We examined problematic eating behaviors among a sample of young autistic adults to better understand the purported relationship between autism and eating disorders. We hypothesized that autistic participants would score higher on measures of problematic eating behavior compared to a non-autistic comparison group, but that autistic participants would not report elevated levels of weight and shape concern. We also conducted an exploratory analysis to examine the extent to which each autism diagnostic criterion was associated with problematic eating behavior.
Seventy-four autistic and 40 non-autistic young adults aged between 18 and 25 years completed an online survey consisting of the Eating Disorder Examination Questionnaire (EDE-Q), Nine-Item Avoidant/Restrictive Food Intake Disorder Screen (NIAS), autism spectrum quotient (AQ), and Autism Eating Behavior Questionnaire.
Autistic individuals self-reported higher levels of problematic eating behavior than non-autistic individuals as measured using the EDE-Q, NIAS, and Autism Eating Behavior Questionnaire; however, contrary to expectations, weight and shape concern were also elevated. Autism diagnostic criteria explained a combined 19.2% of the variance in EDE-Q global score and 19.0% of the variance in NIAS total score; however, individually, only diagnostic criterion B4 (sensory sensitivities) was significantly associated with EDE-Q global score, and only diagnostic criterion B3 (restricted interests) was significantly associated with NIAS total score.
These results suggest that autistic individuals may experience autism-focused eating behaviors in conjunction with, rather than instead of, typical eating disorder cognitions.
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Data Availability Statement
The data from this study are available at https://osf.io/5fk2a/
Aardoom, J. J., Dingemans, A. E., Slof Op’t Landt, M. C. T., & Van Furth, E. F. (2012). Norms and discriminative validity of the eating disorder examination questionnaire (EDE-Q). Eating Behaviours, 13(4), 305–309. https://doi.org/10.1016/j.eatbeh.2012.09.002
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Baron-Cohen, S., Jaffa, T., Davies, S., Auyeung, B., Allison, C., & Wheelwright, S. (2013). Do girls with anorexia nervosa have elevated autistic traits? Molecular Autism, 4, Article 24. https://doi.org/10.1186/2040-2392-4-24
Baron-Cohen, S., Wheelwright, S., Skinner, R., Martin, J., & Clubley, E. (2001). The autism spectrum quotient (AQ): Evidence from Asperger syndrome/high functioning autism, males and females, scientists and mathematicians. Journal of Autism and Developmental Disorders, 31(1), 5–17. https://doi.org/10.1023/A:1005653411471
Barrionuevo, B. A., Chowdhury, A. R., Lee, J. M., Dueker, N. D., Martin, E. R., Pericak-Vance, M. A., & Cuccaro, M. (2020). Family history of eating disorder and the broad autism phenotype in autism. Autism Research, 13(9), 1573–1581. https://doi.org/10.1002/aur.2378
Bentz, M., Jepsen, J. R. M., Pedersen, T., Bulik, C. M., Pedersen, L., Pagsberg, A. K., & Plessen, K. J. (2017). Impairment of social function in young females with recent-onset anorexia nervosa and recovered individuals. Journal of Adolescent Health, 60(1), 23–32. https://doi.org/10.1016/j.jadohealth.2016.08.011
Berg, K. C., Peterson, C. B., Frazier, P., & Crow, S. J. (2012). Psychometric evaluation of the eating disorder examination and eating disorder examination–questionnaire: A systematic review of the literature. International Journal of Eating Disorders, 45(3), 428–438. https://doi.org/10.1002/eat.20931
Brede, J., Babb, C., Jones, C., Elliott, M., Zanker, C., Tchanturia, K., Serpell, L., Fox, J., & Mandy, W. (2020). “For me, the anorexia is just a symptom, and the cause is the autism”: Investigating restrictive eating disorders in autistic women. Journal of Autism and Developmental Disorders, 50(12), 4280–4296. https://doi.org/10.1007/s10803-020-04479-3
Chien, Y. L., Wu, C. S., & Tsai, H. J. (2020). The comorbidity of schizophrenia spectrum and mood disorders in autism spectrum disorder. Autism Research, 14(3), 571–581. https://doi.org/10.1002/aur.2451
Fairburn, C. G., & Beglin, S. J. (1994). Assessment of eating disorders: Interview or self-report questionnaire? International Journal of Eating Disorders, 16(4), 363–370. https://doi.org/10.1002/1098-108X(199412)16:4%3c363::AID-EAT2260160405%3e3.0.CO;2-%23
Faul, F., Erdfelder, E., Lang, A. G., & Buchner, A. (2007). G*Power 3: A flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behavior Research Methods, 39(2), 175–191. https://doi.org/10.3758/bf03193146
Gillberg, C. (1983). Are autism and anorexia nervosa related? The British Journal of Psychiatry, 142(4), 428. https://doi.org/10.1192/bjp.142.4.428b
Hobson, H., Westwood, H., Conway, J., McEwen, F. S., Colvert, E., Catmur, C., Bird, G., & Happé, F. (2020). Alexithymia and autism diagnostic assessments: Evidence from twins at genetic risk of autism and adults with anorexia nervosa. Research in Autism Spectrum Disorders, 73, Article 101531. https://doi.org/10.1016/j.rasd.2020.101531
Hoekstra, R. A., Bartels, M., Cath, D. C., & Boomsma, D. I. (2008). Factor structure, reliability and criterion validity of the autism-spectrum quotient (AQ): A study in Dutch population and patient groups. Journal of Autism and Developmental Disorders, 38(8), 1555–1566. https://doi.org/10.1007/s10803-008-0538-x
Joshi, G., Petty, C., Wozniak, J., Henin, A., Fried, R., Galdo, M., Kotarski, M., Walls, S., & Biederman, J. (2010). The heavy burden of psychiatric comorbidity in youth with autism spectrum disorders: A large comparative study of a psychiatrically referred population. Journal of Autism and Developmental Disorders, 40(11), 1361–1370. https://doi.org/10.1007/s10803-010-0996-9
Karjalainen, L., Gillberg, C., Råstam, M., & Wentz, E. (2016). Eating disorders and eating pathology in young adult and adult patients with ESSENCE. Comprehensive Psychiatry, 66, 79–86. https://doi.org/10.1016/j.comppsych.2015.12.009
Keys, A., Brozek, J., Henshel, A., Michelson, O., & Taylor, H. L. (1950). The biology of human starvation (Vols. 1–2). University of Minnesota Press.
Kinnaird, E., Norton, C., Stewart, C., & Tchanturia, K. (2019). Same behaviours, different reasons: What do patients with cooccurring anorexia and autism want from treatment? International Review of Psychiatry, 31(4), 308–317. https://doi.org/10.1080/09540261.2018.1531831
Kinnaird, E., Norton, C., & Tchanturia, K. (2017). Clinicians’ views on working with anorexia nervosa and autism spectrum disorder comorbidity: A qualitative study. BMC Psychiatry, 17(1), Article 292. https://doi.org/10.1186/s12888-017-1455-3
Kloosterman, P. H., Keefer, K. V., Kelley, E. A., Summerfeldt, L. J., & Parker, J. D. A. (2011). Evaluation of the factor structure of the autism-spectrum quotient. Personality and Individual Differences, 50(2), 310–314. https://doi.org/10.1016/j.paid.2010.10.015
Koomar, T., Thomas, T. R., Pottschmidt, N. R., Lutter, M., & Michaelson, J. J. (2021). Estimating the prevalence and genetic risk mechanisms of ARFID in a large autism cohort. Frontiers in Psychiatry, 12, Article 668297. https://doi.org/10.3389/fpsyt.2021.668297
Kurita, H., Koyama, T., & Osada, H. (2005). Autism-spectrum quotient-Japanese version and its short forms for screening normally intelligent persons with pervasive developmental disorders. Psychiatry and Clinical Neurosciences, 59(4), 490–496. https://doi.org/10.1111/j.1440-1819.2005.01403.x
Lai, M. C., Kassee, C., Besney, R., Bonato, S., Hull, L., Mandy, W., Szatmari, P., & Ameis, S. H. (2019). Prevalence of co-occurring mental health diagnoses in the autism population: A systematic review and meta-analysis. The Lancet, 6(10), 819–829. https://doi.org/10.1016/S2215-0366(19)30289-5
Lang, K., Lopez, C., Stahl, D., Tchanturia, K., & Treasure, J. (2014). Central coherence in eating disorders: An updated systematic review and meta-analysis. The Word Journal of Biological Psychiatry, 15(8), 586–598. https://doi.org/10.3109/15622975.2014.909606
Leader, G., Tuohy, E., Chen, J. L., Mannion, A., & Gilroy, S. P. (2020). Feeding problems, gastrointestinal symptoms, challenging behavior and sensory issues in children and adolescents with autism spectrum disorder. Journal of Autism and Developmental Disorders, 50(4), 1401–1410. https://doi.org/10.1007/s10803-019-04357-7
Leppanen, J., Sedgewick, F., Treasure, J., & Tchanturia, K. (2018). Differences in the theory of mind profiles of patients with anorexia and individuals on the autism spectrum: A meta-analytic review. Neuroscience and Biobehavioral Reviews, 90, 146–163. https://doi.org/10.1016/j.neubiorev.2018.04.009
Mayes, S. D., & Zickgraf, H. (2019). Atypical eating behaviors in children and adolescents with autism, ADHD, other disorders, and typical development. Research in Autism Spectrum Disorders, 64, 76–83. https://doi.org/10.1016/j.rasd.2019.04.002
Mond, J. M., Hay, P. J., Rodgers, B., Owen, C., & Beumont, P. J. V. (2004). Validity of the eating disorder examination questionnaire (EDE-Q) in screening for eating disorders in community samples. Behaviour Research and Therapy, 42(5), 551–567. https://doi.org/10.1016/S0005-7967(03)00161-X
Murray, A. L., McKenzie, K., Kuenssberg, R., & Booth, T. (2017). Do the autism spectrum quotient (AQ) and autism spectrum quotient short form (AQ-S) primarily reflect general ASD traits or specific ASD traits? A bi-factor analysis. Assessment, 24(4), 444–457. https://doi.org/10.1177/1073191115611230
Nalbant, K., Kalaycı, B. M., Akdemir, D., Akgül, & Kanbur, N. (2019). Emotion regulation emotion recognition and empathy in adolescents with anorexia nervosa. Eating and Weight Disorders - Studies on Anorexia Bulimia and Obesity, 24(5), 825–834. https://doi.org/10.1007/s40519-019-00768-8
Nazar, B. P., Peynenburg, V., Rhind, C., Hibbs, R., Schmidt, U., Gowers, S., Mcdonald, P., Goddard, E., Todd, G., Micali, N., & Treasure, J. (2018). An examination of the clinical outcomes of adolescents and young adults with broad autism spectrum traits and autism spectrum disorder and anorexia nervosa: A multi-centre study. International Journal of Eating Disorders, 51(2), 174–179. https://doi.org/10.1002/eat.22823
Nicely, T. A., Lane-Loney, S., Masciulli, E., Hollenbeak, C. S., & Ornstein, R. M. (2014). Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. Journal of Eating Disorders, 2, Article 21. https://doi.org/10.1186/s40337-014-0021-3
Nickel, K., Maier, S., Endres, D., Joos, A., Maier, V., Tebartz van Elst, L., & Zeeck, A. (2019). Systematic review: Overlap between eating, autism spectrum, and attention-deficit/hyperactivity disorder. Frontiers in Psychiatry, 10, Article 708. https://doi.org/10.3389/fpsyt.2019.00708
Nielsen, S., Anckarsäter, H., Gillberg, C., Gillberg, C., Råstam, M., & Wentz, E. (2015). Effects of autism spectrum disorders on outcome in teenage-onset anorexia nervosa evaluated by the Morgan-Russell outcome assessment schedule: A controlled community-based study. Molecular Autism, 6, Article 14. https://doi.org/10.1186/s13229-015-0013-4
Oldershaw, A., Treasure, J., Hambrook, D., Tchanturia, K., & Schmidt, U. (2011). Is anorexia nervosa a version of autism spectrum disorders? European Eating Disorders Review, 19(6), 462–474. https://doi.org/10.1002/erv.1069
Penelo, E., Negrete, A., Portell, M., & Raich, R. M. (2013). Psychometric properties of the eating disorder examination questionnaire (EDE-Q) and norms for rural and urban adolescent males and females in Mexico. PLoS ONE, 8(12), e83245. https://doi.org/10.1371/journal.pone.0083245
Rhind, C., Bonfioli, E., Hibbs, R., Goddard, E., Macdonald, P., Gowers, S., Schmidt, U., Tchanturia, K., Micali, N., & Treasure, J. (2014). An examination of autism spectrum traits in adolescents with anorexia nervosa and their parents. Molecular Autism, 5, Article 56. https://doi.org/10.1186/2040-2392-5-56
Rica, R., Solar, M., Compte, E. J., & Sepúlveda, A. R. (2021). Establishing the optimal male cut-off point: Confirmatory factor analysis of the eating disorder examination-questionnaire (EDE-Q) in a representative sample of Spanish university students. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity. Advance online publication. https://doi.org/10.1007/s40519-021-01234-0
Rose, J. S., Vaewsorn, A., Rosselli-Navarra, F., Wilson, G. T., & Weissman, R. S. (2013). Test-retest reliability of the eating disorder examination–questionnaire (EDE-Q) in a college sample. Journal of Eating Disorders, 1, Article 42. https://doi.org/10.1186/2050-2974-1-42
Schaefer, L. M., Smith, K. E., Leonard, R., Wetterneck, C., Smith, B., Farrell, N., Riemann, B. C., Frederick, D. A., Schaumberg, K., Klump, K. L., Anderson, D. A., & Thompson, J. K. (2018). Identifying a male clinical cutoff on the eating disorder examination–questionnaire (EDE-Q). International Journal of Eating Disorders, 51(12), 1357–1360. https://doi.org/10.1002/eat.22972
Sharp, W. G., Berry, R. C., McCracken, C., Nuhu, N. N., Marvel, E., Saulnier, C. A., Klin, A., Jones, W., & Jaquess, D. L. (2013). Feeding problems and nutrient intake in children with autism spectrum disorders: A meta-analysis and comprehensive review of literature. Journal of Autism and Developmental Disorders, 43(9), 2159–2173. https://doi.org/10.1007/s10803-013-1771-5
Spek, A. A., van Rijnsoever, W., van Laarhoven, L., & Kiep, M. (2020). Eating problems in men and women with an autism spectrum disorder. Journal of Autism and Developmental Disorders, 50(5), 1748–1755. https://doi.org/10.1007/s10803-019-03931-3
Tchanturia, K., Adamson, J., Leppanen, J., & Westwood, H. (2019). Characteristics of autism spectrum disorder in anorexia nervosa: A naturalistic study in an inpatient treatment programme. Autism, 23(1), 123–130. https://doi.org/10.1177/1362361317722431
Westwood, H., Eisler, I., Mandy, W., Leppanen, J., Treasure, J., & Tchanturia, K. (2016a). Using the Autism-Spectrum Quotient to measure autistic traits in anorexia nervosa: A systematic review and meta-analysis. Journal of Autism and Developmental Disorders, 46(3), 964–977. https://doi.org/10.1007/s10803-015-2641-0
Westwood, H., Mandy, W., & Tchanturia, K. (2017). Clinical evaluation of autistic symptoms in women with anorexia nervosa. Molecular Autism, 8, Article 12. https://doi.org/10.1186/s13229-017-0128-x
Westwood, H., Stahl, D., Mandy, W., & Tchanturia, K. (2016b). The set-shifting profiles of anorexia nervosa and autism spectrum disorder using the Wisconsin card sorting test: A systematic review and meta-analysis. Psychological Medicine, 46(9), 1809–1827. https://doi.org/10.1017/S0033291716000581
Woodbury-Smith, M. R., Robinson, J., Wheelwright, S., & Baron-Cohen, S. (2005). Screening adults for Asperger syndrome using the AQ: A preliminary study of its diagnostic validity in clinical practice. Journal of Autism and Developmental Disorders, 35(3), 331–335. https://doi.org/10.1007/s10803-005-3300-7
Zhou, Z. C., McAdam, D. B., & Donnelly, D. R. (2018). Endophenotypes: A conceptual link between anorexia nervosa and autism spectrum disorder. Research in Developmental Disabilities, 82, 153–165. https://doi.org/10.1016/j.ridd.2017.11.008
Zickgraf, H. F., & Ellis, J. M. (2018). Initial validation of the nine item avoidant/restrictive food intake disorder screen (NIAS): A measure of three restrictive eating patterns. Appetite, 123, 32–42. https://doi.org/10.1016/j.appet.2017.11.111
We thank two anonymous reviewers for helpful comments on an earlier draft of this manuscript.
This research was supported by the Hamish Ramsay Fund.
This study was approved by the Flinders University Human Research Ethics Committee (Project No. 2161). All procedures used in this study adhere to the tenets of the Declaration of Helsinki (1964).
Informed consent was obtained from all individual participants included in the study.
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Young, R.L., Smith, P., Lim, A. et al. The Relationship Between Autism Diagnostic Criteria and Problematic Eating Behaviors. Adv Neurodev Disord 6, 53–64 (2022). https://doi.org/10.1007/s41252-021-00231-9
- Problematic eating
- Eating disorder