Eating disorders (ED) are behavioral disorders characterized by severe disturbance in eating habits and associated distressed emotions. Early discovery and treatment can lead to complete recovery from these psychiatric disorders.
Studies regarding eating disorders in Pakistan are few and far between. Therefore, this study aims to determine the prevalence of disordered eating attitudes among female university students of Lahore, Pakistan.
This observational study was conducted from March, 23 to May, 23. Data was collected from 400 female students from different universities in Lahore, Pakistan. SCOFF and EAT-26 were used for screening of Eating Disorders.
Analysis was done using SPSS software. Of the 400 participants, 47% were at risk of ED according to SCOFF, 38.8% were at risk according to EAT-26.There was significant positive correlation between BMI and the two scales such that female with higher BMI were at greater risk of developing disordered eating attitudes. Scores of the two scales were also consistent with each other.
Almost half of the participants were at risk of ED and can benefit from a change in their behavioral patterns. Awareness should be raised regarding such issues. Appropriate nutrition education in relation to body weight is needed to change behaviors.
UNIVERSITY OF VETERINARY AND ANIMAL SCIENCES
Abstract:
Background
Eating disorders (ED) are behavioral disorders characterized by severe disturbance in eating habits and associated distressed emotions. Early discovery and treatment can lead to complete recovery from these psychiatric disorders.
Aim
Studies regarding eating disorders in Pakistan are few and far between. Therefore, this study aims to determine the prevalence of disordered eating attitudes among female university students of Lahore, Pakistan.
Methods
This observational study was conducted from March, 23 to May, 23. Data was collected from 400 female students from different universities in Lahore, Pakistan. SCOFF and EAT-26 were used for screening of Eating Disorders.
Results
Analysis was done using SPSS software. Of the 400 participants, 47% were at risk of ED according to SCOFF, 38.8% were at risk according to EAT-26.There was significant positive correlation between BMI and the two scales such that female with higher BMI were at greater risk of developing disordered eating attitudes. Scores of the two scales were also consistent with each other.
Conclusions
Almost half of the participants were at risk of ED and can benefit from a change in their behavioral patterns. Awareness should be raised regarding such issues. Appropriate nutrition education in relation to body weight is needed to change behaviors.
Keywords:
Eating Disorders, Disordered Behaviors, SCOFF, EAT-26, University Students, Female, Pakistan
Background:
The concept of ED was described for the first time by Morton, who labeled this disorder as Nervous Consumption (Pearc and Richard 2004). Later it was defined as a set of mental illnesses distinguished by abnormal eating patterns (Erskine et al. 2016). The DSM-5 criteria classifies ED as AN (Anorexia Nervosa), BM (Bulimia Nervosa) and BED (Binge Eating Disorder) (American Psychiatric Association 2013). Anorexia Nervosa is characterized by extreme fear of weight gain and disruption of body image. Bulimia Nervosa involves repetitive episodes of binge eating (Wade 2019). BED is consuming large amounts of food in a short time span (Van Strien et al. 2013).BED has the highest prevalence among other EDs (American Psychiatric Association 2013; Guerdjikova et al.).
ED remains a significant clinical factor contributing to the morbidity and mortality of young women (Garner et al. 1983; Tavolacci et al. 2015a). A type of ED known as Anorexia Nervosa has highest mortality rate among other mental disorders, a prototype ED, has the highest mortality rate among mental disorders (Arcelus et al. 2011). Studies from America found frequency of ED to be alarmingly high (Kwan et al. 2017; Lipson and Sonneville 2017). Many risk factors lead to the development of ED in university students (J. et al. 2019; Musaiger et al. 2013).
A complete recovery from EDs can be achieved by early discovery and treatment of EDs (Becker et al. 2004; Fichter et al. 2006). The Sick, Control, One stone, Fat, Food (SCOFF) (Aoun et al. 2015; Morgan et al. 1999)and Eating Attitudes Test-26 (EAT-26) (Kang et al. 2017; Mitsui et al. 2017) are two relevant measures for ED identification that can help with screening and early ED detection in college students. On this basis, we formulated the hypothesis that prevalence of ED among Pakistani female university students is comparable to that of other Asian countries. The results from our study will help add to the pool of knowledge regarding ED among Pakistani female students and will also allow for comparisons with other cultural groups (Pike et al. 2014).
Materials and Methods:
Study Design
This research was an observational study conducted from March, 23 to May, 23 in universities of Lahore. Punjab University, Lahore College for Women, Government College University, University of Veterinary and Animal Sciences, Govt. MAO Graduate College, and Education University are among the universities covered by the study. The study was approved by the Food Science and Human Nutrition department of the University of Veterinary Animal Sciences, Lahore. Data were gathered through the use of questionnaires.
Sampling
420 students were chosen as the sample size, which was determined using a 95% confidence interval and a 5% maximum error. The final study compromised of 400 female university students indicating a response rate of 95%. The volunteers who were female and enrolled in universities were chosen. Female University Students was used as inclusion criteria.
Questionnaire Development
Before creating the questionnaire for this survey study, a number of articles on eating disorders among female students were consulted. There were four sections to the questionnaire. Items on demographics, such as participant age, education, academic category, and living situation, were included in the first section. Anthropometric measurements including height, weight, BMI, and BMI category made up the second section. The SCOFF and EAT-26 scales, which are frequently used to assess for presence of eating disorders, were also included (Garner et al. 1983; Garner and Garfinkel 1979; Morgan et al. 1999). Each of these assessments is valid and quite reliable for diagnosing eating problems.
SCOFF Scale
A screening instrument called the SCOFF scale, created by Morgan et al. (Morgan et al. 1999), contains 5 questions about various elements of eating disorders. These concern topics including vomiting, losing control of one's eating, weight loss, feeling obese, and a life dominated by food. The scale was first developed by Hill et al. (Hill et al. 2010) while Aydemir et al. (Aydemir et al. 2015) tested its validity. The Arabic version that was used in this study has a sensitivity of 80.0% and specificity of 72.7% (Aoun et al. 2015). Scores are calculated as follows: Each "Yes" receives a score of 1, and each "No" receives a score of 0. An eating disorder is present if the overall score is ≥ 2.
EAT-26 Scale
ED can be properly screened by specialists by using EAT-26 (Williams et al. 1982). This scale contains 26 questions regarding dieting, food perception and oral control (Garner and Garfinkel 1979). Each item has 6 response options with a score ranging from 0-3 (‘always’ = 3, ‘usually’ = 2, ‘often’ = 1, ‘sometimes’ = 0, ‘rarely’ = 0 and ‘never’ = 0). Item 26 is scored in reverse manner (‘always’ = 0, ‘usually’ = 0, ‘often’ = 0, ‘sometimes’ = 1, ‘rarely’ = 2 and ‘never’ = 3). A score ≥ 20 is characteristic of disordered eating attitude as demonstrated by Garner et al (Garner et al. 1982).
Behavioral Scale
The EAT-26 further includes behavioral questions indicative of possible ED. There are 5 questions in this scale that help in determination of extreme eating behaviors. Participants who endorse atleast pen of these items have high potential of having ED. Such individuals need by trained psychologists (Garner et al. 1985; Garner et al. 1984; Garner et al. 1982).
Recruitment
Participants were reached through visiting universities. We went to different classes in universities in Lahore. Additionally, the study was advertised through posters on online platform. We also collected data by using Google forms.
Data Collection
Female university students were given a total of 420 questionnaires, and their consent was obtained orally to safeguard the privacy of their information. The number of questionnaires distributed in each university varied from 60-70. Questionnaires were completed under the supervision of the interviewer. The completed questionnaires were then returned by the respondents. About 20 questionnaires had blank or incomplete responses. Over the course of two weeks, distribution and collecting were conducted.
Statistical Analysis
The collected data was analyzed by using SPSS Statistics Software Version 26. Body Mass Index BMI was calculated by using height and weight. (Consultation WHOE 2004)BMI ≥ 30.00 indicates obesity, 25.00 ≤ BMI < 30 overweight, 18.5 ≤ BMI < 25 defines the normal range, BMI < 18.5 is considered as underweight (Consultation WHOE 2004; World Health Organization 2020).Univariate analysis of EAT-26 and SCOFF variables was conducted. The relationship of demographic parameters to the two eating disorder scales was also measured using ANOVA and T-test. Lastly, Pearson correlation was used to determine the relationship between SCOFF and EAT-26.
Results:
Characteristics of Participants
The researchers distributed over 430 questionnaires among female students. Out of these, 400 questionnaires were returned by study participants, yielding net response rate of 93%. Majority of respondents (394; 98.5%) were in the 18–25 age range. Most respondents (292; 73%) were residing with their families while the remaining were living in student dormitories (108; 27%). More than half of the participants (289; 72.3%) were from the science faculties, while the remaining participants (111; 27.8%) belonged to humanities and computer faculties. Mean ± SD of BMI was 21.8 ± 9.6 kg/m2. From which, 220 (55.6%) of the participants had “Normal” BMI, 101 (25.5%) fell within the "underweight" range, and 75 (19%) belonged to “overweight/obese" category.
EAT-26 and SCOFF Scores
Table 1 shows mean ± SD scores and Cronbach α value for the scales used in the study. The EAT-26 scale had higher internal consistency as compared to SCOFF scale which had low internal consistency. According to the EAT-26 scale, the number of female students considered to be at high risk of disordered eating attitudes was 155 (38.8%), while according to the SCOFF, the number was 188 (47%). There was high level of agreement between EAT-26 and SCOFF scores, as indicated by significant and positive correlation between the two scales (Table 2).
Univariate Analysis of SCOFF Scores
There was no significant correlation (p =0.47) between age and SCOFF scores. Although there was a significant positive link between BMI values and SCOFF scores (Spearman Correlation r = 0.148, p < 0.05), which is consistent with the EAT-26 data. Females with greater BMI values had higher SCOFF scores. Students studying science had mean SCOFF scores (1.55 ± 1.2) that were significantly different from those studying humanities (1.86 ± 1.3) (p = .037).
Univariate Analysis of EAT-26 Scores
There was no significant correlation (p = 0.85) between age and EAT-26 scores. There was significant and positive correlation between BMI and EAT-26 (r =0.106, p < 0.05) suggestive of higher risk of ED among females with higher BMI values. Females in the academic field of computer had a mean ± SD on the EAT-26 of 20 ± 10.9, females in science had a mean ± SD of 16.85 ± 11.1 while females in humanities had a mean ± SD of 18.81 ± 10.6. The difference was non-significant (p > 0.15). Analysis of EAT-26 items indicated that out of the 155 high-risk individuals, 62.5% (n = 97) reported “cutting food into small pieces”, 59.4% (n = 92) were “terrified of being overweight” and 56.7% (n = 88) reported that “food dominates their life”. According to behavioral scale, more than half (54%) did not support any of the items, whereas 184 people (46.2%) endorsed at least one of the extra ED behaviors.
Discussion:
Body dissatisfaction and unhealthy dietary choices and behaviors are quite common among university students (American College Health Association 2014). Early diagnosis and treatment of ED is difficult to make in university students (Sim et al. 2010). Scales like SCOFF can be used easily to check risk in students. Scoff study conducted in Finland determined a prevalence of 9.7% (Lähteenmäki et al. 2009) while in France 20.5% prevalence was indicated (Tavolacci et al. 2015b). This study also aims to check the prevalence of disordered eating behaviors among female university students in Pakistan by using the SCOFF and EAT- 26 scales. Results obtained from EAT-26 were more reliable as compared to SCOFF even though SCOFF is a much simpler screening tool (Hautala et al. 2009). This fact was demonstrated by internal consistency of SCOFF being lower than EAT-26. However, Studies in past have reported the internal consistency to be acceptable despite the low cronbach alpha value (Rueda et al. 2005; Sierv et al. 2005).
Comparison with other studies conducted worldwide showed that rates of eating disorder attitudes in present study were higher than those obtained in USA (Eisenberg et al. 2011; Phillips et al. 2015), France (Tao and Sun 015), China (Yu et al. 2015), Iran (Naeimi et al. 2016) and Thailand (Pattanathaburt P 2013). Results obtained from our study were corresponding to other Asian countries. Percentages of females suffering from ED in Asian countries are as follows: 29% in Nepal (Thapa and Thapa 2015); 26.6% in India (Upadhyah A 2014); 37.6% in Bangladesh (Pengpid et al. 2015); 48.8% in Vietnam (Ko et al. 2015). A 1992 study in Lahore, Pakistan in female adolescents found 10.3% prevalence (Mumford et al. 1992). 20 years later, a study in 2014 showed 21.6% prevalence (Shaikh and Kayani 2014). In contrast, the current study found that according to SCOFF scale 38.8% and according to EAT-26 scale 47% scored above the cut-point.
The higher rates in studies are attributed to changing lifestyle and dietary patterns in Pakistan. This is particularly because our culture is being exposed to westernized lifestyle patterns. Asian countries have a social environment where ideal weight is much lower than western countries (Wardle et al. 2006).Social media is also largely influencing young generation of Pakistan. People can pass public judgments on other’s posts (Perloff 2014).Social networks are a place for individuals to make social comparisons regarding body image (Lee 2014). Women who share self-images on these platforms have greater levels of dissatisfaction with their body shape (McLean et al. 2015). As a result, ED are 20 times more common in female compared to male (Arıca et al. 2011).
The two scales showed almost similar relationship between most variables. There was no significant correlation between age and the two scales. However, BMI was significant in relation to both EAT-26 score and SCOFF score. This was unsurprising, as similar findings have been reported in other studies (Fortes et al. 2014; Memon et al. 2012; Wong et al. 2014). Female students with higher BMI had higher risks of ED and such a positive association was also found in other studies (Field et al. 2003; Jahrami et al. 2019; Stice et al. 2005; Tayhan Kartal and Yabancı Ayhan 2020). The study also included the living status and faculties of students enrolled in universities. However, analysis showed no significant relation of these two variables with the scale scores. Almost half of participants endorsed the following item of EAT-26: “I am terrified about being overweight”. The current study revealed that the most highly endorsed item was “I find myself preoccupied with food” on the Bulimia Scale, whereas the item “I cut my food into small pieces” was most endorsed on Oral Control Scale. This shows that females are highly conscious about their body weight and image. Our cultural expectations requires women to be thin so that they can be physically attractive. So, women use different means like dieting and extreme exercising to become thinner (Murray and Touyz 2012). These behaviors gives them a sense of control over their food. There was strong positive correlation between scores of the SCOFF and EAT-26.
The study had some limitations that should be taken into account. The two scales used in this study are only screening tools and they cannot be used to make a diagnosis. Hence, there remains a need to further investigate the true prevalence of ED in Pakistan. Secondly, this survey was only conducted in Lahore. So, the results cannot be generalized in other cities of Pakistan. Furthermore, the study followed a cross-sectional design and can only give explorative relation with variables. The current study should be followed up with large number of students taken from universities all over Pakistan. Determinants and outcomes of ED also needs to be looked into in our region as there is also lack of research in this regard.
Conclusions:
Our study successfully demonstrated the prevalence of eating disorders in female university students in Lahore, Pakistan. There was a positive relation between BMI and the two screening scales. The results of SCOFF and EAT-26 closely correlated but EAT-26 was found to be much more reliable for screening of EDs. This suggests that screening should be properly carried out in clinical settings. Steps should be taken towards the early detection and treatment of such psychological disorders. We propose that a larger study with greater sample size should be conducted all over Pakistan to strengthen the evidence generated by our study. Moreover, Future studies should also focus on the determinants of EDs like stress and social pressure.
Abbreviations:
ED: Eating Disorders; SD: Standard Deviation; SCOFF: Sick, Control, One, Fat, Food; EAT-26: Eating Attitudes Test-26; BMI: Body Mass Index
Declarations:
Ethical approval
Complete anonymity and participant confidentiality were upheld throughout the study. Each subject gave their oral agreement after the researcher explained the study's goals and methodology. Moreover, The Ethical Review Committee of the University of Animal and Veterinary Sciences(UVAS), Lahore also gave the ethical approval.
Consent for publications
All the members that participated in the research gave their consent to the publication of their data.
Availability of data and materials
Not applicable
Competing interests
There are no competing interest to disclose.
Funding
This research accepted no external funding.
Author’s Contributions
Conceptualization-MZ, SA; Questionnaire Development-MZ; Data Collection-MZ, SA, LS, AJ, SM; Data Entry-MZ, SA, LS, AJ, SM; Data Analysis-MZ, SA; Abstract-MZ; Background-LS, AJ, MZ; Methodology-MZ, Results-MZ, SA; Discussions- MZ, SA; Conclusions-MZ, SM, Formatting and Referencing- MZ.
All the authors have read and are satisfied with the final version of the manuscript.
Acknowledgements
We thank our supervisor Dr Azmat Ullah Khan, for guiding us in this project.
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Table 1 : Analysis of SCOFF and EAT-26 Scores
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Table 2 : Correlation between SCOFF AND EAT-26 Scores
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