Identification of high risk and early stage eating disorders: first validation of a digital screening tool

Background Eating disorders are amongst the deadliest of all mental disorders, however detection and early intervention rates remain extremely low. Current standardised screening questionnaires can be arduous or confronting and are ill-validated for online use, despite a universal shift to digital healthcare. The present study describes the development and pilot validation of a novel digital screening tool (the InsideOut Institute-Screener) for high risk and early stage eating disorders to drive early intervention and reduced morbidity. Methods We utilised a mixed cross-sectional and repeated measures longitudinal survey research design to assess symptom severity and recognised parameters of statistical validity. Participants were recruited through social media and traditional advertising, and through MTurk. An Eating Disorders Examination Questionnaire (EDE-Q) global score of 2.3 and assessment of eating disorder behaviours was used to determine probable ED. 1346 participants aged 14–74 (mean [SE] age 26.60 [11.14] years; 73.8% female, 22.6% male) completed the survey battery. 19% were randomised to two-week follow-up for reliability analysis. Results Strong positive correlations between the IOI-S and both the EDE-Q global (rs = .88) and SCOFF (rs = .75) total score were found, providing support for the concurrent validity of the scale. Inter-item correlations were moderate to strong (rs = .46–.73). Correlations between the IOI-S and two measures of social desirability diverged, providing support for the discriminant validity of the scale. The IOI-S demonstrated high internal consistency (α = .908, ω = .910) and excellent two-week test–retest reliability (.968, 95% CI 0.959–0.975; p ≤ 0.1). The IOI-S accurately distinguished probable eating disorders (sensitivity = 82.8%, specificity = 89.7% [AUC = .944], LR+ = 8.04, LR− = 0.19) and two stepped levels of risk. Conclusions and relevance The present study provides excellent initial support for the psychometric validity of the InsideOut Institute digital screening tool, which has the potential to streamline early intervention in the hopes of reducing current high morbidity and mortality. Further validation should be undertaken in known clinical populations. Plain English Summary Eating disorders are amongst the deadliest of all mental disorders, however detection and early intervention rates remain extremely low. The present study describes the initial psychometric validation of a novel digital screening tool (the InsideOut Institute Screener) for high risk and early stage eating disorders, for self-referral and/or use in primary care. 1346 participants aged 14–74 of all genders completed a survey battery designed to assess common parameters of statistical validity. Strong support was found for the screener’s ability to accurately measure eating disorder risk and symptomatology. The screener was highly positively correlated with a well known and extensively validated long form self-report questionnaire for eating disorder symptomatology. This study is a pilot validation and the genesis of a project that aims ultimately to drive early intervention leading to reduced morbidity and mortality rates in this illness group.

Eating for numbing: a community-based study of trauma exposure, emotion dysregulation, dissociation, body dissatisfaction and eating disorder symptoms

Objective The current study tests the relationship between eating disorder (ED) symptoms and trauma exposure. The mechanisms via which trauma is related to ED symptoms have not been sufficiently examined. This study examines the complex role of dissociation and emotional dysregulation in the context of trauma, BMI, ED symptoms and body dissatisfaction (BD). We hypothesized that dissociation and emotional dysregulation would mediate the relationship between trauma exposure and ED symptoms/BD. We further hypothesized that BMI would play a moderating role in this association. Method A community sample of 229 (16.2% male) participants, with a mean age of 29.08 ± 10.68 reported online on traumatic events (Life Events Checklist), dissociation (Dissociative Experiences Scale-II), emotional dysregulation (Difficulties in Emotional Regulation Scale), ED symptoms (Eating Disorders Examination-Questionnaire) and BD (Figure Rating Scale). Results Participants reported experiencing a mean of 2.87 ± 2.27 traumatic events, with a relatively high percentage (~86%) reporting at least one. The most commonly reported traumatic events were transportation accidents and physical assault. Although frequency of traumatic events did not directly predict ED symptoms, BMI, dissociation, emotional dysregulation and BD did. An SEM model showed that traumatic events predicted ED symptoms indirectly through dissociation, emotional dysregulation and BMI. Dissociation and emotional dysregulation predicted ED symptoms directly. BMI also moderated the association between traumatic events and both ED symptoms and BD. Conclusions Therapists treating patients with high BMI or obesity should be aware of these relationships and investigate the possibility that trauma and/or PTSD may underlie the presenting disordered eating or eating disorder.

Eating Disorder Examination Questionnaire (EDE-Q-13): expanding on the short form

Objective The Eating Disorders Examination–Questionnaire (EDE-Q) is widely used but time-consuming to complete. In recent years, the advantages and disadvantages of several brief versions have therefore been investigated. A seven-item scale (EDE-Q-7) has excellent psychometric properties but excludes items on bingeing and purging. This study aimed to evaluate a thirteen-item scale (EDE-Q-13) including items on bingeing and purging. Method Participants were 1160 (188 [11.4%] males) community volunteers of mean age 28.79 ± 9.92. They completed the full EDE-Q in Hebrew, as well as measures of positive body experience, social and emotional connection, life satisfaction, positive and negative affect and positive eating. The six EDE-Q items about bingeing and purging, recoded to correspond to the response categories of the other EDE-Q questions, were added to the EDE-Q-7, resulting in the EDE-Q-13. Results Confirmatory factor analysis confirmed the hypothesized EDE-Q-13 structure, including the bingeing and purging subscales. Strong positive correlations were found between the EDE-Q-13 and the original EDE-Q scores. The EDE-Q-13 showed convergent validity with related measures. Conclusions The EDE-Q-13 in Hebrew is a brief version of the EDE-Q that includes bingeing and purging subscales and has satisfactory psychometric properties. Its use in clinical and research contexts is encouraged.

Establishment of a Japanese version of the Sick, Control, One Stone, Fat, and Food (SCOFF) questionnaire for screening eating disorders in university students

Objective This study aimed to validate the Sick, Control, One stone, Fat, and Food (SCOFF) questionnaire in relation to the Eating Disorders Examination Questionnaire (EDE-Q) and to examine the appropriateness of a question concerning weight loss among Japanese university students. The psychometric properties of the two Japanese versions were determined among 649 Japanese college students. The original version (SCOFF-O) employed the original item 3, whereas the revised version (SCOFF-2.5) modified the item to “Have you recently lost more than 2.5 kg within three months?” Validity was tested relative to EDE-Q. Results The test–retest reliabilities of SCOFF-O and SCOFF-2.5 were 0.52 and 0.57, while the correlations of SCOFF-O and SCOFF-2.5 with EDE-Q were r = 0.53 and r = 0.56. The sensitivity and specificity of SCOFF-O were 65.2 and 89.7, and those of SCOFF-2.5 were 69.5 and 86.5, respectively. There were significant correlations between the question concerning losing 2.5 kg and the EDE-Q subscales. The Japanese version of SCOFF-2.5 is an appropriate tool for the early screening of eating disorders among Japanese university students.

Community norms for the eating disorder examination questionnaire (EDE-Q) among cisgender bisexual plus women and men

Purpose Cisgender bisexual plus (including bisexual, pansexual, and polysexual) women and men experience unique health concerns including eating disorders. The purpose of this study was to develop community norms for eating disorder attitudes and disordered eating behaviors in cisgender bisexual plus women and men using the Eating Disorders Examination Questionnaire (EDE-Q). Methods Participants were cisgender bisexual plus women (n = 462) and men (n = 93) participants in The PRIDE Study, an existing study of sexual and gender minority people. Results Mean and standard deviation of EDE-Q scores among cisgender bisexual plus women and men, respectively, were: Global (1.75 ± 1.26, 1.56 ± 1.18), Restraint (1.34 ± 1.44, 1.42 ± 1.53), Eating Concern (0.96 ± 1.13, 0.63 ± 0.96), Weight Concern 2.27 ± 1.55, 1.89 ± 1.46), and Shape Concern 42 ± 1.62, 2.30 ± 1.57). Among cisgender bisexual plus women and men, respectively, 27.5% and 22.6% scored in the clinically significant range on the Global score. Bisexual plus women and men reported any occurrence (≥ 1/28 days) of dietary restraint (19.3%, 23.7%), objective binge episodes (11.1%, 10.8%), excessive exercise (4.5%, 5.4%), self-induced vomiting (1.7%, 0.0%), and laxative misuse (0.4%, 1.1%), respectively. A lower percentage of age-matched cisgender bisexual plus women (18–25 years) reported any occurrence of objective binge episodes, self-induced vomiting, laxative misuse, and excessive exercise than previously published in young women. Age-matched cisgender bisexual plus men (18–26 years) reported higher weight concern subscale scores than previously published in young men. Conclusions These norms should aid clinicians in applying and interpreting the EDE-Q scores of cisgender bisexual plus women and men. Level of evidence Level V: cross-sectional descriptive study

Eating Disorder Examination Questionnaire (EDE-Q-13): Expanding on The Short Form

Objective: The Eating Disorders Examination–Questionnaire (EDE-Q) is widely used but is time-consuming to complete. In recent years, the advantages and disadvantages of several brief versions have therefore been investigated. A seven-item scale (EDE-Q-7) has excellent psychometric properties but excludes items on bingeing and purging. This study aimed to evaluate a thirteen-item scale (EDE-Q-13) including items on bingeing and purging. Method: Participants were 1,160 (188; 11.4% males) community volunteers aged 28.79±9.92. They completed the full EDE-Q and measures of positive body experience, social and emotional connection, life satisfaction, positive and negative affect and positive eating. The six EDE-Q items about bingeing and purging, recoded to correspond to the response categories of the other EDE-Q questions, were added to the EDE-Q-7, resulting in the EDE-Q-13. Results: Confirmatory factor analysis confirmed the hypothesized EDE-Q-13 structure, including the bingeing and purging subscales. Strong positive correlations were found between the EDE-Q-13 and the original EDE-Q scores. The EDE-Q-13 showed convergent validity with related measures. Conclusions: The EDE-Q-13 is a brief version of the EDE-Q that includes bingeing and purging subscales and has satisfactory psychometric properties. Its use in clinical and research contexts is encouraged.

How women with and without eating disorders perceive their own and others’ bodies: a case-control study

Background: Body dissatisfaction is a key part of the psychopathology of eating disorders, but there is a lack of consensus as to whether the dissatisfaction arises from misperception of body size, and if such misperception applies to others’ as well as own size. Methods: We conducted a case control study of women with and without an eating disorder, confirmed using the Eating Disorders Examination. We used a range of measures to investigate differences between groups in their perception of others’ and own body size, and satisfaction with own size, including rating photographs of other women, manipulating an avatar to “own” and “ideal” size, and novel implicit measures (Lexical Decision and Implicit Association Tasks). Results: We recruited 30 cases and 30 controls. Cases rated 12% more photographs of other women as overweight and 7% fewer as underweight, even after adjusting for participant BMI. We found no evidence for a difference between groups in the accuracy of their avatar representation of own size, but cases rated themselves as larger using a VAS scale and had a smaller avatar-demonstrated “ideal BMI” (case ideal BMI: 15.5 (95% CI 14.1, 16.9); control ideal BMI: 21.6 (95% CI 21.6 (20.4, 22.8)). We found no strong evidence for between-group differences on implicit measures. Discussion: Our results suggest that people with eating disorders are equally accurate at judging size, but have lower set points for their view of “normal weight” than controls. This lower threshold for what constitutes “normal” weight may contribute to patients with eating disorders’ dissatisfaction with their own size.

Assessing the Clinical Utility of the Eating Beliefs Questionnaire

The Eating Beliefs Questionnaire (EBQ) is a valid and reliable self-report tool measuring positive and negative beliefs about binge eating. This study sought to further investigate the clinical utility of the EBQ using a clinical binge eating sample and a healthy control comparison group. Clinical participants were 74 individuals seeking treatment for eating disorders: 38 with bulimia nervosa and 36 with binge eating disorder. Healthy controls were 114 individuals recruited from the general community. Participants all completed a test battery that included the EBQ. Diagnoses of clinical participants were confirmed using the semi-structured interview, the Eating Disorders Examination, administered by a trained clinician. The EBQ and its subscales showed good internal consistency, and significant differences between the clinical and nonclinical groups were observed for EBQ total and subscales scores, but not between the two clinical groups. Receiver operating characteristic (ROC) curve analyses revealed optimal cutoff scores for the EBQ, which demonstrated excellent sensitivity, specificity, and positive and negative predictive values. Results from this study provide further evidence in support of the EBQ’s psychometric properties. Clinical cutoff scores can be used to assess severity of binge eating-related cognitions in both research and clinical settings.

Eating Disorders in Males: A Case Series Study to Evaluate Putative Risk Factors

This case series aimed to describe the clinical features and symptomatic onset of eating disorders (EDs), to characterize male puberty development and to identify potential risk factors (RFs) for EDs and specific life events preceding ED symptoms. Ten males with current ED diagnoses participated in this study. All participants were interviewed with the Eating Disorders Examination, the Oxford Risk Factor Interview, and a semi-structured clinical interview for the evaluation of males’ puberty development. Almost all participants began their EDs with dieting. Half of the participants mentioned the development of muscle mass and experiences of embarrassment related to undressing in front of their peers. A history of peer aggression and/or teasing was the only RF experienced by all the participants.