ED Article

7/28/2019 ED Article

1/10

ORIGINAL ARTICLE

Prevalence and correlates of self-induced vomiting as weight-control

strategy among adolescents in Taiwan

Yiing Mei Liou, Ya-Wen Hsu, Jow-Fei Ho, Che-Hung Lin, Wen-Yen Hsu and Tsan-Hon Liou

Aims. This study was designed to assess the prevalence and correlates of self-induced vomiting to control body weight among

adolescents in Taiwan.

Background. Over the past decades, the rate of obesity among children in Taiwan has nearly tripled. Educational authorities

have devoted considerable effort to prevent the increase in childhood obesity.

Design. An observational exploratory design to investigate the problem of using unhealthy weight-reduction strategy.

Methods. This study consists of a cross-sectional study aimed at collecting national representative data. We chose 120 repre-

sentative schools using a three-stage stratified systematic sampling design with probability proportionate to the size of the

population in Taiwan. Participants consisted of 8673 girls and 7043 boys, aged 1018 old.Results. Of the participants, 13% reported using self-induced vomiting, the prevalence being highest in participants aged 1012

(159%) and lowest in participants aged 1618 (75%). Several factors were significantly and positively associated with the use

of self-induced vomiting as a weight-loss strategy, specifically subjects who (1) watched television, used computer, surfed the

Internet or played video games for greater than or equal to two hours/day, (2) consumed fried food every day and (3) ate night-

time snacks every day (odds ratio = 1 55, 210 and 151, respectively; p < 005). Eating breakfast every day and sleeping for

more than eight hours a day were both protective factors against the use of self-induced vomiting to control body weight (odds

ratio = 043 and 086, respectively; p < 005).

Conclusions. Self-induced vomiting was prevalent among adolescents who had tried to lose weight; sedentary lifestyle, shorter

sleep length and unhealthy eating habits may contribute significantly to this behaviour among these adolescents.

Relevance to clinical practice. School nurses who are helping adolescents lose weight should also pay attention to the possibility

they are using self-induced vomiting as a weight-control strategy.

Key words: adolescent, diet, nurses, nursing, purging, screen time, sleep, weight control

Accepted for publication: 22 January 2011

Introduction

Obesity is a widespread and growing problem in industria-

lised countries and is increasingly becoming an important

medical, psychosocial and economic issue. Over the recent

three decades, the prevalence of obesity in paediatric age

groups has nearly tripled (Ogden et al. 1997, 2008). The

prevalence of being obesity has increased to the point it now

Authors: Yiing Mei Liou, RN, PhD, Associate Professor, Institute ofClinical and Community Health Nursing and Director, School

Health Research Center, National Yang-Ming University; Ya-Wen

Hsu, MD, Attending Physician, Department of Physical Medicine

and Rehabilitation, Shuang Ho Hospital, Taipei Medical University;

Jow-Fei Ho, PhD, Director, Department of Higher Education,

Ministry of Education; Che-Hung Lin, MS, Special Committee

Member, Department of Physical Education, Ministry of Education;

Wen-Yen Hsu, MD, Resident, Department of Physical Medicine and

Rehabilitation, Wan Fang Hospital, Taipei Medical University; Tsan-

Hon Liou, MD, PhD, Director, Department of Physical Medicine andRehabilitation, Shuang Ho Hospital, Taipei Medical University and

Assistant Professor, Graduate Institute of Injury Prevention, Taipei

Medical University, Taipei, Taiwan

Correspondence: Tsan-Hon Liou, Director, Obesity Research Center,

Shuang Ho Hospital, Taipei Medical University, 291, Jhongjheng

Rd., Jhonghe, Taipei County 23561, Taiwan. Telephone: +886 2

22490088 ext. 1600.

E-mail: [email protected]

2011 Blackwell Publishing Ltd, Journal of Clinical Nursing 1doi: 10.1111/j.1365-2702.2011.03739.x


2/10

constitutes an important public health issue. Chu (2005)

found that the prevalence of childhood obesity in Taiwan has

increased steadily from 19802000. Our serial survey in

Taiwan revealed that the prevalence of childhood obesity

increased significantly from 199254% in men and from

142175% in women in 19912003 (Liou et al. 2009).

Interventions aimed at adolescents may help reduce the rate of

obesity during the transition from adolescence to adulthood

and thereby prevent some of the long-term health conse-

quences of obesity (Westenhoefer 2002, Desai et al. 2008).

Background

The consensus for the treatment of obesity in adolescents

includes diet control, an increase in physical activity and

making various lifestyle modifications. However, during

adolescence, adolescents are more concern with their

appearance and indeed half to two-thirds of adolescents in

the USA report trying to lose weight for health or beauty(Lowry et al. 2005, Centers for Disease Control and

Prevention 2010a,b).

Purging and vomiting

As a result of a lack of information or by obtaining unreliable

information from the Internet, adolescents are likely to use

unhealthy weight-control strategies (Centers for Disease

Control and Prevention 2010a,b). Consequently, many ado-

lescents have tried purging and vomiting as weight-control

strategies (Nakamura et al. 1999, Thomas et al. 2005,

Neumark-Sztainer et al. 2006). Purging and vomiting can

result in various medical complications, particularly over the

long term and may trigger eating disorders, including an

increased risk of binge eating (Favaro & Santonastaso 1996,

Neumark-Sztainer et al. 2006). In a five-year longitudinal

study using a large survey sample called Eating Among Teens

Project, Neumark-Sztainer et al. (2006) reported that dieting

and unhealthy weight-control behaviours predict outcomes

related to obesity (269-fold) and eating disorders (32-fold).

Furthermore, purging and vomiting has been associated with

greater fluctuation of body mass index (BMI), earlier men-

arche and laxative misuse (Reba et al. 2005, Mond et al.2006). In two cohorts with a diagnosis of anorexia nervosa,

Reba-Harrelson et al. (2008) determined that female partic-

ipants who used purging or vomiting were three times more

likely to use diet pills. In some cases, self-induced vomiting

was associated with the severity of depression, impulsiveness,

anxiety and the presence of personality disorders (Edler et al.

2007).

Despite these negative health effects, vomiting and

purging are not an uncommon weight-control strategy

among adolescents. Nowadays, as awareness of the

importance of losing weight grows, methods for losing

weight and slimming are proliferating in Taiwan. Although

orlistat has been approved for childhood obesity, it is not

widely accepted (Viner et al. 2010). While every attempt is

made to tackle childhood obesity, it is also important to

encourage adolescents to follow obesity treatment guide-

lines instead of using unhealthy weight-control strategies.

Therefore, the authors set out to evaluate the prevalence

and the associated features of self-induced vomiting in a

large sample of Taiwanese students.

The aim

The study was designed to assess the prevalence and

correlates of Taiwanese adolescents using self-induced vom-

iting as a weight-control method, to provide reliable data forphysicians and school nurses to better understand weight-

control strategies used by adolescents.

Methods

Design

The Ministry of Education, Taiwan, invited us to conduct

nationwide health and growth studies in 2006. This study

was undertaken to determine the physical growth and

development of students aged 1018 in Taiwan between 1

December 200615 February 2007 (Liou et al. 2007, 2010).

The authors added questions to an observational explor-

atory survey to detect unhealthy weight-reduction behav-

iours.

Ethical considerations

The institutional review board approved this study. School

participation was approved by the educational authorities.

Before enrolling in this study, participants parents or legal

guardians signed the informed consent to indicate permis-

sion for their adolescents to participate in the study, if theychose to do so. Besides, only those students who returned

the consent form were asked to complete the study

questionnaires and their participation. Students participa-

tion in this study was voluntary, as they could refuse to

take part. Details of the study design have been previously

reported elsewhere (Liou 2004, Liou et al. 2010, Chien

et al. 2011).

YM Liou et al.

2 2011 Blackwell Publishing Ltd, Journal of Clinical Nursing


3/10

Setting and sample

The Taiwan area was divided into four regional districts

(north, middle, south and east). In this study, we used a three-

stage stratified systematic sampling design with the schools

sample number being proportionate to its size. The cut-off

points were designed to group schools into four clusters

according to the number of students in each of the four areas.In each of four clusters, schools were listed in sequence

according to the number of students. We selected specific

schools according to equally proportionate allocation, bal-

ancing the distribution of public and private schools, partic-

ipants ethnicity and the schools level of economic resources.

Subsequently, we used the sampling method of probability

proportional in size to draw out the specific classes and

students according to proportional allocation.

Participants came from 55 elementary schools (n =

10,882), 38 secondary high schools (n = 12,387), 18 senior

high schools (n = 6741) and 15 vocational schools (n =

4209), yielding a total sample of 34,219. Of these, the

parents of 31,751 students gave permission and completed

the questionnaire, for a response rate of 92 8% (Liou et al.

2007). The total number of subjects represented about 1 22%

of the student population in Taiwan (n = 2,601,578). Of

these, we only chose as candidates those who reported

experience of weight reduction. There were 15,716 subjects

(495%) who reported having tried to lose weight in the past

year and completed the questionnaire. The response rate is

915% (1454 missing data).

Procedures

Schoolteachers at each of the selected schools collected the

completed questionnaires, which were uniform in format

across schools, after half-day training on how to complete

and collect the forms properly. School nurses measured the

height and body weight of participants in a standardised

manner with a portable metal stadiometer and a digital or

balanced beam scale from SeptemberOctober 2006.

Measurements

We used BMI and applied the definition of the International

Obesity Task Force (IOTF) for underweight, normal, over-

weight and obesity (Cole et al. 2000, 2007). The project

survey National physical growth and development of

Taiwanese students, which includes several questions to

assess physical activity, sedentary behaviour, sleep duration

and dietary behaviour, was used for this study. Adding to this

survey, we developed those survey items that had previously

been validated and were similar to those used in the

International Physical Activity Survey, Taiwan, as described

below (Liou 2004, Bauman et al. 2009, Liou et al. 2010).

Physical activity

The questions (International Physical Activity Questionnaire

Youth Show Card Version) (Liou et al. 2010) were adapted

from the widely used International Physical Activity Ques-

tionnaire (IPAQ) (Craig et al. 2003, Liou et al. 2008, Bau-

man et al. 2009). These questions assessed the amount of

moderate and vigorous activity by the participants over the

preceding seven-day period. Vigorous-intensity physical

activity referred to activities that required a strong physical

effort and made people breathe much harder than normal.

Moderate-intensity physical activity referred to activities that

required moderate physical effort and made people breathe

somewhat harder than normal. Both were considered only

when they had been performed for at least 10 minutes at a

time. The authors provided more than ten culture-sensitiveexamples of specific activities for adolescents after each

question. Respondents were asked the average time spent on

physical activities during the preceding seven days and the

average time spent sitting each day. The content validity

indices were 098 each for language and meaning similarity

between the English and Taiwanese versions of IPAQs self-

administered short questionnaire. The consistency values

between the English and Taiwanese versions have intraclass

correlation coefficients (ICC) of 070 (Liou et al. 2008).

Overall, the reproducibility of the data obtained using the

IPAQ questionnaires was 078090 (ICC). The concurrent

validity for comparisons of the IPAQ long version and seven-

day recall of physical activity (Sallis et al. 1993) was 081 and

085, respectively. The criterion validity using accelerometers

is 053 (Craig et al. 2003, Liou 2004, Liou et al. 2010).

Sedentary behaviours

Several survey items adapted from the School Health Profiles

(Centers for Disease Control and Prevention 2010a,b) were

included to assess the routine amount of time spent in (1)

television viewing, (2) using computers, Internet, or playing

video games (not for homework), (3) reading books, news-

papers and magazines for fun, (4) transportation by vehicleand (5) studying and completing homework. The participants

reported the average number of hours per day spent engaging

in these behaviours. The content validity index was 099.

Testretest reliability was 094097 (ICC) (Liou et al. 2010).

Sleep

The quantity and quality of sleep was estimated using the

Pittsburgh Sleep Quality Index (seven components) (Buysse

Original article Eating habits, lifestyle and self-induced vomiting

2011 Blackwell Publishing Ltd, Journal of Clinical Nursing 3


4/10

et al. 1989). The content validity index was 095, and test

retest reliability was 071 (ICC). Concurrent validity with the

seven-day log was 094 (Spearman q) (Liou et al. 2010).

Diet

We measured 12 eating behaviours, including consumption

of water, fruit, vegetables, milk, protein, carbohydrates, fat,

fried foods, cake, sugar-containing drinks, breakfast and

night snacking. The content validity index was 089, and test

retest reliability was 072079 (ICC). Concurrent validity

with the Nutritional Chamberlain Line (Professional Edition,

version 2001/2003) that is based on food composition data-

bases in Taiwan was 074077 (Spearman q) (Liou et al.

2010).

Self-induced vomiting and eating less

This information was obtained using questionnaires that

asked the participants to respond to the following statements:

I vomit after I have eaten to lose weight and I tried to eat

less to lose weight. The content validity index was 088 and

096, and testretest reliability was 089 and 097 (ICC).

Participant responses were evaluated as dichotomous out-

comes, with clustering of always, usually and often re-

sponses on the positive side of the scale and sometimes,

rarely and never responses on the negative (Liou et al.

2010).

Data analysis

Statistical analyses were performed using the Statistical

Package for Social Science 15.0 software (SPSS Institute

Inc., Chicago, IL, USA). We used chi-square to test for

categorical variables. We used the independent t-test to

compare differences in bodyweight between groups. Multi-

variate logistic regression analyses were performed to exam-

ine the relationship between self-induced vomiting and

associated weight-loss strategies. The differences between

the groups were considered significant if p < 005.

Table 1 Percentage of subjects using self-

induced vomiting as a weight-loss strategy

Variables

Total

(n = 15,716)

Non-

vomiting

(n = 13,666)

Vomiting

(n = 2050)v2 test

p-valuen n (%) n (%)

Gender

Female 8673 7772 896 901 104


5/10

Results

Demographics and related factors of weight reduction

Table 1 presents the basic characteristics of participants.

There were 15,716 subjects (8673 girls and 7043 boys) who

ranged from 1018 years of age at the time data were

collected. Of these, 29% were categorised as overweight and

obese. Only 87% of the participants attained the goal of

eating five servings of fruit and/or vegetables each day. A

total of 218%, 169% and 57% of the participants

consumed fried food, sugar-containing drinks and night-time

snacks on a daily basis, respectively.

Prevalence of self-induced vomiting

The prevalence of self-induced vomiting was 13% among

subjects who had tried to lose weight, varying from 75

159% in different age categories. Men had a higher

prevalence of self-induced vomiting than women (163%

vs. 104%). Adolescents aged 1015 had a higher rate of

self-induced vomiting than those aged 1618 in both

genders. Adolescents at younger ages are thus at higher risk

of using this unhealthy weight-control strategy. Underweight

(181%) and obese (166%) adolescents are more likely to

use self-induced vomiting than other weight groups. With

univariate analysis, self-induced vomiting is significantly

associated with some lifestyle patterns including physical

activity level, screen time and sleep length as well as eating

habits including eating breakfast, night snack, desserts and

fried foods (Table 1).

The associations between self-induced vomiting and

related factors

For both genders, the odds ratios (OR) of possible risk factors

for self-induced vomiting are shown in Table 2. Stepwise

logistic regression analysis demonstrated that the following

variables were significantly associated with self-induced

vomiting: (1) aged 1012 and 1315 years (vs. 1618 years);

(2) being overweight and obese (vs. normal weight/under-weight); (3) screen time more than two hours/day (vs. less

than two hours/day) (i.e., time spent watching television,

using computers, on the Internet or playing video games); (4)

Table 2 Stepwise logistic regression analy-

sis of self-induced vomiting and associated

factors among adolescents who had

attempted weight reductionVariables

Total Females Males

OR 95% CI OR 95% CI OR 95% CI

Age, years

1012 204 174239 190 149241 226 185277

1315 197 171226 188 153230 216 179260

1618 1 1 1

Weight status*

Normal and

underweight

076 064090 056 041076 107 087132

Overweight 079 065095 067 047094 086 069109

Obese 1 1 1

Screen time

2 hours/day 155 137176 152 126182 157 132187


6/10

sleep length greater than eight hours/day (vs. less than

eight hours/day); (5) eating breakfast every day (vs. not every

day); (6) eating fried food and night-time snacks every day

(vs. not every day).

The associated factors between self-induced vomiting and

different weight status

As previously described, the prevalence of self-induced

vomiting is different between each weight status. Table 3

demonstrates the odds ratio of associated factors with self-

induced vomiting in different weight status. It shows that

there were two factors that prevented self-induced vomiting.

Eating breakfast every day was an independent factor in each

weight category, while sleep length more than eight hours

every day was found to be another preventive factor in the

normal weight group. There were four factors that signifi-

cantly facilitated using self-induced vomiting, including

eating fried foods every day, more than two hours of screen

time every day, eating night-time snacks daily and having

more than five servings of vegetables and fruits every day.

Discussion

This study provides comprehensive data on the prevalence

of using self-induced vomiting as a weight-control method

in Taiwan. In this representative cross-sectional study of

adolescents, we found 13% of subjects who had tried to

lose weight used self-induced vomiting as their weight-loss

strategy. The prevalence of self-induced vomiting among

adolescents has been reported to vary from 14% in Brazil

(Nunes et al. 2003) to 3 0% in young Australian college

men (ODea & Abraham 2002), to 33% in Italian

teenagers (Guarino et al. 2005). The CDC reports that

Table 3 Stepwise logistic regression analy-

sis of self-induced vomiting and associated

factors among adolescents who had

attempted weight reduction by differing

weight status

Weight status* Variable

Cut-off

point

Female Male

OR 95% CI OR 95% CI

Underweight Eating fried foods Every day 201 144282 242 119495

Other 1 1

Eating breakfast Every day 033 024047 030 015057

Other 1 1

Eating snacks at night Every day 387 186808

Other 1

Normal Screen time, hours/day 2 158 127195 188 151235


7/10

40% of students in the USA had vomited or taken laxatives

to lose weight or to keep from gaining weight during the

last 30 days (Centers for Disease Control and Prevention

2010a,b). Nakamura et al. (1999) demonstrated that 54%

of Japanese high school female students had an eating

disorder as defined by a total Eating Attitudes Test (EAT-

26) score above the cut-off point. They also found that

older age, higher BMI, a distorted body image and

obsessive-compulsive tendencies were related to eating

disorders. Gusella et al. (2008) found that 24% of subjects

were significantly more likely to have engaged in self-

induced vomiting in the high-risk group (The Childrens

version of the Eating Attitudes Test score 20 or higher). Our

study found the prevalence of self-induced vomiting as a

weight-loss strategy was 13% in Taiwan adolescents. The

prevalence is relatively high compared with previous studies,

which may be partly because this prevalence is among

subjects who had tried weight loss rather than the general

population. However, Hay et al. (2008) found that thepoint prevalence of eating disorder behaviours increased

twofold over the past decade in South Australia. Educa-

tional authorities and school nurses should be alerted to this

trend.

The source of the discrepancy between boys and girls

regarding prevalence of self-induced vomiting is unclear. One

reason may be weight status, as boys had a higher rate of

obesity than girls compared with previous studies and current

surveys in Taiwan (Liou et al. 2007, 2009). Second, from the

point of view of energy intake, boys are more likely to

increase their caloric intake as they mature than girls. This

gender-specific difference may also result from men having a

greater tendency to novelty seeking characterised by excite-

ment in response to novel stimuli, impulsivity, dramatisation

and thrill seeking. In this study, it is also noted that younger

adolescents (aged 1015) had a twofold higher likelihood of

using self-induced vomiting than the older adolescents (ages

1618). In other words, the prevalence of self-induced

vomiting decreases as years of growth. This is possibly due

to the younger adolescents beginning to become aware of

changes in body weight and shape, but they do not have

enough information about it or sufficient economic resources

to make use of better weight-loss techniques. They may adoptunhealthy weight-loss methods they find through the Internet

or cable TV. In short, they may regard self-induced vomiting

as an easy and cheap way to lose weight.

Although the severity of eating disorders does not neces-

sarily predict the degree of being overweight (Castellini et al.

2008), this study revealed that there is a significant associ-

ation between self-induced vomiting and weight status

(p < 005). The overweight and obese groups had a higher

likelihood of using self-induced vomiting to control their

body weight. Neumark-Sztainer et al. (2006) found that

dieting and unhealthy weight-control behaviours are associ-

ated with higher risk for gains in BMI. Self-induced vomiting

is not an effective weight-control strategy and in fact is a risk

factor for long-term weight gain and other eating disorders.

In this study, we found that self-induced vomiting is

significantly associated with sedentary behaviours and

unhealthy eating habits, which are likewise risk factors for

developing obesity later in life (Chaput et al. 2006, Vicente-

Rodriguez et al. 2008, Dubois et al. 2009). That means using

self-induced vomiting to control body weight eventually leads

to weight gain rather than weight loss. There is a vicious

cyclical relationship between overweight and self-induced

vomiting. Health professionals and school nurses should

educate adolescent populations on healthy and effective

weight-loss strategies.

Research has shown that adolescent dieters, particularly

those practicing unhealthy weight-control behaviours, maybe less likely to consume fruits and vegetables and adequate

amounts of calcium rich foods, compared with non-dieters

(Neumark-Sztainer et al. 1997). However, this relationship

was not demonstrated for Taiwan. However, Taiwan ado-

lescents who skipped breakfast and consumed fried foods

every day were more likely to use self-induced vomiting as a

weight-loss strategy. Breakfast skipping and consuming high-

energy foods are both established risk factors for the use of

self-induced vomiting and also for childhood obesity (Dubois

et al. 2009).

Limitations of this study

There are two limitations to this type of study. First, the data

for this study were obtained from a nationwide cross-

sectional survey rather than from a longitudinal cohort,

thereby preventing further assessment of cohort and time

effects. Second, the purpose of this study was to investigate

the prevalence of self-induced vomiting; the EAT-26 ques-

tionnaire was not designed to assess other eating disorders,

preventing further comparison between this and other stud-

ies. Besides, as prevalence of self-induced vomiting is highest

in the youngest respondents, further study is needed toexplore the possibility of using self-induced vomiting among

children below the age of ten.

Conclusions

It can be concluded from these results that self-induced

vomiting might serve as an early marker for the development

of obesity and/or other eating- and weight-related problems




8/10

later in life. Families and schools should attempt to identify

and mitigate behaviours associated with obesity among

adolescents as early as possible. Austin et al. (2007) found

that school-based obesity prevention programmes success-

fully reduce the prevalence of disordered weight-control

behaviours. Early interventions focused on helping adoles-

cents with self-induced vomiting develop positive feelings

about themselves, their weight, shape and physical appear-

ance and may ultimately have a protective effect on these

individuals (Westenhoefer 2001).

Relevance to clinical practice

Self-induced vomiting is prevalent among Taiwan adolescents

who had attempted weight reduction. Self-induced vomiting

is strongly associated with obesity and various other risk

factors. Those who use self-induced vomiting have the

associated features of sleeping less, more sedentary behav-

iour, skipping breakfast and enjoying eating fried foods. Allof these are risk factors for developing obesity later in life.

This study conclusively demonstrated that adolescents are

aware of the importance of weight control yet inappropri-

ately use self-induced vomiting to treat obesity despite the

negative consequences to health. Further, those using self-

induced vomiting rarely followed other recommendations for

healthy weight control. Further government initiatives, epi-

demiological and clinical studies of obesity are needed to

reduce this kind of unhealthy weight-loss behaviour in

Taiwan adolescents. An awareness of these factors is impor-

tant for Taiwanese nursing professionals who interact with

schoolchildren who want to control their weight, especially

the younger adolescents. Greater understanding may then

lead to more appropriate nursing care that promotes healthy

weight control among adolescents. This knowledge should be

helpful for school nurses caring for overweight children in

Taiwan.

Acknowledgement

The authors thank the Ministry of Education, Taiwan, for

providing financial support to this research.

Contributions

Study design: YML, T-HL; data collection and analysis:YML, J-FH, C-HL, Y-WH, W-YH and manuscript prepara-

tion: YML, T-HL, Y-WH.

Conflict of interest

None.

References

Austin SB, Kim J, Wiecha J, Troped PJ,

Feldman HA & Peterson KE (2007)

School-based overweight preventive

intervention lowers incidence of disor-

dered weight-control behaviors in early

adolescent girls. Archives Pediatrics and

Adolescent Medicine 161, 865869.

Bauman A, Bull F, Chey T, Craig CL,

Ainsworth BE, Sallis JF, Bowles HR,

Hagstromer M, Sjostrom M & Pratt M,

IPS Group (Country level authors:

Argentina: Daz Colodrero G, Bazan N

& Kunic H, Australia: Bauman A,

Merom D & Smith B, Belgium: De

Bourdeaudhuij I, Lefevre J & Philippa-erts R, Brazil: Matsudo SM & Matsudo

VR, Canada: Craig CL & Cameron C,

China PRC: Yang L & Hua F, Colom-

bia: Gomez LF, Czech Republic: Fromel

K & Mitas J, Hong Kong SAR China:

Macfarlane D & Bacon-Shone J, India:

Reddy SK, Joshi P, Goenka S & Pra-

bhakaran D, Japan: Katsumura T &

Murase N, Lithuania: Volbekiene V,

Baubliene R, McLean G & Carr H,

Norway: Tomten H anderssen SA,

Portugal: Sardinha L, Mota J, Saudi

Arabia: Al-Hazzaa HM, Spain: Serra

Majem L & Roman B, Sweden: Sjo s-

tro m M, Hagstro mer M, Bergman P,

Taiwan: Liou YM & Hung YT, USA:

Ainsworth BE & Hipp D) (2009) The

International Prevalence Study on

Physical Activity: results from 20

countries. International Journal of

Behavioral Nutrition and Physical

Activity 6, 125.

Buysse DJ, Reynolds CF 3rd, Monk TH,

Berman SR & Kupfer DJ (1989) ThePittsburgh Sleep Quality Index: a new

instrument for psychiatric practice and

research. Psychiatry Research 28, 193

213.

Castellini G, Lapi F, Ravaldi C, Vannacci A,

Rotella CM, Faravelli C & Ricca V

(2008) Eating disorder psychopathol-

ogy does not predict the overweight

severity in subjects seeking weight loss

treatment. Comprehensive Psychiatry

49, 359363.

Centers for Disease Control and Prevention

(2010a) Childhood Overweight and

Obesity. Available at: http://www.cdc.

gov/obesity/childhood/index.html (ac-

cessed 2 April 2002).

Centers for Disease Control and Prevention

(2010b) Youth Risk Behavior Surveil-

lance United States, 2009. Surveil-

lance Summaries. Morbidity and

Mortality Weekly Report 2010, 59.

Chaput JP, Brunet M & Tremblay A (2006)

Relationship between short sleeping

hours and childhood overweight/obes-ity: results from the Quebec en Forme

Project. International Journal of Obes-

ity 30, 10801085.

Chien LY, Liou YM & Chang P (2011) Low

defecation frequency in Taiwanese

adolescents: association with dietary

intake, physical activity and sedentary

behavior. Journal of Paediatrics and

YM Liou et al.



9/10

Child Health, In press. Doi: 10.1111/

j.1440-1754.2010.01990.x

Chu NF (2005) Prevalence of obesity in

Taiwan. Obesity Review 6, 271274.

Cole TJ, Bellizzi MC, Flegal KM & Dietz

WH (2000) Establishing a standard

definition for child overweight and

obesity worldwide: international sur-

vey. British Medical Journal 320,12401243.

Cole TJ, Flegal KM, Nicholls D & Jackson

AA (2007) Body mass index cut offs to

define thinness in children and adoles-

cents: international survey. British

Medical Journal 335, 194201.

Craig CL, Marshall AL, Sjostrom M,

Bauman AE, Booth ML, Ainsworth

BE, Pratt M, Ekelund U, Yngve A,

Sallis JF & Oja P (2003) International

physical activity questionnaire: 12-

country reliability and validity. Medi-

cine Science in Sports and Exercise 35,

13811395.

Desai MN, Miller WC, Staples B & Brav-

ender T (2008) Risk factors associated

with overweight and obesity in college

students. Journal of American College

Health 57, 109114.

Dubois L, Girard M, Potvin Kent M, Farmer

A & Tatone-Tokuda F (2009) Breakfast

skipping is associated with differences

in meal patterns, macronutrient intakes

and overweight among pre-school

children. Public Health Nutrition 12,

1928.

Edler C, Haedt AA & Keel PK (2007) Theuse of multiple purging methods as an

indicator of eating disorder severity.

International Journal of Eating Disor-

ders 40, 515520.

Favaro A & Santonastaso P (1996) Purging

behaviors, suicide attempts and psy-

chiatric symptoms in 398 eating disor-

dered subjects. International Journal of

Eating Disorders 20, 99103.

Guarino R, Pellai A, Bassoli L, Cozzi M, Di

Sanzo MA, Campra D & Guala A

(2005) Overweight, thinness, body self-

image and eating strategies of 2,121

Italian teenagers. Scientific World

Journal5, 812819.

Gusella J, Goodwin J & van Roosmalen E

(2008) I want to lose weight: early risk

for disordered eating? Journal of Pae-

diatrics and Child Health 13, 105110.

Hay PJ, Mond J, Buttner P & Darby A

(2008) Eating disorder behaviors are

increasing: findings from two sequential

community surveys in South Australia.

PLoS ONE 3, e1541.

Liou YM (2004) The website of the sur-

veillance system of the physical activity.

The Bureau of Health Promotion,

Department of Health, Taiwan, R.O.C.

Available at: http://140.129.162.186/

ipaq3 (accessed 2 April 2002).

Liou YM, Chen MY, Chiang LC, Chien LY,Chang PL & Hung YT (2007) Experi-

ences of a nation-wide integrated pro-

gram for healthy body weight among

students. Journal of Nursing54, 3036.

Liou YM, Jwo CJ, Yao KG, Chiang LC &

Huang LH (2008) Selection of appro-

priate Chinese terms to represent

intensity and types of physical activity

terms for use in the Taiwan version of

IPAQ. Journal of Nursing16, 252263.

Liou TH, Huang YC & Chou P (2009)

Prevalence and secular trends in over-

weight and obese Taiwanese children

and adolescents in 19912003. Annals

of Human Biology 36, 176185.

Liou YM, Liou TH & Chang LC (2010)

Sedentary leisure time and sleeping less

determine obesity among Taiwan ado-

lescents. Journal of Advanced Nursing

66, 12461256.

Lowry R, Galuska DA, Fulton JE, Burgeson

CR & Kann L (2005) Weight manage-

ment goals and use of exercise for

weight control among U.S. high school

students, 19912001. Journal of Ado-

lescent Health Care 36, 320326.

Mond JM, Hay PJ, Rodgers B, Owen C &Mitchell JE (2006) Correlates of self-

induced vomiting and laxative misuse

in a community sample of women.

Journal of Nervous and Mental Disease

194, 4046.

Nakamura K, Hoshino Y, Watanabe A,

Honda K, Niwa S, Tominaga K, Shimai

S & Yamamoto M (1999) Eating

problems in female Japanese high

school students: a prevalence study.

International Journal of Eating Disor-

ders 26, 9195.

Neumark-Sztainer D, Story M, Dixon LB,

Resnick M & Blum R (1997) Correlates

of inadequate consumption of dairy-

product s among adolescents. Journal

of Nutrition Education and Behavior

19, 1220.

Neumark-Sztainer D, Wall M, Guo J, Story

M, Haines J & Eisenberg M (2006)

Obesity, disordered eating and eating

disorders in a longitudinal study of

adolescents: how do dieters fare 5 years

later? Journal of the American Dietetic

Association 106, 559568.

Nunes MA, Barros FC, Anselmo Olinto

MT, Camey S & Mari JD (2003)

Prevalence of abnormal eating behav-

iours and inappropriate methods of

weight control in young women from

Brazil: a population-based study. Eat-ing and Weight Disorders 8, 100106.

ODea JA & Abraham S (2002) Eating and

exercise disorders in young college men.

The Journal of American College

Health 50, 273278.

Ogden CL, Troiano RP, Briefel RR, Kucz-

marski RJ, Flegal KM & Johnson CL

(1997) Prevalence of overweight among

preschool children in the United States,

1971 through 1994. Pediatrics 99, E1.

Ogden CL, Carroll MD & Flegal KM

(2008) High body mass index for age

among US children and adolescents,

2003-2006. Journal of the American

Medical Association 299, 24012405.

Reba L, Thornton L, Tozzi F, Klump KL,

Brandt H, Crawford S, Crow S, Fichter

MM, Halmi KA, Johnson C, Kaplan

AS, Keel P, LaVia M, Mitchell J,

Strober M, Woodside DB, Rotondo A,

Berrettini WH, Kaye WH & Bulik CM

(2005) Relationships between features

associated with vomiting in purging-

type eating disorders. International

Journal of Eating Disorders 38, 287

294.

Reba-Harrelson L, Von Holle A, ThorntonLM, Klump KL, Berrettini WH, Brandt

H, Crawford S, Crow S, Fichter MM,

Goldman D, Halmi KA, Johnson C,

Kaplan AS, Keel P, LaVia M, Mitchell

J, Plotnicov K, Rotondo A, Strober M,

Treasure J, Woodside DB, Kaye WH &

Bulik CM (2008) Features associated

with diet pill use in individuals with

eating disorders. Eating Behaviors 9,

7381.

Sallis JF, Buono MJ, Roby JJ, Micale FG &

Nelson JA (1993) Seven-day recall and

other physical activity self-reports in

children and adolescents. Medicine &

Science in Sports & Exercise 25, 99

108.

Thomas JJ, Keel PK & Heatherton TF

(2005) Disordered eating attitudes and

behaviors in ballet students: examina-

tion of environmental and individual

risk factors. International Journal of

Eating Disorders 38, 263268.




10/10

Vicente-Rodriguez G, Rey-Lopez JP, Mar-

tin-Matillas M, Moreno LA, Warnberg

J, Redondo C, Tercedor P, Delgado M,

Marcos A, Castillo M & Bueno M

(2008) Television watching, video-

games and excess of body fat in Spanish

adolescents: the AVENA study. Nutri-

tion 24, 654662.

Viner RM, Hsia Y, Tomsic T & Wong IC

(2010) Efficacy and safety of anti-

obesity drugs in children and

adolescents: systematic review and

meta-analysis. Obesity Review 11,

593602.

Westenhoefer J (2001) Establishing good

dietary habits - capturing the minds of

children. Public Health Nutrition 4,

125129.

Westenhoefer J (2002) Establishing dietary

habits during childhood for long-term

weight control. Annals of Nutrition &

Metabolism 46(Suppl. 1), 1823.

The Journal of Clinical Nursing (JCN) is an international, peer reviewed journal that aims to promote a high standard of

clinically related scholarship which supports the practice and discipline of nursing.

For further information and full author guidelines, please visit JCN on the Wiley Online Library website: http://

wileyonlinelibrary.com/journal/jocn

Reasons to submit your paper to JCN:High-impact forum: one of the worlds most cited nursing journals and with an impact factor of 1 194 ranked 16 of 70

within Thomson Reuters Journal Citation Report (Social Science Nursing) in 2009.

One of the most read nursing journals in the world: over 1 million articles downloaded online per year and accessible in over

7000 libraries worldwide (including over 4000 in developing countries with free or low cost access).

Fast and easy online submission: online submission at http://mc.manuscriptcentral.com/jcnur.

Early View: rapid online publication (with doi for referencing) for accepted articles in final form, and fully citable.

Positive publishing experience: rapid double-blind peer review with constructive feedback.

Online Open: the option to make your article freely and openly accessible to non-subscribers upon publication in Wiley

Online Library, as well as the option to deposit the article in your preferred archive.

YM Liou et al.


ED Article

Documents

Transcript of ED Article