Semistarvation-Associated Eating Behaviors Among College Binge Eaters: A Preliminary Description and Assessment Scale

Semistarvation-Associated Eating Behaviors Among College Binge Eaters: A Preliminary Description and Assessment Scale – Statistical Data Included

M. M. Hagan

Binge eating is a central feature of bulimia and binge-eating disorder (BED), a proposed diagnosis of binge eating with no compensatory purging,[1] which also occurs in about half of the cases of anorexia nervosa.[1-3] Current diagnostic assessments and clinical studies generally limit descriptions of binge-eating behavior to its diagnostic criteria, including rapid consumption of large quantities of food in a discrete period of time, feelings of distress, and a sense that once eating has started, the individual has no control to stop it.[1]

More detailed descriptions of binge eating are found in historical and empirical accounts of semistarvation. In these accounts, binge eating is described as behavior following a period of limited food intake (ie, semistarvation) that occurred in men, women, and children as a result of wartime food shortages, imprisonment in enemy camps,[4-11] and being marooned during expeditions.[12-16] Binge eating was also a common consequence of experimental semistarvation when wartime dietary regimens were simulated in young-adult male volunteers.[17-20]

Whether semistarvation was voluntary or involuntary, the victims of semistarvation and the research volunteers continued to engage in peculiar habits and rituals once food was freely available. These behaviors (summarized in Table 1) describe a rapid and frantic eating pattern that is accompanied by distress and a lack of control over food intake, as occurs in BEDs in the general population, such as bulimia and some cases of anorexia nervosa.[1]

TABLE 1

Eating Behaviors of Victims of Semistarvation and Starvation-Research Volunteers Long After Food Was Plentifully Available

Behavior/source

Voracious appetites followed by large and rapid food

intake[9,11,16-18,21,44]

Lack of control and distress over amounts eaten[11,17,20,21]

Complaints of hunger despite huge meals[17,21]

Belief that eating triggers hunger[17]

Cravings and preference (carbohydrates, tats,

sweets)[5,18-20,45]

Obsession with food[10,11,14,15,17,19,45,46]

Secrecy and defensiveness over food[9,10,17,18]

New preoccupation with body shape and weight[17,47]

Impulsivity (shopping for nonfood items, self-harm,

anger, violence)[18,20,21]

Scavenging or eating from garbage containers[11,18,20]

Stealing, hiding, hoarding food[10,20,21]

Manipulating others for food[9]

Making bizarre mixtures of food[18]

Eating unpalatable and inappropriate food (raw meat,

scraps)[20,21]

Thickening foods (with flour, oatmeal)[8]

Excessive flavoring (eg, with tea, coffee, lemon crystals)[8]

Excessive heating of food[24]

Excessive spicing of food[24]

Poor table manners (eg, licking knives and bottle lids,

collecting crumbs, gnawing at bones)[24]

“Souping” food and “filling up” with liquids[18,20]

Preferring to eat in isolation[17,18]

Self-induced and overeating-induced vomiting[8,19,20]

Dreading having to choose foods to eat[17]

Self-deprecation and negative affect from eating habits[17,20]

Taking drastic measures to resist binges[20]

Recidivist binge eating despite interference with quality

of life[8,9,18,45,47]

During semistarvation, aberrant behaviors, such as hoarding food, hostility, and eating out of garbage containers, can be regarded as adaptive. However, their persistence after recovery from malnutrition and a return of food availability sources (eg, with intakes from 6000 to more than 8000 kcals/day) is anomalous[9,12,14,16-18,21] and suggests a clear and persistent post-semistarvation syndrome. In the Minnesota semistarvation experiment, only 3 of the 26 volunteers considered their eating habits to be normal, even after 13 weeks of refeeding.[17,18]

Taken together, the common and frequent presence of these peculiar behaviors surrounding binge eating suggests that semistarvation-associated behaviors are part of a syndrome and might also occur in binge eaters. This is intimated in a few reports that describe strange behaviors in binge eaters, largely reported in anecdotal form (Table 2). Despite the prevalence of BEDs in today’s society and continued attempts to diagnose and treat these disorders, however, the more aberrant aspects of binge eating have not been objectively identified or quantified.

TABLE 2

Descriptions of Aberrant Behaviors Observed in Modern Binge Eating and Eating Disorder Patients

Behavior/source

Binges that were like “rapid and grotesque eating

orgies”[43(p443)]

Secrecy, hoarding, and hiding food[48-50]

Raiding candy machines and refrigerators[51]

Terrible table manners/leaving considerable messes of

food/containers[51]

Eating inappropriate/highly disliked food (raw, frozen,

baby food)[48,51]

Impulsivity (nonfood shopping)[52,53]

Rummaging through garbage for food[48,51]

Seeking out isolation to eat[54]

Taking extraordinary measures to procure binge foods

(eg, late-night food runs, going shop to shop,

manipulating others)[43,51,55]

Taking drastic measures to resist binges[51]

Our purpose in conducting the present study was to determine the extent to which various eating habits and rituals elicited by experience with semistarvation are shared by students not having diagnoses who report binge eating. We hypothesized that students in the high-binge group engage in behaviors that are more abnormal than commonly believed. We developed the Semistarvation-Associated Behaviors Scale (SSABS) to probe the prevalence of peculiar post-semistarvation behaviors in college students who meet the proposed criteria for binge eating outlined in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). Inclusion of dieting frequency and administration of the scale to a largely Hispanic population and to male as well as female participants helped us address gaps in the binge-eating literature, such as the relationship of binge eating to gender, dieting, and cultural status.

METHOD

Participants

Respondents were primarily volunteers from an introductory psychology course at the University of Texas, El Paso, who participated to fulfill a class requirement (N = 25). In addition, we recruited a group of high-binge eaters (N = 15) through a flier stating the proposed criteria for BED listed in the DSM-IV.[1] We obtained approval from the Institutional Review Board of the University of Texas at El Paso before the experiment. Participants gave written consent by reading and signing an agreement that their participation could be stopped at any time during the study, that all material would be kept confidential, and that data obtained would be used for scientific purposes only.

Although we centered our study on the female population (N = 32), we also examined data from 8 men. The mean age of the total sample was 25.4 years, SD = 8.61, range = 18 to 53 years. Sixty percent of the respondents were of Hispanic descent, 30% were Anglo American, and the remaining 10% were African American, Asian, Native American, or listed “other” in response to the question about ethnicity.

Of the high-binge sample, 13% reported having been diagnosed with an eating disorder (anorexia nervosa, bulimia nervosa, or BED, as defined for the participants). Suspicion of having an eating disorder without formal diagnosis was reported by an additional 56.5% of the high-binge group.

Measures

Participants were instructed in the SSABS to refer to the word binge as a time they overate; we intended that the term would be interpreted in a subjective manner.[22,23]

Categorization Into Low-Binge and High-Binge Groups

Students answered 10 yes/no questions taken from the diagnostic statements for the proposed BED.[1] The sum of yes responses made up the individual BE (binge eating) scores (see Appendix A). Classification into the high- or low-binge group was based on a median split.

The Semistarvation-Associated Behaviors Scale

After completing the 10 diagnostic criteria questions for a BE score, participants completed the SSABS. We constructed the SSABS on this subject sample from a preliminary group of 78 items that included only those items that were found to correlate with the total SSABS score at r = .40 (p [is less than] .01). This item-analysis resulted in the current 49-item scale (see Appendix B). Each item required a response from 1 (never) engaging in the behavior to 5 (always) doing so.

Because the SSABS was in a preliminary stage, we left room for comment on 5 of the items so that participants could provide information on practices not specifically listed. The bulk of the questions measured habits surrounding food and food intake, consequences from these behaviors, and measures to resist the behaviors. We took the items from behaviors described in the historical semistarvation literature and the few clinical descriptions reporting semistarvation-like behaviors shown in Tables 1 and 2. Other items in the SSABS were related to frequency of dieting and engaging in compensatory behaviors (eg, vomiting, fasting, excessive exercise).

Statistical Analyses

We derived the SSABS score by summing the values of the responses on the Likert-type scale across all items. We used Cronbach’s alpha to assess degree of internal consistency between the SSABS items, and we used separate analyses of variance to assess differences between high-binge and low-binge groups and differences between ethnic groups on dieting and SSABS scores. Interactions were reported if significant.

We used Pearson’s correlation coefficient (1-tailed) to examine the relationship between nondichotomized data, including dieting frequency and BE scores. We examined more detailed data for SSABS items according to percentages of respondents reporting the behaviors outlined in each item, and we indexed degrees of frequency by the mean response to each item.

RESULTS

The Effect of High-Binge and Low-Binge Status on Semistarvation-Associated Behaviors

BE scores ranged from 0 to 10. We used a median BE score of 6.5 to split the participants into the high-binge (score of [is greater than or equal to] 7; n = 19) or low-binge group (score of [is less than or equal to] 6; n = 21) based on participants’ responses to the 10 DSM-IV criteria for BED.[1] The participant’s scores were bimodally distributed with 22.5% scoring a low of 3 and 17.5% scoring a high of 10 points. Compensatory behavior (one of the SSABS items) was not correlated with BE scores, [R.sup.2] = .00, not significant (ns).

As we expected, the 49 SSABS items measuring aberrant eating behavior were highly correlated with each other, alpha = .96. An analysis of variance revealed that the SSABS clearly differentiated high-binge from low-binge groups, F(1, 39) = 54.95, [R.sup.2] = .60, p [is less than] .0001.

The following results pertain to the analysis of the women only because women were a majority (32 of 40) of our sample. Their behaviors showed some important differences from men’s; results for the men are described separately.

Dieting, Binge-eating Status, and Semistarvation-Associated Behaviors

Dieting frequency was related to the participants’ BE scores (r = .37, p [is less than] .02). However, we found a stronger relationship between dieting frequency and semistarvation-like behaviors as assessed by the SSABS (r = .54, p [is less than] .001).

Effect of Ethnicity on Dieting and Semistarvation-Associated Behaviors

In the low-binge group (n = 21), only one or two people were Anglo Americans and 18 were Hispanic. Ethnicity was more equally distributed in the high-binge group (n = 19), with 8 Anglo and 8 Hispanic participants. Ethnicity was not significantly related to frequency of dieting or semistarvation-associated behaviors, all F(1, 17) [is less than] .15, ns.

Binge Eating, Semistarvation-Associated Behaviors, and Dieting in the High-Binge Group

Increasing BE scores were not related to reported frequency of semistarvation-associated behaviors in the high-binge group, r = .02, ns. However, increasing frequency of dieting was related to increasing experience of semistarvation-associated behaviors, r = .53, p [is less than] .01. As already noted, BE scores comprised all 10 DSM-IV proposed criteria for BED. Of these individual criteria, binge eating when not hungry, binge eating alone because of embarrassment over how much is eaten, and binge eating an average of 2 or more days a week were most strongly related to semistarvation-associated behaviors as assessed by the SSABS (r = .62, .65, and .67, p [is less than] .01, respectively).

Binge-eating Status, Dieting, and Semistarvation-Associated Behaviors in Male Participants

In the men, only binge-eating status based on the BE score was related to semistarvation-associated behaviors (r = .86, p [is less than] .01). For men, we found no positive relationship between dieting and BE scores or between dieting and the SSABS items (r = -.24 and -.54, ns, respectively).

Frequency and Descriptive Data From the SSABS

The data in Table 3 show the percentage of participants from low-binge or high-binge groups who engaged in activities found in the semistarvation syndrome. Group means reflect the frequency with which these activities were performed. Some of the items refer to measures undertaken to prevent binge eating. Most of the respondents “often” got busy with other activities (42%); dieted, exercised (37%), or chewed gum (32%); and “sometimes” drank liquids to fill up (42%) or sipped coffee or tea (32%) to keep from binge eating. High-binge participants reported they chewed and spat out food (53%), chewed nonedibles (37%), adulterated food to make it less tempting (53%), and used punishment rituals (37%).

TABLE 3 Percentages and Mean Frequency Scores of Respondents Who Reported Behaviors Measured by the Semistarvation-Associated Behaviors Scale

Binge eaters

High Low High

Eating behaviors (%) (%) M

Eat with poor table manners 90 52 3.0

Eat food straight out of cans 69 14 2.7

Eat food while still frozen 47 14 1.7

Eat food while still too hot 89 48 3.0

Eat food picked off the floor 37 5 1.5

Eat soiled or dirty food 32 0 1.5

Eat part of food wrappings 47 5 1.5

Trash food but later eat it 26 0 1.5

Eat spoiled, expired, rotted food 37 0 1.5

Eat food raw meant to be cooked 74 29 2.4

Eat chewable vitamins as if candy 42 10 1.7

Eat medicines as if regular food 32 5 1.6

Eat others’ leftovers while washing 53 10 2.0

Eat food disliked any other time 68 5 2.2

“Stretch-out” food by diluting 53 5 1.7

Add ingredients to “thicken” food 58 10 2.1

Cut food up to make it last longer 95 24 2.8

Binge while driving 58 19 2.2

Lead vendors to believe food is for

others 84 10 2.8

Pretend to save food for others 79 5 2.8

Steal food 47 5 1.9

Hoard or hide food 84 10 3.0

Lie about having binged 90 10 3.2

Manipulate others to binge 89 5 3.2

Save food until alone to binge 89 10 3.3

Act or feel defensively about food 78 25 3.0

Gastrointestinal symptoms 100 57 3.7

Unusual sleepiness 95 57 3.5

Skip important or social events 58 0 2.2

Miss school classes or work days 47 0 1.7

Interference with interests 74 10 2.7

Violence towards others 63 0 2.0

Contemplation of suicide 37 5 1.6

Binge eaters

Low

Eating behaviors M p <

Eat with poor table manners 1.9 .001

Eat food straight out of cans 1.2 .000

Eat food while still frozen 1.1 .01

Eat food while still too hot 1.7 .000

Eat food picked off the floor 1.1 .01

Eat soiled or dirty food 1.0 .01

Eat part of food wrappings 1.0 .01

Trash food but later eat it 1.0 .05

Eat spoiled, expired, rotted food 1.0 .01

Eat food raw meant to be cooked 1.3 .001

Eat chewable vitamins as if candy 1.1 .01

Eat medicines as if regular food 1.1 .05

Eat others’ leftovers while washing 1.1 .001

Eat food disliked any other time 1.1 .000

“Stretch-out” food by diluting 1.1 .01

Add ingredients to “thicken” food 1.1 .001

Cut food up to make it last longer 1.3 .000

Binge while driving 1.2 .001

Lead vendors to believe food is for

others 1.1 .000

Pretend to save food for others 1.1 .000

Steal food 1.1 .001

Hoard or hide food 1.2 .000

Lie about having binged 1.1 .000

Manipulate others to binge 1.1 .000

Save food until alone to binge 1.1 .000

Act or feel defensively about food 1.4 .000

Gastrointestinal symptoms 2.0 .000

Unusual sleepiness 1.9 .000

Skip important or social events 1.0 .01

Miss school classes or work days 1.0 .000

Interference with interests 1.1 .000

Violence towards others 1.0 .01

Contemplation of suicide 1.1 .01

Note. Means range from 1 for never to 5 for always.

By contrast, none of these measures was reported by the low-binge group. Methods to avoid binge eating that this group mentioned included throwing food away, going to sleep, calling friends, taking diet pills, limiting availability of money and “trigger” foods that tended to set off a binge, reading the nutritional value of foods, overcooking and overseasoning food, and even pouring detergent over the desired food. Participants volunteered information on other perceived “abnormal” or “weird” eating behaviors, including hovering over food, obsessing over the next meal, eating off others’ plates, eating while cooking, binge eating before arrival of invited dinner guests to avoid eating with them, squeezing fat out of food with napkins, and eating in the middle of the night.

COMMENT

In this pilot study, we assessed the presence of aberrant eating behaviors that have been shown to emerge as a sequel to semistarvation. Victims of war and famine, as well as participants in controlled semistarvation experiments, develop frenzied and disturbed behaviors toward food and food intake that persist long after food is plentiful and readily available.[8,17.18,20,21,24] These behaviors among binge eaters have not been well identified or quantified in previous research. Our results with college students showed that their classification into low-binge or high-binge eating status on the basis of DSM-IV criteria for BED is clearly predicted from their reported frequency of semistarvation-like symptoms on the SSABS. The high-binge group admitted to these behaviors, including peculiar eating habits, drastic methods to resist binges, and persistence in these behaviors despite significant physical, emotional, and lifestyle consequences. In women, increased frequency of dieting was strongly related to reported experiences with semistarvation-associated behaviors.

Women in our high-binge group engaged in hoarding, stealing, lying, secrecy, defensiveness, licking, scraping, scooping, and diluting food, making strange mixtures of food (concocting), eating inappropriate foods, or eating appropriate foods in a clearly inappropriate manner. These behaviors are similar to those behaviors observed in cases of genuine semistarvation. Foods that were disliked or avoided at any other time were also reportedly eaten during binges, much as did participants in the Minnesota semistarvation experiment, who overate without regard to taste or texture.[18]

The frenzied approach to eating that may be appropriate, even adaptive, during a famine or in an enemy concentration camp was reported by modern college students, particularly those reporting frequent dieting. We assessed affective qualitative data for one of these behaviors–bizarre mixing of food. This habit was reported to elicit many negative emotions, ranging from numbness to depression and disgust, apart from the negative emotions that emerged after eating the concoctions. Such behaviors may be clinically important because they may add to or exacerbate the psychopathology of binge eating.

Similar emotions are ascribed to binge eating in general. Bulimia nervosa patients feel unhappiness, anger, and anxiety before binge eating, then experience disgust, guilt, fatigue, depression, humiliation, and self-contempt after they binge.[25] The source of negative affect in eating disorders is generally attributed to the act of overeating itself and to the lack of control that characterizes it. However, negative emotions are reported to occur before ingestion and during the concocting process, stressing the important contributions that pre-binge rituals and habits may have on the negative affect that is typical of BED.

Women in the high-binge group identified with measures aimed at resisting their disturbed food consumption behaviors in addition to their peculiar treatment of food and food-intake behaviors. Historical reports give examples–limiting oneself to a certain amount of food, chewing gum, smoking, compulsive coffee drinking, and even self-mutilating–to stop the perceived shameful behaviors.[13,17,26] Responses to the SSABS indicate that students in the high-binge group commonly engage in similar measures and also chew and spit out food, chew nonedible foods, adulterate foods, and threaten themselves with punishment to make food and eating less tempting. None of these behaviors was reported by participants with low BE scores, who were instructed to refer to “a binge” as a time when they had overeaten.

We also assessed the effect of high-binge and low-binge status on semistarvation-associated behaviors in a sample of 8 male participants, but the size of that sample limits the value of our results for broader generalization. We found interesting relationships warranting inclusion of a larger male population in future studies. Other studies have shown that men choose to lose weight by exercising more often than by dieting.[27] Women chose to lose weight more often by dieting and reducing caloric intake to a greater degree and more frequently than men do.[28,29] A certain degree of caloric restriction, therefore, may be necessary for the behavioral symptoms of semistarvation to develop.

Our present findings for women are consistent with the semistarvation literature, in that there was a strong relationship between how often the women dieted and how commonly they engaged in semistarvation-associated behaviors. This finding is also consistent with studies that suggest a predisposing effect of dieting on BED.[30-32] The present results extend these findings by showing that dieting is associated with the severity of binge eating. However, dieting is a multidimensional phenomenon. The SSABS allowed for only a limited assessment of dieting. It would be valuable to assess responses on the SSABS against other dimensions of dieting, such as current weight-loss behaviors compared with past weight-loss and weight-loss history,[30,33,34] dieting intensity, and perceived caloric intake.[35]

Another meaningful finding with the SSABS is that the prevalence of semistarvation-related behaviors seemed not to differ by ethnicity. Recent epidemiologic studies show that eating disorders cross racial and cultural boundaries.[36,37] The present data extend these findings by suggesting that the expression of semistarvation-like behaviors in binge eating is also cross-cultural.

The SSABS addresses information not currently available in eating-behavior assessment instruments, specifically aberrant habits and rituals, resistance, and consequential outcomes of binge eating. The small sample we surveyed (40 participants, 32 women and 8 men) is a limitation we faced in developing the SSABS. However, the strong statistical relationships we found warrant further use of this scale in binge-eating populations.

We might also add the traditional caveats for self-reported behavior (eg, more face than predictive validity, misinterpretation, and response bias). Although eating-disorder patients have been shown to deny symptoms in self-reports[5,38] others have shown self-report scores in binge-eating and body-shape concerns to be higher than those generated through interviews.[39] In support of the clinical utility of self-report tools, Hetherington et al[40] assessed pathological eating by using videotapes (an objective measure) and reported that scores showed a high correlation with the Eating Attitudes Test and the Bulimic Investigatory Test-Edinburgh, both self-report measures. Other researchers have found a kappa value of .57, representing fair-to-good agreement beyond chance between self-report and expert ratings (interview and longitudinal evaluation) in the diagnosis of BED in women.[23]

In its present preliminary form, the SSABS found unusual behaviors to be quite common among high-binge participants. More important, we believe that participants will admit and report these behaviors if given an appropriate medium in which to do so. Thus, implementation of the SSABS may eventually challenge the presumed idiosyncratic nature of peculiar eating behaviors. In addition, the SSABS may help make it possible to assess the obsessive-compulsive and addictive nature of binge eating. One might expect that a clinical sample would respond to these behaviors with even more frequency, especially if the participants also engaged in dieting.

In addition to the data we analyzed, we noted several unexpected outcomes from our survey. After completing the SSABS, several in the high-binge group informed us that the process had given them a more objective view of their eating behavior. In the clinical setting, denial of the life-quality impact of binge-eating behavior is a stubborn problem.[38,41-43] Some of the participants recognized that they “had a problem” but did not appreciate its full significance until they responded to the graphic items on the scale. Others were surprised to learn that they were not alone in acting out some of the more shameful and bizarre behaviors.

Participants’ realization that their behaviors were symptoms of a prevalent disease may be therapeutically useful, at least in prompting the participants to seek professional help. After participating in this experiment, two students reported that they had begun to attend a binge-eating support group.

Several of the control participants (those with low BE scores) remarked on the bizarre nature of the SSABS questions, and commented with disbelief that others actually engaged in such strange eating behaviors. The greater understanding of and sensitivity to the serious nature of contemporary BEDs, that the participants gained are outcomes that this study hopes to advance among those who do research in eating behavior and clinicians who interact directly with eating-disorder patients.

College students who binge eat do not resemble either victims of war and famine or the Minnesota semistarvation volunteers, whose appearances have been likened to World War II concentration camp victims. We propose that the presence of common semistarvation symptoms among our high-binge group who also engaged in what might be perceived as “normal” dieting indicates a greater pathology in BEDs than suggested in the literature.

NOTE

For additional information, please address comments to M. M. Hagan, PhD, Department of Psychiatry, University of Cincinnati Medical Center, PO Box 670559, Cincinnati, OH 670559, e-mail: haganmm@email.uc.edu

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APPENDIX A

Questions for Binge-Eating Disorder (BE) Score

All of us, at: one time or another, have overeaten. For this questionnaire, we will refer to a time when you have overeaten as a “binge.” Overeating will be called “bingeing.”

Please answer “yes” or “no” to the following questions:

1. When you binge, is it usually done all at one

sitting (within 2 hours)? Yes No

2. When you binge, is the amount of food definitely

larger than most people would eat in a

similar period of time and under similar

circumstances? Yes No

3. While bingeing, do you eat more rapidly than

normal? Yes No

4. While bingeing, do you eat until you are

uncomfortably full? Yes No

5. Do you binge when you are not hungry? Yes No

6. Do you binge alone because you’re

embarrassed by how much you are eating? Yes No

7. Do you feel disgusted with yourself,

depressed, or guilty after overeating? Yes No

8. Do you feel distressed (deeply bothered)

about binge eating? Yes No

9. Does your binge eating occur, on average,

2 days a week or more? Yes No

10. While bingeing, do you have a sense that

you cannot control your eating once it

has started? Yes No

Dr Hagan is a postdoctoral fellow in the Department of Psychiatry at the University of Cincinnati Medical Center, Cincinnati, Ohio. Both Dr Whitworth and Dr Moss are with the Department of Psychology at the University of Texas at El Paso, where Dr Whitworth is a professor emeritus and Dr Moss is a professor.

COPYRIGHT 1999 Heldref Publications

COPYRIGHT 2000 Gale Group