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Project

BINGE EATING AND PURGING IN COLLEGE STUDENTS: CROSS-SECTIONAL AND LONGITUDINAL MULTIVARIATE CORRELATES

INTRODUCTION AND BACKGROUND Binge eating and purging behaviors (BPB) are symptomatic behaviors which can be present in eating disorders and other mental disorders, as well as in non-pathological conditions. Specifically, binge eating refers to episodes during which a person rapidly consumes an excessive quantity of food while feeling a sense of loss of control; purging behaviors are inappropriate compensatory behaviors, aiming to prevent weight gain, which can follow bingeing episodes or exist independently (American Psychiatric Association, 2013). Binge eating and purging behaviors (BPB) are common in western countries (McBride et al., 2013). Estimates for the prevalence of binge eating are in the 4.2% - 11.2% range (more commonly reported by female than male respondents; Reichborn-Kjennerud et al., 2003) and 1.3% - 2.4% for purging (with 3 times higher odds for women; Mitchison & Mond, 2015). The peak of incidence of these disordered eating behaviors is late adolescence (Lewinsohn et al., 2000; Sim et al., 2013), and the transition to college has been highlighted as a period at risk for their development (Compas et al., 1986; Levine, 1996; Slane et al., 2014; Yu et al., 2018). BPB are associated with both physical and mental health problems (Fairweather-Schmidt et al., 2015; Kärkkäinen et al., 2018; Wade et al., 2012). Mood and anxiety disorders (Berg et al., 2009; Keski‐Rahkonen & Mustelin, 2016), substance use, post-traumatic stress, personality disorders (Solmi et al., 2014; Woodside et al., 2001), suicidal thoughts and behaviors and non-suicidal self-injury (Eisenberg et al., 2011; Micali et al., 2015) have been associated with BPB either in isolation, or in consideration of a limited set of comorbidities and potential confounders. BPB frequently co-occur with other mental health problems (Auerbach et al., 2018) making hard to understand whether BPB are uniquely associated with specific mental health problems and/or long term consequences. Given that BPB are relatively common in youth and that most of western high-school graduates enroll in college (Institute for Statistics, UNESCO), it is surprising that the potential role of BPB in academic performance and career has scantly been investigated. Our previous study found that BPB (especially binge eating) are relatively common and associated with mental health problems, comparatively low academic performance, and higher risk of academic failure among college first-year students (Serra et al., 2020). To our knowledge, only few other studies on this subject exist (Hoerr et al., 2002; Yanover & Thompson, 2008), suggesting that subjective academic interference in students with such symptoms. Further work on this topic is needed to clarify the longitudinal role of BPB in academic performance, student’s mental health (including Suicidality and non-suicidal self-injury) and help seeking behavior. Also, these results will need to be tested in association to sociodemographic confounders and other mental health problems to clarify the possible, individual role of BPB in the prediction of such outcomes. The project is part of a larger study using data from the Leuven College Surveys, carried out in annual surveys of college since the academic years 2012-2013 and 2013-2014, as part of the WHO World Mental Health International College Student Initiative (WMH-ICS; http://www.hcp.med.harvard.edu/wmh/college_student_survey.php). The WMH-ICS aims to collect cross-national epidemiological information about mental health problems among college populations worldwide. Building upon these findings, the initiative will investigate the efficacy of various interventions promoting students’ well-being, social integration, and academic functioning.  B. GENERAL HYPOTHESIS AND SPECIF AIMS OF THE PROJECT This PhD has its foundation in a previous work titled “Twelve-month binging and purging behaviors in college freshmen: prevalence, psychiatric comorbidity, and academic performance” (Serra et al., 2020) and a series of other articles focusing on the same pool of subjects (Bruffaerts et al., 2018; Kiekens et al., 2016; Mortier et al., 2015; Ebert et al., 2019; Benjet et al., in press). The current PhD builds on these findings by further investigating BPB in their longitudinal association with other mental health problems, academic functioning, and help-seeking behaviors,. More specifically the research questions are: - Does BPB at baseline have an impact on academic functioning throughout the academic career? - Does BPB at baseline predict the onset of comorbid mental problems (eg major depressive disorder, anxiety disorder, or substance use disorder) or suicidal thoughts and behaviors (ie suicide ideation, plan, and/or attempt) at follow-up? - What are risk and protective factors against the onset of comorbid mental problems and/or suicidal thoughts and behaviors in students with BPB? - How many students with BPB are or have been in treatment? Are there specific treatment barriers for students with BPB, and how does service use relates to the onset of comorbid mental disorders and suicidal thoughts and behaviors? The setup is exploratory in nature, and, hence, hypotheses-generating instead of hypotheses-testing. The available data allows to improve on existing knowledge in multiple ways. First, the use of both cross-sectional and longitudinal data will offer a more dynamic perspective on the clinical course of BPB among college students. Second, the possibility of testing multivariate models, including a wide range of clinical and sociodemographic risk factors, could lead to more specific and un-ambiguous prediction models of BPB, its risk/protective factors, and its prospective consequences. Third, the relative numerosity of the sample will offer the possibility of performing sub-group analysis and to study multivariate mediation and moderation models, pushing the understanding of this phenomenon farther. Ultimately, we are confident that the obtained results will lead to a more detailed understanding of BPB in emerging adults, with implications on the clinical field, but also on the level of policy makers in their efforts of C. METHODOLOGY Sampling The data gathering was carried out in two phases. In phase 1, cross-sectional data on the students enrolled in university for the first time was gathered (Generation Students [GS]). In Phase 2, these students were followed-up until 2018, providing four waves of longitudinal data. The longitudinal data that will be used in the current PhD is already collected between 2012 and 2018. The sample is the population of GS of the KULeuven with a follow-up of the baseline sample of the academic years 2012-2013 and 2013-2014 (ie one baseline assessment with four follow-up assessments). At baseline, each GS was invited by the Student Affairs Office for a medical check-up at the student’s Health Centre (MPTC). This occasion was used to administer an electronic survey. The baseline (T0) population consists of 4,889 first-year students (weighted response rate [RR] 73%), with 2,434 students in the first (conditional RR=67%), 1,982 in the second (conditional RR=81%), 1,759 in the third (conditional RR=89%), and 1,641 in the fourth follow-up assessment (conditional RR=93%). All data are weighted in order to tackle non-response bias and maintain representativity. The overall RRs are far above the commonly reported mean RR of 39.6% found in a meta-analysis of 68 e-surveys (Cook et al., 2000). The e-survey used the online surveying software of Qualtrics Labs Inc © (UT, U.S.), which is available in Dutch and English. Students invited to the MPTC completed the e-survey in convenient circumstances, i.e., on a computer installed in a private room. At follow-up, students could choose their own environment to complete the survey. Prior studies suggested that the use of e-surveys increases the honesty of people’s reporting of sensitive information (Watson et al., 2001). Internal subsampling was used to reduce respondent burden. This allowed an optimal balance of response time and number of items assessed. Included instruments and variables Information about freshman socio-demographic characteristics was obtained from the KU Leuven students’ administration office and included gender, age, nationality, parents’ financial situation, parental education, parental familial composition, university group membership, and secondary school educational type. Survey items assessed sexual orientation and living situation at college. Suicidal thoughts and behaviours items were taken from the Self-Injurious Thoughts and Behaviours Interview (SITBI; Nock et al., 2007). STB was conceptualized as a continuum (Nock et al., 2012), starting with suicidal ideation (“Did you ever in your life have thoughts of killing yourself?”), possibly accompanied by a suicide plan (“Did you ever think about how you might kill yourself [e.g., taking pills, shooting yourself] or work out a plan of how to kill yourself?”), and then leading in some cases to a suicide attempt (“Have you ever made a suicide attempt [i.e., purposefully hurt yourself with at least some intent to die]?”). Suicidal ideation was clearly differentiated from a mere death wish (“Did you ever wish you were dead or would go to sleep and never wake up?”). Parental psychopathology and traumatic experiences in childhood-adolescence (i.e. prior to the age of 17) were assessed using 19 items adapted from the CIDI-3.0 childhood section (Kessler and Ustun, 2004), the Adverse Childhood Experience Scale (Felitti et al., 1998), and the Bully Survey (Swearer and Cary, 2003), including parental psychopathology, physical abuse, emotional abuse, or sexual abuse. Risk for 12-month mental disorder was assessed with the Global Appraisal of Individual Needs Short Screener (GAIN-SS; Dennis et al., 2006) including: internalizing disorders (depression, anxiety, sleep problems, post-traumatic stress, and suicidal ideation), externalizing disorders (attention deficit, hyperactivity/impulsivity, and conduct problems), substance disorders (abuse and dependence symptoms), and crime/violence related disorders (drug-related, property, and interpersonal crime). Past year eating disorder symptoms (i.e., binge eating and purging behaviour) were assessed with two items taken from the Mini International Neuropsychiatric Interview Screen (Sheehan et al., 1998). Non-suicidal self-injury was assessed with the corresponding item from the SITBI (cf. above; Nock et al., 2007) that asked students “Did you ever do something to hurt yourself on purpose, without wanting to die (e.g., cutting yourself, hitting yourself, or burning yourself)?”. Stressful events experienced in the past 12-months were assessed using items assessing life-threatening illness or injury of a family member or close friend, accidents or death of a family member or close friend, or interpersonal events (e.g., break-up with a romantic partner, serious betrayal by someone other than one’s partner. Students' academic outcome has been provided from the central services of the KU Leuven for which the study had an approval of the Rectoral Services. Data was de-identified for further analyses. Only the researchers, bound by the law of confidentiality, were able to recall the identity of students, to enable further surveying in Phase 2. Students will be fully informed and will provide informed consent. The Ethical Committee of the KU Leuven gave their approval (B322201215611) as did the Belgian Privacy Commission (VT005040180). Statistics All analyses will use descriptive and bivariate statistics and multivariate between-data (e.g., logistic regression models) and within-data approaches (e.g., hierarchical models for change). To address possible nonresponse bias, statistical weights will be constructed making use of non-response analyses and sociodemographic data. Multivariate regression models will be constructed both cross-sectionally (measurements clustered within units) and prospectively (measurements clustered within persons). The proportion of explained variance, the Bayesian Information Criterion (BIC), Difference in Deviance Tests (DID) and Ockham’s razor principle of generalizability will guide model comparisons. Analyses will be performed with available version of SPSS, and R. D. Milestones and timing of the PhD project In year 1 we will focus on an up-to-date systematic review of available literature that will provide a comprehensive and useful basis for the research and publications to build on. Year 2 will be devoted to comprehensive bivariate and multivariate exploratory analyses based upon data from the cross-sectional survey of Phase 1 of the project. In year 3-4 we will focus on the development of predictive multivariate risk and protective models on mental health problems, help-seeking behavior in students and academic performance. These data will be based on the longitudinal follow-up of our base sample. Years 5-6 consist of the finalization of the PhD and the public, scientific, and policy dissemination of the findings. With regard to feasibility, the project takes root on strong existing publications and will build on that, using the readily available, high quality data. E. Conclusion This study will lead to new information on the epidemiology of BPB in young adults. This will be achieved using a complex analytical approach. The study will provide significant additions and advances to both science and clinical practice by examining theoretically derived and clinically useful prediction models for BPB. Data will be weighted for a wide range of sociodemographic and clinically relevant variables and for non-response in order to provide a realistic and representative analysis of students’ mental health, help-seeking behaviors and academic performance in relation to a relatively common and easily assessable behavior, i.e. BPB. This could provide multiple parties with useful information: the university and policymakers will have access to a scientifically-informed and empirically-derived instrument and method of identifying students at risk for BPB and related risk in academic performance from their first university year. Available prospective data can lead to indications on the longitudinal course of such cases, leading to recommendations regarding the assessment and improvement of student mental health and, perhaps most importantly, recommendations for the prevention of student mental health problems. References - American Psychiatric Association. (2013). 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Date:20 Apr 2021 →  Today
Keywords:Eating disorders, students, mental health
Disciplines:Behavioural sciences
Project type:PhD project