Retrospective Maternal Report of Early Eating Behaviors in Anorexia Nervosa
1Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University, Richmond, Virginia
2Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill North Carolina
3Semel Institute for Neuroscience & Human Behavior, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, California
4Department of Psychology, Michigan State University, East Lansing, Michigan
5Department of Psychiatry, University of Maryland School of Medicine, Baltimore, Maryland
6Roseneck Hospital for Behavioral Medicine, Prien, Germany and Department of Psychiatry, University of Munich (LMU), Munich, Germany
7New York Presbyterian Hospital-Westchester Division, Weill Medical College of Cornell University, White Plains, New York
8Eating Recovery Center, Denver, Colorado
9Department of Psychiatry, The Toronto Hospital, Toronto, Canada
10Department of Clinical Neuroscience and the, Neuropsychiatric Research Institute, Fargo, North Dakota
11Department of Psychiatry, Institute of Psychiatry, Kings College, London, United Kingdom
12Department of Psychiatry, University of Pennsylvania, School of Medicine, Philadelphia, Pennsylvania
13Department of Psychiatry, University of California, San Diego, California
14Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
The relation between early feeding problems and eating behaviors and subsequent disordered eating remains unclear (Jacobi, Hayward, de Zwaan, Kraemer, & Agras, 2004
). Several longitudinal studies have provided evidence that childhood feeding problems and eating behaviors are associated with the later development of eating pathology (Kotler, Cohen, Davies, Pine, & Walsh, 2001
; Marchi & Cohen, 1990
). For example, Marchi and Cohen (1990)
found that maternal reports of picky eating and digestive problems in childhood were predictive of anorexia nervosa (AN) symptomotology in early adolescence and that maternal report of picky eating in early adolescence was predictive of AN symptomatology in later adolescence. On the other hand, maternal reports of pica and digestive problems in childhood were associated with bulimia nervosa (BN) symptomatology in later adolescence. In this same cohort, Kolter et al. (2001)
found that maternal reports of eating conflicts, struggles around meals, and unpleasant meals during childhood were associated with the development of broadly defined AN (amenorrhea not required) during adolescence or young adulthood, and that maternal report of eating too little in childhood was modestly protective for the development of BN across this same interval.
Cross-sectional studies have also revealed associations between early feeding problems and eating behaviors and disordered eating (Micali et al., 2007
; Nicholls & Viner, 2009
; Råstam, 1992
). For example, maternal report of infant feeding problems has been linked to self-reported lifetime AN by age 30 (Nicholls & Viner, 2009
) and retrospective maternal report of early gastrointestinal problems has been associated with AN in adolescence (Råstam, 1992
). In addition, individuals with BN have been described by their mothers as eating a lot, eating more quickly, and being less picky between the ages of six and ten compared to their healthy sisters (Micali et al., 2007
In contrast, several investigations have failed to find an association between maternal report of early feeding problems and eating behaviors and later AN (Shoebridge & Gowers, 2000
) and BN (Mitchell, Boutacoff, & Wilson, 1986
). Micali et al., 2007
found no evidence that childhood eating difficulties predicted AN when comparing affected and unaffected sisters. Thus, the association between early feeding problems and eating behaviors and subsequent disordered eating remains somewhat ambiguous and additional studies are needed to complete our understanding of the developmental nature of these disorders. Nonetheless, it is plausible that differential early manifestations of eating behavior may presage or influence the course and expression of later eating disorder symptoms, impacting not only diagnosis (AN vs. BN), but also behavioral symptoms characteristic of diagnostic subtypes (e.g., AN restrictive subtype vs. AN binge-purge subtype).
AN presents as either the restricting or binge-purge subtype and some individuals with AN report purging in the absence of binge eating. Diagnostic crossover between subtypes does occur, typically within the first three to five years of illness and many patients retain their initial subtype profile throughout the course of illness (Bulik, Sullivan, Fear, & Pickering, 1997
; Strober, Freeman, & Morrell, 1997
; Tozzi, et al., 2005
). Yet, a complete understanding of diagnostic fluidity has not yet been reached.
The purpose of this exploratory study was to examine associations between AN subtype and retrospective maternal report of early feeding, picky eating, and gastrointestinal problems. In this secondary analysis, we hypothesized that childhood picky eating would be associated with the restricting subtype of AN as such early experiences could contribute to an eating avoidance pattern or a tolerance for hunger. We also hypothesized that infant gastrointestinal problems would be more commonly associated with AN subtypes characterized by purging symptomatology.
Of the 325 women included in this study, 154 (47.4%) were classified as RAN, 93 (28.6%) as PAN, and 78 (24.0%) as AN-B. The mean (standard deviation) age of eating disorder onset was 16.4 (3.2) years and mean duration of AN up to the time of enrollment was 7.2 (6.1) years. At the time of interview, the average age of participants was 25.5 (8.0) years. No across group differences existed for age (χ2 = 3.48; p < .07) or age of eating disorder onset (χ2 = 3.62; p < .06). Duration of eating disorder was different across AN subtypes (χ2 = 8.06; p < .005) with the RAN group having the shortest duration, 6.1 (5.6) years, followed by the AN-B group, 8.2 (6.3) years and the PAN group, 8.3 (6.3) years.
presents the frequencies of the variables from the childhood feeding questionnaire. The majority (77.7%) of the women in this sample was breastfed and 86.5% of individuals were introduced to solid food prior to seven months of age. Overall, 11.6% of women in this sample were described by their mothers as picky eaters at least once a week between the ages of one and five and 14.5% of individuals were reported to have experienced infant vomiting. presents the results of the multinomial logistic regression models. No measure of infant feeding, childhood picky eating, or infant gastrointestinal problems predicted AN subtype.
Frequencies, n (%), for responses to infant and childhood questionnaire items by anorexia nervosa subtype
Results, χ2 (p-value), from the multinomial logistic regression models predicting anorexia nervosa subtype from measures of infant feeding, childhood picky eating, and infant gastrointestinal problems.
Finally, as we were unable to account for the non-independence of the data due to the inclusion of affected relatives in the multinomial logistic regression analyses, we randomly selected a subsample of unrelated participants (n = 165) and applied the analyses to this subset. The results remained unchanged (not shown).