Advanced

Disordered eating among Swedish adolescents : Associations with emotion dysregulation, depression and self-esteem

Hansson, Erika LU (2017)
Abstract (Swedish)
Vägen till en ätstörning, som exempelvis anorexia nervosa eller hetsätningsstörning leder alltid förbi ett gränsland där energiintaget stegvis förändras. Kanske stoppar man i sig aningen mindre mat på måndagen än man gjorde på söndagen och på tisdagen lite mindre än på måndagen. Eller kanske man frivilligt stoppar fingrarna i halsen någon gång när man känner att man har ätit för mycket.
Detta gränsland kan benämnas störda ätbeteenden (disordered eating; DE) (Neumark- Sztainer, Wall, Eisenberg, Story, & Hannan, 2006; Waaddegaard, Thoning, & Petersson, 2003) och här vistas många ungdomar (Hautala et al., 2011; Herpertz- Dahlmann et al., 2008). De flesta tar sig därifrån efter en tid medan andra kanske lever ett helt liv i detta... (More)
Vägen till en ätstörning, som exempelvis anorexia nervosa eller hetsätningsstörning leder alltid förbi ett gränsland där energiintaget stegvis förändras. Kanske stoppar man i sig aningen mindre mat på måndagen än man gjorde på söndagen och på tisdagen lite mindre än på måndagen. Eller kanske man frivilligt stoppar fingrarna i halsen någon gång när man känner att man har ätit för mycket.
Detta gränsland kan benämnas störda ätbeteenden (disordered eating; DE) (Neumark- Sztainer, Wall, Eisenberg, Story, & Hannan, 2006; Waaddegaard, Thoning, & Petersson, 2003) och här vistas många ungdomar (Hautala et al., 2011; Herpertz- Dahlmann et al., 2008). De flesta tar sig därifrån efter en tid medan andra kanske lever ett helt liv i detta gränsland där inte bara energiintaget regerar, utan där individen ofta även upplever svårigheter med att reglera sina känslor, sina depressiva tankar och sin låga självkänsla. Gränslandet är därför, helt bortsett från att ibland vara språngbrädan till en ätstörningssjukdom, väl värt att undersöka för sin egen del. Av denna anledning genomfördes tre studier av sammanlagt 1265 ungdomar (54,5 % flickor), dels i syfte att undersöka förekomsten av DE, men även för att ytterligare klargöra sambanden mellan DE, emotionsreglering, depression och låg självkänsla.
I studie I utvärderades ett kortfattat instrument, kallat SCOFF (Morgan, Reid, & Lacey, 1999), som ofta används för att bedöma DE. Namnet SCOFF baseras på en akronym bestående av de springande punkterna i fem frågor rörande viktnedgång och tankar kring mat som ska besvaras med ”ja” eller ”nej”. I den första studien kartlades även hur många av ungdomarna som uppvisade någon form av DE. Det visade sig att fler flickor än pojkar hade bekymmer med DE, och dessutom i högre grad, vilket är i linje med tidigare forskning (t.ex. Hautala et al., 2008). Den inledande studien väckte även ett antal frågor rörande SCOFFs användbarhet i ungdomspopulationer som exempelvis huruvida SCOFF verkligen är en bra metod för att mäta DE och ifall endast ett ”ja”-svar (istället för två) ibland borde leda till fortsatt utvärdering om förekomsten av DE, som exempelvis påståendet om man någonsin framkallat kräkningar för att man känt att man ätit för mycket.
Bedömningen av ätstörningsproblematik bör, enligt vissa forskare, ske med hjälp av en kontinuerlig skala där man tar hänsyn till sjukdomsgrad, medan andra argumenterar för att ätstörningsproblematik skall bedömas kategoriskt, genom en uppdelning i olika sjukdomsklassificeringar (Williamson, Gleaves, & Stewart, 2005). Oavsett

tillvägagångssätt tycks varken kontinuerliga eller kategoriska modeller fånga hela ätstörningsspektrat (Williamson et al., 2005) och av denna anledning genomfördes en personorienterad analys i studie II. DE bedömdes genom en klusteranalys baserad på subskalorna tillhörande Eating Disorders Examinations Questionnaire (EDE-Q); återhållsamhet, samt bekymmer med ätandet, vikten respektive figuren. De olika grupper som formades baserat på dessa skalor relaterades sedan till förmågan till emotionsreglering, nivå av depressiva tankar och självkänsla. Fyra av sex flickgrupper (50 %) och fem av sex pojkgrupper (24 %) uppvisade poäng som låg över gränsvärdet för en ätstörning. Siffrorna pekar på en generellt hög nivå av DE vilket delvis skulle kunna ha att göra med en alltför tillåtande poäng för att avgränsa en ätstörning från DE. Likväl tyder de på en omfattande allmän problematik. De grupper som uppvisade olika former av DE hade generellt även problem med emotionsreglering, depressiva tankar och låg självkänsla även om vissa undantag fanns. Lägst självkänsla återfanns hos en grupp flickor och en grupp pojkar som båda hade poäng långt över gränsvärdena gällande figur- och viktbekymmer. Detta resultat är i linje med tidigare forskning som visat att en överdriven uppfattning om figur och vikt är starkt relaterat till låg självkänsla (Dunkley & Grilo, 2007). Ett något oväntat fynd var en grupp flickor och en grupp pojkar som båda hade höga poäng på återhållsamhet (restraint) men vars resultat ändå tydde på god emotionsregleringskompetens, fåtalet depressiva symptom och en god självkänsla.
I den tredje studien undersöktes eventuella samband mellan barns och föräldrars DE och emotionsreglering samt gemensamma måltider i familjens inverkan på barns DE. Därtill undersöktes även huruvida någon del av föräldrarnas beteende skulle kunna användas för att förutsäga sannolikheten för DE hos barnen. Resultaten i den tredje studien visade att DE är ett större problem i ungdomsåren än hos vuxna vilket påvisats tidigare (t.ex. Neumark-Sztainer, 2005; Büyükgöze‐Kavas, 2007). Vidare visade både ungdomarna och föräldrarna en svag association mellan DE och emotionsreglering.Gällande emotionsreglering så fanns det vissa likheter mellan föräldrarna och barnen, men de såg lite olika ut beroende på barnets kön. Till exempel var föräldrarnas emotionsregleringsstrategier associerade till flickornas emotionsregleringsstrategier, impulskontroll och känslomässiga mål, men endast till pojkarnas emotionsregleringsstrategier. Endast det familjegemensamma middagsmålet var relaterat till barnens DE och emotionsreglering, och slutligen visade studie III att förekomsten av en ätstörning hos föräldern var det enda som ökade sannolikheten för DE hos barnet.
Sammanfattningsvis visade resultaten att många ungdomar, framför allt flickor, men även pojkar, lider av DE och även att DE är associerat med sämre emotionsreglering, fler depressiva tankar och en lägre självkänsla. Det visade sig också att de instrument som idag finns att tillgå sannolikt inte är optimala för att utvärdera förekomsten av DE. Som ett exempel på detta är det tveksamt om det verkligen kan vara okej att svara ”ja” på frågan om man någonsin framkallat kräkningar för att man känt sig obekvämt mätt utan att detta leder till ett besök hos skolhälsovården. Resultaten visade också på vikten av att inte se DE som ett tillstånd utan det finns stora skillnader i problematik även mellan olika grupper av samma kön. Dessa skillnader kan vara betydande vid utformandet av olika strategier för att kunna hjälpa ungdomarna.
Föräldrarnas roll i DE visade sig också vara av betydelse men mer forskning krävs, gärna i en specifikt svensk, eller åtminstone nordisk kontext där föräldraansvaret är jämnare fördelat än i de flesta andra länder. (Less)
Abstract
The path to an eating disorder (ED) always leads through a borderland, which, in this thesis, is referred to as disordered eating (DE) (Neumark-Sztainer, Wall, Eisenberg, Story, & Hannan, 2006; Waaddegaard, Thoning, & Petersson, 2003). In this borderland, people tend to make unhealthy eating choices, such as greatly reducing their food intake, self-inducing vomiting, or engaging in binge eating, but not to the extent that they would receive an ED diagnosis. Nevertheless, DE can have a strong negative effect on psychological health. Approximately 15%–52% of all adolescents, depending on the gender and the study’s focus, are found within the borderland between a healthy diet accompanied by psychological well-being and full-blown ED... (More)
The path to an eating disorder (ED) always leads through a borderland, which, in this thesis, is referred to as disordered eating (DE) (Neumark-Sztainer, Wall, Eisenberg, Story, & Hannan, 2006; Waaddegaard, Thoning, & Petersson, 2003). In this borderland, people tend to make unhealthy eating choices, such as greatly reducing their food intake, self-inducing vomiting, or engaging in binge eating, but not to the extent that they would receive an ED diagnosis. Nevertheless, DE can have a strong negative effect on psychological health. Approximately 15%–52% of all adolescents, depending on the gender and the study’s focus, are found within the borderland between a healthy diet accompanied by psychological well-being and full-blown ED (e.g. Hautala et al., 2011; Herpertz-Dahlmann et al., 2008). While most of these individuals return to a more or less healthy diet after engaging in DE for some time, others continue to engage in DE and also tend to have trouble regulating their emotions, depression, and low self-esteem. For these reasons, DE itself, apart from being a springboard to EDs, is well worth exploring.
At the outset of this thesis, an instrument assessing DE among 1265 adolescents (54.5% girls) was validated. This easily administered questionnaire, referred to by the acronym SCOFF (Morgan, Reid, & Lacey, 1999), comprises five questions assessing possible eating disturbances that are all answered using a “yes”/“no” answer format. The results showed that more girls than boys suffered from DE, and that girls also suffered from more severe DE, which is in line with previous research (e.g. Hautala et al., 2008). Additionally, this assessment of the SCOFF gave rise to the question of whether a positive answer on only certain items (instead of the stipulated cut-off of two) is necessary for indicating the possible presence of DE among adolescents, such as the item assessing whether individuals had ever vomited because they felt uncomfortably full.
To further explore DE among adolescents, a person-oriented approach to identify specific patterns of DE based on the subscales of the Eating Disorders Examination Questionnaire (EDE-Q) (restraint, eating, weight, and shape concerns) was used. There were six different DE patterns for both boys and girls. The associations of these patterns with emotion dysregulation, depressive symptoms, and self-esteem, which all are related to DE (e.g. Shea & Pritchard, 2007; Svaldi, Griepenstroh, Tuschen-Caffier, & Ehring, 2012), were also assessed. Four of the six girl clusters and five of the six boy clusters showed scores above the cut-off for a clinical ED on at least one of the four indicators. Furthermore, although the “non-problematic” pattern was substantial, including 50% and 76% of girls and boys, respectively, a large portion of adolescents were part of clusters reporting generally high levels of DE. This might partly have to do with my use of an overly permissive cut-off, but nevertheless indicates that a considerable amount of adolescents suffer from DE. Generally, individuals in the DE patterns showed worse emotion regulation, depressive thoughts, and self-esteem than did those in the “non-problematic” patterns. However, some exceptions were found, which emphasizes the utility of analyzing different patterns of DE, not merely severity. Specifically, both girls and boys belonging to the pattern characterized by scores well above the cut-off on shape and weight concerns reported the lowest levels of self-esteem. Moreover, girls and boys in the pattern with scores above the cut-off on restraint showed good emotion regulation skills, few depressive symptoms, and high self-esteem.
In Study III, the possible links between adolescents’ and parents’ possible DE and emotion dysregulation were explored, alongside the possible impact of shared family meals on DE. This study further examined whether it is possible to predict DE among adolescents according to their parents’ behaviors. Both DE and emotion dysregulation were found to be more frequent among adolescents than among parents. Furthermore, both adolescents and parents showed weak but significant associations between DE and emotion dysregulation, and showed similarities regarding specific aspects of emotion regulation, although the associations were gender specific. For example, parental emotional strategies were associated with girls’ emotional strategies, impulse control, and emotional goals, but only with boys’ emotional strategies. The only factor that was (weakly) associated with DE and emotion regulation among adolescents was the number of dinners that they shared with the family. Additionally, parental ED was the only predictor of current adolescent DE.
In summary, the results of this thesis showed that many adolescents, especially girls, suffer from DE as well as poor emotional regulation, depressive thoughts, and low self-esteem. This is a problem, especially given that existing instruments for evaluating DE do not seem optimal, especially for boys. For instance, answering “yes” to the question of ever having engaged in self-induced vomiting because you have felt too full is probably best followed by a visit to the school nurse. Furthermore, the results indicated the importance of viewing DE not as a singular problem, but as a collection of different problems, even among individuals of the same gender. These differences call for different strategies aimed at helping adolescents achieve a healthier diet. Finally, while the parental influence of DE was significant, more research is required, preferably in a Swedish or Nordic context, where parental responsibility is not as heavily reliant on the mother as in other countries. (Less)
Please use this url to cite or link to this publication:
author
supervisor
opponent
  • Professor Rø, Øyvind, Oslo universitetssykehus HF
organization
alternative title
Störda ätbeteenden bland svenska ungdomar
publishing date
type
Thesis
publication status
published
subject
keywords
Disordered eating, emotion dysregulation, depression, self-esteem, SCOFF, parental associations
pages
123 pages
defense location
Edens hörsal, Paradisgatan 5H, Lund
defense date
2017-06-15 13:00
ISBN
978-91-7753-328-3
978-91-7753-327-6
language
English
LU publication?
yes
id
1033975a-5c42-4ef5-9576-c88d7be6516b
date added to LUP
2017-05-12 09:08:12
date last changed
2017-05-24 10:58:57
@phdthesis{1033975a-5c42-4ef5-9576-c88d7be6516b,
  abstract     = {The path to an eating disorder (ED) always leads through a borderland, which, in this thesis, is referred to as disordered eating (DE) (Neumark-Sztainer, Wall, Eisenberg, Story, &amp; Hannan, 2006; Waaddegaard, Thoning, &amp; Petersson, 2003). In this borderland, people tend to make unhealthy eating choices, such as greatly reducing their food intake, self-inducing vomiting, or engaging in binge eating, but not to the extent that they would receive an ED diagnosis. Nevertheless, DE can have a strong negative effect on psychological health. Approximately 15%–52% of  all adolescents, depending on the gender and the study’s focus, are found within the borderland between a healthy diet accompanied by psychological well-being and full-blown ED (e.g. Hautala et al., 2011; Herpertz-Dahlmann et al., 2008). While most of these individuals return to a more or less healthy diet after engaging in DE for some time, others continue to engage in DE and also tend to have trouble regulating their emotions, depression, and low self-esteem. For these reasons, DE itself, apart from being a springboard to EDs, is well worth exploring.<br>
At the outset of this thesis, an instrument assessing DE among 1265 adolescents (54.5% girls) was validated. This easily administered questionnaire, referred to by the acronym SCOFF (Morgan, Reid, &amp; Lacey, 1999), comprises five questions assessing possible eating disturbances that are all answered using a “yes”/“no” answer format. The results showed that more girls than boys suffered from DE, and that girls also suffered from more severe DE, which is in line with previous research (e.g. Hautala et al., 2008). Additionally, this assessment of the SCOFF gave rise to the question of whether a positive answer on only certain items (instead of the stipulated cut-off of two) is necessary for indicating the possible presence of DE among adolescents, such as the item assessing whether individuals had ever vomited because they felt uncomfortably full.<br>
To further explore DE among adolescents, a person-oriented approach to identify specific patterns of DE based on the subscales of the Eating Disorders Examination Questionnaire (EDE-Q) (restraint, eating, weight, and shape concerns) was used. There were six different DE patterns for both boys and girls. The associations of these patterns with emotion dysregulation, depressive symptoms, and self-esteem, which all are related to DE (e.g. Shea &amp; Pritchard, 2007; Svaldi, Griepenstroh, Tuschen-Caffier, &amp; Ehring, 2012), were also assessed. Four of the six girl clusters and five of the six boy clusters showed scores above the cut-off for a clinical ED on at least one of the four indicators. Furthermore, although the “non-problematic” pattern was substantial, including 50% and 76% of girls and boys, respectively, a large portion of adolescents were part of clusters reporting generally high levels of DE. This might partly have to do with my use of an overly permissive cut-off, but nevertheless indicates that a considerable amount of adolescents suffer from DE. Generally, individuals in the DE patterns showed worse emotion regulation, depressive thoughts, and self-esteem than did those in the “non-problematic” patterns. However, some exceptions were found, which emphasizes the utility of analyzing different patterns of DE, not merely severity. Specifically, both girls and boys belonging to the pattern characterized by scores well above the cut-off on shape and weight concerns reported the lowest levels of self-esteem. Moreover, girls and boys in the pattern with scores above the cut-off on restraint showed good emotion regulation skills, few depressive symptoms, and high self-esteem.<br>
In Study III, the possible links between adolescents’ and parents’ possible DE and emotion dysregulation were explored, alongside the possible impact of shared family meals on DE. This study further examined whether it is possible to predict DE among adolescents according to their parents’ behaviors. Both DE and emotion dysregulation were found to be more frequent among adolescents than among parents. Furthermore, both adolescents and parents showed weak but significant associations between DE and emotion dysregulation, and showed similarities regarding specific aspects of emotion regulation, although the associations were gender specific. For example, parental emotional strategies were associated with girls’ emotional strategies, impulse control, and emotional goals, but only with boys’ emotional strategies. The only factor that was (weakly) associated with DE and emotion regulation among adolescents was the number of dinners that they shared with the family. Additionally, parental ED was the only predictor of current adolescent DE.<br>
In summary, the results of this thesis showed that many adolescents, especially girls, suffer from DE as well as poor emotional regulation, depressive thoughts, and low self-esteem. This is a problem, especially given that existing instruments for evaluating DE do not seem optimal, especially for boys. For instance, answering “yes” to the question of ever having engaged in self-induced vomiting because you have felt too full is probably best followed by a visit to the school nurse. Furthermore, the results indicated the importance of viewing DE not as a singular problem, but as a collection of different problems, even among individuals of the same gender. These differences call for different strategies aimed at helping adolescents achieve a healthier diet. Finally, while the parental influence of DE was significant, more research is required, preferably in a Swedish or Nordic context, where parental responsibility is not as heavily reliant on the mother as in other countries.},
  author       = {Hansson, Erika},
  isbn         = {978-91-7753-328-3 },
  keyword      = {Disordered eating,emotion dysregulation,depression,self-esteem,SCOFF,parental associations},
  language     = {eng},
  pages        = {123},
  school       = {Lund University},
  title        = {Disordered eating among Swedish adolescents : Associations with emotion dysregulation, depression and self-esteem},
  year         = {2017},
}