Over the past decade, there has been increasing interest in assessing eating disorders from a cross-cultural perspective. The Eating Disorders Inventory (EDI) is an instrument that has been used in eating disorder research and is known to be reliable and valid.
INTRODUCTION
DISORDERED EATING ACROSS CULTURES
RATIONALE FOR A VALIDITY STUDY
For example, Lee, Lee, and Leung (1998) attempted to determine the validity of the EDI with a Chinese population. This weakens the effectiveness of the EDI as a screening instrument for eating disorders in the Chinese population.
LITERATURE REVIEW
INTRODUCTION
DEFINITIONS
- Validity
- Reliability
Test-retest reliability is determined by applying the measure twice to the same group of test subjects. Reliability is determined by the correlation between the first and second application of the measure.
Eating disorders
- Culture, culture bound syndrome and acculturation
The binge eating and inappropriate compensatory behaviors both occur on average at least twice a week for 3 months. The criteria for Binge-Eating Disorder as described by the American Psychiatric Association, (2000), are as follows:
A GLOBAL OVERVIEW OF EATING DISORDERS
A FEMINIST PERSPECTIVE ON EATING DISORDERS The last two decades have seen a paradigm shift within feminist thought. This needs
Thinness is seen as the ideal because it symbolizes self-control and shows the ability to delay gratification. These are essential qualities if you want to compete in a male-dominated world (Eichenbaum & Orbach 1992).
EATING DISORDERS ACROSS CULTURES
Research shows that African American women also have lower body dissatisfaction and higher body image ideals than their white counterparts. There is also evidence that body image is influenced by socio-economic status and that women with low socio-economic status have lower body image ideals than women with higher socio-economic status (O'Neill, 2003).
ACCULTURATION
As Western ideals of thinness are embraced, these young women appear to be more at risk of developing eating disorders (Wassenaar et al., 2000). Eating disorders appear to have escalated with increasing economic growth and appear to be a growing problem in low-income groups (Nasser et al., 2001).
NON-FAT PHOBIA ANOREXIA
The traditional Western concept of so-called fatphobia appears to be just one of the associated features of anorexia nervosa. 34; Epidemiological studies in the Western community generally found a very low prevalence of anorexia nervosa” (Hsu, 1990, as cited in Nasser et al., 2001).
ANOREXIA DISGUISED BEHIND A RELIGIOUS FACADE
CULTURAL PURGING PRACTISES
There are various preparations available from pharmacies and other traditional medical practitioners that use herbs to cleanse the body of harmful impurities. The practice of using an enema or emetic to cleanse the body of disease means that the entire system is cleansed rather than a single affected organ (Leclerc-Madlala, 1994).
INSTRUMENTS USED IN EATING DISORDERS
- QUESTIONNAIRES
- Body-Image Ideals Questionnaire (BIQ)
- Eating Attitudes Test (EAT) Description
- Multiaxial Assessment of Eating Disorder Symptoms (MAEDS)
- Survey for Eating Disorders (SEDs)
- TOOLS SPECIFICALLY FOR BULIMIA NERVOSA .1 Bulimic Inventory Test, Edinburgh (BITE)
- The Bulimia Test (BULIT) Description
- INTERVIEWS
- Eating Disorders Examination (EDE) Description
- TOOLS FOR THE ASSESSMENT OF CHANGE IN EATING DISORDERS
- Eating Inventory Description
- University of Rhode Island Change Assessment Scale (URICA)
- Anorexia Nervosa Stages of Change Questionnaire (ANSOCQ)
There was adequate concurrent and discriminant validity (Anderson et al., 1999 as cited in Martin et al., 2000). It has been shown to be a reliable and valid measure for the assessment of eating disorders as defined in the DSM-IV (American Psychiatric Association, 2000) (Kutlesic et al., 1998 as cited in Martin et al., 2000).
THE INSTRUMENTS CHOSEN
The EDI-2 (Garner, 1991) is a newer, revised and updated version of the EDI and was considered as a possible tool for use in the current research project. The advantages and disadvantages of EDI-2 will be discussed in more detail to gain a more in-depth understanding of why EDI was chosen for this research project. The EDI-2 is a widely used self-report measure (Ghaderi & Scott, 2002). The item-total scale correlations for nonpatient college students appeared to be lower than reported on the original EDI subscales. As a result, the subscales were retained because they appeared to have relevance to a subset of eating disorders (Garner & Olmstead, . 1984).
EDI-2 has not been used as widely as EDI, and less research is available on EDI-2. The questionnaire is also significantly longer, which could lead to greater resistance in filling it out.
SHORTCOMINGS OF USING THE EATING DISORDERS INVENTORY (EDI)
Third, the EDI fails to consider the full spectrum of psychopathological features of anorexia nervosa. Finally, the EDI measures cognitive and behavioral characteristics of eating disorders, namely anorexia nervosa and bulimia nervosa, but does not include questions about, for example, amenorrhea, weight, height or use of oral contraceptives. The EDI alone is insufficient in formulating a diagnosis of eating disorders (Ghaderi & Scott, 2002).
To improve the EDI as a screening measure that can be used for clinical evaluation, the above additional questions could be included to make a differential diagnosis of eating disorders (Augestad & Flanders, 2003).
RELIABILITY OF THE EATING DISORDERS INVENTORY (EDI)
THE ORIGINAL VALIDATION OF THE EATING DISORDERS INVENTORY (EDI)
Discriminant validity: The EDI subscales, Drive for Thinness, Body Dissatisfaction and Bulimia were found to be more correlated with other measures that assessed eating and dieting behavior and less correlated with measures of more general psychopathology (Williamson, Anderson, .luckman & Jackson as cited in Allison, 1995). Criterion-related validity, which is the ability of items to discriminate between eating-disordered and non-patient samples, was determined by administering the EDI to a small group (n=49) of recovered anorexic patients. The recovered anorexia scored lower than the anorexic group on every subscale of the EDI.
In addition, anorexic patients were similar to the mean of the nonpatient group (Garner & Olmstead, 1984). It can be concluded that the EDI has been relatively well validated and appears to be reliable (Augstad & Flanders, 2003).
SHORTCOMINGS OF THE EATING DISORDERS INVENTORY (EDI)
METHODOLOGY
- AIMS
- HYPOTHESES
- SAMPLE
- PROCEDURE
- The EDI questionnaire
- The clinical interview
- INSTRUMENTS FOR ASSESSMENT .1 The EDI questionnaire
- Additional data collected
- Clinical interview
- DATA ANALYSIS
- The EDI subscales
- Validation study
- ETHICAL ISSUES .1 Preserving autonomy
- Preserving confidentiality and anonymity
- Limits to confidentiality
- Non-maleficence
- Potential harm
- Benefits
- ANTICIPATED PROBLEMS
Of the sample that completed the EDI questionnaires and signed consent to be part of an in-depth interview (5), 2% declined when recruited for interview. The co-investigator (an experienced clinician with 20 years of clinical experience and some international publications in eating disorders) conducted twenty-six of the thirty interviews, and the researcher added additional questions she felt were relevant or had been omitted. The co-investigator approached the interviews 'blind', in other words unaware of the participant's EDI score.
At the conclusion of each interview, the co-investigator provided his clinical impressions of the participants. In closing, the interviewees were thanked for their participation in the interview and provided a summary of the results after the study was completed. Mean scores and standard deviations for the eight EDI subscales were calculated separately for Blacks, Asians, and Whites.
The co-researcher also made predictions of the three {Drive for Thinness, Bulimia and Body Dissatisfaction) EDI subscales. An analysis of the EDI cut-offs on the three subscales was used to determine the definitions of high and low scorers.
RESULTS
- RELIABILITY OF THE EDI
- THE EDI SUBSCALES .1 Mean subscale scores
- Comparison of mean subscale scores by race
- Pearson's correlations between subscales
- Proportional differences above cut-off points
- PILOT VALIDATION OF THE EDI
- Cross tabulation: clinical rating and EDI rating
The percentage of black, Asian and white participants above the cut-off points on the Drive for Thinness subscale. The percentage of black, Asian and white participants above the cut-off points on the Bulimia subscale. The percentage of black, Asian and white participants above the cut-off points on the Body Dissatisfaction subscale.
The percentage of black, Asian, and white participants above the cut-off scores on the Inefficacy subscale. The percentage of Black, Asian, and White participants above the cut-off scores on the Perfectionism subscale. The percentage of Black, Asian, and White participants above the cut-off scores on the Interpersonal Distrust subscale.
Percentage of Black, Asian, and White participants above cutoff scores on the Interoceptive Awareness subscale. Percentage of Black, Asian, and White participants above cutoff scores on the Fears of Maturity subscale.
- The relationship between observed and expected counts
- Strength of association: Kendalls tau
- ADDITIONAL COMPARISONS
- Cross tabulation: clinical rating and race
- Cross tabulation: clinical rating and BMI rating
- Cross tabulation: EDI rating and BMI rating
- The strength of the association: Kendall's tau
- Cross tabulation: EDI rating and race
- Cross tabulation: BMI (pathological/normal) and race
- SUMMARY
- The larger sample (N=257)
- The pilot validation comprising (n=30) participants
The chi-square test (see Table VIII below) was performed to determine the association between the two variables, namely EDI assessment and clinical interview. Kendall's tau was performed to determine the strength of the association between the clinical assessment and the EDI assessment. The chi-square test was performed to determine the association between the two variables, namely, clinical assessment and race.
The correlation between the clinical assessment and the BMI assessment is summarized in Table XI below. The correlation between EDI rating and BMI rating is summarized in Table XIII below. This indicates that the correlation between EDI rating and BMI rating is not significant.
The Chi-square test was performed to determine the association between the two variables, namely EDI Rating and Race. The chi-square test was performed to determine the association between the two variables, namely BMI (pathological/normal) assessment and race.
DISCUSSION
- THE EDI SUBSCALES .1 Mean subscale scores
- Comparison of mean subscale scores by race .1 Drive for thinness
- Body dissatisfaction
- Comparative means and standard deviations of three studies
- Pearson's correlation between subscales
- Proportional differences above cut-off points
- THE PILOT VALIDATION
- An adjustment in methodology to fulfil chi-square assumption The aim of this research, as previously discussed, is towards the pilot validation of the
- Cross tabulation: clinical rating and EDI rating
- ADDITIONAL COMPARISONS
- EDI rating and BMI rating
- MAJOR SHORTCOMINGS .1 Chi-square test
- The clinical interview
- SUMMARY
- Suggestions for further research
- CONCLUSION
The results showed a 100% correlation between low scores on the EDI and low scores on the clinical interview. There was a 64% concordance between the best scores on the EDI and the best scores on the clinical interview. A number of statistical tests were performed to determine the significance of the relationship between the EDI score and the clinical interview.
The chi-square test was performed to determine the significance of the relationship of the EDI rating and the clinical rating. The results of the cross-tabulation show that the clinical rating and race are not associated and the chi-square analysis revealed that there is no significance between the two factors. The match between the EDI score and the clinical. interview was calculated to determine the validity of the EDI cross-culturally.
However, there was a 64% agreement between high scorers on the EDI and high scorers on the clinical interview. The results therefore indicated that there was a strong correspondence between the EDI and clinical interview.
Reliability and preliminary validity of the Eating Disorders Survey (SEDs): A self-report questionnaire for the diagnosis of eating disorders. Religious language in advertising and anorexia nervosa in Wesl.J£ European Journal of Clinical Nutrition, 57,43-51. Implementation of the Eating Disorders Inventory in a sample of black, white and mixed schoolchildren in Zimbabwe.
Cross-cultural validity of the eating disorder inventory: a study of Chinese patients with eating disorders in Hong Kong. Psychometric properties of the Eating Disorders Inventory (EDI-1) in a non-clinical Chinese population in Hong Kong. The prevalence of eating disorder pathology in a cross-ethnic population of female students in South Africa.
Appendix C
