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A term paper about bulimia in teenagers.

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By: ara annie del yecyec bsn3 :

A TERM PAPER ON BULIMIA IN TEENAGERS By: ara annie del yecyec bsn3

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ABSTRACT There are few reports that describe the manifestation of bulimia nervosa (BN) among adolescents. Moreover, none make reference to the comparative clinical manifestation of adolescent BN and adolescent anorexia nervosa. Nor are any reports available of how distinct partial-syndrome BN cases are from those that meet full diagnostic criteria for BN . The objective of this study is to describe 3 groups of adolescents, those with a full-syndrome eating disorder (BN and anorexia nervosa) or partial-syndrome BN, and to compare these groups along demographic, general psychopathology, and eating disorder variables . The stu -

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dy population included adolescent participants with eating disorders. All participants completed an assessment prior to treatment. Weight and height were obtained from all participants. Participants also completed a baseline demographic questionnaire ( eg , menstrual status, ethnicity, and family status), Beck Depression Inventory, Rosenberg Self-Esteem Scale, and the Eating Disorder Examination.

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AKNOWLEDGEMENT First and foremost, the researcher would like to thank our clinical instructor, Mrs. Emily Lagura , RN for the valuable guidance and advice. He inspired us greatly to work in this project. His willingness to motivate us contributed tremendously to our term paper. Also , the researcher would like to take this opportunity to thank our families and friends for their understandings and supports on us in completing this term paper.

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Finally , an honorable mention goes to our Almighty GOD for providing her with knowledge and strength to make this term paper possible.

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Chapter 1 Introduction In the previous decade, the prevalence of eating disorders has progressively increased, whereas the severity of observed cases has progressively decreased. The substantial number of subclinical cases as well as the high prevalence of intermediate forms of dieting and eating concerns led to the continuum hypothesis that is defended by several authors. According to this hypothesis, eating disorders lie on a continuum ranging from normal eating to full-syndrome eating disorders . Studies regarding prevalence usually focus on the full-syndrome eating disorders, but less severe forms of eating disorders are believed to affect a large number of

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individuals, especially adolescent girls. According to the continuum hypothesis, subclinical levels of eating disorders differ only by degree. Those who exhibit subclinical eating disorders are considered at risk of developing full-syndrome eating disorders early recognition and swift treatment is imperative. This highlights the importance of studying the problem before the development of a full-blown disorder. In this context, it is essential to perform population-based studies that usually use self-reporting scales . High scores do not necessarily indicate a severe eating disorder; however, these scales can be useful to identify subjects at a subclinical level .

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Biological , social, familial, and psychological factors seem to be associated with eating disorders. Overweight has been studied as a cause of body dissatisfaction and eating disorders, and evidence suggests that the normative body fat increase associated with the onset of pubescence may predispose girls to eating disorders. Moreover, high social class was typically associated with eating disorders, especially anorexia nervosa. Familial and parental characteristics also have been considered significant in the development of eating disorders. Literature shows that a family's concern for weight and shape can contribute to a climate for eating disorders and parental modeling is correlated with weight-loss attempts

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and body esteem of the children. Considering psychological factors, depression and eating disorders, as clinical problems, are strongly associated. Although all of these potential determinants have been studied, conflicting results are found in the literature and more research is needed to clarify the associations between these determinants and eating disorders. Furthermore, the main body of research concerns bulimia nervosa and anorexia nervosa, which occur mainly in adolescence and late adolescence; there still is a lack of research concerning the determinant factors of milder forms of eating disorders that occur at younger ages . The aim of the present study was to evaluate the association

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of psychological, biological, social, and familial characteristics with eating disorder symptomatology in 13-year-old Portuguese adolescents.

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Chapter II METHODS PARTICIPANTS Participants were evaluated. Policies and procedures were developed to guarantee data confidentiality and protection and written informed consent was obtained both from the adolescents and their parents or legal guardians. We identified 2788 eligible adolescents (2126 in public and 662 in private schools). Forty-four (1.6%) could not be reached (missing classes during the study period) and 582 (20.9%) did not return signed consent forms and were considered refusals. This resulted in a 77.5% overall proportion of participation, similar in public and private

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schools (77.9% vs 77.0%; P = .71), with 2161 students providing information for at least part of the proposed assessment. In addition, 125 (4.5%) were excluded because of no information on key variables for this work (Eating Disorders Inventory [EDI]). The final sample includes 2036 students (1052 girls [51.7%] and 984 boys [48.3%]). MEASURES The baseline evaluation comprised 2 self-administered questionnaires and a physical examination. Physical examinations were performed at school between 8AM and 10AM. One questionnaire was completed at

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home and another was completed at school immediately before physical examination . ADOLESCENT INFORMATION At school, adolescents completed a general questionnaire comprising information on health-related behaviours. The EDI is a self-report instrument designed to measure psychological and behavioural traits associated with eating disorders. It has 64 items divided into 8 subscales. Three core subscales assess attitudes and behaviours toward weight, eating, and body shape (drive for thinness, bulimia, body dissatisfaction) and the other 5

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subscales measure general psychological features associated with, but not unique to, eating disorders (ineffectiveness, perfection, interpersonal distrust, interoceptive awareness, maturity fears). On a 6-point Likert scale, individuals indicate how each item applies to them, from "always" to "never." Scores are then weighted from 0 to 3, higher scores indicating worse symptomatology. Subscale scores are the sum of all items for that particular subscale. The EDI is a widely used instrument with good psychometric properties, and the 3 core subscales also presented good psychometric properties when used with 13-year-old adolescents.

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The BDI-II is a 21-item self-report scale that assesses the severity of current depressive symptoms and has shown good psychometric characteristics. Each item is rated on a 4-point scale from 0 to 3. The total score can range from 0 to 63, with higher scores reflecting more severe depression. The following cut-off score guidelines were pointed out: 0 to 13, minimal depression; 14 to 19, mild depression; 20 to 28, moderate depression; and 29 to 63, severe depression. The BDI-II was previously validated in a adolescent population, being considered an adequate measure of depressive symptoms in adolescents, and 13 was the cut-off indicated to define adolescents presenting depressive problems.

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The EDI subscale scores and BDI-II scores were only computed when the questionnaires had more than two-thirds of the items answered. In that case, any missing values were replaced with the mean score presented by the adolescent in each particular EDI subscale or BDI-II scale. Anthropometrics were obtained at school with the subject in light indoor clothes and no shoes. Weight was measured using a weighing scale in kilograms and height was measured in centimeters using a tape measure. Body mass index (BMI; calculated as weight in kilograms divided by height in meters squared) was classified according to the age-specific percentiles developed by the

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United States Centers for Disease Control and Prevention as at risk of overweight (BMI between the 85th and the 95th percentile) and overweight (BMI above the 95th percentile ). Because there were no physical conditions at school to assure the privacy needed to evaluate adolescents' pubertal development according to Tanner criteria, age at menarche was recorded as a pubertal development indicator for girls. PARENT INFORMATION Through the home questionnaire, parents were asked to report the number of completed years of education, clinical information (namely previous diagnosis

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of depression), current height and weight, and desired weight. Adolescents were classified, taking into account the parent with a higher level of education, and this information was used as a proxy for socioeconomic status. Exposure to parental depression was considered when at least 1 parent reported depression. Parental BMI was computed based on self-reported height and weight, and parents were classified according to the World Health Organization as normal (<25 kg/m 2 ), overweight ( 25 and 30 kg/m 2 ), or obese ( 30 kg/m 2 ). An indirect measure of body weight satisfaction was used, subtracting desired weight from the current self-reported weight. If the

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difference between current and desired weight was more than 2 kg, parents were classified as dissatisfied. DATA ANALYSIS To evaluate the association between psychological, biological, social, and familial characteristics and eating disorder symptomatology, simple linear regression was used. Drive for thinness, bulimia, and body dissatisfaction were the dependent variables, and type of school (public vs private), grade at school, age at menarche, BMI, depressive symptomatology, parents' education, mothers' and fathers' BMI (all as continuous variables), parents' depression (none vs at least 1), and mothers' and fathers' body-weight satisfaction (satisfied vs dissatisfied) were

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entered as independent variables. In the final model, multiple linear regression was used. Type of school, grade at school, age at menarche, BMI, depressive symptomatology, and parents' education were considered as potential confounders. Owing to the nonnormal distribution, a bootstrap method was applied to resample and confirm the reliability of the 95% confidence intervals (CI) obtained from the full data set. Statistical analyses were performed using SPSS version 14.0 (SPSS Inc , Chicago, Illinois) except for bootstrap analysis which was performed using R software version 8.0 (R Foundation, Vienna, Austria).

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CHAPTER 3 RESULTS Sample characteristics are presented separately for boys and girls in Table 1 . Boys' and girls' mean EDI subscale scores are compared in Table 2 . Girls presented significantly higher mean scores than boys on the drive for thinness (4.84 vs 2.61; P < .001), body dissatisfaction (7.63 vs 4.47; P < .001), and ineffectiveness (3.85 vs 2.72; P < .001) subscales. Boys presented significantly higher mean scores on the perfectionism (6.90 vs 5.66; P < .001) and maturity fears (7.12 vs 6.44; P < .001) subscales .

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Table 3 presents the 3 core EDI subscale mean scores according to adolescent characteristics. Adolescents in the lower school years with higher BMI and worst depressive symptomatology whose mothers had higher BMI and were dissatisfied with their own weight presented higher drive-for-thinness scores. Additionally, girls with an early age at menarche presented significantly higher mean scores in this subscale. Boys whose parents had less education and whose fathers had higher BMI and were dissatisfied with their own weight also scored higher in this subscale.

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Adolescents who attended public schools, were in the lower school years, and presented the worst depressive symptomatology scored higher in the bulimia subscale. Additionally boys whose parents had less formal education also presented significantly higher scores in this subscale. Adolescents with higher BMI and the worst depressive symptomatology whose mothers and fathers had higher BMI and whose mothers were dissatisfied with their own weight presented significantly higher mean scores on the body dissatisfaction subscale. Girls with an early age at menarche also presented significantly higher mean scores. Boys who attended public schools and were

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in the lower school years whose parents had a lower level of formal education also presented significantly higher scores in this subscale. Despite the results shown in Table 3 reflecting an effect of different variables in each of the 3 subscales, a common model was chosen for multivariate analysis. No multicollinearity was found between independent variables. Table 4 presents crude and adjusted coefficients and 95% CI for boys and girls with the 3 core EDI subscales as dependent variables in linear multiple regression analysis. For drive-for-thinness scores for girls and boys, respectively, BMI (β = 0.55; 95% CI, 0.46-0.65 and β = 0.36; 95% CI, 0.30-0.42) and depressive symptoma -

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tology (β = 0.22; 95% CI, 0.18-0.26 and β = 0.10; 95% CI, 0.06-0.14) remained significantly and positively associated. For boys, grade in school (β = –0.89; 95% CI, –1.24 to –0.54) presented a significant inverse relation with drive-for-thinness score but, for girls, parents' education (β = 0.10; 95% CI, 0.02-0.17) had a significant positive effect in this subscale.

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For both girls and boys, respectively, depression symptomatology (β = 0.08; 95% CI, 0.06-0.10 and β = 0.11; 95% CI, 0.08-0.15) had a significant positive association with bulimia, and grade in school (β = –0.71; 95% CI, –1.02 to –0.40 and β = –0.80; 95% CI, –1.12 to –0.47) presented significant negative association with this subscale. Additionally, for boys, parents' education (β = –0.07; 95% CI, –0.12 to –0.02) had a significant negative effect in this subscale. Body mass index (β = 0.94; 95% CI, 0.82-1.05 and β = 0.61; 95% CI, 0.52-0.70) and depressive symptomatology (β = 0.30; 95% CI, 0.25-0.35 and β = 0.19; 95% CI, 0.13-0.25) were positively associated

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with body dissatisfaction score for girls and boys, respectively. Parents' education (β = –0.11; 95% CI, –0.19 to –0.03) had a negative effect on boys' body dissatisfaction scores but had a positive significant effect on girls' scores (β = 0.10; 95% CI, 0.00-0.19).

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CHAPTER 4 COMMENT Consistent with previous studies, our results showed that BMI was associated with eating disorder symptomatology. In the present study, in both sexes, as BMI increased, concern with dieting and weight (drive for thinness) and dissatisfaction with the overall shape of the body or with body parts (body dissatisfaction) also increased. The association between depressive and eating disorders symptomatology found in the present study has also been previously reported for adolescents. In both girls and boys, we observed that depressive symptoms were positively associated with the subscales drive for thinness

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(concern about dieting and losing weight), bulimia (a tendency toward uncontrollable voracity and negative feelings associated with eating), and body dissatisfaction (dissatisfaction with body shape). Also in accordance with previous research,age at menarche was not found to be a significant determinant of eating disorder symptomatology. However, we must consider that we had relied only on age at menarche as a pubertal development indicator for girls, which could be a methodological limitation when interpreting our results. Research about the association between socioeconomic status and eating disorders has generated conflicting results. In the present study, a significant inverse asso -

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ciation between parental education and eating disorder symptomatology was found for boys. For girls, parental education was positively related with eating disorders symptomatology. There is general consensus by most, but not all, investigators that the prevalence of eating disorders is higher in those of higher socioeconomic status. A reverse relation between eating disorders and socioeconomic status was also demonstrated by several studies. It is difficult to compare our results with other studies because most of them comprise only girls and use different methodologies to evaluate eating disorder symptomatology or socioeconomic status. Our study

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comprised girls and boys and it is rational to expect that there is a sex effect on the association between socioeconomic status and eating disorder symptomatology. Eating disorders are particularly prevalent in girls, and in 13-year-old we hypothesize that this kind of symptomatology is still associated with elites (persons enjoying superior social or economic status ) ) and that parents with higher education mediate attitudes that contribute to the development of eating disorder symptomatology. In boys, higher scores may be related to a global psychological impairment usually associated with lower socioeconomic status. Besides parental education, academic perfor -

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mance and the type of school Poor academic performance is known to be associated with lower social class, although we believe that in our sample this variable and parents' education do not measure equally. Independent of parents' education, for boys, the grade attended by the adolescent also presented a negative association with 2 of the 3 EDI subscales and, for girls, the grade attended had a significant negative effect only in the bulimia subscale score. The type of school did not present any significant association in boys or girls. After adjustment, no relation was found between parents' BMI, depression, or body weight dissatisfaction and children's eating disorders in the present study.

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This study was conducted with a large sample of 13-year-old adolescents. In addition, adolescents who did not complete the EDI (1.6%) were excluded from analysis. Adolescents who completed the EDI had better academic performance (7.6 vs 7.2 years of school; P < .001) and had parents with higher levels of formal education (10.4 vs 9.0 years of school; P < .001). Although these differences reached statistical significance, the adolescents who did not complete the EDI were small in number and we believe that the results were not biased. Furthermore, no significant differences were found regarding the other variables analysed.

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The cross-sectional nature of this study limits the ability to determine temporal relations and only by following up this cohort will it be possible to determine the real effect of the exposures. However, we believe that, particularly for parents' characteristics (except parents' depression), the results were not affected by reverse causality. In spite of the discussed limitations, this study identifies factors related to eating disorder symptomatology in a large sample comprising young girls and boys from a nonclinical population, a major strength of the study. The findings of this study are important to consolidate the existing knowledge concerning girls and add new knowledge concerning boys.

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CHAPTER 5 CONCLUSION Results Partial-syndrome BN cases are clinically quite similar to their full-syndrome counterparts. Only objective binge eating episodes and purge frequency distinguished BN and partial-syndrome BN cases. Anorexia nervosa cases, on the other hand, were quite distinct from BN and partial-syndrome BN cases on almost all variables. Conclusion Early recognition and swift treatment of eating disorders in adolescents, regardless of whether a diagnostic threshold is met, are imperative because they will lead to early intervention thereby potentially improving eating disorder recovery rates.

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BIBLIOGRAPHY 1. Cotrufo P, Gnisci A, Caputo I. Brief report: psychological characteristics of less severe forms of eating disorders: an epidemiological study among 259 female adolescents. J Adolesc. 2005;28(1):147-154. WEB OF SCIENCE | PUBMED 2. Franko DL, Omori M. Subclinical eating disorders in adolescent women: a test of the continuity hypothesis and its psychological correlates. J Adolesc. 1999;22(3):389-396. FULL TEXT | WEB OF SCIENCE | PUBMED

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3. Morandé G, Celada J, Casas JJ. Prevalence of eating disorders in a Spanish school-age population. J Adolesc Health. 1999;24(3):212-219. PUBMED 4. Shisslak CM, Crago M, Estes LS. The spectrum of eating disturbances. Int J Eat Disord. 1995;18(3):209-219. WEB OF SCIENCE | PUBMED 5. Graber JA, Brooks-Gunn J. Co-occurring eating and depressive problems: an 8-year study of adolescent girls. Int J Eat Disord. 2001;30(1):37-47. FULL TEXT | PUBMED

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6. le Grange D, Loeb KL, Van Orman S, Jellar CC. Bulimia nervosa in adolescents: a disorder in evolution? Arch Pediatr Adolesc Med. 2004;158(5):478-482. FREE FULL TEXT

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APPENDIX Abbreviations: BDI- Beck Depression Inventory BMI- Body Mass Index BN- Bulimia Nervosa CI- Confidence Intervals DT- Drive for Thinness EDI- Eating Disorders Inventory KG- Kilogram M- Meter SD- Standard Deviation VS- Versus

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CURICULUM VITAE Personal Information: Name : Ara Annie Del Yecyec Address : B3 L8, RJP Senangote Village, Tagum City Birth date: October 19, 1992 Age: 18 years old Father’s Name: Armando Yecyec Occupation: Manager Mother’s Name: Edilina Yecyec Occupation: None Sibling: Ardel Lyn Yecyec

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Educational Background: Elementary: Magugpo Pilot Imelda Elementary School ( Sy 2003- 2004) High School: Tagum City National High School ( Sy 2007-2008) College: Tagum Doctors College, Inc. ( Sy 2010-2011)

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