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Several reports show that stress and psychiatric ill health are increasing in adolescents. Eating disorders (ED) and related conditions such as depression, self-injurious behaviour and suicide attempts are becoming more common, especially among young women. Eating disorders include two main categories: anorexia nervosa (self-starvation) and bulimia nervosa (binge eating and compensatory actions). These disorders do not only involve deviations in eating behaviour, but also include several severe physiological and psychiatric symptoms.
The aetiology of eating disorders remains largely unclear, and multifactorial models that integrate biological, psychological and social perspectives are necessary in the investigation of risk factors and the natural history of these conditions. The overall aim of the present thesis was to integrate bio-psycho-social aspects in the study of the aetiology and clinical course of eating disorders.
The studies included are based on two different data sets. Study I is based on the Uppsala Birth Cohort Multigenerational Study (UBCoS Multigen), a longitudinal register-based study including information about families spanning over three generations. The sample includes all men and women born at the Uppsala University Hospital between the years 1915-1929 and their descendants born up to 2002. The database is unique in enabling researchers to study intergenerational associations. The second data set is a clinical sample of severely ill, eating disorder inpatients from a specialized clinic (Study II-IV).
Our results indicate that social background can be of importance in the development of eating disorders; higher education in parents and maternal grandparents was associated with higher risk of hospitalization for ED. Further we found a higher risk of ED in women with the highest marks in school. The clinical studies showed that patients with eating disorders had higher scores on somatic stress and physiological tension, as well as on cognitive-social anxiety as compared to healthy controls. The co-morbidity with self-injurious behaviour and suicide attempts was high, especially in patients with bulimia nervosa. Among the bulimia nervosa patients low social adaptation, negative childhood environment and low childhood adjustment were more common. Biological markers as measured by cytokines showed higher levels of pro-inflammatory proteins in the patient group. Personality traits indicating anxiety and aggression were associated with increased levels of cytokines. Finally neuropsychological impairments and negative self-evaluations were common in both anorexia and bulimia nervosa.
Eating disorders are to be considered an increasing public health problem. Studies on the interplay between social factors, interpersonal variations in behaviour, and biological aspects of eating pathology are essential for a better understanding of eating disorders.

Karolinska Institutet

On a new framework for anorexia nervosa, learning to eat is central intervention; as patients regain a normal pattern of eating their problems dissolve. Mandometer®, a development of previous methods, allows simultaneous recording of eating rate and the development of satiety as well as experimental manipulation of eating rate. By measuring eating behavior during the course of a meal with this method, women were divided into those eating at a decelerated rate and those eating at a constant rate. Decelerated eaters are able to resists experimental challenges such as eating at an increased or decreased rate, but linear eaters eat more or less food in these experimental conditions. Satiety develops similarly in both decelerated and lineal eaters. Linear eaters develop a pattern of eating similar to that of anorexic patients when eating at a decreased rate, they eat less food yet experience an increase in satiety. Linear eaters can learn to eat at a decelerated rate and if they do they can resist overeating when tested to eat at a high rate. As a result of the learning, they also score lower on restrained eating, a cognitive construct thought of as a cause of eating behavior. Skipping dinner increases the linearity of eating and reduces food intake in women but has the opposite effect in men; these changes in eating behavior can be reversed by feedback on how to eat during the meal. The conditions of the school dinner in secondary schools are such that the speed of eating increases by 50% and food intake gets distorted from its normal pattern. The change can be reversed by eating in a relaxed condition or by feedback on how to eat during the meal. It is suggested that linear eating is a risk factor for eating disorders and that the risk can be reduced by practicing eating using feedback on how to eat properly.

Objective. Previous studies that have investigated the relation between binge eating and long-term outcome of bariatric surgery have shown mixed results. Does binge eating before or after bariatric surgery affect long-term BMI, health related quality of life (HRQL) or psychopathology after surgery? The objective of the present study was to address these questions that might help decide to what extent binge eating needs to be addressed in the context of bariatric surgery. Method. We assessed 173 bariatric patients, pre- to 3 years after surgery, regarding weight, binge eating, HRQL and psychopathology.Results. Binge eating, pre- and post-treatment, were unrelated to long-term BMI outcome. Binge eating post-treatment was associated with more psychopathology, and lower HRQL.Conclusion. Pre- or post-treatment binge eating does not predict long-term BMI outcome, hence exclusions from surgery for only this reason is difficult to motivate. However, results show that binge eating post-surgery is common, and is associated to more psychopathology and lower HRQL. The poor psychological health status of post-surgical patients with binge eating also motivates studies with longer follow-ups, to investigate whether post-surgical binge eating might increase the vulnerability for future weight regain and complications, beyond three years. The high rate of binge eating after surgery and its negative association with HRQL and psychopathology indicates that we need to be observant of the occurrence and potential effects of binge eating in the context of bariatric surgery.

Örebro universitet, Medicinsk fakultet.

Background: Despite a plethora of research, there are serious limitations in our 

knowledge of outcome in eating disorders. Almost all studies have been compromi- 

sed by the problem of treatment dropout or non-participation in follow-ups. There 

exists a lack of consensus in definitions of outcome and choice of outcome measures, 

and there is a dearth of studies focusing on how patients subjectively perceive reco- 

very. The overall aim of this thesis was to address problems in measuring outcome 

after treatment for eating disorders, with an emphasis on methodological issues. 

Specific areas of investigation included non-participation in long-term follow-ups, 

the role of self-image in treatment dropout, outcome among patients who drop out, 

patients’ subjective perspectives of recovery, and the impact of different methods 

of measuring outcome. 

Method: Four quantitative studies (I, II, III and V) were conducted within the frame- 

work of a large Swedish multi-centre study of eating disorders, which adopted a pro- 

spective, longitudinal and naturalistic design. Study IV was a qualitative investigation 

encompassing interviews with former ex-patients who were considered recovered. 

Results: Study I suggested that the reasons for non-participation in research were 

mainly patient related (69%). Those declining further participation in follow-ups 

were reported significantly lower levels of obsession-compulsion and anxiety, while 

those not traceable reported significantly higher levels of hostility at admission. Study 

II suggested that patients who dropped out from treatment initially presented with 

less negative self-image and fewer psychological problems compared to those who 

remained in treatment. Low levels of self-blame discriminated dropouts from com- 

pleters and remainers, and significantly predicted treatment dropout. Study III found 

no significant differences between dropouts and completers at follow-up, with the 

exception that dropouts were more dissatisfied with treatment. However, patterns of 

treatment response revealed that those who completed treatment made significantly 

greater changes in terms of reduced eating disorder symptoms, fewer psychological 

problems and a more positive self-image compared to dropouts. Study IV found 

that patients who had recovered from an eating disorder tended to describe other 

dimensions of outcome than those usually reported in follow-ups. Patients tended 

to view recovery in terms of being able to relate in a relaxed and accepting manner 

to food, their bodies, themselves as individuals, and their social environment. Some 

perceived recovery in terms of coping better with emotions, while others experienced 

themselves as healthier than people generally regarding food and weight. Study V 

applied some of the most frequently used outcome measures for eating disorders 

and found marked variations in the number of patients who could be considered in 

remission. Overall remission rates varied from 24.3% to 77.8%, depending on the 

outcome measure used. 

Discussion: The results suggest that non-participation and dropout are not unitary 

phenomena. There is also a need for greater consensus on how eating disorder out- 

come should be measured. This is necessary in order to make comparisons between 

different outcome studies meaningful, and to elucidate the overall picture of eating 

disorders outcome. 

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Anorexia Nervosa is a psychiatric illness with peak onset in ages 14-17. Most cases recover within a few years, but the illness can have a fatal outcome or long duration. Multifactor causes of anorexia nervosa include genetics, personality, family, and socio-cultural factors.

This study measures mortality, recovery from anorexia nervosa, and psychosocial outcome of patients with adolescent onset anorexia nervosa that were treated in Child and Adolescent Psychiatry in northern Sweden from 1980 to 1985. In addition, this study assesses the predictive value of background variables and studies perfectionism in relation to recovery. Finally, this study looks at how patients understand the causes of their anorexia nervosa and how they view their recovery process.

Follow ups were made 8 and 16 years after initial assessment at CAP. Quantitative and qualitative methods were used. These included a semistructured interview, DSM diagnostics of eating disorders (including GAF), and the self-assessment questionnaires EDI and SCL-90. The interview also contained questions about causes and recovery.

Recovery increased from 68% to 85% from first to second follow-up and the mortality rate was 1%. Somatic problems and paediatric inpatient care during the first treatment period could predict long-term outcome of eating disorders. Most former patients had a satisfying family and work situation. At both follow-ups, individuals with long-term recovery had a lower level of perfectionism than those that recovered later. On individual levels, eating disorder symptoms and psychiatric symptoms decreased during recovery, whereas the levels of perfectionism stayed the same. Causes were attributed to self, family, and socio-cultural stressors outside of the family. The most common self-reported causes were high own demands and perfectionism. All recovered subjects could remember and describe a special turning point when the recovery started and 62% saw themselves as an active agent in the recovery process. Supportive friends, treatment, activities, family of origin, boyfriend, husband, and children were also helpful in the recovery process.

Compared to other outcome studies, the results were good. In spite of the good outcome, some individuals had a long duration of illness and were not yet fully recovered after 16 years of follow-up. Predictors of non-recovery were related to initial somatic problems. Levels of perfectionism were associated to recovery and patients with initial high levels of perfectionism may need more complex treatment strategies. Results from the study also implied that one should stimulate the patients’ social contacts and their sense of self-efficacy in their recovery- process.

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Karolinska Institutet, Stockholm Negative self-image is considered typical of eating disorders. The present thesis aimed to study clinically relevant aspects of self-image in adult patients taking part in a large naturalistic and longitudinal project at specialist units for eating disorders in Sweden. Self-image was measured using the Structural Analysis of Social Behavior (SASB), and examined together with clinical and background variables at initial presentation and at follow-up. Important aspects of treatment, such as diagnosis, treatment satisfaction, outcome and dropout were the focus of four studies. In Study I, eating disorder patients were found to have more negative interpersonal profiles compared to controls. When diagnostic groups were compared, patients with anorexia nervosa were more self-controlling, self-hating and self-blaming, as well as less self-emancipated and self-loving. Patients with binge eating disorder were more self-affirming than patients with anorexia nervosa and bulimia nervosa, as well as less self-controlling than patients with anorexia nervosa and patients with atypical eating disorders. In Study II, patients who became unsatisfied with treatment were characterised by significantly more negative self-image, as well as higher levels of eating disorder and psychiatric symptoms compared to satisfied and highly satisfied patients. Unsatisfied patients expressed higher expectations of treatment interventions focusing on insight and lower expectations of interventions focusing on control. Overall satisfaction with treatment was predicted by interventions focusing on support and control of eating problems. In Study III, high levels of self-hate were significantly related to poor outcome; other variables related to poor outcome included low occupational status, problematic interpersonal relationships, eating disorder symptoms, high levels of self-emancipation, and psychiatric symptoms. In Study IV, patients who dropped out had less negative self-image and fewer psychological problems at intake compared to patients who had completed treatment or who were still in treatment; low levels of self-blame predicted dropout. Results of these studies suggest that eating disorder patients have significant problems with negative self-image. Examining self-image at initial assessment may help to identify patients at risk for negative therapeutic interactions. It may be especially important for therapists to pay attention to underlying interpersonal dynamics, to avoid being drawn into interactions that confirm negative self-image and are detrimental to treatment . Läs mer & ladda ner avhandlingen här

Researchers have recently combined clinical and cognitive areas of research in order to investigate the role of cognitive factors in explaining how emotional disorders are developed and maintained. It is believed that biased cognitive processing of emotionally relevant information can greatly affect emotional responses and behaviour where insights into such cognitive processes can have invaluable clinical implications.

The present thesis investigates the role of cognitive biases for information related to food and body appearance in individuals with eating disorders (ED) and those with non-clinically eating disorder-related concerns (NED). Are ED characterised by cognitive biases toward such information related to their specific concerns? Are such cognitive biases specific to clinical ED or present also in NED samples? Are cognitive biases operating at both conscious and unconscious levels of cognitive processing?

The tasks used to pursue these questions were: the emotional Stroop task, an Internet version of the emotional Stroop, Jacoby’s white noise paradigm and a recognition task. The influence of priming on the emotional Stroop task was also investigated in order to test whether the use of this task could be extended to more complex investigations than selective attention.

Results provide support for that cognitive processing of information related to eating and body appearance is biased in individuals with ED. It is, however, unclear whether such biased processing is specific to clinical ED. Findings further suggest that cognitive biases occur primarily at unconscious levels of cognitive processing. Support was also obtained for that the emotional Stroop task is sensitive to priming where initial body perception may be one factor influencing cognitive responses toward negative self referent words following exposure to thin ideal images. Results further suggest that the emotional Stroop task successfully can be administered via the Internet where manipulating task delivery and response mode may increase the sensitivity of this task. Some of the advantages of administering the emotional Stroop task via Internet over traditional methods are access to more heterogeneous samples, more ecologically valid situations, reduced costs and minimisation of demand characteristics.

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Background: Despite growing concern about the development of pediatric obesity, there is still controversy about its classification. International classification systems have been proposed and national systems are in use in many countries, often in parallel. Most proposed classification systems are distribution-based and not anchored to either fatness, metabolic risk or risk of adult obesity.

Aims: To assess the diagnostic accuracy of BMI, WC and W-ER for fatness, the characteristics of commonly used classification systems, and to estimate the relationship between diagnostic tests for overweight, insulin resistance and cholesterol profile.

Design: SWEDES is a prospective cohort study of 481 children followed from birth until age 17y, and their mothers. BMIdevelopment was assessed retrospectively from healthcare records, and clinical measurements at age 17y were performed. Measurements included height, weight, WC, HC, body composition (FM, FFM), and blood samples. Proposed classification systems for childhood and adolescent obesity were evaluated by use of ROC analyses. Through regression analyses, the association between different screening measures and insulin resistance (HOMA-IR) was also investigated.

Results: The IOTF/Cole classification system was found to be highly specific (0.95-1.00), but insensitive for fatness, especially in females (0.22-0.25). The outcome was shown to be fairly insensitive to the choice of gold standard to define fatness. The same characteristics remained in longitudinal analyses when using BMI at different ages as diagnostic tests for both BMI-based and FMIbased overweight in late adolescence. Using alternative measures as indicators of total fatness revealed that WC and BMI display similar diagnostic accuracy, while WHR performs significantly worse, also when evaluated against blood variables. In boys, the associations between simple anthropometric measures and insulin resistance were weaker than for detailed body composition measures, while in girls no significant associations were observed. The associations between BMI in childhood and adolescence and blood variables were non-existent or weak, implying that anchorage of classification against such outcomes may be complicated.

Conclusion: Currently proposed BMI-based classification systems for adolescent overweight are highly specific, but less sensitive for fatness as well as for metabolic risk. The awareness about the trade-offs involved in applying such classification systems should be raised, since it may affect efficiency in the usage of healthcare and public health resources. A classification system designed for international monitoring cannot be optimal for the different needs of risk group stratification in such different settings as specialized care, public health and targeted prevention. Misuse is likely to result in wasted resources as well as foregone health improvements.

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The determination of body composition is a key to the understanding of the relation between obesity and disease. In order to evaluate body composition data, reference values are needed. Since methods with high validity and reproducibility are expensive and often time consuming, simpler techniques based on anthropometry are needed. The prevalence of the metabolic syndrome is increasing. Consensus regarding a clinically useful definition of the syndrome predicting mortality and related morbidity is needed.Aims: 1) to establish population-based sex- and age-specific reference data with respect to dual energy x-ray absorptiometry (DEXA) determined body composition, 2) to examine if individual rather than fixed total body potassium/fat-free mass (TBK/FFM) ratios could improve FFM determinations, 3) to establish and validate optimal weight-for-height indices for prediction of body fat, and, 4) to analyse associations between definitions of the metabolic syndrome and mortality and atherosclerotic morbidity.Methods: 1135 men and women, 37-61 years of age from the Swedish Obese Subjects (SOS) reference study. In addition, 149 subjects aged 30-58 years from the intervention trail XENical in the prevention of Diabetes in Obese Subjects (XENDOS) were included in prediction of body fat. Body mass index (BMI) ranged from 17.6 to 46.1 kg/m2. Body composition was measured by DEXA, and TBK was determined by whole body counting. Anthropometric measurements: body weight, height, waist and hip circumferences and sagittal trunk diameter. Biochemistry: diabetes- and cardiovascular risk factors and hepatic function tests.Results: The prevalence of obesity in the SOS reference study was 10% in both men and women. At BMI 25 kg/m2, relative (absolute) body fat was 24% (19 kg) in men and 36% (25 kg) in women. Secular increases in abdominal fat distribution were observed in women but not in men. In sex-specific equations, TBK/FFM could be predicted from weight, height and age with errors <5%. Body fat in kg could be optimally and linearly predicted by weight/height (W/H) whereas percent body fat was optimally and curvilinearly predicted by BMI. Percent body fat asymptotically reached an upper maximal value of 56% in men and 52% in women. All-cause mortality was increased significantly in subjects with the metabolic syndrome according to WHO but not according to the EGIR (European Group for the study of Insulin Resistance) or the ATPIII (Adult Treatment Panel-III) definitions of the metabolic syndrome. Incident atherosclerotic morbidity was related to the WHO and EGIR definitions of the metabolic syndrome but not to the ATPIII definition.Conclusions: 1) Sex- and age-specific reference data on body composition has been provided. 2) In each sex, TBK/FFM can be predicted from age, weight and height. 3) Body fat in kg should be predicted from W/H rather than percent body fat from BMI. 4) Inclusion of glucose intolerance and/or insulin resistance as obligatory criteria in the definition of the metabolic syndrome seems to be important for the prediction of mortality and incident atherosclerotic morbidity. Läs mer & ladda ner avhandlingen här

Adolescence means an increased risk for eating disorders (ED) and the female gender is the most important risk factor. Empirical studies of the perceptions of gender ideals—as potential mediating factors between the socio-cultural context and ED—were this thesis’ primary goals. Further aims implied evaluating the psychometric properties of the Eating Disorders Inventory for Children (EDI-C) and providing normative data for boys and girls concerning self-assessed ED symptoms and related psychological traits.

The EDI-C has satisfying psychometric properties, and normative data are now provided. The vast majority of preadolescent and adolescent boys and girls (n=4725) are not preoccupied with weight concerns, but 1–3% of the boys and 9–20% of the girls here indicate feelings of anxiety and problematic attitudes. An increase of self-reported ED symptoms occurs during female preadolescence and early adolescence.

Responses to three open-ended questions—addressing perceived and personal gender ideals of adolescent boys (n=347) and girls with (n=204) and without (n=417) an ED—indicate that girls are, compared to boys, more involved in images of ideals. The perceived ideal man and ideal woman differ in body size and strength. This corresponds with different health risk behaviours reported in boys (body building) and girls (dieting). Awareness of media ideals and an ability to discriminate them from individual values was common in the normal groups and in girls who had recovered from an ED. A poor outcome was associated with thinness stated as ideals of the media, without mentioning good looks. Factors that could predict outcome at the 3-year follow-up of an ED in adolescent girls were: good looks (media ideal), maturity fears, profession (individual ideal), sexual debut, and vomiting.

The addition of a gender perspective would add a dimension to programmes aiming at preventing and treating ED in adolescence.

Obesity has become an important health problem worldwide. It increases the medical risks and affects daily living. Environmental factors such as diet and sedentary lifestyle are likely to be the cause. In Sweden, the number of obese people has nearly doubled during the past 20 years and now totals nearly 500 000. Obesity continued to increase in the Swedish population between 1996/97 and 2000/01. In economic terms, the direct health care cost may be approximately 2 % of the total expenditure for health and medical service and corresponds to a cost of approximately three billion SEK per year. The indirect cost due to absence from work and early retirement are at least equally high. The aim of this thesis was to study the effect of education, supervision of health care professionals and theimplementation and outcome of a structural behaviourally oriented psycho-educational treatment programme to motivate clinical treatment of obesity. PAPER I describes an extensive structural behavioural treatment programme based on conventional treatment of patients. PAPER II analyses the effects of education, supervision of health professionals and the introduction of a structural behavioural treatment programme, and furthermore studies what factors facilitate the implementation and start up of obesity treatment programmes. PAPER III analyses and describes the results in four different group treatment settings in Swedish health care for long-term treatment of obese subjects. The four programmes included all the behaviour modification but differed regarding components and follow Up. PAPER IV explores analyses and describes the outcome and the problem of dropout among obese o utpatients in an academic obesity unit. It also illustrates the reasons for drop out, and investigates the patients' diagnoses, attendance at group meetings and at the complementary treatment.

MAIN RESULTS AND FINDINGS. A structural behavioural treatment programme could motivate and facilitate the implementation of obesity treatment in large scale in health care and also increase the possibility for weight maintenance in the patients. Education of health care professionals is a good investment. Significantly more of those who started the behavioural treatment programme had previous theoretical education and clinical experience of obesity. Guidance and supervision of the health care professionals had a significant positive influence on starting up the treatment program. Significantly more of those who started up the behavioural treatment programme had a go-ahead from the management and support from physicians, and were part of a team or had a colleague to work with. In addition, they could also find the time to organise and plan the treatment. Education, workplace organisation, and a structural behavioural treatment programme, seem to be significant factors in facilitating and increasing the likelihood for a start. Outcome - The structural behavioural treatment programme produced a small weight reduction, maintained after two years, and the programme has been working satisfactorily as a cornerstone in different settings. The programme can be adjusted to various complementary treatments and produced weight reduction for healthy obese subjects as well as for obese subjects with medical complications. We found no significant differences between weight reduction after two years and the type of treatment studied, the amount of complementary treatment available and the number of health care professionals involved in the treatment. The effects of the complementary treatment gradually subside. After two years, the results of the weight reduction of the four treatments programmes are similar. However, this could at least partly be due to the fact that obese patients with more problems were recruited to the more comprehensive programmes. This study has highlighted the difficulties of long-term clinical treatment of obese outpatients even in the specialised obesity clinic. The findings demonstrate that educated and experienced personnel, together with an extended package of treatment options, are not enough to keep patients in treatment for two years. Even though the dropout rate was high, two thirds of the included subjects reduced their weight - a satisfactory result in a clinical setting. These results show that implementation of this structured behavioural treatment model for weight management is feasible and effective in different health care settings. Läs mer & ladda ner avhandlingen här

This dissertation consists of two cross-sectional population studies (studies I and IV), and two prospective studies (studies II and III).

In study I the relative importance of obesity for self-rated health with focus on age and gender differences were examined among 5,080 (2,366 males) participants in a national survey. Data were gathered through questionnaires. An inverse association was found between BMI and self-rated health. The relation was most pronounced among middle-aged men and women. An association between obesity and functional impairment, chronic disease and an impaired mental well-being was found for both men and women. For women there was also an association between obesity and chronic pain.

In study II a qualitative method was used to examine which factors 15 participants in a one-year behaviour modification weight reduction programme considered important for eating habits and weight change. The participants were interviewed three times during the programme and once one year after the programme had ended. The interviews were analysed with a qualitative method, grounded theory. External stimuli, stress and emotional reasons affected eating habits before the programme started and one year after the programme had ended. Non-sufficient support was another reason mentioned as reason for regain of lost weight.

In study III an association between locus of control orientation and weight loss was examined in a one-year follow up of 41 participants in a weight reduction programme. A questionnaire with 40 questions was used to assess the locus of control orientation before the programme started and one year later. There was no change in locus of control orientation after one year. The weight loss after one year was positively associated with an initial internal locus of control orientation.

In study IV a representative sample of 2,810 subjects from a population study was interviewed on sexual satisfaction, sexual abuse and life satisfaction. Age and gender were controlled for in the analyses. The older group of obese men reported a decrease in sexual desire compared with five ears earlier and the older group of overweight men reported involuntary participation in sexual activities more often than the normal weight group. Though the older group of obese women more often than the other BMI-groups were diagnosed with a lingering disease, there was no difference in satisfaction with physical health between the BMI-groups.

An inverse association between BMI and self-rated health as well as an association between obesity and impaired physical and mental well-being implies a dialogue between care taker and care giver on which treatment would match the caretaker's current needs for an improved well being. The results indicate that unless the factors behind an excessive eating are addressed in obesity treatment, they will obstruct the weight reduction and maintenance of lost weight. An internal locus of control orientation could be supported in weight reduction treatment. Untreated experiences of sexual trauma could be an important pre-treatment variable to consider in weight reduction programmes.

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