RESEARCH REPORT

doi:10.1111/j.1360-0443.2006.01633.x

Eating disorders and substance abuse in Canadian women: a national study

Niva Piran1 & Tahany Gadalla2
Ontario Institute for Studies in Education at the University of Toronto, Canada1 and Faculty of Social Work at the University of Toronto, Canada2

ABSTRACT Aims This study aimed to examine the comorbidity between eating disorders and substance use in a large nationally representative sample of Canadian adult women. Recent as well as life-time measures of substance use were used. Design The research was based on secondary analyses of data collected, using multi-stage stratied probability sampling, by Statistics Canada in the Mental Health and Well-being cycle 1.2 of the Canadian Community Health Survey (CCHS). Measurements The Eating Attitude Test (EAT-26) was used to measure risk of eating disorders. Alcohol use, dependence and interference, and illicit drug use, dependence and interference were measured using relevant modules from the short form of the Composite International Diagnostic Interview (CIDI-SF). Participants Data on a nationally representative sample of Canadian adult women, grouped into three age groups, were used for this research. Findings Alcohol dependence and alcohol interference were associated signicantly with the risk for an eating disorder in the three adult age groups. Signicant associations were also found in the three age groups between risk for an eating disorder and the life-time abuse of and dependence on illicit drugs. Signicant associations were found in the 1524 and 2544-year age groups when the 12-month time-frame was used. Conclusions The study ndings support the call for the development of short screening instruments for adult women with eating disorders and substance abuse, as well as for the development of treatment strategies that address the co-occurrence of eating disorders and substance use. Keywords Co-occurrence, dependence, eating disorders, substance abuse.

Correspondence to: Niva Piran, AECP (7225), OISE/University of Toronto, 252 Bloor Street W, Toronto, Ontario, Canada M5S 1V6. E-mail: npiran@oise.utoronto.ca Submitted 12 September 2005; initial review completed 6 December 2005; nal version accepted 22 May 2006

INTRODUCTION Studies in clinical populations have repeatedly suggested comorbidity between disordered eating patterns and substance use [1]. Clinical samples of women with eating disorders have been found to have a high rate of substance use [24] and women with substance use diagnoses have been found to have a high rate of disordered eating patterns [5,6]. The elevation in substance use has been found in women diagnosed with bulimia nervosa and bingeing and purging anorexia, but not in restricting anorexia [7]. However, as clinical-based studies are affected by sampling biases, researchers have highlighted the role of population-based studies in determining the extent and nature of comorbidity between disordered eating patterns and substance abuse [8,9].

To date, most of the studies that have examined the association between disordered eating patterns and substance use in non-clinical samples have been conducted with students. Studies conducted in middle and high schools found associations between body weight and shape concerns, as well as dieting, bingeing and purging and tobacco smoking, alcohol drinking and cannabis use [1012]. Studies conducted in university samples often found an association between disordered eating patterns and substance use. In particular, studies often reported on an association between alcohol consumption and disordered eating patterns [1315], although this association was not found in a few of these studies [16]. Similarly, associations have been found between disordered eating patterns and tobacco smoking [17]. To date, only a few studies which have examined the association between disordered eating patterns and
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substance use have been conducted with adult women in community-based samples. The only study which employed a nationally representative sample assessed the relationship between bulimia nervosa and alcohol abuse and dependence in 3006 women in the United States [8]. Participants were selected by multi-stage geographic sampling and interviews were conducted by telephone. The authors found a higher rate of alcohol dependence among women with bulimia nervosa compared with women with no bulimia or with binge eating disorder. No such differences were found in the rates of alcohol abuse. The binge eating disorder group was not different from the control group. A study of patients of general practitioners in Oxfordshire that employed a matched design found that rates of current alcohol consumption were comparable between women with bulimia nervosa and psychiatric and normal controls, although a larger number of bulimic women and women with other psychiatric difculties had a history of high alcohol consumption [9]. In addition, more bulimics had used illicit drugs or smoked tobacco compared to psychiatric and normal controls [18]. The present investigation aimed to add to existing research in a number of ways. First, it aimed to examine the association between disordered eating attitudes and behaviors and substance use in a nationally representative sample of Canadian women. Secondly, the study aimed to utilize the national sample of Canadian women to examine the association between disordered eating attitudes and behaviors and a range of substance classes. The one other study that used a nationally representative sample of women focused exclusively on alcohol abuse and dependence [8]. Thirdly, the present investigation aimed to examine the pattern of association separately in three different age groups of women, spanning the whole adult age range. No such data are available to date. Fourthly, while most non-clinical studies to date examined frequency and quantity of alcohol consumption in relation to disordered eating, the present investigation employed measures of alcohol abuse and dependence as well as of illicit drugs abuse and dependence. METHOD Data This research was based on secondary analyses of data collected by Statistics Canada in cycle 1.2 of the Canadian Community Health Survey (CCHS) on Mental Health and Well-being, and are available for public use [19]. The sampling method employed was a multi-stage stratied cluster probability sampling in which dwelling was the nal sampling unit. The sample was stratied by province, and urban versus rural regions, within province.

This survey was conducted in 2002 with 36 984 respondents, representing approximately 98% of the Canadian population aged 15 years or older who resided in private dwellings in the 10 provinces. Of the respondents, 20 211 were women and 16 773 were men. Data analyses were conducted on the whole sample of women. Residents of the three territories, people living in Indian Reserves or Crown Lands, residents of institutions, fulltime members of the Canadian Armed Forces and residents of some remote regions were excluded from the survey. The survey provides information on life-time and past 12-month prevalence of various mental disorders and mental health problems, access to and use of mental health-care services and disability associated with mental health. The survey also collected information on sociodemographic characteristics, income, stress, medication use and social support. Data were collected mainly in face-to-face interviews using the computer-assisted personal interviewing (CAPI) method. Collection by telephone was conducted in only 14% of cases nationally when travel was prohibitive or the respondent refused to conduct the interview in person. Statistics Canada uses probability sampling in which each respondent represents, besides herself, a number of women with the same demographic characteristics who are not in the sample. These are called sampling weights. These sampling weights correct for oversampling and non-response, thus producing estimates which are representative of the Canadian population and not just the sample itself. Because the analyses conducted for this study are conned to a subset of the respondents, these weights were rescaled so that the average weight for the subsample analyzed is 1. All analyses presented in this paper were weighed using these adjusted weights.

Eating attitudes and behaviors Two screener questions were used to assess respondents life-time and the previous 12-month concerns with eating attitudes and behaviors. Respondents who reported being concerned about their weight during the 12 months prior to the interview were administered the Eating Troubles module, EAT-26. This module is based on the Eating Attitude Test (EAT) [20]. The EAT-26 is a widely used standardized measure of the extent of symptoms and concerns characteristic of eating disorders, although it does not yield a specic diagnosis. It is an abbreviated version of the EAT-40 questionnaire [21]. The EAT-26 test score ranges between a minimum of zero and a maximum of 78, and individuals scoring above 20 are considered at risk for having an eating disorder [20]. The reliabilities of the EAT obtained in this sample were 0.87, 0.83 and 0.82 in the 1524, 2544 and 45 years and over age groups, respectively.
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Alcohol use Three variables were used to measure level of alcohol consumption: number of drinks in the past week, alcohol dependence and alcohol interference. Respondents were asked about the number of alcohol drinks they had had on each day of the week prior to the interview day. These amounts were added up to estimate the respondents weekly consumption of alcohol. The CCHS uses the short form of the Composite International Diagnostic Interview (CIDI-SF) [22] to derive an alcohol dependence score for each respondent. The CIDI-SF is a structured diagnostic instrument that provides diagnostic estimates according to the operationalization of some of the criteria of the Diagnostic and Statistical Manual version III, revised (DSM-III-R) classication for psychoactive substance use disorder [23]. Respondents who reported having had ve drinks or more on one occasion at least once during the previous 12 months, and those who reported having had ve drinks or more during another 12-month period in their lives were administered the alcohol dependence questions. Respondents were asked whether they exhibited any of the following seven symptoms within the 12 months prior to the interview: being drunk at work/ school, or while taking care of a child; tolerance (need for markedly increased amounts of alcohol to achieve desired effect); withdrawal; drinking larger amounts than was intended; spending a great deal of time in activities necessary to obtain, use or recover from effects of drinking; giving up social, occupational or recreational activities because of drinking; and continued drinking despite knowledge of having physical or psychological problem that is likely to have been caused or exacerbated by alcohol. Respondents who endorsed three or more of these symptoms were classied as displaying alcohol dependence. Five items were used to measure the level of interference that alcohol use had on the respondents daily activities and responsibilities. The average score of these ve items ranges between a minimum of 0 and a maximum of 10. This score was further dichotomized such that an average score of 4 or more was used as an indication that alcohol use interfered signicantly with the individuals normal routine, occupational/academic functioning, social activities or relationships [19]. All the alcohol consumption variables used here refer to the 12 months prior to the interview. Illicit drug use Four variables were used to assess life-time and 12-month use of various illicit drugs, cannabis drug use (excluding one-time use), illicit drug use (excluding one-time cannabis), dependence on illicit drugs and illicit drug

interference. Questions related to illicit drug use were based on Canadas Alcohol and Other Drugs Survey (CADS) [24]. Respondents were asked whether they used any of the following classes of drugs: marijuana/ cannabis/hashish, cocaine/crack, amphetamines (speed), MDMA (ecstasy), hallucinogens/PCP/LSD, heroin or steroids (life-time as well as in the past year). Cannabis drug use variables indicate whether respondents have used marijuana, cannabis or hashish in a respondents lifetime, and in the past year, excluding one-time use in a life-time. The variable illicit drug use indicates whether respondents used any of the above drugs, excluding onetime use of cannabis. Number of illicit drugs used comprises a count of the different classes of drugs respondents used. Illicit drug dependence assesses whether the respondent met the criteria for illicit drug dependence in the year prior to the interview. These criteria, modied from the CIDI, are operationalized partially to the denitions of the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition [23]. Respondents were classied as drugdependent if they reported three or more of the following six symptoms, all exhibited within the same 12-month period: tolerance; withdrawal; taking larger amounts than was intended; spending a great deal of time in activities necessary to obtain, use or recover from the drug effects; reduced important activities because of drug use; and continued drug use despite knowledge of having physical or psychological problem that is likely to have been caused or exacerbated by the drug. Five items were used to measure level of interference, due to illicit drug use, in respondents home responsibilities, ability to attend school, ability to work at a job, close relationships and social life in the 12 months prior to the interview. The average score of these ve items ranges between a minimum of 0 and a maximum of 10. This score was dichotomized further such that an average score of 4 or more is used as an indication that use of illicit drugs interfered signicantly with the individuals normal routine, occupational/academic functioning or social activities or relationships [19].

Data analysis Pearsons c2 tests, Fishers exact tests (used when expected cell count is less than 5, a required assumption for using the Pearson c2 test) and t-tests were used to assess the statistical signicance of the association between risk of eating disorders and substance abuse and dependence. Estimates of standard errors which take into account the clustered nature of the sample were derived from tables of coefcients of variation published by Statistics Canada [19]. Expected probabilities of random co-occurrence of eating disorders and substance use
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Table 1 Measures of alcohol consumption, illicit drug use and body weight concerns in Canadian women by age group (years) (percentages and standard errors). 1524 years n = 3220 % (SE) Strong fear of being overweight: 12 months Strong fear of being overweight: life-time Eating attitude test score greater than 20 Alcohol dependence: 12 months Alcohol interference: 12 months Cannabis drug use, excluding one-time cannabis: 12 months Cannabis drug use, excluding one-time cannabis: life-time Illicit drug use, excluding one-time cannabis: 12 months Illicit drug use, excluding one-time cannabis: life-time Dependence on illicit drug: 12 months Illicit drug interference: 12 months 25.9 41.3 3.8 4.3 2.3 25.9 41.1 27.0 42.4 1.8 2.2 (1.22) (1.40) (0.52) (0.54) (0.39) (1.22) (1.38) (1.27) (1.42) (0.36) (0.39) 2544 years n = 7535 % (SE) 21.9 38.0 3.0 1.5 0.6 8.9 38.2 9.4 40.0 0.4 0.3 (0.81) (0.99) (0.34) (0.23) (0.14) (0.55) (1.02) (0.57) (1.04) (0.11) (0.12) > 44 years n = 9456 % (SE) 13.3 24.6 2.4 0.3 0.2 1.7 12.7 1.7 13.3 0.0 0.0 (0.57) (0.69) (0.27) (0.07) (0.08) (0.22) (0.67) (0.22) (0.57)

disorders were calculated and compared with observed probabilities. In order to control for Type I error and due to the large number of signicance tests performed, ndings with signicance levels between 0.01 and 0.05 are considered marginal, while ndings with signicance levels less than 0.01 are considered of statistical importance.

or relationships of 46 202, 29 883 and 9347 Canadian women aged 1524, 2544 and 45 years or older, respectively. A total of 370 02, 21 151 and 671 Canadian women were classied as dependent on illicit drugs in the same three age groups, and for 43 525, 13 803 and 1654 Canadian women, illicit drugs interfered with their daily lives. Risk of eating disorders and alcohol use

RESULTS Of the 20 211 women who responded to the CCHSHealth and Mental Health survey, 3220 (15.9%) were aged 1524 years, 7535 (37.3%) were aged 2544 years and 9456 (46.8%) were aged 45 years or older. Eightyve per cent of women aged 1524 years, 77% of women aged 2544 years and 75% of women aged above 44 years were Canadian-born. Table 1 presents 12-month and life-time prevalence rates of eating disorders and substance use, dependence and interference by Canadian women in the three age groups. Examination of this table reveals that approximately 26% of women aged 1524 years reported having a strong fear of being overweight in the past year, compared with 22% of women aged 2544 years and 13% of women aged 45 years or older. Of these women, only 122 (3.8%), 223 (3.0%) and 228 (2.4%), were classied by the EAT-26 score as being at risk of having an eating disorder. Using the sampling weights described in the Data section, it can be estimated that 76 673, 140 192 and 143 648 Canadian women in the three age groups were at risk of having an eating disorder at the time of the survey. Using the sampling weights described in the Data section it can be estimated that, in 2002, alcohol drinking interfered signicantly with the normal routine, occupational or academic functioning, or social activities

As shown in Table 1, for 1524-year-old women the prevalence rate of risk for eating disorders was found to be 3.8% and that of alcohol interference 2.3%. If these conditions were independent, the probability that they co-occur at random/by chance only was 0.08% (3.8% 2.3%). The observed probability of the co-occurrence of eating disorders and alcohol interference in this age group was 0.25%, three times the random/chance probability, indicating an association between the two conditions. Similarly, the observed probability of co-occurrence of these two conditions in the 2544-year age group was 0.08% which is four times the probability of them co-occurring by chance alone, and in the 45 years and older age group it was 0.03%, which was eight times the probability of them occurring by chance alone. Table 2 includes rates of alcohol and drug use for women with EAT > 20 and EAT 20, standard errors and signicance levels (P-values) of c2 or Fishers exact tests of association between risk of eating disorders and substance use disorders in Canadian women by age group. As shown in this table, risk of eating disorders was associated signicantly with alcohol dependence for women in all three age groups. Similarly, risk of eating disorder was signicantly associated with alcohol interference in all three age groups. Life-time cannabis and illicit drug use was associated signicantly with risk of
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Table 2 Association between risk of eating disorders (EAT-26 score = 20 versus > 20) and alcohol and drug use in Canadian women by age group (percentages and standard errors). EAT-26 Score Alcohol dependence: 12 months Alcohol interference: 12 months Cannabis drug use: 12 months (excluding one-time use) Cannabis drug use: life-time (excluding one-time use) Illicit drug use: 12 months (excluding one-time cannabis) Illicit drug use: life-time (excluding one-time cannabis) Dependence on illicit drugs: 12 months Illicit drugs interference 12 months Sample size Score 20 Score > 20 Score 20 Score > 20 Score 20 Score > 20 Score 20 Score > 20 Score 20 Score > 20 Score 20 Score > 20 Score 20 Score > 20 Score 20 Score > 20 Score 20 Score > 20 1524 years % (SE) 4.1 (0.50)** 9.3 (4.00) 2.1 (0.37)** 6.9 (3.5) 25.4 (1.27)**** 40.0 (6.80) 40.6 (1.38)*** 54.5 (7.35) 26.5 (1.32)*** 40.8 (6.84) 41.8 (1.42)**** 57.7 (7.78) 1.6 (0.35)*** 6.9 (3.50) 1.9 (0.28)**** 9.8 (4.08) 3093 122 2544 years % (SE) 1.4 (0.23)** 3.7 (2.12) 0.6 (0.15)*** 2.7 (1.7) 8.7 (0.55)*** 15.7 (4.11) 38.0 (0.99)*** 47.1 (5.87) 9.2 (0.57)**** 17.1 (4.27) 39.6 (1.03)**** 52.8 (5.81) 0.4 (0.12)* 1.8 (1.44) 0.3 (0.12) 0.9 (0.90) 7270 222 > 44 years % (SE) 0.2 (0.07)** 1.2 (1.20) 0.1 (.04)*** 1.1 (0.90) 1.7 (0.22) 1.5 (1.31) 12.5 (0.66)*** 18.8 (4.30) 1.7 (0.22) 1.5 (1.31) 13.1 (0.56)**** 21.4 (4.35) 0.0 0.0 0.0 0.0 9168 229

*P < 0.05, **P < 0.01, ***P < 0.005, ****P < 0.0005.

eating disorders in all three age groups. However, 12-month cannabis and illicit drug use was associated signicantly with risk of eating disorders only in the 1524 and 2544-year-old women only. In addition to the measures represented in Table 2, average number of drinks in the past week was signicantly higher for women younger than 45 years, who were at risk of having eating disorders compared to women in the same age group who were not (t = 2.12, df = 2397 for ages 1524, and t = 4.19, df = 5757 for ages 2544). Risk of eating disorders and illicit drug use Rates of life-time and past 12-month use of cannabis drug use, illicit drug use, dependence on and interference of illicit drugs were all found to be higher among women aged 1524 years who were classied at risk of eating disorders compared to women who were not. These associations were highly statistically signicant, as shown in Table 2. Similar trends were found for women aged 2544 years with one exception; rate of illicit drug interference was not found to be associated signicantly with risk of eating disorders. For women aged 45 years and above, only life-time measures of drug use were found to be associated signicantly with risk of eating disorders. The observed probability of the co-occurrence of eating disorders and illicit drug interference in the

1524-year age group was found to be 0.37%, which was 4.5 times the probability of these two conditions co-occurring by chance alone. Similarly, the observed probability of co-occurrence of these two conditions in the 2544-year age group was found to be 0.03%, which was three times the probability of them co-occurring by chance alone. No women were found to have both conditions in the 45 years and older age group. Table 3 presents cross-tabulations of women in the three age groups by EAT-26 score versus number of drug types/classes used by participants during their life-time and during the past 12 months. As can be seen in this table, the proportions of women using more types/classes of drugs were higher among those with a high EAT-26 score. Life-time drug use was associated signicantly with high EAT-26 score for women in all three age groups (P < 0.0005, < 0.0005 and < 0.002). Past 12-month drug use was associated signicantly with high EAT-26 score for women aged 1524 and 2544 years (P < 0.0005).

DISCUSSION The study aimed to examine the association between risk for an eating disorder (as assessed by a score of more than 20 on the EAT) and substance abuse and dependence in a nationally representative study of Canadian
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Table 3 Number of illicit drug classes used in life-time (excluding one time cannabis) and past year vs. risk of having an eating disorder for Canadian women by age group (percentages and standard errors). Life-time excluding one-time use No. of drugs 0 1 2 3 Total 2544 years, c2 test: life, P < 0.0005; 12 months, P < 0.0005 0 1 2 3 Total > 45 years, c2 test: life, P = 0.002; 12 months, P = 0.853 0 1 2 3 Total EAT > 20 % (SE) 45.9 33.1 9.2 12.3 122 50.0 33.0 11.3 5.8 224 79.4 16.4 1.8 2.8 228 (7.19) (6.60) (3.95) (4.68) (5.50) (5.34) (3.50) (2.75) (5.38) (3.94) (1.40) (1.73) EAT 20 % (SE) 59.0 30.6 6.6 3.9 3094 61.6 28.8 5.7 4.0 7277 87.3 10.3 1.4 1.0 9177 (1.59) (1.38) (0.69) (0.53) (1.23) (0.98) (0.46) (0.41) (0.87) (0.55) (0.19) (0.17) 12 months No. of drugs 0 1 2 Total 0 1 2 Total 0 1 2 Total EAT > 20 % (SE) 54.1 (7.27) 28.8 (6.19) 17.2 (5.29) 122 80.7 (5.73) 15.7 (4.06) 3.6 (2.05) 224 97.8 (3.42) 2.4 (1.70) 0.0 228 EAT 20 % (SE) 70.2 (1.47) 24.2 (1.18) 5.6 (0.66) 3093 90.4 (0.54) 8.6 (0.58) 1.0 (0.20) 7277 98.2 (0.59) 1.8 (0.22) 0.0 9176

Age 1524 years, c2 test: life, P < 0.0005; 12 months, P < 0.0005

women. The study further aimed to examine this issue in three different age groups, 1524, 2544 and 44 years and above. The results suggest an association between the risk for an eating disorder and life-time alcohol dependence and interference during the past year in all three age groups. Further, results suggest an association between disordered eating and cannabis and other illicit drug abuse during the past year among the 1524 and 2544-year-olds. In addition, the number of different illicit substance classes used was found to be related signicantly to the degree of disordered eating attitudes and behaviors. This is the rst nationally representative sample that has examined the association between risk for an eating disorder and a number of substance classes, including alcohol, cannabis and other illicit drugs, in different age groups across the adult age range, while using different measures of consumptions including use, dependence and interference. The signicant association between risk for an eating disorder and alcohol drinking was found on all measures of alcohol consumption. Alcohol dependence and alcohol interference were associated signicantly with the risk for an eating disorder in the three adult age groups, while the number of drinks consumed during the past week was associated signicantly with risk for an eating disorder in the 1524 and 2544-year age groups. The observed probabilities of the co-occurrence of risk for an eating disorder and alcohol interference was three to eight times higher in the three age groups than the probability that these conditions would co-occur by chance alone. This pattern of ndings conrms, in a nationally representa-

tive sample and across a number of alcohol drinking measures, previous research ndings conducted mainly in clinical and school settings [1]. The ndings are also in line with the results of an association between bulimia nervosa and alcohol dependence obtained in a nationally representative US sample [8]; nevertheless, in that study no relationship was found between bulimia nervosa and alcohol abuse, and in a number of other studies no relationship has been found between alcohol consumption measures of drinking frequency or the total number of drinks consumed per week and eating disorders [15]. However, alcohol consumption is a complex behavior, and measures of frequency or total number of drinks consumed per week that are not necessarily associated with adverse consequences may not yield the same pattern of results as measures of the tendency to binge drink and other measures that involve adverse consequences to drinkers lives [15,25]. Indeed, in the present investigation the association between alcohol consumption measures and risk for an eating disorder is stronger and more consistent across the age span in consumption measures that tend to be associated with adverse consequences. The use of more strict criteria of three, rather than one, adverse consequences in the denition of alcohol dependence in the present investigation may also explain the difference between the ndings of the present investigation and an American study regarding alcohol abuse [8]. The present investigation found signicant associations between alcohol consumption, dependence and interference and disordered eating attitudes and
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behaviors in three different age groups of adult women from age 15 years and over. While no previous study has utilized three different age groups of adult women, research studies using women of different age ranges have found a signicant relationship between disordered eating patterns and alcohol consumption. An association between dieting, bingeing and purging and alcohol consumption has been found in adolescents [10,12], in university students [14,15] and in a community-based study of adult women [8]. There has been no study to date that has reported on the association between disordered eating attitudes and behaviors and alcohol dependence and interference in an older sample of women aged 44 years and over. Because the measures of alcohol dependence and interference examined a 12-month, rather than a life-time, time period, the ndings suggest that the co-occurrence of disordered eating and alcohol dependence and abuse is a relevant health issue for adult women throughout the age range. The ndings of the study also indicate signicant associations between risk for an eating disorder and the lifetime abuse of and dependence on illicit drugs in all three age groups. Signicant associations were also found in the 1524 and 2544-year age groups when the 12-month time-frame was used. The low level of association between risk for an eating disorder and current abuse of and dependence on illicit drugs in the 44 years and over age group probably relates to the low level of consumption of illicit drugs in this older group of women. A similar pattern was found when the number of substance classes of illicit drugs the women used was considered. Signicant associations were found in all three groups when life-time use was considered, and in the two younger adult groups when the past 12 months were considered. To date, the relationship between risk for an eating disorder and the use of illicit substances has not been investigated in a nationally representative sample. Similarly, the patterns of association have not been explored separately for different age groups in the same study. None the less, a few separate studies with women of different ages have found a signicant relationship between disordered eating and the use of illicit substances. Associations between the use of a number of illicit substances and disordered eating patterns have been found in other community samples [9,26]. The study indicates that, as with alcohol consumption, the co-occurrence of disordered eating and substance abuse and dependence is a relevant health issue for adult women. This study aimed to address the question of whether the occurrence of risk for an eating disorder and substance use, dependence and interference occur at a higher rate than would be expected through random occurrence. Such a study can be tested only in the general

population [27], hence the importance of the study. The methodology of the study, however, does not allow for the examination of specic conceptual models that could account for the observed relationship [27]. However, a brief discussion of possible explanations that have been put forward regarding the observed association between substance use and eating disorders is warranted. One explanation highlights the role of dietary restraint in understanding the co-occurrence of disordered eating patterns and substance use. Attempts at dietary restraint and weight loss may lead to the use of illicit substances that are central nervous system stimulants, such as amphetamines or cocaine [28]. In addition, dietary restraint may result in intake disinhibition both in terms of eating binges and drinking binges [15]. Alcohol drinking restraint, motivated by the need to avoid high caloric intake, may also result in drinking binges [15]. Another line of thought has emphasized the role of disregulation in the co-occurrence of disordered eating patterns and substance use [15]. According to this view, regulatory challenges may be expressed through engagement in different disordered eating and drug consumption behaviors. This particular explanation may be related to the hypothesis that eating and substance use disorders may be both associated with impulsivity [4]. Another line of thought has emphasized the role of negative feelings and emotional instability in understanding the co-occurrence of eating disorders and substance abuse [13]. While the consumption of particular substances may affect patterns of food intake, the eating measure used in the survey, the EAT-26, focuses on disordered eating behaviors and cognitions that are related specically to body dissatisfaction and weight preoccupation. A signicant elevation on this measure (score >20) is therefore not expected to occur due to the alteration of food intake due to substance consumption. Studies to date that have aimed to explore the shared etiology of disordered eating and substance use, however, have used correlational designs and hence could not lead to inferences regarding causality. The study has a number of limitations. While the study utilized a widely used and psychometrically tested measure to assess risk for an eating disorder, this measure does not provide diagnostic information [29]. The results on this measure and other interview questions are subject to errors of recall. Further, the measure of number of alcoholic drinks consumed during the past week is probably inuenced by situational factors. This is a population-based study, so the proportions of women at risk for an eating disorder or drug dependence/ interference are very small and are therefore associated with large standard errors. In particular, the standard errors are larger for the older age group where there is less engagement in the target behaviors.
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The study has a number of strengths. It is the rst nationally representative study that has examined the relationship between risk for an eating disorder and substance abuse and dependence, including both alcohol and illicit substances. Further, the study utilizes measures of substance use that go beyond frequency and quantity to assess interference and dependence [15]. The use of the CAPI method is another strength of the study. Moreover, the study indicates the relevance of this association to different age groups across the adult age span. The immediate clinical implications of the ndings of this study suggest the importance of assessing for substance use in adult women of all ages with disordered eating attitudes and behaviors, and assessing for disordered eating patterns in women of all ages who show patterns of substance abuse [30]. From a treatment perspective, and depending on the hypothesized etiological model explaining the association between disordered eating patterns and substance use, as well as on the clinical presentation of women with co-occurring difculties, clinicians may want to address patterns of dietary restriction, the modulation of negative affective states or impulsive discharge of tension states. In particular, the need to increase awareness to exposure to high-risk situations and monitoring of antecedent events as well as psychoeducational information and coping skill enhancement regarding the adoption of a healthy life style have been emphasized [31]. Hence, the study supports the call for the development of short screening instruments for adult women with eating disorders and substance abuse, as well as for the development of treatment strategies that address the co-occurrence of eating disorders and substance use. References
1. Holderness C. C., Brooks-Gunn J., Warren M. P. Co-morbidity of eating disorders and substance abuse: review of the literature. Int J Eat Disord 1994; 16: 134. 2. Bulik C. M., Sullivan P. F., Carter F. A., Joyce P. R. Life-time comorbidity of alcohol dependence in women with bulimia nervosa. Addict Behav 1997; 22: 43746. 3. Bushnell J. A., Wells J. E., McKenzie J. M., Hornblow A. R., Oakley-Browne M. A., Joyce P. R. Bulimia comorbidity in the general population and in the clinic. Psychol Med 1994; 24: 60511. 4. Wiederman M. W., Pryor T. Substance use among women with eating disorders. Int J Eat Disord 1996; 20: 1638. 5. Grilo C. M., Levy K. N., Becker D. F., Edell W. S., McGlashen T. H. Eating disorders in female inpatients with vs. without substance use disorders. Addict Behav 1995; 20: 25560. 6. Hudson J. I., Weiss R. D., Pope H. G. Jr, McElroy S. K., Mirin S. M. Eating disorders in hospitalized substance abusers. Am J Drug Alcohol Abuse 1992; 18: 7585. 7. Stock S. L., Goldberg E., Corbett S., Katzman D. K. Substance use in female adolescents with eating disorders. J Adolesc Health 2002; 31: 17682.

8. Dansky B. S., Brewerton T. D., Kilpatrick D. G. Comorbidity of bulimia nervosa and alcohol use disorders: results from the National Womens Study. Int J Eat Disord 2000; 27: 18090. 9. Welch S. L., Fairburn C. G. Impulsivity or comorbidity in bulimia nervosa: a controlled study of deliberate self-harm and alcohol and drug misuse in a community sample. Br J Psychiatry 1996; 169: 4518. 10. Field A. E., Austin S. B., Frazier A. L., Gillman M. W., Camargo C. A., Colditz G. A. Smoking, getting drunk and engaging in bulimic behaviors: in which order are the behaviors adopted? J Am Acad Child Adolesc Psychiatry 2002; 41: 84653. 11. Killen J. D., Taylor C. B., Telch M. J., Robinson T. N., Maron D. J., Saylor K. E. Depressive symptoms and substance use among adolescent binge eaters and purgers: a dened population study. Am J Public Health 1987; 77: 153941. 12. Neumark-Sztainer D., Story M., Dixon L. B., Murray D. M. Adolescents engaging in unhealthy weight control behaviors: are they at risk for other health-compromising behaviors? Am J Public Health 1998; 88: 9525. 13. Benjamin L., Wulfert E. Dispositional correlates of addictive behaviors in college women: binge eating and heavy drinking. Eat Behav 2005; 6: 197209. 14. Krahn D. D., Kurth C. L., Gomberg E., Drewnowski A. Pathological dieting and alcohol use in college womena continuum of behaviors. Eat Behav 2005; 6: 4352. 15. Stewart S. H., Angelopoulos M., Baker J. M., Boland F. J. Relations between dietary restraint and patterns of alcohol use in young adult women. Psychol Addict Behav 2000; 14: 7782. 16. Dunn E. C., Larimer M. E., Neighbors C. Alcohol and drugrelated negative consequences in college students with bulimia nervosa and binge eating disorder. Int J Eat Disord 2002; 32: 1718. 17. Saules K. K., Pomerleau C. S., Snedecor S. M., Mehringer A. M., Shadle M. B., Kurth C. et al. Relationship of onset of cigarette smoking during college to alcohol use, dieting concerns, and depressed mood: results from the young womens health survey. Addict Behav 2004; 29: 8939. 18. Welch S. L., Fairburn C. G. Smoking and bulimia nervosa. Int J Eat Disord 1998; 23: 4337. 19. Statistics Canada. Public Use Microdata Documentation. Canadian Community Health Survey, Mental Health and Well-being. Ottawa: Tunneys Pasture; 2002. 20. Garner D. M., Olmsted M. P., Bohr Y., Garnkel P. E. The Eating Attitudes Test: psychometric features and clinical correlates. Psychol Med 1982; 12: 8718. 21. Garner D. M., Garnkel P. E. The Eating Attitudes Test: an index of the symptoms of anorexia nervosa. Psychol Med 1979; 9: 2739. 22. Kessler R. C., Andrews G., Mroczek D., Ustun B., Wittchen H. The World Health Organization Composite International Diagnostic Interview Short-Form (CIDI-SF). Int J Meth Psychiatr Res 1998; 7: 17185. 23. American Psychiatric Association (APA). Diagnostic and Statistical Manual of Mental Disorders, 3rd edn. revised, DSM-III-R. Washington, DC: APA; 1987. 24. Statistics Canada. Canadas Alcohol and Other Drugs Survey (CADS). Ottawa: Tunneys Pasture; 1994. 25. Wechsler H., Davenport A., Dowdall G., Moeykens B., Castillo S. Health and behavioral consequences of binge
Addiction, 102, 105113

2006 The Authors. Journal compilation 2006 Society for the Study of Addiction

Eating disorders and substance abuse in Canadian women

113

drinking in college: a national survey of students at 140 campuses. JAMA 1994; 272: 16727. 26. von Ranson K. M., Iacono W. G., McGue M. Disordered eating and substance use in an epidemiological sample. I. Associations within individuals. Int J Eat Disord 2002; 31: 389403. 27 Wonderlich S. A., Mitchell J. E. Eating disorders and comorbidity: empirical, conceptual, and clinical implications. Psychopharmacol Bull 1997; 33: 38190. 28. Nappo S. A., Tabach R., Noto A. R., Galduroz J. C., Carlini E. A. Use of anorectic amphetamine-like drugs by Brazilian women. Eat Behav 2002; 3: 15365.

29. Mintz L. B., OHalloran M. S., Mulholland A. M., Schneider P. A. Questionnaire for eating disorder diagnoses: reliability and validity of operationalizing DSM-IV criteria into a selfreport format. J Counsel Psychol 1997; 44: 6379. 30. Grilo C. M., Sinha R., OMalley S. Eating disorders and alcohol use disorders. Alcohol Res Health 2002; 26: 15160. 31. Sinha R., OMalley S. S. Alcohol and eating disorders: implications for alcohol treatment and health services research. Alcohol Clin Exp Res 2000; 24: 13129.

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