|Year : 2022 | Volume
| Issue : 1 | Page : 74-80
Prevalence and characteristics of eating disorders among college students of a nonmetro city of Gujarat
Chintan Madhusudan Raval1, Renish Bhupendrabhai Bhatt2, Deepak S Tiwari3, Bharat N Panchal4
1 Department of Psychiatry, GMERS Medical College Dharpur, Gujarat, Patan, India
2 Consultant Psychiatrist, Sai Shraddha Hospital, Jamnagar, Gujarat, India
3 Department of Psychiatry, M P Shah Medical College, Jamnagar, Gujarat, India
4 Department of Psychiatry, Government Medical College, Bhavnagar, Gujarat, India
|Date of Submission||18-Mar-2021|
|Date of Decision||13-Jul-2021|
|Date of Acceptance||11-Oct-2021|
|Date of Web Publication||05-Jan-2022|
Dr. Chintan Madhusudan Raval
52/53 Kalanagar Society, Near Railway Second Garnala, Patan - 384 265, Gujarat
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: There is a relative paucity of prevalence data about eating disorders (EDs) in India among young population. Aims: We aimed to estimate the prevalence and characteristics of EDs and abnormal eating behaviors among college students of a nonmetro city of Gujarat. Setting and Design: A cross-sectional survey was done among five colleges of a nonmetro city in Gujarat from February to September 2019. Subjects and Methods: Total 790 college students were assessed using a semi-structured format, Eating Attitudes Test-26, and Bulimic Investigatory Test Edinburgh followed by structured clinical interview as per DSM-5 criteria for EDs. Statistical Analysis: Outcomes were expressed in frequency, proportion, mean, and standard deviation. P values were calculated by Pearson Chi-square test or Fisher's exact test to determine the significance of the result. Results: The prevalence of abnormal eating behaviors was 25.2% (n = 199). Anorexia nervosa (AN) was not detected. The prevalence of bulimia nervosa (BN) was 0.2% and other specified feeding or eating disorder (OSFED) was 0.6%. “Being aware of calorie content” (53.7%) and “preoccupation with desire of thinness” (46.3%) were commonly found. “Impulse to vomit after meals” (2.5%) was least common. Lower body mass index was found among subjects with abnormal eating behavior. None of the subjects had amenorrhea. Conclusions: The prevalence of disordered eating behaviors, BN, and OSFED was 25.2%, 0.2%, and 0.6%, respectively. AN was not detected. OSFED was the most common ED and the characteristic “body image disturbance” was the most common symptom.
Keywords: Anorexia nervosa, binge-eating disorder, Bulimic Investigatory Test Edinburg, bulimia nervosa, Eating Attitudes Test-26, eating disorder
|How to cite this article:|
Raval CM, Bhatt RB, Tiwari DS, Panchal BN. Prevalence and characteristics of eating disorders among college students of a nonmetro city of Gujarat. Ind Psychiatry J 2022;31:74-80
Eating disorders (EDs) are characterized by abnormal eating patterns which may be either too less intake or excessive eating. This leads to physical and emotional health problems to individual. The common forms of EDs are anorexia nervosa (AN), bulimia nervosa (BN), and binge-ED (BED). People with AN have morbid fear of fatness, self-induced starvation, and medical signs of starvation. BN is characterized by episodes of binge-eating and compensatory behaviors like purging or doing excessive exercise. BED is characterized by recurrent episodes of binge eating in the absence of the inappropriate compensatory behaviors of BN. In a review published in 2015, the authors have noted that the estimated lifetime prevalence of AN, BN, and BED is 0.9%, 1.5%, and 3.5%, respectively, in women and 0.3%, 0.5%, and 2.0% in men according to the National Comorbidity Survey. The authors who explored the prevalence of EDs in India have reported that the amount of research in the area of ED in India is relatively sparse. Approximately 20% of college women experience transient bulimic symptoms at some points during their college years.
Within the broader field of EDs, it is important to recognize that the study of EDs in Asia is still in its early stages and that research is limited, albeit quickly expanding. There is a lack of systematic studies which examine the nature and prevalence of EDs in the non-Western world including India as compared to the Western world. Thus, EDs still remain an under-researched area in India.
Hence, considering the relative paucity of data on prevalence of EDs among vulnerable population in India, this study was planned to estimate the prevalence and characteristics of EDs among college students of a nonmetro city of Gujarat state in India.
| Subjects And Methods|| |
The study was approved by the Institutional Ethics Committee affiliated with Government Medical College located in the concerned city. A cross-sectional descriptive observational study was done between February and September 2019 among undergraduate students of five colleges of a nonmetro city of Gujarat having population of 7.5 lacks. The study sample comprised 834 college students. Subjects were recruited from five randomly selected colleges of the city. Systematic random sampling was used for selection of subjects from each college. The minimum sample size of 771 was calculated using the OpenEpi version two-open source calculator. We assumed prevalence of any ED including AN, BN, BED, other specified feeding or ED (OSFED), and unspecified feeding or EDs (UFED) 2.05% among population and absolute precision 1%. The confidence interval was kept at 95% and design effect was one.
The study was carried out in two steps including screening step followed by a structured clinical interview. Total 834 college students were approached after obtaining permission from the heads of respective institutions. Twenty-seven participants were unwilling to participate in the study. Written informed consent was obtained from each participant after explaining the objectives and method of the study. Subjects were explained how to fill study case record form. The questions in the case record form were explained to subjects, and the meaning of terms that were found difficult was clarified up to their satisfaction. Case record forms were filled in the classrooms under supervision of investigator(s).
The case record form included three sections, namely demographic data including height, weight, and menstrual history; Eating Attitudes Test-26 (EAT-26); and Bulimic Investigatory Test Edinburgh (BITE). EAT-26 and BITE were translated in the vernacular language Guajarati using the standard dictionaries. The translation was validated by back translation to English and comparison with original form by a group of experts who were well versed with both languages. Gujarati version was used for nonprofessional course including arts and commerce course students. English version was used for professional course students.
EAT-26 is a valid, reliable, and cost-effective self-rating questionnaire useful as an objective screening tool for AN. It includes 26 items assessing respondents' attitude and behaviors related to food and eating. Each item is rated on a six-point Likert scale ranging from “always” to “never.” The total score of EAT-26 may vary from 0 to 78. There are separate behavioral questions with dichotomous responses assessing binge-eating or binge-purging behavior and past history of treatment for EDs. It examines feelings and behaviors associated with AN. If a given subject has EAT-26 score more than or equal to 20 or has “yes” answer on any one dichotomous behavior question or subject is significant underweight, then he or she would be considered to have “possible ED.”
BITE is a 33-item self-report questionnaire designed to identify subjects with symptoms of BN or BED. It has been used as a screening tool to identify binge eaters in given population. The subjects were asked to complete BITE based on their feelings and behavior over the past 3 months. BITE has two subscales, namely symptom subscale and severity subscale. Both provide a degree of symptoms and an index of the severity of binge-eating and binge-purging behavior as defined by their frequency. The maximum possible symptom score is 30. Based on the score obtained on symptom scale of BITE, the subjects were divided into three groups as high (>20), medium (10–19), and low scores (<10). In BITE severity subscale, a score of 5 or more was considered clinically significant and 10 or more indicated a high degree of severity of binge-eating and binge-purging behavior. Those subjects with high score have a high probability of BN.
The EAT-26 or BITE screen-positive subjects were assessed within 15 days after screening by a psychiatrist who was unaware about the screen status of subject. The psychiatrist made individual structured clinical interview according to DSM-5 diagnostic criteria for AN, BN, BED, other specified feeding or eating disorder (OSFED), or UFED and for all screen-positive subjects.
The data were analyzed with GraphPad InStat statistical analysis software version 3.06. Qualitative data were expressed in frequency and proportion whereas quantitative data were expressed in mean and standard deviation. The prevalence of EDs and high-risk abnormal eating behaviors was calculated with 95% confidence interval. P values were calculated by Pearson Chi-square test of independence or Fisher's exact test when applicable to determine the significance of the result and P < 0.05 was considered statistically significant.
| Results|| |
Out of 807 participants who returned filled case record form, 790 subjects returned complete case record form giving a response rate of 97.8%. Twenty-seven participants did not agree to participate in the study. The mean age of all subjects was 20.4 years (range: 17–35) and standard deviation (SD) of 1.6. The mean body mass index (BMI) of all subjects was 19.5 and SD was 3.4 (range: 11.0–37.4). The demographic and mean values of BMI, EAT-26, and BITE scores are shown in [Table 1].
Males had higher BMI, EAT-26, and BITE (symptom) scores compared to females. BITE severity scale did not significantly differ between males and females (1.41 vs. 1.46, P = 0.3130).
Out of 790 screened subjects, the prevalence of EAT-26-positive screens was 20.5% (162 subjects) with risk of ED and the prevalence of BITE-positive screens was 4.7% (37 subjects). Hence, overall 25.2% (n = 199/790) of the subjects were found with disordered eating behaviors on either EAT or BITE. Total 199 subjects (162 + 37) were called for structured clinical interview. Structured clinical interview detected two subjects with BN (prevalence: 0.2%) and five subjects with OSFED (prevalence: 0.6%). All seven subjects who received ED diagnosis on structured clinical interview were female. Out of 162 high-risk subjects screened by EAT-26, 150 (92.6%) were female and 12 (7.4%) were male.
Almost half (n = 84, 51.8%) of the subjects screened by EAT-26 at high risk for EDs had normal BMI. As shown in [Table 2], severely underweight (BMI <16) and obese (BMI >30) subjects were more among the EAT-26 screened positive group compared to the EAT-26-negative group.
|Table 2: Body mass index of Eating Attitudes Test-26 screened positive and negative subjects|
Click here to view
The responses of all subjects on EAT-26 questionnaire are shown in [Table 3] (dieting subscale), [Table 4] (bulimia and food preoccupation subscale), and [Table 5] (oral control subscale). Subjects were divided into two groups: high risk screen positive (162 subjects) and screen negative (628 subjects). Out of 162 high-risk subjects, the most frequently reported items were “aware of calorie content of food I eat” (53.7%, n = 87), “preoccupied with desire to be thinner” (46.29%, n = 75), “preoccupied with having fat on body” (38.27%, n = 62), and “think about burning up calories when I exercise” (38.27%, n = 62). However, 27.77% (n = 45) were engaged in dieting behavior and only 2.46% (n = 4) had impulse to vomit after meals.
|Table 4: Analysis of bulimia and food preoccupation subscale of Eating Attitudes Test-26|
Click here to view
As shown in [Table 6], BMI did not differ significantly among BITE screened positive and BITE-negative subjects. [Table 7], [Table 8], [Table 9] show the results of BITE individual item analysis divided into symptom subscale 1, symptom subscale 2, and binge-eating subscale, respectively.
|Table 6: Body mass index of Bulimic Investigatory Test Edinburg screened positive and negative individuals|
Click here to view
|Table 7: Bulimic Investigatory Test Edinburg symptom scale item analysis for subscale 1|
Click here to view
|Table 8: Bulimic Investigatory Test Edinburg symptom scale item analysis for subscale 2|
Click here to view
| Discussion|| |
The present study is comparable in sample size with other similar studies done among the same age group populations from the non-Western world. This study observed that overall 25.2% (n = 199) of the subjects were found with disordered eating behaviors on either EAT or BITE. The prevalence of positive screens for EDs among college students ranges from 8% to 17% and up to 20% in a national survey. A recent study from Mysore city of South India among students of 15–25 years' age group, reported that 26.6% of students displayed abnormal eating attitudes and eating discrepancies. Hence, the results of the current study are consistent with previous similar studies.
We did not find any case of AN in study sample. A study among 662 MBBS course college students of Madras also reported that they could not find any case of AN or bulimia among their subjects. The authors also noted that many experienced mental health professionals shared that they have hardly seen a case of AN or BN during their clinical practice. A extensive review from Western countries has examined studies which used similar two-stage screening methods reported that the average prevalence of AN is 0.3% among young female population. According to literature, the prevalence of bulimia ranges from 1% to 4% among young women and BN is more prevalent than AN. Our study also supports this trend.
We detected two subjects with BN (0.2% prevalence). This is lesser than the prevalence reported by a study among 504 North Indian college girl students from an industrial town in the foothills of the Himalayas which reported a 0.4% prevalence of BN using BITE screening tool. The lower prevalence of BN in our study can be explained due to study design where screened participants were also subjected to structured clinical interview.
The striking finding in our study is that we found five subjects (0.6% prevalence) with other specified feeding or EDs (OSFED). Previous studies have shown that the majority of the patients with EDs fall into the category of ED not otherwise specified., Hence, the subthreshold forms of ED were most prevalent among our subjects. A study from Madras in South India reported that subsyndromal EDs what they described as “eating distress syndrome” are more prevalent in India as compared to classical EDs.
All detected subjects with any ED were females in the current study. However, total male subjects in the study were 34 (4% of sample) and none of them were detected with any ED. Less is known about prevalence among males, but AN is far less common in males than in females, with clinical populations generally reflecting approximately a 10:1 female-to-male ratio.
“Enjoy trying new rich foods” was a commonly endorsed item by all subjects in both screen-positive and screen-negative subjects. This suggests that the presence of “trying new rich foods” is a good predictor of having ED. “Being aware of the calorie content of food” was the most common reported item among EAT-26-positive subjects. The characteristic body image disturbance expressed as “preoccupation with a desire to be thinner” was the second most commonly endorsed item. “Thought of burning up calories when exercise” and “preoccupation with thought of having fat on body” both were the third most common items among them. More than half (56.7%) of the BITE-positive subjects also reported “thought of becoming fat terrify them.” This suggests that distorted perception of body shape and obsessive preoccupations about thinness were highest among subjects. This finding is in contrast to the notion that distorted body image is predominantly seen in the Western world and not in non-Western population. Studies from non-Western countries reported that patients often present without prominent expression of weight concerns. Younger individuals with AN may have atypical presentation including denial of “fear of fatness.” A recently published review article also reported that nonfat phobic variant of AN is frequently reported in various countries and hence retained in ED NOS category. The earliest published case reports and case series of AN from India do not show body image disturbance. Although, the relentless desire for slimness is often not considered important for attractive appearance in many areas of Gujarat and heftiness and is accepted a sign of attractive and “healthy look.” The finding of our study indicates that the Western theme of attractive appearance in slimness has been spread with time in this region too.
Current or recent history of amenorrhea was not reported by any of the screen-positive subjects in our study. The presence of amenorrhea suggests strong biological disturbance. Amenorrhea is often associated with severely undernutritional status. DSM-IV criterion that required an individual to exhibit amenorrhea for minimum 3 months to qualify for a diagnosis of AN was removed in DSM-5. The present study also supports this change. In a review article in 2009, the authors concluded that amenorrhea is a physiologically important disturbance often seen in association with AN and a useful indicator of clinical severity. However, they have suggested that it should not be included as essential core criteria in DSM-5 for the diagnosis of AN.
“Impulse to vomit after meals” (1%, n = 7) and “vomit after meals” (1%, n = 7) were the least prevalent items among subjects and did not differ between screen-positive and screen-negative subjects. A study conducted among 2489 Brazilian college students has reported that 3.3% of subjects had vomiting behavior.
Although the weight fluctuation of more than 5 lbs/week was more among BITE-positive subjects compared to BITE-negative subjects (37.8% vs. 8.8%, P < 0.0001), BMI did not significantly differ among BITE-positive and BITE-negative subjects. Literature suggests that most of the patients with BN maintain normal weight throughout the duration of disorder. Severely underweight (BMI <16) and obese (BMI >30) subjects were more among EAT-26 screen-positive groups compared to EAT-26 screen-negative ones. This suggests that lower BMI and obesity are associated with disordered eating behavior.
This is the first descriptive original research study emerging from Gujarat in Western India which has examined relatively large sample compared to previous studies on EDs among similar population in the region. However, the study was based on college students' sample, hence the findings cannot reflect the general population trends of EDs. Future research is recommended involving large-scale community sample to confirm the findings of this study.
| Conclusions|| |
The prevalence of disordered eating behaviors, BN, and OSFED was 25.2%, 0.2%, and 0.6%, respectively. AN was not detected. OSFED was the most common ED, and the characteristic “body image disturbance” was the most common symptom.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Sharan P, Sundar AS. Eating disorders in women. Indian J Psychiatry 2015;57:S286-95.
Sadock BJ, Sadock VA, Ruiz P. Feeding and eating disorders. In: Pataki CS, Sussman N, editors. Kaplan and Sadock's Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 11th
ed. New Delhi: Wolters Kluwer/Lippincott Williams and Wilkins; 2015. p. 516.
Soh NL, Walter G. Publications on cross-cultural aspects of eating disorders. J Eat Disord 2013;1:4.
Srinivasan TN, Suresh TR, Jayaram V, Fernandez MP. Eating disorders in India. Indian J Psychiatry 1995;37:26-30.
] [Full text]
Garner DM, Olmsted MP, Bohr Y, Garfinkel PE. The eating attitudes test: Psychometric features and clinical correlates. Psychol Med 1982;12:871-8.
Henderson M, Freeman CP. A self-rating scale for bulimia. The 'BITE'. Br J Psychiatry 1987;150:18-24.
Eisenberg D, Nicklett EJ, Roeder K, Kirz NE. Eating disorder symptoms among college students: Prevalence, persistence, correlates, and treatment-seeking. J Am Coll Health 2011;59:700-7.
Nivedita N, Sreenivasa G, Sathyanarayana Rao TS, Malini SS. Eating disorders: Prevalence in the student population of Mysore, South India. Indian J Psychiatry 2018;60:433-7.
] [Full text]
Hoek HW, van Hoeken D. Review of the prevalence and incidence of eating disorders. Int J Eat Disord 2003;34:383-96.
Bhugra D, Bhui K, Gupta KR. Bulimic disorders and sociocentric values in north India. Soc Psychiatry Psychiatr Epidemiol 2000;35:86-93.
Ricca V, Mannucci E, Mezzani B, Di Bernardo M, Zucchi T, Paionni A, et al
. Psychopathological and clinical features of outpatients with an eating disorder not otherwise specified. Eat Weight Disord 2001;6:157-65.
Turner H, Bryant Waugh R. Eating disorder not otherwise specified (EDNOS): Profiles of clients presenting at a community eating disorder service. Eur Eat Disord Rev 2004;12:18-26.
Walsh BT. Feeding and eating disorders. In: First MB, Ward MN, editors. Diagnostic and Statistical Manual of Mental Disorders. 5th
ed. Arlington, VA: American Psychiatric Association; 2013. p. 340-1.
Lee S, Ho TP, Hsu LK. Fat phobic and non-fat phobic anorexia nervosa: A comparative study of 70 Chinese patients in Hong Kong. Psychol Med 1993;23:999-1017.
Keel PK, Klump KL. Are eating disorders culture-bound syndromes? Implications for conceptualizing their etiology. Psychol Bull 2003;129:747-69.
Call CC, Attia E, Walsh BT. Feeding and eating disorders. In: Sadock BJ, Sadock VA, Ruiz P, editors. Kaplan and Sadock's Comprehensive Textbook of Psychiatry. 10th
ed. New Delhi: Wolters Kluwer/Lippincott Williams and Wilkins; 2017. p. 5285-330.
Attia E, Roberto CA. Should amenorrhea be a diagnostic criterion for anorexia nervosa? Int J Eat Disord 2009;42:581-9.
Alvarenga Mdos S, Lourenço BH, Philippi ST, Scagliusi FB. Disordered eating among Brazilian female college students. Cad Saude Publica 2013;29:879-88.
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]