Elsevier

Appetite

Volume 95, 1 December 2015, Pages 544-553
Appetite

A new social-family model for eating disorders: A European multicentre project using a case–control design

https://doi.org/10.1016/j.appet.2015.08.014Get rights and content

Highlights

  • •

    Our socio-family model operated uniquely for eating disorder sub-types.

  • •

    Verbally abusive parents were related to eating disorders with bulimic symptoms.

  • •

    Influences from the family and the media had a broad impact in EDNOS and controls.

  • •

    Prevention should be tailored to diagnosis-specific eating disorder profiles.

Abstract

Objective

To examine a new socio-family risk model of Eating Disorders (EDs) using path-analyses.

Method

The sample comprised 1264 (ED patients = 653; Healthy Controls = 611) participants, recruited into a multicentre European project. Socio-family factors assessed included: perceived maternal and parental parenting styles, family, peer and media influences, and body dissatisfaction. Two types of path-analyses were run to assess the socio-family model: 1.) a multinomial logistic path-model including ED sub-types [Anorexia Nervosa-Restrictive (AN-R), AN-Binge-Purging (AN-BP), Bulimia Nervosa (BN) and EDNOS)] as the key polychotomous categorical outcome and 2.) a path-model assessing whether the socio-family model differed across ED sub-types and healthy controls using body dissatisfaction as the outcome variable.

Results

The first path-analyses suggested that family and media (but not peers) were directly and indirectly associated (through body dissatisfaction) with all ED sub-types. There was a weak effect of perceived parenting directly on ED sub-types and indirectly through family influences and body dissatisfaction. For the second path-analyses, the socio-family model varied substantially across ED sub-types. Family and media influences were related to body dissatisfaction in the EDNOS and control sample, whereas perceived abusive parenting was related to AN-BP and BN.

Discussion

This is the first study providing support for this new socio-family model, which differed across ED sub-types. This suggests that prevention and early intervention might need to be tailored to diagnosis-specific ED profiles.

Section snippets

Sociocultural influences of eating pathology

The tripartite influence model (Thompson, Coovert, & Stormer, 1999) is one model of sociocultural influences, which proposes that three areas of influence (family, peers and the media) are important predecessors in the development of eating pathology. These three influences are also thought to affect body dissatisfaction indirectly, via two processes: (i) internalization of unrealistic and in many cases unattainable appearance standards (the thin ideal) and (ii) increased appearance comparison.

Parenting behaviours and eating pathology

Despite being comprehensive, the tripartite influence model does not address the role of parenting styles in affecting pressures from the family. The literature on parenting styles and EDs has generally found that compared to healthy controls, ED patients report that their parents displayed significantly lower levels of care, increased level of overprotection (Caglar-Nazali et al., 2014) and more critical comments about weight and shape (Tetley, Moghaddam, Dawson, & Rennoldson, 2014). However,

Differences in the socio-family factors across ED sub-types

Whereas several reviews (Jacobi et al., 2004, Rikani et al., 2013) have inferred similarities in the sociocultural and parental risk factors for the different ED sub-types, other studies (Hilbert et al., 2014, Machado et al., 2014) have revealed differences in these risk factors across Anorexia Nervosa (AN) and Bulimia Nervosa (BN). BN patients have, for instance, been found to be especially influenced by a history of dieting, childhood obesity, abusive relationships (including abusive

The current study

The present study was part of the Fifth European Framework project on “Healthy Eating”, a collaboration of eight countries with the common task of examining the individual and environmental factors related to EDs (Krug et al., 2013, Penelo et al., 2011). The main aim of the current study was to assess a new socio-family model for EDs using a large sample of clinical ED patients and healthy controls from four European countries (UK, Spain, Italy, and Slovenia). A further aim was to assess

Participants

The present study was part of a larger European Project “The Healthy Eating Project”, which employed a case–control design comprising a total of 1264 female participants (653–ED; 611-healthy controls). Four centres from four European countries (Spain, UK, Slovenia, and two for Italy) participated in the current study: the University Hospital of Bellvitge, Barcelona, Spain; the Eating Disorders Research Unit, Institute of Psychiatry, London, UK; the Department of Neurosciences, University of

Sociodemographic characteristics

Table 1 contains the sociodemographic characteristics for the total sample stratified by total ED patients, ED sub-types, and controls. Significant differences for all sociodemographic measures were obtained between the ED patients and the controls, with the exception of highest education level for participants and mother's highest education. The ED patients were significantly older and were more commonly employed than the healthy controls, which may account for the fact that more controls than

Discussion

The current study is the first to assess a new socio-family model in a clinical ED population from four European countries (UK, Spain, Italy and Slovenia). When the model was assessed for the overall sample using ED sub-types as a categorical outcome, we found that perceived influences from the family and the media were directly related to all ED sub-types. Conversely, peer influences were found to be directly related only to AN-BP and BN. Perceived influences from the family, peers and the

Limitations of the study

The results of the current study should be interpreted in the context of several important limitations. Primarily, the design was cross-sectional (with retrospective assessments) therefore temporal precedence and causation cannot be established. There may also be recall bias. It should also be noted that the parenting variables were the perception of the participants not the parents themselves. Secondly, it is possible that although we characterised the model as describing the onset of EDs, a

Implications and future research

Possible differences in our socio-family model across ED sub-types are interesting from a theoretical perspective, but are also important to better select high-risk individuals for targeted prevention and intervention programs. The findings from our individual socio-family models suggest that interventions aimed at reducing abusive parenting styles may be more beneficial in preventing EDs characterized by mainly bulimic symptomatology. Conversely, a focus on family and media influences may be

Conclusion

To conclude, the current study sought to assess a new socio-family model for EDs in a large case–control sample from four (UK, Spain, Italy and Slovenia) different European countries. Collectively, the current findings build on previous theory and research underscoring the importance of the three influences (family, peer and media) outlined in the tripartite influence model on the onset of clinical ED. Findings from the current study also suggest that the variables included in our socio-family

Acknowledgements

Financial support was received from the European Union (Framework—V Multicenter Research Grant, QCK1-1999-916). CIBERobn is an initiative of ISCIII.

References (55)

  • A. Tetley et al.

    Parental bonding and eating disorders: a systematic review

    Eating Behavior

    (2014)
  • T.L. Tylka

    Refinement of the tripartite influence model for men: dual body image pathways to body change behaviors

    Body Image

    (2011)
  • T.L. Tylka et al.

    Support for an expanded tripartite influence model with gay men

    Body Image

    (2012)
  • E.A. Young et al.

    Family functioning, peer influence, and media influence as predictors of bulimic behavior

    Eating Behavior

    (2001)
  • G. Abbate-Daga et al.

    Resistance to treatment and change in anorexia nervosa [corrected]: a clinical overview

    BMC Psychiatry

    (2013)
  • K.L. Allen et al.

    Maternal and family factors and child eating pathology: risk and protective relationships

    Journal of Eating Disorders

    (2014)
  • M. Anderluh et al.

    Lifetime course of eating disorders: design and validity testing of a new strategy to define the eating disorders phenotype

    Psychological Medicine

    (2009)
  • APA

    DSM-IV-TR: Diagnostic and statistical manual of mental disorders

    (2000)
  • J.L. Bakalar et al.

    Recent advances in developmental and risk factor research on eating disorders

    Current Psychiatry Reports

    (2015)
  • G.W. Cheung et al.

    Evaluating goodness-of-fit indexes for testing measurement invariance

    Structural Equation Modeling

    (2002)
  • C.G. Fairburn et al.

    Risk factors for anorexia nervosa: three integrated case-control comparisons

    Archives of General Psychiatry

    (1999)
  • M. First et al.

    Users guide for the structured clinical interview for DSM IV Axis I disorders – Research version (SCID-I, version 2.0)

    (1996)
  • D.M. Garner et al.

    The eating attitudes test: an index of the symptoms of anorexia nervosa

    Psychological Medicine

    (1979)
  • P. Groleau et al.

    Childhood emotional abuse and eating symptoms in bulimic disorders: an examination of possible mediating variables

    International Journal of Eating Disorders

    (2012)
  • S.G. Helder et al.

    The genetics of eating disorders

    Current Topics in Behavioral Neuroscience

    (2011)
  • A. Hilbert et al.

    Risk factors across the eating disorders

    Psychiatry Research

    (2014)
  • C. Jacobi et al.

    Coming to terms with risk factors for eating disorders: application of risk terminology and suggestions for a general taxonomy

    Psychological Bulletin

    (2004)

    • Cited by (14)

    View all citing articles on Scopus
    1

    Joint senior authors.

    View full text
    Copyright © 2015 Elsevier Ltd. All rights reserved.