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Recurrent Binge Eating in Black American Women
Ruth H. Striegel-Moore, PhD;
Denise E. Wilfley, PhD;
Kathleen M. Pike, PhD;
Faith-Anne Dohm, PhD;
Christopher G. Fairburn, MD
Arch Fam Med. 2000;9:83-87.
ABSTRACT
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Context Recurrent binge eating is a core diagnostic feature of bulimia nervosa and binge eating disorder, and in samples of white women has been associated with obesity and psychiatric symptoms. Eating disorders have been believed to occur primarily among white women; in fact, the limited preliminary data available suggest that black women may be as likely as white women to report binge eating.
Objective To examine race differences in prevalence of behavioral symptoms of eating disorders and clinically significant recurrent binge eating.
Design Community survey.
Setting General community in Connecticut and Boston, Mass.
Participants A community sample of 1628 black women and 5741 white women (mean age, 29.7 years) participated in a telephone survey designed to ascertain the presence, during the preceding 3 months, of binge eating and extreme weight control behaviors (vomiting, laxative or diuretic abuse, or fasting).
Main Outcome Measure Interviewer-based phone assessment of recurrent binge eating and behavioral symptoms of eating disorders.
Results Black women were as likely as white women to report binge eating or vomiting during the preceding 3 months, and were more likely to report fasting and the abuse of laxatives or diuretics. Recurrent binge eating was more common among black women than among white women. In both race groups, recurrent binge eating was associated with elevated body weight and increased psychiatric symptoms.
Conclusion Results suggest that recurrent binge eating is a significant problem among black and white women. Health professionals need to be ready to respond to this health risk behavior.
INTRODUCTION
EATING DISORDERS involving recurrent binge eating pose a significant risk to the health and psychological adjustment of women. Recurrent binge eating (the persistent pattern of eating a large amount of food, accompanied by a sense of loss of control over the eating episode) is a core diagnostic feature of bulimia nervosa and of binge eating disorder.1 Among professional and lay groups, eating disorders have been believed to occur primarily among white women. However, initial survey studies suggest that minority women are as likely as white women to report binge eating.2 This literature is limited by the use of samples of convenience,3 a reliance on instruments of unknown reliability,4 small sample sizes for minority groups,5 or the absence of an assessment of the clinical significance of the reported eating disturbance.6 Studies focusing specifically on dieting and purging in black women have yielded mixed results.7 Dieting seems to be less common among black women than among white women,6, 8-9 whereas purging, particularly the use of laxatives for weight control, may be as common among black women as among white women.6
Binge eating is associated with obesity in white women.10-11 Given the fact that obesity is a major health problem among black women,12-13 recurrent binge eating may also be common among black women. In addition, recurrent binge eating is associated with impairment in psychological adjustment among white women.11-16 Whether recurrent binge eating is associated with comparable levels of psychiatric symptoms in black women is not known.
The purpose of this study was to ascertain the prevalence rates of binge eating and other behavioral symptoms of bulimia nervosa and binge eating disorder in a community sample of adult black women and white women. The study also sought to examine racial differences in 2 important clinical correlates of recurrent binge eating: obesity and psychiatric distress. Because epidemiological studies of white women have shown that behavioral symptoms of eating disorders are most common in young adult women,17-18 the study focused on women between the ages of 18 and 40 years.
PARTICIPANTS AND METHODS
SUBJECTS AND RECRUITMENT
The study protocol was approved by Wesleyan University's Institutional Review Board. To establish a community-based sample of adult women, we purchased commercial mailing lists through MetroMail (MetroMail Corp, Lincoln, Neb). These commercially available lists are typically generated for marketing purposes and enable targeted mailings to demographic groups. We chose the list approach because we wanted to target a specific age group (18-40 years) and specific race groups (white and black). The database of marketing lists is established through census data, driver's license registration, telephone books, birth records, and information obtained through marketing surveys. Information available from these lists included a person's name, address, and telephone number. These lists are highly accurate regarding sex of the person; accuracy of the person's age is less satisfactory because, in some cases, this information is collapsed into broad age categories (eg, 16-50 years), thus making it difficult to target a precise age; accuracy of age and address further depend on how recently the database has been updated.
The list for this study included the names of women aged 18 to 40 years located in distinct geographic areas in the state of Connecticut, and in the greater Boston, Mass, area. These areas were selected to provide a racially mixed sample of adult women of diverse socioeconomic backgrounds and to capture metropolitan, suburban, and rural populations. From these lists, 16,474 names were randomly selected and potential participants were contacted by mail and telephone. The letter of invitation described the project as a study of women's health and adjustment, and alerted potential subjects that they would receive a call in the near future. Trained interviewers then called potential participants and obtained informed consent to proceed with the telephone interview.
Three thousand ninety-one women could not be contacted for the following reasons: their letters were returned as undeliverable and/or their telephones had been disconnected (2699 women), they were deceased (6 women), or they could not be reached despite 15 call-back attempts (386 women). In addition, 271 names were dropped after the interviewer determined that no one in the household was able to answer the telephone call in English, and 8 were dropped because the respondent had a severe language impairment. These 3370 names were excluded when calculating response rate. Of the remaining 13,104 women, 11,938 consented to participate (91.1%). Unfortunately, we do not have any information about the women whose telephones were disconnected or whose letters were returned as undeliverable. This may limit generalizability of our results.
Because of inaccuracies in the lists, not every woman who consented to participate was eligible for inclusion in the study. Ineligibility because of age resulted in the elimination of 3831 women; 738 women were excluded because the respondent did not meet the eligibility criterion for race (408 were Hispanic, 127 were Asian, and 134 were of mixed racial/ethnic background) or did not provide race/ethnicity information (69 women). The final sample comprised 7369 adult women.
All instruments described below were administered by telephone by trained staff of the New England Research Institute, Watertown, Mass.
INSTRUMENTS
To determine presence and frequency of core behavioral symptoms of eating disorders, questions were used from the Eating Disorder Examination, a standardized diagnostic interview of established reliability and validity.19 Specifically, participants were asked whether, during the past 3 months, they had engaged in overeating with a sense of loss of control (binge eating), fasting, or self-induced vomiting, had or used laxatives or diuretics for weight control. Use of diuretics or laxatives by recommendation or prescription of a health care professional was not considered an eating disorder symptom and such use was not coded. To calculate test-retest reliability, 160 women (44 black and 116 white) were called back within 4 weeks by a second interviewer who repeated the telephone interview. Test-retest reliability coefficients ( ) were as follows: overeating, r = 0.79 (black, 0.79; white, 0.79); overeating with loss of control, r = 0.63 (black, 0.57; white, 0.67); fasting, r = 0.30 (black, 0.28; white, 0.31); vomiting, r = 0.50 (black, 0.48; white, 0.51); using laxatives, r = 0.44 (black, 0.54; white, 0.39); or using diuretics, r = 0.22 (black, 0.48; white, 0.18). The values likely are attentuated because of the low base rate of these behaviors.20 The agreement ratios (percent agreement) were as follows: overeating, 143 (89.4%) of 160 women; overeating with loss of control, 126 (78.8%) of 160 women; vomiting, 150 (93.8%) of 160 women; laxative use, 149 (93.1%) of 160 women; fasting, 134 (83.8%) of 160 women; and diuretic use, 144 (90%) of 160 women.
Degree of psychiatric distress was assessed with a modified 16-item version of the General Health Questionnaire (GHQ), a widely used screening instrument for psychiatric disorder.21 In its questionnaire format, the GHQ provides 4 response choices (not at all, no more than usual, rather more than usual, and much more than usual) and responses are scored by setting the 2 most healthy responses to 0 and the 2 more symptomatic responses to 1. Pilot testing of the telephone administration suggested that reading the 4-level response categories was cumbersome. Therefore, participants were asked to indicate whether during the previous 3 months, they had experienced the symptoms more than usual (0, no; 1, yes). The 16 GHQ items refer to either mood or anxiety disorder symptoms. A total symptom score was derived by adding across all 16 symptoms. In addition, at the end of the call, demographic information (race, age, and educational attainment) and self-reported height and weight data were collected. Research has shown that self-reported height and weight are highly correlated with actual height and weight and are sufficiently valid for use in epidemiological studies.22-24 Body mass index (BMI) was calculated by dividing weight (in kilograms) by height (in meters squared). Telephone calls took approximately 10 minutes.
DATA ANALYSES
To determine race differences in prevalence of behavioral symptoms of disordered eating,  2 tests were used. For 2 found to be significant, odds ratios and confidence intervals were computed following the methods described by Fleiss.25 To determine whether women with recurrent binge eating (cases) differed from women who did not meet the criterion for recurrent binge eating (controls), 2 (race) x 2 (case status) analyses of variance were calculated, using age, BMI, and total GHQ score as the dependent variables.
RESULTS
SAMPLE DESCRIPTION
The sample comprised 1628 women who identified themselves as black and 5741 women who described themselves as white. Their mean age was 29.73 years (SD, 4.5 years); black women (28.33 years [SD, 5.0 years]) were slightly younger than white women (30.13 years [SD, 4.3 years]; F1,7365 = 37.46; P<.001). Participants were grouped by level of education as follows: high school degree or less (n = 1691 [23.0%]), some college (having taken college courses but not earned a college degree: n = 2704 [36.7%]), and college graduate (n = 2969 [40.3%]). The black women reported less education than the white women (2 = 201.04; P<.001). The mean BMI was 24.62 (SD, 5.2); black women (27.01 [SD, 6.0]) had higher BMIs than white women (23.94 [SD, 4.7]; F1,7365 = 43.77; P<.001). The participants' mean GHQ score was 3.2 (SD, 3.6), and black women (3.87 [SD, 3.8]) had higher GHQ scores than white women (2.97 [SD, 3.5]; F1,7365 = 17.55; P<.001).
PREVALENCE OF BEHAVIORAL SYMPTOMS OF EATING DISORDERS
Binge eating at least once during the preceding 3 months was reported by comparable numbers of black women (n = 136 [8.4%]) and white women (n = 507 [8.8%]; 2 = 1.19; P = .55). Following convention, recurrent binge eating was operationalized as reporting a minimum average of 2 episodes per week during the past 3 months, and was considered suggestive of the presence of an eating disorder of clinical severity.1 Recurrent binge eating was reported by significantly more black women (n = 74 [4.5%]) than white women (n = 150 [2.6%]; 2 = 16.07; P = .0001). The odds ratio of a recurrent binge eater being black was 1.77 (95% confidence interval, 1.34-2.37).
Table 1 summarizes how many participants reported having engaged in the use of an extreme weight control behavior at least once during the preceding 3 months. The 2 groups did not differ in their prevalence of self-induced vomiting. However, compared with white women, black women were significantly more likely to report fasting, laxative abuse, or diuretic abuse.
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Prevalence of Current Extreme Compensatory Behaviors*
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CORRELATES OF RECURRENT BINGE EATING IN BLACK WOMEN AND WHITE WOMEN
Next, we explored the relationship between age, educational status, BMI, and degree of psychiatric distress and recurrent binge eating, using 2 (race) x 2 (case status) analyses of variance. Results of analyses of covariance adjusting for race differences in age, education, BMI, and GHQ total score are available on request from the authors. Adjusting for these variables did not substantively change the results described below. The interaction terms of racexcase status were nonsignificant in all analyses: on all correlates of recurrent binge eating explored in this study, the black cases did not differ from the white cases above and beyond the race differences observed in the total sample.
Those women who met criteria for recurrent binge eating (cases, 224 women) did not differ from those who did not meet criteria for recurrent binge eating (controls, 7145 women) in age (29.82 years [SD, 4.7] and 29.73 years [SD, 4.5], respectively; F1,7365 = 0.50, P = .48). Case status was significantly and inversely related with educational attainment (2 = 19.83; P<.001). Cases (33.5%) were slightly more likely than noncases (22.6%) to be in the lowest category of educational attainment (high school degree or less: 2 = 14.45; P = .0001), and less likely to be college graduates (28.1% and 40.7%, respectively; 2 = 14.23, P = .0001). Cases (28.60 [SD, 7.5]) had significantly higher BMIs than controls (24.49 [SD, 5.1]; F1,7365 = 95.75; P<.001) and cases (6.79 [SD, 4.7]) reported more psychiatric symptoms than controls (3.06 [SD, 3.5]; F1,7365 = 214.24; P<.001).
COMMENT
A major aim of this study was to examine race differences in the point prevalence of eating disorder symptoms. Black women were as likely as white women to report that they had engaged in the behaviors of binge eating and self-induced vomiting during the preceding 3 months. In addition, more black women than white women reported that they had used laxatives, diuretics, or fasting to control their weight. These findings are consistent with race patterns of lifetime prevalence rates for a nationally representative sample of white and black adults.6
It has been cautioned that the public health implications of prevalence rates of behavioral symptoms are not clear unless a severity threshold is used to differentiate occasional symptoms from recurrent behavioral patterns.26-27 Therefore, the present study also examined race differences in binge eating at a severity level that was suggestive of the presence of a clinical eating disorder.1 Using the severity criterion of a minimum average of 2 binge eating episodes per week for a duration of 3 consecutive months, almost twice as many black women as white women were identified as probable eating disorder cases. Our results therefore challenge the widely held view that black women are immune to developing eating disorders.
Consistent with earlier studies of white women,28 we found a strong association between recurrent binge eating and weight status in black women; indeed, mean BMI values suggest that, regardless of race, recurrent binge eaters are overweight. The clinical significance of recurrent binge eating is illustrated further by the significant association between binge eating and psychiatric distress. In both racial groups, women who acknowledged recurrent binge eating reported a significantly greater number of psychiatric symptoms. While this association has been shown repeatedly in studies of predominantly white clinic patients,11, 14, 27 our data suggest that it also applies to a large, community-based sample and to black women. Health professionals working with obese populations need to be as ready with a black woman as with a white woman to initiate assessment and, if indicated, treatment of an eating disorder.
Several methodological limitations need to be acknowledged. First, a number of potential participants could not be located because of invalid telephone numbers or addresses. This may limit generalizability of results. Second, weight and height were determined by self-report, a method that may result in an underestimate of BMI values. However, research has shown that self-reported height and weight are highly correlated with actual height and weight22-23 and has found no correlation between accuracy of self-reported weight and binge eating.24 This suggests that measurement error should not affect differentially the accuracy of self-reported weight of recurrent binge eaters compared with controls. Third, a revised version of the GHQ was used in this study. Nonetheless, our results showing elevated levels of psychiatric distress among binge eaters are consistent with findings reported in the literature.15, 28 Fourth, the increased use of diuretics by the black women in our sample may be related to easier access to diuretics because of the increased likelihood of their having a family member with hypertension. However, the greater use of fasting and laxatives suggests a pattern of increased nonvomiting purging efforts among black women compared with white women.
However, these limitations are offset by several strengths. First, our study recruited participants directly from the community. Previous studies have shown that patient samples are significantly more likely to be obese and exhibit significantly greater levels of psychiatric comorbidity than community-based samples.29-30 Second, this is the first large-scale epidemiological study of recurrent binge eating in black women, a population largely ignored in the eating disorders literature. Third, assessment of disordered eating was based on telephone interviews, a method found superior to self-report questionnaire surveys.31 Fourth, our study achieved a high response rate (exceeding 90%). While we cannot provide race-specific refusal rates because the telephone lists did not identify the race of the potential participant, all women were informed that the study asked questions about women's health and adjustment, and refusing participation by ending the telephone interview was rare in both racial groups. Hence, it seems unlikely, for example, that black women with recurrent binge eating were more eager to participate than black women who did not binge eat.
CONCLUSIONS
Our results suggest that recurrent binge eating is a significant problem among young adult black women in terms of the number of women affected and the potential physical and mental health problems associated with recurrent binge eating. Our findings support the need to include black women in studies of eating disorders, to raise awareness among health care providers, and to educate black women regarding the availability of effective treatments for eating disorders.
AUTHOR INFORMATION
Accepted for publication May 18, 1999.
This study was supported by grant 1R01MH52348-01A1 from the National Institute of Mental Health, Rockville, Md (Dr Striegel-Moore), and Principal Fellowship 046386 from the Wellcome Trust, London, England (Dr Fairburn).
Corresponding author: Ruth H. Striegel-Moore, PhD, Department of Psychology, Wesleyan University, Middletown, CT 06459 (e-mail: rstriegel{at}wesleyan.edu).
From the Departments of Psychology, Wesleyan University, Middletown, Conn (Dr Striegel-Moore), and the State University of California at San Diego (Dr Wilfley); the Departments of Psychiatry, Columbia Presbyterian Medical Center, New York, NY (Dr Pike), and Warneford Hospital, Oxford University, Oxford, England (Dr Fairburn); and the Graduate School of Education and Allied Professions, Fairfield University, Fairfield, Conn (Dr Dohm).
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