Introduction

Binge-eating disorder (BED) is a provisional new diagnosis, included in the 4th edition of the Diagnostic and Statistical Manual of Mental Disorders.¹ Although weight is not a diagnostic criterion of BED, the majority of patients with BED are overweight.² Among obese adults seeking help for obesity, binge eating without purging appears to be a prevalent problem with an estimated prevalence rate of 20–50%.^2,3,4,5,6

To our knowledge, the prevalence of binge eating in obese adolescents has only been dealt with in three studies. Severi et al⁷ reported that in a sample of obese youngsters, 18% of the boys and 27% of the girls had binge-eating problems. The second study, by Berkowitz et al,⁸ examined binge eating in obese girls seeking treatment for severe obesity. Using a diagnostic interview, 30% of the girls were found to engage in manifest binge eating. Britz et al⁹ detected binge-eating episodes in 57% of the female and 35% of the male obese adolescents studied.

However, there are some issues that limit the generalizability of the prevalence data available. First, in the three studies, the number of obese adolescents was relatively small.^7,8,9 Moreover, the study by Berkowitz et al⁸ did not include male adolescents. As previous studies suggest that BED occurs in a substantial minority of men seeking treatment for obesity, it is important to include males as well as females.^2,5,10 Secondly, the data of the studies were retrieved from adolescents between the ages of 13 and 21 y.^7,8,9 To our knowledge, no studies were published about binge eating in obese children younger than 13. Finally, in each of the three studies, the information gathered about binge eating was based on different measures. The prevalence rate and the definition of binge eating may differ across the studies because of the variety of the assessment instruments.^11,12

The present study was designed to address some of the limitations in current research on binge eating. The first aim of the study was to investigate the prevalence of BED in a larger sample of boys and girls seeking help for obesity, using the eating disorder examination (EDE).¹³ The EDE is an intensively studied interview having several advantages over alternative methods of assessment. It is considered to be the golden standard for the diagnosis of specific eating disorder psychopathology.^13,14,15 It is the only instrument that directly assesses the diagnostic criteria of all eating disorders and differentiates between the various forms of overeating. In order to use the EDE with children, the Child EDE (ChEDE) was designed, which is an adaptation of the original adult version of the EDE.¹⁶

The second purpose of the study was to examine whether the severity of binge eating is associated with the degree of overweight. Compared with obese adults who do not binge, those adults that do binge are more likely to weigh more.^17,18,19 However, the results have been mixed with other studies reporting no difference between obese individuals with and without binge eating.^8,20 We expected obese children with binge-eating problems that did not purge to weigh more because of the excessive energy intake resulting from the binge-eating episodes.

The third objective of the study was to assess the age of onset of binge eating in youngsters experiencing binge-eating episodes. There is evidence that eating disorders already occur among 7-y-old children,¹⁶ but, to the best of our knowledge, no studies are published about the age of onset of binge eating in children of this age. The evidence available on the subject relies solely on retrospective reports in obese adults. An additional aim was to identify a developmental factor, including the age of onset of overweight, which may distinguish children and adolescents with binge eating from those that do not binge. In obese adults, it has been demonstrated that binge eaters have an earlier onset of obesity,²¹ and that overweight precedes binge eating.²²

Method

Subjects

A sample of 196 obese children and adolescents (78 boys and 118 girls) between the ages of 10 and 16 participated in the study (M=12.73 y, s.d.=1.75). All subjects were seeking help for obesity. The sample was selected in such a manner that it consisted both of obese children seeking inpatient and outpatient treatment. All obese children seeking inpatient or outpatient treatment between July 1999 and December 2001 were invited to participate. The response rate was 72%. Children younger than 10 or older than 16 and mentally retarded children were excluded from the study. All participating children obtained a diagnosis of primary obesity. The mean weight was 81.25 kg (s.d.=19.32) and the mean height was 160.70 cm (s.d.=9.89), corresponding to a mean body mass index (BMI) of 31.15 (s.d.=5.34). The degree of overweight was expressed in the adjusted BMI (see below). The group had a mean adjusted BMI of 172.69% (s.d.=27.09) with a range of 120–253%. Informed consent was obtained from both the children and their parents. The group of children that did not participate consisted of 44 girls and 37 boys. Their mean age was 12.56 (s.d.=1.80) and their mean overweight was 166.75% (s.d.=25.40). No significant differences were found between the participants and the nonparticipants as regards age and degree of overweight. A -quadrate analysis (²(1)=0.39, NS) showed no significant sex differences between the two groups. The study was approved by the local research ethics committee. The subjects were visited at their homes before they entered into treatment.

Measures

Body weight

The BMI (weight/height²) was calculated for each child. In order to make BMI comparisons between obese children of different ages, the adjusted BMI is used in this study. The formula is [actual BMI/ percentile 50 of BMI for age] 100. The 50th percentiles of the BMI for age and sex are based on normative data.²³

Binge-eating pathology

The EDE¹³ is a standard investigator-based interview measuring the severity of the core psychopathology of eating disorders and generating eating disorder diagnoses. The Child EDE was designed for use in populations of Dutch children following the recommendations made by Bryant-Waugh et al,¹⁶ Bryant-Waugh and Fairburn (personal communication). The ChEDE was modified to make certain questions more concrete for children and some of the items were reformulated to assess intent rather than actual behaviour.¹⁶ Preliminary findings suggest that the ChEDE is a sensitive measurement to assess key psychopathological features among children. The subscale scores are in line with the norms for adults.¹⁶

The ChEDE contains four subscales designed to provide a profile of individuals in terms of four major areas of eating disorder psychopathology: restraint, eating concern, shape concern and weight concern. In addition, the ChEDE measures three forms of overeating: objective bulimic episodes (OBEs), subjective bulimic episodes and objective overeating episodes, and four methods of weight control: self-induced vomiting, laxative misuse, diuretic misuse and intense exercising.

Tests of the discriminant validity of the EDE among subgroups of eating disordered individuals^24,25, tests of inter-rater reliability^25,26,27,28 and tests of concurrent validity²⁷ all support its use. The EDE has demonstrated good internal consistency^24,29 and the test–retest reliability has been well established.²⁸

The interviewers were trained by two certified trainers for the adult version and the child version of the EDE. The interviewers were clinical psychologists and were provided with video and audio tapes.

The diagnosis of BED was based upon EDE-symptom ratings as they pertained to research criteria for the BED of the DSM-IV.¹ The DSM-IV requires two binge-eating episodes a week in the absence of inappropriate compensatory behaviours to make a diagnosis of BED. Additional questions regarding the specific research criteria of the DSM-IV allowed all BED criteria to be assessed.

Age of onset of binge eating, overeating and overweight

Additional questions were asked regarding the age of onset of overweight, overeating and binge eating. The age of onset of overweight was defined by asking the parents: 'At what age did your child become overweight?' The age of onset of overeating, respectively binge eating, was conservatively defined as the age at which the first significant and persistent behavioural characteristic of an eating disorder began (regular episodes of overeating with or without loss of control), rather than the age at which the subject first met the full diagnostic criteria for BED. Only when overeating, respectively binge eating, was relevant, the following question was asked: 'At what age did you first have an episode of the type we have just described (referring to an episode of overeating, respectively objective bulimic episode)?'

Statistics

The results were expressed as mean (s.d.) or percentage of the sample. Categorical data (gender, presence of BED, presence of OBEs) were analysed using the ² statistic. Continuous data (age, adjusted BMI, severity of OBEs, ChEDE-subscales, ages of onset) were compared using t-tests, multivariate analyses of covariance (MANCOVAs) or univariate analyses of covariance (ANCOVAs). Data were analysed using the SPSS version 10.0. P-values less than 0.05 were considered statistically significant.

In order to increase the generalizability of the results, we opted to combine the data from both samples. The separate data from each sample are displayed in the tables.

Results

Characteristics of the respondents of the two samples

Sample 1 consisted of 158 children and adolescents (65 boys and 93 girls) between the ages of 10 and 16, recruited from a Medical Paediatric Centre that has a waiting list of 100 youngsters a year seeking inpatient treatment for their obesity. The mean age of the subjects in sample 1 was 12.77 (s.d.=1.81). The participants had a mean weight of 81.28 kg (s.d.=19.50) and an average height of 160.50 cm (s.d.=10.44), corresponding to a mean BMI of 31.22 (s.d.=5.26). The mean adjusted BMI for the sample was 172.88% (s.d.=26.31).

Sample 2 consisted of 38 participants (13 boys and 25 girls) who had applied for an outpatient weight loss treatment at the University Hospital. The mean age of the sample was 12.58 (s.d.=1.46) with a mean adjusted BMI of 171.94% (s.d.=30.47). The participants had a mean weight of 81.12 kg (s.d.=18.85) and an average height of 161.57 cm (s.d.=7.25), corresponding to a mean BMI of 30.87 (s.d.=5.75). The mean adjusted BMI for sample 2 was 171.94% (s.d.=30.47).

The main characteristics of the outpatient sample and the inpatient sample are shown in Table 1. No significant differences were found between the two samples as regards age and degree of overweight. A -quadrate analysis (²(1)=0.43, NS) also showed no significant sex differences between the inpatient sample and the outpatient sample.

Table 1 - General characteristics of obese children and adolescents seeking help.

Full table

Prevalence of disturbance of eating

Table 2 presents the prevalence of the different patterns of overeating found in both samples of obese subjects seeking help. Combining the estimates of prevalence of the two samples, two subjects (1%), both female, met the full diagnostic criteria for BED. In all, 18 subjects (9.2%) experienced at least one OBE over the previous 3 months (OBE, overeating with loss of control), but did not endorse all of the other DSM-criteria that are required for a diagnosis of BED. Of these subjects, 13 were female and five were male. Seven subjects (3.6%) reported they had tried to control their shape or weight by self-induced vomiting, laxative or diuretic misuse, or intense exercising over the previous 3 months. Three of these subjects were female and four were male. Since the regular use of these inappropriate compensatory behaviours occurred in the absence of binge eating, no subject was considered bulimic. Episodic overeating was more common. A total of 24 subjects (12.2%) had experienced at least one episode of objective overeating (OO, overeating without loss of control) in the past month. Nine of these were female and 15 were male.

Table 2 - Prevalence of eating patterns.

Full table

In order to compare the present study with previous studies in the subsequent analyses two groups were put together: subjects with BED and subjects displaying subclinical binge eating. In this group, the average number of OBEs was 11.65 (s.d.=18.50) over the previous 3 months. A t-test revealed a significant difference between obese girls and obese boys in the presence of OBEs, with girls having significantly more OBEs than boys (t (118)=2.18, P<0.05).

The mean ChEDE-scores of the full sample (n=196) were 0.96 (s.d.=0.92) for restraint, 0.62 (s.d.=0.75) for eating concern, 1.90 (s.d.=1.11) for weight concern and 1.83 (s.d.=1.26) for shape concern. A MANCOVA was conducted on the eating pathology measures (ChEDE) with two between-subject factors: binge category (OBE subjects vs non-OBE subjects) and sex, while controlling for degree of overweight (adjusted BMI) and age. The results of the MANCOVA indicated a multivariate main effect for the binge category, F (4,186)=2.54, P<0.05. The univariate F-tests revealed significant results for eating concern F (1, 195)=3.77, P<0.01 and shape concern F (1,195)=4.37, P<0.05. There was no significant multivariate main effect for sex. Furthermore, there was no significant interaction effect for sex and binge category. Controlling for age and degree of overweight, subjects with OBEs are more concerned about their eating and shape than subjects without OBEs.

To compare the subjects of the inpatient sample with those of the outpatient sample, a MANCOVA was conducted on eating pathology measures (ChEDE) with the seeking help status (inpatient vs outpatient) as a between-subject factor, while controlling for degree of overweight (adjusted BMI) and age. The multivariate F-test revealed no significant main effect for the seeking help status. An ANCOVA was conducted on the severity of binge eating (frequency of OBEs) with seeking help (inpatient vs outpatient) as a between-subject factor, while controlling for degree of overweight (adjusted BMI) and age. No significant effect for severity of binge eating was found. Controlling for overweight and age, subjects seeking inpatient treatment and outpatient treatment do not differ in eating pathology or in severity of binge eating.

Binge eating and weight

An ANCOVA, entering age as a covariate, for degree of overweight (adjusted BMI) revealed a significant difference between the subjects with OBEs and those without OBEs. Controlling for age, the subjects that suffered from OBEs in the past 3 months had significantly higher ABMI than those without OBEs (F (1,194)=5.805, P<0.05). A significant relationship was found between the degree of overweight and the severity of binge eating (r=0.20, P<0.01). The presence of OBEs was associated with a significantly higher adjusted BMI.

Age of onset of overeating, binge eating and overweight

As shown in Table 3, the onset of binge eating occurred between the ages of 6 and 15. In general, for the entire group with binge-eating problems, the mean age of the first overweight was 6.75 (s.d.=3.26), the age of the first episode of objective overeating was 9.31 (s.d.=2.90) and the age of the first OBE was 10.88 (s.d.=2.60).

Table 3 - Age of onset of binge eating and overweight in obese children and adolescents seeking help.

Full table

In assessing the progression of mean onset ages, it appears that overweight precedes overeating and binge eating. Paired samples t-tests revealed a significant difference between the ages of onset of overweight and overeating (t (12)=3.96, P<0.01), between the ages of overweight and binge eating (t (15)=5.90, P<0.001) and between the ages of overeating and binge eating (t (12)=4.19, P=0.001). With one single exception, all subjects engaging in OBEs stated that their obesity had set in prior to their first binge.

In terms of onset of overweight, there was no significant difference between subjects with and those without OBEs.

Discussion

This is the first study that determined the prevalence of BED in obese children. BED was rarely found in the sample of obese children seeking inpatient or outpatient treatment. Only two of the 196 (1%) obese youngsters met the full diagnostic criteria for BED. Eating disturbances such as binge eating, episodic overeating and the use of inappropriate compensatory behaviours were more common. Previous studies of binge eating in obese adolescents, however, reported much higher prevalence estimates.^7,8,9 Several factors may explain the low prevalence of binge eating in this sample. First, the method used in this study is different from those used in previous studies. Secondly, the subjects in the present study may have been too young. It is possible that a larger number of children in this study may develop an eating disorder at a more advanced age, given that childhood obesity is related to the development of bulimia nervosa as well as BED.^30,31

Binge eating was more prevalent in girls than in boys. Gender differences in anorexia and bulimia nervosa are substantial. However, our study underlines the fact that these differences occur to a lesser extent among obese binge eaters. Our findings corroborate the sex ratios that are reported in the previous studies with obese adolescents.^7,9

Children with binge-eating problems are more concerned about their eating and shape, suggesting that a subgroup of obese children suffers from eating-related problems. The present findings confirm those found in adults. This highlights the importance of recognizing binge eating in obese children. Since no weight control programmes are available for obese children that are successful in reducing symptoms of disordered eating,³² it is not surprising that these children have a poor treatment outcome given the evidence that binge eating is related to poor treatment outcome.^33,34

In line with adult literature,^17,18,19 the present study suggests that subjects with OBEs are more likely to weigh more than those without OBEs. This is in contrast with other studies.^8,20

The present study offers preliminary evidence that binge eating can emerge at an early age, before adolescence. The results support the assumption that overweight precedes binge eating.²² Until now, the evidence available relied solely on retrospective reports from adults. The present study is the first to have determined the age of onset of overweight and binge eating in obese children. So far, little research has been carried out on risk factors for BED. The results of the present study are in line with those of the study of Fairburn et al,³¹ indicating that childhood obesity is a risk factor to BED.

All children engaging in OBEs stated that overeating preceded their first OBE. The question is whether overeating without loss of control can be considered as a precursor of binge eating. Our study found a considerably large amount of children (16%) engaging in OO without describing a loss of control (objective overeaters). It remains yet unknown whether loss of control is an essential component making children more vulnerable to develop binge-eating problems in adulthood.³⁵ Consequently, we examined exploratory the difference between the objective overeaters and binge eaters. Objective overeaters were statistically indistinguishable from binge eaters. Both groups had comparable ages as well as a comparable degree of overweight and eating-related psychopathology. They even reported comparable frequencies of episodes of intake of large amounts of food. In line with Nicholls et al,³⁶ we suggest the use of more flexible criteria in the screening of eating disorders among children. Younger subjects in particular may not fulfil the criteria, but may nevertheless show a considerable psychological distress or eating-related psychopathology. Until now, children engaging in overeating (even if it occurs without a sense of loss of control) seem to be a particularly neglected group at risk. A practical implication of this result is the necessity to be vigilant for the potential risk of binge eating when working with obese children. This underlines the importance of finding indicators of binge eating.

The present study has some limitations. The findings cannot be generalized to the general paediatric obese population. Obese individuals seeking treatment show a greater psychological distress and more eating disorders than obese individuals not seeking treatment.^20,37,38 It would be interesting to assess the prevalence of binge eating in a more representative sample of obese teenagers via a population-based study. A second limitation is that the data were only available on 72% of the potential participants. This could be a reason why the prevalence rate of binge eating may underestimate the true prevalence among young obese boys and girls. There is evidence that eating problems are disproportionately common among those that do not give permission to take part in surveys on eating disorders.³⁹ Finally, the age of onset of overweight was based on the parents' report. In future research, it would be more reliable to use an objective definition of what is meant by the term 'overweight'.

Future research may increase our understanding of eating disorders in obese individuals by providing long-term follow-up assessments of obese children and adolescents at risk of developing diagnosable eating disorders and exploring the impact of other variables such as self-esteem, depression, psychopathology and family functioning.

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn. American Psychiatric Association: Washington, DC; 1994.
2. Spitzer RL, Yanovski S, Wadden T, Wing R, Marcus MD, Stunkard A, Devlin M, Mitchell J, Hasin D, Horne RL. Binge eating disorder: its further validation in a multisite study. Int J Eat Disord 1993; 13: 137–153. | Article | PubMed | ISI | ChemPort |
3. Bruce B, Wilfley D. Binge eating among the overweight population: a serious and prevalent problem. J Am Diet Assoc 1996; 96: 58–61. | PubMed |
4. Varnado PJ, Williamson DA, Bentz BG, Ryan DH, Rhodes SK, O'Neil PM, Sebastian SB, Barker SE. Prevalence of binge eating in obese adults seeking weight loss treatment. Eating Weight Disord 1997; 2: 117–124.
5. Spitzer RL, Devlin M, Walsh BT, Hasin D, Wing R, Marcus M, Stunkard A, Wadden T, Yanovski S, Agras WS, Mitchell J, Nonas C. Binge eating disorder: a multisite field trial of the diagnosis criteria. Int J Eat Disord 1992; 11: 191–203. | Article |
6. Yanovski SZ, Nelson JE, Dubbert BK, Spitzer RL. Association of binge eating disorder and psychiatric comorbidity in obese subjects. Am J Psychiatry 1993; 150: 1472–1479. | PubMed |
7. Severi F, Verri A, Livieri C. Eating behaviour and psychological profile in childhood obesity. Adv Biosci 1993; 90: 329–336.
8. Berkowitz R, Stunkard AJ, Stallings VA. Binge-eating disorder in obese adolescent girls. Ann NY Acad Sci 1993; 699: 200–206. | PubMed |
9. Britz B, Siegfried W, Ziegler A, Lamertz C, Herpertz-Dahlmann BM, Remschmidt H Wittchen H-U, Hebebrand J. Rates of psychiatric disorders in a clinical study group of adolescents with extreme obesity and in obese adolescents ascertained via population based study. Int J Obes Relat Metab Disord 2000; 24: 1707–1714. | Article | PubMed | ChemPort |
10. Striegel-Moore RH, Wilson GT, Wilfley DE, Elder KA, Brownell KD. Binge eating in a obese community sample. Int J Eat Disord 1998; 23: 27–37. | PubMed |
11. Wilson GT. Assessment of binge eating. In: Fairburn CG, Wilson GT (eds). Binge Eating: Nature, Assessment and Treatment. Guilford Press: New York; 1993. pp 227–249.
12. Wilfley DE, Schwartz MB, Spurell EB, Fairburn CG. Assessing the specific psychopathology of binge eating disorder patients: interview or self-report? Behav Res Th 1997; 35: 1151–1159.
13. Fairburn CG, Cooper Z. The eating disorder examination. In: Fairburn CG, Wilson GT (eds). Binge Eating: Nature, Assessment and Treatment, 12th edition. Guilford Press: New York; 1993. pp 317–360.
14. Garner, DM. Measurement of eating disorder psychopathology. In: Fairburn CG, Brownell KD (eds). Eating Disorders and Obesity: A Comprehensive Handbook (Second Edition). Guilford Press: New York; 2002. pp 141–146.
15. Black CMD, WilsonGT. Assessment of eating disorders: interview versus questionnaire. Int J Eat Disord 1996; 20: 43–50.
16. Bryant-Waugh RJ, Cooper PJ, Taylor CL, Lask BD. The use of the eating disorder examination with children: a pilot study. Int J Eat Disord 1996;19: 391–397. | Article | PubMed | ChemPort |
17. Adami GF, Gandolfo P, Bauer B, Scopinaro N. Binge eating in massively obese patients undergoing bariatric surgery. Int J Eat Disord 1995; 17: 45–50. | PubMed |
18. French SA, Jeffery RW, Sherwood NE, Neumark-Sztainer D. Prevalence and correlates of binge eating in a nonclinical sample of woman enrolled in a weight gain prevention program. Int J Obes Relat Metab Disord 1999; 23: 576–585. | Article | PubMed |
19. Yanovski SZ. Binge eating disorder: current knowledge and future directions. Obes Res 1993; 1: 306–324.
20. Telch CF, Stice E. Psychiatric comorbidity in women with binge eating disorder: prevalence rates from a non-treatment-seeking sample. J Consult Clin Psychol 1998; 66: 768–776. | Article | PubMed | ISI | ChemPort |
21. Grissett NI, Fitzgibbon ML. The clinical significance of binge eating in an obese population: support for BED and questions regarding its criteria. Addict Behav 1996; 21: 57–66. | PubMed |
22. Spurrell EB, Wilfley DE, Tanofsky MB, Brownell K. Age of onset for binge eating: are there different pathways to binge eating? Int J Eat Disord 1997; 21: 55–65. | PubMed |
23. Frederiks AM, van Buuren S, Wit JM, Verloove-Vanhorick SP. Body index measurements in 1996–1997 compared with 1980. Arch Dis Childhood 2000; 82: 107–112.
24. Cooper Z, Cooper PJ, Fairburn CG. The validity of the eating disorder examination and its subscales. Br J Psychiatry 1989; 154: 807–812. | PubMed |
25. Wilson GT, Smith D. Assessment of bulimia nervosa: an evaluation of the eating disorders examination. Int J Eat Disord 1989; 8: 173–179.
26. Cooper Z, Fairburn CG. The eating disorder examination: a semi-structured interview for the assessment of the specific psychopathology of eating disorders. Int. J Eat Disord 1987; 6: 1–8.
27. Rosen JC, Vara L, Wendt S, Leitenberg H. Validity studies of the eating disorder examination. Int J Eat Disord 1990; 9: 519–528.
28. Rizvi SL, Peterson CB, Crow SJ, Agras WS. Test–retest reliability of the eating disorder examination. Int. J. Eat. Disord 2000; 28: 311–316. | Article | PubMed |
29. Beumont PJV, Kopec-Schrader EM, Talbot P, Touyz SW. Measuring the specific psychopathology of eating disorder patients. Austr Zealand J Psychiatry 1993; 27: 506–511.
30. Fairburn CG, Welch SL, Doll HA, Davies BA, O'Connor ME. Risk factors for bulimia nervosa. A community-based, case–control study. Arch Gen Psychiatry 1997; 54: 509–517. | PubMed | ChemPort |
31. Fairburn CG, Doll HA, Welch SL, Hay PJ, Davies BA, O'Connor ME. Risk factors for binge eating disorder. A community-based, case–control study. Arch Gen Psychiatry 1998; 55: 425–432. | Article | PubMed | ISI | ChemPort |
32. Epstein LH, Paluch RA, Sealens BE, Ernst MM, Wilfley DE. Changes in eating disorder symptoms with pediatric obesity treatment. J Pediatr 2001; 139: 58–65. | Article | PubMed | ISI | ChemPort |
33. Fitzgibbon ML, Kirshenbaum DS. Heterogenity of clinical presentation among obese individuals seeking treatment. Addict Behav 1990; 15: 291–295.
34. Fitzgibbon ML, Kirshenbaum DS. Distressed binge eating as a distinct subgroup among obese individuals. Addict Behav 1991; 16: 441–451. | PubMed |
35. Morgan CM, Yanovski SZ, Nguyen TT, McDuffie J, Sebring NG, Jorge MR, Keil M, Yanovski JA. Loss of control over eating, adiposity, and psychopathology in overweight children. Int J Eat Disord 2002; 31: 430–441. | Article | PubMed | ISI |
36. Nicholls D, Chater R, Lask B. Children into DSM don't go: a comparison of classification systems for eating disorders in childhood and adolescence. Int J Eat Disord 2000; 28: 317–324. | Article | PubMed | ISI | ChemPort |
37. Basdevant A, Pouillon M, Lahlou N, Le Barzic M, Brillant M, Guy-Grand B. Prevalence of binge-eating disorder in different populations of French women. Int J Eat Disord 1995; 18: 309–315.
38. Fitzgibbon ML, Stolley MR, Kirshenbaum DS. Obese people who seek treatment have different characteristics than those who do not seek treatment. Health Psychol 1993; 12: 342–345. | Article | PubMed | ISI | ChemPort |
39. Beglin SJ, Fairburn CG. Women who choose not to participate in surveys on eating disorders. Int J Eat Disord 1992; 12: 113–116.

Acknowledgements

This study was funded by a doctoral fellowship awarded to the first author by Special Research funds, Ghent University. The authors thank Christopher G. Fairburn for his comments and the staff of the Zeepreventorium De Haan and the Youth Obesity Clinic of Ghent University Hospital.