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This study examined the association between loss of control and eating disorder psychopathology in a community sample of women of Hispanic origin. Seventy-seven monolingual Spanish-speaking Latinas recruited from the community were administered the Spanish language version of the Eating Disorders Examination (S-EDE). Latinas who reported regular (at least once weekly) loss of control—through objective bulimic episodes (OBEs) and/or subjective bulimic episodes (SBEs)—with compared with Latinas who did not report regular loss of control. Latinas who reported LOC did not differ significantly from Latinas who denied LOC in age, current body mass index, or highest adult weight. Latinas who reported LOC had significantly more frequent weight cycling and significantly higher scores on all S-EDE subscales. The findings suggest that regular loss of control over eating—regardless of the amount of food consumed—may be a marker for the presence of eating disorder psychopathology.
Binge eating is a core diagnostic criterion for bulimia nervosa and binge eating disorder (BED) in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV; American Psychiatric Association [APA], 1994). The DSM-IV defines binge eating as over-eating episodes that are unusually large consumed while experiencing a sense of loss of control (LOC). In addition to binge eating, defined in certain assessment measures as objective bulimic episodes (OBEs; Fairburn & Cooper, 1993), individuals with eating disorders sometimes report LOC while eating smaller quantities of food. These latter types of eating episodes have been defined as subjective bulimic episodes (SBEs; Fairburn & Cooper, 1993).
Research examining the distinction between OBEs and SBEs has been inconclusive but has clearly raised the question of whether the presence of loss of control—regardless of the amount of food consumed—should be given more importance in the diagnosis of clinically significant binge eating. Eating by adults (Guss, Kissileff, Devlin, Zimmerli, & Walsh, 2002) and children (Theim et al., 2007) while experiencing LOC generally involves consuming more calories and fat than when not experiencing LOC. Keel and colleagues (2005) found that women with BN and women meeting all criteria for BN except for the size criterion for binge-eating did not differ in other aspects of eating disorder severity. In a community sample of women with a range of disordered eating, the two types of eating episodes with LOC (OBEs and SBEs) were not differentially associated with eating disorder or general psychopathology (Latner et al., 2007).
This preliminary study aimed to examine the potential significance of loss of control over eating in a community sample of monolingual (Spanish-speaking-only) Latinas. This is an important research avenue since obesity rates among Latinas are higher than those found among Caucasians (Ogden et al., 2006), and disordered eating associated with obesity is not uncommon in Latinas (Hrabosky & Grilo, 2007). This study, conducted completely in Spanish, aimed to contribute to the small body of literature on disordered eating in the nation’s largest, and fastest growing, minority population (Anez, Paris, Bedregal, Davidson, & Grilo, 2005).
Participants were 77 monolingual (Spanish-speaking-only) women of Hispanic origin (diverse backgrounds of Spanish-speaking countries) who responded to advertisements. Mean age was 41.5 years (SD=13.6) and mean BMI was 29.1 (SD=5.9).
Flyers written in Spanish were posted in an urban setting. The flyers invited Latinas at least 18 years of age to participate in a study of eating and health and offered $50 compensation. IRB approval was obtained and participants provided written informed consent in Spanish.
The Spanish language version of the Eating Disorders Examination (S-EDE) was administered by trained fully bilingual doctoral-level research clinicians. The S-EDE (Grilo, Lozano, & Elder, 2005), like the EDE (Fairburn & Cooper, 1993), is a semi-structured investigator-based interview that focuses on the past 28 days. The S-EDE assesses the frequency of different forms of overeating with and without subjective loss of control (LOC), and produce four subscale scores (Restraint, Eating Concern, Shape Concern, and Weight Concern) and one total score. The S-EDE demonstrated good psychometric properties (Grilo et al., 2005). The Spanish-language version of the Questionnaire on Eating and Weight Patterns-Revised (QEWP-R; Yanovski, 1993) was used to assess age when first overweight, highest adult weight, and frequency of weight-cycling (defined as number of times lost and regained 20 or more pounds).
Sixteen (21%) of the 77 participants reported regular LOC episodes on the S-EDE. Four participants reported regular OBEs but not regular SBEs, ten reported regular SBEs but not regular OBEs, and two reported regular SBEs and OBEs. Independent t-tests were used to compare individuals who reported regular (i.e., frequency of at least weekly (White et al., 2006)) LOC episodes (OBEs and/or SBEs) and those who did not. As shown in Table 1, the two groups did not differ in age, current BMI, age when first overweight, or highest adult weight. The LOC group had significantly more frequent weight cycling and higher scores on all S-EDE subscales.
Roughly 21% of a community sample of Latinas reported experiencing loss of control over eating at least once weekly. Although no differences existed in current BMI between Latinas who reported versus denied LOC, those who reported LOC had significantly more frequent weight cycling and higher scores on all S-EDE subscales. The findings for Latinas extend those recently reported for various community and clinical groups (Keel et al., 2005; Latner et al., 2007) suggesting that regular loss of control over eating—regardless of the amount of food consumed—may be an excellent marker for the presence of eating disorder psychopathology.
The findings highlight the need for future research on the importance of LOC over eating to determine best methods of assessment, diagnostic utility, and treatment. In terms of assessment, it is important to note that the reliability of existing interview and self-report methods for SBEs has been questioned (Elder & Grilo, 2007; Grilo, Masheb & Wilson, 2001). One possibility is that SBEs may naturally occur in a variable fashion, and thus the lower reliability could be due to actual fluctuations for these types of eating episodes. It could also be simply that interviewers and respondents completing assessments may struggle with labeling when overeating becomes “unusually large.” Our clinical experience is that it is often fairly clear whether respondents experience episodes of LOC and whether they overeat but that the specific quantification of number of episodes and their exact timing tends to be more challenging.
In terms of diagnostic issues, we highlight recent concerns about the high prevalence of eating disorder not otherwise specified (EDNOS). Fairburn and colleagues (2007) examined cases of EDNOS to assess whether the high prevalence (60% in their sample) could be attributed to cases that were similar to and better be categorized as anorexia nervosa, BN, or BED. Relaxing the criteria for these eating disorders made little difference except when they expanded the definition of a binge to include any episode of eating with LOC (i.e., OBEs or SBEs), the prevalence of EDNOS dropped to one third of the sample.
In terms of clinical implications, Latner et al. (2007) speculated that SBEs might be less responsive to treatment than OBEs. If so, this suggests the need to develop additional specific therapeutic strategies to target SBEs specifically. LOC also seems relevant with bariatric surgery patients. Studies that have examined binge eating in bariatric surgery patients reported low rates post-operatively (Latner, Wetzler, Goodman, & Glinski, 2004; White et al., 2006). However, these patients’ post-surgical gastric capacity makes it practically impossible to consume “unusually large” amounts. Many bariatric surgery patients who reported binge eating prior to surgery reported continued feelings of LOC post-operatively even when eating small quantities of food (Kalarchian, Marcus, Wilson, Labouvie, Brolin, & LaMarca, 2002; Niego et al., 2007).
We note this preliminary study’s limitations and strengths. Limitations include our limited sample size and reliance on a study group of Spanish-speaking-only Latinas who responded to recruitment flyers. Findings may not generalize to persons who are unwilling to participate in research, to bi-lingual Latinas who might be more acculturated, or to clinical samples. Strengths include using an established standardized interview administered by trained bilingual doctoral psychologists with a diverse group of Latinas under-represented in research.
This research was supported in part by National Institutes of Health grants: DK66555 Minority Supplement (Elder) and DK49587, DK49587S, K24 DK070052 awarded to Grilo, and by the Donaghue Research Foundation (Grilo).
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