Results of a National Initiative

ORIGINAL RESEARCH
Suggested citation for this article: Austin SB, Ziyadeh NJ, Forman S, Prokop LA, Keliher A, Jacobs D. Screening high school students for eating disorders: results of a national initiative. Prev Chronic Dis 2008;5(4). http://www.cdc.gov/pcd/issues/2008/oct/07_0164.htm. Accessed [date].
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Abstract
Introduction
Early identification and treatment of disordered eating and weight control behaviors may prevent progression and reduce the risk of chronic health consequences.
Methods
The National Eating Disorders Screening Program coordinated the first-ever nationwide eating disorders screening initiative for high schools in the United States in 2000. Students completed a self-report screening questionnaire that included the Eating Attitudes Test (EAT-26) and items on vomiting or exercising to control weight, binge eating, and history of treatment for eating disorders. Multivariate regression analyses examined sex and racial/ethnic differences.
Results
Almost 15% of girls and 4% of boys scored at or above the threshold of 20 on the EAT-26, which indicated a possible eating disorder. Among girls, we observed few significant differences between ethnic groups in eating disorder symptoms, whereas among boys, more African American, American Indian, Asian/Pacific Islander, and Latino boys reported symptoms than did white boys. Overall, 25% of girls and 11% of boys reported disordered eating and weight control symptoms severe enough to warrant clinical evaluation. Of these symptomatic students, few reported that they had ever received treatment.
Conclusion
Population screening for eating disorders in high schools may identify at-risk students who would benefit from early intervention, which could prevent acute and long-term complications of disordered eating and weight control behaviors.
Introduction
The acute and chronic medical and psychiatric consequences of eating disorders are well documented. Anorexia and bulimia nervosa are associated with comorbid medical conditions such as osteoporosis and complications of the gastrointestinal, cardiovascular, and endocrine systems (1-3). Binge eating disorder has been linked with psychiatric comorbidity and severe obesity (4). Compared with the general population, people with anorexia or bulimia nervosa are at increased risk of suicide (5,6). More prevalent forms of disordered weight control behaviors, such as vomiting and abuse of laxatives, are also associated with a range of negative health outcomes, such as esophagitis, gastric rupture, and impairment of digestive functioning (7-9). Additionally, disordered eating behaviors may be causally related to overweight and obesity (10-12).
In the United States, the lifetime prevalence of anorexia nervosa, bulimia nervosa, and binge eating disorder are estimated to be 0.9%, 1.5%, and 3.5%, respectively, among women and 0.3%, 0.5%, and 2.0%, respectively, among men (4). Men may make up 10%-25% of the population with anorexia nervosa or bulimia nervosa (4,13) and
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the US Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only and does not imply endorsement by any of the groups named above.
www.cdc.gov/pcd/issues/2008/oct/07_0164.htm • Centers for Disease Control and Prevention
S. Bryn Austin, ScD, Najat J. Ziyadeh, MPH, Sara Forman, MD, Lisa A. Prokop, BA, Anne Keliher, MMHS, Douglas Jacobs, MD
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The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the US Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only
and does not imply endorsement by any of the groups named above.
nearly half of cases of binge eating (4). Median age of onset
for the 3 disorders is estimated to be 18-21 years (4).
Disordered weight control behaviors and symptoms that
do not necessarily meet psychiatric criteria for an eating
disorder diagnosis (7) are estimated to be as much as 20
times more common in community samples (14) than
are those behaviors and symptoms that meet diagnostic
criteria. In 2005 the Youth Risk Behavior Surveillance
System (YRBSS) found that 6.2% of girls and 2.8% of boys
reported vomiting or taking laxatives in the past month
to lose or maintain weight (15). The Minnesota Student
Survey of more than 81,000 high school students found
that, among girls, in the past year, 8.8% vomited to control
their weight, 1.9% used laxatives for weight control, and
25.6% reported binge eating; comparable estimates from
this study for the 3 behaviors in boys were 1.6%, 1.7%,
and 12.5%, respectively (16). The proportion of high school
youth who report these behaviors that have been treated
for their eating disorder symptoms is unknown.
Some studies have found a higher prevalence of disordered
eating behaviors and attitudes among white girls
than among girls of color, particularly African American
girls, although others have reported varying results (16-
23). The 2005 YRBSS documented a similar proportion of
white and Latina high school girls who reported vomiting
or using laxatives in the past month to control weight
(6.7% and 6.8%, respectively); these behaviors were least
commonly reported by African American girls (4%) (15).
In the Minnesota Student Survey, compared with white
girls, Latina and Asian girls, but not African American or
American Indian girls, reported higher rates of disordered
eating behaviors (16). In another school-based study, however,
vomiting and laxative use to control weight were more
common in African American than in white girls (24).
In research with boys, findings have been more consistent
in documenting equal or higher risk in boys of color
relative to white boys. In the 2005 YRBSS, Latino boys
reported the highest rate (3.9%) of vomiting and laxative
abuse in the past month, while a similar proportion of
white (2.3%) and African American (2.8%) boys reported
these disordered weight control behaviors in the past
month (15). In the Minnesota Student Survey, compared
with white boys, Latino, Asian, and American Indian boys,
but not African American boys, reported higher rates of
disordered eating and weight control behaviors (16). The
Commonwealth Fund survey of more than 6,700 US youth
in grades 5 through 12 found that African American and
Latino boys reported higher rates of ever having binged
and purged than did white boys (21).
Early identification and intervention for a range of mental
health problems may reduce risk of progression of the
illness, relapse, and comorbid conditions (25). A shorter
period between symptom onset and start of treatment
may improve prognosis for recovery from anorexia (26)
and bulimia nervosa (27). Early detection through schoolbased
screening can shorten the period between symptom
onset and accessing care and help adolescents begin treatment
at younger ages. Support staff in schools may be
ideally situated to help identify at-risk youth of both sexes
and all races/ethnicities, make referrals for clinical evaluation
and treatment, and offer in-school support (28).
Working with staff in schools across the country in the
winter of 2000, the National Eating Disorders Screening
Program (NEDSP) coordinated, to our knowledge, the
first-ever nationwide eating disorders screening initiative
for high schools in the United States. The program was
designed to promote early detection and treatment-seeking
in adolescents with untreated eating disorder symptoms.
NEDSP’s parent organization, the national nonprofit
organization Screening for Mental Health (http://www.
mentalhealthscreening.org), has coordinated a number
of national, broad-scale screening initiatives in schools,
workplaces, communities, and the military that address
depression, bipolar disorder, anxiety disorders, and alcohol
abuse; it has also screened for eating disorders on
college campuses (29). For the present analysis, our aims
were to evaluate the screening program’s ability to reach
symptomatic youth who had not yet accessed treatment
and to examine sex and racial/ethnic differences in symptoms
and treatment history.
Methods
The NEDSP Program
NEDSP staff sent out registration information about
the program by direct mail and e-mail to individual
membership lists of national professional organizations
for school psychologists, nurses, and counselors to invite
high schools across the country to enroll in the program.
Representatives from high schools then contacted NEDSP
to enroll. All participating high schools were provided with
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the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only
and does not imply endorsement by any of the groups named above.
a questionnaire to screen for student eating disorders; educational
materials for use in classrooms or assemblies; and
technical assistance to help staff implement the screening,
handle student requests to discuss eating disorders, and
make appropriate referrals for evaluation and treatment.
NEDSP educational materials included a video and discussion
guide, participatory classroom curriculum, and
activity guide. All materials were designed to help motivate
students to seek help with eating disorder symptoms.
Care was taken to design materials that did not glamorize
eating disorders or provide unnecessary details about
disordered weight control methods. Educational content
addressed healthy diet and activity, signs and symptoms
to watch out for in friends and family, availability and efficacy
of treatment, and the need to seek help for symptoms.
In addition, materials offered students guidance on how
to talk with a friend or family member who may have an
eating disorder (30).
Screening questionnaire
High schools administered the anonymous, self-report
eating disorders screening questionnaire to students in
classrooms and assemblies. The survey included the
Eating Attitudes Test (EAT-26), a validated eating disorders
screening instrument (31). Possible scores on the
EAT-26 range from 0 to 78. A score of 20 or above indicates
that a person may have an eating disorder and should be
evaluated further by a mental health professional. The
student screening questionnaire also included items that
assessed how often in the past 3 months students had
vomited to control their weight, engaged in eating binges,
or exercised to lose or control their weight. Each of these
behavioral questions was followed by 7 response options:
never, less than once per month, 1-3 times per month, once
per week, 2-6 times per week, once per day, and more than
once per day. The item on vomiting was adapted from the
YRBSS (32). The questionnaire included an item on past
treatment for eating disorders and items on sex, age, race/
ethnicity, height, and weight.
Participants and sampling procedure
A total of 270 public, private, and parochial high schools
signed up to participate in the screening program, and
152 schools from 34 states completed the screening and
educational components of NEDSP. Ninety-eight schools
returned more than 35,000 student screening forms for
analysis. Because of cost constraints on data entry, a subset
of student screening forms were randomly selected for
analysis by using a 2-stage, clustered-sampling method.
First, 33 schools were randomly sampled from the 98 that
returned screening forms, then a random sample of forms
was selected from these schools; the number of forms
selected from a school was proportional to the number
received from that school. Because of a change in protocol
at the data entry site, 8 of the 33 schools had all of their
surveys entered rather than a proportional random sample;
therefore, weighting was used in analyses to adjust for
the oversampling of student surveys from these 8 schools.
This 2-stage selection procedure resulted in a sample of
5,740 screening forms.
Variables and data analysis
Total EAT-26 scores were computed by adding individual
item scores. For students who were missing 1 or 2 items
on the EAT-26 (n = 272), total scores were scaled to values
within the full possible range of the instrument. Students
who were missing 3 or more items were excluded from
analysis. A binary term for EAT-26 score was created on
the basis of the recommended cutoff of a score of 20 as an
indication of a possible eating disorder. Binary terms were
created for each of the items on disordered behavior in the
past 3 months: any report of vomiting to control weight,
binge eating once a week or more, and exercising to lose or
control weight more often than once per day.
Multivariate linear and logistic regression models were
used to test sex and racial/ethnic group differences in
mean EAT-26 scores and frequencies of reporting disordered
eating and weight control behaviors and ever having
been treated for an eating disorder. Multivariate models
examining sex differences controlled for age and race/ethnicity,
and models examining racial/ethnic group differences
controlled for age and were stratified by sex.
In secondary analyses to explore whether symptom type
and severity may explain sex differences in treatment
history, we tested 4 multivariate models that estimated
the odds of ever having been treated for an eating disorder,
comparing girls with boys within each symptom-type
subgroup of students, controlling for symptom severity.
Thirty-nine students who did not respond to the eating
disorders treatment history item were excluded. All models
controlled for sex, age, race/ethnicity, and extreme thinness,
which was included because it is a widely recognized
sign and symptom of eating disorders (33) and is readily
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The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the US Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only
and does not imply endorsement by any of the groups named above.
observable. Extreme thinness was classified according to
the World Health Organization definition of grade 1 thinness
as a body mass index (BMI) less than 18.5 kg/m2 in
adults aged 18 years or older (34), then coded by using
age- and sex-specific BMI values for ages younger than 18
years to correspond with the adult cutoff (35). Subsample
restrictions and additional covariates included in each
model were as follows: model 1, restricted to the subgroup
of students (n = 518) with an EAT-26 score of 20 or higher,
controlled for total EAT-26 score; model 2, restricted to
the subgroup of students (n = 435) who reported vomiting
to control their weight in the past 3 months, controlled for
vomiting frequency; model 3, restricted to the subgroup
of students (n = 366) who reported binge eating once per
week or more in the past 3 months, controlled for binge
frequency; model 4, restricted to the subgroup of students
(n = 155) who reported exercising more than once per day
to lose or control weight in the past 3 months, which is the
highest severity level assessed for this item.
For all models, generalized estimating equation methods
were used to account for the clustered study design
by using SAS PROC GENMOD (SAS Institute Inc, Cary,
North Carolina) (36). After 173 surveys were excluded
because of missing data, the analytic sample included
5,567 students. Compared with students included in analyses,
those excluded were less likely to describe themselves
as white (P = .002) and more likely to have not reported
a race/ethnicity (P < .001); we found no differences in age, sex, EAT-26 score, disordered eating or weight control behaviors, or past eating disorder treatment (P > .05).
Analysis of NEDSP data was approved by the institutional
review board at Children’s Hospital Boston.
Results
The sample included 58% (3,252) girls and 42% (2,315)
boys; 3% (189) were African American, 2% (93) American
Indian, 2% (134) Asian/Pacific Islander, 5% (303) Latino,
83% (4,629) white, and 4% (219) reported no ethnicity. The
mean age was 15.9 (standard deviation 1.0) years. Girls
were 3 to 5 times more likely than boys to score at or above
the threshold on the EAT-26, to report vomiting to control
their weight in the past 3 months, and to have ever been
treated for an eating disorder (Table 1).
Among girls, few significant differences were found in
eating disorder symptoms across racial/ethnic groups
(Tables 2A and 2B). Compared with white girls, Latina
girls were less likely and American Indian girls were more
likely to score 20 or more on the EAT-26, and African
American and American Indian girls were more likely
to report exercising more than once per day to control
their weight. In contrast, among boys, African American,
American Indian, Asian/Pacific Islander, and Latino boys
were consistently more symptomatic than were white boys
across the range of disordered eating and weight control
symptoms and behaviors.
Within symptom subgroups defined by EAT-26 score
and binge eating, girls were roughly 3.5 times more likely
to report that they had been treated for an eating disorder
than were boys with comparable symptom severity (Table
3). Within the symptom subgroup defined by exercising
once a day or more often to control weight, girls were
almost 8 times more likely than boys to report having
been treated for an eating disorder. In contrast, within the
subgroup that reported vomiting, no sex difference was
observed in the odds of having ever received treatment. In
most models, extreme thinness was positively associated
with the odds of having been treated for an eating disorder,
but age and race/ethnicity were not, controlling for sex
and symptom type and severity (data not shown).
Discussion
NEDSP, to our knowledge the first national screening
program for eating disorders held in high schools across
the United States, found that almost 1 in 4 girls and 1
in 10 boys reported at least 1 disordered eating or weight
control symptom serious enough to warrant further evaluation
by a health professional. Applying these findings
to the roughly 35,000 students who completed screening
questionnaires, we estimate that close to 7,000 students
with potential eating disorder symptoms were identified
in participating schools. Furthermore, a large proportion
of symptomatic students had never been treated for an
eating disorder. Depending on the symptom type, the proportion
of symptomatic students who had never received
treatment was 83% to 95% of boys and 83% to 86% of girls.
These results support 2 conclusions: 1) national screening
for eating disorders in high schools reached a large number
of students who were likely to have symptoms of disordered
eating and weight control and 2) most symptomatic
high school students were untreated. Coupled with evidence
that early detection and intervention may improve
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The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the US Department of Health and Human Services,
the Public Health Service, the Centers for Disease Control and Prevention, or the authors’ affiliated institutions. Use of trade names is for identification only
and does not imply endorsement by any of the groups named above.
treatment outcomes (26,37,38), these findings underscore
the suitability of population screening (39) in high schools
as a strategy to identify youth in need of clinical evaluation
for eating disorders.