Eating disorders among Moroccan medical students: cognition and behavior



Dear Readers,

Please find below a study that was published in Dove Press. We share this study for research and information purpose only.



Eating disorders among Moroccan

medical students: cognition and




Introduction and aim: Eating disorders (EDs) are complex, multifactorial diseases linked to biological, developmental, psychological, and sociocultural factors. Medical students are among subjects at high risk of EDs. The aim of the present investigation was to evaluate EDs among 710 Moroccan medical students with a focus on cognition and behavior related to EDs.

Methods: Sociodemographic, economic, and clinical data were collected. Validated questionnaires, such as the SCOFF (Sick, Control, One Stone, Fat, Food) questionnaire and the Eating Disorder Inventory 2 (EDI2), were administered.

Results: The male:female ratio was 0.53, mean age was 21±2 years, 11.1% of participants were underweight, 13.4% were overweight, and 1.8% were obese. A middle socioeconomic level was found in 84.9% of cases. The prevalence of EDs in students was 32.8% (37.6% among females and 23.7% among males) and that of weight-control behaviors 18.5%. Increased body-mass
index values were significantly associated with dieting (P<0.001), fasting (P=0.044), and the use of appetite suppressants (P=0.037).

Conclusion: It appears that the impact of EDs is high, affecting a third of medical students, with significant use of harmful weight-control behaviors. We also found that dimensions of bulimia, perfectionism, body dissatisfaction, and ineffectiveness, parts of the core of EDs, were found in future medical practitioners.

Keywords: eating disorders, cultural factors, medical students, screening, body image, body mass index.


Eating disorders (EDs) are complex, multifactorial diseases linked to a variety of parameters, including biological, developmental, psychological, and sociocultural factors,1–6 among others. While initially it was thought that only white women from wealthy contexts could be affected by EDs, due to the cultural impact on the perception of health and the self in relation to the physical body (EDs as “culture-bounded” disorders),7 EDs have been reported and described also in non-Western populations, including Morocco.8,9 In these settings, especially young adults and teenagers seem to attribute particular importance to their physical appearance, being influenced by
the Western models of body shape and slimness.10 Various factors contribute to the adoption of such standards: in particular, mass media and new information and communication technologies play a major role, giving distorted and potentially misleading messages concerning nutrition, encouraging on the one hand excessive food uptake and consumption, while on the other promoting the ideal of a slim body typical of media stars and celebrities.10

Correspondence: Nicola Luigi Bragazzi Department of Health Sciences (DISSAL), School of Public Health, University of Genoa, 1 Via Antonio Pastore, Genoa 16132, Italy Tel +39 010 353 7664 Email

Psychology Research and Behavior Management 2019:12 submit your manuscript | Azzouzi et al

These contradictory messages mostly target women more than men, although this difference has weakened over time. Subthreshold/subclinical and clinical EDs have an estimated lifetime prevalence varying between 0.21% and 2.22%, depending on the diagnostic criteria used and type of ED.11 Many studies have documented increasing inappropriate attitudes and behaviors toward eating and body image among young non-Western women, with the burden
expected to rise in the next few decades in low- and middle income countries.12

Medical students are among those at high risk of developing EDs.13

According to a recent systematic review of the literature and meta-analysis,13 which pooled 19 cross-sectional studies (5,722 participants from Brazil, China, India, Malaysia, Pakistan, Turkey, UK, and the US), the overall prevalence of ED risk was 10.4% (95% CI 7.8%–13.0%).

In more detail, prevalence estimates between studies ranged from 2.2% (China) to 29.1% (India). Several factors may explain such high rates of EDs among medical students, such as being adolescents/young adults, academic stress, workload, and exposure to diseases and death.13 However, little is known about the impact of EDs on future medical practitioners in Morocco. As such, the aim of the present investigation was to evaluate EDs among medical students with a focus on ED-related cognition and behavior and associated determinants.



Participants and procedures


This study was conducted between January and April 2013. Recruitment was done through convenience sampling of medical students from the medical faculty and the University Hospital of Fez (Morocco). The study included medical students from the first to the sixth year. We excluded from the study students who did not agree to take part in the investigation, partially filled in the questionnaire (<80% of items), and who were absent at the time of the research.

Data were collected anonymously, and thorough explanations were provided to each student on the purpose of the study, definition of EDs, and their classification according to the Diagnostic and Statistical Manual of Mental Disorders IV – text revision. Each participant signed a written, informed consent. The present investigation was carried out according to the 1964 Declaration of Helsinki and its subsequent amendments. Ethical clearance
for the protocol study was obtained from Sidi Mohammed Ben Abdellah University of Fez, Fez, Morocco. A pilot feasibility study was conducted with 20 students to test the study protocol.

Data collection Sociodemographic and economic data These data included age, sex, marital status, and number of children (if any), monthly income of the family or household of the subject, and educational level. These variables were clustered together, and based on the results of the clustering analysis, socioeconomic level was stratified into low, middle, and high. Clinical data
These data included clinical, personal, and familial history of subjects. We also estimated body-mass index (BMI) values calculated by weight/(height)2

Weight was expressed in kilograms and height in meters. Subjects were stratified accordingly into underweight, normal weight, overweight, and obese subjects, according to the World Health Organization’s interpretation of BMI thresholds.

Weight-control behavior

We investigated restrictive behaviors (including diet, fasting, and use of appetite suppressants), and purgative behaviors (including vomiting and use of laxatives and diuretics).

SCOFF questionnaire

The SCOFF (sick, control, one stone [6.5 kg], fat, food) questionnaire is a highly accurate instrument characterized by sound psychometric properties. It has been translated and validated in French, and this version is recommended by the French National Authority for Health (Haute Autorité de Santé). SCOFF is considered a simple, effective ED-screening tool, especially when used in student populations. The French version of the questionnaire is characterized by sensitivity of 94.6%, specificity of 94.8%, positive predictive value of 65%,
and negative predictive value of 99%.14 SCOFF is an acronym of five items of the questionnaire: intentional vomiting (“Do you make yourself sick because you feel uncomfortably full?”), loss of control over diet (“Do you worry that you have lost control over how much you eat?), weight loss (“Have you
recently lost more than 1 st [6.5 kg] in a 3-month period?”), body dissatisfaction (“Do you believe yourself to be fat when others say you are too thin?”), and intrusive thoughts about food (“Would you say that food dominates your life?”). Possible answers to the questions are dichotomous (yes/no, 2-point Likert scale), and two positive responses are highly predictive
of EDs. In the present study, subjects with a positive SCOFF score were defined as being at risk of EDs.


Eating Disorder Inventory The Eating Disorder Inventory 2 (EDI2) was developed by Garner et al15 within a conceptual framework that assumes
Psychology Research and Behavior Management 2019:12

EDI2 is a comprehensive clinical assessment of both cognitive and behavioral profiles of subjects concerning eating behaviors and associated conduct. The validity of this inventory was found to be excellent, because all scales were able to differentiate subjects with EDs from control subjects.15


The questionnaire comprises 91 items, and explores eleven dimensions: namely, drive for thinness, bulimia, body dissatisfaction, ineffectiveness, perfectionism, interpersonal distrust, interoceptive awareness, maturity fears, impulse regulation, asceticism, and social insecurity. In the present study, given the aim of our investigation, we decided to focus on four:

1. bulimia subscale (EDI-B), which allows exploration of cognition and behavior related to uncontrolled alimentation

2. ineffectiveness subscale (EDI-I), which highlights low self-esteem and measures feelings of personal efficacy, solitude, inadequacy, and lack of control over one’s own life

3. perfectionism subscale (EDI-P), which allows exploration of perfectionism traits related to EDs

4. body-dissatisfaction subscale (EDI-BD), which measures dissatisfaction with the overall silhouette and specific areas of the body that constitute a concern for subjects with disturbed eating behavior Answers were rated on a scale of 6 points and then calculated on a 4-point scale: each item was evaluated in terms of frequency of behavior or thought, from “Always” to “Never”. Statistical analysis Data were analyzed using SPSS version 13.0. Qualitative
variables are expressed as numbers and percentages, and quantitative variables as average ± SD or median and interquartile range. The nonparametric Mann–Whitney test was used for comparisons of abnormally distributed quantitative variables, and Pearson’s c2 test or Fisher’s exact test carried out to compare qualitative variables. The threshold of significance was set at P<0.05.



Characteristics of subjects

Among a total of 730 questionnaires submitted, 710 were retained (97.3%). Only 20 questionnaires were excluded because they had been partially filled in. The sex ratio (male:female) was 0.53. The mean age was 21 (range: 16–31)
years and mean BMI 22.9 kg/m2 , with 11.1% of cases being underweight, 13.4% overweight, and 1.8% obese. A medium socioeconomic level was found in most students (84.9%; Table 1).

EDs and weight-control behavior among medical students

The prevalence of ED-related behavior and practices in students was 32.8% (37.6% among females, 23.7% among males). Prevalence was higher among females (P<0.001).

Weight-control behavior was found in 18.5% of students: 6.5% declared being on a diet, 7% used fasting, 3% used appetite suppressants, and 1.7% induced vomiting, besides laxatives and diuretics, which were found to a lesser extent (Table 2).

We could not find significant differences between males and females in terms of weight-control behavior. While socioeconomic level did not influence such practices, increased BMI was significantly associated with dieting (P<0.001), fasting (P=0.044), and use of appetite suppressants (P=0.037; Table 2).


Weight-control behavior was significantly (P<0.001) higher among subjects scoring higher for EDs (34.2%) vs those scoring lower (11.9%). On univariate analysis, dieting (P<0.001), fasting (P<0.001), induced vomiting (P=0.006), and appetite suppressants (P=0.001) were associated with these practices.

On multivariate analysis adjusting for confounding factors, only dieting (OR 2.18, P=0.029), fasting (OR 3.23, P<0.001), induced vomiting (OR 4.56, P=0.030), and appetite suppressants (OR 3.65, P=0.017) were associated with EDs (Table 3).


Table 1 Sample characteristics

Characteristics Age (years), mean ± SD 21.27±2.02 Sex, n (%) Male Female
248 (34.9) 462 (65.1) Level of study, n (%) Year 1 Year 2 Year 3 Year 4 Year 5
Year 6 197 (27.7) 92 (13) 137 (19.3) 180 (25.4) 83 (11.7) 21 (3)

Socioeconomic level, n (%) Low Middle High Not specified 24 (3.4) 603 (84.9) 62 (8.7) 21 (3) Body-mass index, n (%) Underweight Normal Overweight
Obese Not specified 79 (11.1) 465 (65.5) 95 (13.4) 13 (1.8) 58 (8.2)

Table 2 Association of weight-control behavior with sex, socioeconomic level, and body-mass index Sex Socioeconomic level Body-mass index Male, n (%) Female, n (%) Total, n (%) P Low, n (%) Middle, n (%) High, n (%) P Underweight, n (%) Normal, n (%) Overweight, n (%) Obese, n (%) P Dieting 13 (5.3) 33 (7.2) 46 (6.5) 0.209 1 (4.2) 36 (6) 7 (11.3) 0.21 1 (1.3) 20 (4.3) 12 (12.6) 5 (38.5) <0.001 Fasting 14 (5.6) 36 (7.8) 50 (7) 0.181 2 (8.3) 43 (7.1) 4 (6.5) 0.877 2 (2.5) 27 (5.8) 12 (12.6) 0 0.044

Vomiting 2 (0.8) 10 (2.2) 12 (1.7) 0.15 0 10 (1.7) 1 (1.6) 0.999 0 9 (1.9) 3 (3.2) 0 0.432

Laxatives 0 5 (1.1) 5 (0.7) 0.116 0 4 (0.7) 1 (1.60) 0.488 1 (1.3) 3 (0.6) 1 (1.1) 0 0.471

Appetite suppressant 6 (2.4) 15 (3.2) 21 (3) 0.357 2 (8.3) 17 (2.8) 1 (1.6) 0.236 0 12 (2.6) 7 (7.4) 0 0.037

Diuretics 1 (0.5) 4 (1) 5 (0.8) 0.419 0 4 (0.8) 0 0.999 0 2 (0.5) 1 (1.1) 1 (7.7) 0.097

Table 3 Evaluation of weight-control behavior by univariate and multivariate analyses SCOFF Univariate analysis Multivariate analysis P OR 95% CI P-value Adjusted OR 95% CI Negative, n (%) Positive, n (%) Inferior Superior Inferior

Superior Dieting 19 (4) 27 (11.7) <0.001 3.16 1.719 5.819 0.029 2.18 1.085 4.398

Fasting 17 (3.6) 33 (14.3) <0.001 4.48 2.438 8.233 <0.001 3.23 1.696 6.163

Vomiting 3 (0.6) 9 (3.9) 0.006 6.36 1.706 23.740 0.030 4.56 1.154 18.008

Laxatives 1 (0.2) 4 (1.7) 0.059 8.33 0.926 74.997 0.337 3.17 0.301 33.440

Appetite suppressant 6 (1.3) 15 (6.5) 0.001 5.42 2.073 14.152 0.017 3.65 1.266 10.555

Diuretics 2 (0.5) 3 (1.5) 0.234 2.98 0.494 17.963 0.914 1.11 0.156 7.979

Abbreviation: SCOFF, sick, control, one stone (6.5 kg), fat, food.

EDI2 for medical students Scores on the EDI-B (P<0.001), EDI-BD (P<0.001), EDI-I (P<0.001), and EDI-P (P=0.003) subscales were higher in subjects with ED-related behavior (Table 4). Male students showed no significant difference in comparison with female students on the EDI-B or EDI-BD. However, EDI-I (P=0.026) and EDI-P (P=0.001) scores were significantly higher among female students. Socioeconomic level was not associated with any of the EDI subscales.

Increased BMI was associated with the EDI-B (P=0.001) and EDI-BD (P<0.001) subscales, but not significantly with EDI-I or EDI-P.


The goal of this work was to investigate the ED-related cognitive–behavioral background among medical students. We found that ED-associated practices were quite widespread (affecting approximately a third of the sample), with 18.5% of the students declaring that they used weight-control strategies
that might threaten their health. While the extant scholarly literature is generally focused on females, we included also male subjects. We found a nonnegligible prevalence rate among males (23.7%), without significant difference regarding weight-control strategies.

Our investigation has demonstrated that the use of weightcontrol behavior, such as diets, fasting, self-induced vomiting, and appetite suppressants, is quite widespread among medical students. Increase in BMI was significantly related to restrictive weight-control strategies. In the literature, few studies have assessed ED prevalence among students.

A Moroccan study carried out among high school students found a prevalence of 0.8% for bulimic syndrome,8 whereas another study conducted among students from four Moroccan university faculties found a prevalence of 4% for bulimic syndrome and 63.8% for unusual eating behaviors, with a
clear predominance among medical students.9

A Tunisian survey found that 10% of medical students were adopting bulimic behaviors.16

Literature data confirmed a close relationship between body image and eating behavior. Self-critical body image is part of the clinical picture of patients with subthreshold/subclinical forms and diagnostic criteria of anorexia nervosa.

Studies have shown that 25%–40% of students are concerned about their body image and wish to control their weight and food intake.17–19 Our results are similar to these findings. There was no significant difference between sexes, although it has been reported that girls tend to have more body dissatisfaction than boys and express more satisfaction when they are underweight compared to normal-weight and overweight subjects.17–19.

Table 4 Evaluation of the EDI2 subscales by ED-related practices, sex, socioeconomic level, and body-mass index Subscale SCOFF Sex Socioeconomic level Body mass index Positive, Md (IQR) Negative, Md (IQR) P Male, Md (IQR) Female, Md (IQR) P Low, Md (IQR) Middle, Md (IQR)
High, Md (IQR) P Underweight, Md (IQR) Normal, Md (IQR) Overweight,
Md (IQR) Obese, Md (IQR)

EDI2-B 0 (0–2) 1 (0–4) <0.001 0 (0–2) 0 (0–2) 0.387 1 (0–2) 0 (0–2) 0.5 (0–2) 0.865 0 (0–2) 0 (0–2) 1 (0–4.25) 4 (0.75–6) 0.001

EDI2-BD 2 (0–6) 7.5 (2.25–13) <0.001 4 (1–8.5) 4 (0–10) 0.831 3 (0.25–9.75) 4 (0–9) 5 (0–11.75) 0.418 1 (0–5) 3 (0–7) 9 (4–14) 20 (14–24) <0.001

EDI2-I 1 (0–3) 2 (0–5) <0.001 1 (0–3) 2 (0–5) 0.026 1 (0–3.75) 1 (0–4) 1 (0–3) 0.943 2 (0–5) 1 (0–4) 2 (0–4) 3 (1–6) 0.302

EDI2-P 9 (5.5–12) 10 (7–13) 0.003 8 (5–11) 10 (6–13) 0.001 7 (3.75–12.25) 9 (6–12) 8.5 (6–12) 0.294 9 (7–13) 9 (6–12) 9 (6–12) 9 (6–11) 0.55

Abbreviations: EDI 2, Eating Disorder Inventory 2; Md, median; B, bulimia; BD, body dissatisfaction; I, ineffectiveness; IQR, interquartile range; P, perfectionism; SCOFF, Sick, Control, One Stone, Fat, Food questionnaire.

Male subjects demonstrate that body dissatisfaction is linked to overweight and obesity, and not to leanness.20,21

Studies have underlined that subjects using weight-control strategies are more dissatisfied with their bodies than other subjects.22,23 On the other hand, body dissatisfaction and BMI predict EDs in both sexes.20,21 Body perfectionism, either selforiented or socially influenced, is indeed connected with purgative or restrictive behavior. On the other hand, it is necessary
to specify that perfectionism may not be systematically related to pathological behaviors and EDs, and as such should be differentiated between adaptive and maladaptive. Dysfunctional perfectionism, together with anxious–depressive symptoms in medical students, can be associated with the development
of EDs, leading to feelings of ineffectiveness.24,25 Furthermore, classically EDs patients come from wealthy backgrounds and settings.1

However, in our investigation socioeconomic level was not a predictor of EDs. This could reflect cultural differences between Morocco and Western countries.

Further studies should replicate our findings with a focus on the role of mass media and information and communication technologies in a more globalized and interconnected society.

Our investigation has some strengths, such as the sample size. However, our work presents also several limitations, including the single-center study design and the use of some (and not all) subscales of the EDI2. Future studies should
explore ED-related practices and behavior among other future health actors, such as pharmacists or nurses.



We found a risk of EDs reaching a third of medical students, with significant use of harmful weight-control behavior. We also found that the dimensions of bulimia, perfectionism, body dissatisfaction, and ineffectiveness, parts of the core of EDs, were present in future practitioners. However, due to the aforementioned shortcomings, further research in the field is needed, especially among Moroccan individuals.

A better understanding of certain features of EDs found in nonclinical populations would make possible a high level of specificity and thus efficiency in the development of prevention and screening programs and even treatment.



The authors report no conflicts of interest in this work.


1. Culbert KM, Racine SE, Klump KL. Research review: what we have
learned about the causes of eating disorders – a synthesis of sociocultural, psychological, and biological research. J Child Psychol Psychiatr.

2. Schmidt U. Aetiology of eating disorders in the 21(st) century: new answers
to old questions. Eur Child Adolesc Psychiatry. 2003;12(Suppl 1):I30–I37.

3. Culbert KM, Racine SE, Klump KL. Hormonal factors and disturbances
in eating disorders. Curr Psychiatry Rep. 2016;18(7):65.

4. Treasure J, Zipfel S, Micali N, et al. Anorexia nervosa. Nat Rev Dis
Primers. 2015;7:15074.

5. Stice E, Gau JM, Rohde P, Shaw H. Risk factors that predict future
onset of each DSM-5 eating disorder: predictive specificity in high-risk
adolescent females. J Abnorm Psychol. 2017;126(1):38–51.

6. Batnitzky AK. Cultural constructions of “obesity”: understanding body size, social class and gender in Morocco. Health Place. 2011;17(1):345–352.

7. Keel PK, Klump KL. Are eating disorders culture-bound syndromes?
Implications for conceptualizing their etiology. Psychol Bull. 2003;129(5):747–769.

8. Ghazal N, Agoub M, Moussaoui D, Battas O. Fréquence et facteurs de risque du jeu pathologique chez une population de joueurs à Casablanca [Prevalence of bulimia among secondary school students in Casablanca]. Encephale. 2001;27(4):338–342. French.

9. Manoudi F, Adali L, Asri F, Tazi I. Epidemiologic approach of bulimia and unusual eating behaviour in the University of Marrakech (Morocco). Annales Médico-Psychologiques. 2010;168(9):694–697.

10. Yamamiya Y, Cash TF, Melnyk SE, Posavac HD, Posavac SS. Women’s exposure to thin-and-beautiful media images: body image effects of media-ideal internalization and impact-reduction interventions. Body Image. 2005;2(1):74–80.

11. Qian J, Hu Q, Wan Y, et al. Prevalence of eating disorders in the general population: a systematic review. Shanghai Arch Psychiatry. 2013;25(4):212–223.

12. Erskine HE, Whiteford HA, Pike KM. The global burden of eating disorders. Curr Opin Psychiatry. 2016;29(6):346–353.

13. Jahrami H, Sater M, Abdulla A, Faris MA, AlAnsari A. Eating disorders
risk among medical students: a global systematic review and metaanalysis. Eat Weight Disord. Epub 2018 May 21.

14. Garcia FD, Grigioni S, Chelali S, Meyrignac G, Thibaut F, Dechelotte P. Validation of the French version of SCOFF questionnaire for screening of eating disorders among adults. World J Biol Psychiatry. 2010;11(7):888–893.

15. Garner DM, Olmstead MP, Polivy J. Development and validation of a
multidimensional eating disorder inventory for anorexia nervosa and bulimia. Int J Eat Disord. 1983;2(2):15–34.

16. Abla-Houissa SBEN, Khaloui M, Saada B, et al. Conduites boulimiques
Chez les étudiants en médecine [Bulimia among medical students].
Ann Tun Psychiatr. 1997;2:104–106. French.

17. Schwitzer AM, Rodriguez LE. Understanding and responding to eating
disorders among college women during the first-college year. Journal
of The First Year Experience. 2002;14(1):41–63.

18. Cooley E, Toray T. Body image and personality predictors of eating disorder
symptoms during the College years. Int J Eat Disord. 2001;30(1):28–36.

19. Haberman S, Luffey D. Weighing in college students’ diet and exercise
behaviors. J Am Coll Health. 1998;46(4):189–191.

20. Presnell K, Bearman SK, Stice E. Risk factors for body dissatisfaction
in adolescent boys and girls: a prospective study. Int J Eat Disord.

21. Austin SB, Haines J, Veugelers PJ. Body satisfaction and body weight:
gender differences and sociodemographic determinants. BMC Public
Health. 2009;9(1):313.

22. Mäkinen M, Puukko-Viertomies L-R, Lindberg N, Siimes MA, Aalberg
V. Body dissatisfaction and body mass in girls and boys transitioning
from early to mid-adolescence: additional role of self-esteem and eating
habits. BMC Psychiatry. 2012;12(1):1–8.

23. Stice E, Whitenton K. Risk factors for body dissatisfaction in adolescent
girls: a longitudinal investigation. Dev Psychol. 2002;38(5):669–678.

24. Enns MW, Cox BJ, Sareen J, Freeman P. Adaptive and maladaptive
perfectionism in medical students: a longitudinal investigation. Med
Educ. 2001;35(11):1034–1042.

25. Wade TD, Wilksch SM, Paxton SJ, Byrne SM, Austin SB. How perfectionism and ineffectiveness influence growth of eating disorder risk in
young adolescent girls. Behav Res Ther. 2015;66:56–63.




About Author

Islam and Eating Disorders founded in 2012 – run by Maha Khan, the blog creates awareness of Eating Disorders in the Muslim world, offers information and support for sufferers and their loved ones.

Leave A Reply