General Hospital Psychiatry xxx (2014) xxx–xxx
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Psychiatric-Medical Comorbidity
Sex differences and eating disorder risk among psychiatric conditions, compulsive behaviors and substance use in a screened Canadian national sample☆ Karen M. Davison, Ph.D., R.D. a, b,⁎, Gillian L. Marshall-Fabien, Ph.D., M.S.W. c, Lovedeep Gondara, M. S. Computer Science (candidate), B. Tech. d a
Intersections of Mental Health Perspectives in Addictions Research Training (IMPART) Program, British Columbia Centre of Excellence for Women’s Health, Vancouver, BC, Canada Health Science Program, Department of Biology, Kwantlen Polytechnic University, Surrey, BC, Canada c Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, OH, USA d British Columbia Cancer Agency, Vancouver, BC, Canada b
a r t i c l e
i n f o
Article history: Received 23 February 2014 Revised 5 April 2014 Accepted 9 April 2014 Available online xxxx Keywords: Sex differences Eating disorder Psychiatric conditions Substance use
a b s t r a c t Objective: This study examined sex differences and eating disorder risk among psychiatric conditions, compulsive behaviors (i.e., gambling, suicide thoughts and attempts) and substance use in a nationally representative sample. Method: Data from participants of the Canadian Community Health Survey Cycle 1.2 who completed the Eating Attitudes Test (n=5116) were analyzed. Sex differences were compared among psychiatric comorbidities according to eating disorder risk, binging, vomiting and dieting behavior. Poisson regression analysis provided prevalence ratios (PRs) of disordered eating adjusting for age, marital status, income, body mass index and recent distress. Results: Pronounced sex differences were associated with eating disorder risk (PRs 4.89–11.04; all P values b .0001). Findings of particular interest included significantly higher PRs for eating disorder risk in males associated with gambling (PR 5.07, Pb .0001) and for females associated with steroid and inhalant use as well as suicide thoughts and attempts (PRs 5.40–5.48, all P values b .0001). Discussion: The findings from this detailed exploration of sex differences and eating disorder risk among psychiatric conditions, compulsive behaviors and substance use suggest that problem gambling, the use of inhalants and steroids and suicidal ideation in relationship to eating disorder risk warrant further investigation. © 2014 Elsevier Inc. All rights reserved.
Disordered eating often occurs with mood and anxiety disorders, as well as substance use [1,2]; however, little is known about sex differences that may occur among various psychiatric conditions. Research suggests there are sex differences among psychiatric comorbidities [3–5] and symptoms such as excess laxative use [6], weight dissatisfaction, dieting, fasting, vomiting, binging, purging and exercising excessively for weight control [7–8]; however, results vary. This investigation capitalized upon the availability of a large, national sample from the Canadian Community Health Survey Cycle 1.2 (CCHS 1.2) to examine in detail sex differences in disordered eating among a range of psychiatric conditions, compulsive behaviors and substances used. 1. Methods The CCHS 1.2 on Mental Health and Well-being [9] was a national survey that included 36,984 respondents (1 person was randomly
☆ The authors have no conflicts of interest to declare. ⁎ Corresponding author at: School of Nursing, University of British Columbia, T201 2211 Wesbrook Mall, Vancouver, BC, Canada V6T 2B5. Tel.: +1 604 300 0331; fax: +1 604 820 2774. E-mail address: [email protected] (K.M. Davison).
selected from 48,047 sampled private dwellings), representing approximately 98% of the Canadian population aged 15 years or older in the 10 provinces. Interviews were conducted by well-trained lay interviewers using computer-assisted procedures while participants were usually at their residence (86% of cases) and, where required, done in English, French, Chinese and Punjabi. There was an 87% household-level response rate; among eligible individuals, the response rate was 89%. The overall response rate was 77%. After participants responded to questions related to psychiatric conditions, compulsive behaviors and use of substances, they were asked two eating attitudes and behaviors screener questions: (1) Was there ever a time in your life when you had a strong fear or a great deal of concern about being too fat or overweight? and (2) During the past 12 months, did you have a strong fear or a great deal of concern about being too fat or overweight? Those who answered “yes” (n= 5116) to both screener questions formed the study sample, and the Eating Attitudes Test (EAT-26) was administered to them. Individuals excluded from the CCHS 1.2 included those living in health care institutions; on Aboriginal reserves; on government-owned land; in the Yukon, Northwest Territories, Nunavut, or in remote regions; or who were full-time members of the Canadian Armed Forces.
http://dx.doi.org/10.1016/j.genhosppsych.2014.04.001 0163-8343/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Davison K.M., et al, Sex differences and eating disorder risk among psychiatric conditions, compulsive behaviors and substance use in a screened Canadi..., Gen Hosp Psychiatry (2014), http://dx.doi.org/10.1016/j.genhosppsych.2014.04.001
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K.M. Davison et al. / General Hospital Psychiatry xxx (2014) xxx–xxx
1.1. Measures: eating disorder risk and symptoms, psychiatric comorbidities and covariates Eating disorder risk was assessed using the EAT-26 [10], a 26-item measure of symptoms and concerns related to eating disorders, which contains Likert-type scale responses. A total score of 20 or greater suggests risk for having an eating disorder. Analysis using the EAT-26 consisted of comparison of respondents above and below the cutoff score and those with affirmative responses (i.e., answers of “often,” “usually,” or “always”) to questions about binging, vomiting and dieting behavior. The CCHS 1.2 interview was based on The World Mental Health Composite International Diagnostic Interview [11]; Diagnostic and Statistical Manual of Mental Disorders [12] algorithms were supported. Psychiatric measures selected were major depression, major depressive episode (MDE) or mania (past 12 months), panic disorder and posttraumatic stress disorder (PTSD). Measures of alcohol interference were based on average scores of 4 or greater on five items that measured alcohol use and the person's functioning. Substance use measures [13] were also based on responses to whether either in the past 12 months or during their lifetime marijuana/cannabis/hashish (excluding one time use), cocaine/crack, inhalants (glue/gasoline/other solvents), amphetamines (speed), 3,4-methylenedioxy-Nmethylamphetamine (MDMA or ecstacy) hallucinogens/phencyclidine (PCP)/lysergic acid diethylamide (LSD), heroin or steroids were used. Gambling severity, dichotomized as non-/non-problem/low-risk gamblers versus moderate risk/problem gamblers, was based on frequency and type of gambling activities (e.g., casino games, lotteries, Internet gambling) in the past 12 months. Suicide factors included suicidal thoughts or attempts in the past 12 months. Some respondents were not asked the appropriate question to determine suicidal thoughts or attempts and, in these cases, Statistics Canada used an imputation strategy to assign values [19]. Sociodemographic and
health-related covariates included age, education, marital status, income, body mass index (BMI) [14] and the Chronicity of Distress and Impairment Scale, which assessed chronicity and associated impairment with distress in the past month [15]. 1.2. Analysis Measurements of association included Fisher's Exact Test and binomial tests of two proportions. Poisson regression with robust variance provided prevalence ratios (PRs) of eating disorder risk, binging and dieting behavior by psychiatric comorbidities and sex adjusted for the covariates. Interactions of each psychiatric comorbidity with sex and age were also analyzed. 2. Results and discussion Of the 5116 respondents screened to complete the EAT-26, 74% were female, 50% were married, 24% had less than high school, 53% were between the ages of 15 and 39 years and 15% were considered low income based on Canadian government standards. The findings of sex differences of eating disorder risk and symptoms among different psychiatric comorbidities (Table 1) are consistent with previous investigations [3,8,16–19]. Of interest were associations of sex differences and eating disorder risk with gambling (higher prevalence in males), steroid and inhalant use, as well as suicide thoughts and attempts (higher prevalence in females). The underlying mechanisms for these relationships may be related to impulsiveness and higher novelty seeking [20]. Sex differences in relationship to eating disorder risk (i.e., EAT-26 score N20), binging and dieting behavior were consistently significant in the Poisson regression analysis (Table 2) with pronounced effects (PRs ranged from 4.9 to 11.04; all P values b .0001) for eating disorder risk.
Table 1 Prevalence of disordered eating behaviors according to psychiatric-related comorbidities in a national subsample screened for eating disorder risk (n=5116) Classificationa
EAT-26 N20b Totals Yes
Depression Gamblingf MDE Mania Panic disorder PTSD Suicide thoughts Suicide attempt Substance use Alcoholg Cannabis h Cocaine/crack h Ecstacy h Hallucinogens, PCP or LSD Heroinh Inhalantsh Speed h Steroidh
h
Bingesc Sex
No
W
2.7⁎⁎⁎ 3.5⁎⁎⁎ 4.9⁎⁎⁎ 1.3⁎⁎⁎ 9.5⁎⁎⁎ 7.4⁎⁎⁎ 7.6⁎⁎⁎ 16.4⁎⁎⁎ 5.6⁎⁎⁎ 2.5⁎⁎ 2.5⁎ 3.7⁎⁎⁎ 2.8⁎⁎⁎ 3.0 3.3⁎ 3.2⁎⁎⁎ 1.4
Totals M
Yes
0.8 71.7 1.3 1.7 1.6 1.7 1.5 0.9
4.0⁎⁎⁎ 3.0⁎⁎ 6.6⁎⁎⁎ 15.3⁎⁎⁎ 12.2⁎⁎ 10.2⁎ 11.9⁎⁎⁎ 24.1⁎⁎
0.8 5.1 1.5 1.7 3.3 2.8 2.2 3.5
8.3⁎⁎⁎ 11.7⁎ 13.8⁎⁎⁎ 20.4⁎⁎⁎ 15.7⁎⁎⁎
2.1 1.7 1.7 1.7 1.7 1.8 1.7 1.7 1.8
14.2⁎⁎⁎ 5.7⁎⁎⁎ 5.5⁎⁎⁎ 7.4⁎⁎⁎
2.1 0.5 0.7 1.1 5.6 1.0 1.5 0.8 0.6
15.0⁎ 10.9⁎⁎⁎ 10.9⁎⁎ 11.7⁎ 9.4⁎
6.5 7.2⁎ 6.9⁎ 7.1⁎⁎⁎ 4.9⁎
Vomitsd
18.3 15.6⁎⁎⁎ 27.4⁎⁎⁎
10.6 19.2⁎⁎⁎ 15.6 7.9
Sex No
W
Dieting behaviore
Totals M
Yes
3.5 7.0 5.0 6.6 6.4 19.7 6.1 6.6
9.3⁎ 11.5 14.4 22.3 16.1 17.9 16.3 28.6
5.9 11.9 11.8 16.3 14.0 20.0 13.7 22.2
0.8⁎
7.1 6.4 6.6 6.8 6.7 7.0 6.8 7.3 7.0
17.4 13.0⁎ 12.3 13.0 11.3⁎ 7.7 15.0 20.0 12.5
11.5 6.5 8.5 8.3 5.3 14.8 25.6 8.3 4.5
2.7⁎ 1.2⁎ 1.4⁎ 1.9⁎ 2.0⁎⁎⁎ 4.5⁎⁎ 3.0⁎ 9.4⁎
4.4 1.1⁎ 3.1⁎⁎ 1.3 1.5 3.0⁎⁎⁎ 6.3⁎⁎⁎
2.6
By sex No
W
Totals M
Yes
Sex No
W
M
0.3 5.4 0.5 0.5 0.7 0.6 0.4 0.6
10.3 5.3 1.4 4.5 1.6 1.9 3.9 7.8
0.2 3.0 0.0 0.0 0.0 0.0 0.8 0.0
24.7⁎⁎⁎ 19.4 25.7⁎ 24.2 22.0 27.7 25.5 36.2⁎
20.0 23.7 22.6 23.2 23.3 23.2 23.1 23.1
27.0⁎⁎⁎
21.2 28.6 28.6⁎ 42.1⁎
18.2 20.9 16.5 10.2 25.6 24.0 17.7 11.1
0.6 0.6 0.6 0.6 0.5 0.6 0.6 1.0 0.7
4.7 1.6 1.9 1.7 2.7 5.1 3.3 10.0 6.3
0.0 0.4 0.5 1.7 0.5 3.7 2.6 8.3 0.0
29.3 25.1 25.4 31.3⁎ 26.0 18.2 23.2 43.8⁎ 21.1
24.6 23.0 23.1 23.0 23.0 23.4 23.3 22.8 23.3
30.2 30.0⁎⁎ 28.2 34.4 29.0⁎ 20.5 26.7 60.0⁎ 12.5
27.9 16.1 20.6 23.3 19.5 14.8 17.9 16.7 27.3
18.6 28.2⁎ 30.4⁎
⁎ Pb.05. ⁎⁎ Pb.001. ⁎⁎⁎ Pb.0001. a All variables refer to last 12 months unless indicated otherwise. b EAT-26 item questions; scores N20 indicate participant at eating disorder risk. c EAT-26, Q05: You go on eating binges where you feel you may not be able to stop (always, usually, and often responses coded as 1). d EAT-26, Q10: You vomit after you eat (always, usually, and often responses coded as 1). e EAT-26, Q24: You engage in dieting behavior (always, usually, and often responses coded as 1). f Non-, non-problem, or low-risk gambler vs moderate risk or problem gambler. g Based on Alcohol Interference score. h Lifetime use; inhalants includes glue, gasoline, or other solvent use.
Please cite this article as: Davison K.M., et al, Sex differences and eating disorder risk among psychiatric conditions, compulsive behaviors and substance use in a screened Canadi..., Gen Hosp Psychiatry (2014), http://dx.doi.org/10.1016/j.genhosppsych.2014.04.001
K.M. Davison et al. / General Hospital Psychiatry xxx (2014) xxx–xxx
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Table 2 PRs (with 95% confidence intervals) of disordered eating behaviors by psychiatric-related comorbidities and sex, adjusted for sociodemographics, BMI, and recent distressa Classificationa
Condition
Sex
Condition
EAT-26 N20b Depression Gamblinge MDE Mania Panic disorder PTSD Suicide thoughts Suicide attempt Substance use Alcoholg Cannibish Cocaine/crackh Ecstacyh Inhalantsh Hallucinogens, PCP or LSDh Heroinh Speedh Steroidh
2.83 1.97 2.61 2.64 3.38 2.76 3.53 4.98
(2.33–3.43)⁎⁎⁎ (1.22–3.20)⁎ (2.11–3.22)⁎⁎⁎ (1.64–4.25)⁎⁎⁎f (2.29–4.98)⁎⁎⁎ (1.91–3.99)⁎⁎⁎ (2.69–4.63)⁎⁎⁎ (3.30–7.51)⁎⁎⁎f
5.11 5.07 4.89 5.47 5.19 5.35 5.40 5.36
3.85 1.29 1.71 2.45 1.94 1.77 1.80 1.69 0.96
(2.29–6.47)⁎⁎⁎f (1.04–1.61)⁎ (1.25–2.33)⁎⁎ (1.58–3.81)⁎⁎⁎ (1.08–3.45)⁎ (1.32–2.39)⁎⁎⁎
11.04 (6.35–19.17)⁎⁎⁎f 5.54 (4.25–7.24)⁎⁎⁎ 5.69 (4.35–7.44)⁎⁎⁎ 5.55 (4.26–7.22)⁎⁎⁎ 5.48 (4.21–7.13)⁎⁎⁎ 5.70 (4.36–7.46)⁎⁎⁎ 5.45 (4.19–7.10)⁎⁎⁎ 5.55 (4.25–7.24)⁎⁎⁎ 5.40 (4.15–7.03)⁎⁎⁎
(0.81–4.03) (1.56–2.50)⁎ (0.26–3.56)
Sex
Condition
Bingesc (3.93–6.65)⁎⁎⁎ (3.74–6.86)⁎⁎⁎ (3.75–6.36)⁎⁎⁎ (4.20–7.13)⁎⁎⁎ (3.98–6.78)⁎⁎⁎ (4.11–6.96)⁎⁎⁎ (4.16–7.02)⁎⁎⁎ (4.13–6.97)⁎⁎⁎
Sex
Dieting behaviord
2.01 1.87 2.45 2.26 2.49 1.97 0.93 0.93
(1.39–2.92)⁎⁎⁎ (1.14–3.07)⁎ (1.87–3.20)⁎⁎⁎ (1.41–3.63)⁎⁎⁎ (1.53–4.04)⁎⁎⁎ (1.30–3.00)⁎ (0.90–0.97)⁎ (0.90–0.97)⁎⁎
1.61 1.61 1.53 1.69 1.61 1.58 1.05 1.06
(1.19–2.17)⁎ (1.15–2.27)⁎ (1.14–2.06)⁎ (1.25–2.28)⁎ (1.19–2.17)⁎ (1.17–2.15)⁎ (0.96–1.14) (0.98–1.16)
1.14 0.79 1.05 0.95 1.28 0.93 0.65 0.65
(0.98–1.33) (0.53–1.17) (0.91–1.22) (0.64–1.40) (0.91–1.81) (0.68–1.28) (0.51–0.84)⁎⁎ (0.51–0.84)⁎
1.48 1.39 1.48 1.48 1.49 1.50 1.09 1.09
(1.27–1.72)⁎⁎⁎ (1.17–1.65)⁎⁎⁎ (1.27–1.72)⁎⁎⁎ (1.28–1.73)⁎⁎⁎ (1.28–1.73)⁎⁎⁎ (1.29–1.74)⁎⁎⁎ (1.08–1.11)⁎⁎⁎ (1.08–1.11)⁎⁎
2.65 1.30 1.74 1.78 2.38 1.30 1.50 1.04 1.12
(1.44–4.87)⁎ (0.98–1.73) (1.24–2.45)⁎ (1.06–2.97)⁎ (1.40–4.04)⁎⁎⁎ (0.98–1.97) (0.64–3.52) (0.63–1.70) (0.29–4.26)
2.87 1.69 1.72 1.65 1.66 1.66 1.64 1.63 1.63
(1.49–5.56)⁎ (1.24–2.30)⁎ (1.27–2.33)⁎⁎⁎ (1.22–2.22)⁎ (1.23–2.23)⁎ (1.23–2.25)⁎ (1.21–2.21)⁎ (1.20–2.20)⁎⁎⁎ (1.20–2.20) ⁎
1.74 1.10 1.17 1.51 1.18 1.23 0.68 1.09 1.11
(1.23–2.45)⁎ (0.96–1.26) (0.96–1.43) (1.15–1.99)⁎ (0.79–1.76) (1.02–1.48)⁎
1.71 1.51 1.51 1.51 1.49 1.51 1.48 1.50 1.49
(1.20–2.42)⁎ (1.30–1.76)⁎⁎⁎ (1.30–1.76)⁎⁎⁎ (1.29–1.75)⁎⁎⁎ (1.28–1.74)⁎⁎⁎ (1.30–1.76)⁎⁎⁎ (1.27–1.72)⁎⁎⁎ (1.29–1.74)⁎⁎⁎ (1.28–1.74) ⁎⁎⁎
(0.35–1.35) (0.86–1.39) (0.53–2.29)
⁎ Pb.05. ⁎⁎ Pb.001. ⁎⁎⁎ Pb.0001. a Chronicity of Distress and Impairment Scale [16]. All variables refer to last 12 months unless indicated otherwise indicated. b Eating troubles defined as those did and did not exceed the EAT-26 score for eating disorder risk (cutoff score=20). Age (P values=.05–0.0001) and incomes (all P values b.0001) were significant for all regression analyses, except alcohol use. BMI was significant for all (all P values b.0001). c EAT-26, Q05: You go on eating binges where you feel you may not be able to stop (always, usually and often responses coded as 1). Marital status and BMI were significant for all analysis at Pb.05. d EAT-26, Q24: You engage in dieting behavior (always, usually and often responses coded as 1). e Non-, non-problem, or low-risk gambler vs moderate risk or problem gambler. f Interpret with caution because of limited precision. g Based on Alcohol Interference score. h Lifetime use; inhalants include glue, gasoline or other solvent use.
To the authors' knowledge, this is the first study to report sex differences of eating disorder risk among different psychiatric comorbidities that controlled for other relevant factors. Psychiatric comorbidity of eating disorder risk may be attributed to affective dysregulation among the same neurotransmitter systems [20]. Associations of eating disorder risk with substance use may be linked with impulsivity [21], the drug's properties (e.g., anorexic properties of methamphetamines and cocaine [22], appetite stimulation of marijuana leading to weight control behaviors) [23], or as means to escape from aversive emotions [24]. This study's findings are limited given the cross-sectional design which negates determination of temporal sequence. The EAT-26 focuses on disordered eating behaviors and attitudes related to body dissatisfaction and thus may not account for how particular substances may alter patterns of food intake [6]. In spite of these limitations, this detailed exploration of sex differences in eating disorder risk among several psychiatric comorbidities in a nationally representative sample yielded novel clinical findings including substances most likely to be used in relationship to binging and dieting behaviors. In addition, the results suggest that problem gambling, use of inhalants and steroids, as well as suicide thoughts and attempts that are rarely studied in relationship to eating disorder risk warrant further investigation. Acknowledgments/Disclosure of Conflicts This project was supported by a Langara College Research Committee grant. The opinions expressed in this paper do not represent the opinions of Statistics Canada, the agency providing the data for this investigation. References [1] Blinder BJ, Cumella EF, Sanathara VA. Psychiatric cormorbidites of female inpatients with eating disorders. Psychosom Med 2006;68:454–62.
[2] Touchette E, Henegar A, Godart NT, Pryor L, Falissard B, Tremblay RE, et al. Subclinical eating disorders and their comorbidity with mood and anxiety disorders in adolescent girls. Psychiatry Res 2011;185:185–92. [3] Lähteenmäki S, Saarni S, Suokas J, Saarni S, Perälä J, Lönnqvist J, et al. Prevalence and correlates of eating disorders among young adults in Finland. Nord J Psychiatry 2014;68(3):196–203. [4] Hudson JI, Hiripi E, Pope Jr HG, Kessler RC, et al. The prevalence and correlation of eating disorders in the National Comorbidity Survey Replication Study. Biol Psychiatry 2007;61:348–58. [5] Bulik CM, Sullivan PF, Carter FA, Joyce PR. Lifetime comorbidity of alcohol dependence in women with bulimia nervosa. Addict Behav 1997;22:437–46. [6] Anderson CB, Bulik CM. Gender differences in compensatory behaviors, weight and shape salience, and drive for thinness. Eat Behav 2004;5:1–11. [7] Lewinsohn PM, Seeley JR, Moerk KC, et al. Gender differences in eating disorder symptoms in young adults. Int J Eat Disord 2002;32:426–40. [8] Striegel-Moore RH, Rosselli F, Perrin N, DeBar L, Wilson GT, May A, et al. Gender difference in the prevalence of eating disorder symptoms. Int J Eat Disord 2009;42:471–4. [9] Statistics Canada. Canadian Community Health Survey (CCHS), Cycle 1.2: Derived Variable (DV) Specifications. Ottawa: Statistics Canada; 2002. [10] Garner DM, Olmsted MP, Bohr Y, Garfinkel PE. The eating attitudes test: psychometric features and clinical correlates. Psychol Med 1982;12:871–8. [11] Kessler RC, Ustün TB. The World Mental Health (WMH) Survey Initiative Version of the World Health Organization (WHO) Composite International Diagnostic Interview (CIDI). Int J Methods Psychiatr Res 2004;13:93–121. [12] American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Washington: American Psychiatric Association; 1994. [13] Statistics Canada. Canada's Alcohol and Other Drugs Survey, 1994. Ottawa: Statistics Canada: Special Surveys Division; 1994. [14] Al Sabbah H, Vereecken CA, Elgar FJ, Nansel T, Aasvee K, Abdeen Z, et al. Body weight dissatisfaction and communication with parents among adolescents in 24 countries: international cross-sectional survey. BMC Public Health 2009;9:52. [15] Kessler RC, Andrews G, Mroczek D, Ustun B, Wittchen HU. The World Health Organization Composite International Diagnostic Interview short-form (CIDI-SF). Int J Methods Psychiatr Res 1998;7:171–85. [16] Gadalla T, Piran N. Eating disorders and substance abuse in Canadian men and women: a national study. Eat Disord 2007;15:189–203. [17] Gadalla T, Piran N. Co-occurrence of eating disorders and alcohol use disorders in women: a meta analysis. Arch Womens Ment Health 2007;10:133–40. [18] Tozzi F, Thornton LM, Klump KL, Fichter MM, Halmi KA, Kaplan AS, et al. Symptom fluctuation in eating disorders: correlates of diagnostic crossover. Am J Psychiatry 2005;162:732–40. [19] Dansky BS, Brewerton TD, Kilpatrick DG. Comorbidity of bulimia nervosa and alcohol use disorders: results from the National Women's Study. Int J Eat Disord 2000;27:180–90.
Please cite this article as: Davison K.M., et al, Sex differences and eating disorder risk among psychiatric conditions, compulsive behaviors and substance use in a screened Canadi..., Gen Hosp Psychiatry (2014), http://dx.doi.org/10.1016/j.genhosppsych.2014.04.001
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Psychiatric-Medical Comorbidity
Sex differences and eating disorder risk among psychiatric conditions, compulsive behaviors and substance use in a screened Canadian national sample☆ Karen M. Davison, Ph.D., R.D. a, b,⁎, Gillian L. Marshall-Fabien, Ph.D., M.S.W. c, Lovedeep Gondara, M. S. Computer Science (candidate), B. Tech. d a
Intersections of Mental Health Perspectives in Addictions Research Training (IMPART) Program, British Columbia Centre of Excellence for Women’s Health, Vancouver, BC, Canada Health Science Program, Department of Biology, Kwantlen Polytechnic University, Surrey, BC, Canada c Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, Cleveland, OH, USA d British Columbia Cancer Agency, Vancouver, BC, Canada b
a r t i c l e
i n f o
Article history: Received 23 February 2014 Revised 5 April 2014 Accepted 9 April 2014 Available online xxxx Keywords: Sex differences Eating disorder Psychiatric conditions Substance use
a b s t r a c t Objective: This study examined sex differences and eating disorder risk among psychiatric conditions, compulsive behaviors (i.e., gambling, suicide thoughts and attempts) and substance use in a nationally representative sample. Method: Data from participants of the Canadian Community Health Survey Cycle 1.2 who completed the Eating Attitudes Test (n=5116) were analyzed. Sex differences were compared among psychiatric comorbidities according to eating disorder risk, binging, vomiting and dieting behavior. Poisson regression analysis provided prevalence ratios (PRs) of disordered eating adjusting for age, marital status, income, body mass index and recent distress. Results: Pronounced sex differences were associated with eating disorder risk (PRs 4.89–11.04; all P values b .0001). Findings of particular interest included significantly higher PRs for eating disorder risk in males associated with gambling (PR 5.07, Pb .0001) and for females associated with steroid and inhalant use as well as suicide thoughts and attempts (PRs 5.40–5.48, all P values b .0001). Discussion: The findings from this detailed exploration of sex differences and eating disorder risk among psychiatric conditions, compulsive behaviors and substance use suggest that problem gambling, the use of inhalants and steroids and suicidal ideation in relationship to eating disorder risk warrant further investigation. © 2014 Elsevier Inc. All rights reserved.
Disordered eating often occurs with mood and anxiety disorders, as well as substance use [1,2]; however, little is known about sex differences that may occur among various psychiatric conditions. Research suggests there are sex differences among psychiatric comorbidities [3–5] and symptoms such as excess laxative use [6], weight dissatisfaction, dieting, fasting, vomiting, binging, purging and exercising excessively for weight control [7–8]; however, results vary. This investigation capitalized upon the availability of a large, national sample from the Canadian Community Health Survey Cycle 1.2 (CCHS 1.2) to examine in detail sex differences in disordered eating among a range of psychiatric conditions, compulsive behaviors and substances used. 1. Methods The CCHS 1.2 on Mental Health and Well-being [9] was a national survey that included 36,984 respondents (1 person was randomly
☆ The authors have no conflicts of interest to declare. ⁎ Corresponding author at: School of Nursing, University of British Columbia, T201 2211 Wesbrook Mall, Vancouver, BC, Canada V6T 2B5. Tel.: +1 604 300 0331; fax: +1 604 820 2774. E-mail address: [email protected] (K.M. Davison).
selected from 48,047 sampled private dwellings), representing approximately 98% of the Canadian population aged 15 years or older in the 10 provinces. Interviews were conducted by well-trained lay interviewers using computer-assisted procedures while participants were usually at their residence (86% of cases) and, where required, done in English, French, Chinese and Punjabi. There was an 87% household-level response rate; among eligible individuals, the response rate was 89%. The overall response rate was 77%. After participants responded to questions related to psychiatric conditions, compulsive behaviors and use of substances, they were asked two eating attitudes and behaviors screener questions: (1) Was there ever a time in your life when you had a strong fear or a great deal of concern about being too fat or overweight? and (2) During the past 12 months, did you have a strong fear or a great deal of concern about being too fat or overweight? Those who answered “yes” (n= 5116) to both screener questions formed the study sample, and the Eating Attitudes Test (EAT-26) was administered to them. Individuals excluded from the CCHS 1.2 included those living in health care institutions; on Aboriginal reserves; on government-owned land; in the Yukon, Northwest Territories, Nunavut, or in remote regions; or who were full-time members of the Canadian Armed Forces.
http://dx.doi.org/10.1016/j.genhosppsych.2014.04.001 0163-8343/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Davison K.M., et al, Sex differences and eating disorder risk among psychiatric conditions, compulsive behaviors and substance use in a screened Canadi..., Gen Hosp Psychiatry (2014), http://dx.doi.org/10.1016/j.genhosppsych.2014.04.001
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K.M. Davison et al. / General Hospital Psychiatry xxx (2014) xxx–xxx
1.1. Measures: eating disorder risk and symptoms, psychiatric comorbidities and covariates Eating disorder risk was assessed using the EAT-26 [10], a 26-item measure of symptoms and concerns related to eating disorders, which contains Likert-type scale responses. A total score of 20 or greater suggests risk for having an eating disorder. Analysis using the EAT-26 consisted of comparison of respondents above and below the cutoff score and those with affirmative responses (i.e., answers of “often,” “usually,” or “always”) to questions about binging, vomiting and dieting behavior. The CCHS 1.2 interview was based on The World Mental Health Composite International Diagnostic Interview [11]; Diagnostic and Statistical Manual of Mental Disorders [12] algorithms were supported. Psychiatric measures selected were major depression, major depressive episode (MDE) or mania (past 12 months), panic disorder and posttraumatic stress disorder (PTSD). Measures of alcohol interference were based on average scores of 4 or greater on five items that measured alcohol use and the person's functioning. Substance use measures [13] were also based on responses to whether either in the past 12 months or during their lifetime marijuana/cannabis/hashish (excluding one time use), cocaine/crack, inhalants (glue/gasoline/other solvents), amphetamines (speed), 3,4-methylenedioxy-Nmethylamphetamine (MDMA or ecstacy) hallucinogens/phencyclidine (PCP)/lysergic acid diethylamide (LSD), heroin or steroids were used. Gambling severity, dichotomized as non-/non-problem/low-risk gamblers versus moderate risk/problem gamblers, was based on frequency and type of gambling activities (e.g., casino games, lotteries, Internet gambling) in the past 12 months. Suicide factors included suicidal thoughts or attempts in the past 12 months. Some respondents were not asked the appropriate question to determine suicidal thoughts or attempts and, in these cases, Statistics Canada used an imputation strategy to assign values [19]. Sociodemographic and
health-related covariates included age, education, marital status, income, body mass index (BMI) [14] and the Chronicity of Distress and Impairment Scale, which assessed chronicity and associated impairment with distress in the past month [15]. 1.2. Analysis Measurements of association included Fisher's Exact Test and binomial tests of two proportions. Poisson regression with robust variance provided prevalence ratios (PRs) of eating disorder risk, binging and dieting behavior by psychiatric comorbidities and sex adjusted for the covariates. Interactions of each psychiatric comorbidity with sex and age were also analyzed. 2. Results and discussion Of the 5116 respondents screened to complete the EAT-26, 74% were female, 50% were married, 24% had less than high school, 53% were between the ages of 15 and 39 years and 15% were considered low income based on Canadian government standards. The findings of sex differences of eating disorder risk and symptoms among different psychiatric comorbidities (Table 1) are consistent with previous investigations [3,8,16–19]. Of interest were associations of sex differences and eating disorder risk with gambling (higher prevalence in males), steroid and inhalant use, as well as suicide thoughts and attempts (higher prevalence in females). The underlying mechanisms for these relationships may be related to impulsiveness and higher novelty seeking [20]. Sex differences in relationship to eating disorder risk (i.e., EAT-26 score N20), binging and dieting behavior were consistently significant in the Poisson regression analysis (Table 2) with pronounced effects (PRs ranged from 4.9 to 11.04; all P values b .0001) for eating disorder risk.
Table 1 Prevalence of disordered eating behaviors according to psychiatric-related comorbidities in a national subsample screened for eating disorder risk (n=5116) Classificationa
EAT-26 N20b Totals Yes
Depression Gamblingf MDE Mania Panic disorder PTSD Suicide thoughts Suicide attempt Substance use Alcoholg Cannabis h Cocaine/crack h Ecstacy h Hallucinogens, PCP or LSD Heroinh Inhalantsh Speed h Steroidh
h
Bingesc Sex
No
W
2.7⁎⁎⁎ 3.5⁎⁎⁎ 4.9⁎⁎⁎ 1.3⁎⁎⁎ 9.5⁎⁎⁎ 7.4⁎⁎⁎ 7.6⁎⁎⁎ 16.4⁎⁎⁎ 5.6⁎⁎⁎ 2.5⁎⁎ 2.5⁎ 3.7⁎⁎⁎ 2.8⁎⁎⁎ 3.0 3.3⁎ 3.2⁎⁎⁎ 1.4
Totals M
Yes
0.8 71.7 1.3 1.7 1.6 1.7 1.5 0.9
4.0⁎⁎⁎ 3.0⁎⁎ 6.6⁎⁎⁎ 15.3⁎⁎⁎ 12.2⁎⁎ 10.2⁎ 11.9⁎⁎⁎ 24.1⁎⁎
0.8 5.1 1.5 1.7 3.3 2.8 2.2 3.5
8.3⁎⁎⁎ 11.7⁎ 13.8⁎⁎⁎ 20.4⁎⁎⁎ 15.7⁎⁎⁎
2.1 1.7 1.7 1.7 1.7 1.8 1.7 1.7 1.8
14.2⁎⁎⁎ 5.7⁎⁎⁎ 5.5⁎⁎⁎ 7.4⁎⁎⁎
2.1 0.5 0.7 1.1 5.6 1.0 1.5 0.8 0.6
15.0⁎ 10.9⁎⁎⁎ 10.9⁎⁎ 11.7⁎ 9.4⁎
6.5 7.2⁎ 6.9⁎ 7.1⁎⁎⁎ 4.9⁎
Vomitsd
18.3 15.6⁎⁎⁎ 27.4⁎⁎⁎
10.6 19.2⁎⁎⁎ 15.6 7.9
Sex No
W
Dieting behaviore
Totals M
Yes
3.5 7.0 5.0 6.6 6.4 19.7 6.1 6.6
9.3⁎ 11.5 14.4 22.3 16.1 17.9 16.3 28.6
5.9 11.9 11.8 16.3 14.0 20.0 13.7 22.2
0.8⁎
7.1 6.4 6.6 6.8 6.7 7.0 6.8 7.3 7.0
17.4 13.0⁎ 12.3 13.0 11.3⁎ 7.7 15.0 20.0 12.5
11.5 6.5 8.5 8.3 5.3 14.8 25.6 8.3 4.5
2.7⁎ 1.2⁎ 1.4⁎ 1.9⁎ 2.0⁎⁎⁎ 4.5⁎⁎ 3.0⁎ 9.4⁎
4.4 1.1⁎ 3.1⁎⁎ 1.3 1.5 3.0⁎⁎⁎ 6.3⁎⁎⁎
2.6
By sex No
W
Totals M
Yes
Sex No
W
M
0.3 5.4 0.5 0.5 0.7 0.6 0.4 0.6
10.3 5.3 1.4 4.5 1.6 1.9 3.9 7.8
0.2 3.0 0.0 0.0 0.0 0.0 0.8 0.0
24.7⁎⁎⁎ 19.4 25.7⁎ 24.2 22.0 27.7 25.5 36.2⁎
20.0 23.7 22.6 23.2 23.3 23.2 23.1 23.1
27.0⁎⁎⁎
21.2 28.6 28.6⁎ 42.1⁎
18.2 20.9 16.5 10.2 25.6 24.0 17.7 11.1
0.6 0.6 0.6 0.6 0.5 0.6 0.6 1.0 0.7
4.7 1.6 1.9 1.7 2.7 5.1 3.3 10.0 6.3
0.0 0.4 0.5 1.7 0.5 3.7 2.6 8.3 0.0
29.3 25.1 25.4 31.3⁎ 26.0 18.2 23.2 43.8⁎ 21.1
24.6 23.0 23.1 23.0 23.0 23.4 23.3 22.8 23.3
30.2 30.0⁎⁎ 28.2 34.4 29.0⁎ 20.5 26.7 60.0⁎ 12.5
27.9 16.1 20.6 23.3 19.5 14.8 17.9 16.7 27.3
18.6 28.2⁎ 30.4⁎
⁎ Pb.05. ⁎⁎ Pb.001. ⁎⁎⁎ Pb.0001. a All variables refer to last 12 months unless indicated otherwise. b EAT-26 item questions; scores N20 indicate participant at eating disorder risk. c EAT-26, Q05: You go on eating binges where you feel you may not be able to stop (always, usually, and often responses coded as 1). d EAT-26, Q10: You vomit after you eat (always, usually, and often responses coded as 1). e EAT-26, Q24: You engage in dieting behavior (always, usually, and often responses coded as 1). f Non-, non-problem, or low-risk gambler vs moderate risk or problem gambler. g Based on Alcohol Interference score. h Lifetime use; inhalants includes glue, gasoline, or other solvent use.
Please cite this article as: Davison K.M., et al, Sex differences and eating disorder risk among psychiatric conditions, compulsive behaviors and substance use in a screened Canadi..., Gen Hosp Psychiatry (2014), http://dx.doi.org/10.1016/j.genhosppsych.2014.04.001
K.M. Davison et al. / General Hospital Psychiatry xxx (2014) xxx–xxx
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Table 2 PRs (with 95% confidence intervals) of disordered eating behaviors by psychiatric-related comorbidities and sex, adjusted for sociodemographics, BMI, and recent distressa Classificationa
Condition
Sex
Condition
EAT-26 N20b Depression Gamblinge MDE Mania Panic disorder PTSD Suicide thoughts Suicide attempt Substance use Alcoholg Cannibish Cocaine/crackh Ecstacyh Inhalantsh Hallucinogens, PCP or LSDh Heroinh Speedh Steroidh
2.83 1.97 2.61 2.64 3.38 2.76 3.53 4.98
(2.33–3.43)⁎⁎⁎ (1.22–3.20)⁎ (2.11–3.22)⁎⁎⁎ (1.64–4.25)⁎⁎⁎f (2.29–4.98)⁎⁎⁎ (1.91–3.99)⁎⁎⁎ (2.69–4.63)⁎⁎⁎ (3.30–7.51)⁎⁎⁎f
5.11 5.07 4.89 5.47 5.19 5.35 5.40 5.36
3.85 1.29 1.71 2.45 1.94 1.77 1.80 1.69 0.96
(2.29–6.47)⁎⁎⁎f (1.04–1.61)⁎ (1.25–2.33)⁎⁎ (1.58–3.81)⁎⁎⁎ (1.08–3.45)⁎ (1.32–2.39)⁎⁎⁎
11.04 (6.35–19.17)⁎⁎⁎f 5.54 (4.25–7.24)⁎⁎⁎ 5.69 (4.35–7.44)⁎⁎⁎ 5.55 (4.26–7.22)⁎⁎⁎ 5.48 (4.21–7.13)⁎⁎⁎ 5.70 (4.36–7.46)⁎⁎⁎ 5.45 (4.19–7.10)⁎⁎⁎ 5.55 (4.25–7.24)⁎⁎⁎ 5.40 (4.15–7.03)⁎⁎⁎
(0.81–4.03) (1.56–2.50)⁎ (0.26–3.56)
Sex
Condition
Bingesc (3.93–6.65)⁎⁎⁎ (3.74–6.86)⁎⁎⁎ (3.75–6.36)⁎⁎⁎ (4.20–7.13)⁎⁎⁎ (3.98–6.78)⁎⁎⁎ (4.11–6.96)⁎⁎⁎ (4.16–7.02)⁎⁎⁎ (4.13–6.97)⁎⁎⁎
Sex
Dieting behaviord
2.01 1.87 2.45 2.26 2.49 1.97 0.93 0.93
(1.39–2.92)⁎⁎⁎ (1.14–3.07)⁎ (1.87–3.20)⁎⁎⁎ (1.41–3.63)⁎⁎⁎ (1.53–4.04)⁎⁎⁎ (1.30–3.00)⁎ (0.90–0.97)⁎ (0.90–0.97)⁎⁎
1.61 1.61 1.53 1.69 1.61 1.58 1.05 1.06
(1.19–2.17)⁎ (1.15–2.27)⁎ (1.14–2.06)⁎ (1.25–2.28)⁎ (1.19–2.17)⁎ (1.17–2.15)⁎ (0.96–1.14) (0.98–1.16)
1.14 0.79 1.05 0.95 1.28 0.93 0.65 0.65
(0.98–1.33) (0.53–1.17) (0.91–1.22) (0.64–1.40) (0.91–1.81) (0.68–1.28) (0.51–0.84)⁎⁎ (0.51–0.84)⁎
1.48 1.39 1.48 1.48 1.49 1.50 1.09 1.09
(1.27–1.72)⁎⁎⁎ (1.17–1.65)⁎⁎⁎ (1.27–1.72)⁎⁎⁎ (1.28–1.73)⁎⁎⁎ (1.28–1.73)⁎⁎⁎ (1.29–1.74)⁎⁎⁎ (1.08–1.11)⁎⁎⁎ (1.08–1.11)⁎⁎
2.65 1.30 1.74 1.78 2.38 1.30 1.50 1.04 1.12
(1.44–4.87)⁎ (0.98–1.73) (1.24–2.45)⁎ (1.06–2.97)⁎ (1.40–4.04)⁎⁎⁎ (0.98–1.97) (0.64–3.52) (0.63–1.70) (0.29–4.26)
2.87 1.69 1.72 1.65 1.66 1.66 1.64 1.63 1.63
(1.49–5.56)⁎ (1.24–2.30)⁎ (1.27–2.33)⁎⁎⁎ (1.22–2.22)⁎ (1.23–2.23)⁎ (1.23–2.25)⁎ (1.21–2.21)⁎ (1.20–2.20)⁎⁎⁎ (1.20–2.20) ⁎
1.74 1.10 1.17 1.51 1.18 1.23 0.68 1.09 1.11
(1.23–2.45)⁎ (0.96–1.26) (0.96–1.43) (1.15–1.99)⁎ (0.79–1.76) (1.02–1.48)⁎
1.71 1.51 1.51 1.51 1.49 1.51 1.48 1.50 1.49
(1.20–2.42)⁎ (1.30–1.76)⁎⁎⁎ (1.30–1.76)⁎⁎⁎ (1.29–1.75)⁎⁎⁎ (1.28–1.74)⁎⁎⁎ (1.30–1.76)⁎⁎⁎ (1.27–1.72)⁎⁎⁎ (1.29–1.74)⁎⁎⁎ (1.28–1.74) ⁎⁎⁎
(0.35–1.35) (0.86–1.39) (0.53–2.29)
⁎ Pb.05. ⁎⁎ Pb.001. ⁎⁎⁎ Pb.0001. a Chronicity of Distress and Impairment Scale [16]. All variables refer to last 12 months unless indicated otherwise indicated. b Eating troubles defined as those did and did not exceed the EAT-26 score for eating disorder risk (cutoff score=20). Age (P values=.05–0.0001) and incomes (all P values b.0001) were significant for all regression analyses, except alcohol use. BMI was significant for all (all P values b.0001). c EAT-26, Q05: You go on eating binges where you feel you may not be able to stop (always, usually and often responses coded as 1). Marital status and BMI were significant for all analysis at Pb.05. d EAT-26, Q24: You engage in dieting behavior (always, usually and often responses coded as 1). e Non-, non-problem, or low-risk gambler vs moderate risk or problem gambler. f Interpret with caution because of limited precision. g Based on Alcohol Interference score. h Lifetime use; inhalants include glue, gasoline or other solvent use.
To the authors' knowledge, this is the first study to report sex differences of eating disorder risk among different psychiatric comorbidities that controlled for other relevant factors. Psychiatric comorbidity of eating disorder risk may be attributed to affective dysregulation among the same neurotransmitter systems [20]. Associations of eating disorder risk with substance use may be linked with impulsivity [21], the drug's properties (e.g., anorexic properties of methamphetamines and cocaine [22], appetite stimulation of marijuana leading to weight control behaviors) [23], or as means to escape from aversive emotions [24]. This study's findings are limited given the cross-sectional design which negates determination of temporal sequence. The EAT-26 focuses on disordered eating behaviors and attitudes related to body dissatisfaction and thus may not account for how particular substances may alter patterns of food intake [6]. In spite of these limitations, this detailed exploration of sex differences in eating disorder risk among several psychiatric comorbidities in a nationally representative sample yielded novel clinical findings including substances most likely to be used in relationship to binging and dieting behaviors. In addition, the results suggest that problem gambling, use of inhalants and steroids, as well as suicide thoughts and attempts that are rarely studied in relationship to eating disorder risk warrant further investigation. Acknowledgments/Disclosure of Conflicts This project was supported by a Langara College Research Committee grant. The opinions expressed in this paper do not represent the opinions of Statistics Canada, the agency providing the data for this investigation. References [1] Blinder BJ, Cumella EF, Sanathara VA. Psychiatric cormorbidites of female inpatients with eating disorders. Psychosom Med 2006;68:454–62.
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