dolescents, nd future reserch is required to investigte the potentil impct of inge or LOC eting on the outcome of oth mediction nd ehviorl weight-loss interventions in this popultion. Strengths of this study include the use of interview methodology for the investigtion of eting-disordered pthology nd the rcilly diverse smple. However, ecuse mny dolescents in this study were extremely overweight, our findings re limited in tht they my not generlize to smples of less overweight teens or to helthy weight teens. The reltively smll size of the BED group my lso hve provided potentilly unstle estimtes of the chrcteristics of overweight, tretmentseeking dolescents with BED. In summry, our findings suggest tht sizele numer of overweight teens seeking weight loss struggle with LOC nd/or inge eting. Furthermore, lthough dolescents endorsing recent, suthreshold inge eting do not experience distress to the sme degree s those with DSM-IV-TR BED, they do report greter distress thn those who hve not experienced LOC eting. Given this higher level of distress, overweight dolescents who report inge eting, even t suthreshold levels, my enefit from interventions focused on their LOC eting experiences in ddition to trditionl ehviorl modifiction techniques for weight loss. Finlly, frequent or recent inge eting my serve s n intervention trget for the prevention of fullsyndrome eting disorders nd excessive weight gin. Acknowledgments Portions of this mnuscript were presented t the 2004 Interntionl Conference on Eting Disorders, Orlndo, Florid. Supported y Z01-HD (J.A.Y.). Dr Ynovski is Commissioned Officer in the United Sttes Pulic Helth Service. Received July 29, 2005; revisions received Decemer 26, 2005 nd Jnury 18, 2006; ccepted Ferury 19, 2006 References Achench, T. M., & Elderrook, C. (1991). Mnul for the Child Behvior Checklist nd Revised Child Behvior Profile. Burlington, VT: University of Vermont Deprtment of Psychitry. Ackrd, D. M., Neumrk-Sztiner, D., Story, M., & Perry, C. (2003). Overeting mong dolescents: Prevlence nd ssocitions with weight-relted chrcteristics nd psychologicl helth. Peditrics, 111, Americn Psychitric Assocition (APA). (2000). Dignostic nd sttisticl mnul of mentl disorders text revision (4th ed.). Wshington, DC: Author. Berkowitz, R., Stunkrd, A. J., & Stllings, V. A. (1993). Binge-eting disorder in oese dolescent girls. Annls of the New York Acdemy of Science, 699, Brynt-Wugh, R. J., Cooper, P. J., Tylor, C. L., & Lsk, B. D. (1996). The use of the eting disorder exmintion with children: A pilot study. Interntionl Journl of Eting Disorders, 19, Connor, D. F., Edwrds, G., Fletcher, K. E., Bird, J., Brkley, R. A., & Steingrd, R. J. (2003). Correltes of comorid psychopthology in children with ADHD. Journl of the Americn Acdemy of Child nd Adolescent Psychitry, 42, Cooper, Z., Cooper, P. J., & Firurn, C. G. (1989). The vlidity of the eting disorder exmintion nd its suscles. British Journl of Psychitry, 154, Costello, E. J., & Angold, A. (1988). Scles to ssess child nd dolescent depression: Checklists, screens, nd nets. Journl of the Americn Acdemy of Child nd Adolescent Psychitry, 27, Crow, S. J., Agrs, W. S., Hlmi, K., Mitchell, J. E., & Kremer, H. C. (2002). Full syndroml versus suthreshold norexi nervos, ulimi nervos, nd inge eting disorder: A multicenter study. Interntionl Journl of Eting Disorders, 32, Curry, J. F., & Crighed, W. E. (1993). Depression. In T. H. Ollendick & M. Hersen (Eds.), Hndook of child nd dolescent ssessment (pp ). Nedhm Heights, MA: Allyn nd Bcon. de Zwn, M., Mitchell, J. E., Howell, L. M., Monson, N., Swn-Kremeier, L., Roerig, J. L., et l. (2002). Two mesures of helth-relted qulity of life in morid oesity. Oesity Reserch, 10, de Zwn, M., Mitchell, J. E., Seim, H. C., Specker, S. M., Pyle, R. L., Rymond, N. C., et l. (1994). Eting relted nd generl psychopthology in oese femles with inge eting disorder. Interntionl Journl of Eting Disorders, 15, Decluwe, V., Bret, C., & Firurn, C. G. (2003). Binge eting in oese children nd dolescents. Interntionl Journl of Eting Disorders, 33, Firurn, C. G., & Cooper, Z. (1993). The eting disorder exmintion. In C. G. Firurn & G. T. Wilson

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