CCC 1072±4133/99/040279±07$17.50 European Eating Disorders ReviewCopyright *c 1999 John Wiley & Sons, Ltd and Eating Disorders Association. 7(4), 279±285 (1999)

European Eating Disorders Review

Eur. Eat. Disorders Rev. 7, 279±285 (1999)

Paper

The Role of Infant Characteristics and MaternalBehaviour in the Development of LaterEating Disorders

Bernice Andrews* and Carol BrownRoyal Holloway, University of London, U.K.

The relation of infant characteristics (prematurity and low birth weight withoutprematurity) and maternal behaviour involving infant feeding method and her ownproblem eating was investigated in 149 eating disordered (ED) individuals and86 controls. The ED group were signi®cantly more likely to report having been bornprematurely, that they were bottle fed and that their mothers had dieted or restrictedfood intake. Rates were elevated for all types of ED but were particularly high foranorexia of the binge-eating/purging type. Mother's dieting was related to bottlefeeding but not to prematurity. Respondents reporting prematurity were also morelikely to report being bottle fed. This indication that infant characteristics might beinvolved in the development of eating disorders warrants further investigation in alarger study using independent records. Copyright *c 1999 John Wiley & Sons, Ltdand Eating Disorders Association.

INTRODUCTION

Given the increasing interest in the role of childhood factors and early familyenvironment in the development of eating problems, surprisingly little atten-tion has been paid to early infant characteristics and the way these mightrelate to maternal behaviour in producing later eating disorders. This paperexplores the relationship of prematurity, low birth weight and mother's feedingmethods and her own eating patterns to later eating disorders.

Prematurity is usually de®ned as a birth weight of less than 2.5 kg, as a resultof birth before the 37th week and therefore due to insuf®cient growing time inthe womb. However, some babies are low birth weight at full term (Cole andCole, 1993; Macfarlane and Mugford, 1984). With the exception of an early

*Correspondence to: Bernice Andrews, Department of Psychology, Royal Holloway, University of London,Egham, Surrey, TW20 0EX, U.K.

study by Crisp (1970) who found no signi®cant differences between birthweights of anorexic patients and patients with neurotic or affective disorders,prematurity and low birth weight have not to date been investigated as riskfactors for later eating disorders. There are however hints in the literaturesuggesting that further investigation might be warranted. For example, bothare sometimes due to maternal malnutrition (Cole and Cole, 1993). Thissuggests the possibility that some mothers of premature and low weight infantsmay have experienced some form of disordered eating. As there is evidence ofa link between eating problems in mothers and daughters (e.g. Hill et al.,1990), prematurity and low birth weight might be signi®cant factors in thislink.

Another way in which prematurity and low birth weight might be involvedin the development of eating disorders is via their biological and emotionaleffects. Biological effects on the infant include the inability to suck, swallowand digest properly. The emotional effects for the mother may also be great, forexample, she may respond negatively to the child's apparent fragility, to theisolation of the baby in an incubator, and to the early separation from theinfant (Klaus and Kennell, 1982). This early separation could disrupt theformation of an affectional bond, and it has been suggested that even with full-term babies contact between mother and neonate in the ®rst few hours of lifemay facilitate the formation of this emotional attachment (Klaus and Kennell,1982). Mothers of premature babies also tend to show less emotional involve-ment and exhibit overprotectiveness towards their infant (Cole and Cole,1993) which is the kind of rigid parental style reported in studies of eatingdisorder sufferers (e.g. Szmukler et al., 1985).

In this regard there is the question of whether early feeding may also play arole in the development of eating disorders. Bottle feeding, for example mayprovide less emotional closeness for the child and possibly involves a morestructured and rigid feeding schedule. In the only study to investigate earlyfeeding in eating disordered patients, contrary to the hypothesis, it was foundthat anorexic patients (n � 46) were more likely to have been bottle fed thanmatched patients diagnosed with neurotic or affective disorders (Crisp, 1969).

In light of the above discussion the aim of this study was to investigatepreviously under-researched infant and maternal factors in the development ofeating disorders. Speci®c aims were to:

. Examine whether differences exist in prematurity and low birth weight(without prematurity) between eating disordered (ED) respondents andcontrols, and between ED types.

. Replicate and extend previous evidence of a relationship between anorexiaand bottle feeding by comparing reports of mothers' methods of earlyfeeding (i.e. breast or bottle) between the ED respondents and controls,and between ED types.

B. Andrews and C. Brown Eur. Eat. Disorders Rev. 7, 279±285 (1999)

Copyright *c 1999 John Wiley & Sons, Ltd and Eating Disorders Association. 280

. Replicate and extend the previously reported relationship between eatingproblems in mothers and daughters by comparing reports of mothers' eatingproblems between ED respondents and controls, and between ED types.

METHOD

The sample

One hundred and forty-nine eating disordered (ED) individuals and 86 con-trols took part in this study. The groups were comparable for gender and age:97 per cent of the ED group and 96 per cent of controls were female; the meanages for the groups were 28.8 years (SD � 8.4 years) for the ED group, and28.8 years (SD � 11.9 years) for the controls.

The ED group were drawn from 200 members of the Eating DisorderAssociation in the U.K. who volunteered to take part in research (the EDAhas 4000 members overall). Eighty per cent (159/200) returned the mailedquestionnaire. Ten were excluded as they did not reach DSM-IV criteria for aneating disorder (American Psychiatric Association, 1994).

One hundred potential control participants were approached to take partin the study and none refused. Fifty were students from Royal Holloway,University of London, and the other 50 were mainly health professionals, froma local hospital, the majority of whom were nurses. All completed the short-ened Eating Attitudes Test (EAT26: Garner et al., 1982). Fourteen had a scoreof 20 or more and were excluded, as scores above this may indicate an eatingdisorder (Garner et al., 1982).

Measures

Infant characteristics and maternal behaviourAll respondents were asked on the questionnaire to provide their birth weight,and whether they had been born at least 4 weeks before term. Those born 4 ormore weeks early, weighing 2.5 kg or less were classi®ed as premature. TwoED respondents who indicated they weighed less than 2.5 kg at birth alsoindicated that they were born early, but by less than 4 weeks. As this informa-tion was not requested (and therefore not provided by other respondents), thedecision was taken to exclude them from analyses concerning prematurity.

Respondents were asked whether they had been predominantly breast fed(breast feeding continuing beyond mother's hospital stay) or bottle fed (bottlefeeding after mother left hospital). They were also asked: `did/does yourmother have any problems with food?'. Those who answered `yes' were askedto specify what the problem was. Respondents were instructed to consult theirmother or other relations for further information regarding the above questionsif necessary. Responses to questions on maternal eating problems wereclassi®ed by the authors into three categories: mother dieted or restricted

Eur. Eat. Disorders Rev. 7, 279±285 (1999) Infant and Maternal Characteristics

Copyright *c 1999 John Wiley & Sons, Ltd and Eating Disorders Association. 281

intake of food; mother overate or indulged in comfort eating with no mentionof dieting; mother restricted intake for medical reasons (all involved foodallergy or gastrointestinal problems). There was high interrater agreement forthe categories (89 per cent) and disagreements were resolved by discussion.

Eating disorder typesED respondents answered further questions to classify types of disorder. Thequestionnaire included items relating to DSM-IV criteria for anorexia andbulimia nervosa (American Psychiatric Association, 1994). Forty-six wereclassi®ed as Restricting Anorexics (RAN), 61 as having anorexia of the binge-eating/purging type (BAN), and 39 having bulimia (BN).

Data were analysed using two-tailed chi-squared and Fisher's exact prob-ability tests (where the smallest expected frequency was less than 5), andlogistic regression.

RESULTS

Table 1 shows the proportions in the ED and control groups of the variablesunder investigation. The ED group were signi®cantly more likely to reportprematurity, to report they had been bottle rather than breast fed, and thattheir mothers had dieted or restricted food intake. However, they were nomore likely to report low birth weight without prematurity, or that theirmothers overate or restricted food intake for medical reasons.

The next stage of the analysis was to examine more closely the relationshipbetween the different ED types and the three signi®cant variables. While therewere no signi®cant differences between the groups for prematurity, feedingmethod and mother's dieting (w2�2� � 1.0, 3.98 and 3.23 respectively), Table 2shows that the signi®cant difference in infant feeding methods observedbetween the ED group and controls may well have been due to the BAN group

Table 1. Infant characteristics and maternal behaviour in eating disorder andcontrol groups

Group Eatingdisordered %

Control%

Fisher'sexact p

wwwww2(1)

Premature 10 (13/131) 2 (1/62) 0.04 4.32*Low birth weight, not premature 2 (3/131) 3 (2/62) 0.01Predominantly bottle fed 59 (79/134) 43 (31/72) 4.75*Mother dieted/restricted food intake 21 (30/146) 8 (7/86) 6.21*Mother overate/comfort ate 11 (16/146) 7 (6/86) 0.99Mother restricted food (medical) 3 (4/146) 6 (5/86) 0.30 2.29

*p5 0.05.Numbers in denominators vary due to missing values.

B. Andrews and C. Brown Eur. Eat. Disorders Rev. 7, 279±285 (1999)

Copyright *c 1999 John Wiley & Sons, Ltd and Eating Disorders Association. 282

who were the most likely to report having been bottle fed. This group also hadthe highest proportion reporting prematurity and mothers who dieted, althoughproportions were elevated in all ED groups compared with the controls.

We examined the interrelationships between prematurity, breast feeding andmother's dieting to see if this could throw light on the signi®cant relationshipsalready observed. Those born premature were more likely than other respond-ents to report having been bottle fed: 83 per cent versus 52 per cent,w2�1� � 4.30, p5 0.5, but were no more likely than other respondents toreport that their mother had dieted: 21 per cent versus 17 per cent, Fisher'sexact p � 0.71, n.s. Mothers who had dieted, however, were signi®cantly morelikely to have bottle fed, according to the respondents, than mothers who hadnot: 72 per cent versus 50 per cent, w2�1� � 5.32, p5 0:05. A logisticregression indicated that prematurity and mother's dieting were independentlyrelated to the likelihood of reporting having been bottle fed: Wald � 3.85,p5 0.05, and 4.22, p5 0.05 respectively.

Finally, a logistic regression was carried out to explore the relativecontributions of prematurity, feeding method and mother's dieting to therisk of eating disorder (where eating disorder was coded as a dichotomousvariable: yes/no). While the overall model was signi®cant, w2�3� � 12.82,p5 0.01, none of the variables made a signi®cant independent contributionto the prediction of ED, although the contributions of mother's dieting andfeeding method almost reached signi®cance, Wald � 3.44, p5 0.07 and 3.40,p5 0.07 respectively.

DISCUSSION

To our knowledge, this is the ®rst study to demonstrate a signi®cant relation-ship between eating disorders and prematurity. It also replicates and extendsCrisp's (1969) ®nding of a relationship between anorexia nervosa and infantfeeding methods in a larger sample of ED respondents with `normal' controls.Rates of prematurity and bottle feeding were elevated among all eatingdisorder types, but appeared particularly high among respondents with anor-exia of the binge-eating/purging type. The signi®cant relationship between EDand prematurity could not be explained by mother's eating problems, as

Table 2. Infant characteristics and maternal behaviour by eating disorder type

Group RAN % BAN % BN %

Premature 9 (4/44) 13 (7/55) 6 (2/32)Predominantly bottle fed 51 (23/45) 69 (38/55) 53 (18/34)Mother dieted/restricted food intake 15 (7/48) 25 (15/59) 21 (8/39)

RAN, restricting anorexia; BAN, anorexia binge-eating/purging type; BN, bulimia.Numbers in the denominator vary due to missing values.

Eur. Eat. Disorders Rev. 7, 279±285 (1999) Infant and Maternal Characteristics

Copyright *c 1999 John Wiley & Sons, Ltd and Eating Disorders Association. 283

suggested in the Introduction, as mother's dieting/restricted eating was notrelated to prematurity. It is possible, however that infant feeding methods maybe a mediating factor in the relationship: bottle feeding was independentlyrelated to prematurity and mother's dieting and made a marginally independ-ent contribution to the prediction of ED when all were considered together. Ifthis ®nding can be replicated and strengthened in a larger sample, it hasimportant implications for health policy, and education of expectant mothers.

In the absence of prematurity, low birth weight was unrelated to ED. It isimportant to note, however, that both prematurity and low birth weight arerelatively rare in af¯uent Western societies; only a small proportion of all therespondents in the current study reported prematurity, and an even smallerproportion reported low birth weight without prematurity. There was also theproblem that many respondents could not provide this information, and thereduced numbers in the analyses, along with the small proportions with thesefactors, combined to lower the power of the statistical tests. However, giventhe preliminary ®ndings, further investigation is warranted in a larger samplewhere numbers can add power to multivariate analysis, and where there is alsoaccess to of®cially documented information on prematurity and birth weight.

It is of note that the method of infant feeding was associated with mother'sdieting. Mothers who dieted or restricted food intake were more likely,according to the respondents, to have favoured bottle over breast feeding. Thissuggests that the decision to bottle feed may be related to the personality ofthe mother, as well as to the characteristics of the infant. Further detailedresearch is needed to explore this possibility as our questionnaire did notspecify the timing of maternal eating problems; it is possible that somemothers who were currently dieting had not thought of doing so in therespondent's infancy. Nevertheless, it seems possible that biological factors,related to prematurity, and psychological factors, related to mothers' parentingstyle, may both play a part in the development of eating disorders (althoughthe ®ndings do not rule out a genetic contribution). However, because of therelative rarity of prematurity compared with early adverse family and otherexperiences already implicated in the development of eating disorders, it mayonly ever explain a small proportion of the variance.

One problem with the research involves the validity of using a postalquestionnaire, and the personal nature of the enquiry. The validity may bequestionable since individuals with eating disorders may be prone to mis-perceiving and misreporting information about their own growth and eatinghistories, and about their mother's eating patterns. As such, some of the datagathered in this study may have greater face validity than others. For example,Haggard et al. (1960) reported in their study that data concerning birth weightand breast feeding were initially found to be quite accurate compared to moresubjective reports of attitudes towards the infant following birth, but overa period of time even the reliability coef®cients for the `hard fact' data

B. Andrews and C. Brown Eur. Eat. Disorders Rev. 7, 279±285 (1999)

Copyright *c 1999 John Wiley & Sons, Ltd and Eating Disorders Association. 284

(birth weight etc.) tended to decrease. Caution is therefore required in theinterpretation of the ®ndings reported in the current study.

Despite such cautions, by investigating hitherto under-researched factorsin the development of eating disorders the study opens up a number ofimportant new avenues of enquiry. It would appear that a new area concerningthe characteristics of infants and their mothers in the development of eatingdisorders is awaiting investigation and could be explored in more detail andwith more rigour in future studies than was possible currently. An attempt tovalidate retrospective data would also be a useful contribution.

ACKNOWLEDGEMENTS

We should like to thank the Eating Disorders Association for arrangingquestionnaire distribution to their members and to all participants who gavetheir time to ®ll in the questionnaires. We are also grateful to Professor ArthurCrisp for helpful comments on an earlier draft of this paper.

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CRISP, A. H. (1970). Reported birth weights and growth rates in a group of patientswith primary anorexia nervosa (weight phobia). Journal of PsychosomaticResearch, 14, 23±50.

GARNER, D. M., Olmstead, M. P., Bohr, Y. and Gar®nkel, P. E. (1982). The eatingattitudes test: psychometric features and clinical correlates. PsychologicalMedicine, 12, 872±878.

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Eur. Eat. Disorders Rev. 7, 279±285 (1999) Infant and Maternal Characteristics

Copyright *c 1999 John Wiley & Sons, Ltd and Eating Disorders Association. 285