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Risk for Disordered Eating Relates to both Gender and Ethnicity for College Students

Department of Food Science and Human Nutrition, College of Human Ecology (S.L.H., T.B., D.R.K.), Michigan State University, East Lansing, Michigan
Olin Health Center, Health Education Department (R.B.), Michigan State University, East Lansing, Michigan
Office of Supportive Services (B.L.), Michigan State University, East Lansing, Michigan

Address reprint requests to: Dr. Sharon Hoerr, Michigan State University, Department of Food Science and Human Nutrition, 204 G.M. Trout Bldg., East Lansing, MI, 48824. Email: hoerrs{at}msu.edu

	ABSTRACT

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS CONCLUSION REFERENCES

 
Objective: To estimate the frequency of disordered eating behaviors among college students and associations by gender, ethnicity, participation in social organizations and college athletics and to determine whether responses to eight health behavior and attitude questions and body weight predicted a high score on the Eating Attitudes Test (EAT)-26, a screening instrument used to identify risks of developing an eating disorder.

Methods: Subjects were a convenience sample of 1,899 college students (cleaned to 1620) who attended four classes, were members of 14 sororities or lived in five residence halls. Students reported height and weight and responded to the EAT-26 and eight items regarding health behaviors and attitudes.

Results: Among women and men, 4.5% and 1.4%, respectively, reported previous treatment for an eating disorder, and 10.9% of women and 4.0% of men were at risk for eating disorders (scores 20 on EAT). Among African-Americans, 8.3% of women were at risk. One group of women who lived separately in a social sorority had the highest risk of 15%. The frequency of "weight concerns interfering with academic performance" and "eliminating high fat foods" was moderately correlated to risk for disordered eating for both genders. Body mass only weakly related to risk for disordered eating and the association varied by subgroup.

Conclusion: Students at risk for disordered eating report weight concerns interfering with their academic performance and include both men and African-Americans, as well as Caucasian American women. Sorority women living in separate residences might be at increased risk.

Key words: disordered eating, gender, ethnicity, eating behaviors, sorority, athletes, college students, fat, BMI

	INTRODUCTION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS CONCLUSION REFERENCES

 
Young adulthood, especially during the transition to a college setting, can be a vulnerable time for development and/or continuation of eating disorders when parents generally have little control or influence on eating behaviors [1–3]. The prevalence of diagnosed eating disorders in various samples of college women has been reported to be 1.3% to 5% [4–5] although speculation is that the prevalence is much higher. Disordered eating patterns and weight cycling appear to be a growing issue for young men [2,5–8].

There are many reports of diagnostically, sub-threshold problems centering around dissatisfaction with body image and weight preoccupation in collegiate groups, especially females and those of European American ancestry [9,10], although males and certain ethnic groups are not protected from risk for developing eating disorders [9–13]. In one study, 6%, 25% and 30% of college students were extremely worried about anorexia nervosa or bulimia, weight control, and body image, respectively [14]. Both the risk for and prevalence of disordered eating is strongly correlated with concern about body weight, body image and extreme weight control behaviors [3,15,16]. Dieting or energy restriction has been positively associated with body weight in some studies of post-menarcheal females [9], but not in others [17]. Diagnosed bulimics and binge-eaters do present a range of body weights, but diagnosed cases are a fraction of those with restrained eating behaviors who might be at risk for disordered eating [4,5].

Peer groups can have a great deal of influence on college students’ eating behaviors [1]. Students involved in university-sanctioned activities find that certain organizations sometimes reinforce the attainment of a specific weight or size for continued participation. Within the college community there are subgroups of students sometimes at greater risk of developing or continuing eating-related problems, such as those in sororities [3] or in collegiate athletics [18].

The objectives of this investigation were as follows: 1) to estimate the frequency of disordered eating behaviors among college students, 2) to determine the association of disordered eating behaviors with the student’s gender, ethnicity, participation in social organizations and collegiate athletics and 3) to determine whether body weight and responses to eight health behavior and attitude items were associated with a high score on the Eating Attitudes Test (EAT)-26, a screening instrument used to identify risks of developing an eating disorder. Subgroup analyses were to determine differences by gender, ethnicity and participation in social organizations or collegiate athletics. Therefore, findings reported here should be useful to target interventions for both prevention and treatment.

	MATERIALS AND METHODS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS CONCLUSION REFERENCES

 
Subjects
Subjects were a convenience sample of students living in five co-educational residence halls, 14 sororities and four upper level, academic classes, three of which were health-related. (Sororities are social organizations to which the current members anonymously elect women for membership.) Three thousand surveys were distributed to students at these sites, and 2,000 were returned for a 67% response rate; 1,899 surveys were considered usable prior to data cleaning.

Procedures
A one page, two-sided, survey was adapted from materials distributed by the National Eating Disorders Screening Program [19]. Following approval from the University Committee on Research in Human Subjects, the survey was prepared for optical computer scanning and 3,000 copies were printed. Fifteen student volunteers, trained as peer health educators, and 20 residence life advisors assisted investigators with distribution and collection of surveys. In the residence halls, surveys were distributed during lunch and dinner hours outside the cafeterias. Peer health educators also distributed the surveys during several, individual, social sorority house meetings and in four academic classes. Survey respondents indicated their consent to participate in this anonymous survey by completing and returning the questionnaire that stated the following. "Participation in this study is voluntary. By completing the survey, you indicate your consent to include your responses in this study. Your responses will be completely confidential."

Returned surveys were reviewed for completeness and then electronically scanned at the university computer center. Data files were returned in ASCII format and entered by student research assistants into the Statistical Package for the Social Sciences (SPSS) software, Version 7.1 for Windows.

Survey Instrument
The original instrument from the National Eating Disorders Screening Program included 26 items from the standardized Eating Attitudes Test (EAT-26) [19–21]. These 26 items are scored using a six-item Likert scale and summed to obtain a numerical score corresponding to "risk for eating disorders." Summative scores could range from 0 = no risk to 78 = highest risk. A score 20 on the EAT-26 indicates a clinical referral is appropriate for assessment of a possible eating disorder, and we used this indicator to define "risk for eating disorder." The original instrument also contained a question about previous treatment for an eating disorder; we calculated the frequency of those responding "yes."

In addition to the EAT-26 scale and question about previous treatment for an eating disorder, the national survey instrument included four items about health behaviors related to bingeing (no, yes), purging (no, yes), use of laxatives, diet pills or diuretics for weight control (no, yes) and recent suicide thoughts or attempts (no, yes) [19]. To these items, we added six questions asked two years earlier in a similar survey. These six items and their response categories follow.

1. Do you eliminate foods based on fat gram content? With 5 point Likert response, rarely (5) to always (1).
   
2. Over the last two years, how many times have you lost and regained 10 pounds? With responses 1, 2, 3, 4, 5, other.
   
3. Do your concerns about eating or weight interfere with your relationships, i.e. avoiding family and friends to binge, purge or exercise? With 4 point Likert response, all of the time (4) to never (1).
   
4. Do your concerns about eating or weight interfere with academic work performance? With 4 point Likert response, all of the time (4) to never (1).
   
5. Women only: Have you missed two or more menstrual periods within the last six months? (Yes, no)
   
6. Height in inches (50–89 inches); Weight in pounds (0–399 pounds).
   

For demographics, ethnicity was self-defined by checking African-American, American Indian, American Asian, Caucasian-American, Hispanic American or International student. Students were asked if they participated in athletics at any of the following levels: intramural, intercollegiate or recreational. Only those indicating "intercollegiate" were identified here as college athletes. Finally, for "Affiliations and Residence," students could check student governance, Greek, on campus housing, off campus housing and Greek housing. Students referred to themselves as "Greek" when they were members of private, social organizations identified by Greek letters and for which older members anonymously select new members. "Greek" women are members of sororities and "Greek" men, of fraternities, most of which on this campus require first year members (usually second year students), to live in separate, private residences owned by the social organization.

Statistical Analysis
The investigators computed Body Mass Index (BMI = kg/m²) from the students’ reports of their height (in inches) and weight (in pounds). Some respondents (n = 100) did not report their height and weight. Eight subjects were eliminated from the dataset with heights less than 58 inches and four, with height greater than 78 inches. Thirteen people were eliminated who reported weights less than 80 pounds.

Subjects were excluded if they were missing any variable included in the regression analysis by listwise deletion (n = 226). For example, 53 subjects failed to report gender. Then, descriptive statistics were run for men and women separately and examined for differences by ethnicity, membership in social organizations and participation in athletics. Some Chi square analyses were run by gender and ethnicity for frequencies of practicing certain behaviors like bingeing. Correlation matrices by gender and subgroup identified inter-variable relationships and the nine factors or variables most likely to predict "risk for eating disorder" in multiple regression analyses. The "risk for eating disorder" from the EAT-26 score was predicted using forward, stepwise, multiple regression analysis for various subgroups, based on gender, ethnicity, sorority membership and participation in inter-collegiate athletics. The nine variables entered into the regression equations were bingeing, purging, use of laxatives, diet pills or diuretics, elimination of high-fat foods, weight cycling, eating or weight concerns interfering with social relationships, or academic/work performance, recent suicide thoughts or attempts and BMI.

	RESULTS

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS CONCLUSION REFERENCES

 
Respondents with complete datasets (n = 1620) were predominantly Caucasian (81%), female (74%), first and second year students (60%), or those who lived in residence halls (55%) (Table 1). Among women and men, 4.5% and 1.4%, respectively, had been previously treated for an eating disorder, and three times as many women than men were at risk for eating disorders, 10.9% vs. 4.0%, respectively (Table 2). Among men, the frequency of eating disorder risks tended to be the highest in those who participated in inter-collegiate athletics. Among 16 male athletes, two had vomited for weight control, and two had used diet pills. The frequency of bingeing, purging, use of laxatives/diet pills/diuretics and eliminating high-fat foods was higher in women than in men, but the frequency of weight cycling was similar for both genders. Such eating and weight concerns interfering with academic performance were reported by 17.4% of women and 10.4% of men. One-third of both women and men had lost and regained 10 pounds two or more times in the last two years. Interestingly, frequency of weight cycling was highest for men in athletics and lowest for women in athletics. Most women (70%) eliminated high-fat foods, but so did about 43% of men.

There was no significant difference in risk for disordered eating between female members of sororities (12.9%) and those not in sororities and living in residence halls (10.1%). However, the risk tended to vary among sororities with a high of 15% in one sorority where all the women lived in the house (n = 40) vs. rates in the other sororities similar to those for women who were not sorority members (data not shown). Comparisons between members of sororities and those who were not demonstrated that those in sororities reported greater use of diet pills (25% vs. 16%), elimination of high fat foods (75% vs. 68%) and weight concerns interfering with social relationships (26% vs. 20%, respectively).

The correlations between weight concerns interfering with academic performance and risk for disordered eating were significant for every group, except male athletes (Table 3). Correlations ranged from r = 0.25 for men to r = 0.58 for African-American women. About 7% of men and 9% of women reported having thoughts of suicide (Table 2). The relation of suicidal thoughts to risk for eating disorders was highest for the female athletes (r = 0.43, n = 34).

	DISCUSSION

 
Analysis of this large sample demonstrated two particular sub-groups who appeared at high risk for disordered eating: sorority women, primarily those from one sorority house, and athletes, both male and female. The 4.5% of women here who reported having been previously treated for an eating disorder is within the 1% to 5% reported in literature [4–5], although no national data on prevalence exist. Of special concern to university administrators might be that the risk for disordered eating correlated with students’ weight concerns interfering with their academic performance. Both women (17.4%) and men (10.4%) reported that their weight concerns interfered with their academic performance. If these percentages could be generalized to the entire campus, then the numbers of students at special risk for disordered eating and mental health problems could be from 2000 men to 3600 women.

Some studies have reported athletes to be at increased risk for disordered eating [22,23], while others have failed to report such risk [24]. In the present study, we did not find significantly increased risk of disordered eating in athletes (n = 50), although they tended to have higher frequencies.

Investigators of disordered eating on college campuses have examined whether one’s peer group and environmental-living preferences might foster norms in which disturbed eating patterns and distorted body image become not only acceptable, but perhaps valued. Schulken et al. found women living in sorority houses, compared to college women who were not, had a greater fear of becoming fat, greater body dissatisfaction and weight preoccupation, as well as higher concern with dieting—all behaviors which put them at risk for the development of an eating disorder [3]. However, another study compared sorority women who lived on and off campus and found no increased risk for development of bulimic behavior in communal living situations [25]. This raises the question of whether belonging to and living with a specific group, such as a sorority, causes these disordered eating and body image problems or whether students who are more prone to having high concern regarding eating, weight and body size tend to gravitate towards these memberships. Findings from our study, in which 14 separate social sororities were anonymously surveyed, suggest that it was one house in particular wherein the risk for disordered eating was an unusually serious problem. This sorority house was a social organization of Caucasian-American women. All sorority members (n = 40) lived together in their own separate residence.

About 14% of the sample in this present study reported themselves to be other than Caucasian-American. There is substantial evidence that risk for disordered eating and body dissatisfaction historically has been highest in Caucasian-Americans. However, studies show body dissatisfaction high in Asian American college women [13] and Taiwanese college students [26,27]. Body concerns might be increasing among African American women as well [9,27,28], and the social pressures on appearance in a collegiate environment make this reasonable. In this study, the frequency of risk for disordered eating and of bingeing was lowest in African-American women, a finding supported by others [29].

In a study at the University of Pittsburgh, researchers obtained similar results to ours with respect to the high frequency of eliminating foods based solely on fat content [30]. There are noted health risks for individuals consuming a diet excessive in fat, but eliminating or extremely limiting fat intake is of some concern as well [31]. The common message in the media, and often in the health field, which consumers hear is "fat is bad." This "fear" of eating certain types of foods can be a precursor for a disordered eating pattern [32]. Our results support this connection, because the elimination of high-fat foods correlated with an EAT-26 score 20.

Recently, other researchers have identified additional health behavior items correlated with EAT-26 scores, such as: "How many diets have you been on in the past year?" "Do you feel you should be dieting?" "Do you feel dissatisfied with your body size?" and "Does your weight affect the way you feel about yourself" [33]. A direct question regarding dieting behaviors, "Do you sometimes use laxatives, diuretics, or diet pills to control your weight?" did not perform as well as the other test items [33]. In our study, however, use of laxatives, diuretics or diet pills was a significant predictor only for women, while the question about purging predicted the risk for eating disorders among both women and men. The question about bingeing was significant for women rather than for men.

BMI was a significant, but very weak, predictor only for females. Disordered eating is not as related to weight status as it is to body dissatisfaction and dieting [15,26]. Also, it is possible that BMI might be a more significant predictor for risk of disordered eating among younger adolescents than young adult women in college [17]. Others have found that males are more satisfied with their bodies and weight than are females [27], just as found in this assessment. One interesting, recent study on college students in England found that it was the frame size, particularly of the lower trunk, and not fatness, which predicted young women’s weight behaviors [34]. Frame size was not examined in the present study.

Although large, the present study was limited by use of a convenience sample, which differed from the campus population and limits the generalizability of findings. The sample was not ethnically diverse and was predominately female. We do not know how non-respondents might have differed from respondents, other than by the demographics reported in Table 1. Because most data collection occurred during residence hall meals, it is unlikely, however, that students who skip meals would have participated in this survey. It would be desirable to obtain a large, representative sample of males and females, especially from different ethnic groups and from collegiate athletes for different sports. The predictors, shown in Table 3, accounted for 24% to 75% of the variance in risk for disordered eating. Other important factors operating, but not identified in this study, might be genetic predisposition, developmental synchronicity of student with peer group [35] and family communication patterns [25]. Finally, self-reported weights in epidemiological surveys tend to be under-reported by nearly five pounds by both males and females [36].

Despite these limitations, this study resulted in a high response rate from a large sample of college students permitting some assessments by sub-group. The findings of high risk for eating disorders in college women are similar to those found on other campuses [2,4–5]. Anonymous data entry by house for Greek sororities meant we could examine risk for disordered eating more specifically by environment than in previous studies. Use of a mostly standardized instrument in a short survey that could be optically scanned supports the validity of our findings, enhanced students’ participation in the survey and reduced costs of the analysis. A significant strength of this study was the collaboration and cooperation of several campus units such as student health services, student counseling, computing services, residence life staff, academic faculty and interested undergraduate students. We hope such cooperation can be an efficient prototype for other campuses to collect data, track trends and target subgroups for special attention.

	CONCLUSION

TOP ABSTRACT INTRODUCTION MATERIALS AND METHODS RESULTS CONCLUSION REFERENCES

 
Based on findings reported here, there are several major implications for nutritionists and health professionals. These implications relate to ethnicity, gender, sororities and academics.

Risk for disordered eating and body dissatisfaction influence a substantial number of collegiate men and African-Americans, as well as Caucasian-American women, and they report that such concerns impact their academic performance. Adequate resources must be available to address health problems before students become dysfunctional. Students come to college with preconceived attitudes about fat, fitness and body weight obtained from family and friends at home [25]. Providing parents with information on disordered eating at parent orientation and through campus mailings could get helpful material to both parents and students. Many parents help finance their children’s college education, but might be unaware that risk for disordered eating can interfere with academic performance. Increased awareness of factors affecting this investment might help parents recognize negative food and body image messages consciously or unconsciously passed to their children.

Finally, it may be time for nutrition professionals to call for nationally representative samples of young adults to estimate the prevalence of risk for disordered eating and its accompanying predictors by ethnicity and gender. National health nutrition objectives should not focus solely on obesity, without concomitant attention to dysfunctional behaviors young people use to manage their weight in our obesigenic environment.

Received March 22, 2001. Accepted March 25, 2002.

	REFERENCES

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