Behau. Res. Ther. Vol. 30, No. 1, pp. 59-62, 1992 Printed in Great Britain. All rights reserved
CASE HISTORIES No counterregulation
0005-7967/92 $5.00 + 0.00 Copyright 0 1991 Pergamon Press plc
AND SHORTER
COMMUNICATIONS
after breaking the external restraint of children
ANITA JANSEN,* JUDITH VAN DEN BERG and KRISTEL BULTEN Department of Mental Health Sciences/Experimental Psychopathology, Limburg University, P.O. Box 616, 6200 MD Maastricht, The Netherlands (Received for publication 9 July 1991) Summary-At the present, it is unknown how restraint and binge eating/counterregulation are exactly related. Earlier studies on this relationship suffer from two main shortcomings: the studies are all correlational in nature or could not rule out the contribution of confounding variables such as weight loss. The present study investigated whether a break of restraint is a sufficient condition for the occurrence of counterregulation by studying a restrained sample which is not liable to dieting practices and weight loss. The externally imposed restraint on children with regard to eating sweets was broken. However, after breaking their external restraint the children did not counterregulate. It is discussed whether restraint of food intake is really as important for binge eating as it is claimed to be or whether it is merely a consequence or an epiphenomenon of binge eating.
INTRODUCTION: The eating disorder bulimia nervosa is, amongst other things, characterized by recurrent episodes of binge eating, i.e. the rapid consumption of large amounts of food in a discrete period of time (American Psychiatric Association, 1987). Binge eating usually goes hand in hand with the intention to restrain food intake (Polivy & Herman, 1985; Wardle, 1980). Restraining food intake is claimed to be a risk factor for binge eating: about 80% of patients with bulimia nervosa tried to lose weight by strictly restraining their food intake prior to the onset of binge eating (Pyle, Mitchell & Eckert, 1981; Fairburn & Cooper, 1982; Striegel-Moore, Silberstein & Rodin, 1986; Rossiter, Wilson & Goldstein, 1989; Mizes, 1985; Fairburn, Cooper & Cooper, 1986). Furthermore, about 50% of the anorexia nervosa patients develop binge eating episodes about 9-18 months after the onset of the strict restraining practices (Wardle & Beinart, 1981; Polivy & Herman, 1985; Laessle, Tuschl, Kotthaus & Pirke, 1989) and non-clinical restrained eaters report significantly more binge eating than unrestrained eaters (Wardle, 1980). Also, laboratory studies on food intake show that especially restrained eaters are prone to disinhibition and overeating. Several studies show that restrained Ss do not regulate their food intake normally: after a break of their restraint (e.g. by eating a preload which is rich in calories) they eat more than when their restraint had not been broken (i.e. when they had not eaten a preload). This typical eating pattern is called counterregulation. In contrast, unrestrained Ss regulate their food intake: after they have eaten a preload they eat less than when they had not eaten a preload (Herman & Mack, 1975; Hibscher & Herman 1977; Ruderman & Christensen, 1983; Jansen, Oosterlaan, Merckelback & van den Hout, 1988). However, the abovementioned data on the co-occurrence of restraining food intake and bingeing have been derived retrospectively from clinical reports. Also, the laboratory studies which show the co-occurrence of restraint and counterregulation are in fact of a correlational nature: restraint is associated with counterregulation but the causal role of restraint has yet to be demonstrated. It should not be ruled out that bingeing causes restraint or that there is a third underlying mechanism which explains the co-occurrence of restraint and bingeing. Only twice the casuality issue between restraining food intake and bingeing was studied empirically. In the early fifties, Keys, Brozek, Henschel, Mickelson and Taylor (1950) studied 36 soldiers on a semi-starvation diet for 24 weeks. After several months, the soldiers had lost 26% of their initial weight. When food was available again, after the experiment, the soldiers indulged in severe binge eating episodes. Lately, Wardle and Beales (1988) studied the effects of restraint on laboratory food intake regulation. Overweight Ss took part in a weight loss treatment program, in which some of them dieted and some did not. After 3 weeks, only the ‘dieters’ showed the typical laboratory phenomenon of counterregulation. However it should be noted that Keys’ bingeing soldiers were extremely underweight and Wardle and Beales’ counterregulating dieters had lost significantly more weight than the non-dieters who did not counterregulate. It thus cannot be ruled out that weight loss instead of restraint determined the excessive food intake. There is no direct data which supports the causality between pure restraint of food intake (without weight loss) and counterregulation/binge eating. Note that it is rather difficult to disentangle the pure effect of restraint and the contribution of confounding variables, such as weight loss, in a typical sample of restrained eaters. Nevertheless, from an etiological point of view, it is highly important to know whether it is merely the restraintness which predisposes to binge eating/counterregulation. If restraintness indeed is a sufficient condition for the occurrence of counterregulation, the straightforward assumption is that breaking restraint in restrained Ss who are of normal weight and not even preoccupied with weight gain/loss will still lead to counterregulation. Therefore, in the present study, a S sample was chosen that is liable to a restraint on intake but is not involved in any dieting practices and weight loss. We hypothesized that breaking the externally imposed restraint on childen with regard to eating sweets will lead to counterregulation. More specifically, it is hypothesized that externally restrained children who eat a large sweet preload will subsequently eat more than externally restrained children who do not eat a preload. *Author
for correspondence. 59
60
CASE HISTORIES
AND
Table
External restraint (ERQ) Age (yr) Weight (kg) Height (m)
SHORTER
COMMUNICATIONS
I. S characteristics
Preloaded (n = 13) M (SD)
Non-preloaded (n = 14) M (SD)
I
P
19.7 (5.2) 8.8 (0.7) 32.3 (4.8) I .41 (0.08)
20.1 (6.8) 8.6 (0.5) 33.3 (3.4) I .43 (0.06)
0.19 1.18 0.59 0.77
NS NS NS NS
NS = not significant. METHOD Subjects Children were recruited by an advertisement in the local newspaper and a letter circulating in primary schools. The advertisement and letter asked for 8 and 9-yr old, non-dieting girls of normal weight to participate in a study on taste preferences of young children. Twenty-seven girls took part in the experiment. The children were all of normal weight according to national weight tables. Answers on a questionnaire which asked for food preferences, eating habits, and the intention to diet, indicated that none of the childen was dieting. S characteristics are shown in Table 1. Assessment of external restraint In piloting this study, the authors determined levels of external restraint by interviewing twelve (couples of) parents. During these interviews, it appeared that Dutch parents always put considerable restraint on the amount of sweets their children were permitted to eat. Our starting point therefore was that Dutch children always are externally restrained with regard to eating sweets. To obtain a more objective measure of external restraint and in order to control for the level of external restraint we composed a list of 11 statements, based on the clinical interviews and our knowledge on the concept of restraint. The questionnaire asks for typical restraint rules: whether the child was permitted to eat as many sweets as she wanted to, whether she wishes to eat more sweets than she was permitted to, and whether parents paid attention to the amounts of sweets their child eats (see Table 2). The level of external restraint imposed on the Ss participating in the experiment was determined by their parents’ answers on this External Restraint Questionnaire (ERQ). Procedure Parents who enrolled their daughter for participation were sent a questionnaire which asked for the child’s age, weight, food preferences, eating habits and dieting practices. After inspection of the returned questionnaire an appointment was made. Until participation, the Ss and their parents did not know that it was a study on tasting sweets. In order to control pre-experimental food intake Ss were asked to eat a normal lunch or breakfast 2 hr before participation in the Experiment. The intake of sweets during the experiment could thus not be influenced by deprivation. All Ss were run individually between 10.00 a.m. and 5.00 p.m. on Saturday and Sunday so that the children did not have to stay away from school. Ss were randomly assigned to the preload or no-preload condition and the number of Ss run in each condition was balanced at various times of the day. After entering the laboratory, the child was shown the room in which her parent(s) waited for her. Then the first experimenter and the child went to an armoured chamber at the other end of the passage. A second experimenter explained the procedure to the parents who gave their consent and filled in the ERQ. In the meantime, the first experimenter put the child at her ease by chattering a bit. After a couple of minutes, the experimenter started a 15-min interview on ‘rules at home’. The child was asked what things she was permitted to do and which things were forbidden by her parents. For example, she was asked at what time she had to go to sleep, whether she had to finish her food every day and so on. These things were written on a flap-over; forbidden things were written in red whereas permitted things were written with a black style. During the interview children in the preload condition ate two milky-ways (i.e. 5Og and 220 cals). Usually, the perceived destroy of restraint is claimed to be the crucial thing in counterregulation. By means of the interview and flap-over the authors meant to stress the child’s awareness of rules and the break of a rule when eating two milky-ways. After 15 mins the interview was finished and eight pre-weighed, large dishes with diverse soft sweets and a glass of water were brought in by a third experimenter. Each dish contained approx. 900 g of soft sweets. The sweets were broken into small pieces and presented in large amounts so that Ss could inconspicuously eat a lot. The S was instructed how to fill in the forms on which she had to mark whether she liked the sweets or not. The child was invited to taste the sweets. It was stressed that she could eat as much as she wanted to but that she was not obliged to eat anything. Then the experimenter Table 2. External Restraint Questionnaire (ERQ) 1. You have just had a warm meal together with your daughter. Immediately after the meal your daughter asks you whether she may have a bar of chocolate. Do you find it permissahle for your daughter to eat chocolate at that moment? 2. Your daughter has no appetite for the warm meal. She does want to eat potato-crisps, Do you allow your daughter to not participate in eating the warm meal but to eat the crisps? 3. Your daughter returns from school and asks for a biscuit. After eating three biscuits she asks for another. Do you give her another biscuit? 4. Your daughter gets a little fatter. Do you pay attention to ensure that she eats less sweets for a while? 5. Assume that your daughter can determine herself how many sweets she may eat. Do you think your daughter would eat sweets more often? 6. Do you pay close attention to how many sweets your daughter eats? 7. Do you consciously give your daughter ‘healthy’ sweets (like an apple) instead of candy? 8. Imagine that one day your daughter has eaten too many sweets, Do you make sure that she eats less sweets the next day? 9. Are you afraid that your daughter will become too fat if she eats too many sweets? IO. Do you think your daughter would like to eat more sweets than you allow her to? 1I, Do you try to keep as close an eye as possible on how many sweets your daughter eats? Questions l-3 were answered never (3), sometimes (2), often (I), always (0). Questions 41 I were answered never (O), sometimes (I), often (2) always (3).
CASE HISTORIES
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SHORTER
61
COMMUNICATIONS
left the room and the child was left alone for 10min. After 10min the experimenter returned and the child’s weight and height were determined by the first experimenter. Then she was given a present and she went back to her parents. The sweets that remained were reweighed by the third experimenter and the Ss’ total intake (in grams) was determined. RESULTS Manipulation
check
Were our Ss really restrained? Scores on the ERQ (see Table 2 and compare Table 1) indicate that all children participating in the experiment were liable to an external restraint on their sweet eating. Did we break a restraint? Parents were asked whether their childen were permitted to eat two milky-ways at once. The preload appeared to be restraint-breaking: parents all declared that their children were not permitted to eat two milky-ways at once. Intake of sweets
Data are presented in Table 3. The r-test showed no significant difference in intake: preloaded Ss ate as many sweets as non-preloaded ones [r(25) = 1.0, NS]. To control for differences in the amount of external restraint, two post hoc analyses were carried out. First the four Ss with a lower score than 15 on the ERQ were thrown out of the analysis. No significant difference emerged [t(21) = 0.87, NS]. Next, an Analysis of Variance (ANOVA) was carried out on the data. The main factors were Group (high vs low external restraint; median split) and Condition @reload vs no-preload). No main effects (resp. [F(l, 26) = 0.07, NS] and [F(l, 26) = 0.8, NS]) and no interaction effect [F(l, 26) = 0.35, NS] emerged. Ss in both conditions did not differ in time [r(25) = 0.2, NS] and amount [?(26) = 0.2, NS] of pre-experimental food intake and in the intake of water during the experiment [t(25) = 1.62, NS]. In short, data indicate that there were no differences in the amount of sweets eaten by preloaded girls as compared to non-preloaded ones. DISCUSSION
In the present study, the hypothesis that a break of restraint in otherwise restrained Ss should end up in counterregulation could not be corroborated. After breaking the externally imposed restraint on childen with regard to eating sweets no counterregulation emerged. Restrained children who ate a large sweet preload did not eat more sweets afterwards than restrained children who had not eaten the preload. Ss did not counterregulate and, curiously, they also did not regulate their intake. How come? The level and nature of restraint as well as the experimental situation deserve some attention. Concerning the level of restraint: non-regulation of restrained eaters has been documented earlier (Ruderman & Christensen, 1983; Jansen et al., 1988). Non-regulation instead of counterregulation may be due to low median split scores on the restraint scale: counterregulating Ss came from studies with a median split of 16 and 17 on the Restraint Scale (Herman & Mack, 1975; Spencer & Fremouw, 1979), whereas in studies with non-regulating Ss the median split was 13 and 12 (Ruderman & Christensen, 1983; Jansen et al., 1988). Ruderman, Belzer and Halperin (1985) found that only Ss scoring above 17.3 on the Restraint Scale counterregulated. It thus sounds plausible that counterregulation occurs in studies with higher medians, whereas non-regulation occurs in studies with a lower median. Note that, although the children in the present study were restrained in their intake of sweets, they were not extremely restrained. For these children, eating sweets is not principally forbidden. The ANOVA showed, however, that also highly restrained children (ERQ > 20) did not eat more after a preload than without one. In line with this it can be argued that the nature of restraint (intrinsic vs extrinsic) is important. The present S sample differs from a typical sample of restrained eaters: the children were externally restrained, i.e. extrinsically motivated, whereas a typical sample of restrained eaters is intrinsically motivated to restrict food intake. However, if the nature of restraint indeed is important, then restraint theory at least has to specify that it is not restraint as such which predisposes to excesses, but that it is an intrinsically motivated restraint which is a risk factor for binge eating. Next question, then, is why intrinsically motivated restraintness should lead to counterregulation whereas extrinsically motivated restraintness should not. Furthermore, the experimental situation considers attention. Although the experimenter had a nice talk with the child for at least 20 min and although she had the impression that the children were at their ease, it cannot be ruled out that the children did not feel free to eat as much as they, in fact, wanted to. The large standard deviation in intake, however, at least shows that some children felt free to eat: the interindividual intake varied enormously. Anyway, data of the present study do show that a break of restraint is not a sufficient condition for counterregulation to occur. What does this mean? Clearly, a (perceived) break of restraint is not a sufficient condition for counterregulation to occur and we already knew that a (perceived) break of restraint is not a necessary condition for counterregulation to occur. As to the issue of necessity, high-calorie preloads, preloads perceived as such and even anticipated preloads are not the only stimuli which lead restrained eaters to overeat. Studies show that restrained eaters also overeat when they are in a strong emotional state, as when depressed or anxious (Herman & Polivy, 1975; Baucom & Aiken, 1981; Frost, Goolkasian, Ely & Blanchard, 1982; Ruderman, 1985a, b; Schotte, Cools & McNally, 1990). Also, restrained eaters ‘counterregulate’ after intensive smelling of food (Jansen & van den Hout, 1991). Thus, a (perceived) break of restraint is not a necessary condition for triggering excessive eating in restrained eaters. Table 3. Results Preloaded (n = 13) M (SD)
Intake of sweets (g) Intake of water (g) Pre-experimental food intake (calories) Time since pre-experimental food intake (h) NS = not significant.
46.4 (16.7) 76.1 (49.6) 236.5 (194.3) 1.9 (1.2)
Non-preloaded (n = M W)
55.4 (28.2) 45.1 (49.8) 252.7 (230.7) 1.8 (1.3)
14) f
P
1.0 1.6 0.2 0.2
NS NS NS NS
62
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The present study shows that a break of restraint is not a sufficient condition for counterregulation to occur. Earlier, failed replications of counterregulation in restrained eaters are reported (see Jansen et al., 1988). Remarkably, in those studies restrained eaters were selected by the restraint subscale of the Dutch Eating Behaviour Questionnaire (DEBQ; Van Strien, Frijters, Bergers & Defores, 1986). The DEBQ-restraint subscale selects successful restrained eaters, i.e. restrained eaters who do not, periodically, indulge in overeating practices. These reports and the present findings at least question whether it is merely the restraint which predisposes to counterregulation. The data suggest that there must be another factor which, whether or not combined with restraintness, induces counterregulation. All in all, one wonders how, exactly, restraint and binge eating/counterregulation are related to each other. The break of restraint is not a necessary, nor a sufficient condition for counterregulation/binge eating to occur. It should not be ruled out that restraintness of substance intake is merely a consequence or epiphenomenon of Ss prone to regulation disorders. Of course more research is needed before firm conclusions can be drawn.
REFERENCES American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders (3rd edn-rev.). Washington, D.C.: American Psychiatric Association. Baucom, D. H. & Aiken, P. A. (1981). Effect of depressed mood on eating among obese and nonobese dieting and nondieting persons. Journal of Personality and Social Psychology, 41, 577-585. Fairburn, C. G. & Cooper, P. J. (1982). Self-induced vomiting and Bulimia Nervosa: An undetected problem. British Medical Journal, 284, 1135-l 155. Fairburn, C. G., Cooper, Z. & Cooper, P. J. (1986). The clinical features and maintenance of Bulimia Nervosa. In Brownell, K. D. & Foreyt J. P. (Eds), Handbook of eating disorders: Physiology, psychology, and treatment of Obesity, Anorexia, and Bulimia (pp. 389404). New York: Basic Books. Frost, R. O., Goolkasian, G. A., Ely, R. J. & Blanchard, F. A. (1982). Depression, restraint and eating behavior. Behaviour Research and Therapy, 20, 113-121. Herman, C. P. & Mack, D. (1975). Restrained and unrestrained eating. Journal of Personality, 43, 647660. Herman, C. P. & Polivy, J. (1975). Anxiety, restraint, and eating behaviur. Journal of Abnormal Psychology, 84, 666672. Hibscher, J. A. & Herman, C. P. (1977). Obesity, dieting, and the expression of ‘obese’ characteristics. Journal of Comparative Physiology and Psychology, 91, 374-380. Jansen, A. & van den Hout, M. (1991). On being led into temptation: ‘counterregulation’ of dieters after smelling a ‘preload’. Addictive Behaviors. In press. Jansen, A., Oosterlaan, J., Merckelbach, H. & van den Hout, M. A. (1988). Non-regulation of food intake in restrained, emotional, and external eaters. Journal of Psychopathology and Behavioral Assessment, 10, 3455354. Keys, A., Brozek, J., Henschel, A., Mickelsen, 0. & Taylor, H. L. (1950). The biology of human starvation. Minneapolis: The University of Minnesota Press. Laessle, R. G., Tuschl, R. J., Kotthaus, B. C. & Pirke, K. M. (1989). Behavioral and biological correlates of dietary restraint in normal life. Appetite, 12, 83-94. Mizes, S. (1985). Bulimia: A review of its symptomatology and treatment. Advances in Behaviour Research and Therapy, 7, 91-142. Polivy, J. & Herman, C. P. (1985). Dieting and bingeing: A causal analysis. American Psychologist, 40, 913-201. Pyle, R., Mitchell, J. & Eckert, E. (1981). Bulimia: A report of 34 cases. Journal of Clinical Psychiatry, 42, 6@64. Ruderman, A. (1985a). Restraint, Obesity and Bulimia. Behaviour Research and Therapy, 2, 151-156. Ruderman, A. J. (1985b). Dysphoric mood and overeating: A test of restraint theory’s disinhibition hypothesis. Journal of Abnormal Psychology, 94, 78-85. Ruderman, A. J. (1983). The restraint scale: A psychometric investigation. Behaviour Research and Therapy, 21, 253-258. Ruderman, A. J. & Christensen, H. (1983). Restraint theory and its applicability to overweight individuals. Journal of Abnormal Psychology, 92, 210-215. Ruderman, A. J., Belzer, L. J. & Halperin, A. (1985). Restraint, anticipated consumption, and overeating. Journal of Abnormal Psychology, 94, 547-555. Rossiter, E. M., Wilson, G. T. & Goldstein, L. (1989). Bulimia Nervosa and dietary restraint. Behavioural Research and Therapy, 27, 465468. Schotte, D. E., Cools, J. & McNally, R. (1990). Film-Induced Negative Affect Triggers Overeating in Restrained Eaters. Journal of Abnormal Psychology, 3, 317-320. Spencer, J. A. & Fremouw, W. J. (1979). Binge eating as a function of restraint and weight classification. Journal of Abnormal Psychology, 88, 262-267. Striegel-Moore, R. H., Silberstein, L. R. & Rodin, J. (1986). Toward an understanding of risk factors for Bulimia. American Psychologist, 41, 246-263, Van Strien, T., Frijters, J. E. R., Bergers, G. P. A. & Defares, P. B. (1986). The Dutch Eating Behaviour Questionnaire (DEBQ) for assessment of restrained, emotional, and external eating behavior. International Journal ofEating Disorders, 2, 295-315. Wardle, J. (1980). Dietary restraint and binge eating. Behauiour Analysis and Modification, 4, 201-209. Wardle, J. & Beales, S. (1988). Control and loss of control over eating: An experimental investigation. Journal of Abnormal Psychology, 97, 3540. Wardle, J. & Beinart, H. (1981). Binge eating: A theoretical review. Brifish Journal of Clinical Psychology, 20, 97-109.
CASE HISTORIES No counterregulation
0005-7967/92 $5.00 + 0.00 Copyright 0 1991 Pergamon Press plc
AND SHORTER
COMMUNICATIONS
after breaking the external restraint of children
ANITA JANSEN,* JUDITH VAN DEN BERG and KRISTEL BULTEN Department of Mental Health Sciences/Experimental Psychopathology, Limburg University, P.O. Box 616, 6200 MD Maastricht, The Netherlands (Received for publication 9 July 1991) Summary-At the present, it is unknown how restraint and binge eating/counterregulation are exactly related. Earlier studies on this relationship suffer from two main shortcomings: the studies are all correlational in nature or could not rule out the contribution of confounding variables such as weight loss. The present study investigated whether a break of restraint is a sufficient condition for the occurrence of counterregulation by studying a restrained sample which is not liable to dieting practices and weight loss. The externally imposed restraint on children with regard to eating sweets was broken. However, after breaking their external restraint the children did not counterregulate. It is discussed whether restraint of food intake is really as important for binge eating as it is claimed to be or whether it is merely a consequence or an epiphenomenon of binge eating.
INTRODUCTION: The eating disorder bulimia nervosa is, amongst other things, characterized by recurrent episodes of binge eating, i.e. the rapid consumption of large amounts of food in a discrete period of time (American Psychiatric Association, 1987). Binge eating usually goes hand in hand with the intention to restrain food intake (Polivy & Herman, 1985; Wardle, 1980). Restraining food intake is claimed to be a risk factor for binge eating: about 80% of patients with bulimia nervosa tried to lose weight by strictly restraining their food intake prior to the onset of binge eating (Pyle, Mitchell & Eckert, 1981; Fairburn & Cooper, 1982; Striegel-Moore, Silberstein & Rodin, 1986; Rossiter, Wilson & Goldstein, 1989; Mizes, 1985; Fairburn, Cooper & Cooper, 1986). Furthermore, about 50% of the anorexia nervosa patients develop binge eating episodes about 9-18 months after the onset of the strict restraining practices (Wardle & Beinart, 1981; Polivy & Herman, 1985; Laessle, Tuschl, Kotthaus & Pirke, 1989) and non-clinical restrained eaters report significantly more binge eating than unrestrained eaters (Wardle, 1980). Also, laboratory studies on food intake show that especially restrained eaters are prone to disinhibition and overeating. Several studies show that restrained Ss do not regulate their food intake normally: after a break of their restraint (e.g. by eating a preload which is rich in calories) they eat more than when their restraint had not been broken (i.e. when they had not eaten a preload). This typical eating pattern is called counterregulation. In contrast, unrestrained Ss regulate their food intake: after they have eaten a preload they eat less than when they had not eaten a preload (Herman & Mack, 1975; Hibscher & Herman 1977; Ruderman & Christensen, 1983; Jansen, Oosterlaan, Merckelback & van den Hout, 1988). However, the abovementioned data on the co-occurrence of restraining food intake and bingeing have been derived retrospectively from clinical reports. Also, the laboratory studies which show the co-occurrence of restraint and counterregulation are in fact of a correlational nature: restraint is associated with counterregulation but the causal role of restraint has yet to be demonstrated. It should not be ruled out that bingeing causes restraint or that there is a third underlying mechanism which explains the co-occurrence of restraint and bingeing. Only twice the casuality issue between restraining food intake and bingeing was studied empirically. In the early fifties, Keys, Brozek, Henschel, Mickelson and Taylor (1950) studied 36 soldiers on a semi-starvation diet for 24 weeks. After several months, the soldiers had lost 26% of their initial weight. When food was available again, after the experiment, the soldiers indulged in severe binge eating episodes. Lately, Wardle and Beales (1988) studied the effects of restraint on laboratory food intake regulation. Overweight Ss took part in a weight loss treatment program, in which some of them dieted and some did not. After 3 weeks, only the ‘dieters’ showed the typical laboratory phenomenon of counterregulation. However it should be noted that Keys’ bingeing soldiers were extremely underweight and Wardle and Beales’ counterregulating dieters had lost significantly more weight than the non-dieters who did not counterregulate. It thus cannot be ruled out that weight loss instead of restraint determined the excessive food intake. There is no direct data which supports the causality between pure restraint of food intake (without weight loss) and counterregulation/binge eating. Note that it is rather difficult to disentangle the pure effect of restraint and the contribution of confounding variables, such as weight loss, in a typical sample of restrained eaters. Nevertheless, from an etiological point of view, it is highly important to know whether it is merely the restraintness which predisposes to binge eating/counterregulation. If restraintness indeed is a sufficient condition for the occurrence of counterregulation, the straightforward assumption is that breaking restraint in restrained Ss who are of normal weight and not even preoccupied with weight gain/loss will still lead to counterregulation. Therefore, in the present study, a S sample was chosen that is liable to a restraint on intake but is not involved in any dieting practices and weight loss. We hypothesized that breaking the externally imposed restraint on childen with regard to eating sweets will lead to counterregulation. More specifically, it is hypothesized that externally restrained children who eat a large sweet preload will subsequently eat more than externally restrained children who do not eat a preload. *Author
for correspondence. 59
60
CASE HISTORIES
AND
Table
External restraint (ERQ) Age (yr) Weight (kg) Height (m)
SHORTER
COMMUNICATIONS
I. S characteristics
Preloaded (n = 13) M (SD)
Non-preloaded (n = 14) M (SD)
I
P
19.7 (5.2) 8.8 (0.7) 32.3 (4.8) I .41 (0.08)
20.1 (6.8) 8.6 (0.5) 33.3 (3.4) I .43 (0.06)
0.19 1.18 0.59 0.77
NS NS NS NS
NS = not significant. METHOD Subjects Children were recruited by an advertisement in the local newspaper and a letter circulating in primary schools. The advertisement and letter asked for 8 and 9-yr old, non-dieting girls of normal weight to participate in a study on taste preferences of young children. Twenty-seven girls took part in the experiment. The children were all of normal weight according to national weight tables. Answers on a questionnaire which asked for food preferences, eating habits, and the intention to diet, indicated that none of the childen was dieting. S characteristics are shown in Table 1. Assessment of external restraint In piloting this study, the authors determined levels of external restraint by interviewing twelve (couples of) parents. During these interviews, it appeared that Dutch parents always put considerable restraint on the amount of sweets their children were permitted to eat. Our starting point therefore was that Dutch children always are externally restrained with regard to eating sweets. To obtain a more objective measure of external restraint and in order to control for the level of external restraint we composed a list of 11 statements, based on the clinical interviews and our knowledge on the concept of restraint. The questionnaire asks for typical restraint rules: whether the child was permitted to eat as many sweets as she wanted to, whether she wishes to eat more sweets than she was permitted to, and whether parents paid attention to the amounts of sweets their child eats (see Table 2). The level of external restraint imposed on the Ss participating in the experiment was determined by their parents’ answers on this External Restraint Questionnaire (ERQ). Procedure Parents who enrolled their daughter for participation were sent a questionnaire which asked for the child’s age, weight, food preferences, eating habits and dieting practices. After inspection of the returned questionnaire an appointment was made. Until participation, the Ss and their parents did not know that it was a study on tasting sweets. In order to control pre-experimental food intake Ss were asked to eat a normal lunch or breakfast 2 hr before participation in the Experiment. The intake of sweets during the experiment could thus not be influenced by deprivation. All Ss were run individually between 10.00 a.m. and 5.00 p.m. on Saturday and Sunday so that the children did not have to stay away from school. Ss were randomly assigned to the preload or no-preload condition and the number of Ss run in each condition was balanced at various times of the day. After entering the laboratory, the child was shown the room in which her parent(s) waited for her. Then the first experimenter and the child went to an armoured chamber at the other end of the passage. A second experimenter explained the procedure to the parents who gave their consent and filled in the ERQ. In the meantime, the first experimenter put the child at her ease by chattering a bit. After a couple of minutes, the experimenter started a 15-min interview on ‘rules at home’. The child was asked what things she was permitted to do and which things were forbidden by her parents. For example, she was asked at what time she had to go to sleep, whether she had to finish her food every day and so on. These things were written on a flap-over; forbidden things were written in red whereas permitted things were written with a black style. During the interview children in the preload condition ate two milky-ways (i.e. 5Og and 220 cals). Usually, the perceived destroy of restraint is claimed to be the crucial thing in counterregulation. By means of the interview and flap-over the authors meant to stress the child’s awareness of rules and the break of a rule when eating two milky-ways. After 15 mins the interview was finished and eight pre-weighed, large dishes with diverse soft sweets and a glass of water were brought in by a third experimenter. Each dish contained approx. 900 g of soft sweets. The sweets were broken into small pieces and presented in large amounts so that Ss could inconspicuously eat a lot. The S was instructed how to fill in the forms on which she had to mark whether she liked the sweets or not. The child was invited to taste the sweets. It was stressed that she could eat as much as she wanted to but that she was not obliged to eat anything. Then the experimenter Table 2. External Restraint Questionnaire (ERQ) 1. You have just had a warm meal together with your daughter. Immediately after the meal your daughter asks you whether she may have a bar of chocolate. Do you find it permissahle for your daughter to eat chocolate at that moment? 2. Your daughter has no appetite for the warm meal. She does want to eat potato-crisps, Do you allow your daughter to not participate in eating the warm meal but to eat the crisps? 3. Your daughter returns from school and asks for a biscuit. After eating three biscuits she asks for another. Do you give her another biscuit? 4. Your daughter gets a little fatter. Do you pay attention to ensure that she eats less sweets for a while? 5. Assume that your daughter can determine herself how many sweets she may eat. Do you think your daughter would eat sweets more often? 6. Do you pay close attention to how many sweets your daughter eats? 7. Do you consciously give your daughter ‘healthy’ sweets (like an apple) instead of candy? 8. Imagine that one day your daughter has eaten too many sweets, Do you make sure that she eats less sweets the next day? 9. Are you afraid that your daughter will become too fat if she eats too many sweets? IO. Do you think your daughter would like to eat more sweets than you allow her to? 1I, Do you try to keep as close an eye as possible on how many sweets your daughter eats? Questions l-3 were answered never (3), sometimes (2), often (I), always (0). Questions 41 I were answered never (O), sometimes (I), often (2) always (3).
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left the room and the child was left alone for 10min. After 10min the experimenter returned and the child’s weight and height were determined by the first experimenter. Then she was given a present and she went back to her parents. The sweets that remained were reweighed by the third experimenter and the Ss’ total intake (in grams) was determined. RESULTS Manipulation
check
Were our Ss really restrained? Scores on the ERQ (see Table 2 and compare Table 1) indicate that all children participating in the experiment were liable to an external restraint on their sweet eating. Did we break a restraint? Parents were asked whether their childen were permitted to eat two milky-ways at once. The preload appeared to be restraint-breaking: parents all declared that their children were not permitted to eat two milky-ways at once. Intake of sweets
Data are presented in Table 3. The r-test showed no significant difference in intake: preloaded Ss ate as many sweets as non-preloaded ones [r(25) = 1.0, NS]. To control for differences in the amount of external restraint, two post hoc analyses were carried out. First the four Ss with a lower score than 15 on the ERQ were thrown out of the analysis. No significant difference emerged [t(21) = 0.87, NS]. Next, an Analysis of Variance (ANOVA) was carried out on the data. The main factors were Group (high vs low external restraint; median split) and Condition @reload vs no-preload). No main effects (resp. [F(l, 26) = 0.07, NS] and [F(l, 26) = 0.8, NS]) and no interaction effect [F(l, 26) = 0.35, NS] emerged. Ss in both conditions did not differ in time [r(25) = 0.2, NS] and amount [?(26) = 0.2, NS] of pre-experimental food intake and in the intake of water during the experiment [t(25) = 1.62, NS]. In short, data indicate that there were no differences in the amount of sweets eaten by preloaded girls as compared to non-preloaded ones. DISCUSSION
In the present study, the hypothesis that a break of restraint in otherwise restrained Ss should end up in counterregulation could not be corroborated. After breaking the externally imposed restraint on childen with regard to eating sweets no counterregulation emerged. Restrained children who ate a large sweet preload did not eat more sweets afterwards than restrained children who had not eaten the preload. Ss did not counterregulate and, curiously, they also did not regulate their intake. How come? The level and nature of restraint as well as the experimental situation deserve some attention. Concerning the level of restraint: non-regulation of restrained eaters has been documented earlier (Ruderman & Christensen, 1983; Jansen et al., 1988). Non-regulation instead of counterregulation may be due to low median split scores on the restraint scale: counterregulating Ss came from studies with a median split of 16 and 17 on the Restraint Scale (Herman & Mack, 1975; Spencer & Fremouw, 1979), whereas in studies with non-regulating Ss the median split was 13 and 12 (Ruderman & Christensen, 1983; Jansen et al., 1988). Ruderman, Belzer and Halperin (1985) found that only Ss scoring above 17.3 on the Restraint Scale counterregulated. It thus sounds plausible that counterregulation occurs in studies with higher medians, whereas non-regulation occurs in studies with a lower median. Note that, although the children in the present study were restrained in their intake of sweets, they were not extremely restrained. For these children, eating sweets is not principally forbidden. The ANOVA showed, however, that also highly restrained children (ERQ > 20) did not eat more after a preload than without one. In line with this it can be argued that the nature of restraint (intrinsic vs extrinsic) is important. The present S sample differs from a typical sample of restrained eaters: the children were externally restrained, i.e. extrinsically motivated, whereas a typical sample of restrained eaters is intrinsically motivated to restrict food intake. However, if the nature of restraint indeed is important, then restraint theory at least has to specify that it is not restraint as such which predisposes to excesses, but that it is an intrinsically motivated restraint which is a risk factor for binge eating. Next question, then, is why intrinsically motivated restraintness should lead to counterregulation whereas extrinsically motivated restraintness should not. Furthermore, the experimental situation considers attention. Although the experimenter had a nice talk with the child for at least 20 min and although she had the impression that the children were at their ease, it cannot be ruled out that the children did not feel free to eat as much as they, in fact, wanted to. The large standard deviation in intake, however, at least shows that some children felt free to eat: the interindividual intake varied enormously. Anyway, data of the present study do show that a break of restraint is not a sufficient condition for counterregulation to occur. What does this mean? Clearly, a (perceived) break of restraint is not a sufficient condition for counterregulation to occur and we already knew that a (perceived) break of restraint is not a necessary condition for counterregulation to occur. As to the issue of necessity, high-calorie preloads, preloads perceived as such and even anticipated preloads are not the only stimuli which lead restrained eaters to overeat. Studies show that restrained eaters also overeat when they are in a strong emotional state, as when depressed or anxious (Herman & Polivy, 1975; Baucom & Aiken, 1981; Frost, Goolkasian, Ely & Blanchard, 1982; Ruderman, 1985a, b; Schotte, Cools & McNally, 1990). Also, restrained eaters ‘counterregulate’ after intensive smelling of food (Jansen & van den Hout, 1991). Thus, a (perceived) break of restraint is not a necessary condition for triggering excessive eating in restrained eaters. Table 3. Results Preloaded (n = 13) M (SD)
Intake of sweets (g) Intake of water (g) Pre-experimental food intake (calories) Time since pre-experimental food intake (h) NS = not significant.
46.4 (16.7) 76.1 (49.6) 236.5 (194.3) 1.9 (1.2)
Non-preloaded (n = M W)
55.4 (28.2) 45.1 (49.8) 252.7 (230.7) 1.8 (1.3)
14) f
P
1.0 1.6 0.2 0.2
NS NS NS NS
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The present study shows that a break of restraint is not a sufficient condition for counterregulation to occur. Earlier, failed replications of counterregulation in restrained eaters are reported (see Jansen et al., 1988). Remarkably, in those studies restrained eaters were selected by the restraint subscale of the Dutch Eating Behaviour Questionnaire (DEBQ; Van Strien, Frijters, Bergers & Defores, 1986). The DEBQ-restraint subscale selects successful restrained eaters, i.e. restrained eaters who do not, periodically, indulge in overeating practices. These reports and the present findings at least question whether it is merely the restraint which predisposes to counterregulation. The data suggest that there must be another factor which, whether or not combined with restraintness, induces counterregulation. All in all, one wonders how, exactly, restraint and binge eating/counterregulation are related to each other. The break of restraint is not a necessary, nor a sufficient condition for counterregulation/binge eating to occur. It should not be ruled out that restraintness of substance intake is merely a consequence or epiphenomenon of Ss prone to regulation disorders. Of course more research is needed before firm conclusions can be drawn.
REFERENCES American Psychiatric Association (1987). Diagnostic and statistical manual of mental disorders (3rd edn-rev.). Washington, D.C.: American Psychiatric Association. Baucom, D. H. & Aiken, P. A. (1981). Effect of depressed mood on eating among obese and nonobese dieting and nondieting persons. Journal of Personality and Social Psychology, 41, 577-585. Fairburn, C. G. & Cooper, P. J. (1982). Self-induced vomiting and Bulimia Nervosa: An undetected problem. British Medical Journal, 284, 1135-l 155. Fairburn, C. G., Cooper, Z. & Cooper, P. J. (1986). The clinical features and maintenance of Bulimia Nervosa. In Brownell, K. D. & Foreyt J. P. (Eds), Handbook of eating disorders: Physiology, psychology, and treatment of Obesity, Anorexia, and Bulimia (pp. 389404). New York: Basic Books. Frost, R. O., Goolkasian, G. A., Ely, R. J. & Blanchard, F. A. (1982). Depression, restraint and eating behavior. Behaviour Research and Therapy, 20, 113-121. Herman, C. P. & Mack, D. (1975). Restrained and unrestrained eating. Journal of Personality, 43, 647660. Herman, C. P. & Polivy, J. (1975). Anxiety, restraint, and eating behaviur. Journal of Abnormal Psychology, 84, 666672. Hibscher, J. A. & Herman, C. P. (1977). Obesity, dieting, and the expression of ‘obese’ characteristics. Journal of Comparative Physiology and Psychology, 91, 374-380. Jansen, A. & van den Hout, M. (1991). On being led into temptation: ‘counterregulation’ of dieters after smelling a ‘preload’. Addictive Behaviors. In press. Jansen, A., Oosterlaan, J., Merckelbach, H. & van den Hout, M. A. (1988). Non-regulation of food intake in restrained, emotional, and external eaters. Journal of Psychopathology and Behavioral Assessment, 10, 3455354. Keys, A., Brozek, J., Henschel, A., Mickelsen, 0. & Taylor, H. L. (1950). The biology of human starvation. Minneapolis: The University of Minnesota Press. Laessle, R. G., Tuschl, R. J., Kotthaus, B. C. & Pirke, K. M. (1989). Behavioral and biological correlates of dietary restraint in normal life. Appetite, 12, 83-94. Mizes, S. (1985). Bulimia: A review of its symptomatology and treatment. Advances in Behaviour Research and Therapy, 7, 91-142. Polivy, J. & Herman, C. P. (1985). Dieting and bingeing: A causal analysis. American Psychologist, 40, 913-201. Pyle, R., Mitchell, J. & Eckert, E. (1981). Bulimia: A report of 34 cases. Journal of Clinical Psychiatry, 42, 6@64. Ruderman, A. (1985a). Restraint, Obesity and Bulimia. Behaviour Research and Therapy, 2, 151-156. Ruderman, A. J. (1985b). Dysphoric mood and overeating: A test of restraint theory’s disinhibition hypothesis. Journal of Abnormal Psychology, 94, 78-85. Ruderman, A. J. (1983). The restraint scale: A psychometric investigation. Behaviour Research and Therapy, 21, 253-258. Ruderman, A. J. & Christensen, H. (1983). Restraint theory and its applicability to overweight individuals. Journal of Abnormal Psychology, 92, 210-215. Ruderman, A. J., Belzer, L. J. & Halperin, A. (1985). Restraint, anticipated consumption, and overeating. Journal of Abnormal Psychology, 94, 547-555. Rossiter, E. M., Wilson, G. T. & Goldstein, L. (1989). Bulimia Nervosa and dietary restraint. Behavioural Research and Therapy, 27, 465468. Schotte, D. E., Cools, J. & McNally, R. (1990). Film-Induced Negative Affect Triggers Overeating in Restrained Eaters. Journal of Abnormal Psychology, 3, 317-320. Spencer, J. A. & Fremouw, W. J. (1979). Binge eating as a function of restraint and weight classification. Journal of Abnormal Psychology, 88, 262-267. Striegel-Moore, R. H., Silberstein, L. R. & Rodin, J. (1986). Toward an understanding of risk factors for Bulimia. American Psychologist, 41, 246-263, Van Strien, T., Frijters, J. E. R., Bergers, G. P. A. & Defares, P. B. (1986). The Dutch Eating Behaviour Questionnaire (DEBQ) for assessment of restrained, emotional, and external eating behavior. International Journal ofEating Disorders, 2, 295-315. Wardle, J. (1980). Dietary restraint and binge eating. Behauiour Analysis and Modification, 4, 201-209. Wardle, J. & Beales, S. (1988). Control and loss of control over eating: An experimental investigation. Journal of Abnormal Psychology, 97, 3540. Wardle, J. & Beinart, H. (1981). Binge eating: A theoretical review. Brifish Journal of Clinical Psychology, 20, 97-109.
