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. 2008 Feb;13(2):105–110. doi: 10.1093/pch/13.2.105

‘I want to lose weight’: Early risk for disordered eating?

Joanne Gusella 1,, Jacqueline Goodwin 1, Erica van Roosmalen 2
PMCID: PMC2528733  PMID: 19183713

Abstract

The present study examined the risk of disordered eating and its relation to attempts to lose weight by surveying a Maritime Canadian sample of 247 girls and boys in grades 6, 7 and 8. Current attempts to lose weight were highest in grade 8 girls (41% of girls and 9% of boys) compared with grade 6 (14% of girls and 24% of boys) and grade 7 (21% of girls and 13% of boys) children. Of those trying to lose weight, 71.4% were in the average range for weight and height, 12.2% were overweight and 16.3% were obese. The Children’s version of the Eating Attitudes Test (ChEAT) was used to assess eating attitudes and behaviours, and the Rosenberg Self-Esteem Scale was used as a measure of self-esteem. The results showed that 8.5% of the children fell in the high-risk group for disordered eating (ChEAT score 20 or higher). Those in the high-risk group were significantly more likely to fear being overweight (90%), to have tried to lose weight in the past (81%), to be currently trying to lose weight (76%), and to have engaged in binge eating (38%) and self-induced vomiting (24%). The best predictor of membership in the high-risk group for girls was current attempts at weight loss and having lower self-esteem. Only two boys fell in the high-risk group. Body mass index and current weight category (underweight, average, overweight and obese) could not explain the differences between the low- and high-risk groups. Knowing that a child is trying to lose weight can aid in identifying youth at risk for disordered eating, and can provide an opportunity for preventive education.

Keywords: Adolescence, Dieting, Eating disorders, Obesity, Prevention, Risk


With their release of a global strategy on diet and exercise in 2004, the World Health Organization (WHO) moved recent debates regarding obesity and overweight from industrialized countries to a global level (1). The WHO (2) reported that the phenomena of obesity and overweight have reached disturbing levels with global impact across all ages and socioeconomic levels. Canadian research reports steady increases in weight among both adult (3,4) and paediatric populations (57) over the past 30 years. The increasing impact of obesity and overweight in terms of population health outcomes and the resulting burdens on our health care system is significant (8). With growing professional and public awareness of this mounting public health concern come questions regarding effective intervention. Professionals at the front line of health education have begun to voice concerns about potentially unhelpful or even dangerous outcomes of poorly planned obesity prevention and treatment efforts, particularly as they apply to children and adolescents. Many of these concerns focus on a lack of attention to the linkages between the prevention and treatment of obesity and eating disorders (911). A key question is whether focusing early adolescents on weight-related issues may increase the likelihood that they will engage in unhealthy methods of weight loss.

Incidence studies have suggested that one in 200 adolescent girls and young women develop anorexia nervosa. An additional 1% to 3% develop bulimia nervosa (12,13). Recent studies indicate that sensitivity to weight issues begins even earlier than adolescence. In 2000, the Nova Scotia Public Health Board (14) reported that by grade 6, one in four girls and one in 10 boys had been on a diet. These findings are in keeping with other large Canadian studies (15). In a school-based sample of girls in grades 6 to 8, 10.5% were found to be at risk of disturbed eating attitudes and behaviours, placing them at greater risk of developing an eating disorder (15); a second female sample found that 13% were at risk in roughly the same age group (12 to 14 years), and 16% were at risk in older adolescents (15 to 18 years of age) (16).

Generally, eating disorders are viewed as less prevalent in males compared with females. While this is true, there is an increased prevalence of males in ‘early-onset anorexia nervosa’, with some samples suggesting that the ratio may be 10:3 (female:male) compared with 10:1 (female:male) in older adolescents and adults (17). Genetic factors, along with pressures in the youth’s family, and social and sports environments can increase the risk of developing an eating disorder (17). Research has focused mainly on the factors that make girls vulnerable to losing weight and their methods of weight loss compared with boys. However, there are studies (18) indicating that overweight girls and boys are at an increased risk for disordered eating and weight control behaviours such as binge eating, fasting, skipping meals, inducement of vomiting, and use of diuretics, diet pills or emetics. Recent research (19) suggests that adolescent dieting is associated with weight gain in part due to an increase in binge eating among dieters. Such findings speak to the importance of including boys in our samples, and remembering that overweight children are at risk of eating disordered attitudes and behaviours in their attempts to lose weight.

Low self-esteem is one factor that has been shown to place girls at higher risk of disordered eating. In one prospective study (20), 11- to 12-year-old girls with lower self-esteem were at higher risk of developing an eating disorder by 15 to 16 years of age. In a second study (21), adolescents with higher scores on disordered eating had lower self-esteem and greater participation in health risk behaviours.

The present study examined the relationship between attempted weight loss, disordered eating attitudes and behaviours, and self-esteem in a community sample of early adolescent boys and girls in Halifax, Nova Scotia. A strength of the study is the inclusion of boys, and the young age group studied. It was hypothesized that youth who indicated they were actively engaged in attempts to lose weight at the time of the study would be more likely to endorse disordered eating attitudes and behaviours as measured by the Children’s version of the Eating Attitudes Test (ChEAT [22]). Implications of the current findings for clinical intervention with youth are discussed.

Methods

In 2002, the Halifax Regional School Board assisted the research team with recruitment across five urban, public schools. This recruitment occurred following ethics approval by both the Halifax Regional School Board and the IWK Health Centre, a regional health centre for women, children and youth in Halifax, Nova Scotia. Through the use of classroom lists, it was possible to identify a demographically representative sample for the Metro Halifax area among students in grades 6, 7 and 8. A research assistant was permitted to speak to each class about the study and to provide consent forms for students and their parents to sign. Using class lists, 561 students were identified as enrolled in the selected classrooms. Some students may have been absent on the day that the information session was conducted with students. Of those identified, 248 students returned the appropriate parent and child consent forms, and completed the survey within the 1 h class period. Only one survey was excluded due to incompletion, leaving 247 surveys for analysis.

Measures

The survey completed by the students included two standardized clinical measures – the ChEAT (22) and the Rosenberg Self-Esteem Scale (RSES [23]). The ChEAT is a 26-item, six-point, forced choice, self-report inventory in which dieting behaviours, food preoccupation, bulimia and concerns about being overweight are measured (22). It is a child-friendly, modified version of the Eating Attitude Test (EAT) designed by Garner and Garfinkel (24). ChEAT scores of 20 or more have been associated with more disturbed eating attitudes and behaviours and an increased vulnerability toward development of an eating disorder (ie, high-risk range). The ChEAT has psychometrics which resemble that of the widely used and accepted EAT scale with a solid internal and test-retest reliability. The ChEAT scale has a similar factor analytic structure to the EAT scale, and has demonstrated moderate concurrent validity with additional measures of weight management behaviours and body dissatisfaction (25,26).

The RSES (23) was also administered to this sample. This measure, widely used in previous eating disorder research, is a brief, unidimensional measure of global self-esteem that has strong reliability, acceptable convergent validity and excellent discriminate validity (27). Additional questions pertaining to demographic variables (ie, ‘What is your cultural, ethnic or family background?’), weight loss attempts (eg, ‘Are you trying to lose weight today?’ ‘Have you ever tried to lose weight?’), patterns of eating (eg, ‘In a typical day, I eat breakfast’ – with a yes or no response option), growth and development (eg, self-reported current weight and height and pubertal onset) and school environment (eg, Likert scales in response to a number of prompts such as, ‘My school encourages physical activity’) were also included in the survey. Body mass index (BMI) was calculated based on the self-reported height and weight. This method has been found to be reliable when considering weight-related morbidities and behaviours in general paediatric and adolescent samples (2730). BMI was also categorized into four weight categories according to percentiles – underweight (less than the 15th percentile), average weight (16th to 84th percentile), overweight (85th percentile or greater) and obese (95th percentile or greater) (31).

Statistical Analyses

In total, data from 247 participants were obtained. χ2 with the Yates’ correction for continuity were used to conduct comparisons when the dependent variable was a categorical variable (eg, trying to lose weight, trying to gain weight and low risk versus high risk on the ChEAT). ChEAT and RSES scores were prorated if the student completed over 75% of the answers. As a result, three student surveys were prorated on the ChEAT, and nine on the RSES. Univariate ANOVA were used when the dependent variable was continuous (ie, ChEAT, BMI and RSES). A sequential logistic regression analysis was undertaken to explore which variables were the best predictors of high-risk scores on the ChEAT, and included ‘trying to lose weight today’, self-esteem and weight categories.

Results

The present sample was comprised of 105 boys and 142 girls with an average age of 12.6±0.91 years and an age range from 11 to 15 years. This sample was representative of urban students within metropolitan Halifax – 78% Caucasian, 12% Asian and 10% African Canadian. Table 1 shows sample distributions of BMI and self-esteem scores. The BMI was calculated on 221 students because 27 students failed to report their height or weight data. Of those youth currently trying to lose weight, 71.4% were in the average range for weight, 12.2% in the overweight range and 16.3% in the obese range. As females progress through grades 6 to 8, there is a significant drop in self-esteem scores compared with male youths (P<0.05).

TABLE 1.

Characteristics of the study participants

Grade 6
Grade 7
Grade 8
Characteristic Boys (n=21) Girls (n=28) Boys (n=61) Girls (n=43) Boys (n=23) Girls (n=71)
BMI*, mean (SD) 18.42 (3.34) 18.15 (2.07) 19.89 (3.19) 19.53 (4.05) 20.40 (3.35) 20.04 (2.76)
Self-esteem, mean (SD) 33.14 (5.76) 33.75 (5.03) 33.29 (3.99) 30.36 (5.30) 34.48 (4.15) 30.79 (4.93)

*Body mass index (BMI) was calculated as weight (kg) divided by height (m2)

Disordered Eating Attitudes and Behaviour

As noted in Table 2, a significant sex by grade interaction was found (P<0.05) indicating that, although boys actually start out with higher ChEAT scores than girls in grade 6, by grade 8, girls have significantly higher scores. As reported in Table 3, 8.5% of the total sample of youth fell within the high-risk range on the ChEAT (ie, scores 20 or greater). Of the 21 youth in the high-risk group, 19 were girls and two were boys (P<0.01). A significant difference was noted between the average ChEAT scores of the low-risk and the high-risk groups (P<0.01). The sample of high-risk youth reported significantly greater levels (P<0.01) of disordered eating attitudes and behaviours in terms of a desire to be thinner, fear of being overweight, binge eating and self-induced vomiting. This was not accounted for by a difference in BMI between the two groups. In addition, youth in the high-risk group were more likely to have lower self-esteem than youth in the low-risk group (P<0.01).

TABLE 2.

Prevalence of eating attitudes and behaviours among boys and girls

Grade 6
Grade 7
Grade 8
Characteristic Boys (n=21) Girls (n=28) Boys (n=61) Girls (n=43) Boys (n=23) Girls (n=71)
ChEAT*, mean (SD) 10.29 (11.05) 6.57 (7.83) 5.30 (4.29) 6.65 (6.61) 4.83 (3.46) 10.66 (11.39)
Key ChEAT items, n (%)
 Desire to be thinner* 4 (19.05) 4 (14.29) 6 (9.84) 10 (23.26) 1 (4.35) 25 (35.21)
 Fear of overweight* 8 (38.10) 6 (21.43) 14 (22.95) 11 (25.58) 3 (13.04) 31 (43.66)
 Binge eating, NS 4 (19.05) 1 (3.57) 3 (4.92) 1 (2.33) 1 (4.35) 5 (7.04)
 Purging, NS 2 (9.52) 0 (0) 0 (0) 0 (0) 0 (0) 3 (4.23)
Weight loss attempts†‡, n (%)
 Tried to lose weight in past 6 (28.57) 7 (25.00) 19 (31.15) 17 (39.53) 7 (30.43) 47 (66.20)
 Currently trying to lose weight 5 (23.81) 4 (14.29) 8 (13.11) 9 (20.93) 2 (8.70) 29 (40.85)

Sample size is one fewer than the full sample because one respondent’s survey was incomplete.

*Sex by grade interaction (P<0.05);

Sex differences significant (P<0.05);

Grade differences significant (P<0.05). ChEAT Children’s version of the Eating Attitudes Test; NS Not significant

TABLE 3.

Prevalence of eating attitudes and behaviours by risk category

Low risk (ChEAT <20) (n=226) High risk (ChEAT =20) (n=21)
ChEAT score, mean (SD) 5.56 (4.63) 29.57 (9.68)*
Desire to be thinner, n (%) 32 (14.16) 18 (85.71)*
Fear about overweight, n (%) 54 (23.89) 19 (90.48)*
Tried to lose weight in past, n (%) 86 (38.05) 17 (80.95)*
Currently trying to lose weight, n (%) 41 (18.14) 16 (76.19)*
Binge eating, n (%) 7 (3.10) 8 (38.10)*
Self-induced vomiting, n (%) 0 (0) 5 (23.81)*
Male sex, n 103 2*
Female sex, n 123 19*
BMI, mean (SD) 19.53 (3.12) 20.90 (3.53)
Self-esteem, mean (SD) 32.65 (4.64) 27.67 (6.13)*

Sample size is one fewer than the full sample because one respondent’s survey was incomplete.

*P<0.01;

Body mass index (BMI) mean (SD) values are calculated based on sample sizes of n=203 in the low-risk category and n=18 in the high-risk category, because not all respondents indicated their current weight and/or height. ChEAT Children’s version of the Eating Attitudes Test

Weight Loss Attempts

Table 2 reports the prevalence of eating attitudes and behaviours among the sample of girls and boys. Of note, there is a significant grade and sex difference in past and current attempts to lose weight; females over time are more frequently reporting attempts to lose weight.

Predictors of High-Risk Status on the ChEAT

Table 4 reports the results of a sequential logistic regression analysis conducted to examine whether youth who were actively engaged in attempts to lose weight would be more likely to be at high risk of disordered eating attitudes and behaviour (ie, to be in the high-risk category as measured by the ChEAT). For the logistic regression, weight category was expressed as three dummy variables – underweight (less than the 15th percentile), average weight (16th to 84th percentile), overweight (85th percentile or greater) and obese (95th percentile or greater), and ‘average weight’ acted as the reference group. The risk group membership was the focus of outcome with current attempts at dieting, self-esteem and weight category scores used as predictor variables. Sex was not included as a variable because boys were under-represented in the high-risk group (n=2). On the basis of the predictor variables entered as a block, 35.1% of the variance in group membership was accounted for. Of the predictor variables, current attempts to lose weight (P<0.0001) and self-esteem scores (P<0.002) significantly predicted membership in the high-risk group. Weight category was not a significant predictor. Importantly, simply knowing that the youth was currently trying to lose weight increased their chances of being in the high-risk category by 10-fold. In a youth with low self-esteem, attempting to lose weight was even more likely to be associated with disordered eating attitudes and behaviour.

TABLE 4.

Regression analysis

Factor OR 95% CI P
Currently trying to lose weight 10.44 3.16–34.49 <0.00
Self-esteem 0.83 0.73–0.93 0.00
Weight category
 Underweight 0.00 0.00 0.99
 Overweight 3.65 0.88–15.23 0.08
 Obese 0.42 0.07–2.77 0.42
Average weight (reference) 1.00

Interpretation

The present investigation sought to explore connections among attempted weight loss, disordered eating attitudes and behaviours, and self-esteem in a demographically representative sample of grade 6 to 8 students from the Metro Halifax area. The results of the present study revealed that by grade 8, a larger percentage of girls had attempted to lose weight (66%) compared with boys (30%). Girls continued to be more likely to be currently trying to lose weight (41% of girls and 9% of boys). Significantly, 8.5% of the total sample of students fell within the high-risk range on a measure of disordered eating attitudes and behaviours. This is lower than the 13% found in a sample from three large urban Canadian cities (16). The high-risk youth were most likely to be fearful of being overweight; 24% were engaged in self-induced vomiting and 38% endorsed binge eating. BMI levels alone could not explain the significant differences in attitudes and behaviours reported between the low- and high-risk groups. Girls were significantly more likely to fall in the high-risk category compared with boys. Self-esteem levels were noted to be significantly more problematic for youth scoring within the high-risk group compared with low-risk adolescents. Current active attempts to lose weight and self-esteem scores significantly enhanced prediction of which individuals were placed within the high-risk category of the ChEAT. Interestingly, just knowing that an individual was currently attempting to lose weight at the time of the study increased the ability to predict their inclusion in the high-risk category of the ChEAT by 10-fold. The results of our analyses also suggest that being male or having higher self-esteem may be protective factors when considering which adolescents are most likely to be included in the high-risk category for disordered eating attitudes and behaviours. While being male may decrease one’s risk, there were two boys who fell into the high-risk group, reminding us that they are not immune to disordered eating, and in fact, the number of males seeking service for an eating disorder is increasing in our clinic and in other Canadian paediatric centres.

The present study adds to previous research indicating that a high percentage of students in early adolescence, particularly females, are attempting to lose weight. These findings add further evidence of the high rates of weight dissatisfaction and dieting among both children and adolescents in industrialized countries (16,18,32,33). Additionally, that 8.5% of the current sample of students, with girls far outnumbering boys, fell within the high-risk range for disordered eating attitudes and behaviours again closely mirrors previous Canadian reports of teens utilizing unhealthy means to effect weight loss (16). The finding that BMI levels were not significantly related to risk group membership on the ChEAT indicates that the perception of being fat is a most critical variable with regard to dieting and that there is evidence of dieting and disordered eating occurring across all weight classes during adolescence (34). As found in previous cross-sectional studies (18,35), our results also suggest that self-esteem difficulties are a significant correlate of young adolescents who report disordered eating attitudes and behaviours, suggesting that self-esteem enhancement strategies to help prevent disordered eating in youth within the school setting are promising ways of decreasing unhealthy weight loss strategies (36).

The girls who were at greatest risk for disordered eating attitudes and behaviours were those who were currently attempting to lose weight and had lower self-esteem. In terms of prevention, it would be important for the family physician, paediatrician or mental health professional to know when a girl is dissatisfied with her weight and trying to lose weight because this places her in a high-risk category for disordered eating, and in some cases, for developing an eating disorder. It would be false to assume that only overweight youth are trying to lose weight; in fact, 71.4% were in the average weight range. Given the lower self-esteem of girls who are at risk, it is also important to know how best to talk to them about weight, healthy eating and activity. The 2004 position statement (37) on dieting in adolescence put forth by the Canadian Paediatric Society is particularly thorough in its recommendations, including the use of Canada’s Food Guide, discouraging dieting, fasting, skipping meals, encouraging age-appropriate physical activity, doing a regular screening for dieting behaviours as a part of routine health care, and educating oneself regarding the difference between a realistic ‘healthy weight’ and ‘cosmetically desired weight’.

Strengths of the present study include the recruitment of a demographically representative community sample of Metro Halifax across three grade levels, the focus on exploring correlates of disordered eating attitudes and behaviours, and the inclusion of data on both male and female students. Possible limitations of the present study mirror those common to previous research (16) including the cross-sectional design precluding the assessment of symptoms over time, the absence of a structured diagnostic interview to diagnose clinical disorder and the small number of youth in the high-risk group. A larger sample would allow an examination of the characteristics of boys in the high-risk group.

The present study provides support for the link between attempts to lose weight and risk for disordered eating attitudes and behaviours. The results have clinical application suggesting that asking youth, in a sensitive way, whether they are satisfied with their weight or attempting to lose weight, as part of an overall screening, would provide an opportunity to educate them regarding healthy weight ranges, healthy eating and activity. Given the sensitivity of youth to their weight, the aim would be to decrease the number of youth who enter into disordered eating patterns leading to unhealthy eating and activity patterns, without doing any harm to their self-esteem. Further research examining how youth would want their physicians and paediatricians to talk to them about weight-related issues is warranted.

Acknowledgements

The authors thank the Social Sciences and Humanities Research Council of Canada for the research grant, the Halifax Regional School Board for helping to access a representative population of students in their system, Heidi MacLeod (research assistant) who administered the survey, and Public Health Nurses – Cathy Streatch and Ruth Anne Morris – who were helpful partners throughout the project.

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