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ICMR SHORT TERM STUDENTSHIP (STS) 2013

REFERENCE ID: 2013-01251

TITLE

Prevalence of eating disorders, perceived socio-cultural stress and ideal body

image in adolescents.

INDEX

CONTENT PAGE NUMBER

TITLE 1

INTRODUCTION 2

REVIEW OF LITERATURE 4

AIMS & OBJECTIVES 8

MATERIALS AND METHODS 8

OBSERVATIONS AND RESULT 14

DISCUSSION 25

CONCLUSION 28

SUMMARY 29

REFERENCES 30

APPENDICES 32

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INTRODUCTION

Eating disorders are characterized by disturbed and exaggerated behaviors towards

food, eating and body shape. They include disorders such as anorexia nervosa, bulimia

nervosa, psychogenic vomiting and binge eating disorders. Adolescence is a critical

period where eating disorders and negative body images are most likely to develop.

Negative body image in adolescents can lead to the development of potentially harmful

behaviors which can have hazardous complications on their physical and emotional

health. Eating disorders are emerging a global health problem for adolescents. [1]

Sancho C et al conducted a school based study on eating disorders in Spanish

adolescents and found that the prevalence of eating disorders was 3.81%. Their study

concluded that Eating Disorders that began at early ages in less severe forms and in

females often persisted with increasing severity. [2]

Mammen P et al conducted a hospital based study in South India on eating

disorders and found the prevalence to be 1.25%. They also discussed that the prevalence

of eating disorders appeared to be increasing within the multicultural Indian population.

[3]

Chang YJ et al assessed eating disorder-related thoughts and behaviors in high-

school adolescents. They found that maladaptive eating behaviors were significantly

associated with overestimation of body weight, unrealistic body weight goal,

dissatisfaction with body weight, and weight loss experiences. [4]

Pruneti C et al conducted a study on eating behaviors and body image perception

in Italian adolescents and found excessively rigid self-perception of body image and

dysfunctional eating habits. They suggested that there may be a role of family, friends,

media and socio-cultural factors in shaping distorted ideas of body image in adolescents

and subsequent abnormal eating behaviors. They strongly emphasized the need for health

care professionals, policy makers, and educational authorities to conduct research on

adolescent eating disorders. [5]

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Shroff H et al studied the influence of media and the interpersonal relations on

body image and eating disturbance in India and found that teasing and internalization

mediated the effect of BMI on body dissatisfaction and in certain cases influenced drive

for thinness. [7]

Akan GE et al determined that low self-esteem and high public self-consciousness

were associated with greater levels of problematic eating behaviors and attitudes and

body dissatisfaction. [8]

The rationale behind conducting this study was that epidemiological studies on

eating disorders can have implications for adolescents, health care providers and

policymakers. Currently, there is paucity of literature on eating disorders and perceived

socio-cultural stress and ideal body image in adolescents in developing countries such as

India. Our study attempts to assess the prevalence of eating disorders among adolescents

and explore relations between eating disorders, perceived socio-cultural stress and ideal

body image among adolescents. We hope that the knowledge obtained from the study

can provide newer insight into the magnitude of the problem and accordingly future

strategies can be planned for their appropriate management.

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REVIEW OF LITERATURE

A literature search was conducted using PUBMED and MEDLINE databases and

studies relevant to the arena of eating disorders were reviewed. We have attempted

to analyze studies pertaining to our study and have accordingly discussed

contextual findings in relevant sections of prevalence of eating disorders, perceived

sociocultural pressure and ideal body image in adolescents. We have evaluated the

literature available and have discussed findings of studies which showed maximum

relevance to our study. Towards the end of the review of literature, we have

highlighted essential critical aspects pertaining to our research.

Prevalence of Eating Disorders:

In a study conducted by Semiz and Kavakcı in Sivas Province, Turkey the

point prevalence rate for Eating Disorders among all the participants was 1.52%,

with binge eating disorder being the most prevalent Eating Disorder.[9]

The

prevalence of anorexia nervosa has been investigated mainly in samples of young

women in Europe and North America, where the average point prevalence has

been 0.3% . Hoek and van Hoeken found that anorexia among adolescents aged 15

– 19 years had significantly increased each decade since 1930. [10, 11]

A study done

in 6 European countries found lifetime prevalence estimates as 0.5% for both

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anorexia and bulimia nervosa, with significantly higher prevalence among females

than males.[12]

The Perceived Socio-cultural Pressure:

A study conducted by Shomaker LB et al investigated interpersonal influences on

changes in adolescent’s symptoms of disordered eating over one year. The study

revealed that interpersonal pressure to be thin and criticism about appearance

predicted increases in disordered eating over time. Further, adolescents'

perceptions and friends' reports of pressure to be thin predicted changes in

disordered eating over time thus concluding that perceived socio-cultural pressure

to be thin has an important impact on disordered eating during adolescence [13]

Jackson T et al found an important linkage in appearance-related social pressure,

social comparison as well as appearance concerns with increased eating disorder

symptomatology among young people in china. [14]

Ideal-body image stereo-types:

Nouri M et al did a study on two groups, namely European American and Asian

American samples. Here it was noted that Internalization of the thin ideal body

image explained the media exposure-body dissatisfaction association equally well

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for both groups. Results also suggested that Asian Americans may be employing

unhealthy weight control behaviors, and may be prone to developing eating

disorders, at rates similar to European American youngdult females.[15]

Indian studies:

Mishra SK et al did a study in Sikkim, India with the results showing a growing

concern about ideal body image and weight reduction among adolescents in India

particularly among urban girls of affluent families. The study argued that eating

disorder, once a problem of the Western world, is now creeping in among

adolescents of the developing world as a consequence of rapid lifestyle changes

over the past few decades.[16]

Chugh R et al conducted a study on affluent

adolescent girls of Delhi and their eating and weight concerns. Their study showed

that concerns about excess weight were prevalent among the adolescent girls, even

among those who were normal-weight and underweight. It also showed that the

level of satisfaction with body size decreased with increase in weight. The study

emphasized on the association between body image and Eating Disorders and

stated that weight concerns and dissatisfaction with body size may pose a threat to

a healthy nutritional state, and may develop into precursors of a later eating

disturbance. [17]

A study done by King MB and Bhugra D on schoolgirls living in a

north-indian town showed that despite prevalent scores for eating disorders on

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closer scrutiny, the pattern of responses revealed misinterpretations of a large

number of questions possibly on a conceptual basis.[18]

The above studies have reported an increasing prevalence of eating disorders

over time especially in western countries. Trends seem to be catching up in

developing countries especially metropolitan cities that have been described.

Studies described have varied methodology. Ressler A states that even though

eating disorders of anorexia nervosa and bulimia have reached epidemic

proportions in our population today, especially among adolescent and adult

women, often these disorders go undiagnosed and frequently untreated because

patients rarely disclose their symptoms to their physician, therapist or dietitian thus

making the studies regarding prevalence of Eating disorders inaccurate at times. [19]

Very few studies have used valid and reliable questionnaires for assessing

prevalence of eating disorders. Overall, literature pertaining to eating disorders in

adolescents is sparse in India.

Hence the need for our study which attempts to study the prevalence of

eating disorders, perceived socio-cultural pressure and the perceived ideal body

image stereotype in adolescents.

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AIMS AND OBJECTIVES OF THE STUDY:

1) To estimate the prevalence of eating disorders in adolescents

2) To study perceived socio-cultural stress in adolescents

3) To assess ideal body image in adolescents

4) To explore relation between perceived socio-cultural stress, ideal body

image and eating disorders in adolescents

MATERIALS AND METHODS

STUDY TYPE:

Open label cross sectional survey

STUDY POPULATION :

Adolescents (10 -19 years) (according to the WHO definition of adolescents)

studying in 2 High Schools of Mumbai comprised our study population.

SITE OF STUDY:

The above mentioned schools were sites of data collection. The design of the

study, tabulation of results, analysis and interpretation of results was done at MGM

Medical College, Navi Mumbai

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PERIOD OF STUDY:

July - August 2013

SELECTION CRITERIA:

Adolescent studying in the selected English medium high schools were eligible to

participate in the study.

Inclusion criteria : The following adolescents were included:

1. Age between 10-19 years

2. Adolescents willing to participate in the study

3. Adolescents present on required date of data collection in the School.

Exclusion criteria : The following students were excluded:

1. Students below 10 years and above 19 years

2. Adolescents with severe medical problems, severe mental retardation and severe

sensory handicaps rendering them uncooperative for self-rated assessments were

excluded

SAMPLE SIZE:

The sample size was calculated using the formula

n = [(Z1 – α/2)/ ω] 2 [π (1-π)]

Whereπ is hypothesized population proportion. Z is determined by the α level, the

value of z for the chosen level of α can be found using a standard normal

distribution table ω is the half width of desired confidence interval . The half

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width is half the confidence interval. If we use a confidence interval of 10

percentage points the half width is 5 points. Z1-α/2 = 1.96(95% confidence

interval) π = 0.0381 (hypothesized prevalence 3.81%) [5]

(1-π) =0.9619, ω =0.01

Therefore, sample size ‘n’= [(1.96/0.01)]2[0.0381* 0.9619] = 1407.

(Sancho C et al conducted a school based study on eating disorders in adolescents and

found that the prevalence of eating disorders was 3.81%.) [2]

Hence, the sample size calculated apriori for our study was1407.

STUDY DESIGN :

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DATA COLLECTION AND PROCEDURE:

This study was conducted in a high school set up after presenting the proposal to

the Institution Ethics Committee Review. Permission of the principal of the

selected English speaking high schools was obtained. Assent from teachers and

parents were obtained. Informed consent from the adolescents were obtained The

data was collected in a phased manner covering respective standards of students in

age ranges of adolescents between 10 to 19 years on selected data collection dates.

Adolescents were informed about the ongoing study and those willing to

participate in the study were provided with the predesigned data collection form,

informed consent documents and self-rated scales. Predesigned data collection

form covered the demographic data and height and weight of the adolescents.

Eating disorder scale, Perceived Socio-cultural pressure scale and Ideal Body

Stereotype Scale (Revised) was distributed to the adolescents for self-rating.

Instructions were provided by the investigator. Confidentiality and anonymous

nature of their responses was emphasized while collecting data. A record was

maintained of the number of adolescents who participated in the study and the

number of completed and incomplete forms. Sample size calculated of 1407

complete forms was statistically analyzed.

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INSTRUMENTS USED: ( Refer appendix for complete scales)

1. Proforma : A predesigned data collection proforma which comprised of age,

sex, class, religion, language spoke, residential area, height and weight of

the adolescent.

2. Eating Disorder Diagnostic Scale :

The Eating Disorder Diagnostic Scale (EDDS) is a 22 item questionnaire that

assesses the presence of three eating disorders - anorexia nervosa, bulimia nervosa

and binge eating disorder. The scale is a valid and reliable scale for assessing

eating disorders. Clinical diagnoses from this scale has temporal reliability (mean

kappa = .80), criterion validity (mean kappa = .83), test-retest reliability (r = .87)

and internal consistency (mean alpha = .89) [6]

3. The Perceived Sociocultural Pressure Test

This is a self rated scale for adolescents. It assesses the pressure perceived by

adolescents from their family and friends to be thin. It has been found to be a valid

and reliable instrument with an internal consistency of alpha=.88 and a test-retest

reliability of r=.93.[6

4. Ideal Body Stereotype Scale (REVISED)

This is a self rated scale for adolescents with internal consistency (alpha =.91) and

test-retest coefficient of r=.80. It assesses the internalization of thin body image.

The scale asks adolescents to indicate their level of agreement with statements

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concerning what attractive women look like (e.g., “Slender women are more

attractive”) using a 5-point response format ranging from1 = strongly disagree to

5 = strongly agree. It is valid and reliable. [6]

STATISTICAL TOOLS:

1. The data was tabulated and analyzed using Statistical Package for Social

Sciences (SPSS) version 17.0

2. The Chi square test and T-test test was used to test statistical significance

between categorical variables at p < 0.05.

3. Results were further analyzed using Descriptive statistics and logical regression.

4. Charts and graphs are used to demonstrate the findings

CONFIDENTIALITY AND ETHICAL CONSIDERATIONS: :

Institute Ethics committee approval was obtained from Institutional Ethics Review

Committee (IERC) prior to data collection. Written informed consent was taken

and complete confidentiality was maintained.

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OBSEVATIONS AND RESULTS

Eating Disorders:

Demographic Distribution: Gender profile: Out of the 1407 respondents, 40.65% were male and 59.35% were

female.(Refer Table 1).

There was a significant association between gender & prevalence of Eating

Disorder. Females were significantly more likely to have an Eating Disorder as

compared to males (P = 0.000). (Refer Table 2)

Table 1: Gender Distribution

Table 2: Gender and Eating Disorder Level Gender Total

Male Female

Eating Disorder Level (Range)

Low (0-20)

Count 489 594 1083

% within Gender 85.5% 71.1% 77.0%

Moderate (21-40)

Count 70 204 274

% within Gender 12.2% 24.4% 19.5%

High (41-60)

Count 13 37 50

% within Gender 2.3% 4.4% 3.6%

Total

Count 572 835 1407

% within Gender 100.0% 100.0% 100.0%

Gender Number Percentage

Male 572 40.65

Female 835 59.35

Total 1407 100

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b

b

On the bases of range of Eating Disorder, more males (85.5%) fall in the Low ED

level as compared to females (71.1%) thus concluding that majority of males don’t

have or are less likely to have an ED whereas more females (4.4%) as compared to

males (2.3%) fall in the High ED level thus concluding that females are more

likely to have an ED as compared to males. [P=.000]

Age profile: Age of the adolescents used as sample ranged from 13 to 17 years.

There was no significant association found between any particular age group and

prevalence of eating disorders. (P = 0.445)

Sample profile by religion: Majority of the sample population were Hindus

(1084; 72.7 %), 219( 15.56 % ) were Muslim, 158 ( 11.22% ) were Christian, 6

were Sikh( 0.42% ) and 0% others. There was no significant association between

Religion and prevalence of Eating Disorder. [P=.565]

Prevalence of Eating disorder as assessed by Eating Screen: Overall 23% of the sample had score ranging from moderate to severe eating

problems. We found a prevalence of 3.6% in the sample as represented by cut off

scores in the range of severe scores for eating disorder as assessed by the Eating

Screen.

According to the analysis, Eating Disorder scores ranged from 0 to 60. A score of

upto 20 would imply, No or Very Low level of Eating Disorder, between 21-40

being a moderate level, whereas more than 41 being a High level of Eating

disorder. (Table 3). No or Low ED scores comprised of maximum frequency (1083

respondents out of a sample of 1407, i.e. in 77%), moderate scores were seen in

273 (19.5%) respondents. High scores were seen in 50 (3.6%) respondents i.e. 3.6

percent prevalence was seen for high level of Eating Disorder.

Hence in our study the prevalence of eating disorder was 3.6%.

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Table 3: Eating Disorder Level

Number Percentage Cumulative

Percent

Valid

Low (0-20) 1083 77.0 77.0

Moderate (21-40) 274 19.5 96.4

High (41-60) 50 3.6 100.0

Total 1407 100.0

Figure 1:

Eating Disorder Level

Item analysis of selective items of the Eating screen:

Felt fat: According to the analysis, 1055 ( ie 75%) respondents out of a studied

sample of 1407 responded “that they either did not feel fat or felt only very slightly

fat ”. 235 respondents (16.7%) felt moderately fat , whereas 117 (8.3%) felt

extremely fat.

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Figure 2:

Binge eating and loss of control during eating: Most prevalent practice seen in

the adolescents with valid Eating Disorder was binge eating (episodes of

uncontrollable eating). 515 respondents i.e. 36.6% of 1407 people admitted to

eating what other people would regard as an unusually large amount of food

frequently. 427 respondents i.e. 30.3% of 1407 respondents felt a loss of control

during these frequent binge episodes. When asked about frequency of Binge

Eating; 65.6 % of the respondents i.e. 923 respondents out of 1407 confirmed to

have binged at least one day a week. Nearly 20% students i.e. 282 admitted to

binging for three or more days a week. 60 students (4.3%) mentioned that they

resorted to binge eating for 6 or 7 days of the week

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Figure 3:

Figure 4:

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Figure 5:

Vomiting and purging: Eight percent of adolescents claimed to vomit on purpose

1 to 3 times per week to prevent weight gain or counteract the effects of eating. 28

students (2%) mentioned that they resorted to vomiting for 4 to 12 times per week.

Figure 6:

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Use of excessive Exercise, Skipping meals, laxatives, diuretics, birth pills:

A large no. of adolescents i.e. 31.6% reported of engaging in excessive exercise of

about 1 to 4 times a week to counteract the effects of overeating episodes.

Another method of prevention of weight gain observed among the high school

students was fasting (skipping more than 2 meals in a row). 21.6% claimed to be

fasting 1-4 times a week. Use of laxatives or diuretics to prevent weight gain or

counteract the effects of eating was seen to be next to none (.1%) among the

adolescents. The study found that the Indian community of adolescents has not , as

of now accepted or resorted to birth control pills as a weight control method with

100 percent of the sample(Table 4) claiming to not taking birth control pills of any

kind.

Table 4: Adolescent’s seen taking Birth Control Pills

Number Percentage Cumulative

Percent

Valid No 1407 100.0 100.0

CORRELATIONS AMONG EATING DISORDER AND BMI AND MISSED

MENSTRUAL CYCLES: Correlation between prevalence of Eating Disorder and

BMI was found to be positive (+0.311) and significant (P=0.000).Thus the increase

in an adolescent’s BMI is related with an increase of the person’s chances of

getting or having an Eating Disorder. Correlation between prevalence of Eating

Disorder and Number of Menstrual Cycles Missed was found to be positive

(+0.093) and significant (P=0.007).Thus an increase in the number of Menstrual

Cycles Missed by a female is related with an increase of the female’s chances of

getting or having an Eating Disorder.

Perceived Socio-cultural Pressure:

According to the analysis as assessed by Perceived Sociocultural pressure scale,

scores ranged from 0 to 5. A score of <=2.0 would imply, No or Very Low

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Pressure, between 2.1-3.5 being a moderate level, whereas more than 3.5 being a

High level of Perceived Socio-cultural Pressure. (Table 5)

We found the prevalence of high perceived sociocultural distress in 4.3% of

adolescents. Overall, 18.3% of adolescents showed moderate to severe levels of

sociocultural pressure related to eating.

No or Low Pressure scores comprised of maximum respondents (1148 respondents

out of a sample of 1407, i.e. in 81.7%), moderate scores were seen in 197 (14%)

respondents. High scores were seen in 61 (4.3%) respondents that is 4.3 percent

prevalence was seen for high levels of Perceived Socio-cultural stress.

Table 5: Perceived Socio-cultural Pressure Level

Number Percentage Cumulative

Percentage

Valid

Low (<= 2.0) 1148 81.7 81.7

Moderate (2.1 - 3.5) 197 14.0 95.7

High (>3.5) 61 4.3 100.0

Total 1407 100.0

Figure 7

1148

1976182% 14% 4%

No or low score Moderate score High score

Scores for Percieved Socio-cultural Pressure

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Correlations between Perceived Sociocultural stress and BMI:

Correlations between Mean Perceived socio-cultural stress and BMI shows

significance of P=.0006. This shows that the adolescents having high BMI are the

ones who report having felt high pressure from the society about their weight and

looks.

According to responses given, adolescent’s with BMI higher than standard value

(>=25) felt pressure and a strong message from the Media (TV, Magazines) to

have a thin body. They also felt high level of pressure from their families to lose

weight.

No significant association between Perceived Socio-cultural Pressure and other

Demographic Values like Age, Gender or Religion is seen.

IDEAL BODY IMAGE:

According to the analysis as assessed by Ideal Body Stereotype scale, scores

ranged from 0 to 5. A score of <=2.0 would imply, No or Very Low stereotype,

between 2.1-3.5 being a moderate level , whereas more than 3.5 being a High level

of Ideal Body Image Stereotype. (Table 6)

Our study found that 36.3% of adolescents had high levels of Ideal body image

stereotype. 75.7% of students showed moderate to severe levels of ideal body

image stereotypes.

No or Low stereotype scores comprised of 342 respondents out of a sample of

1407, i.e. in 24.3%, moderate scores comprised of maximum number of

respondents i.e. 554(39.4%). High scores were seen in 511 (36.3%) respondents

i.e. 36.3 percent prevalence was seen for high levels of Ideal Body Image

Stereotype.

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Table 6: Ideal Body Image Stereotype Level

Number Percentage Cumulative Percentage

Valid

Low (<= 2.0) 342 24.3 24.3

Moderate (2.1 - 3.5) 554 39.4 63.7

High (>3.5) 511 36.3 100.0

Total 1407 100.0

Figure 8:

No significant association between Ideal Body Image and other Demographic

Values like Age, Gender, BMI or Religion is seen.

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CORRELATIONS BETWEEN EATING DISORER, PERCEIVED SOCIO-CULTURAL

PRESSURE AND IDEAL BODY IMAGE

We also explored relations between perceived socio-cultural stress, ideal body

image and eating disorders in adolescents. Our study correlated the findings of our

3 questionnaires and concluded that;

A. Correlation between ED and Perceived socio-cultural stress was found be

significant with P=.000 .Thus an increase in socio-cultural pressure on an

adolescent is related to an increase in the chances of the adolescent having or

getting an Eating Disorder. This shows that adolescent’s that had high socio-

cultural pressure were more likely to have an Eating Disorder.

B. Correlation between ED and Ideal body image was found to be non-

significant with P=.051 in our study.

C. Correlation between Perceiver socio-cultural stress and Ideal body image

was found to be non-significant with P=.152 in our study.

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DISCUSSION

In our study, the prevalence of moderate and severe Eating Disorders was found to

be 23%, with severe eating disorder 3.6% and moderate eating disorder 19.5%.

This was similar to the prevalence rates of severe eating disorders found in other

studies conducted on adolescents [2]

Our study found that females were more likely to have an Eating Disorder than

males. This is comparable to the study done in European countries. [12]

Our study showed that correlation between prevalence of Eating Disorder and BMI

was found to be positive and significant .Thus concluding that the increase in an

adolescent’s BMI is related with an increase of the person’s chances of getting or

having an Eating Disorder. This result is similar to a study done by James et al in

2008 which states that there is prevalence of high BMI among individuals with

binge eating disorder than respondents without any eating disorder. [23]

One of the major correlations of our study was between Perceived Socio cultural

Pressure and Eating Disorders. The correlation came out to be positive and

significant thus concluding that adolescents who have high socio-cultural pressure

are more likely to have an Eating Disorder.These findings are consistent with prior

works which indicated the importance of perceived socio-cultural pressure to be

thin in the emergence of disordered eating symptoms among early and middle

adolescent girls [20, 21]

In our study, BMI of adolescents was positively correlated to the socio-cultural

pressure faced by them leading to body dissatisfaction and higher risk of Eating

Disorder. This is comparable to the study done in India. [7]

The correlation between Perceived Socio cultural Pressure and other demographic

values like Gender, Age and Religion was insignificant according to the results our

study. In terms of Gender, this suggests that the pattern of relations among

pressures and eating disorders is similar for adolescent girls and boys. Such

findings contest socio-cultural theory’s traditional assumptions that pressure to be

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thin is exclusively relevant for girls. This is consistent with previous studies done

in Denver. [13]

According to our results, 75.7 % of adolescents had moderate to severe body image

stereotypes, 39.4% moderate and 36.3% high. However, the ideal body image had

no significant association with Eating Disorders in our study. These results are

different as compared to certain studies which report that body image

dissatisfaction predicted increases in disordered eating among middle adolescent

girls. [20]

This may be due to cultural influence as compared to western studies.

However, the findings are in agreement with other studies that have not found

significant evidence that ideal body image stereotype has predicted changes in

eating disorders in adolescents.[22]

In terms of the result of our Eating Screen, our analysis showed that from the

various weight control measures used by adolescents, the most frequently adopted

technique was Binge Eating with 37% students succumbing to binging frequently

and around 4.3% admitting to do it as often as 6 to 7 days a week.

Other methods used by adolescents to prevent weight gain were vomiting and

purging (8% of our sample), excessive exercise (31.6%) and fasting frequently

(21.6%).Use of laxatives or diuretics to prevent weight gain or counteract the

effects of eating was negligible in our sample. These results are in contrast with

studies done in the western world which show the prevalence of these measures to

be of a higher percentage than ours, with 13.4% of their sample reporting recent

bingeing, 8.8% reporting purging behaviors, and 8.5% reporting laxative use. [24]

The reason behind this contrast is most likely the difference in socio-cultural

activities and environment between the western countries and India.

Despite a lesser prevalence of unhealthy eating practices in India in comparison

with the western world, our study clearly shows an alarming increase in disordered

eating and its associated mal-practices in adolescents of India.

Along with Eating Disorders, our study shows a 4.3% prevalence of Socio-cultural

Pressure which in turn correlates with Eating Disorder and makes its occurrence

more likely.

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Our study also shows a 36.3% prevalence of Ideal Body Image stereotype in our

sample. This signifies the increasing stereotypes in our society leading to an

increase in Body Image Dissatisfaction in today’s adolescents.

Limitations of the study:

Some possible limitations of our study were that the period of study was relatively

a shorter period of two months and the sample size was moderate with confidence

interval taken as 95% with a 5% mean error. The questionnaire was a self-rated

scale and this could sometimes lead to incorrect reporting.Additionally, because

the survey was confidential, the actual eating behaviors and attitudes of the student

respondents could not be confirmed through direct personal interview.

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CONCLUSION:

We conclude that the prevalence of high level of Eating Disorders is 3.6%,

Perceived Socio-cultural Pressure is 4.3% and Ideal body Image is 36.3%.

Our study concludes that there is a significant correlation between Eating

Disorders and Perceived Socio-cultural Pressure thus indicating that adolescent’s

that have high socio-cultural pressure are more likely to have an Eating Disorder.

Other significant findings of our study are; females are more likely to have an

Eating Disorder as compared to males, Eating Disorder and BMI are positively

correlated thus suggesting that the increase in an adolescent’s BMI is related with

an increase of the person’s chances of getting or having an Eating Disorder.

The survey also shows that 36.6% of the adolescents admitted to eating what other

people would regard as an unusually large amount of food frequently and 4.3% of

the sample admitted to binge eating as frequently as 6 or 7 times. Other disordered

eating habits implemented by adolescents to prevent weight gain and their

respective frequencies found as per our study are vomiting and purging (8%

moderately and 2% excessively), excessive exercise (31.6%) and skipping

meals(21.6%).

Clinical implications of the study : The findings of this study suggest the need for

early detection and intervention of eating disturbances and ideal body image

stereotypes. Additionally, an intervention and prevention program should be

implemented among adolescents and its effects should be examined. Research such

as the present study provides targets for early intervention which may protect some

at-risk individuals from progressing to significant eating pathology.

Research implications of this study suggest that future studies should focus on

obtaining larger samples of adolescents in order to further identify and establish

the presence of eating disordered behavior and associated pressures. As prior

research has suggested, when an eating disorder develops into a chronic condition,

the impairments and disabilities associated with the disorder have a major impact

on the patient’s life, which often persists long term.

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SUMMARY

Background: Epidemiological studies on eating disorders can have implications for

adolescents, health care providers and policymakers. Currently, there is paucity of

literature on eating disorders and perceived socio-cultural stress and ideal body image in

adolescents in developing countries such as India.

Objectives :(a)To estimate the prevalence of eating disorders in adolescents. (b)To study

perceived socio-cultural stress in adolescents. (c)To assess ideal body image in

adolescents. (d)To explore relation between perceived socio-cultural stress, ideal body

image and eating disorders in adolescents.

Methodology: Open label, cross sectional, questionnaire based survey conducted in high

school set up. Students in age ranges of adolescents between 10 to 19 years were

provided with the predesigned data collection form, informed consent documents and

self-rated scales. Eating disorder scale, Perceived Socio-cultural pressure scale and Ideal

Body Stereotype Scale (Revised) was distributed to the adolescents for self-rating.

Confidentiality and anonymous nature maintained. Sample size calculated of 1407.

Complete forms were statistically analyzed using

SPSS, regression analysis, t test and chi square tests. Institutional Ethics Committee

approval was obtained and informed written consent was taken.

Result: Out of 1407 respondents, 40.65% were male and 59.35% were female. There was

a significant association between gender & prevalence of Eating Disorder. Females were

significantly more likely to have an Eating Disorder as compared to males. The

prevalence of high level Eating Disorder is 3.6%. We also found that 16.7% felt

moderately fat, whereas 8.3% felt extremely fat all the time. It was seen that 36.6%

respondents resorted to binge eating. The frequency of Binge eating was found to be

significant with 65.6 % of the respondents confirming to have binged at least one day a

week. Nearly 20% admitted to binging for three or more days a week and 4.3%

mentioned that they resorted to binge eating for 6 or 7 days of the week. The study found

a significant association between Eating Disorders and Perceived Socio-cultural Pressure

and a positive correlation between Eating Disorder and BMI. We conclude that the

prevalence of high level eating disorder is 3.6%, perceived socio-cultural pressure is

4.3% and ideal body image stereotype is 36.3%. The findings of this study suggest the

need for early detection and intervention of eating disturbances and ideal body image

stereotypes. Additionally, an intervention and prevention program should be

implemented among adolescents and its effects should be examined.

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REFERENCES

1.Growing Through Adolescence.World Health Organization Europe and NHS Scotland 2004.

(http://ec.europa.eu/health/ph_projects/2004/action3/docs/2004_3_7_1_en.pdf)

2.Sancho C et al.Epidemiology of eating disorders: a two year follow up in an early adolescent

school population.Eur Child Adolesc Psychiatry.2007Dec;16(8):495-504.

3.Mammen P et al.Prevalence of eating disorders and psychiatric comorbidity among children

and adolescents.Indian Pediatr.2007May;44(5):357-9.

4. Chang YJ et al.Survey on eating disorder-related thoughts,behaviors, and their relationship

with food intake and nutritional status in female high school students in Taiwan.J Am Coll

Nutr.2011Feb;30(1):39-48.

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adolescents.Acta Biomed.2004Dec;75(3):179-84.

6.EricStice.Eating disorder scales.

(http://homepage.psy.utexas.edu/homepage/group/sticelab/scales/)

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Int J Eat Disord. 2004 Mar;35(2):198-203.

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psychological functioning: a comparison of African-American,Asian-American, and Caucasian

college women. Int J Eat Disord. 1995Sep;18(2):181

9.Semiz M, Kavakcı O, Yağız A, Yontar G, Kugu N. [The Prevalence of Eating

Disorders and Comorbid Psychiatric Disorders in the SivasProvince Neuropsychological

Assessment in Conversion Disorder].Turk PsikiyatriDerg. 2013 Fall;24(3):149-57.

10.Hoek, HW, van Hoeken D. Review of the prevalence and incidence of eating disorders.

International Journal of Eating Disorders, 2003 383-396

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prevalence study in a general population sample. Psychosomatic Medicine, 2003; 65, 701-708

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Meza A, Haro JM, Morosini P; ESEMeD-WMH Investigators. The epidemiology of eating

disorders in six European countries: results of the ESEMeD-WMH project. J Psychiatr Res. 2009

Sep;43(14):1125-32.

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disordered eating. Eat Behav. 2009 Apr;10(2):97-106.

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factors and culturally defined appearance concerns. JPsychosom Res. 2007 Feb;62(2):241-9.

15:Nouri M, et al. Media exposure, internalization of thethin ideal, and body dissatisfaction:

comparing Asian American and EuropeanAmerican college females.Body Image. 2011

Sep;8(4):366-72.

16: Mishra SK, Mukhopadhyay S. Eating and weight concerns among Sikkimeseadolescent girls

and their biocultural correlates: an exploratory study. PublicHealth Nutr. 2011 May;14(5):853-9.

17:Chugh R, Puri S. Affluent adolescent girls of Delhi: eating and weightconcerns. Br J Nutr.

2001 Oct;86(4):535-42.

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FertilWomens Med. 1998 May-Jun;43(3):133-8.

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A longitudinal grouping analysis. Behavior Therapy 1998;29(2):257–276.

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McKnight longitudinal risk factor study. American Journal of Psychiatry 2003;160(2):248–254.

22:Vohs KD, Voelz ZR, Pettit JW, Bardone AM, Katz J, Abramson LY, Heatherton TF, Joiner

TE. Perfectionism, body dissatisfaction, and self-esteem: An interactive model of bulimic

symptom development. Journal of Social and Clinical Psychology 2001;20(4):476–497

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24:Journal of Rural Community Psychology ,Volume E14 (2) , Amanda R. Alfano, Tamara L.

Hodges & Terrill Saxon ,Baylor University http://www.marshall.edu/jrcp/V14N2/14.2%20-

%20Alfano.pdf dated 10-10-2013, Eating Disordered Behavior in Rural High Schools: A

Descriptive Study of Adolescent Risk and Teacher Perceptions .

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APPENDICIS: APPENDIX 1

CASE STUDY FORM:

Date of filling questionnaire :____/____/______(dd/mm/yy)

Participant’s Name:_______________________________________

(To be torn off)

--------------------------------------------------------------------------------------------

DEMOGRAPHIC DATA

1. Age (years):_______

2. Sex : Male Female

3. Name of school: __________________________

4. Class: __________________________________

5. Religion:________________________________

6. Language spoken:________________________

7. Residential area:__________________________

8. Weight (in kgs):__________________________

9. Height (in ft.):____________________________

Researchers only

Date entered:_________

Initials:_________

Date verified:_________

Initials:_________

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APPENDIX 2

Informed Consent Form

This document is to certify that I, _______________________________

hereby freely agree to participate as a volunteer in an investigation (experiment,

program, study) as an authorized part of joint educational and research program

of MGM Medical College, Navi Mumbai and Indian Council of Medical

Research, Delhi.

The research project and my role in research project have been fully

explained to me by the investigators and I understand their explanation as well as

what will be expected of me by virtue of my participation in this research project.

A copy of procedures with my participation has been provided and discussion in

detail with me.

I have been given an opportunity to ask questions and all such

questions amend enquiries have been understood to my satisfaction.

I understand that I’m free to decline to answer any specific items or

questions in interviews or questionnaire.

I understand that participation in the research project is voluntary.

Although the person will ask my name, I understand that all enquiries

will be kept in strictest confidence.

______________ __________________________

Date Signature of Subject

I , the undersigned have defined and fully explained the investigation to the

above subject.

______________ ___________________________

Date Signature of Investigator

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APPENDIX 3

EATING DISORDER DIAGNOSTIC SCALE

EATING SCREEN

Please carefully complete all questions (Please encircle your responses)

Over the past 3 months… Not at all Slightly Moderately Extremely 1. Have you felt fat?. . . . . . . . . . . . . . . . . . . 0 1 2 3 4 5 6

2. Have you had a definite fear that you

might gain weight or become fat?. . . . . . . . . . 0 1 2 3 4 5 6

3. Has your weight influenced how you think

about (judge) yourself as a person?. . . . . . . . . 0 1 2 3 4 5 6

4. Has your shape influenced how you think

about (judge) yourself as a person?. . . . . . . . . 0 1 2 3 4 5 6 5. During the past 6 months have there been times when you felt you have eaten what other people would

regard as an unusually large amount of food (e.g., a quart of ice cream) given the circumstances? . . . . . . .

. YES NO

6. During the times when you ate an unusually large amount of food, did you experience a loss

of control (feel you couldn't stop eating or control what or how much you were eating)? . . . . . YES NO

7. How many DAYS per week on average over the past 6 MONTHS have you eaten an unusually large

amount of food and experienced a loss of control? 0 1 2 3 4 5 6 7

8. How many TIMES per week on average over the past 3 MONTHS have you eaten an unusually large

amount of food and experienced a loss of control? 0 1 2 3 4 5 6 7 8 9 10 11 12

13 14

During these episodes of overeating and loss of control did you… 9. Eat much more rapidly than normal?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO

10. Eat until you felt uncomfortably full?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . YES NO

11. Eat large amounts of food when you didn't feel physically hungry?. . . . . . . . . . . . . YES NO

12. Eat alone because you were embarrassed by how much you were eating?. . . . . . . . YES NO

13. Feel disgusted with yourself, depressed, or very guilty after overeating?. . . . . . . . . YES NO

14. Feel very upset about your uncontrollable overeating or resulting weight gain?. . . YES NO 15. How many times per week on average over the past 3 months have you made yourself vomit to

prevent weight gain or counteract the effects of eating? 0 1 2 3 4 5

6 7 8 9 10 11 12 13 14

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16. How many times per week on average over the past 3 months have you used laxatives or diuretics to

prevent weight gain or counteract the effects of eating? 0 1 2 3 4 5

6 7 8 9 10 11 12 13 14

17. How many times per week on average over the past 3 months have you fasted (skipped at least 2

meals in a row) to prevent weight gain or counteract the effects of eating? 0 1 2

3 4 5 6 7 8 9 10 11 12 13 14

18. How many times per week on average over the past 3 months have you engaged in excessive

exercise specifically to counteract the effects of overeating episodes? 0 1 2 3

4 5 6 7 8 9 10 11 12 13 14 19. How much do you weigh? If uncertain, please give your best estimate. lbs. 20. How tall are you? _Please specify in inches (5 ft.= 60 in.)___ in. 21. Over the past 3 months, how many menstrual periods have you missed? 0 1 2 3 n/a 22. Have you been taking birth control pills during the past 3 months?. . . . . . . . YES NO

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APPENDIX 4

PERCEIVED SOCIOCULTURAL PRESSURE SCALE

Perceived Sociocultural Pressure Scale

Please circle the response that best captures your own experience: none some a lot 1. I've felt pressure from my friends to lose weight. . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5

2. I've noticed a strong message from my friends to have a thin body. . . . . . . 1 2 3 4 5

3. I've felt pressure from my family to lose weight . . . . . . . . . . . . . . . . . . . . . 1 2 3 4 5

4. I've noticed a strong message from my family to have a thin body. . . . . . . 1 2 3 4 5

5. I've felt pressure from people I've dated to lose weight. . . . . . . . . . . . . . . . 1 2 3 4 5

6. I've noticed a strong message from people I've dated to have a thin body. . 1 2 3 4 5

7. I've felt pressure from the media (e.g., TV, magazines) to lose weight . . . . 1 2 3 4 5

8. I've noticed a strong message from the media to have a thin body. . . . . . . . 1 2 3 4 5

9. Family members tease me about my weight or body shape . . . . . . . . . . . . . 1 2 3 4 5

10. Kids at school tease me about my weight or body shape. . . . . . . . . . . . . . . 1 2 3 4 5

Scoring: (for researchers only)

Circled responses would be averaged to form a scale score

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APPENDIX 5

IDEAL BODY STEREOTYPE SCALE (REVISED)

Ideal Body Stereotype Scale – revised

How much do you agree with these statements: strongly disagree neutral agree strongly

disagree agree

1. Slender women are more attractive. . . . . . . . . . . . . . . . 1 2 3 4 5

2. Women who are in shape are more attractive. . . . . . . . 1 2 3 4 5

3. Tall women are more attractive . . . . . . . . . . . . . . . . . . 1 2 3 4 5

4. Women with toned (lean) bodies are more attractive. . 1 2 3 4 5

5. Shapely women are more attractive . . . . . . . . . . . . . . . 1 2 3 4 5

6. Women with long legs are more attractive. . . . . . . . . . 1 2 3 4 5

Scoring: (for researchers only)

Circled responses would be averaged to form a scale score.