1. health and fitness
2. disorders

Substance Use & Misuse, 46:523–534, 2011
C 2011 Informa Healthcare USA, Inc.
Copyright ISSN: 1082-6084 print / 1532-2491 online
DOI: 10.3109/10826081003725260
ORIGINAL ARTICLE
Disordered Eating and Substance Use Among a Female Sample
of Mexican Adolescents
Claudia Unikel1 , Tammy Root2 , Ann Vonholle2 , Rene´ Ocampo3 and Cynthia M. Bulik2
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1
Instituto Nacional de Psiquiatria Ramon de la Fuente Mu˜niz, Investigaciones Epidemiologicas y Psicosociales, DF,
Mexico; 2 University of North Carolina at Chapel Hill, Department of Psychiatry, Chapel Hill, North Carolina, USA;
3
Secretaria de Salud, Oficina de Investigacion Operativa, DF, Mexico
(SES) and marginalization status (i.e., urban, rural)—with
greater substance use in urban areas compared with rural areas (Wiles et al., 2007)—there are only two studies,
with contrasting results, that have measured the comorbidity of DE, substance use, and socioeconomic status, one
in the Bermuda and the other in Spain (Marlowe, 2005;
Rodriguez et al., 2001).
Furthermore, little research has examined substance
use and DE in different Latino populations (Erickson &
Gerstle, 2007; Guiao & Thompson, 2004; Granillo et al.,
2005; Rich & Thomas, 2008; Robinson et al., 1996). Rich
and Thomas (2008) found similar scores on the eating attitudes test in female students of Latino, African, and European origin. This similarity may reflect changes in the
pressure to lose weight among Latinas and African Americans. On the other hand, Guiao and Thompson (2004)
found in a U.S. study that included female adolescent that
consumption of drinks per occasion was similar between
Latino and Native Americans.
The purpose of this paper is to bridge an important gap
in the literature by examining the relation between DE and
substance use among Mexican female adolescents across
SES and marginalization status. We hypothesize higher
prevalence of alcohol and tobacco use among adolescents
with DE compared with those without DE, and we predict
greater alcohol and tobacco use with decreased marginalization status (i.e., higher SES). A study regarding substance use, disordered eating, and marginalization is important in Mexico for several reasons, including the lack
of studies regarding this topic in Mexico (there is only one
previous study to our knowledge, which did not include a
The relation between disordered eating and substance
use was examined among Mexican female adolescents
in a probabilistic sample of 2537 high school students
in central Mexico, stratified by marginalization status
and migratory intensity, obtained during 2006–2007
school year. The Brief Disordered Eating Questionnaire and the World Health Organization and United
Nations Division of Narcotic Drugs recommendations
for substance use assessments were used. Prevalence
and odds ratios for disordered eating and substance use
items were calculated separately across low and high
marginalization groups. Study’s implications and limitations are noted, as well as future research and prevention strategies are suggested.
Keywords disordered eating, substance use, marginalization
status, adolescents, Mexico
INTRODUCTION
Risk1 for disordered eating (DE) and substance use
emerges and increases throughout adolescence (Field
et al., 2002). The comorbidity between DE and substance
use has also been well-documented with patterns of behavior varying depending on DE presentation (Blinder,
Cumella, and Sanathara, 2006; Bulik et al., 2004; Conason, Brunstein Klomek, & Sher, 2006; Franko et al., 2005;
Higuchi, Suzuki, Yamada, Parrish, & Kono, 1993; Luce,
Engler, & Crowther, 2007; Pisetsky, Chao, Dierker, May,
& Striegel-Moore, 2008). Although substance use has
been shown to vary depending on socioeconomic status
This research was funded by the Consejo Nacional de Ciencia y Tecnolog´ıa.
1
The reader is reminded that the concept–process of risk-being at risk are often noted in the literature, without an adequate delineation of their
dimensions (linear, nonlinear), their “demands”, the critical necessary conditions (endogenously as well as exogenously; from a micro to a macro
level) which are necessary for them to operate (begin, continue, become anchored, and integrate, change as de facto realities change, cease, etc.) or
not to and whether their underpinnings are theory-driven, empirically-based, individual and/or systemic stake holder-bound, based upon “principles
of faith” or what. It is necessary to consider such issues if these terms are not to remain as yet additional shibboleths in a field of many stereotypes. If
we don’t currently know, in a generalizable sense—to state this. Editor’s note.
Address correspondence to Dr. Claudia Unikel, Ph.D., Instituto Nacional de Psiquiatria Ramon de la Fuente Muniz, Investigaciones
Epidemiologicas y Psicosociales, Calz. Mexico-Xochimilco 101, Col San Lorenzo Huipulco, DF 14370, Mexico; E-mail: [email protected]
523
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C. UNIKEL ET AL.
measure for socioeconomic status) and the high comorbidity of substance use and DE.
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Prevalence of Alcohol and Tobacco Use Among
Adolescents
Alcohol and tobacco are the two most commonly
used substances among Mexican and American adolescents (Johnston, O’Malley, & Bachman, 2002; VillatoroVelazquez et al., 2009). It has been estimated that 22.7%
of 10–19-year-old Mexicans have tried alcohol and 8.4%
tried alcohol for the first time between 10 and 14 years
of age (Henry, Lazcano, Hern´andez-Prado, & Oropeza
Ab´undez, 2007). Similar to alcohol, the initiation of tobacco typically begins before 10th grade with nearly half
of adolescents reportedly having tried cigarettes between
15 and 17 years of age (Medina-Mora, Pena-Corona,
Cravioto, Villatoro, & Kuri, 2002). Student Population
Surveys in Mexico City (Villatoro-Velazquez et al., 2009)
report a prevalence of 69.4% for lifetime alcohol use in
females, 57.7% for past year, and 41% for past month. Regarding the tobacco use, the prevalence of lifetime tobacco
use has been estimated to be 47.1%, 29% for use in the
past year, and 16.4% for use in the past month (VillatoroVelazquez et al., 2009).
In Mexico, both alcohol and tobacco use have been
shown to be higher in urban areas compared with rural
areas. When examining past year use in an adult sample,
43% of women in urban settings consumed alcohol compared with 19% in rural settings, and 5% in both rural and
urban settings were excessive alcohol consumers, characterized by the use of five or more drinks per occasion
(Medina-Mora Icaza et al., 2002). Related to adolescence,
the prevalence of alcohol use among Mexican females in
urban areas has been estimated at 25% relative to 10% in
rural areas (Medina-Mora Icaza et al., 2002).
Similarly, the prevalence of tobacco use has been reported to be higher among Mexican adolescents living in
urban areas with 5% of females and 15% of males reporting use compared with 1% and 11.3%, respectively,
in rural areas (Kuri-Morales, Gonzalez-Roldan, Hoy, &
Cortes-Ramirez, 2006; Yamamoto et al. 2008).
Disordered Eating and Substance Use
Disordered Eating is characterized as “inappropriate eating behaviours defined by DSM IV (APA, 1994) not
meeting frequency and duration criteria with diagnostic
requirements.” These behaviors consist of concern for
weight gain, binge eating with a feeling of lack of control,
purging and restrictive eating behaviors aimed at weight
reduction (Unikel, 2003).
The relation between DE and substance use has been
well documented in the literature in the United States
(Gadalla & Piran, 2007; Holderness, Brooks-Gunn, &
Warren, 1994a, 1994b; Tomeo, Field, Berkey, Colditz, &
Frazier, 1999; Wolfe & Maisto, 2000), whereas in Mexico
we have the knowledge of only one study (Gutierrez et al.,
2001). Research suggests a higher prevalence of substance use among individuals with DE in both the United
States and Mexico (Gutierrez, Mora, Unikel Santoncini,
Villatoro Velazquez, & Medina-Mora Icaza, 2001; Pisetsky et al., 2008; Striegel-Moore & Huydic, 1993; Timmerman, Wells, & Chen, 1990; von Ranson, Iacono, &
McGue, 2002) and young adults (Krahn, Kurth, Demitrack, & Drewnosky, 1992; Luce et al., 2007). A study of
Mexican adolescents revealed that 25.2% of females with
DE reported lifetime substance use compared with 10.5%
without DE behaviors, with a similar trend reported for
past year and past month use (Gutierrez et al., 2001).
Regarding alcohol use in the United States, prevalence
among those with eating disorders is generally higher
compared with the general population. The National Center on Addiction and Substance Abuse at Columbia University (2003) report that female adolescents with DE
symptoms are twice as likely to report alcohol use (63.9%
versus 38.6%) and binge drinking (43.0% versus 20.8%)
compared with females without DE symptoms (Field
et al., 2002). Likewise, the reverse is true–-adolescent females who report current drinking behavior (37.4% versus 17.5%) and binge drinking (43.0% versus 20.8%) are
more likely to report recent eating disorder symptoms.
Furthermore, alcohol use and abuse has been found to predict worsening of bulimic symptoms in community samples (Cooley & Toray, 2001) and the frequency of weight
loss behaviors in adolescents (Garry, Morrissey, & Whetstone, 2003). One hypothesis for the co-occurrence of alcohol use and DE is that adolescents who drink may be
more likely to perceive themselves as overweight (Welch
& Fairburn, 1996). Subsequently, these faulty perceptions
can lead to the use of dieting practices such as taking
diet pills or laxatives, vomiting, and fasting (The National
Center on Addiction and Substance Abuse at Columbia
University, 2003). Although substance use is often considered to be less common among individuals who engage
in calorie restriction (e.g., restricting subtype of anorexia
nervosa) compared with individuals engaging in binge and
purge behaviors (Haug, Heinberg, & Guarda, 2001), recent investigations indicate that alcohol and illicit drug use
is elevated in individuals who restrict caloric intake (Root
et al., 2009), suggesting that research on DE and substance
use should focus on a wide spectrum of DE behaviors.
Tobacco use is also more common among adolescent
females with DE compared with those without (45.6%
versus 21.6%), and adolescent females reporting current
tobacco use are more likely to report recent DE (43.3%
versus 20.0%) (The National Center on Addiction and
Substance Abuse at Columbia University, 2003). Several
studies indicate dieting and weight concerns to be associated with smoking initiation among preadolescent and
adolescent females (Field et al., 2002; Gard & Freeman,
1996; Tomeo, Field, Berkey, Colditz, & Frazier 1999; Rodriguez, Novalbos, Martinez, Escobar, & Castro, 2004);
unhealthy weight control behaviors have also been linked
to tobacco use in middle school adolescents (Garry, Morrissey, & Whetstone, 2003). One hypothesis for the increased risk of adolescent smoking is the generalized belief that smoking is an effective method of weight control
(French, Perry, Leon, & Fulkerson, 1994). Specifically,
females who are pursuing a thin-ideal, who fear weight
DISORDERED EATING AND SUBSTANCE USE
gain, or who attempt to compensate for eating binges or
overeating may be likely to initiate smoking for weight
control purposes (Stice & Shaw, 2003).
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Comorbidity of Disordered Eating, Substance Use,
and Socioeconomic Status
Research on the relation between SES and substance use
has resulted in conflicting findings. Studies carried out in
Latin America found that adolescents with higher socioeconomic status or living in urban areas constitute the majority of consumers of tobacco (Yamamoto et al., 2008).
Opposite conditions exist in the United States (Soteriades & DiFranza, 2003) and Sweden (Novak, Ahlgren,
& Hammarstr¨om, 2007), where higher education levels
have lower prevalence rates of smoking, likely attributable
to better knowledge about the harmful effects of tobacco
consumption.
In relation to alcohol consumption, studies carried out
in Europe and New Zealand reported that problematic
alcohol use (five drinks or more per occasion) during
adolescence was associated with low SES during childhood, whereas other studies carried out in the United
States found that adolescents from high SES displayed
risky alcohol use, but not alcohol dependence (Trim &
Chasin, 2008; Wiles et al., 2007). In Latin America, alcohol use increases with SES (Ortiz-Hern´andez, LopezMoreno, & Borges, 2007), although alcohol dependence
is more strongly associated with low SES.
Although research on substance use and SES is mixed,
evidence suggests that high SES is a risk factor for eating disorders (Toro & Castro, 2005). Several studies have
examined SES and DE in Mexican samples (BarrigueteMelendez et al., 2009; Unikel-Santoncini, BojorquezChapela, Villatoro-Velazquez, Fleiz-Bautista, & MedinaMora Icaza, 2006) and found, in general, that risk for DE
increased with SES. For example, a study in Mexican students using father’s educational level as a proxy of socioeconomic level found that DE increased along with
father’s educational level with the 1997 and 2000 measures, although with the 2003 measure these differences
were blurred out (Unikel-Santoncini et al., 2006). Only
two studies have reported evidence for DE in rural communities with the first reporting weight gain preoccupation in a sample of Pur´epecha Indians (Bojorquez-Chapela
& Unikel Santoncini, 2004) reporting change in eating
habits and increased exercise behavior with the purpose
of losing weight in a sample of adult women in Morelos Mexico (Perez-Gil, Vega-Garcia, & Romero-Juarez,
2007). Data from the National Health and Nutrition Survey 2006 revealed that adolescents of 10–19 years of age
showed a twofold prevalence of disordered eating compared with those in rural settings (Barriguete-Melendez
et al., 2009).
Research on the comorbidity of DE and substance
use across SES has not been given as much attention.
One study conducted in Spain, measuring the comorbidity of substance use and eating disorders (Rodriguez
et al., 2001), did not find significant differences by SES,
although both subtypes of anorexia nervosa—restricting
and binge/purge—had a higher prevalence among those
525
of high SES, whereas Bulimia nervosa did not differ
across SES levels. Another study conducted in Bermuda
(Marlowe, 2005) found that the highest prevalence of DE
among black students that used alcohol or other drugs,
who have a chronic physical illness, who have parents that
are workers, separated parents, and families where there
is a member with some mental disorder and lower socioeconomic level.
The study of socioeconomic and cultural differences
with regard to the presentation of eating disorders (ED)
and substance use problems has been controversial. There
has been a lack of consensus on the presentation of
EDs across high and low socioeconomic statuses (Gard
& Freeman, 1996; Marlowe 2005; Power, et al., 2008;
Rodriguez et al., 2004). For example, while Gard and
Freeman (1996) found in their review study a statistically significant relationship between higher socioeconomic status and the presence of an eating disorder,
particularly anorexia nervosa, Rodriguez et al. (2004) in
a case-control study in Spain found no significant differences in the distribution of cases in terms of socioeconomic status (index comprised of the father’s and mother’s
occupation and educational level, and housing and the
town’s characteristics). Another cross-sectional study carried out in Bermuda that compared socioeconomic status (measured by parental occupation as an indicator)
among disordered eating teenagers (according to the EAT40 and BITE scales; Marlowe, 2005) found a higher prevalence among those teenagers whose parents were workers. Lastly, in a study carried out in Ecuadorian adolescents, a lower socioeconomic status persistently predicted
higher means EAT scores and probability of meeting clinical criteria. That is, students from lower socioeconomic
level schools were 2.2 times more likely to meet formal
criteria on the EAT-40 (Power, Power, & Ca˜nadas, 2008).
Similar findings have emerged for substance use with differences in consumption depending on the socioeconomic
status. For example, it has been found that alcohol consumption is more prevalent in high socioeconomic statuses (Ortiz, Lopez, & Borges, 2007), possibly due to sociocultural norms and resources for alcohol purchases. On
the other hand, it is possible that a higher socioeconomic
status implies that both parents work and that this could
lead to inadequate supervision of their children, which is
associated with early onset of substance use and the link
with peers who use substances (Clark, 2004). In spite of
this, alcohol abuse and dependence are reportedly more
prevalent among the lower socioeconomic classes/levels.
Thus, it is important to examine ED and alcohol use behaviours across a range of socioeconomic statuses.
METHODS
Sample
Data were collected from eleven different settings in the
Estado de Mexico, a state in central Mexico. The Estado
de Mexico is the second largest state in Mexico, representing the 13.7% of the national population of which 10.3%
are 15–19 years old (Henry, Lazcano, Hern´andez-Prado,
& Oropeza Ab´undez, 2007).
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C. UNIKEL ET AL.
Participating schools were selected proportional to the
number of students enrolled in the 2005–2006 school year
of officially registered schools with the Public Education Secretariat. All female students at each participating
school were surveyed with the exception of one school in
which only half of the classrooms were included because
of the large number of students enrolled. Male students
were not included in the current study due to low prevalence of DE.
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Measures
A cross-sectional study with a stratified and probabilistic
design sampling process was used. The sample was stratified according to the level of marginalization and migratory intensity. Marginalization level is a measure that enables to differentiate states and municipalities from their
population deficiencies’ social impact, and measures the
intensity of the lack of access of the population to the essential needs for the development of its entire capabilities. It considers four structural dimensions of marginalization: the lack of access to education, type of housing,
monetary income, and population distribution (Anzaldo &
Prado, 2006), and it is divided in five categories: very low,
low, medium, high and very high (Instituto Nacional para
el Federalismo y el Desarrollo Municipal, 2006). The Migratory Intensity Index is constructed from data from the
National Household Census, and it combines and weighs
data from households that in the reference period reported
a circular migrant member, a returned member, a member
living in the United States or the reception of remittances
(Alba, 2004), and it is divided in five categories from very
low to very high (Consejo Nacional de Poblaci´on National
Population Council (CONAPO; Tuir´an, Fuentes, & Avila,
2000).
The six strata obtained for the sampling were derived
from combinations of marginalization and migratory intensity as defined below. In terms of finding a sufficient
population for the sample design, categories had to be reduced to two levels for marginalization: (1) low marginalization was categorized for localities with very low, low,
and medium marginalization, and (2) high marginalization was categorized for localities with high and extremely
high marginalization. Categories for intensity of migration were reduced to three levels: (1) low migratory intensity was categorized for localities with very low and low
migration intensity, (2) medium migratory intensity for localities with medium migration intensity, and (3) high migratory intensity for localities with high and very high migration intensities.
Demographic data included were age, place of origin,
parents’ educational level and occupation, indigenous languages spoken by the student and her parents, migratory
status of any of her relatives, utilities, and conveniences
they had access to in their homes.
The brief questionnaire to measure risky eating behaviors is a 10-item Likert scale measure assessing the
following DE variables during the past three months:
fear of weight gain, self-induced vomiting, fasting, dieting, excessive exercise, diet pill use, diuretic mis-
use, laxative misuse, binge eating, and lack of control
during binge eating. The questionnaire has previously
been validated with female adolescents, young adult student populations, and eating disorder patients in Mexico
City (Unikel-Santoncini, Bojorquez-Chapela, & CarrenoGarcia, 2004), as well as with student female adolescents in the Estado de M´exico.2 Questions are answered
in a four-option format (never or hardly ever, sometimes,
frequently-–two times in a week, very frequently–-more
than two times in a week). A score of >10 is used to define at risk or possible cases of eating disorders (UnikelSantoncini et al., 2004). In the current study, individuals
were characterized as low-risk DE for a score <11 and
high-risk DE for those scoring >10.
Alcohol and tobacco use was measured with the student questionnaire version 2003 originally designed by
Smart et al. (1980) which was translated into Spanish
and validated by Medina-Mora and colleagues (MedinaMora, Castro, Campillo-Serrano, & Gomez-Mont, 1981)
in a sample of Mexican students. The questionnaire assesses substance use as recommended by the World
Health Organization and the United Nations Division of
Narcotic Drugs (Smart et al., 1980; United Nations Division of Narcotic Drugs, 1976) and has been used in the
Student Substance Use Surveys in Mexico during the last
20 years. For the purpose of this study, only the alcohol
and tobacco use sections were used. The following items
were used for the current study: ever drank alcohol, drank
during past 12 months, drank during past 30 days, binge
drinking past 12 months, gotten drunk past 12 months,
ever smoke, smoke past 12 months, and smoke past 30
days. All substance use variables were coded based on a
“yes” or “no” response.
Procedure
The protocol was approved by the Ram´on de la Fuente
Mu˜niz National Institute of Psychiatry ethics committee
and evaluated by the Consejo Nacional de Ciencia y Tecnolog´ıa (CONACYT) who gave the funding. School authorities were asked for written authorization for student
participation in the study, and students were asked for verbal consent for voluntary and anonymous reply of selfreport questionnaires.
The application of the self-report questionnaire was
conducted prior to the written consent obtained from the
school authorities who were informed about the research
objectives and of the anonymous, confidential and voluntary character of the study. Previously trained staff attended each selected school and applied the questionnaires to the entire female population that attended school
that day. Students were asked for their verbal consent
and were told that their height and weight would be
measured after the completion of the questionnaire. The
2
Unikel Santoncini, C., G´omez-Peresmitr´e, G., and BojorquezChapela, I. (2008). Manual de Aplicaci´on del Cuestionarios de Factores
de Riesgo de Trastornos de la Conducta Alimentaria. Instituto Nacional
de Psiquiatr´ıa Ram´on de la Fuente Mu˜niz. Conacyt SEP Project 200401-46560. Mexico, City.
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DISORDERED EATING AND SUBSTANCE USE
questionnaire was applied to the whole classroom giving
verbal and written instruction to students.
The average duration for the completion of the survey was one hour, after which students were weighed and
measured by trained personnel using a standardized protocol and given a leaflet on warning signs for identifying
eating disorders as well as recommendations for a healthy
diet. The data were analyzed using SPSS version 13.0
(SPSS, 2004) and SAS version 9.1 procedures for survey
sample data (The SAS Institute, 2003).
Logistic regression was used to estimate odds for both
DE and substance use. The first analysis estimated differences in odds of both DE and substance use across
marginalization groups. The second analysis estimated
differences in odds of substance use by DE status. The
last analysis estimated odds of substance use by DE status and if these differences changed across marginalization groups.
Statistical Analysis
Demographics
It should be noted that because the sample design is a
survey sample based on population characteristics and
not a simple random sample, the mean and variance estimates differ from commonly reported estimates. In this
case, data were collected using a survey sample design
to represent the entire female population enrolled in public schools registered with the Mexican Public Education
Secretariat for the 2005–2006 school years in the State of
Mexico. Means are sample estimates of the entire population mean and not derived from simple mean calculations
for a sample (Kish, 1995). The standard errors as referenced in this paper represent a measure of the standard deviation of the sampling distribution. In contrast, standard
deviations, as are commonly presented for simple random
samples, are not presented because they are not applicable
for the sample analyzed in this paper.
Prevalence and odds ratios for DE and substance use
items were calculated separately across low and high
marginalization groups. Prevalence and odds ratios were
also calculated for substance use by DE status. Finally,
prevalence and odds ratios were calculated for substance
use items for low and high marginalization across DE
status. For all analyses the Rao–Scott modified test was
used to assess significant differences in prevalence. This
test is a version of the Pearson chi-square test with design adjustments from the survey sample design. The
Wald chi-square statistics were used for odds ratio tests.
All reported p-values were adjusted for multiple testing
using the method of false discovery rate (Benjamini &
Hochberg, 1995).
Across the total sample, participants ranged in age from
15 to 19 years (M = 16.28 years; standardized error of
the mean (SEM) = .04). BMI ranged from 13.53 kg/m2
to 40.26 kg/m2 with a mean BMI of 22.76 kg/m2 (SEM =
.04). Both mother’s and father’s education ranged from
“no education (1)” to “graduate or PhD (7)” with mean
education for mothers and fathers between “elementary
(2)” and “middle school (3)” (Mmothers = 2.71; SEM =
.06; Mfathers = 2.87; SEM = .07).
Of the total sample, 70.8% (n = 1670) was characterized in the low marginalization group and the remaining
29.2% was in the high marginalization group (n = 687).
Across the sample, 95.8% (n = 2176) were in the no DE
group and 4.2% were categorized as DE (n = 96). Of
those in the DE group, 2.6% (n = 59) were in the low
marginalization group and 1.6% (n = 37) were in the high
marginalization group, which did not result in a statistically significant group difference.
RESULTS
Disordered Eating Items Across Low and High
Marginalization
Table 1 presents prevalence and statistically significant
odds ratios between the low and high marginalization
groups for the DE items. The fear of weight gain and excessive exercise resulted in statistically significant differences across groups with the low marginalization group
1.30 times more likely to have fear of weight gain and 1.18
times more likely to engage in excessive exercise. The remaining variables did not result in statistically significant
group differences.
TABLE 1. Prevalence and odds ratios of endorsement for lifetime disordered eating items in individuals with low vs. high
marginalization (N = 2357)
Fear of weight gain
Self-induced vomiting
Fasting
Dieting
Excessive exercise
Diet pills
Diuretic misuse
Laxative misuse
Binge eating
Lack of control while binge eating
Low marginalization (%)
(n = 1670)
High marginalization (%)
(n = 687)
1199 (73)
90 (5)
255 (15)
448 (27)
1017 (62)
36 (2)
33 (2)
51 (3)
749 (46)
376 (23)
456 (67)
46 (7)
96 (14)
186 (27)
390 (58)
14 (2)
16 (2)
21 (3)
323 (48)
170 (25)
χ 2 (p-value)
Odds ratio
(95% CI)
10.09 (< .003) 1.30 (1.10, 1.52)
ns
ns
ns
11.96 (< .001) 1.18 (1.08, 1.30)
ns
ns
ns
ns
ns
Note: CI = confidence interval, ns = nonsignificant. Total n varies across alcohol and tobacco variables due to missing values.
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C. UNIKEL ET AL.
TABLE 2. Prevalence and odds ratios for alcohol and tobacco use in individuals with low vs. high marginalization (N = 2357)
Alcohol
Ever drank
Drank past 12 months
Drank past 30 days
Binge drank past 12 months
Drank past 12 months
Tobacco
Ever smoke
Smoke past 12 months
Smoke past 30 days
Low marginalization (%)
(n = 1670)
High marginalization (%)
(n = 687)
1110 (68)
643 (60)
504 (47)
755 (46)
507 (47)
406 (63)
227 (59)
196 (51)
328 (48)
188 (48)
852 (54)
563 (65)
284 (33)
285 (45)
159 (56)
64 (23)
χ 2 (p-value)
Odds ratio (95% CI)
ns
ns
ns
ns
ns
18.57 ( < .001)
18.53 ( < .001)
14.42 ( < .001)
1.41 (1.21, 1.65)
1.49 (1.24, 1.79)
1.68 (1.29, 2.20)
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Note: CI = confidence interval, ns = nonsignificant. Total n varies across alcohol and tobacco variables due to missing values.
Alcohol and Tobacco Use Across Low and High
Marginalization
Mean age for first alcoholic beverage was 14.30 years
(SEM = .07) for the low marginalization group and 14.41
years (SEM = .06) for the high marginalization group.
Mean age for first cigarette for the low and high marginalization groups was 14.41 years (SEM = .07) and 13.92
(SEM = .04) years, respectively. No statistically significant differences were found for the mean age of the first
alcoholic beverage or first cigarette across marginalization
groups.
Table 2 presents prevalence and odds ratios for the
alcohol and tobacco use items across the low and high
marginalization groups. No statistically significant group
differences were found for any of the alcohol variables.
Statistically significant differences across the marginalization groups did emerge however for, ever smoke,
smoke past 12 months, and smoke past 30 days with those
in the low marginalization group more likely to endorse all
three items.
Prevalence of Substance Use by Disordered Eating
Status
Table 3 presents prevalence and odds ratios for endorsement for alcohol and tobacco items across DE status.
Alcohol. Overall, the prevalence of all alcohol use
items was higher in the high-risk DE group compared with
the low-risk DE group. The high-risk DE group was at increased risk of endorsing all alcohol items.
Tobacco. The prevalence of tobacco items was higher
for the high-risk DE group compared with the low-risk DE
group. Those in the high-risk DE group were 3.29 times
more likely to endorse ever smoke and 2.68 times as likely
to endorse smoking during past 12 months. No statistically significant group difference emerged for smoking
during past 30 days.
Prevalence of Substance Use by Low and High
Marginalization and Disordered Eating Status
The prevalence for alcohol and tobacco items by
marginalization and disordered eating status combinations is presented in Table 4.
Alcohol. Overall, alcohol use was higher for those in
the high-risk DE group for both low and high marginalization, with slightly higher prevalence among the low
marginalization group for all alcohol use items except
binge drinking past 12 months, which was higher in the
high marginalization group. No statistically significant
differences were found for low and high marginalization
by DE status for any of the alcohol use items.
TABLE 3. Prevalence and odds ratios for alcohol and tobacco use for individuals with high-risk vs. low-risk disordered eating
status (N = 2357)
Alcohol
Ever drank
Drank past 12 months
Drank past 30 days
Binge drank past 12 months
Drank past 12 months
Tobacco
Ever smoke
Smoke past 12 months
Smoke past 30 days
Low-risk DE (%)
(n = 2176)
High-risk DE (%)
(n = 96)
χ 2 (p-value)
Odds ratio (95% CI)
1382 (65)
778 (59)
622 (47)
965 (44)
616 (46)
79 (84)
60 (80)
58 (77)
76 (79)
51 (66)
5.23 (< .03)
14.99 (< .001)
6.64 (< .02)
66.09 (< .001)
19.35 (< .001)
2.69 (1.15, 6.28)
2.62 (1.61, 4.26)
3.80 (1.38, 10.49)
4.75 (3.26, 6.91)
2.29 (1.58, 3.31)
1022 (50)
646 (62)
301 (29)
72(77)
54 (82)
35 (53)
16.86 (< .001)
3.93 (< .05)
3.29 (1.86, 5.81)
2.68 (1.01, 7.09)
ns
Note: CI = confidence interval, ns = nonsignificant. Total n varies across alcohol and tobacco variables due to missing values.
529
DISORDERED EATING AND SUBSTANCE USE
TABLE 4. Prevalence for alcohol and tobacco items for low (n = 1670) and high (n = 687)
marginalization across disordered eating (DE) statusa
Low marginalization
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Alcohol
Ever drank
Drank past 12 months
Drank past 30 days
Binge drank past 12 months
Drank past 12 months
Tobacco
Ever smoke
Smoke past 12 months
Smoke past 30 days
High marginalization
Low-risk DE
High-risk DE
Low-risk DE
High-risk DE
1024 (66)
581 (37)
451 (29)
685 (44)
453 (29)
49 (83)
39 (66)
41 (69)
46 (78)
36 (61)
358 (58)
197 (32)
171 (28)
280 (45)
164 (26)
29 (78)
21(57)
16 (43)
30 (81)
16 (43)
770 (49)
508 (33)
248 (16)
51 (86)
39 (66)
26 (44)
252 (41)
138 (22)
53 (9)
21(57)
14 (38)
9 (24)
Note: a = no statistically significant differences emerged; CI = confidence interval; ns = nonsignificant.
Total n varies across alcohol and tobacco variables due to missing values.
Tobacco. Tobacco use was higher for those in the highrisk DE group for both low and high marginalization,
with higher prevalences for the low marginalization group
compared with the high marginalization group. No statistically significant differences were found for low and high
marginalization by DE status for any of the tobacco use
items.
DISCUSSION
We sought to further understand the nature of the relation among marginalization, DE, and substance use with
data from a Mexican sample. Five main findings emerged:
(1) a higher prevalence of DE was found among the
low marginalization group; (2) no differences were found
for the alcohol use between low and high marginalization groups; (3) the low marginalization group endorsed
greater tobacco use; (4) alcohol and tobacco use was both
higher among those at risk for DE; and (5) alcohol and tobacco use was greater among those at risk for DE in the
low marginalization group. Although some of the study’s
findings replicate results already reported in the literature,
such as the higher prevalence of DE and of substance use
among those at risk for DE in the low marginalization
group, this study is unique because it is the first study
carried out in Mexico to compare DE and substance use
across marginalization status and it highlights the presence of the coexistence of risk behavioral manifestations
in adolescents.
The results of the current study suggest a higher prevalence of DE in populations with higher SES (i.e., low
marginalization), which is consistent with other studies
carried out in Mexican populations (Barriguete-Melendez
et al., in press). For example, Barriguete-Melendez et al.
(2009) found in a national household survey that rural settings, typically characterized by lower income compared
with urban settings (Araujo, 2005), displayed significantly
less DE than urban settings. Other studies in Mexico City
(Aguilar & Rodriguez, 1997; Rivera, 1997), have reported
greater DE in students attending private schools than in
those enrolled in public schools, a parameter used as a
proxy of SES (Henry et al., 2007; Ortiz-Hern´andez et al.,
2007; Power et al., 2008).
DE is present along a wide range of populations with
adverse socioeconomic situations in Mexico and seems to
be more prevalent in urbanized settings where marginalization is lower. Although in the current study, DE scores
were lower in high marginalization settings, it is important to note that fear of gaining weight, excessive exercise,
and binge eating were reported by a substantial percentage of students (67%, 48%, and 58%, respectively). This
finding is notable given that Mexico is currently second in
the world in terms of prevalence of obesity (Henry et al.,
2007; Sanchez-Castillo, Pichardo-Ontiveros, & Lopez,
2004), which is a risk factor for DE particularly when adolescents are trying to attain a thin ideal (Graber, BrooksGunn, Paikoff, & Warren, 1994).
Regarding the substance use, no differences were found
for alcohol use, but for tobacco, use was greater in the
low marginalization group supporting previous research
in which substance use has been shown to be higher
among Mexican students in urban settings (Kuri-Morales
et al., 2006; Yamamoto et al., 2008). One possible explanation for the greater prevalence of tobacco use in low
marginalization is that those in high marginalization settings might follow more traditional family customs with
stricter expectations, including cigarette use.
According to other studies carried out in the United
States (Gadalla & Piran, 2007; Gutierrez et al., 2001;
Holderness et al., 1994a, 1994b; Tomeo et al., 1999; Wolfe
& Maisto, 2000), substance use was higher among students with high DE scores. Similar results were found in
a study carried out by Guti´errez et al. (2001) among student populations in Mexico City. According to a metanalysis carried out by Gadalla & Piran (2007), the association between behaviors and attitudes that put adolescents
at risk for eating disorders and alcohol use has a moderate to high effect. The prevalence of the coexistence of
DE and excessive past year alcohol use in our findings
was considerable (79%) and higher than that reported in
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530
C. UNIKEL ET AL.
Mexico City adolescents (37%) (Gutierrez et al., 2001)
and in the Youth Risk Behavior Surveillance System in
the United States (Pisetsky et al., 2008), although in these
studies excessive alcohol use was defined as five or more
cups per occasion with a monthly frequency. Pisetsky et
al. (2008) report that 36% of adolescents with abnormal
eating behavior endorsed five or more cups of alcohol in
the past 30 days.
Wiseman et al. (1998), in a study carried out in the
United Sates, found that adolescents in the general population who smoked tobacco had higher scores on drive
for thinness, body dissatisfaction and interoceptive awareness, compared with nonsmokers, suggesting that among
adolescents without an eating disorder, those who smoke
may be more worried about weight control practices than
those who do not smoke. Adolescents at risk for disordered eating who smoke may reflect a propensity to use
psychoactive drugs.
The presence of DE in the high marginalization group
underscores the need for the Mexican Health and Education Systems to provide resources for professionals and
educators in order to detect early cases of adolescents involved in substance use or DE. Regarding the economic
crisis that wraps the country, efforts should be addressed
to develop prevention strategies using new cost-effective
technologies using the internet, as well as those prevention
programs that involve adolescents as their own agents of
change for their younger counterparts. Research in eating
disorders being a nascent field in Mexico lacks specialized
professionals and treatment facilities, and thus an effort to
divulge and offer knowledge on this area is of mounting
importance.
Declaration of Interest
The authors report no conflict of interest. The authors
alone are responsible for the content and writing of this
paper.
Study’s Limitations
Limitations to our study must be considered. First, as with
all cross-sectional studies, no inferences regarding causality can be made. Second, our results can only be generalized for female public high-school students from the Estado de Mexico, and no other inferences can be addressed
to a particular ancestry or age groups, considering that
the Mexican population comprises a wide range of ethnic groups with multiple origins and cultural manifestations. Third, the use of self-report measures must be taken
into account. Finally, the lack of data from boys’ behaviors limits conclusions based on gender.
CONCLUSIONS
The results of the current study provide information about
DE and substance use across marginalization status, by
providing evidence for a positive relationship between
DE and substance use in Mexican female adolescents,
and the trend for both behaviors being more prevalent in
less marginalized populations. These findings suggest that
more attention should be paid to the coexistence of DE
and substance use, particularly given research suggesting
that this comorbidity is also related to other risky behavior
including suicidal intents, robbery and compulsive sexual
behavior (Higuchi et al., 1993). Furthermore, such behaviors are linked with a poorer outcome for treatment and
increased mortality (Catterson, Pryor, Burke, & Morgan,
1997; Keel et al., 2003).
Additionally, our findings suggest that attention should
be paid to adolescents from high marginalized settings,
which until recently were thought not to be affected by abnormal eating behaviors. Studies in the United States have
emphasized the increasing prevalence of eating disorders
and substance use disorders among adolescents pertaining
to ethnic groups different from those of European origin,
including the Latino or Hispanic-origin population (Erickson & Gerstle, 2007; Guiao & Thompson, 2004; Granillo
et al., 2005; Rich & Thomas, 2008; Robinson et al., 1996).
´
RESUM
E´
Conduite alimentaire de risque et utilisation de
substances chez des d’adolescentes mexicaines
L’objectif de ce travail est d’examiner la relation entre conduites alimentaires de risque et l’utilisation
de substances chez des adolescentes mexicaines de
diff´erents niveaux socio´economiques. M´ethodes: Nous
avons e´ tudi´e un e´ chantillon probabilistique de 2357
e´ tudiantes de lyc´ee, de l’Etat de Mexico (Mexique),
stratifi´e par le niveau de marginalisation et d’intensit´e
de migration. Nous avons calcul´e la pr´evalence et les
odds ratios s´epar´ement pour la conduite alimentaire et
l’utilisation de substances par niveau de marginalisation; pour l’utilisation de substances par type de conduite alimentaire, et aussi, pour l’utilisation de substances
par niveau de marginalisation et conduite alimentaire.
R´esultats: Nous avons trouv´e des diff´erences significatives pour la peur de grossir et la pratique excessive
d’exercice entre groupes, avec plus de risques pour les jeunes filles avec le moindre niveau de marginalisation. Il y
a des diff´erences significatives pour l’utilisation de tabac,
parfois, pendant la derni`ere ann´ee et ce dernier mois, et ce
sont les adolescentes du groupe de moindre marginalisation celles qui pr´esentent les pourcentages les plus e´ lev´es.
Il n’y a pas eu de diff´erences statistiquement significatives a` propos de la consommation d’alcool, dans aucune
e´ valuation r´ealis´ee. Il n’y a pas eu de diff´erence significative, par niveau de marginalisation et de conduite alimentaire de risque dans l’utilisation de tabac ou d’alcool. Discussion: Cette e´ tude offre des informations a` propos de
la conduite alimentaire de risque et l’utilisation de substances par niveau de marginalisation, et montre la relation
positive qui existe entre ces deux conduites chez les adolescentes mexicaines lyc´eennes e´ tudi´ees, et la tendance de
ces conduites d’ˆetre plus pr´esentes dans les groupes les
moins marginalis´es.
DISORDERED EATING AND SUBSTANCE USE
Mots cl´es: conduite alimentaire de risque, utilisation
de substances, niveau de marginalisation, Mexique.
531
Ph.D. in Health Psychology, both from the National Autonomous
University of Mexico. She collaborates with many educational
institutions around the country, is the author of many scientific
papers, and is member of the National Research System.
RESUMEN
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Conducta alimentaria de riesgo y uso de sustancias en
una muestra de mujeres adolescentes mexicanas
El objetivo del presente trabajo es examinar la relaci´on
entre conductas alimentarias de riesgo y el uso de sustancias en mujeres adolescentes pertenecientes a diversos
niveles socioecon´omicos. M´etodo: estudiamos una muestra probabil´ıstica de 2357 estudiantes de nivel medio superior en el Estado de M´exico, estratificada por nivel de
marginaci´on e intensidad de migraci´on. Se calcularon la
prevalencia y las razones de momios separadamente para
la conducta alimentaria y el uso de sustancias por niveles de marginaci´on; para el uso de sustancias por tipo
de conducta alimentaria y para el uso de sustancias por
nivel de marginaci´on y conducta alimentaria. Resultados:
se encontraron diferencias estad´ısticamente significativas
para el miedo a engordar y la pr´actica excesiva de ejercicio entre grupos, mostrando mayor riesgo las adolescentes con menor nivel de marginaci´on. Se encontraron
diferencias estad´ısticamente significativas entre los grupos de marginaci´on para el uso de tabaco alguna vez, en
el u´ ltimo a˜no y en el u´ ltimo mes, siendo las adolescentes
en el grupo de menor marginaci´on aquellas con mayores porcentajes; mientras que no se encontraron diferencias estad´ısticamente significativas en ninguna de las
evaluaciones sobre uso de alcohol. Tampoco se encontraron diferencias estad´ısticamente significativas por nivel
de marginaci´on y conducta alimentaria de riesgo en el uso
de alcohol o tabaco. Discusi´on: el presente estudio proporciona informaci´on acerca de la conducta alimentaria
de riesgo y el uso de sustancias por nivel de marginaci´on,
mostrando evidencia sobre la relaci´on positiva que existe
entre la ambas conductas en mujeres adolescentes mexicanas, y la tendencia de ambas conductas a ser m´as prevalentes en las comunidades menos marginadas.
Palabras claves: conducta alimentaria de riesgo, uso
de sustancias, nivel de marginaci´on, M´exico.
THE AUTHORS
Claudia Unikel, Ph.D., is a
full-time researcher and parttime clinician at the National
Institute of Psychiatry in
Mexico City. As a pioneer
in the eating disorders
research field in Mexico,
her research has been focused
on risk factors for eating
disorders, the development
of culturally sensitive
assessment instruments for
the detection of disordered
eating among adolescents,
and more recently on the application of prevention strategies.
She received her Masters degree in Clinical Psychology and her
Tammy L. Root, Ph.D.,
is a Postdoctoral Fellow
in Eating Disorders in the
School of Medicine in the
Department of Psychiatry
at the University of North
Carolina at Chapel Hill. Dr.
Root received her Ph.D. from
the Department of Human
Development and Family
Studies at The Pennsylvania
State University. She also
has a Masters degree in
Applied Statistics as well
as a Masters degree in Psychology. Dr. Root’s primary research
interest focuses on understanding genetic and environmental
influences on the comorbidity of eating disorders and substance
use. She is currently involved with the Swedish Twin Registry
Studies and the Price Foundation Studies. Her goal is to elucidate
the current knowledge on this comorbidity in hopes of better
informing prevention and treatment efforts, while simultaneously
applying the most current and innovative methodology for best
answering these research questions.
Ann Von Holle, M.S.,
is a statistician in the
UNC Department of
Psychiatry. She assists
UNC Eating Disorders
Program researchers with
their computing and data
analysis needs. Current work
includes analysis of data
from research projects such
as the Norwegian Mother and
Child Cohort Study, Price
Foundation studies, and most
currently the Swedish Twin
Registry.
Cynthia M. Bulik, Ph.D.,
FAED, is the Jordan
Distinguished Professor
of Eating Disorders in the
Department of Psychiatry in
the School of Medicine at the
University of North Carolina
at Chapel Hill, where she is
also Professor of Nutrition
in the Gillings School of
Global Public Health and the
Director of the UNC Eating
Disorders Program. Her
research includes treatment,
laboratory, epidemiological, twin and molecular genetic studies
of eating disorders and body weight regulation. She also develops
innovative means of integrating technology into treatment for
532
C. UNIKEL ET AL.
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eating disorders and obesity. She has active collaborations
around the world, has published over 320 scientific papers and
chapters on eating disorders, and is the author of the books Eating
Disorders: Detection and Treatment (Dunmore), Runaway Eating:
The 8 Point Plan to Conquer Adult Food and Weight Obsessions
(Rodale), Crave: Why You Binge Eat and How To Stop (Walker),
and Abnormal Psychology (Beidel, Bulik, Stanley; Prentice Hall).
Dr. Bulik holds the first endowed professorship in eating disorders
in the United States.
Ren´e Ocampo, M.D.,
psychiatrist, graduated
from the National Institute
of Psychiatry in Mexico
City. He is a Masters Degree
student in Public Mental
Health at the National
Autonomous University of
Mexico. He is interested
in the research of eating
disorders’ epidemiology and
substance use in adolescents.
GLOSSARY
Alcohol use in the past 12 months: Typically having drunk
alcohol at least once in the last year.
Alcohol use during past 30 days: Typically having drunk
alcohol at least once in the last month.
Binge drinking: Consumption of five or more drinks per
occasion, regardless of frequency. This consumption is
associated with significant physical and mental consequences.
Disordered eating: According to DSM IV, inappropriate
eating behaviors are behaviors that do not meet in frequency and duration with the diagnostic requirements.
These behaviors consist of concern for weight gain, a
sense of lack of control while binge eating, purging,
and restrictive eating behaviors that aim at weight reduction.
Ever used alcohol: Typically having drunk alcohol at least
once ever.
Ever used tobacco: Having smoked tobacco at least once
ever.
Gotten drunk: A syndrome characterized by recent alcohol intake accompanied by psychological or behavioral
changes plus one or more of the following signs: impaired language, lack of coordination, unsteady gait,
nystagmus, impaired attention or memory and stupor
or coma.
Marginalization status: Marginalization level is a measure
that enables to differentiate states and municipalities
from their population deficiencies’ social impact and
measures the intensity of the lack of access of the population to the essential needs for the development of its
entire capabilities. It considers four structural dimensions of marginalization: lack of access to education,
type of housing, monetary income, and population distribution.
Migratory intensity index: This index is constructed from
data from the National Household Census, and it combines and weighs data from households that in the reference period reported a circular migrant member, a returned member, a member living in the United States or
the reception of remittances.
Tobacco use in the past 12 months: Having smoked tobacco at least once in the last year.
Tobacco use during past 30 days: Having smoked tobacco
at least once in the last month.
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