This article was downloaded by: [Temple University Libraries] On: 11 January 2015, At: 21:04 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Women & Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wwah20
Depression and Maladaptive Eating Practices in College Students a
b
Wesley E. Hawkins PhD , Robert J. McDermott PhD , John c
Seeley MS & Michele J. Hawkins PhD
a
a
Department of Public Health Education, University of Oregon, Eugene, OR b
Department of Community and Family Health, University of South Florida c
Oregon Research Institute Published online: 05 Nov 2010.
To cite this article: Wesley E. Hawkins PhD , Robert J. McDermott PhD , John Seeley MS & Michele J. Hawkins PhD (1992) Depression and Maladaptive Eating Practices in College Students, Women & Health, 18:2, 55-67, DOI: 10.1300/J013v18n02_04 To link to this article: http://dx.doi.org/10.1300/J013v18n02_04
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/ page/terms-and-conditions
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
Depression and Maladaptive Eating Practices in College Students Wesley E. Hawkins, P h D Robert J. McDermott, P h D John Seeley, M S Michele J. Hawkins, P h D
ABSTRACT. University students (n = 234) enrolled in sections of a required undergraduate course were administered the Center for Epidemiologic Studies Depression (CES-D) Scale and the Maladaptive Eating Behavior (MEB) Scale to determine if selected maladaplive eating practices correlated with depressive symptoms. Stepwisc multiple regression on data from female subjecls (n = 138) revealcd that four eating practices related lo depression, and produced a multiple R = .68, accounting for 46.2% of Lhe variance. Maladaptive eating practices were not predictive of depression among males (n = 96) with "feeling uncomfortable eating in the presence of olhers" the only significantly correlated variable. This study confirms previous research that has found an association betwcen maladaptive eating practices and depressed mood in nonclinical samples of university students.
INTKODUCTION T w o conditions adversely affecting the health and general wellbeing of young adults are depression and maladaptive eating behavWesley E. Hawkins, PIID is associated with the Department of Public Health Education, University of Oregon, Eugcne, OR 97403. Robert J. McDermott, PhD is associated with Ule Department of Community and Family Health. University of SouUl Florida, 13301 Bruce B. Downs Blvd., Tampa, FL 33612. John Seeley, BS is associated with the Oregon Research Institute. 1715 Franklin Blvd. Eugene, OR 97403. Michele J. Hawkins is associated with the Departmen1 of Public Health Education. University of Oregon. Eugene. OR 97403. Women & Health, Vol. 18(2) 1992 O 1992 by The Haworth Press. Inc. All rights reserved.
55
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
56
WOMEN & HEALTIi
ior. Depression is the most commonly identified mental health problem among college Recent estimates of depression using nonprobability samples of college age men and women have been noted in the literature.'-' McDermott et aL6 estimated that 65% and 51% respectively of college women and men experienced at least transient episodes of depression. McDermott4 also demonstrated in a collegiate sample that depression occurred more frequently in women than in men. Hawkins et al! suggested that this gender difference could be accounted for primarily by examining an element first described by Radloff? and labeled as "depressed ilffect." Eating disorders such as anorexia nervosa and bulimia nervosa are complex conditions believed to have individual, familial, and sociocultural predisposing factors.I0 A recent report suggests that certain hormonal influences also can affect one's predisposition toward bulimia." These conditions and other maladaptive eating practices may reach critical levels in the college p o p u l a t i ~ n . ' ~ - ' ~ Some studies of college students have estimated the prevalence of bulimia nervosa at 8% to 19% among women and up to 5% among In a national probability sample of college students, Drewnowski, Hopkins, and Kessler'' estimated the actual prevalence of bulimia nervosa to be less than 1.0% in women and 0.2% in men. However, these same investigators found the prevalence to be as high as 2.2% among undergraduate women living on campus in group housing. The discrepancy between their data and data from earlier studies may be a matter of sampling procedures, other matters of design rigor, and explication of the DSM-111~'~ criteria for reporting actual bulimia nervosa versus reporting "bulimia nervosalike practices" only. While the presence of several maladaptive eating practices can be associated with depressive symptoms, the nature of this aqsociation is not particularly well delineated in the l i t e r a t ~ r e . ~ . Persons ~"~.~~ with anorexia nervosa or bulimia nervosa have been shown in psychiatric testing to score higher on depression scales than a normal population, but lower than a primarily depressed p~pulation?~.~' Some a u t h ~ r i t i e shave ~ ~ ' ~proposed ~ that eating disorders are variants of affective disorders, while other investigators refute this asserti0n.2~Depression related to eating behavior may not have a common mechanism of cause. Swift et a1." suggest that for the person
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
with anorexia nervosa, depression stems from the physiologic consequences of self-starvation. For the person with bulimia nervosa, depression may be associated with the feelings of guilt and loss of control over eating behavior." Among college students, the practice of overeating has been shown to be associated with some indicators of depression.' This same practice also has been significantly, if weakly correlated with broader measures of depressions6The purpose of this study, therefore, was to explore the relationship between maladaptive eating practices and self-reported symptoms of depression in a sample of university students. Finally, while the relationship of eating disorders and clinical depression is well-documented in the literature, the present research study focuses on the relationship of less severe mood and maladaptive eating behaviors in a non-clinical group.
METHODS A cross-sectional survey research design using 234 subjects (students enrolled in sections of a required undergraduate class at a large university in the pacific Northwest) was carried out in May of 1988. From a pool of 246 potential participants. the non- response rate in the available sample was less than five percent. Two written self-report instruments were administered concurrently in this study. These instruments included the Center for Epidemiologic Studies Depression (CES-D) Scale9and the Maladaptive Eating Behavior (MEB) Scale. The 20-item CES-D Scale examines the frequency with which respondents have experienced specific symptoms of depression during the past week (Appendix A). Individual items are scored from 0 to 3, with "0" indicating a symptom was experienced "rarely or none of the time" (less than I day), "1" indicating a symptom was experienced "some or a little of the time" (1-2 days), "2" indicating a symptom was experienced "occasionally or a moderate amount of time" (3-4 days), and "3" indicating the symptom was experienced "most or all of the time" (5-7 days). After four positively worded items are recoded, the CES-D Scale is summed. A high risk for depression is suggest-
WOMEN & HEALTH
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
58
ed by scores of 16 or 2Feater?.28 Concurrent validity with the Beck Depression Inventory and the Zung Scale3' has been established. The scale has been found to have high internal consi~tenc$"~and acceptable test-retest reliability.!' In studies involving collegiate samples, internal consistency of the CES-D Scale as measured by Cronbach's alpha, was estimated at .88 and .89 re~pectively.~" Moreover, the CES-D Scale has been factor analyzed by adl lo fa and Hawkins et al? to yield four factors: depressed affect (DA), positive affect (PA), somatic or retarded activity (SRA), and interpersonal relations (IR). The similarity of the factor structures across groups is suggestive of construct validity. The MEB Scale (Appendix B) is comprised of 17 items and uses a response format identical to that of the CES-D Scale. Other instruments using this same format have been administered satisfactorily with collegiate samples, and in conjunction the CES-D Scale.'" The 17 items of MEB Scale relate to selected maladaptive eating practices. Efforts to assess content validity were made by means of a literature review, and by a validation panel of experts comprised of three specialists in education about mental health. Because we were studying a non-clinical sample in terms of maladaptive eating and not eating disorders per se, the researchers in the present study used items from a variety of past scales to provide a more extensive range of eating behavior items. A factor analysis was conducted on the MEB Scale that indicated no substructure for the 17 items. Remaining behavioral and demographic items were adapted from the Health scale.'" Using Cronbach's alpha, the intemal consistency of the MEB Scale was estimated to be .91. Data were collected by administering the two primary instruments in a paper-and-pencil format to intact groups of students. Prior to administration, approval was obtained for the study from the University Committee on Research Involving Human Subjects, with the understanding that participation would be voluntary and that anonymity of respondents would be protected. Further permission was obtained from individual course instructors to involve students in the data collection process. Course curricula were reviewed with each instructor to guarantee that formal discussion of maladaptive eating practices, eating disorders, or depression had not occurred prior to the administration of the instruments. Two of the ~
~
~
-
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
Hawkins er al.
59
investigators oversaw data collection to ensure standardization of procedures and format. Data analysis included standard descriptive procedures such as frequencies, percentages, measures of central tendency, and selected crosstabulations. Stepwise multiple regression analysis was used to determine the most salient maladaptive eating behaviors related to depressive symptoms (CES-D Scale score). Canonical correlation analysis was then conducted on the subscales of the CES-D to determine if specific maladaptive eating practicies were more related to specific subconstructs of the depression scale. Data were inspected to meet the assumptions of multiple regression (normality, multicolinearity, outliers, linearity). RESULTS The 234 respondents ranging in age from 17 to 36 years, with the mean equal to 20.1 and the mode equal to 18. Among respondents, 138 (59%) were females and 96 (41%) were males. With respect to race. 198 (84.6%) were white, 2 (0.9%) were black. arid 33 (14.1%) were members of other racial groups. One respondent (0.4%) did not specify race. The range of scores on the CES-D Scale for this sample was 0 to 43 with a mean of 16.9 and a stmdard deviation of 8.7 for males; and 0 to 50 with a mean of 19.2 and a standard deviation of 11.3 among females. Radlof? indicates that scores equal to or greater than 16 are suggestive of depression of at least a transient nature. For this sample, 53.1 % of the males and 60.1 % of the females exceeded this criterion. The proportion of males and females with CES-D Scale scores 5 16 were not significantly different (X2 = 1/14, p = .29). This high level of elevated depressive symptomatology could suggest the cut off at 16 on the CES-D is simply too low. The item-response frequencies for the maladaptive eating practices for males and females comprising the MEB Scale are presented in Table 1 and the most commonly reported eating behaviors (at least 1-2 days per week) included: "I ate something because I felt bored" (59.0%); "I felt guilty after eating" (42.3%); "I ate some-
WOMEN & HEALTH
60
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
thing because I was upset or nervous" (38.4%); "I ate something because 1 felt lonely" (35.0%);"I felt I thought too much about food" (34.6%);and ''I ate so much food so fast that I didn't know how much I ate or how it tasted" (32.9%). Given the established gender differences in depression among college students from past research3" and the gender difference in means for the present sample, separate regression analyses were conducted for males and females. A stepwise analysis using the
Table 1.
Response Frequencies for Maladaptive Eating Practices During the Past Week By Gender
MEB Scale Item
Rarely
Some (1-2davsl
k1 dav)
Eat Fast Eat Lonely Eat Fat Fwd Nervous Eating Eating in presence Eat Bored Vomit after eating Night eating No Fwd 24 Hrs. Eat Hurl
Hid Fwd Used Laxative Thought F w d No Control Hate Self . Guilt Over Eat Guilt After Eat
(63 21 (&&) 43 (97) 13 (87) 46
(13 (31) (9) (33)
28 (30) 13 (14) 3 (3) 9 (9)
98 (71) 42 (31)
73 (76) 24 (17) 21 (22) 8 (6) I (1) 8 (6) 1 (1) 54 (56) 46 03) 30 (31) 40 (29) 10 (10) 10 (7) 2 (2)"
120 (87) 1% (97) 126 (91) 97 (70) 124 (90) 132 (96) 70 (51) 87 (63) 94 (68) 92 (67) 55 (40)
94 (98) 11 (8) 93 (93 4 (3) 91 (95) 11 (8) 71 (74) 29 (21) 96 (100) 8 (6) 95 (99) 3 (2) 83 (87) 36 (26) 84 (88) 23 (17) 92 (96) 26 (19) 80 (83) 20 '15) 81 (84) 45 (33)
' p c .05,Chi-square tests.
p < .01,Chi-square tests.
4 (3) 0 (0) 0 (0) 6 (4) 4 (31 2 (1.0) 18 (13) 15 (11) 7 (5) 14 (10) 19 (14)
5 2 0 4
(5) (2) (0) (4)
62 81 93 83
2 (2) 2 (2) 5 (5) 23 (20 0 (0) 1 (1) 9 (9) 8 (8) 3 (3) 10 (10) 13 (14)
16 (12) 16 (12) 6 (4) 26 (19)
Most (57davsl
.95 (69) 71 (51) 113 (82) 61 (44)
Items may not always total 1005% due to rounding error. "
Occasionally ( 3 4 davsl
0 1 0 2 0 0
4 4
1
(0) (1) (0) (2) (0) (0) (4) (4) (1)
5 (5) 2 (2)
6 8 6 5
(4) 1 (1). (6) 0 (0)" (9) 0 (0)" (4) 0 (0)''
3 (2) 0 (0). 0 (0) 0 (0) 1 (.7) 0 (0) 6 (4) 0 (0) 2 (1) 0 (0)' 1 (.71 0 (0) 13 (9) 0 (0)'. 13 (9) 0 ( O P 11 (8) 0 (0)" 12 (9) 1 (1)" 19 (14) 0 (O)..
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
Hawkins el al.
61
subsample of females in the study revealed four maladaptive eating practices associated with depression (Table 2): "1 ate something because I was upset or nervous" (B = .38), "I felt uncomfortable eating in the presence of others" (B = .27), "I forced myself to vomit after eating'' (B = .24) and "I went without eating solid food for 24 hours to lose weight" (B = .12). The multiple R for the equation was .68,accounting for 46.2%of the variance. A stepwise analysis for the male subsample resulted in less association with depressive symptoms. As the data in Table 2 show, the only correlate of depression among males was "I felt uncomfortable eating in the presence of others" (B = .35). A further analysis was conducted by examining which specific subscales of the CES-D ("Depressed Affect," "Interpersonal," "Somatization" and "Positive Affect") were most related to the significant maladaptive eating behaviors. A canonical correlation analysis was conducted to examine these relationships. Canonical correlation is a multivariate statistical technique that identifies a Table 2:
Stepwise Multiple Regression Results: Male and Female Maladaptive Eating Behaviors As PreCic:ors oi CESD Scde Score
r
RZ
Ad]. RZ
Eating ln Presence of Others
.51
.40
39
,000
.27
Vomit After Eating
.45
.45
.A4
.OOO
.24
No Food For 24 Hours
.11
.47
.45
.a00
Variable
Significance of F
Standardiied Beta
Females (N = 158)
Males (N = 96) Eating In Presence of Others
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
62
WOMEN & HEALTH
linear combination of one variable set that maximally correlates with another variable set. Canonical correlation analysis revealed one significant canonical variate (p < .0001) for females while no significant variates were found for males at the .05 alpha level. The canonical correlation for females was 5 0 , accounting for 25% of the variance. Using a cut off score of .30 for interpretability for structural correlations, the researchers found approximately similar correlations for each subscale in relation to maladaptive eating, thus providing support for treating the CES-D as a total construct. For the maladaptive eating variable set, females who were more likely to report "upset or nervous eating" (.76), "uncomfortable eating in the presence of others" (.79). "forced vomiting after eating" (.66) were also more likely to report in terms of the depression variable set higher "depressed affect" (.89), higher "interpersonal concerns" (.83), negative "positive affect" (--83)and higher "somatization" (.76). One variable from the maladaptive eating behavior set did not meet the .30 cutoff, "no food for 24 hours" (.16).
DISCUSSION The major finding from this study was that specific maladaptive eating practices were related to depressive symptoms for female subjects only. The maladaptive eating practice most associated with depression among females in the sample, "upset or nervous eating," follows from the relationship between eating disorders and insecurity, confusion, fragility of self, and other feelin s of inadequacy advanced by Lueas. Beard. Kranz, and Kurland! Using the present data, one might hypothesize that anxiety is an antecedent factor with respect to maladaptive eating. Fairburn and Coope?' found that women diagnosed with bulimia nervosa demonstrated high levels of anxiety. If anxiety arises from a combination of microstressors and macrostressors, it is conceivable that stress management strategies could be useful adjuvant therapeutic intenentions for individuals who are depressed and engaged in maladaptive eating. Future research should include tests of trait and state anxiety to confirm or refute the role of anxiety in influencing associations between maladaptive eating and depression.
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
Hawkiw er al.
63
The three remaining predictors ("Feeling uncomfortable eating in the presence of others," [forced vomiting] after eating." and "[going without) eating solid food for 24 hours") approximate DSM-IIIR symptoms for bulimia nervosa.19 This finding corroborates a previous view that eating disorders are variants of affective disorder^.^"' However, several items on the MEB Scale comparable to DSM-IIRcriteria for bulimia nervosa were not found to be related to depression. One might anticipate that these variables would correlate with depression, given the presumed co-morbidity of btilimia nervosa and depressive disorder^?^"^ Such was not the case in the present study since DSM-IIR symptoms like "[feeling] out of control where food was concerned" and the "binge eating" variables were unrelated to symptoms of depression. However, it must be remembered that the focus of the present study was not on eating disorders and depression but on the relationship of more extensive maladaptive eating behaviors with less severe mood with a nonclinical sample. As expected, it was found that maladaptive eating practices were more predictive of depression in females than in males. This observation is consistent with past research that found a higher occurrence of eating disorders in females.2436It is possible that depression mediates eating practices differently for males than for females. In their examination of instrument scales to measure the construct of "body image," Franzoi and Shields3' found that male and female factor structures were sufficiently different to warrant the use of different types of instrumentation. It may be the case that alternative (i.e., separate) scales to measure maladaptive eating in. males and females are necessary. Several limitations should be noted in this study. First, we are limited in making antecedent effect relationships as our study was correlational. For example, we cannot determine if those engaging in maladaptive eating behavior caused depression or vice-versa. Another limitation from the present study is the use of self-report data. We can only assume that responses were honest and accurate. Finally, we must consider the lack of generalizability of results given only one sample. More representative and larger samples are needed to increase generalizability of responses. Future research should focus on other variables that may influence maladaptive eating practices and depressive symptoms. Social-
64
W O M E N & HEALTH
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
cognitive variables such as perceived body image, self-esteem, and self-efficacy should be examined for any relevant mediating effects. Furthermore, since depression may have seasonal variations, it may be valuable to note whether related maladaptive eating practices have a similar pattern of occurrence when a single cohort of subjects is sampled repeatedly over weeks or months.
REFERENCES 1. Blumbcrry W, Oliver JM. McClure JN: Validation of the Beck Depression Inventory in a university population using psychiatric estimate as the criterion. J Consul! CIin Psychol 1978; 46: 150-155. 2. Seligman ME: Fall into helplessness. Psyclrology Today 1973; 6(7):43-48. 3. Hawkins WE. McDermo!! RJ, Shields L, Harvey SM: Sex differences in the "depressed affect" factor among selected university students. Psyclwl Rep 1989; 64: 1245-1246. 4. McDermott RJ: Sex differences in depression among selected young adults. Psychol Rep 1987: 60:965-966. 5. McDermolt RJ, Hawkins WE. Duncan D F: Depression and health behavior of adolescents. Psychol Rep 1987; 61: 111-113. 6. McDermott RJ, Hawkins WE. Lit~lefieldEA. Murray S: Health behavior correlates of depression among university students. J Am Coll Health 1989; 38: 115-119. 7. O'Neil MK. Mingie P: Life stress and depression in university students: Clinical illustrations of recent research. J Am Coll Hcaltlr 1988; 36:235-239. 8. Sherer M: Depression and suicide ideation in college students. Psyclrol Rep 1983; 57: 1061-1062. 9. Radloff LS: The CES-D Scale: A self-report depression scale for research in the general population. Applied Psycl~ologicalMeasurement 1977; 1 :385401. 10. Collins ME: Education for healthy body weight: Helping adolescents balance the cultural pressure for thinness. J Sch Health 1988; 58:227-231. 11. Geraciotti TD.Liddle RA: lmpaircd cholecyslokinin secretion in bulimia nervosa. N Engl J Med 1988; 319:683-688. 12. Halmi HA, Falk JR, Schwam E; Binge-eating and vomiting: A survey of a college population. Psychol Med 1981; 11597-706. 13. Hart, K. J., & Ollendick, T. H., (1985). Prevalence of bulimia in working and university women. American Journal of Psychiatry, 142, 851 -854. 14. Katzman MA. Wolchik SA, Braver SL: The prevalence of frequen! binge eating and bulimia in a nonclinical college sample. Inter J Eating Disorders 1984; 3.53-62. 15. Pyle RL. Mitchell JE. Eckert ED. Halvorson PA, Neurnan PA, Golf GM: The incidence of bulimia in freshman college students. lnlcr J Eating Disorders 1983: 275-85.
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
16. Zuckerman DM, Colby A. Ware NC, Lazerson JS: The prevalence of bulimia among college students. Am J Public Health 1986; 76:1135-1137. 17. Pope HG, Hudson JI, Yurgelun-Todd D. Hudson MS: Prevalence of anorexia nervosa and bulimia in Uuce student populations. Inter J Eating Disorders 19843:45-51. 18,'Drewnowski A, Hopkins SA, Kessler RC: The prevalence of bulimia nervosa in the U. S. college student population. Am J Public fleallb 1988; 78:13221325. 19. American Psychiatric Association: Statistical Manual of Mental Disorders, 3rd edition, Revised @SM-IIR). Washington DC:American Psychiatric Association. 20. Cooper PJ, Fairbum CG: The depressive symptoms of bulimia nervosa. J Psychialry 1986; 148:268-274. 21. Swift WJ. Andrews D, Barklage NE: The relationship between affective disorder and eating disorders: A review of !he literature. Am J Psychiatry 1986; 143:290-299. 22. Stonehill E, Crisp AH: Psychoneurotic characteristics of patients wilh anorexia nervosa before and after treatment and at follow-up 4-7 years later. J Psyc. lrosorn Res 1977; 21 :187-193. 23. Weiss SR, Ebert MH:Psychological and behavioral characteristics of normal-weight bulimics and normal-weight conuols. Psychosom Med 1983; 45:293303. 24. Hendren RL: Depression in anorexia nervosa. J Am Acad Child Psychiatry 1983; 2259-62. 25. Hudson JI, Laffer PS. Pope HG: Bulimia related to affective disorder by family history and response to the dexamelhasone suppression test. Am J Psychiatry 1982; 139:685-687. 26. Strober M. Katz JL:Do eating disorders and affective disorders share a common etiology? A dissenting opinion, lnler J Eating Disorders 1987; 6:171180. 27. Johnson C, Lewis C, Hagman J: The syndrome of bulimia. Psychiair Clin Norrh America 1984: 7247-273. 28. Wolinsky FD: The Sociology of Hcallh. Belmont. CA: Wadsworth 1988. 29. Beck AT, Ward CH, Mendelson M, et al.: An inventory for measuring depression. Arch Gen Psychialry 1961; 4:561-571. 30. Zung WWK: A self-rating depression scale. Arch Gen Psyctiialry 1965: 12:63-70. 31. Lucas AR. Beard CM. Kranz JS, Kurland LT: Epidemiology of anorexia and bulimia. Inter J Eating Disorders 1983; 285-89. 32. Fairbum CG, Cooper PJ: Self-induced vomiting and bulimia nervosa: An undetected problem. Br Med J 1982; 284: 1153-1155. 33. American Psychiauic Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DMS-111). Washington DC: American P~yckiarric Associalion.
34. Carter JA, Duncan PA: The practice of self-induced vomiting among high school females. J Scli flealtli 1984; 54450455.
WOMEN
66
& HEALTH
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
35. Carter JA, Eason I: The binge-purge syndrome within a college environment: Bulimarexia. Coll Student J 1983; 17:44-49. 36. Shegel-Moore RH,Silberstein LR. Rodin J: Toward an understanding or risk factors for bulimia Am Psyclrologisl 1986; 41:246-263. 37. Franzoi SL. Shields SA: The body esteem scale: multidimensional structure and sex diflerences in a college population. J Pers Assessmenl 1984; 43: 173-178. APPENDIX A Center for Epidemiologic Studies Depression Scale (Including Factor Designations) Item
Factor
I was bothered by things that usually don't bother me. I did not feel like eating; my appetite was poor. I felt that I could not shake off the blues even with help from my family or friends. I felt that I was just as good as other people. I had trouble keeping my mind on what I was doing. I felt depressed. I felt that everything I did was an effort. I felt hopeful about the future. I thought my life had been a failure. I felt fearful. M y sleep was restless. I was happy. I talked less than usual. I felt lonely. People were unfriendly. I enjoyed life. I had crying spells. I felt sad. I felt that people disliked me. I could not get "going."
*SRA DA
=
=
Somatic Depressed Affect
SRA S RA DA PA S RA DA S RA PA DA DA SRA PA
SRA DA
IR PA DA DA
IR SRA
Hawkins el al.
PA
IR
=
-
Positive Affect Interpersonal Relationship
APPENDIX B
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
The Maladaptive Eating Behavior Scale I ate so much food so fast that I didn't know how much I ate or how it tasted. I ate something because I felt lonely. I ate a lot of fattening food in secret so no one would know about it. I ate something because I was upset or nervous. I felt uncomfortable eating in the presence of others. I qte something because I felt bored. I forced myself to vomit after eating. I got up during the night to eat food simply because I knew it was Ulere. I went without eating solid food for 24 hours in order to lose weight. I ate so much Lhat my stomach hurt. I bought fattening food and hid it in the house so no one would know about it. I took a laxative before or afier eating. I fclt 1 thought too much about food. I fell out of control where food was concerned. I hated myself because I couldn't stop overeating. I felt guilty because I could~l'tstop overeating. I felt guilty after eating.
Women & Health Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wwah20
Depression and Maladaptive Eating Practices in College Students a
b
Wesley E. Hawkins PhD , Robert J. McDermott PhD , John c
Seeley MS & Michele J. Hawkins PhD
a
a
Department of Public Health Education, University of Oregon, Eugene, OR b
Department of Community and Family Health, University of South Florida c
Oregon Research Institute Published online: 05 Nov 2010.
To cite this article: Wesley E. Hawkins PhD , Robert J. McDermott PhD , John Seeley MS & Michele J. Hawkins PhD (1992) Depression and Maladaptive Eating Practices in College Students, Women & Health, 18:2, 55-67, DOI: 10.1300/J013v18n02_04 To link to this article: http://dx.doi.org/10.1300/J013v18n02_04
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content.
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/ page/terms-and-conditions
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
Depression and Maladaptive Eating Practices in College Students Wesley E. Hawkins, P h D Robert J. McDermott, P h D John Seeley, M S Michele J. Hawkins, P h D
ABSTRACT. University students (n = 234) enrolled in sections of a required undergraduate course were administered the Center for Epidemiologic Studies Depression (CES-D) Scale and the Maladaptive Eating Behavior (MEB) Scale to determine if selected maladaplive eating practices correlated with depressive symptoms. Stepwisc multiple regression on data from female subjecls (n = 138) revealcd that four eating practices related lo depression, and produced a multiple R = .68, accounting for 46.2% of Lhe variance. Maladaptive eating practices were not predictive of depression among males (n = 96) with "feeling uncomfortable eating in the presence of olhers" the only significantly correlated variable. This study confirms previous research that has found an association betwcen maladaptive eating practices and depressed mood in nonclinical samples of university students.
INTKODUCTION T w o conditions adversely affecting the health and general wellbeing of young adults are depression and maladaptive eating behavWesley E. Hawkins, PIID is associated with the Department of Public Health Education, University of Oregon, Eugcne, OR 97403. Robert J. McDermott, PhD is associated with Ule Department of Community and Family Health. University of SouUl Florida, 13301 Bruce B. Downs Blvd., Tampa, FL 33612. John Seeley, BS is associated with the Oregon Research Institute. 1715 Franklin Blvd. Eugene, OR 97403. Michele J. Hawkins is associated with the Departmen1 of Public Health Education. University of Oregon. Eugene. OR 97403. Women & Health, Vol. 18(2) 1992 O 1992 by The Haworth Press. Inc. All rights reserved.
55
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
56
WOMEN & HEALTIi
ior. Depression is the most commonly identified mental health problem among college Recent estimates of depression using nonprobability samples of college age men and women have been noted in the literature.'-' McDermott et aL6 estimated that 65% and 51% respectively of college women and men experienced at least transient episodes of depression. McDermott4 also demonstrated in a collegiate sample that depression occurred more frequently in women than in men. Hawkins et al! suggested that this gender difference could be accounted for primarily by examining an element first described by Radloff? and labeled as "depressed ilffect." Eating disorders such as anorexia nervosa and bulimia nervosa are complex conditions believed to have individual, familial, and sociocultural predisposing factors.I0 A recent report suggests that certain hormonal influences also can affect one's predisposition toward bulimia." These conditions and other maladaptive eating practices may reach critical levels in the college p o p u l a t i ~ n . ' ~ - ' ~ Some studies of college students have estimated the prevalence of bulimia nervosa at 8% to 19% among women and up to 5% among In a national probability sample of college students, Drewnowski, Hopkins, and Kessler'' estimated the actual prevalence of bulimia nervosa to be less than 1.0% in women and 0.2% in men. However, these same investigators found the prevalence to be as high as 2.2% among undergraduate women living on campus in group housing. The discrepancy between their data and data from earlier studies may be a matter of sampling procedures, other matters of design rigor, and explication of the DSM-111~'~ criteria for reporting actual bulimia nervosa versus reporting "bulimia nervosalike practices" only. While the presence of several maladaptive eating practices can be associated with depressive symptoms, the nature of this aqsociation is not particularly well delineated in the l i t e r a t ~ r e . ~ . Persons ~"~.~~ with anorexia nervosa or bulimia nervosa have been shown in psychiatric testing to score higher on depression scales than a normal population, but lower than a primarily depressed p~pulation?~.~' Some a u t h ~ r i t i e shave ~ ~ ' ~proposed ~ that eating disorders are variants of affective disorders, while other investigators refute this asserti0n.2~Depression related to eating behavior may not have a common mechanism of cause. Swift et a1." suggest that for the person
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
with anorexia nervosa, depression stems from the physiologic consequences of self-starvation. For the person with bulimia nervosa, depression may be associated with the feelings of guilt and loss of control over eating behavior." Among college students, the practice of overeating has been shown to be associated with some indicators of depression.' This same practice also has been significantly, if weakly correlated with broader measures of depressions6The purpose of this study, therefore, was to explore the relationship between maladaptive eating practices and self-reported symptoms of depression in a sample of university students. Finally, while the relationship of eating disorders and clinical depression is well-documented in the literature, the present research study focuses on the relationship of less severe mood and maladaptive eating behaviors in a non-clinical group.
METHODS A cross-sectional survey research design using 234 subjects (students enrolled in sections of a required undergraduate class at a large university in the pacific Northwest) was carried out in May of 1988. From a pool of 246 potential participants. the non- response rate in the available sample was less than five percent. Two written self-report instruments were administered concurrently in this study. These instruments included the Center for Epidemiologic Studies Depression (CES-D) Scale9and the Maladaptive Eating Behavior (MEB) Scale. The 20-item CES-D Scale examines the frequency with which respondents have experienced specific symptoms of depression during the past week (Appendix A). Individual items are scored from 0 to 3, with "0" indicating a symptom was experienced "rarely or none of the time" (less than I day), "1" indicating a symptom was experienced "some or a little of the time" (1-2 days), "2" indicating a symptom was experienced "occasionally or a moderate amount of time" (3-4 days), and "3" indicating the symptom was experienced "most or all of the time" (5-7 days). After four positively worded items are recoded, the CES-D Scale is summed. A high risk for depression is suggest-
WOMEN & HEALTH
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
58
ed by scores of 16 or 2Feater?.28 Concurrent validity with the Beck Depression Inventory and the Zung Scale3' has been established. The scale has been found to have high internal consi~tenc$"~and acceptable test-retest reliability.!' In studies involving collegiate samples, internal consistency of the CES-D Scale as measured by Cronbach's alpha, was estimated at .88 and .89 re~pectively.~" Moreover, the CES-D Scale has been factor analyzed by adl lo fa and Hawkins et al? to yield four factors: depressed affect (DA), positive affect (PA), somatic or retarded activity (SRA), and interpersonal relations (IR). The similarity of the factor structures across groups is suggestive of construct validity. The MEB Scale (Appendix B) is comprised of 17 items and uses a response format identical to that of the CES-D Scale. Other instruments using this same format have been administered satisfactorily with collegiate samples, and in conjunction the CES-D Scale.'" The 17 items of MEB Scale relate to selected maladaptive eating practices. Efforts to assess content validity were made by means of a literature review, and by a validation panel of experts comprised of three specialists in education about mental health. Because we were studying a non-clinical sample in terms of maladaptive eating and not eating disorders per se, the researchers in the present study used items from a variety of past scales to provide a more extensive range of eating behavior items. A factor analysis was conducted on the MEB Scale that indicated no substructure for the 17 items. Remaining behavioral and demographic items were adapted from the Health scale.'" Using Cronbach's alpha, the intemal consistency of the MEB Scale was estimated to be .91. Data were collected by administering the two primary instruments in a paper-and-pencil format to intact groups of students. Prior to administration, approval was obtained for the study from the University Committee on Research Involving Human Subjects, with the understanding that participation would be voluntary and that anonymity of respondents would be protected. Further permission was obtained from individual course instructors to involve students in the data collection process. Course curricula were reviewed with each instructor to guarantee that formal discussion of maladaptive eating practices, eating disorders, or depression had not occurred prior to the administration of the instruments. Two of the ~
~
~
-
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
Hawkins er al.
59
investigators oversaw data collection to ensure standardization of procedures and format. Data analysis included standard descriptive procedures such as frequencies, percentages, measures of central tendency, and selected crosstabulations. Stepwise multiple regression analysis was used to determine the most salient maladaptive eating behaviors related to depressive symptoms (CES-D Scale score). Canonical correlation analysis was then conducted on the subscales of the CES-D to determine if specific maladaptive eating practicies were more related to specific subconstructs of the depression scale. Data were inspected to meet the assumptions of multiple regression (normality, multicolinearity, outliers, linearity). RESULTS The 234 respondents ranging in age from 17 to 36 years, with the mean equal to 20.1 and the mode equal to 18. Among respondents, 138 (59%) were females and 96 (41%) were males. With respect to race. 198 (84.6%) were white, 2 (0.9%) were black. arid 33 (14.1%) were members of other racial groups. One respondent (0.4%) did not specify race. The range of scores on the CES-D Scale for this sample was 0 to 43 with a mean of 16.9 and a stmdard deviation of 8.7 for males; and 0 to 50 with a mean of 19.2 and a standard deviation of 11.3 among females. Radlof? indicates that scores equal to or greater than 16 are suggestive of depression of at least a transient nature. For this sample, 53.1 % of the males and 60.1 % of the females exceeded this criterion. The proportion of males and females with CES-D Scale scores 5 16 were not significantly different (X2 = 1/14, p = .29). This high level of elevated depressive symptomatology could suggest the cut off at 16 on the CES-D is simply too low. The item-response frequencies for the maladaptive eating practices for males and females comprising the MEB Scale are presented in Table 1 and the most commonly reported eating behaviors (at least 1-2 days per week) included: "I ate something because I felt bored" (59.0%); "I felt guilty after eating" (42.3%); "I ate some-
WOMEN & HEALTH
60
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
thing because I was upset or nervous" (38.4%); "I ate something because 1 felt lonely" (35.0%);"I felt I thought too much about food" (34.6%);and ''I ate so much food so fast that I didn't know how much I ate or how it tasted" (32.9%). Given the established gender differences in depression among college students from past research3" and the gender difference in means for the present sample, separate regression analyses were conducted for males and females. A stepwise analysis using the
Table 1.
Response Frequencies for Maladaptive Eating Practices During the Past Week By Gender
MEB Scale Item
Rarely
Some (1-2davsl
k1 dav)
Eat Fast Eat Lonely Eat Fat Fwd Nervous Eating Eating in presence Eat Bored Vomit after eating Night eating No Fwd 24 Hrs. Eat Hurl
Hid Fwd Used Laxative Thought F w d No Control Hate Self . Guilt Over Eat Guilt After Eat
(63 21 (&&) 43 (97) 13 (87) 46
(13 (31) (9) (33)
28 (30) 13 (14) 3 (3) 9 (9)
98 (71) 42 (31)
73 (76) 24 (17) 21 (22) 8 (6) I (1) 8 (6) 1 (1) 54 (56) 46 03) 30 (31) 40 (29) 10 (10) 10 (7) 2 (2)"
120 (87) 1% (97) 126 (91) 97 (70) 124 (90) 132 (96) 70 (51) 87 (63) 94 (68) 92 (67) 55 (40)
94 (98) 11 (8) 93 (93 4 (3) 91 (95) 11 (8) 71 (74) 29 (21) 96 (100) 8 (6) 95 (99) 3 (2) 83 (87) 36 (26) 84 (88) 23 (17) 92 (96) 26 (19) 80 (83) 20 '15) 81 (84) 45 (33)
' p c .05,Chi-square tests.
p < .01,Chi-square tests.
4 (3) 0 (0) 0 (0) 6 (4) 4 (31 2 (1.0) 18 (13) 15 (11) 7 (5) 14 (10) 19 (14)
5 2 0 4
(5) (2) (0) (4)
62 81 93 83
2 (2) 2 (2) 5 (5) 23 (20 0 (0) 1 (1) 9 (9) 8 (8) 3 (3) 10 (10) 13 (14)
16 (12) 16 (12) 6 (4) 26 (19)
Most (57davsl
.95 (69) 71 (51) 113 (82) 61 (44)
Items may not always total 1005% due to rounding error. "
Occasionally ( 3 4 davsl
0 1 0 2 0 0
4 4
1
(0) (1) (0) (2) (0) (0) (4) (4) (1)
5 (5) 2 (2)
6 8 6 5
(4) 1 (1). (6) 0 (0)" (9) 0 (0)" (4) 0 (0)''
3 (2) 0 (0). 0 (0) 0 (0) 1 (.7) 0 (0) 6 (4) 0 (0) 2 (1) 0 (0)' 1 (.71 0 (0) 13 (9) 0 (0)'. 13 (9) 0 ( O P 11 (8) 0 (0)" 12 (9) 1 (1)" 19 (14) 0 (O)..
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
Hawkins el al.
61
subsample of females in the study revealed four maladaptive eating practices associated with depression (Table 2): "1 ate something because I was upset or nervous" (B = .38), "I felt uncomfortable eating in the presence of others" (B = .27), "I forced myself to vomit after eating'' (B = .24) and "I went without eating solid food for 24 hours to lose weight" (B = .12). The multiple R for the equation was .68,accounting for 46.2%of the variance. A stepwise analysis for the male subsample resulted in less association with depressive symptoms. As the data in Table 2 show, the only correlate of depression among males was "I felt uncomfortable eating in the presence of others" (B = .35). A further analysis was conducted by examining which specific subscales of the CES-D ("Depressed Affect," "Interpersonal," "Somatization" and "Positive Affect") were most related to the significant maladaptive eating behaviors. A canonical correlation analysis was conducted to examine these relationships. Canonical correlation is a multivariate statistical technique that identifies a Table 2:
Stepwise Multiple Regression Results: Male and Female Maladaptive Eating Behaviors As PreCic:ors oi CESD Scde Score
r
RZ
Ad]. RZ
Eating ln Presence of Others
.51
.40
39
,000
.27
Vomit After Eating
.45
.45
.A4
.OOO
.24
No Food For 24 Hours
.11
.47
.45
.a00
Variable
Significance of F
Standardiied Beta
Females (N = 158)
Males (N = 96) Eating In Presence of Others
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
62
WOMEN & HEALTH
linear combination of one variable set that maximally correlates with another variable set. Canonical correlation analysis revealed one significant canonical variate (p < .0001) for females while no significant variates were found for males at the .05 alpha level. The canonical correlation for females was 5 0 , accounting for 25% of the variance. Using a cut off score of .30 for interpretability for structural correlations, the researchers found approximately similar correlations for each subscale in relation to maladaptive eating, thus providing support for treating the CES-D as a total construct. For the maladaptive eating variable set, females who were more likely to report "upset or nervous eating" (.76), "uncomfortable eating in the presence of others" (.79). "forced vomiting after eating" (.66) were also more likely to report in terms of the depression variable set higher "depressed affect" (.89), higher "interpersonal concerns" (.83), negative "positive affect" (--83)and higher "somatization" (.76). One variable from the maladaptive eating behavior set did not meet the .30 cutoff, "no food for 24 hours" (.16).
DISCUSSION The major finding from this study was that specific maladaptive eating practices were related to depressive symptoms for female subjects only. The maladaptive eating practice most associated with depression among females in the sample, "upset or nervous eating," follows from the relationship between eating disorders and insecurity, confusion, fragility of self, and other feelin s of inadequacy advanced by Lueas. Beard. Kranz, and Kurland! Using the present data, one might hypothesize that anxiety is an antecedent factor with respect to maladaptive eating. Fairburn and Coope?' found that women diagnosed with bulimia nervosa demonstrated high levels of anxiety. If anxiety arises from a combination of microstressors and macrostressors, it is conceivable that stress management strategies could be useful adjuvant therapeutic intenentions for individuals who are depressed and engaged in maladaptive eating. Future research should include tests of trait and state anxiety to confirm or refute the role of anxiety in influencing associations between maladaptive eating and depression.
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
Hawkiw er al.
63
The three remaining predictors ("Feeling uncomfortable eating in the presence of others," [forced vomiting] after eating." and "[going without) eating solid food for 24 hours") approximate DSM-IIIR symptoms for bulimia nervosa.19 This finding corroborates a previous view that eating disorders are variants of affective disorder^.^"' However, several items on the MEB Scale comparable to DSM-IIRcriteria for bulimia nervosa were not found to be related to depression. One might anticipate that these variables would correlate with depression, given the presumed co-morbidity of btilimia nervosa and depressive disorder^?^"^ Such was not the case in the present study since DSM-IIR symptoms like "[feeling] out of control where food was concerned" and the "binge eating" variables were unrelated to symptoms of depression. However, it must be remembered that the focus of the present study was not on eating disorders and depression but on the relationship of more extensive maladaptive eating behaviors with less severe mood with a nonclinical sample. As expected, it was found that maladaptive eating practices were more predictive of depression in females than in males. This observation is consistent with past research that found a higher occurrence of eating disorders in females.2436It is possible that depression mediates eating practices differently for males than for females. In their examination of instrument scales to measure the construct of "body image," Franzoi and Shields3' found that male and female factor structures were sufficiently different to warrant the use of different types of instrumentation. It may be the case that alternative (i.e., separate) scales to measure maladaptive eating in. males and females are necessary. Several limitations should be noted in this study. First, we are limited in making antecedent effect relationships as our study was correlational. For example, we cannot determine if those engaging in maladaptive eating behavior caused depression or vice-versa. Another limitation from the present study is the use of self-report data. We can only assume that responses were honest and accurate. Finally, we must consider the lack of generalizability of results given only one sample. More representative and larger samples are needed to increase generalizability of responses. Future research should focus on other variables that may influence maladaptive eating practices and depressive symptoms. Social-
64
W O M E N & HEALTH
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
cognitive variables such as perceived body image, self-esteem, and self-efficacy should be examined for any relevant mediating effects. Furthermore, since depression may have seasonal variations, it may be valuable to note whether related maladaptive eating practices have a similar pattern of occurrence when a single cohort of subjects is sampled repeatedly over weeks or months.
REFERENCES 1. Blumbcrry W, Oliver JM. McClure JN: Validation of the Beck Depression Inventory in a university population using psychiatric estimate as the criterion. J Consul! CIin Psychol 1978; 46: 150-155. 2. Seligman ME: Fall into helplessness. Psyclrology Today 1973; 6(7):43-48. 3. Hawkins WE. McDermo!! RJ, Shields L, Harvey SM: Sex differences in the "depressed affect" factor among selected university students. Psyclwl Rep 1989; 64: 1245-1246. 4. McDermott RJ: Sex differences in depression among selected young adults. Psychol Rep 1987: 60:965-966. 5. McDermolt RJ, Hawkins WE. Duncan D F: Depression and health behavior of adolescents. Psychol Rep 1987; 61: 111-113. 6. McDermott RJ, Hawkins WE. Lit~lefieldEA. Murray S: Health behavior correlates of depression among university students. J Am Coll Health 1989; 38: 115-119. 7. O'Neil MK. Mingie P: Life stress and depression in university students: Clinical illustrations of recent research. J Am Coll Hcaltlr 1988; 36:235-239. 8. Sherer M: Depression and suicide ideation in college students. Psyclrol Rep 1983; 57: 1061-1062. 9. Radloff LS: The CES-D Scale: A self-report depression scale for research in the general population. Applied Psycl~ologicalMeasurement 1977; 1 :385401. 10. Collins ME: Education for healthy body weight: Helping adolescents balance the cultural pressure for thinness. J Sch Health 1988; 58:227-231. 11. Geraciotti TD.Liddle RA: lmpaircd cholecyslokinin secretion in bulimia nervosa. N Engl J Med 1988; 319:683-688. 12. Halmi HA, Falk JR, Schwam E; Binge-eating and vomiting: A survey of a college population. Psychol Med 1981; 11597-706. 13. Hart, K. J., & Ollendick, T. H., (1985). Prevalence of bulimia in working and university women. American Journal of Psychiatry, 142, 851 -854. 14. Katzman MA. Wolchik SA, Braver SL: The prevalence of frequen! binge eating and bulimia in a nonclinical college sample. Inter J Eating Disorders 1984; 3.53-62. 15. Pyle RL. Mitchell JE. Eckert ED. Halvorson PA, Neurnan PA, Golf GM: The incidence of bulimia in freshman college students. lnlcr J Eating Disorders 1983: 275-85.
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
16. Zuckerman DM, Colby A. Ware NC, Lazerson JS: The prevalence of bulimia among college students. Am J Public Health 1986; 76:1135-1137. 17. Pope HG, Hudson JI, Yurgelun-Todd D. Hudson MS: Prevalence of anorexia nervosa and bulimia in Uuce student populations. Inter J Eating Disorders 19843:45-51. 18,'Drewnowski A, Hopkins SA, Kessler RC: The prevalence of bulimia nervosa in the U. S. college student population. Am J Public fleallb 1988; 78:13221325. 19. American Psychiatric Association: Statistical Manual of Mental Disorders, 3rd edition, Revised @SM-IIR). Washington DC:American Psychiatric Association. 20. Cooper PJ, Fairbum CG: The depressive symptoms of bulimia nervosa. J Psychialry 1986; 148:268-274. 21. Swift WJ. Andrews D, Barklage NE: The relationship between affective disorder and eating disorders: A review of !he literature. Am J Psychiatry 1986; 143:290-299. 22. Stonehill E, Crisp AH: Psychoneurotic characteristics of patients wilh anorexia nervosa before and after treatment and at follow-up 4-7 years later. J Psyc. lrosorn Res 1977; 21 :187-193. 23. Weiss SR, Ebert MH:Psychological and behavioral characteristics of normal-weight bulimics and normal-weight conuols. Psychosom Med 1983; 45:293303. 24. Hendren RL: Depression in anorexia nervosa. J Am Acad Child Psychiatry 1983; 2259-62. 25. Hudson JI, Laffer PS. Pope HG: Bulimia related to affective disorder by family history and response to the dexamelhasone suppression test. Am J Psychiatry 1982; 139:685-687. 26. Strober M. Katz JL:Do eating disorders and affective disorders share a common etiology? A dissenting opinion, lnler J Eating Disorders 1987; 6:171180. 27. Johnson C, Lewis C, Hagman J: The syndrome of bulimia. Psychiair Clin Norrh America 1984: 7247-273. 28. Wolinsky FD: The Sociology of Hcallh. Belmont. CA: Wadsworth 1988. 29. Beck AT, Ward CH, Mendelson M, et al.: An inventory for measuring depression. Arch Gen Psychialry 1961; 4:561-571. 30. Zung WWK: A self-rating depression scale. Arch Gen Psyctiialry 1965: 12:63-70. 31. Lucas AR. Beard CM. Kranz JS, Kurland LT: Epidemiology of anorexia and bulimia. Inter J Eating Disorders 1983; 285-89. 32. Fairbum CG, Cooper PJ: Self-induced vomiting and bulimia nervosa: An undetected problem. Br Med J 1982; 284: 1153-1155. 33. American Psychiauic Association: Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DMS-111). Washington DC: American P~yckiarric Associalion.
34. Carter JA, Duncan PA: The practice of self-induced vomiting among high school females. J Scli flealtli 1984; 54450455.
WOMEN
66
& HEALTH
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
35. Carter JA, Eason I: The binge-purge syndrome within a college environment: Bulimarexia. Coll Student J 1983; 17:44-49. 36. Shegel-Moore RH,Silberstein LR. Rodin J: Toward an understanding or risk factors for bulimia Am Psyclrologisl 1986; 41:246-263. 37. Franzoi SL. Shields SA: The body esteem scale: multidimensional structure and sex diflerences in a college population. J Pers Assessmenl 1984; 43: 173-178. APPENDIX A Center for Epidemiologic Studies Depression Scale (Including Factor Designations) Item
Factor
I was bothered by things that usually don't bother me. I did not feel like eating; my appetite was poor. I felt that I could not shake off the blues even with help from my family or friends. I felt that I was just as good as other people. I had trouble keeping my mind on what I was doing. I felt depressed. I felt that everything I did was an effort. I felt hopeful about the future. I thought my life had been a failure. I felt fearful. M y sleep was restless. I was happy. I talked less than usual. I felt lonely. People were unfriendly. I enjoyed life. I had crying spells. I felt sad. I felt that people disliked me. I could not get "going."
*SRA DA
=
=
Somatic Depressed Affect
SRA S RA DA PA S RA DA S RA PA DA DA SRA PA
SRA DA
IR PA DA DA
IR SRA
Hawkins el al.
PA
IR
=
-
Positive Affect Interpersonal Relationship
APPENDIX B
Downloaded by [Temple University Libraries] at 21:04 11 January 2015
The Maladaptive Eating Behavior Scale I ate so much food so fast that I didn't know how much I ate or how it tasted. I ate something because I felt lonely. I ate a lot of fattening food in secret so no one would know about it. I ate something because I was upset or nervous. I felt uncomfortable eating in the presence of others. I qte something because I felt bored. I forced myself to vomit after eating. I got up during the night to eat food simply because I knew it was Ulere. I went without eating solid food for 24 hours in order to lose weight. I ate so much Lhat my stomach hurt. I bought fattening food and hid it in the house so no one would know about it. I took a laxative before or afier eating. I fclt 1 thought too much about food. I fell out of control where food was concerned. I hated myself because I couldn't stop overeating. I felt guilty because I could~l'tstop overeating. I felt guilty after eating.
