Sociocultural Experiences of Bulimic and Non-BulimicAdolescents in a School-Based Chinese Sample

Todd Jackson & Hong Chen

Published online: 26 August 2009# Springer Science + Business Media, LLC 2009

Abstract From a large school-based sample (N=3,084), 49Mainland Chinese adolescents (31 girls, 18 boys) whoendorsed all DSM-IV criteria for bulimia nervosa (BN) orsub-threshold BN and 49 matched controls (31 girls, 18boys) completed measures of demographics and sociocul-tural experiences related to body image. Compared to lesssymptomatic peers, those in the BN group reported higherlevels of appearance pressure from their network of closerelationships and mass media, appearance comparisons andconversations, and fear of negative appearance evaluation.A hierarchical logistic regression analysis based sevenpredictors resulted in the correct identification of 82.7%of respondents, including 83.7% of the BN group and81.7% of controls. Responses on sociocultural measures,especially those reflecting appearance pressure, added to

the classification rate, after controlling for body mass indexand household socioeconomic status. When repeated withineach sex, classification accuracy was 90.3% for girls and86.1% for boys. This study establishes clear links betweensociocultural influences and BN among urban adolescentgirls and boys living in the People’s Republic of China.

Keywords Bulimia nervosa . Sociocultural factors .

Adolescents . China

Bulimia nervosa (BN) is a serious, disabling psychiatriccondition that affects about 1% of females and 0.10% ofmales in the general population and is particularly commonamong adolescent girls and young women (Hoek and vanHoeken 2003; Johnson et al. 2002; Mitchell and Crow2006). Notwithstanding contributions of genetic, biological,and psychological variables to BN, recent theoreticalaccounts such as the tripartite influence model havehighlighted sociocultural factors (e.g., Thompson et al.1999a, b). From this perspective, pressure from threesources—peers, family, and mass media—to conform tounrealistic ideals for physical appearance contribute to bodydissatisfaction and eating disturbances both directly andthrough two mediating mechanisms: the internalization ofsocietal attractiveness ideals including ultra-thinness forwomen and frequent appearance comparisons with peersand media ideals. Features of the tripartite model havegarnered considerable empirical support (e.g., Cafri et al.2005; Jacobi et al. 2004; Stice 2002; Thompson et al.1999a, b), yet the related literature has several gaps.

One such gap is the paucity of research conducted onsamples in highly populated, non-Western countries whererates of body dissatisfaction are comparable to thoseobserved in Western nations. For example, Li et al. (2005)found more than half of normal-weight boys and girls in a

This research was supported by grants from the Foundation programfor Humanities and Social Science research, State EducationCommission (08JAXLX014), the Chinese National Natural ScienceFoundation (30870774), and the School of Arts and Social Sciences,James Cook University. We thank Zhang Tingyan, Rao Ying, HeYulan, Liang Yi, Jiang Xiaxia, Chen Minyan, Pan Chenjing, Liukun,Yang Tingting, and Zhao Yi for assistance with data collection.

T. Jackson :H. Chen (*)Key Laboratory of Cognition and Personality,China Ministry of Education, Southwest University,Chongqing, Chinae-mail: chenhg@swu.edu.cn

T. Jacksone-mail: Todd.Jackson@jcu.edu.au

T. JacksonDepartment of Psychology, James Cook University,Townsville, Australia

H. ChenSchool of Psychology, Southwest University,Chongqing, China

J Abnorm Child Psychol (2010) 38:69–76DOI 10.1007/s10802-009-9350-0

large sample of 3–15 year old Mainland Chinese childrenwere dissatisfied with their current body weight, rates thatapproximate those found in the West (Thompson et al.1999a, b). Eating disturbances also appear to be increasingin China. Compared to past epidemiological work thatfound no cases of BN among adolescent girls in China(Huon et al. 2002), Chen and Jackson (2008) found 1.59%of Chinese girls met criteria for BN or sub-clinical BNemploying more stringent diagnostic criteria.

While sample differences may partially explain variabil-ity in rates of BN in China, the nation’s status as a rapidlydeveloping country cannot be overlooked. According toKeel and Klump (2003), core features of BN such asbingeing and purging are culture-bound and occur only insocieties wherein 1) large amounts of food are easilyaccessed, discreetly consumed and eliminated and 2)thinness and prevention of weight gain are promoted. Thesepre-conditions appear to preside in modern China asreflected in improved standards of living (Bell et al.2001), changes in dietary practices and activity levels(e.g., Du et al. 2004) and thinness as a historically-rootedthin body ideal (Leung et al. 2001) also promoted throughimported media images from developed Asian countriesand the West (e.g., Xie et al. 2006). As well, collectivistvalues such as group belongingness and interpersonalharmony may foster sensitivity to norms and prescribedstandards including those that define attractiveness (Jacksonand Chen 2008a).

Body image and eating concerns of Chinese adolescentshave been linked to tripartite influence model featuresincluding appearance pressure (Chen et al. 2007; Jacksonand Chen 2007, 2008b, c; Xie et al. 2006), thin idealpreferences (Li et al. 2005; Chen and Jackson 2009a, b),and appearance comparison (Chen et al. 2007; Jackson andChen 2008a). Nonetheless, the utility of these factors indifferentiating adolescents meeting criteria for syndromessuch as BN from less symptomatic peers has not beenassessed in a Chinese context. Examining this issue canelucidate sociocultural factors relevant to BN acrosscultures and those that are unique to Western samples inaddition to providing a basis for cross-cultural research onprevention and intervention.

A second gap in research on the tripartite model is thatwith few exceptions (e.g., Presnell et al. 2004; Shroff andThompson 2006), investigators have rarely explored rela-tive strengths of relation between perceived pressure fromdistinct sources and eating pathology. For example, it is notclear whether pressure from mass media expressed throughthe glorification of ultra-slender fashion models or moviestars is more potent in predicting BN symptoms thanpressure from one’s network of relationships expressed viaweight-related criticism or encouragement to lose weight.To an extent, this may be because validated measures of

appearance pressure are either composites that tap pressurefrom multiple sources (e.g., Stice and Agras 1998) or focusnarrowly on specific influences such as mass media (e.g.,Thompson et al. 2004). Clarifying relative effects of massmedia and interpersonal pressure may aid in identifyingspecific strategies most useful for prevention (e.g., medialiteracy versus skills training to manage relationships).

A third limitation in research is that while appearancepressure, idealization and comparison predict to disorderedeating, considerable variance remains unaccounted for bytripartite influence model features. Consequently, othersociocultural factors might have utility in augmenting theapproach. For example, complementing the emphasis onrelatively direct appearance pressure within this model,Jones and colleagues (Jones 2004; Jones and Crawford2006) hypothesized that appearance conversations drawattention to appearance-related issues, reinforce the impor-tance of physical appearance among close friends, andpromote particular standards of attractiveness. In support ofthese contentions, frequent appearance conversations cor-respond with increased internalization of appearance idealsand body dissatisfaction over time (e.g., Jones 2004; Joneset al. 2004). Because self-consciousness (Frankenberger2000) and the importance of peer acceptance (Bukowski etal. 1993) increase during adolescence, fear of negativeevaluation about appearance is a second factor that maybolster the predictive utility of the tripartite influencemodel. Striegel-Moore et al. (1993) note that, especiallyfor girls and young women, the body is a “social object”constantly accessible to others’ evaluations. When a youngwoman feels insecure in general, concerns about others’judgments can extend to evaluations of her body. Empirically,appearance evaluation fears predict body image concernsindependent of conceptually similar constructs such asphysique anxiety (Lundgren et al. 2004) as well as increasesin symptoms of BN (Gilbert and Meyer 2005; Mussap 2007).Notwithstanding evidence that appearance conversations andevaluation fears are relevant to eating disturbances, it is notclear whether their effects extend beyond those of tripartiteinfluence model features.

To address these issues, we examined differences insociocultural experiences of Mainland Chinese adolescentswho met diagnostic criteria for BN or sub-threshold BNand their less symptomatic classmates. Relative to thecomparison sample, adolescents in a BN sample wereexpected to report more appearance pressure from massmedia and close interpersonal networks, more frequentappearance comparisons and conversations with friends,and heightened negative appearance evaluation fears.Responses on sociocultural measures were also expectedto predict membership in BN and comparison groups atbetter than chance levels. Although perceived pressure frommass media and from close social networks were expected

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to contribute to classification accuracy of samples, nohypotheses were generated regarding their relative impact.Finally, we explored the extent to which appearanceconversations and evaluation fears contributed to theprediction of group membership, after controlling foreffects of tripartite model features (appearance pressureand comparison).

Method

Procedure

After receiving IRB approval from Southwest University(SWU), the second author contacted colleagues working inmiddle schools and high schools in Chongqing, a sprawlingmetropolitan city in Southwest China. Permission wassought to conduct research on predictors of body image/eating concerns; all contacted settings granted the request.Informed consent was obtained from each teacher whopermitted data collection in her/his classroom as well as theparent or legal guardian of each eligible child. Teachers ofparticipating classes gave students a survey packet thatincluded a brief description of the study, and an informedconsent outlining the time involved (30–40 min), thevoluntary, anonymous nature of participation, and the rightto withdraw at any point. Research measures were includednext, followed by referral information for those distressedby body image or eating concerns. Students were encour-aged to read items carefully and to answer all if possible.Surveys were completed during class time and returned toteachers separately from consents. Data collection occurredduring March–April, 2008.

Participants

An initial sample of 3,084 students (1,593 girls, 1,488 boys,three unspecified) was recruited. Respondents ranged in agefrom 12 to 18 years (M=14.34 years, SD=1.78) andincluded 1,032 middle school and 2,052 high schoolstudents. Similar to the ethnic group composition of thegeneral population, most students (97.2%) were Han.Others were from nine of 56 ethnic minorities that compriseabout 5% of China’s population. The mean body massindex (BMI) was 19.43 (SD=2.88). Most students reportedliving in a household with a monthly income of 1,000–3,000 Yuan (44.2%) or 3,000–5,000 Yuan (28.5%) withfewer reporting less than 1,000 Yuan (12.3%) or more than5,000 Yuan (15.0%) [One American dollar is worth about 7Yuan].

From their responses on the Eating Disorder DiagnosticScale (EDDS; Stice et al. 2000), 49 students (31 girls, 18boys) endorsed all BN criteria (41%) or sub-threshold BN

(59%) wherein all criteria were endorsed except thatcompensatory behaviour was reported at least once but lessthan twice per week, on average, during the past 3 months.Subsequently, each symptomatic student was matched with aclassmate of the same age, sex, and ethnicity. No one in thecomparison group met BN criteria. The research sample (62girls, 36 boys) was similar to the initial sample in age (M=14.22 years, SD=1.81 years), ethnicity (i.e., 98% Han, 2%Tu), BMI (M=19.46, SD=3.31), and income distribution.

Measures

Back Translation Several scales had been back-translatedinto English in previous published accounts. Other scales(Appearance Conversation, Fear of Negative AppearanceEvaluation, Appearance Pressure from Mass Media) weretranslated into Chinese and back-translated into English bytwo Ph.D students majoring in English at SWU. Minordeviations were discussed by translators and the first authorand modified to better approximate meanings of originalscales.

Eating Disorder Diagnostic Scale (EDDS; Stice et al.2000) The EDDS is a 22-item self report screen based onDSM-IV eating disorder criteria. The scale is reliable,stable, has excellent concordance with structured inter-views, and converges with validated measures of weightand eating concerns, eating disorder risk factors, and socialimpairment (Stice et al. 2000; Stice et al. 2004). The EDDSis sensitive in detecting intervention effects and predictingrisk for subsequent binge eating, compensatory behaviors,and onset of depression (Stice et al. 2004). Aside fromusing the EDDS to identify a bulimic subsample, weassessed the integrity of each sample via a symptomcomposite calculated by summing 19 standardized EDDSitems, excluding those pertaining to height, use of birthcontrol pills, and missed menstrual periods (Stice et al.2000). The composite is reliable and has high concordancewith related measures (Stice et al. 2004). In this study,composite alphas were α=0.92 for girls and α=0.87 forboys.

Appearance Conversations with Friends (Jones et al.2004) This five item scale assesses how often one discussesperceptions and expectations regarding physical appearancewith friends (e.g., “My friends and I talk about howimportant it is to always look attractive”). Each item wasrated between “1 = Not at all” and “5 = Very often”. Inthis research, alphas were satisfactory for girls (0.89) andboys (0.85).

Physical Appearance Comparison Scale (PACS; Thompsonet al. 1991) Four items assessed tendencies to compare

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one’s appearance to that of others. Response options rangedfrom “1 = Never” to “5 = Always.“ The PACS is stable,internally consistent, and reliably related to body dissatis-faction and disordered eating (e.g., Shroff and Thompson2006; Thompson et al. 1991). Alphas were α=0.85 for girlsand α=0.74 for boys in this study.

Perceived Sociocultural Pressure Scale (PSPS; Stice andAgras 1998) Six items of the PSPS tapped appearancepressure from friends (e.g., “I’ve felt pressure from myfriends to change my physical appearance”), family (e.g.,“I’ve felt pressure from my family to change myphysical appearance”) and best friend/significant other.Items were rated between “1 = Not at all” and “5 = VeryMuch.” Stice and Agras (1998) concluded the PSPS hasadequate reliability, stability, and predictive validity. Inthis study, reliabilities were α=0.83 for girls and α=0.78for boys.

Appearance Pressure from Mass Media (Thompson et al.2004) Reported appearance pressure from mass media wascalculated by summing seven items from the Pressuresubscale of the Sociocultural Attitudes Toward AppearanceScale -3 (SATAQ; Thompson et al. 2004). Each statementwas assessed on a scale of agreement from “1 =Completely Disagree” to “5 = Completely Agree”. Thesubscale is internally consistent and a stable factor structureacross different samples, including males (Karazsia andCrowther 2008). In this sample, alphas were high for girls(0.90) and boys (0.86).

Fear of Negative Appearance Evaluation (FNAE, Lundgrenet al. 2004) The six-item FNAE taps frequency of concernsthat others will judge one’s physical appearance in anegative manner. Sample items include “I worry that peoplewill find fault with the way I look” and “I am afraid otherpeople will notice my physical flaws”. Each item was ratedbetween “1 = Never” and “5 = Almost Always True”.

Lundgren et al. reported the scale has high internalconsistency and convergent validity with other measuresof body image, disordered eating, and anxiety in college-age women. Alphas were satisfactory for girls (0.92) andboys (0.87).

Background Data Age, sex, weight, height, and ethnicitywere queried. Estimated monthly household income wasassessed from four options noted above. To assesshousehold socioeconomic status (SES), students wereasked whether their family owned 13 items (e.g., comput-er, dvd, car, washing machine) from Shi et al. (2005).After dropping one negative loading item, television,alphas for household SES were α=0.78 for girls and α=0.84 for boys.

Results

Preliminary Analyses Due to a priori matching, the 49bulimic symptomatic-less symptomatic pairs were identicalfor classroom, gender, age, and ethnicity. Supporting theintegrity of each group, there was a highly significantdifference between bulimia and less symptomatic sampleson the EDDS symptom composite, F (1, 96)=367.89,p<0.0001, η=0.89. Regarding other demographic factors,groups did not differ on reported household income, χ2(3)=5.41, p<0.14, but the BN sample reported higher householdSES and BMI levels than did the comparison sample (seeTable 1).

Main Analyses Initially, a multivariate analysis of covari-ance (MANCOVA) was performed to examine groupdifferences in sociocultural experiences. After controllingfor covariates (household SES and BMI), a multivariateeffect was found, F (7, 90)=14.35, p<0.0001. As shown inTable 1, the BN group scored higher on all socioculturalindices than the comparison group did. Examination of

Measure Group Univariate F p eta

Bulimia Comparison

Mean SD Mean SD

Body mass index 20.20 3.16 19.13 2.11 3.91 0.05 0.20

Household SES 9.14 2.59 7.76 2.93 5.88 0.02 0.24

Appearance pressure (Media) 12.16 4.60 6.51 2.86 42.60 0.001 0.55

Appearance pressure (Close) 17.35 5.57 9.76 3.23 44.37 0.001 0.56

Social comparison 12.22 3.37 8.65 3.23 25.35 0.001 0.46

Appearance conversations 14.45 4.92 10.31 3.93 21.20 0.001 0.43

Appearance evaluation fears 22.02 5.83 13.29 4.61 67.64 0.001 0.64

Table 1 Group Differences inSociodemographic andSociocultural Measures (n=98)

Body mass index and householdSES served as covariates inanalyses of group differences onother measures.

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bivariate associations among measures indicated that whilehousehold SES was unrelated to all scales except perceivedmedia pressure (p<0.01), intercorrelations among BMI andsociocultural measures were all significant, ranging fromr=0.20 (p<0.05) for the association between BMI andappearance conversations to r=0.69 (p<0.001) for thecorrelation between perceived pressure from close relationsand negative evaluation fears.

Subsequently, following guidelines of Morgan et al.(2003), a hierarchical multiple logistic regression assessedthe degree to which members of each group could becorrectly identified from their responses on measures ofhousehold SES and BMI (Step 1), tripartite model features(pressure from media and close relationships, appearancecomparison) in Step 2, and other factors (appearanceconversations, evaluation fears) in Step 3. Compared to aclassification rate of 50% from chance alone, 82.7% ofparticipants, including 83.7% of the BN group and 81.7%of controls, were correctly identified from the predictors, χ2

(7)=69.66, p<0.001. As shown in Table 2, sociodemo-graphic factors, especially household SES, made a signif-icant contribution, but responses on measures in Step 2 hada more prominent impact, χ2 (3)=56.45, p<0.001. Withinthis step, pressure from both close relations and mass mediahad significant associations with group membership.However, appearance conversation and evaluation fears(Step 3) failed to improve the classification rate further,χ2 (2)=3.83, p<0.14.

Boys comprised more than one third of the BN sample,an unexpected finding that allowed for supplementarylogistic regression analyses to assess the utility of socio-

cultural measures in detecting BN within each sex. Forgirls, classification rates of 90.3% were obtained for bothBN and control groups from responses on predictors. Eachstep made a signification contribution to the model, withBMI, household SES, and the measures of appearancepressure emerging significant or marginally significantpredictors (Table 2). Among boys the accuracy rate in acomplementary analysis was 86.1%, including 83.3% ofboys with BN and 88.9% of controls. The block of tripartiteinfluence model measures had a significant impact, withclose appearance pressure emerging as the strongestindividual predictor (Table 2). Measures in Step 3 did notmake unique, additional contributions to the model forboys, χ2 (2)=3.82, p<0.15.

Discussion

While tripartite influence model features have been linkedto body image and eating disturbances in Chinese samples(e.g., Chen et al. 2007; Chen and Jackson 2009b; Li et al.2005; Xie et al. 2006), this study is the first to show howChinese girls and boys meeting criteria for full orsub-threshold BN and less symptomatic peers can bedifferentiate on the basis of these and other factors. Morethan 80% of the entire sample was correctly identified fromtheir responses on sociodemographic and socioculturalmeasures, an accuracy rate similar to that found in a sampleof bulimic and non-bulimic American women completingmeasures of body image, sociocultural influence and stress

Table 2 Multiple Logistic Regression Analyses For Total Sample, Girls, and Boys

Step Predictor Total sample (N=98) Girls (N=62) Boys (N=36)

OR 95% CI p OR 95% CI p OR 95% CI P

1 Body mass index 1.16 0.99–1.37 0.070 1.35 1.04–1.75 0.030 1.07 0.85–1.35 0.590

Household SES 1.20 1.02–1.39 0.020 1.39 1.10–1.79 0.006 1.04 0.83–1.30 0.740

χ2 (2)=9.38, p<0.009 χ2 (2)=13.71, p<0.001 χ2 (2)=0.50, p<0.78

Correctly classified: 62.2% Correctly classified: 71.0% Correctly classified: 52.8%

2 Appearance pressure (Media) 1.26 1.06–1.49 0.009 1.26 0.99–1.56 0.060 1.37 0.93–2.00 0.110

Appearance pressure (Close) 1.39 1.16–1.66 0.001 1.33 1.02–1.74 0.040 1.55 1.12–2.14 0.009

Appearance comparisons 0.98 0.78–1.23 0.860 1.21 0.87–1.68 0.260 0.81 0.54–1.22 0.320

χ2 (5)=65.83, p<0.001 χ2 (5)=50.17, p<0.001 χ2 (5)=24.77, p<0.001

Correctly classified: 82.7% Correctly classified: 83.9% Correctly classified: 83.3%

3 Appearance conversations 0.96 0.76–1.22 0.690 0.95 0.69–1.31 0.740 0.72 0.44–1.19 0.200

Appearance evaluation fears 1.17 0.99–1.38 0.070 1.17 0.83–4.88 0.120 1.88 0.56–1.37 0.570

χ2 (7)=69.66, p<0.001 χ2 (7)=60.11, p<0.001 χ2 (7)=28.60, p<0.001

Total correctly classified: 82.7% Total correctly classified: 90.3% Total correctly classified: 86.1%

OR odds ratio; CI confidence interval.

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(Engler et al. 2006). When analyses were repeated withineach sex, classification rates improved slightly for boys andreached just over 90% for girls. Despite being implicatedinitially in models of disordered eating among Western girlsand young women, this study suggests sociocultural factorsmay have utility in understanding bulimia symptoms ofadolescent girls and boys in specific non-Western cultures.

Measures of tripartite influence model features contributedto classification rates in each regression model aftercontrolling for BMI and household SES. Increased pressurefrom close interpersonal ties and, to a lesser extent, massmedia were predictive of BN group membership albeitappearance comparison did not influence classificationmodels. Eating disturbances have been linked previouslyto reported pressure from family and friends (e.g., Stice andAgras 1998; Stice and Whitenton 2002) as well as massmedia (Grabe et al. 2008) but in collectivist China valuesrelated to maintaining social harmony, cultivating one’snetwork of social relationship, and using social norms toguide behavior (Chen and Jackson 2009a, b) may havebuttressed relations of close social network pressure to BNsymptom presentations.

This study also evaluated whether factors outside thescope of the tripartite influence model added to predictionmodels. These findings were not clear-cut. The effect sizefor fear of negative appearance evaluation was the highestof any sociocultural measure in univariate analyses ofgroup differences. Furthermore, while appearance evalua-tion fear and appearance conversations did not contribute toprediction models for boys or the total sample, theircombined influence improved the classification rate forgirls, independent of other all other predictors. In alllikelihood, high correlations among sociocultural measuresattenuated the impact of those entered last in regressionequations. In concert with longitudinal evidence suggestingfear of negative evaluation contributes to increases in eatingpathology (Gilbert and Meyer 2005), there may be value inconsidering these factors further in related future work.Notably, few researchers have considered psychosocialfactors that explain why some adolescent girls and boysare more susceptible to perceived appearance pressure frominterpersonal and mass media sources. Because fear ofnegative evaluation seems to be highly heritable (Stein etal. 2002), there is a conceptual base for assessing its’ role asa precursor to both reported appearance pressure anddisordered eating in future causal modeling and prospectivestudies.

Notwithstanding evidence that disordered eating haspositive relations with BMI (e.g., Jackson and Chen2008c) and facets of SES (e.g., Chen and Jackson 2008;Lee and Lock 2007) in young Chinese samples, theemergence of these predictors was surprising because apriori matching of groups on the basis of age, sex, and

home classroom was expected to undercut other demo-graphic differences. BMI and household SES were prom-inent in the prediction model for girls but not for boys.Given that thinness is a feminine attractiveness ideal inmany cultures including China (Leung et al. 2001), girlswith a higher BMI may be more prone to negativefeedback, body dissatisfaction and inappropriate compen-satory behavior to reduce discrepancies between their ownbody size and ideals. The socioeconomic advantage of girlsin the BN group may have reflected, in part, relatively easyaccess to large amounts of food that could be purged withdiscretion (Keel and Klump 2003). However, unmeasuredfactors such as higher achievement strivings and parentalexpectations of success can accompany higher SES status(Lee and Lock 2007) and may have contributed to the linkbetween household SES and BN status.

In concert with research on prevention (e.g., Stice and Shaw2004), findings suggest interventions targeting appearancepressure from interpersonal sources can help to reduce bulimictendencies of Chinese adolescents. However, given highintercorrelations among predictors, strategies that addressmultiple factors (media, peers, personal health practices)may be preferable to those having a narrow focus. Forexample, prevention programs based on principles of cogni-tive dissonance foster skills in recognizing and challenging theappeal of unrealistic body image. On the surface, suchprograms may help to reduce negative effects of unrealisticmedia portrayals of body image. Arguably, when offered ingroup settings, such approaches also reduce pressure fromfriends and classmates engaged in these exercises and allowmore realistic expectations about body image to emergewithin certain segments of participant social networks.

These implications aside, limitations of this study mustbe noted along with future research directions. First, whileassessment of disordered eating via anonymous surveys canincrease candor (Keel et al. 2002) and the EDDS hasexcellent concordance with diagnostic interviews, use of astructured interview with follow-up probes in designswould aid in confirming diagnoses. Second, appearanceideals were not assessed due to the possibility of a mixedsex sample and potentially reduced salience of such scalesto boys. Future work might assess whether classificationrates improve with the inclusion of measures of appearanceideals specific to each sex. Third, because students drawnfrom school settings may be relatively high functioning,evaluations are needed among inpatients with BN and thosewho show significant impairment. On a related note, whilethe prediction model for boys showed promise, replicationswith larger male samples are needed to ensure findings arereliable. Finally, including clinical comparison groups infuture work can clarify specificity of relations betweensociocultural factors and eating disorders syndromes versusother forms of psychopathology.

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