Eating Behaviors 14 (2013) 476–483

Contents lists available at ScienceDirect

Eating Behaviors

Disordered eating behaviors in young adult Mexican American women:

Prevalence and associations with health risks
Karen Farchaus Stein a,⁎, Ding-Geng (Din) Chen a, Colleen Corte b, Colleen Keller c, Nicole Trabold a
a
University of Rochester, School of Nursing, 601 Elmwood Avenue, Box SON, Rochester, NY 14642, USA
b
University of Illinois at Chicago, College of Nursing, 845 South Damen Avenue (MC802), Chicago, IL 60612, USA
c
Arizona State University, College of Nursing and Health Innovation, 500 N. 3rd Street, Phoenix, AZ 85004, USA

a r t i c l e i n f o a b s t r a c t

Article history: Recent research has shown that disordered eating behaviors are as prevalent in heterogenous samples of Latinas
Received 5 March 2013 living in the U.S. as in non-Hispanic white women, yet less is known about the prevalence in women of Mexican
Received in revised form 23 July 2013 origin. The primary purpose of this study is to report the prevalence and associations among DE behaviors and
Accepted 7 August 2013
health risk of alcohol, tobacco use and obesity in a sample of N = 472 young adult college enrolled Mexican
Available online 30 August 2013
American (MA) women living in the United States. This report focuses on baseline data from a 12-month repeat-
Keywords:
ed measures longitudinal study. Ecological momentary assessment (EMA) was used to capture the prevalence of
Disordered eating disordered eating and health risk behaviors in the context of everyday activities. Disordered eating behaviors
Mexican American women including purging, binge eating, fasting and exercise were reported by approximately 15% of the sample.
Health risk behaviors Food/calorie restricting, was the most prevalent behavior reported by 48% of the sample and along with binge
eating was a positive predictor of BMI. Fasting was the only disordered eating behavior associated with tobacco
use. These findings suggest that subclinical levels of DE behaviors are prevalent in a community sample of
women of Mexican origin and are associated with health risks of tobacco use and higher BMI. Early identification
of DE behaviors and community-based interventions targeting MA women may help reduce disparities associated
with overweight and obesity in this population.
© 2013 Published by Elsevier Ltd.

1. Introduction from adolescent to young adulthood (Alegria et al., 2007; Barriguete-

Melendez et al., 2009; Marques et al., 2011). However, one limitation
Recent findings suggest that disordered eating behaviors such as of these studies is that most studies completed to date have included
food/calorie restricting, binge eating, self-induced vomiting, laxative heterogenous samples of Latinas despite evidence that significant
and diet pill use for the purpose of weight control are at least as preva- variability exists among subpopulations in health outcomes (Fortmann
lent in Latinas living in the United States as in non-Hispanic white et al., 2012; George, Erb, Harris, & Casazza, 2007), care seeking behaviors
women. For example, a statewide study of middle school students in (Getrich et al., 2012) and access to treatment (Gonzalez et al., 2010).
Massachusetts showed that a greater percentage of Latinas reported In addition to lack of specificity in Latina sample definition, studies
severe weight control behaviors (e.g. diet pill, laxative use, and that focus on disordered eating behaviors across all racial and ethnic
vomiting) in the last month compared to both White and Asian same- groups tend to measure target behaviors using a single question over
sex age mates (Austin et al., 2011). The Minnesota Student Survey a relatively long interval of time (e.g. last month, last year, lifetime).
showed that Hispanic high school freshman and senior level females Although this approach provides molar level evidence of the prevalence
had higher rates of disordered eating behaviors compared to all other of the behaviors, the severity of the level of behavioral involvement
racial and ethnic groups including Whites, Blacks, Asian and Native remain unknown. In addition, the more molar levels of behavioral
American students (Croll, Neumark-Sztainer, Story, & Ireland, 2002). measurement limit ability to explore patterns of correspondence
National epidemiological data both from Latina women residing in the among varying levels of behaviors.
United States and women residing in Mexico found high rates of binge In this study, Creando Posibilidades (Creating Possibilities) we
eating and binge eating disorders and showed a steady progression address these gaps by focusing on women of Mexican origin who
are college-enrolled and living in the United States. We report on
disordered eating and related health risks including alcohol, tobacco
⁎ Corresponding author. Tel.: +1 585 276 6011.
use and body mass index collected at baseline. We use ecological
E-mail addresses: karenf_stein@urmc.rochester.edu (K.F. Stein),
Din_Chen@URMC.Rochester.edu (D.-G.(D.) Chen), ccorte@uic.edu (C. Corte), momentary assessment (EMA) to capture the prevalence and rates of
Colleen.Keller@asu.edu (C. Keller), nicole_trabold@urmc.rochester.edu (N. Trabold). disordered eating behaviors in the context of their daily activities.

1471-0153/$ – see front matter © 2013 Published by Elsevier Ltd.

http://dx.doi.org/10.1016/j.eatbeh.2013.08.001
 K.F. Stein et al. / Eating Behaviors 14 (2013) 476–483 477

1.1. Background and related risk behaviors typically are established earlier in adolescence,
evidence suggests that rates increase during the transition to college
1.1.1. Health correlates and consequences of disordered eating behaviors (Delinsky & Wilson, 2008; Eisenberg, Nicklett, Roeder, & Kirz, 2011;
Until fairly recently, the focus of research on disordered eating LaBrie et al., 2007; Raffaelli et al., 2007).
behaviors has been primarily within the context of the eating disorders
of anorexia, bulimia nervosa and binge eating disorder. However, over 1.3. Study purpose
the last five years, there has been a rapid increase in research that has
examined the prevalence, persistence and consequences of subclinical The primary purpose of this study, referred to as Creando
levels of these behaviors. Studies have shown that disordered eating Posibilidades, is to describe the prevalence and rates of eight disordered
behaviors are prevalent in community based samples of adolescent eating behaviors including binge eating, self-induced vomiting, diet pill,
and young adult females and that these behavioral patterns, once diuretic and laxative use, restricting, fasting and excessive exercise in
established, tend to be stable across time periods as long as ten young adult college enrolled Mexican American women. In addition,
years (Neumark-Sztainer, Wall, Story, & Standish, 2012). In addition, patterns of associations among the disordered eating behaviors and
disordered eating behaviors are predictive of significant behavioral, with other health risk factors including alcohol and tobacco use and
emotional and physical health consequences (Crow, Eisenberg, Story, obesity are examined.
& Neumark-Sztainer, 2008; Ginty, Phillips, Higgs, Heaney, & Carroll,
2012; Goldschmidt, Apen, Sinton, Tanofsky-Kraff, & Wilfley, 2008; Hay 2. Design and methods
et al., 2012; Mond, Hay, Rodgers, Owen, & Mitchell, 2006; Napolitano
& Himes, 2011) For example, Project EAT followed two age-cohorts of 2.1. Design
male and female adolescents (cohort 1 = early adolescents with
mean age of 12.8 years and cohort 2 = middle adolescents with mean In Creando Posibilidades, a 12-month repeated measures longitudi-
age of 15.9 years) in a 10 year longitudinal study (see Neumark- nal design was used to examine the effects of self-cognitions on patterns
Sztainer, Wall, Larson, Eisenberg, & Loth, 2011). At the 5-year follow- of disordered eating behavior during the life transition period of
up, girls who engaged in unhealthy and extreme weight control college-enrollment in young adult women of Mexican origin. Data was
behaviors at baseline were more likely to have an increase in BMI collected at five time points including baseline, 3, 6, 9 and 12 months
compared to those with no behaviors at baseline (Neumark-Sztainer after enrollment. The project was conducted at two sites, Michigan
et al., 2006). and Arizona. Data was collected during the period of 2006 to 2011.
Ten-year follow-up results showed significant stability of behaviors
with dieting and unhealthy eating behaviors persisting in both the 2.2. Participants
younger and older cohorts and the extreme behaviors persisting for
the older cohort girls. In addition, at the 10-year follow-up for both The sample included 482 women recruited from community
normal weight and overweight females, dieting or disordered eating colleges, colleges and universities in the greater Detroit (n = 246)
behaviors at baseline predicted greater increases in BMI (Neumark- and Phoenix (n = 236) areas. Eligibility criteria included: 1) self-
Sztainer et al., 2012). Using the same data set, Crow showed that identified Mexican origin, 2) 18 to 35 years of age, and 3) currently
females engaging in extreme weight control behaviors at baseline enrolled in an undergraduate program at a university, college or
were more likely to report suicide ideation and suicide attempts at a community college and not in final year of study based on credit status.
5-year follow-up compared to females who were not engaging in Women who were pregnant at the time of enrollment (self-report),
those behaviors at baseline (Crow et al., 2008). taking any psychotropic medication or in psychotherapeutic treatment
Other studies have shown that women who engaged in subclinical for an eating disorder or substance use problem were not eligible for
levels of disordered eating behavior have significantly blunted cortisol participation. Participants were recruited through targeted email
reactivity, attenuated vasodilation, and changes in cardiac output, heart messages, letters mailed by school registrars, flyers and announce-
rate and stroke volume in reaction to an acute stressor compared to ments at university and school based Latina student organizations.
controls (Ginty et al., 2012) and higher usage of alcohol, tobacco,
cocaine, amphetamine and prescription drugs (Piran & Robinson, 2011, 2.3. Measures
2006). Disordered eating behaviors are a modifiable source of health
risk, and understanding the prevalence and patterns of co-occurrence We used acculturation, ethnic identity, and generational status
of these behaviors in subpopulations of Latinas is a critical prelude to measures to characterize our sample.
the development of interventions that target reductions in health risks
and health disparities that impact a particularly vulnerable group. 2.3.1. Hazuda Acculturation & Assimilation Scale
Hazuda Acculturation & Assimilation Scale (Hazuda, Stern, &
1.2. Focus on Mexican American college-enrolled young adult women Haffner, 1988) is a self-report measure based on Gordon's assimilation
model. Five subscales measure aspects of acculturation and two scales
In this study, we focus on college-enrolled MA women for several measure assimilation. Three subscale scores (adult proficiency in En-
reasons. First studies have shown that stress contributes to increases glish, adult pattern of English vs Spanish language, and adult interaction
in disordered eating behaviors (Ball & Lee, 2000; Epel, Lapidus, with mainstream society) are transformed to Z-scores and combined
McEwen, & Brownell, 2001; Smyth et al., 2007). For young adult into a composite higher order measure that reflects adult functional
women of Mexican origin, the transition to college is a major develop- integration with mainstream society. Positive scores reflect higher inte-
mental transition that is particularly stressful due to financial difficul- gration with mainstream society.
ties, role demands, cultural values conflicts, exposure to ethnic biases,
discrimination and significant changes in perceived family support 2.3.2. Multigroup Ethnic Identity Measure
(Castillo & Hill, 2004; Niemann, 2000). A recent qualitative study of Multigroup Ethnic Identity Measure (MEIM) (Phinney, 1992) is a
Mexican American women in academia highlighted the denigrating 15-item questionnaire that was developed to measure the process of
and marginalizing interactions reflecting exclusion, ascriptions of inferi- ethnic identity development in adolescent and young adult populations.
ority and disconnection from their ethnic identity that make the college The first 12-items are rated on a five-point scale anchored by “strongly
transition and experience particularly stressful for this population of disagree” (1) to “strongly agree” (5) with higher scores indicating
women (Briscoe, 2012). Second, although patterns of disordered eating higher levels of ethnic identity. The recommended score is a total
478 K.F. Stein et al. / Eating Behaviors 14 (2013) 476–483

scale score, which is the mean of the 12 items. The last 3 items assess 2.3.5. Body mass index
personal ethnicity and are not scored (Phinney, 1992). Construct A portable Detecto 439 Mechanical Doctor Scale that measures
validity is satisfactory (Ponterotto, Gretchen, Utsey, Stracussi, & with high precision (400 lbs × 4 oz.) was used to measure body
Saya, 2003). Alpha coefficients with 417 ethnically diverse high weight. Participants were weighed and measured in street clothes
school students and 136 college students were .81 and .90 respectively and stocking feet, with back and heels against the height rod.
(Phinney, 1992). In another study of 1367 freshman students of Body mass index (BMI) was computed using the following formula:
Mexican background, the alpha coefficient for the MEIM was 0.83 weight (kg) / [height (meters)]2.
(Cuellar, Nyberg, & Maldanado, 1997). The measure has been shown
to discriminate among different ethnic groups in a sample of Euro- 2.4. Procedures
American, Asian, African American, and Latino adolescents and young
adults (Branch, 2001). The alpha coefficient in this sample was 0.87. Women who were interested in participating in the project were
asked to call the research office. After completing a brief screening ques-
2.3.3. Generational status tionnaire, women interested in participating scheduled an appointment
Generational status was determined by responses to three questions for the first of two baseline data collection sessions. The written in-
in the demographic questionnaire related to the participant and formed consent was completed at the start of session 1, followed by
her parents' places of birth. Based on US Census Bureau definitions administration of a number of paper and pencil measures not addressed
(www.census.gov/population/foreign/about/faq.html#Q4) first gener- in this report. The second session that occurred approximately two
ation refers to participants born outside of the US, 2nd generation refers weeks later included completion of paper and pencil questionnaires,
to birthplace of at least one parent outside the US, and 3rd generation and measurement of height and weight, followed by the EMA orienta-
refers to both parents born in the US. tion. Definitions of the target behaviors were provided along with
instructions on behavioral recording and PDA use in an individual orien-
2.3.4. Disordered eating, alcohol and tobacco use behaviors tation session that lasted approximately 45 minutes. A 24-hr practice
A combined event-contingent, and signal-contingent ecological period with a follow-up phone appointment was completed prior to
momentary assessment (EMA) methodology was used to record risk the start of data collection; data from this period was not included in
behavior outcomes. A computerized menu-driven interview was used the analyses. A participant manual with step-by-step description of
to measure disordered eating, alcohol and tobacco use behaviors in the recording and downloading procedures was also provided. At the
the context of everyday life. For five 14-day intervals (baseline, 3, 6, 9 end of the 24-hour period, the data collector phoned the participant to
and 12 months after enrollment), participants were asked to carry answer any questions and the 14-day PDA period began the following
with them a hand-held computer (PDA) during waking hours. Partici- morning. Participants were instructed to download their PDA data to a
pants were instructed to record all targeted behaviors at the time they secure website using a landline telephone at least once a week during
occur (event contingent) and were prompted through related screens the EMA period. Project staff was on call to address PDA problems
to document specific properties of the behaviors and to verify intent whenever they occurred. In consideration of the amount of time and ef-
for the purpose of weight control for each behavior. Responses were fort associated with the detailed EMA recording, participants were paid
automatically entered with a date and time stamp. To enhance record- $30 for the PDA orientation session and 15-day recording period. In ad-
ing compliance, participants were also signaled at three points daily dition, a $15 bonus was given for responding to at least 85% of signals
and asked to document any target behavior that occurred since the over the 14 days.
last signal but was not recorded. To measure weight control behaviors
that occur over an extended and unclearly demarcated time period 3. Data analysis
(e.g. food/calorie restricting and fasting), participants were asked to
respond to questions about these behaviors at the last signal each day. We first conducted descriptive statistical analysis. For continuous
Questions related to disordered eating behaviors were based on outcomes, we report the total number of observations, mean and stan-
DSM-IV definitions of the behaviors. For binge episodes, items from dard deviation, and for categorical outcomes, we report the frequencies.
the EDE (Fairburn & Cooper, 1993) were rewritten to focus on the In addition, we examined the data distributions before we employed
current behavioral episode. Questions about the number of standard statistical regression. From this examination, we found that the behav-
drinks and number of cigarettes smoked were based on items used in ior outcomes were highly skewed with a high number of zeros. To deal
other EMA studies of alcohol use (Collins et al., 1998; Hufford, Shields, with the distributional skewness, we tested several statistical models
Shiffman, Paty, & Balabanis, 2002; Shiffman et al., 1994) and tobacco including the classical Poisson regression, zero-inflated Poisson regres-
use (Townshend & Duka, 2002; Shiffman, Paty, & Gnys, 1996; sion, negative-binomial regression as well as the zero-inflated negative-
Shiffman, Gwaltney, & Balabanis, 2002). binomial regression. We found the negative-binomial regression fits the
Behavioral data collected using EMA has been shown to have high data well. Then we made use of the negative-binomial regression model
validity compared to standard retrospective questionnaires by eliminat- to accommodate the over-dispersion in the data variances which relax
ing cognitive biases associated with recall (Loewenstein, Hamilton, the dependence of the mean and variance function. In fact, the
Alagna, & Reid, 1987; Ptacek, Smith, Espe, & Rafferty, 1994; Stone & negative-binomial regression is a natural extension of the Poisson
Shiffman, 2002). A 14-day interval was selected based on previous count regression from a Bayesian perspective where the mean count
studies that demonstrated that it is sufficient to capture intermittent parameter is assumed to vary according to a gamma distribution so
behaviors such as disordered eating (Wegner et al., 2002), alcohol that an over-dispersion and skewness can be incorporated in this
(Muraven, Collins, Morsheimer, Shiffman, & Paty, 2005) and tobacco regression (Chen & Peace, 2010).To predict BMI, which was normally
use (Mermelstein, Hedeker, Flay, & Shiffman, 2003) in normal com- distributed, we used linear regression.
munity samples while not being overly burdensome.
The EMA data was collected at baseline. For this study, we counted 4. Results
the day as a recording day if the participant responded to at least
one of the three daily signals or made at least one behavioral entry. 4.1. Participant characteristics
On average, participants completed 13.6 days of recordings with 383
participants recording on all 14 days. For participants with fewer than Of the 482 women enrolled in the study, a total of 5 women (Arizona
14 days of recordings, a daily mean was computed for each behavior n = 2 and Michigan n = 3) dropped out of the study before complet-
and multiplied by 14 to standardize sum scores. ing baseline data collection. In addition, five women completed fewer
 K.F. Stein et al. / Eating Behaviors 14 (2013) 476–483 479

than 7 days for EMA recordings and their data was also eliminated from 4.3. Prevalence of alcohol and tobacco use behaviors
the analyses. Therefore, the sample size for the analyses reported in this
paper is 472 women. Women enrolled at the Arizona site were signifi- Forty-five percent (n = 210) of the total sample reported drinking
cantly younger [M = 19.4 (1.4) years] compared to women enrolled at least one standard drink during the 14-day EMA period. Among the
at the Michigan sites [M = 20.2 (3.0); t (352) = −4.1, p = .001]. In women who reported any drinking, the mean number of standard
addition, women at the two sites differed in terms of generational status drinks across the 14-day period was 7.7 (SD = 9.0). Based on the Na-
with a greater percentage of women from Arizona of first generation tional Institute on Alcohol Abuse and Alcoholism (NIAAA) daily risk
and fewer women of 3rd generation compared to women enrolled at limits for women of no more than three drinks in a single day, 114
the Michigan site (Χ2 (3) = 25.0, p b .001). In addition, participants women (54% of those who reported drinking and 24% of the total sam-
from Arizona had significantly lower adult functional integration with ple) exceeded the daily risk limits, referred to as heavy drinking days.
main stream society scores (Hazuda composite M = −0.76, SD = 2.2) The 14-day prevalence of tobacco use our in sample was 13.8% (n =
compared to participants from the Michigan site (M = 0.71, SD = 2.2), 65). None of these women were heavy smokers; 71% of those who re-
t (473) = −7.3, p b .001. No significant group differences were found ported smoking smoked less than 1 cigarette per day. The two heaviest
in ethnic identity. smokers smoked approximately 1/2 pack per day during the 14-day
period.

4.2. Prevalence of disordered eating behaviors 4.4. Body mass index

Table 1 shows the percentage of the sample that recorded at least The mean BMI for our sample was 25.7 (SD = 6.0) with a range from
one episode of disordered eating behavior, alcohol or tobacco use over 16.4 to 62.4. Using Center for Disease Control and Prevention weight
the 14 day EMA recording period. Also shown in Table 1 are descriptive category definitions http://www.cdc.gov/obesity/adult/defining.html,
statistics computed based only on women who engaged in the specific 3.4% (n = 16) of our sample was underweight, 51.5% (n = 241) was
behavior at least once over the 14-day period. In our sample, the preva- normal weight, 25.9% (n = 121) overweight and 19.2% (n = 90)
lence of any purging behaviors (self-induced vomiting, laxative, diuretic obese.
and diet pill use) was 13.6% (n = 64). However, the prevalence of indi-
vidual purging behaviors was low ranging from 1.3% (n = 6) for 4.5. Disordered eating, alcohol and tobacco use behaviors
diuretics to 8.6% (n = 41) for diet pill use.
The criteria used to determine an episode of binge eating is consis- We first examined age, Hazuda total score and MEIM total score as
tent with the DSM-IV and includes ingesting an objectively large quan- predictors of the disordered eating behaviors and found that none of
tity of food within a two-hour interval and accompanied by feelings of these variables were related to disordered eating behaviors. Then bivar-
loss of control. Using these strict criteria, 13.3% (n = 63) of our sample iate negative binomial regression models were used to examine the
engaged in at least one binge episode during the 14-day EMA period. Of extent to which a target behavior was predicted by each of the other
the 63 women who reported binge eating episodes, 20.6% (n = 13) re- disordered eating behaviors. Beta weights, their standard errors and
ported four or more episodes during the period. If sustained, this level significance are shown in Table 2. Predictor variables are in the top
is consistent with the binge frequency criteria for the diagnosis of row and criterion variables are in the left column. Due to the low prev-
both bulimia nervosa and binge eating disorder. Food/calorie restricting alence of vomiting, laxative and diuretic use, these variables were
and fasting were the most common disordered eating behaviors combined with diet pills to form a purging variable. Thus, there were
in our sample with 48.1% (n = 227) reporting on or more days of five disordered eating behaviors (restricting, fasting, binge eating, purg-
restricting and 13.1% (n = 62) reporting one or more days of fasting. ing, and excessive exercise). The mean number of binge eating episodes
Of those who restricted at least one day over the 14-day period, 23.8% for the 14 days was not significantly predictive of other disordered
(n = 54) restricted at least seven or more days. Excessive exercise eating, tobacco or alcohol use behaviors. The number of purging
was defined as the number of days with 1.5 h or more of exercise for episodes predicted the number of heavy drinking days and the number
the purpose of controlling weight. Approximately 18% (n = 83) reported of days of food/calorie restricting. Days of food/calorie restricting signif-
one or more days of exercise that met this criteria. icantly predicted purging episodes, days fasting, and excessive exercise
episodes. Fasting days predicted binge eating episodes, restricting days,
and tobacco use. The number of excessive exercise episodes predicted
Table 1
Prevalence and descriptive statistics for disordered eating, alcohol and tobacco use
days of food/calorie restricting. Though not shown in the table, number
behaviors. of alcohol drinks predicted heavy drinking days (beta = 0.19, p b .001)
and tobacco use (beta = 0.07, p b .05).
Disordered eating Number of cases with at Percent with at M (SD)a
behavior least one behavior least one behavior
episode + episode + 4.6. Disordered eating, tobacco and alcohol use as predictors of BMI
Vomiting 17 3.6% 1.8 (1.1)
Laxative use 11 2.3% 2.5 (3.2) Bivariate linear regression models were used to examine the rela-
Diuretic use 6 1.3% 2.5 (2.8) tionships between the behavioral variables (DE, alcohol and tobacco)
Diet pills 41 8.6% 4.2 (5.4) and BMI (See Table 2). Food/calorie restricting, binge eating, and tobac-
Total purging behaviors 64 13.6% 3.8 (4.7) co use significantly and positively predicted BMI. A multiple linear
Binge eating episodes 63 13.3% 2.6 (2.4)
Restrictingb 227 48.1% 4.9 (3.8)a
regression model was conducted to examine the simultaneous effects
Fastingb 62 13.1% 2.2 (1.8)a of the five disordered eating behaviors on BMI. Results showed that
Exercise Episodesb 83 17.6% 2.0 (1.7) restricting (beta = 0.26, p b .001) and binge eating (beta = 0.62,
Alcohol Use 210 44.5% 7.7 (9.0) p b .01) significantly predicted BMI, but tobacco was no longer a signif-
Smoking 65 13.8% 19.0 (33.2)
icant predictor of BMI.
+ = Number and percentage of cases with at least one episode over 14-day recording
period. 5. Discussion
a
Descriptive statistics are computed for those with one or more episodes of the
behavior over 14 day period (Mean number of episodes over 14-day recording period).
b
Restricting, fasting and excessive exercise are mean number of days of behaviors over Results of this study showed that in a community-based sample of
14-day recording period. college-enrolled young adult women of Mexican origin recruited
480 K.F. Stein et al. / Eating Behaviors 14 (2013) 476–483

Table 2
DE behaviors as predictors of alcohol use, heavy drinking, tobacco use, and BMI.

Binge eating Purging Restricting Fasting Excessive exercise

Est. coef. (SE) Est. coef. (SE) Est. coef. (SE) Est. coef. (SE) Est. coef. (SE)

Binge eating – – .02⁎⁎ (.08) .08⁎⁎⁎⁎ (.05) .44⁎⁎ (.16) .20 (.16)
Purging .02 (.15) – – .20 (.05) .15 (.19) .12 (.18)
Restricting .12⁎⁎⁎⁎ (.07) .09⁎⁎ (.04) – – .47⁎⁎⁎ (.08) .19⁎ (.08)
Fasting .16 (.12) .10 (.07) .30⁎⁎⁎ (.03) – – .15 (.15)
Excessive exercise .15 (.09) .07 (.06) .10⁎⁎ (.03) .20 (.12) – –
Alcohol use .09 (.08) .08 (.05) .02 (.03) .03 (.10) .10 (.10)
Heavy drinking .10 (.07) .10 (.04) .03 (.03) .08 (.10) .11 (.09)
Tobacco use −.02 (.20) −.10 (.12) .01 (.07) .97⁎⁎⁎ (.25) .18 (.25)
BMI .02⁎⁎ (.01) −.00 (.00) .01⁎⁎⁎ (.00) .00 (.01) −.01 (.01)
⁎ p b .05.
⁎⁎ p b .01.
⁎⁎⁎ p b .001.
⁎⁎⁎⁎ p = .06.

based only on ethnicity, gender, age, and college matriculation, disor- Latinas could be a result of measurement issues. As noted above, studies
dered eating behaviors were comparable, or for some behaviors slightly measure behaviors over different time frames ranging from lifetime
lower, than those found in other college enrolled female samples. (Kelly-Weeder, 2011), weekly (Granillo, Jones-Rodriguez, & Carvajal,
Furthermore, among those who engaged in the behaviors, significant 2005; Mintz & Betz, 1988) or even unspecified intervals (see Regan &
variability in severity was found with a few women reporting very Cachelin, 2006). Cross study comparisons are further complicated by
high frequency of the behaviors across the 14-day period. Distinctive the inconsistency in the behaviors studied (e.g. skipping meals instead
patterns of association among DE behaviors were found. The number of food restricting or fasting, use of dietary supplements rather than
of days of food restricting and fasting was associated with level of diet pills or preparations). In addition, previous studies completed to
involvement in several other DE behaviors. Four DE behaviors including date have relied on retrospective recall and used a single, often dichoto-
binge eating, restricting, purging, and fasting were differentially associ- mous question that focused on any instance of the behavior over the
ated with health outcomes of alcohol use, tobacco use, and BMI. Finally, specified time interval. In this study, EMA methodology enabled in vivo
the health outcomes were also differentially associated with each other. measurement of behavioral episodes and the algorithm of questions for
Over the last decade, several studies have addressed the prevalence each behavior enabled us to identify behavioral episodes that met
of subclinical disordered eating behaviors in samples of majority and DSM-IV definitional criteria.
minority college enrolled women, and with the exception of food/calorie Deployment of EMA methodology reduces recall bias and eliminates
restricting, the reported rates have generally been higher than those the need for participants to try to summarize behaviors over an extend-
found in our sample. Rates of self-induced vomiting for weight control ed period of time and allows for measurement to occur in the natural
have ranged from 5 to 7% over a one month to a 12-month estimate environment (Smyth & Stone, 2003; Stone & Shiffman, 2002), providing
(Delinsky & Wilson, 2008; Kelly-Weeder, 2011; Mintz & Betz, 1988), more robust measurement strategies. Studies have shown that recall
and 12% for lifetime estimates (Piran & Robinson, 2006, 2011). Laxative strategies provide overestimates and poor agreement in affect measures
use has ranged from 4–10% monthly to lifetime engagement (Kelly- and behavioral measures when compared to EMA (Shiffman et al.,
Weeder, 2011; Mintz & Betz, 1988; Piran & Robinson, 2006, 2011) and 1997; Stone et al., 1998). EMA has proven to be feasible in accurately
binge eating behaviors ranged from 22% annually to 31% for lifetime, measuring disordered eating behaviors which has been beneficial in un-
and 3–17% of the individuals engaged in binge eating behaviors at least derstanding a more refined pattern of behaviors (Engel, Wonderlich, &
2 times per week or greater (Delinsky & Wilson, 2008; Kelly-Weeder, Crosby, 2005; Smyth et al., 2009). This study extends the knowledge
2011; Piran & Robinson, 2006, 2011). Thirty seven to 40% engaged in base of disordered eating behaviors and their correlates in young adult
restricting annually and 3% of the samples engaged in daily restriction Mexican American women by being the first to use EMA methodology
over the course of one month (Piran & Robinson, 2006, 2011). to capture the behaviors in real-time.
When compared to results of studies that focused on mixed samples Notably, approximately half of the sample engaged in food/calorie
of Latinas from diverse subcultures (e.g. Puerto Rico, Latin American, restricting at least once over the 14-day period and the number of
South American), prevalence rates in our sample of Mexican American days restricting positively and significantly predicted three other DE
women also seem lower than typically reported (see Franko, Becker, behaviors including purging, excessive exercise, and fasting, and there
Thomas, & Herzog, 2007; Reyes-Rodriguez et al., 2010). For example, was a trend toward predicting binge-eating episodes. These findings
in a sample of Latinas seeking treatment at university administered are consistent with those of other cross sectional and longitudinal
family planning clinics (N = 624) almost half of the sample reported studies that showed that restricting behaviors often precede binge
exercise to lose weight in the last 30 days (46.6%) and 16.9% reported eating particularly in females (Goldschmidt, Wall, Loth, Le Grange, &
using diet pills to lose or control weight (Breitkopf & Berenson, 2004). Neumark-Sztainer, 2012; Neumark-Sztainer et al., 2006) and that
Similarly in a study of adolescent Latinas, Croll and colleagues reported dietary restraint was associated with exercise, diet pill use and self-
prevalence rates of vomiting (10.4%) and binge eating (34.4%) that were induced vomiting (Breitkopf & Berenson, 2004; Mond et al., 2006). To-
substantially larger than found in our study (Croll et al., 2002). Whereas gether these findings suggest that as the number of day of restricting in-
in a study of Latina high school athletes, Pernick et al. (2006) found crease, involvement in other disordered eating behaviors increases.
the prevalence rates of vomiting to be larger than we found but the Except for number of days fasting which may be considered an extreme
prevalence of laxative use and binge eating were similar. In this study, form of restricting, other DE behaviors appeared to be more isolated and
the focus was exclusively on women who were Mexican-American unrelated to level of involvement in other behaviors.
college students and we are one of the first to describe disordered eating The prevalence of alcohol use and heavy drinking were somewhat
behaviors and their relationship to alcohol, tobacco and BMI in this higher in our sample compared to the national prevalence rates for
population. Hispanic women of child-bearing age, whereas tobacco use prevalence
The disparity in prevalence rates in our sample compared to previous was slightly lower. The 14-day prevalence rate for alcohol use in our
research with college aged majority women and more diverse samples of sample was 45%; the 30-day prevalence of alcohol use among non-
 K.F. Stein et al. / Eating Behaviors 14 (2013) 476–483 481

pregnant Hispanic women aged 18–44 from the CDC Behavioral Risk an enduring cycle of overeating and food restricting. Community
Factor Surveillance System (BRFSS) data is 36% (Centers for Disease based interventions targeted to overweight and obese young adult
Control and Prevention [CDC], 2012). The 14-day prevalence of heavy Mexican American women are needed to stabilize food intake patterns
drinking (four or more drinks in one day) was 24% in our sample, over time and prevent future weight gain.
whereas the 30-day prevalence of heavy drinking in Hispanic women The primary limitation is that the data in this report are cross-
from the BRFSS data was 10% (CDC, 2012). Smoking prevalence of 14% sectional. This limits our ability to infer causal direction between the
in our sample was slightly lower than national prevalence estimates disordered eating behaviors and our outcomes of BMI, heavy drinking,
for Mexican American adult women. A population-based cohort and tobacco use. However, this report is on the baseline data from a
study to examine risk and protective factors for chronic disease, the His- longitudinal study in which these measures were also obtained at 3, 6,
panic Community Health Study/Study of Latinos, showed that the preva- 9, and 12 months. The findings from the baseline data are suggestive
lence of smoking in U.S. Hispanic women of Mexican descent who are and will guide further analyses of the longitudinal data.
aged 18 and over is 17% (Daviglus et al., 2012). Given that our sample
was experiencing a major developmental transition and likely 6. Conclusions
responding to changes in environment, responsibilities, family relation-
ships and perhaps experiencing conflict between family values and These finding suggest that for Mexican American college-enrolled
roles of young Latinas, the alcohol use and heavy drinking rates reported women, engaging in DE behaviors – even at subclinical levels – is perni-
in our study are not surprising. cious, and may paradoxically lead to obesity and substance use/problems.
Two DE behaviors were differentially associated with substance use Young college women, particularly those who are descended from
in our sample. Purging behaviors (vomiting, diuretics, laxatives, and diet cultural subgroups that have values and family traditions that influence
pills) were associated with the number of heavy drinking days. This women's roles in the family and society, as were our sample of primarily
finding is consistent with other studies that found associations between first and second generation MA women, may be uniquely vulnerable to
purging and alcohol use in community samples (Adebe, Lien, Torgersen, developmental and social transitions related to college life or other
& von Soest, 2012) and in women with eating disorders (Baker et al., developmental milestone changes (Coe, Palmer, Palmer, & DeVito,
2013; Corte & Stein, 2000). In a meta-analysis of 41 studies that 2011). Thus, early identification of DE behaviors in college-enrolled
examined co-occurrence of DE behaviors and alcohol use in clinical, MA women is essential. Community-based interventions targeting
community, and student samples, Gadalla and Piran (2007) found an these women may help reduce disparities associated with overweight
overall effect size of .41 for purging and alcohol use. Because both and obesity in this population.
purging and heavy drinking are considered high-risk behaviors,
women who engage in these behaviors may already be approaching Role of funding sources
serious illness. Funding for this study was provided by NINR Grant R01NR009691-01A2. NINR had no
Fasting was associated with tobacco use in our sample. This is consis- role in the study design, collection, analysis or interpretation of the data, writing the
tent with findings of other studies that have found that smoking is used manuscript, or the decision to submit the paper for publication.
as a weight control strategy by women (Jo, Talmage & Role, 2002; Wee,
Rigotti, Davis, & Phillips, 2001). Population-based data from the Youth Contributors
Risk Behavior Survey showed that adolescent girls who engaged in Example: Authors Stein, Corte, and Keller designed the study and wrote the protocol.
Authors Stein, Chen and Corte were involved in data analysis and interpretation. Author
fasting were three times more likely to be smokers than those who Stein wrote the first draft of the manuscript and all authors contributed to the writing
did not engage in fasting (Seo, Jiang, & Kolbe, 2009). In an experimental and editing of the final manuscript and have approved the final manuscript for
study to determine the effects of fasting on smoking, Leeman, O'Malley, submission.
White, and McKee (2010) randomly assigned smokers to either fasting
for 12 hours or no fasting. During a one-hour laboratory session in Conflict of interest
which participants were permitted to smoke but offered a monetary There are no conflicts of interest to report.
award not to smoke, participants in the fasting condition were more
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