Introduction

Eating disorders as defined by the 10^th revision of the International Classification of Disorders (ICD)-10 are a series of behavioral disorders which are associated with physiological and physical alterations [₁]. They are classified as anorexia nervosa (AN), bulimia nervosa (BN) and eating disorders not otherwise specified (EDNOS) as binge eating disorder by Diagnostic and Statistical Manual of Mental Disorders-IV-Text Revision (DSM-IV-TR) [₂]. The eating disorders, in the group of psychiatric disorders, have a high mortality rate among adolescent and young adult females in developing and especially developed countries [₃]. The individuals with eating disorders have eating related obsessions. The personality profiles that emerged are characterized by low novelty seeking, high harm avoidance, high persistence, and low self-directedness in AN, and by high novelty seeking, high harm avoidance, and low self-directedness in BN [₄]. The etiology of eating disorders is widely accepted to be a combination of genetic, psychological and socio-cultural factors, i.e. they are bio-psycho-social disorders [₅]. The common risk factors across eating disorders include sex, race or ethnicity, childhood eating and gastrointestinal problems, elevated shape and weight concerns, negative self-evaluation, sexual abuse and other adverse events, and general psychiatric co-morbidity [₆].

Eating disorders are major public health problems among adolescents because of their high prevalence and their potentially serious physical and psychosocial consequences [₇₈]. The eating disorders occur equally in males and females before puberty with the ratio increasing to approximately 1:10 during adolescence and 1:20 during young adulthood [₅]. Especially, female college students typically express concerns about body image, body shape, body size, and weight control [₉].

The American Academy of Pediatrics has issued a policy statement on the medical dangers of both bulimic and anorexic behaviors [₁₀]. Compulsory vomiting to which causes those behaviors can result in severe electrolyte imbalances, damage to the esophageal tube, poor dentition, and cardiac abnormalities. Severe caloric deficiency especially in AN can also lead to electrocardiographic and gastrointestinal abnormalities, anemia, amenorrhea, bone loss, and seizures. Eating disorders can be fatal; the mortality rate in women with AN is 12 times greater than that of women in the general population [₁₁].

In various studies [₁₂₁₃], the prevalence of eating disorders have been reported to be between 3.5% to 28.5% among college female students. In our country, some studies have reported this prevalence to be between 6.6% to 13.4% among college female students [₁₄₁₅₁₆].

Eating disorders are known to be chronic, persistent, and refractory ^{to treatment [₁₇]. Considering the high cost and difficulties encountered in treatment for eating disorders, research aimed at understanding how to best prevent eating disorders is imperative [₁₈].}

In adolescent age, increasing of interest to bodily image is basic of eating disorders [₁₉]. Young adulthood, especially during the transition to a college setting, can be a vulnerable time for development and/or continuation of eating disorders when parents generally have little control or influence on eating behaviors [₂₀].

In patients with eating disorders, in recent years, psychometric tests have been used to evaluate different factors that may be present in these patients. Among the many existing tests, two are the most commonly used to evaluate the eating disorders: the Eating Disorders Inventory and the Eating Attitudes Test (EAT-40).

The aims of this study were to determine the prevalence of eating disorders, and to examine potential some risk factors considered related to eating disorders, as well as to present some pertinent comments concerning prevention of eating disorders in a group of university female students

Methods

Setting

Instrument

Sampling

Procedures

Legal ethical consent

Statistics

Results

In this study, in all, the data which were obtained from 312 subjects [127 students (40.7%) in the college of health services and 185 students (59.3%) in the vocational college of health services] were analyzed. Their mean age 20±1.61 years (range 17 to 31). There was no significant difference between the mean ages of 164 students participating in and 312 students not participating in the study (p>0.05) (Unshown datum in the Table).

The age distribution of the study population was stratified as follows: 19 years and below, 34.3%; 20 years, 29.5%; 21 years, 17.3% and 22 years and over, 17.3%. most of the students reported that they resided in the dormitory, followed by in the house with her friends (27.2%). A total of 28.2% of the study group were smokers and 7.4% alcohol consumers. The proportion of people who had a history of any chronic disease such as peptic ulcer, anemia, sinusitis, bronchitis diagnosed by a physician was 14.3%.. The number of those doing regular physical activity was 113 (36.2%). Most students (68.0%) stated that their allowances were enough and higher, followed by low or lower (32.1%). Prevalence of overweight-obesity is determined as 6.1%. The prevalence of overweight/obesity in the subjects was 6.1%. Their mean BMI was 20.59±2.48 kg/m2, ranging from 15.43±2.02 to 32.03±3.67 kg/m2. In those in the college of health services (14.6%), in the age groups of ≤19 (34.3%), in the dormitory (11.8%), not smoking cigarette (13.6%), not consuming alcohol (14.5%), not having any chronic disease (14.7%), doing regular physical activity (16.8%), having very low allowance (26.3%) and not being overweight/obese (14.3%), the prevalences of eating disorder were higher when compared to the other group sociodemographics. There were no difference between those with eating disorders and without eating disorders in terms of their sociodemographic characteristics (p>0.05, for each one). The detailed background characteristics of the students are presented in Table 1.

Figure 1

Table 1: Some socidemographic characters of students by status of eating Disorders

The students’ detailed family characteristics are presented in Table 2. There is only 1 person (0.3%) among the students whose father is illiterate, and three people whose fathers were literate, and the students whose fathers were primary-school graduates (40.1%), and in total, the prevalence of those who at primary school and below was 41.3%. On the other hand, there were 67 people (21.5%) whose fathers were middle-school graduates, 82 people (26.3%) whose fathers were high-school graduates and 34 people (10.9%) whose fathers were university graduates, in total, the proportion of being middle school and over graduates was 58.7% (p>0.05).

There were 19 students (6.1%) whose mothers are illiterate, 20 students (6.4%) whose mothers were literates, 171 students (54.8%) whose mothers were primary-school graduates, and in total, the prevalence of those who at primary school and below was 67.3%. On the other hand, 55 students (17.6%) whose mothers were middle-school graduates, 43 students (13.8%) whose mothers were high-school graduates and 4 students (1.3%) whose mothers were university graduates, in total, the proportion of being middle school and over graduates was 32.7% (p<0.05). The proportion of unemployment for the students’ fathers was 0.6%, whereas this proportion was 85.9% for their mothers. The number of students who stated that their fathers are alcohol consumers was 39 (12.5%), however, the number of students who stated that their mothers are alcohol consumers was 7 (2.2%).

The number of students who had family history of obesity was 48 (15.4%), and the number of students who had a family history of psychological disorder was found to be 1 (0.3%).

There were no difference between those with eating disorders and without eating disorders in terms of the students’ some family characteristics (p>0.05, for each one) except for family income where in those whose family income was very high the prevalence of eating disorder was higher when compared to those whose family incomes were lower (p<0.05). Most of the students reported that their family income was average or low 60.2% (197/312).

Figure 2

Table 2: Some family characteristics of students by status of eating disorder

Discussion

Eating disorders are considered the third most prevalent chronic health condition among females and female students [₂₅]. Therefore, the epidemiology of eating disorders has focused mainly on youth. In this study, 13.8% of the college students rated eating disorders; this ratio appears to be similar to the findings of other studies performed in Turkey [₁₅₁₆]. A similar result has been reported in the studies carried out in some other countries [₂₆₂₇]. The different results declared in various research studies can be derived from different usage of definitions for eating disorders, different screening methods and different study groups.

In this survey, there was not found any differences between the students of two schools in which this study has been conducted in terms of frequency of eating disorder (p>0.05). One of the reasons of this situation can be that both of the schools provide education in the field of health services. It has been reported in some studies [₂₇₂₈] that no difference was not found between similar aimed schools in terms of frequency of eating disorder.

In the current study, there was no relationship between frequency of eating disorder and age groups (p>0.05). This case can be explained through the fact that the range of age of the people who form the study group is similar. A similar result has been reported in various studies [₂₉₃₀]. However, in a study performed by Uzun et al. [₉], it has been reported that there is a negative relation between EAT-40 scores and age, necessitating further research.

The students’ living with their families can be important for them in terms of some comforts provided and psychological support. Therefore, it is expected that there should be less frequency of eating disorder among the ones who stay with their families. However, any difference did not reveal between the frequency of eating disorder and the place where they stay (p>0.05). In some other studies [₃₁₃₂] a similar result has been reported. This show that living place does not affect eating disorders.

Adolescence is the typical time of onset for eating disorders as well as substance use, and therefore this age group warrants further investigation [₃₃]. In this study, no difference was not found between the students who smoke and who do not in terms of frequency of eating disorders (p>0.05). In some other studies [₂₉₃₄] a similar result has been reported. On the other hand, there are also several studies which indicate that smoking is one of the risk factors for eating disorder [₃₅₃₆].

Croll et al. [₃₅] stated that alcohol consumption is among the risk factors for eating disorder. In some studies conducted on adolescents [₃₇₃₈] it has been reported that there is more alcohol consumption especially among the ones having eating disorders, especially BN symptoms. In this study, no difference was detected between the students who consume alcohol and the ones who do not consume in terms of frequency of eating disorder (p>0.05). A relation may have not found because of the facts that the number of people making up the study group is low and the number of people consuming alcohol regularly is low. In some other studies performed [₃₄₃₆] a similar result has been reported.

As part of the developmental process of adolescence the individual undergoes dramatic physical, psychological, and social change. For the adolescent with a chronic illness, these changes may impact on the ability of the adolescent and their family to successfully negotiate the demands of this period [₃₉]. Chronic health conditions may increase dissatisfaction with the body and feelings of isolation from peers, potentially increasing the risk of psychopathology associated with adolescence, such as eating and body image disorder [₄₀]. In some of the studies conducted [₄₁₄₂₄₃], it has been reported that there is a strong connection between chronic somatic diseases and mental disorders. Yet in our study, no difference was found between the students who have any chronic disease diagnosed by a physician and the students who don’t have in terms of frequency of eating disorders (p>0.05).

The studies performed with the aim of evaluating the impact of sports on eating disorders are especially realized on athletes and the results of these studies have been taken into consideration. Female athletes are known to be a potential risk group for developing eating disorder. Taub and Blinde [₄₄] declared in their study that the athletes have the existing behavioral and psychological relations of eating disorders with a higher possibility than the ones who are not athletes. In the study conducted by Hopkinson and Lock [₄₅] it has been reported that the type of the sport does not have an important impact on eating disorder. In this study, no difference has been detected between the students who play sports and who do not in terms of frequency of eating disorders (p>0.05). In the study performed by Fulkerson et al. [₄₆] a similar result has been reported.

The allowance of the students is one of the indirect indicators reflecting the income of the family. There are studies putting forward that as the socio-economic condition of the families gets better, the frequency of eating disorder observed in their children becomes less [₄₇₄₈]. In this study, a relation has not been detected between the frequency of eating disorder and the amount of allowance (p>0.05). This result can be explained by the facts that the students studying in two schools have similar socio-economic background and the number of students was low.

It is known that obesity is a risk factor in emergence of eating disorders and it is among the causes of eating disorders [₄₉₅₀]. Overweight girls show some of the psychological features associated with the development of eating disorders, including a link between concerns and self-esteem based on physical appearance. This may help to explain why childhood obesity increases the risk of a later eating disorder [₅₁]. In this study, there was no difference between the students who are overweight/obese and who are not in terms of frequency of eating disorders (p>0.05). The low prevalence of obesity can be one of the reasons of this situation.

In some studies conducted, it is stated that there is a reverse relation between socio-economic status and eating disorder [₄₈₅₂]. In this study, the average point obtained from EAT-40 scale by the students whose family has a very high income is evaluated as significantly higher than the ones whose family has a good income (p=0.013) and whose family has a low income (p=0.007). However, in a study conducted by Hay [₅₃] it was reported that “No significant differences in rates of these behaviors were found for household income”. In a study conducted by Chen et al. [₅₄] it has been reported that as the income of household increases, the symptoms of eating disorder among family members also increases.

One of the factors that affect the communication between the parents and children is the educational level of parents. The relation of parents having a higher level of education with their children is expected to be better. In a study performed by Kim and his friends [₅₅], it was forward that there was a significantly negative relation between parent-adolescent communication and eating disorders. In our study, no difference was found between the average point the students obtained from EAT-40 scale and the educational level of the father (p>0.05). However, the average point of the students whose mothers’ educational levels are primary school and below was found out as significantly higher than the ones whose mothers’ educational levels were middle school and upper (p<0.05). In a study conducted by Díaz Benavente et al. [₅₆] it was reported that there was no difference between family conditions and EAT-40 scores.

Maor et al. [₅₇] stated that the scores of eating attitude tests are not different between the students whose mothers have jobs and the students whose mothers do not; however, they declared that the scores of eating attitude tests were higher among the students whose fathers were unemployed. In this study, no difference was found between the average point the students obtained from EAT-40 scale and mother-father occupation (for each of them; p>0.05). In the study conducted by Wang et al. [₅₈] a similar result has been reported.

Specific relationships between personality and family factors in the development of eating disorders are still unclear [₅₉]. Tweed and Ryff [₆₀] stated that “adult children of alcoholics were described having more negative relationships with their alcoholic fathers. Daughters of alcoholic fathers were reported having more negative relationships with their fathers in the areas of role performance, affective expression, and control than did sons.” In our study, no difference was found between the average scale points of the students whose mothers-fathers are alcohol consumers and whose mothers-fathers are not (for each of them; p>0.05). García-Vilches et al. [₆₁] declared that there are no significant differences in symptomatologic and psychopathologic variables between the two groups one of whom is alcohol consumer and the other is not. Laporte et al. [₆₂] have reported that parents of women with AN have more problems together with alcohol consumption.

Delgado et al. [₆₃] reported that the people who had history of personal psychiatric disease have very often family history of obesity. Field et al. [₆₄] put forward that the ones whose mothers had history of eating disorder could have a risk factor only if they were young adolescent women. In our study, no difference revealed between average points obtained from the EAT-40 scale by the students whose family had history of obesity and whose family did not have (p>0.05). In the study by Robertson and Palmer [₆₅] a similar result was reported between eating disorders and existence of obesity history in the family.

The cause of eating disorders is complicated and it is not well-understood. There is a genetic proclivity including certain specific environmental risk factors [₁₇]. In some studies carried out [₆₆₆₇] it was pointed out that the existence of psychological disorder history in the family was an important element for eating disorders. In this study, no difference was found between the students who had history of psychological disorder in their family and who did not have in terms of average points that they obtained from EAT-40 scale (p>0.05). The study conducted by Lee et al. [₆₈] also reported a similar result.

Several important limitations should be considered in interpreting the results of our study. One of the limitations of this study was that it was cross-sectional, thus precluding inferences of casualty among variables. The second limitation is the self-reported nature of this study. The third limitation is that the sample of the current study comprised a group of students in just 1 city of Turkey, which may limit generalization of the results. Thus, in order to definitively answer this question, a large sample containing different universities in the country needs to be conducted. The fourth limitation is that using the EAT-40 scale is complicated with chronically ill people as several items of the EAT-40 contain physical issues that are part of an illness and thus may not necessarily reflect eating disorder. Finally, since this scale was used as a screening test, not a definite diagnosis, those who were at the risk of eating disorder were not actually diagnosed with eating disorder.

Conclusion

In this study, it was determined that prevalence of eating disorder is high among female university students. It is decided upon that students should be given psychological counseling service about eating

disorders and periodical screenings should be conducted for early diagnosis and treatment and doubtful cases should be directed to specialized psychiatry clinics for accurate diagnosis.

Correspondence to

Unal AYRANCI
Vatan Cad. 12/A ESKISEHIR-TURKEY
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