Bulimic symptoms in adolescent girls and boys

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  • Bulimic Symptoms in Adolescent Girls and Boys

    Lina A. Ricciardelli,1* Robert J. Williams,2 and Michael J. Kiernan2

    1 School of Psychology, Deakin University, Melbourne, Australia2 School of Social Sciences and Liberal Studies, Charles Sturt University,

    Bathurst, Australia

    Accepted 23 December 1998

    Abstract: Objective: The factor structure of the Bulimic Investigatory Test (BITE) was exam-ined in adolescent girls and boys. Method: Seven hundred and seventy seven adolescents(427 girls and 350 boys) completed the BITE. Results: Consistent with the original scale, onefactor describing overall bulimic symptoms was found for the girls. However, two factorswere required to summarize the boys symptoms: Emotional and Rigid/Disruptive EatingStyle and Food Preoccupation and Binging. Discussion: The results are discussed inrelation to Fairburns (Fairburn. (1995). Overcoming Binge Eating. New York: Guilford) dis-tinction which separates problem from nonproblem binge eating. Further studies are nowneeded to examine the mechanisms underlying the development of bulimic eating in boysand young men. 1999 by John Wiley & Sons, Inc. Int J Eat Disord 26: 217221, 1999.

    Key words: BITE; bulimic symptoms; binge eating


    In recent years, there has been an increasing interest in the bulimic behaviors of boysand men (Carlat & Camargo, 1991; Tanofsky, Wilfley, Spurrell, Welch, & Brownell, 1997).A significant proportion of individuals with bulimia nervosa, approximately 10%, aremales (American Psychiatric Association [APA], 1994). It has been estimated that bulimianervosa affects between 0.1 and 0.7% of adolescent boys and young men (Carlat & Ca-margo, 1991; Garfinkel et al., 1995). In adolescent girls and young women, the prevalencerate of bulimia nervosa varies between 1.1 and 3.5% (APA, 1994; Garfinkel et al., 1995).The prevalence of binge eating disorder is, however, more evenly distributed in men andwomen (Fairburn, 1995; Tanofsky et al., 1997). Estimates of the incidence of binge eatingdisorder in women vary between 1.8 and 4.6% (Castonguay, Eldredge, & Agras, 1995). Ithas been estimated that approximately two males to every three females have binge eatingdisorder (Wilson, Nonas, & Rosenblum, 1993).

    It is recognized that the full syndrome of bulimia nervosa and binge eating disorder

    *Correspondence to: Lina A. Ricciardelli, Ph.D., School of Psychology, Deakin University, 221 Burwood High-way, Burwood 3125 Australia. E-mail: lina@deakin.edu.au

    1999 by John Wiley & Sons, Inc. CCC 0276-3478/99/02021705

    Prod. #1439

  • remains fairly rare. However, bulimic symptoms such as chronic dieting, body imagedisturbance, and self-induced vomiting are commonly reported in university and highschool samples of women (Koenig & Wasserman, 1995; Maude, Wertheim, Paxton, Gib-bons, & Szmukler, 1993). The dominant view in the literature is that subclinical disorderedeating, such as chronic dieting and binging, occurs on a continuum and bulimics representone endpoint (Stice, Ziemba, Margolis, & Flick, 1996). High levels of bulimic symptomshave also been found in nonclinical samples of boys and men. Frequently, these levelshave been found to be comparable to those found in girls and women (Maude et al., 1993;Snow & Harris, 1989).

    Although similar levels of bulimic symptoms have been found in nonclinical samplesof men and women, the nature of these symptoms can vary. Boys and men are less likelyto feel depressed after binging (Carlat & Camago, 1991; Snow & Harris, 1989); they reportless guilt about binge eating; they are less concerned with strict weight control methods;and they are more realistic about ideal body weight (Carlat & Camargo, 1991). In fact,binge eating in men is not seen as abnormal or inappropriate as it is in women. On thecontrary, binging is more socially sanctioned for men than for women (Carlat & Camago,1991). For example, Snow and Harris (1989) found that adolescent boys in comparison togirls thought that binging episodes were normal. Similarly, in a recent study, LaPorte(1997) found that men in comparison to women required a larger amount to be consumedbefore they labeled it a binge. Moreover, in LaPortes study, women associated negativeemotional outcomes with their labeled binges, whereas men experienced mostly gastro-intestinal outcomes.

    Despite some of the notable differences in the kind of bulimic symptoms between malesand females, the same standardized instruments continue to be used for both sexes.Frequently, researchers have pointed out the inappropriateness and the limitations ofsuch practices as we have almost no psychometric data on the same instruments whenused with men. Little has been done to empirically address this crucial issue (Carlat &Camargo, 1991; Dolan & Ford, 1991; Siever, 1994). A study of the construct validity ofinstruments with assess problem eating would provide a method of further investigatingthe nature of the different symptoms between males and females. This study was de-signed to examine the factor structure of one particular instrument in adolescent girls andboys. Adolescents were selected as the onset of bulimic symptoms typically occur duringthis period (APA, 1994). The employed instrument was the Bulimic Investigatory Test(BITE; Henderson & Freeman, 1987) which was designed to assess a broad range ofbulimic symptoms.



    The participants were 427 girls and 350 boys aged between 12 and 17 years from 12 statehigh schools in New South Wales, Australia.


    The BITE was used to assess a broad range of bulimic symptoms. It assesses 30 symp-toms using a yes/no format, thus making it an easy to use and understand format withadolescents (e.g., Do you feel a failure if you break your diet once?). A symptom score

    218 Ricciardelli, Williams, and Kiernan

  • of 20 or more is indicative of a highly disordered eating pattern and scores within therange of 10 to 19 are indicative of subclinical eating problems. The BITE also contains sixitems which are used to calculate a severity rating (e.g., If you binge, how often is this?).Good reliability and validity data for the scale have been provided by Henderson andFreeman (1987) and Williams and Power (1995).


    Both students and their parent/guardians consent were obtained prior to the com-mencement of the study. Students completed the BITE during class time as part of a largersurvey on eating attitudes and gender (Kiernan, Williams, & Ricciardelli, 1996).


    Girls (M = 9.86, SD = 4.73) were found to score significantly higher than boys (M = 7.66,SD = 4.73) on the BITE Symptom scores [t(775) = 7.14, p < .01]. More specifically, 3.9%of the girls and 0.6% of the boys scored above the clinical cutoff score (>19) and 41.3% ofthe girls and 27.1% of the boys scored within the subclinical range (10 to 19). Similarly, thegirls (M = 2.22, SD = 3.60) were found to score significantly higher than the boys (M = 1.31,SD = 2.48) on the BITE Severity scores [t(775) = 4.05, p < .01].

    In order to examine whether the nature of the bulimic symptoms differed between thegirls and boys, the 30 BITE symptoms were subjected to principal components analysis.Using Kaisers criterion and the scree test, one factor was found to adequately summarizethe interrelationships between the BITE items for the girls. This factor, reported in Table1, accounted for 20.8% of the variance and 26 of the 30 items had significant loadings(>.30). Consistent with the original scale, one factor, describing general bulimic patternsof eating, was found for the girls (Henderson & Freeman, 1987).

    Using the same criteria as for the girls, two factors were required to adequately sum-marize the interrelationships between the BITE items for the boys (Table 1). An obliquerotation indicated that the two factors were poorly correlated (r = .15). The first factorwhich accounted for 13.8% of the variance had 12 significant loadings. The items focusedon emotional concerns about eating and overeating (e.g., Item 19: Do you worry thatyou have no control over how much you eat?) and extreme disruptive eating strategies(e.g., Item 8: Does your pattern of eating severely disrupt your life?). The second factorfor the boys which accounted for 8.4% of the variance had 10 significant loadings. Theseitems highlighted food preoccupation (e.g., Item 11: Are there times when all you canthink about is food?) and binging (e.g., Item 14: Do you ever experience overpoweringurges to eat and eat and eat?). The two factors for the boys were labeled Emotional andRigid/Disruptive Eating Style and Food Preoccupation and Binging, respectively.

    For the boys, the two BITE factors corresponded closely to Fairburns (1995) distinctionwhich separates problem from nonproblem binge eating. For many people, binge eatingis distressing as it does affect ones physical and emotional health. Problem binge eatingis more clearly reflected by the first factor, Emotional and Rigid/Disruptive Eating Style.This pattern of eating is associated with anxiety, depression, and feelings of guilt. Formany others, binge eating does not negatively affect their quality of life. Nonproblembinge eating is reflected by the second factor, Food Preoccupation and Binging, as itcontains no references to any negative emotional outcomes associated with overeating.The second type of binging is more socially sanctioned for men than for women (Carlat

    Bulimic Symptoms in Girls and Boys 219

  • & Camargo, 1991; LaPorte, 1997). As binge eating per se in men is less likely to be seen asinappropriate and is also less likely to be associated with negative emotional outcomes,more focus needs to be placed on emotional eating as a potential indicator of problemeating in young men.

    Men are relatively protected from dieting and bulimia because they tend to report lessdissatisfaction with their bodies (Carlat & Camargo, 1991). They are also less likely towant to lose weight and less likely to diet as dieting would take men away from themesomorphic ideal (Carlat & Camargo, 1991; Raudenbush & Zellner, 1997). However,the other well-documented pathway to bulimia and bulimic behaviors is via negativeaffect (Stice et al., 1996). To explain the link between emotional distress and bulimicbehavior, theorists have proposed that binge eating emerges as a way of handling intensenegative affect and a way of coping with stress. It may be this pathway which is activated

    Table 1. Principal component analysis of the BITE for girls and boys


    GirlsFactor I:

    General Factor


    Factor I:Emotional and

    Rigid/DisruptiveEating Style

    Factor II:Food Preoccupation

    and Binging

    1. Regular eating pattern .08 .10 .102. Strict dieter .36 .49 .023. Feel a failure if break diet once .56 .57 .054. Count calories, even when not a diet .32 .58 .025. Fast for a whole day .39 .44 .018. Eating disrupt life .47 .53 .069. Food dominated life .43 .12 .43

    10. Eat and eat until stopped by physicaldiscomfort .42 .07 .52

    11. All you can think about is food .37 .10 .6712. Eat sensibly in front of others and make

    up in private .36 .15 .1113. Stop eating when want to .23 .11 .2614. Experience urges to eat and eat .55 .06 .6115. Eat a lot when feeling anxious .40 .22 .2816. Thought of becoming fat terrifying .39 .30 .0017. Eat food rapidly .37 .10 .5818. Ashamed of eating habits .65 .59 .0619. Worry that you have no control over

    eating .58 .61 .0020. Turn to food for comfort .44 .08 .5521. Able to leave food on the plate .14 .11 .2222. Deceive people about how much you eat .53 .31 .2423. How hungry you feel determines how

    much you eat .15 .22 .0724. Binge on large amounts .64 .05 .5425. Binges leave you miserable .67 .52 .1026. Binge when you are alone .64 .35 .1328. Go to great lengths to satisfy an urge to

    binge .43 .04 .4729. Feel guilty after overeating .57 .55 .0930. Eat in secret .49 .01 .5031. Eating habits normal .51 .27 .0532. Compulsive eater .38 .02 .4433. Weight fluctuate more than five pounds

    in a week .40 .28 .25

    Note: BITE = Bulimic Investigatory Test.

    220 Ricciardelli, Williams, and Kiernan

  • more in men. Studies are now needed to examine the mechanisms underlying the devel-opment of bulimic behaviors in boys and men.


    American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Wash-ington, DC: Author.

    Carlat, D.J., & Camargo, C.A. (1991). Review of bulimia nervosa in males. American Journal of Psychiatry, 148,831843.

    Castonguay, L.G., Eldredge, K.L., & Agras, W.S. (1995). Binge eating disorder: Current state and future direc-tions. Clinical Psychology Review, 15, 865890.

    Dolan, B., & Ford, K. (1991). Binge eating and dietary restraint: A cross-cultural analysis. International Journalof Eating Disorders, 10, 345353.

    Fairburn, C.G. (1995). Overcoming binge eating. New York: Guilford.Garfinkel, P.E., Lin, E., Goering, P., Spegg, C., Goldbloom, D.S., Kennedy, S., Kaplan, A.S., & Woodside, D.B.

    (1995). Bulimia nervosa in a Canadian community sample: Prevalence and comparison of subgroups. Ameri-can Journal of Psychiatry, 152, 10521058.

    Henderson, M., & Freeman, C.P.L. (1987). A self-rating scale for bulimia: The BITE. British Journal of Psychia-try, 150, 1824.

    Kiernan, M.J., Williams, R.J., & Ricciardelli, L.A. (1996). Eating restraint, dieting frequency and disinhibitedeating amongst NSW secondary school students. Australian Journal of Psychology, 48 (Supp.), 113.

    Koenig, L.J., & Wasserman, E.L. (1995). Body image and dieting failure in college men and women: Examininglinks between depression and eating problems. Sex Roles, 31, 407431.

    LaPorte, D.L. (1997). Gender differences in perceptions and consequences of an eating binge. Sex Roles, 36,479489.

    Maude, D., Wertheim, E.H., Paxton, S., Gibbons, K., & Szmukler, G. (1993). Body dissatisfaction, weight lossbehaviours, and bulimic tendencies in Australian adolescents with an estimate of female data representa-tiveness. Australian Psychologist, 28, 128132.

    Raudenbush, B., & Zellner, D.A. (1997). Nobodys satisfied: Effects of abnormal eating behaviors and actual andperceived weight status on body image satisfaction in males and females. Journal of Social and ClinicalPsychology, 16, 95110.

    Siever, M.D. (1994). Sexual orientation and gender as factors in socioculturally acquired vulnerability to bodydissatisfaction and eating disorders. Journal of Consulting and Clinical Psychology, 62, 252260.

    Snow, J., & Harris, M.B. (1989). Disordered eating in South-eastern Pueblo Indians and Hispanics. Journal ofAdolescence, 12, 329336.

    Stice, E., Ziemba, C., Margolis, J., & Flick, P. (1996). The dual pathway model differentiates bulimics, subclinicalbulimics, and controls: Testing the continuity hypothesis. Behavior Therapy, 27, 531549.

    Tanofsky, M.B., Wilfley, D.E., Spurrell, E.B., Welch, R., & Brownell, K.D. (1997). Comparison of men and womenwith binge eating disorder. International Journal of Eating Disorders, 21, 4954.

    Williams, G.J., & Power, K.G. (1995) Manual of the Stirling Eating Disorder Scales....


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