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OBJECTIVE: To assess longitudinally the relationship between measures of adiposity in children over the first 8 y of life with that of their parents and to explore the role of parental adiposity in the development of childhood adiposity. DESIGN: Longitudinal study of measures of adiposity in children. SUBJECTS: A community sample from three health service systems including 114 children followed annually from infancy to age 8 and their 228 biological parents. METHODS: Measurements were assessed at baseline for parents (6 months post-partum for mothers) and at regular intervals for children beginning at age 2 months. Measurements included weight, height, triceps skinfold, subscapular skinfold, midarm circumference, waist and hip. RESULTS: The major findings were: (1) significant correlations between parental body mass index (BMI), both maternal and paternal, and their biological offspring first emerged at age 7; (2) children with two overweight parents had consistently elevated BMI compared to children with either no overweight parents or one overweight parent. These differences became significant beginning at age 7. CONCLUSIONS: This study supports the hypothesis that familial factors (biological and/or environmental) affecting the development of adiposity emerge at specific ages and are related to the adiposity of both parents.

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Little is known about the consequences to children of bottle feeding prolonged beyond age 1 year on caloric intake and overall dietary composition. To obtain these data, 165 children, followed up from infancy, were assessed in these respects for a 24-hour period at age 3 1/2 years. Bottle-fed children (n = 14) consumed more milk than their weaned counterparts (p < 0.001), had a higher mean daily calcium intake (p < 0.05), received fewer calories from carbohydrates (p = 0.034), and received a greater percentage of calories from protein (p = 0.033). There were no significant differences between the groups in total caloric intake, total iron intake, total volume ofjuice, or calories from fat. Pediatricians questioned about the effects of continuing to offer children nutritive liquids from bottles as well as cups (versus offering cups alone) may inform parents that this feeding practice is associated with significantly greater milk consumption and daily calcium intake. However, this study could not find evidence that prolonged bottle feeding at age 3 1/2 years is associated with a significantly decreased total daily iron intake or an increased risk for factors associated with adiposity such as a greater daily calorie intake, a higher body mass index, or greater percentage of total calories derived from fat.

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OBJECTIVE: Because etiologic and maintenance models of binge eating center around dieting and affect regulation, this study tested whether binge eating-disordered (BED) individuals could be subtyped along dieting and negative affect dimensions and whether subtypes differed in eating pathology, social functioning, psychiatric comorbidity, and response to treatment. METHOD: Three independent samples of interviewer-diagnosed BED women (N = 218) were subtyped along dieting and negative affect dimensions using cluster analysis and compared on the outcomes of interest. RESULTS: Cluster analyses replicated across the three independent samples and revealed a dietary subtype (63%) and a dietary-depressive subtype (37%). The latter subtype reported greater eating and weight obsessions, social maladjustment, higher lifetime rates of mood, anxiety, and personality disorders, and poorer response to treatment than did the dietary subtype. DISCUSSION: Results suggest that moderate dieting is a central feature of BED and that affective disturbances occur in only a subset of cases. However, the confluence of dieting and negative affect signals a more severe variant of the disorder marked by elevated psychopathology, impaired social functioning, and a poorer treatment response.

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OBJECTIVE: This case report describes the application of dialectical behavior therapy (DBT) to the treatment of bulimia nervosa in a 20-session manualized therapy. METHOD: The treatment, based on an affect regulation model of eating disorders, was developed to teach emotion regulation skills to replace eating-disordered behaviors. The patient, a 36-year-old woman, had a long history of binge eating and purging that had not responded to 2 years of counseling. In the 4 weeks before treatment began, she reported 13 objective binges and 21 purging episodes. RESULTS AND DISCUSSION: Upon initiating DBT, her binge eating and purging rapidly declined. She achieved abstinence by the fifth week of treatment and maintained it through treatment. In the 6 months following treatment, she reported a total of two objective binge episodes and two purge episodes.

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Eating disorders are severe, relatively chronic conditions that are associated with comorbid psychopathology and adverse medical conditions. The death rate for patients with AN is the highest among psychiatric conditions, with high suicide rates and deaths from physiologic causes. In addition, the costs of therapy for AN are higher than those for schizophrenia. Although somewhat less chronic, BN and binge-eating disorder are costly conditions to treat, similar to or more expensive than the costs for the treatment of OCD. Although antidepressant medication seems to be the most cost-effective treatment in the short term, given the higher relapse rates with antidepressants, it seems that, in the end, CBT may be the most cost-effective approach to the treatment of BN. It is possible that similar figures would occur for binge-eating disorder. The issue of the comparative cost-effectiveness of various treatments for psychiatric disorders has been neglected in the research literature to date. It is important that large-scale RCTs add a sophisticated cost-effectiveness analysis to the design so that physicians can better choose the most effective and cost-effective sequence of therapies for their patients.

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OBJECTIVE: This study examined self-oriented (SOP), socially prescribed (SPP), and other-oriented (OOP) perfectionism in 127 obese women with binge eating disorder (BED). METHOD: Relationships between eating disorder and general psychopathology variables and SOP, SPP, and OOP were assessed. Levels of SOP, SPP, and OOP in the BED sample were compared with those of 32 normal weight women with bulimia nervosa (BN) and 60 obese non-eating-disordered individuals (NED). Structural equation modeling (SEM) was used to test models of the maintenance of BED. RESULTS: Only SPP was significantly associated with eating disorder variables related to BED. All three groups demonstrated similar levels of SPP and OOP. BN and BED groups scored significantly higher than the NED group on SOP only. SEM resulted in two models with good fits. DISCUSSION: Further research is needed on the roles of SPP and SOP in BED and on weight and shape overconcern in BED maintenance models.

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OBJECTIVES: To examine differential parental influences on eating attitudes and behaviors of 8-year-old children with a specific focus on gender effects and to assess the specificity of this relationship. METHOD: One hundred eight infants were monitored from birth and interviewed at age 8 for eating disturbances and negative affect with an adaptation of the McKnight Risk Factor Survey. Parental measures included the Three Factor Eating Questionnaire subscales Disinhibition and Restraint as well as body mass index, assessed at study entry. RESULTS: No gender differences were found for frequencies of children's self-reported eating disturbances. Higher maternal restraint scores predicted worries about being too fat in girls but not in boys. Higher maternal disinhibition scores also differentially predicted weight control behaviors in their daughters. Negative affect in the child was (weakly) predicted by higher maternal body mass index. No association between paternal predictors of disturbed eating and the child's eating disturbances and negative emotionality was found. CONCLUSIONS: The impact of maternal eating disorders and disturbances is much stronger than that of fathers and is specifically directed at their daughters. The clinical importance of these disturbances in terms of precursors of adolescent eating disorders has to be determined by monitoring the sample through puberty.

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OBJECTIVE: The effects of dialectical behavior therapy adapted for the treatment of binge/purge behaviors were examined. METHOD: Thirty-one women (averaging at least one binge/purge episode per week) were randomly assigned to 20 weeks of dialectical behavior therapy or 20 weeks of a waiting-list comparison condition. The manual-based dialectical behavior therapy focused on training in emotion regulation skills. RESULTS: An intent-to-treat analysis showed highly significant decreases in binge/purge behavior with dialectical behavior therapy compared to the waiting-list condition. No significant group differences were found on any of the secondary measures. CONCLUSIONS: The use of dialectical behavior therapy adapted for treatment of bulimia nervosa was associated with a promising decrease in binge/purge behaviors.

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This study evaluated the use of dialectical behavior therapy (DBT) adapted for binge eating disorder (BED). Women with BED (N = 44) were randomly assigned to group DBT or to a wait-list control condition and were administered the Eating Disorder Examination in addition to measures of weight, mood, and affect regulation at baseline and posttreatment. Treated women evidenced significant improvement on measures of binge eating and eating pathology compared with controls, and 89% of the women receiving DBT had stopped binge eating by the end of treatment. Abstinence rates were reduced to 56% at the 6-month follow-up. Overall, the findings on the measures of weight, mood, and affect regulation were not significant. These results support further research into DBT as a treatment for BED.

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The objective of this study was to assess whether private high school students constitute a group that is at high risk for eating pathology. Female and male public and private high school students (N = 465) were compared on self-reported eating disordered attitudes and behaviors. Private high school students reported elevated eating disordered attitudes and behaviors when compared with students from public schools. The results were somewhat stronger for females than males. The findings suggest that private high school students are a group at high risk for eating pathology. The identification of such high risk groups may facilitate etiologic studies and aid in the implementation of targeted prevention programs.

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OBJECTIVE: The purpose of this investigation was to determine the test-retest reliability of the Eating Disorder Examination (EDE). METHOD: This study examined the test-retest and interrater reliability of the EDE in 20 adult women with a range of eating disorder symptoms. Trained assessors administered the EDE to participants on two separate occasions, ranging from 2 to 7 days apart. RESULTS: Test-retest correlations were.7 or greater for all subscales and measures of eating disorder behaviors except for subjective bulimic episodes and subjective bulimic days. Interrater reliability was uniformly high with correlations above.9. DISCUSSION: Results provide further support for the reliability of the EDE, but suggest that smaller binge episodes may not be reliable indicators of eating pathology.

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OBJECTIVE: The aim of this study was to discover clinically useful predictors of attrition and outcome in the treatment of bulimia nervosa with cognitive behavior therapy. METHOD: Pretreatment, course of treatment, and outcome data were gathered on 194 women meeting the DSM-III-R criteria for bulimia nervosa who were treated with 18 sessions of manual-based cognitive behavior therapy in a three-site study. Differences between dropouts and nondropouts and between recovered and nonrecovered participants were first examined descriptively, and signal detection analyses were then used to determine clinically significant cutoff points predicting attrition and abstinence. RESULTS: The dropouts were characterized by more severe bulimic cognitions and greater impulsivity, but it was not possible to identify clinically useful predictors. The participants with treatment failures were characterized by poor social adjustment and a lower body mass index, presumably indicating greater dietary restriction. However, early progress in therapy best predicted outcome. Signal detection analyses revealed that poor outcome was predicted by a reduction in purging of less than 70% by treatment session 6, allowing identification of a substantial proportion of prospective failures. CONCLUSIONS: A cutoff point based on reduction of purging by session 6 usefully differentiates patients who will and will not respond to cognitive behavior therapy for bulimia nervosa, potentially allowing early use of a second therapy.

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OBJECTIVE: This was an investigation of whether treatment with fluoxetine is useful for individuals with bulimia nervosa who do not respond to psychotherapy or relapse afterward. METHOD: Twenty-two patients with bulimia nervosa who had not responded to, or had relapsed following, a course of cognitive behavior therapy or interpersonal psychotherapy were randomly assigned to receive placebo (N=9) or fluoxetine (60 mg/day, N=13) for 8 weeks. RESULTS: The median frequency of binge eating in the previous 28 days declined from 22 to four episodes in the fluoxetine group but increased from 15 to 18 episodes in the placebo group. Similarly, purging frequency in the previous 28 days declined from 30 to six episodes in the fluoxetine group but increased from 15 to 38 episodes in the placebo group. CONCLUSIONS: Fluoxetine may be a useful intervention for patients with bulimia nervosa who have not responded adequately to psychological treatment.

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BACKGROUND: Research suggests that cognitive-behavioral therapy (CBT) is the most effective psychotherapeutic treatment for bulimia nervosa. One exception was a study that suggested that interpersonal psychotherapy (IPT) might be as effective as CBT, although slower to achieve its effects. The present study is designed to repeat this important comparison. METHOD: Two hundred twenty patients meeting DSM-III-R criteria for bulimia nervosa were allocated at random to 19 sessions of either CBT or IPT conducted over a 20-week period and evaluated for 1 year after treatment in a multisite study. RESULTS: Cognitive-behavioral therapy was significantly superior to IPT at the end of treatment in the percentage of participants recovered (29% [n=32] vs 6% [n=71), the percentage remitted (48% [n=53] vs 28% [n = 31]), and the percentage meeting community norms for eating attitudes and behaviors (41% [n=45] vs 27% [n=30]). For treatment completers, the percentage recovered was 45% (n= 29) for CBT and 8% (n= 5) for IPT. However, at follow-up, there were no significant differences between the 2 treatments: 26 (40%) CBT completers had recovered at follow-up compared with 17 (27%) IPT completers. CONCLUSIONS: Cognitive-behavioral therapy was significantly more rapid in engendering improvement in patients with bulimia nervosa than IPT. This suggests that CBT should be considered the preferred psychotherapeutic treatment for bulimia nervosa.

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OBJECTIVE: Because psychoeducational primary prevention programs for eating disorders have met with little success, this preliminary experiment tested a dissonance-based targeted preventive intervention. METHOD: Female undergraduates (N = 30) with elevated body image concerns were assigned to a three-session intervention, wherein they voluntarily argued against the thin ideal, or a delayed-intervention control condition. Participants completed a baseline, termination, and a 1-month follow-up survey. RESULTS: The intervention resulted in a subsequent decrease in thin-ideal internalization, body dissatisfaction, dieting, negative affect, and bulimic symptomatology, with most changes remaining at the 1-month follow-up. DISCUSSION: These preliminary results suggest that this dissonance-based targeted prevention intervention reduces bulimic pathology and known risk factors for eating disturbances, and provide experimental support for the claim that thin-ideal internalization contributes to body dissatisfaction, dieting, negative affect, and bulimic symptoms.

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OBJECTIVE: Although laboratory experiments suggest that negative affect inductions potentiate the relation between dieting and disinhibited eating, little research has tested whether this finding generalizes to binge eating in the natural environment. Thus, we assessed whether negative affect moderated the relation between dieting and binge eating in a passive-observational study. METHOD: This aim was addressed with longitudinal data from a community sample of adolescents (N = 631). RESULTS: For females, dieting and negative affect predicted binge eating in cross-sectional and prospective analyses, but negative affect potentiated the relation between dieting and binge eating only in the cross-sectional analyses. Similar, but attenuated results were found for males. DISCUSSION: Findings converge with those from laboratory studies in suggesting that negative affect moderates the relation between dieting and binge eating, but also imply that dieting and negative affect constitute independent risk factors for binge eating. The lack of prospective effects may suggest that the interactive relations have a short time lag or are difficult to detect prospectively.

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OBJECTIVE: This study investigated the course of eating attitudes and eating-disordered behaviors in a community sample of adult women. METHOD: Participants (N = 166; mean age = 32.8 years) completed the Eating Disorder Inventory (EDI), the Three-Factor Eating Questionnaire (TFEQ), and a questionnaire assessing bulimic behaviors at two time points, 6 years apart. RESULTS: Correlations for rank ordering of scores on these measures were all significant, indicating high rank stability over time. Although rates of specific bulimic behaviors decreased over time, mean scores on eating disorder attitude scales tended to increase. DISCUSSION: Findings challenge the commonly held belief that disturbed eating attitudes decline with age.

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Etiologic models of bulimia center on dieting and negative affect, yet no research has subtyped bulimic individuals according to whether they fit dietary versus negative affect profiles. This study subtyped 265 bulimic women along dieting and depressive dimensions and tested whether subtypes showed differences in eating pathology, clinical correlates, and treatment response. Cluster analysis revealed a pure dietary subtype (62%) and a mixed dietary-depressive subtype (38%). Whereas dietary and dietary-depressive bulimic women showed similar levels of bulimic behaviors, the latter reported more eating and weight obsessions; social maladjustment; higher rates of mood, anxiety, eating, impulse control, and personality disorders; and poorer treatment response. Results suggest dieting is a central feature of bulimia, but depressive affect occurs in only a subset of cases. However, the combination of dieting and depressive affect seems to signal a more severe variant of bulimia.

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OBJECTIVE: Research suggests that eating problems are often present by preadolescence, yet little is known about the age of emergence of these early eating disturbances or risk factors for these behaviors. Thus, we investigated the timing of onset of disturbed eating during childhood and the predictors of these behaviors. METHOD: These aims were addressed by following a sample of children and their parents (N = 216) for the first 5 years of the children's lives. RESULTS: Data suggested that the risk for emergence of inhibited eating, secretive eating, overeating, and vomiting increased annually through age 5. Maternal body dissatisfaction, internalization of the thin-ideal, dieting, bulimic symptoms, and maternal and paternal body mass prospectively predicted the emergence of childhood eating disturbances. Infant feeding behavior and body mass during the first month of life also predicted the emergence of these behaviors. DISCUSSION: Results suggest that eating disturbances emerge during childhood and may be a function of certain parental and child characteristics.

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This study examined the relationship between general maternal parenting style, maternal eating cues, and a child's eating behavior during mealtime. We expected that the general style would relate to the number of specific eating cues and that mothers who used more eating prompts would have children that ate more and at a faster rate. Seventy-seven children (39 girls, 38 boys), aged 3.5 years, visited the laboratory with their mothers for a videotaped lunch. Videotapes of each laboratory visit were coded for the child's eating rate and maternal parenting style, which was measured as the level of maternal control and support and the number and type of eating prompts given during a meal. Caloric intake was also calculated. The number and rate of verbal and physical encouragements and discouragements were significantly related to measures of general maternal parenting style and meal duration. The rates of food offers, food presentations, and total prompts were all significantly related to the child's rate of calorie intake. However, a mother's level of support or control was not related to the child's eating behavior. Although general maternal parenting style did not predict the child's eating behavior, these behaviors were related to the frequency of maternal eating prompts, which in turn were significantly related to the number of calories eaten and the time spent eating by the child. Children who ate the fastest had mothers who delivered eating prompts at a higher frequency. These findings may have implications for the development of obesity later in childhood, as a function of rapid eating or of poor self-regulation.

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