In today’s health-conscious culture, the terms “health” and “fitness” have become iconic, yet dieting may be hazardous if it develops into an eating disorder (ED). In recent years, psychiatry has acquired a better understanding of the nature of EDs, and has appropriately extended the definition to cover a wide range of issues such as anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and avoidant/restrictive food intake disorder, and they have been included in the DSM-5 (2013), the Diagnostic and
Statistical Manual of Mental Disorders (Sawyer et al., 2016).
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Eating disorders among Majmaah
University Students, Saudi Arabia
Fahad Mohammad Alfhaid1, Abdulaziz Saqer A Alanazi2, Mohanned Mohammed R Alraddadi2 , Afrah Saleh M Alrashidi2 , Layla Shoqair O Alrashedi2 , Anas Mohammed Ali Alothaim2 , Mohammed Abdullah M Alqarni2 , Mubarak Ali M Almanaah2
ABSTRACT
Background: Eating disorders (ED) are one of the most prevalent mental issues
that today’s teenagers confront, characterized by a distorted attitude toward
weight and form, as well as a distorted sense of body shape. The purpose of
this study is to identify the prevalence of eating disorders in students at
Majmaah University in the KSA and the variables that affect them.
Methodology: Majmaah University students were selected for this cross-
sectional study. Subjects will be asked to complete a previously tested questionnaire about socioeconomic status, eating habits, Eating Attitudes Test
26 (EAT 26), height, weight, and BMI. Results: Of the 516 students, 82.2% of
the survey participants are between the ages of 20 and 30. 62.8% were male
and 37.2% were male. 28.6% of the participating students were at high risk of
ED and 71.4% were at low risk of ED. There was a significant correlation
between male gender (P = 0.001), BMI (P = 0.02), and risk of ED due to current
smoking status (P = 0.001). Conclusion: In summary, the ED risk reported
among college students in this study is below the reported figures, but
relatively high compared to the global figures. This study highlights an
underestimated health problem among Saudi Arabian college students.
Keywords: eating disorders, mental issues, teenagers, Majmaah University
Students, Saudi Arabia
1. INTRODUCTION
In today’s health-conscious culture, the terms “health” and “fitness” have
become iconic, yet dieting may be hazardous if it develops into an eating
disorder (ED). In recent years, psychiatry has acquired a better understanding
of the nature of EDs, and has appropriately extended the definition to cover a
wide range of issues such as anorexia nervosa (AN), bulimia nervosa (BN),
binge eating disorder (BED), and avoidant/restrictive food intake disorder,
and they have been included in the DSM-5 (2013), the Diagnostic and
Statistical Manual of Mental Disorders (Sawyer et al., 2016).
Eating disorders Medical Science 25(117), November, 2021
To Cite:
Alanazi ASA, Alraddadi MMR, Alrashidi ASM, Alrashedi LSO, Alothaim AMA, Alqarni MAM, Almanaah MAM. Eating disorders among Majmaah University Students, Saudi Arabia. Medical Science, 2021, 25(117), 3007-3016
Author Affiliation:
1Associate professor of family medicine, Majmaah University, Saudi
Arabia; Email: f.alfhaid@mu.edu.sa
2Medical intern, Faculty of Medicine, Majmaah University, Majmaah
City, Saudi Arabia
Peer-Review History
Received: 14 October 2021
Reviewed & Revised: 16/October/2021 to 11/November/2021
Accepted: 12 November 2021
Published: November 2021
Peer-review Method
External peer-review was done through double-blind method.
Eating Disorders are very long-term, sometimes lasting years, and they take a huge toll on individuals who suffer from them. Eating disorders impair
interpersonal, vocational, and academic performance, as well as raising the likelihood of comorbid issues including anxiety, depression, and suicide (Sawyer et al., 2016). Eating disorders are most common in adolescence, with a frequency of 13.5% among women and 3.6% among males, as reported in one major study conducted on college students (Eisenberg et al., 2011).
Unfortunately, little percentage of teenagers and young people get therapy for these issues.
AN is defined as a limitation of caloric intake that results in a substantially low body weight. A patient may also have a concern of gaining weight and/or a problem with how they view their bodies based on the age, sex, and physical health (American Psychiatric Association, 2013). AN affects around 1% of American women once in their survives (Hudson et al., 2007). In teenage
females, it is the third most prevalent chronic illness. When treating afflicted people, doctors typically differentiate between two subtypes: restricting and purging. Purging may take the form of vomiting, although it is communal presented by excessive and/or obsessive activity or diuretic abuse. Because of its physical symptoms, this psychiatric illness poses a significant risk of serious and long-term bodily harm. Electrolyte imbalances and gastrointestinal damage, which often includes the use of laxatives, are prevalent.
Patients with AN; are also more prone to develop osteoporosis, cardiovascular disease, infertility, and a variety of other health problems (Meczekalski et al., 2013). BN is defined by repeated bouts of binge eating, in which a person eats an excessive quantity of food in a short period of time, followed by periods of purging, according to the DSM-5. This purging is an effort loss the calories consumed during the binge, which might otherwise lead to weight gain. Vomiting, abuse of laxatives (or other diuretics), fasting, and extreme exercise are all examples of purging behaviors. This pattern must recur, minimumone time per week for three months on average for a clinical diagnosis to be made (American Psychiatric Association, 2013). BN affects around 1.5 percent of American women at least once (Hudson et al., 2007). Because persistent vomiting may cause severe damage to the oral cavity and esophagus owing to the acidic nature of vomit, healing and therapy of the body are essential components of the recovery process, just as they are in AN.
BED is a kind of ED characterized by repeated and persistent bouts of binge eating, which include eating more quickly than usual, eating huge quantities of food without hunger, and feeling ashamed or sad after overeating. Significant concern, about binge eating and the lack of purging behaviors, as well as the need; that the pattern recursonce per week for three months, are all criteria
for diagnosis. The most prevalent eating disorder in the United States is BED as 3.5% of adult women, 2% of adult males, and up to 1.6% of adolescents are affected (Swanson et al., 2011). University students have different lifestyles. Women at university are more liable to disordered eating, and the risk rises for those who use substances (Perryman et al., 2018).
Anorexia nervosa (AN) has been recorded in the literature since the seventeenth century, with the name “anorexia nervosa” being coined by Queen Victoria’s personal physician, Sir William Gull, in 1874 (Niedzielski et al., 2017). The word is Greek in origin and means “nervous lack of appetite.” Even in the early instances, it was clear that the victims were mostly adolescent females (Palmer et al., 1952). According to Freudian theory, the cause of this conduct was not just a lack of appetite, but rather a combination of factors including the symbolic character of eating (excess, gluttony, guilt, etc.), personality qualities, and components of puberty and sexuality (Bemporad et al., 1992).
Eating disorders have been recorded since 1347–1380 AD, when a girle suffered from a severe type of holy fasting. Her illness is today considered to be the earliest example of AN, but it differs from contemporary AN due to the religious motivations (Galassi et al., 2018). Professionals started to blame parents for EDs in the 1900s, and in certain instances, a “parentectomy” was done; the patients were still mostly adolescent females. The girls were removed from their parents in this operation in the aim of starting the
healing process. AN, BN, and BED are more common than ever before.
According to the National Eating Disorder Association, about 30 million individuals in the United States suffer from eating disorders, with an annual worldwide number of around 70,000 (Hudson et al., 2007; Le Grange et al., 2012).
Many theories think that Westernization is to blame for the increasing incidence of disordered eating since it emphasizes thinness and promotes slenderness (Nasser, 1986; Rauof et al., 2015). In many Arabian nations, significant cross-cultural social shifts have happened in recent decades, and the younger generation’s views and actions have adopted western ideals (Jalali-Farahani et al., 2015; Bas et al., 2004; Latzer et al., 2014). Nonetheless, it has been shown that traditional Arab people regard plumpness as a
symbol of attractiveness, fecundity, and good health (Abdollahi & Mann, 2001). As a result, teenage females are more likely to develop eating disorders as a result of a rising conflict between Western ideals and Arabic customs, and this cultural clash between a traditional culture and an accepted Westernized society (Latzer et al., 2014).
Nonclinical research in many Arab nations have recently shown the significant prevalence of aberrant eating attitudes and practices (Fath Al Alim et al., 2012; Al Sabbah, 2016; Kazim et al., 2017; Bano et al., 2013). Because a disordered eating attitude may evolve into an eating disorder with serious repercussions, early detection is critical to reducing the difficulties of eating disorders
that occur throughout these periods of growth and development (D’Souza et al., 2005). Despite the significant occurrence of ED, there is little research on the subject among university students in Arab nations, especially Saudi Arabia. As a result, in light of the severity of the issue on the one hand, and the lack of information about eating habits on the other, the current research will be
conducted to study EDs among the Majmaah University students, Saudi Arabia.
The objective of this work is to estimate the prevalence and risk influences of eating disorders among university students in
Majmaah University, KSA. The study also aims to find out the prevalence of EDs among Majmaah University students, determine if
there is a link between weight status, eating behaviors, and academic performance in the research population, and to determine if
there are any links between a variety of socio-environmental variables and ED in a group of participating students.
2. METHODOLOGY
Study design and setting
Analytical cross sectional study, in Majmaah University, KSA.
Study duration
This study was conducted from 1st June 2021 to 31st September, 2021.
Study population
Inclusion criteria
Majmaah University students aged 18 years of more, able to read and answer the data collection tool, and willing to participate and
sign the informed consent form.
Exclusion criteria
Students with chronic illnesses, pregnancy, as well as pathological obesity
Sampling
The sample size was planned using the Cochran’s Formula.
Data collection tool
A self-administered questionnaire will be used for data collection for this study. There are two portions to the questionnaire;
Portion (A), which gathered socio-demographic information such as education level, study field, study year, academic performance
last year, nationality, family size, home type, parent’s educational and job, pubertal and health status, height (cm), weight (kg), and
eating habits. Portion (B) The Eating Attitudes Test (EAT-26), which consists of 26 items was used to measureED attitudes. Each
statement is graded on six-points from “always” to “never.” ‘Always’ received 3 points, ‘usually’ received 2 points, ‘often’ received 1
point, and ‘sometimes’, ‘rarely’, and ‘never’ received 0 points. Only the 26th item was scored in the other direction, with 0 points
awarded for ‘always, usually, and frequently,’ and 1, 2, and 3 points awarded for ‘sometimes, seldom, and never,’ correspondingly.
The answers to all 26 questions were added up at the conclusion, and those who scored precisely at or over the cutoff score of 20
were deemed to be at risk of disordered eating attitudes and practices.
Dieting, bulimia and food obsession, and oral control are the three EAT-26 variables, according to (Garner et al., 1983). Dieting,
which entails limiting high-calorie meals and obsessing over body image/shape, has 13 elements in his factor; bulimia and food
obsession, on the other hand, includes thoughts about food, binge, and self-induced vomiting. This dimension contained 6
questions such as “I’ve gone on eating binges that I don’t think I’ll be able to stop,” “I feel like food dominates my life,” and so on;
and oral control includes 7 items that demonstrate the capacity to regulate food intake and professed stress commencing others to
increase weightiness.
EAT 26 has a great internal consistency (α = 0.90) and good criterion-related validity, which means it is very accurate in
categorizing eating disordered and non-eating disordered people. (Al-Subaie et al., 1996), from Saudi Arabia also validated the
EAT-26.
Data collection technique
The researchers distributed the questionnaire online as the questionnaire was distributed online on social media sites (WhatsApp-
Twitter) to be filled out personally. The questionnaire will have a brief introduction explaining the nature of the research and
confidentiality of the information that given to participants.
Data management
All data was entered, prepared examined and analyzed by means of SPSS 23, consumingthe proper statistical procedures for accounting and analysis. P value<0.05 was measured for statistical significance.
Ethical considerations
Approval was obtained by the Research Ethics Committee of Majmaah University with letter number (MUREC-August.4/COM- 2021/38-3). Data was anonymous for patient confidentiality. Use of these anonymous data in this research project was reviewed and approved by the research ethics committee. The collected data was kept safely in a password protected computer.
3. RESULTS
Table 1 illustrates sociodemographic characters of participants. Among 516 participants, 62.8% were males and 37.2% females.
92.6% were single. 24.4% of participants working. 13.6% were smokers. 5.8% were underweight, 23.3% overweight, and 13.9% were
obese. Table (2and 3) illustrates responds and score for EAT-26 questionnaire as 28.6% of participating student were at greatthreat
for ED while 71.4% were at low risk for ED (Figure 1).
Table 1 Sociodemographic characteristics of participants (n=516).
Parameter No. Percent
Gender
Male 324 62.8
Female 192 37.2
Social status
Single 478 92.6
Married 38 7.4
Working status
Working 126 24.4
Not working 390 75.6
BMI
Under weight 30 5.8
Normal weight 294 57.0
Over weight 120 23.3
Obese 72 13.9
smoking status
Non smoker 408 79.1
Current smoker 70 13.6
Ex-smoker 38 7.4
Table 2 Participants’ responds to EAT-26 questionnaire.
Always Usually Often Sometimes Rarely Never
I am terrified of being overweight.
106
20.5%
88
17.1%
52
10.1%
84
16.3%
92
17.8%
94
18.2%
I avoid eating when I feel hungry.
12
2.3%
34
6.6%
38
7.4%
92
17.8%
130
25.2%
210
40.7%
I find myself busy with food.
44
8.5%
42
8.1%
90
17.4%
150
29.1%
102
19.8%
88
17.1%
Keep binge eating until I feel like I can’t stop
42
8.1%
42
8.1%
38
7.4%
92
17.8%
126
24.4%
176
34.1%
I cut my food into small pieces.
38
7.4%
54
10.5%
46
8.9%
126
24.4%
120
23.3%
132
25.6%
I am aware of the calorie content of the foods I
eat.
48
9.3%
72
14.0%
58
11.2%
100
19.4%
78
15.1%
160
31.0%
Especially avoid food with a high
carbohydrate content (eg bread, rice, potatoes,
etc.)
18
3.5%
32
6.2%
58
11.2%
100
19.4%
88
17.1%
220
42.6%
I feel others would prefer if I ate more.
30
5.8%
44
8.5%
40
7.8%
88
17.1%
48
9.3%
266
51.6%
Vomiting after I eat.
6
1.2%
4
.8%
20
3.9%
26
5.0%
46
8.9%
414
80.2%
You feel very guilty after eating.
44
8.5%
44
8.5%
50
9.7%
68
13.2%
68
13.2%
242
46.9%
I’m preoccupied with wanting to be thinner.
102
19.8%
58
11.2%
46
8.9%
90
17.4%
56
10.9%
164
31.8%
I think about burning calories when
exercising.
136
26.4%
88
17.1%
82
15.9%
74
14.3%
34
6.6%
102
19.8%
Others think I’m too skinny.
68
13.2%
40
7.8%
64
12.4%
112
21.7%
64
12.4%
168
32.6%
I’m preoccupied with the idea of having fat on
my body.
106
20.5%
62
12.0%
90
17.4%
80
15.5%
64
12.4%
114
22.1%
Took longer than others to eat my meals.
60
11.6%
66
12.8%
50
9.7%
104
20.2%
78
15.1%
158
30.6%
Avoid foods that contain sugar.
24
4.7%
46
8.9%
58
11.2%
148
28.7%
94
18.2%
146
28.3%
I eat diet foods
14
2.7%
32
6.2%
50
9.7%
120
23.3%
108
20.9%
192
37.2%
I feel like food is controlling my life.
34
6.6%
52
10.1%
90
17.4%
78
15.1%
58
11.2%
204
39.5%
Self-control around food
56
10.9%
66
12.8%
120
23.3%
126
24.4%
78
15.1%
70
13.6%
I feel like other people are pressuring me to
eat.
44
8.5%
62
12.0%
74
14.3%
100
19.4%
72
14.0%
164
31.8%
Give plenty of time and think about food.
38
7.4%
46
8.9%
92
17.8%
108
20.9%
96
18.6%
136
26.4%
You feel uncomfortable after eating sweets.
62
12.0%
46
8.9%
84
16.3%
84
16.3%
84
16.3%
156
30.2%
Engaging in dieting behavior.
36
7.0%
52
10.1%
64
12.4%
90
17.4%
82
15.9%
192
37.2%
I like my stomach to be empty.
26
5.0%
56
10.9%
56
10.9%
122
23.6%
96
18.6%
160
31.0%
You have the urge to vomit after meals.
16
3.1%
18
3.5%
26
5.0%
32
6.2%
56
10.9%
368
71.3%
Enjoy trying new rich foods.
118
22.9%
96
18.6%
100
19.4%
90
17.4%
44
8.5%
68
13.2%
Table 3 Risk for ED according to the score for EAT-26
No. Percent
At high risk for ED 148 28.6%
At low risk for ED 369 71.4%
Figure 1 Risk for ED according to the score for EAT-26 Table 4 shows that 22.9% and 14.3% of students reported eating so hard that they can’t stop once a month and 2-3 times a month respectively. 87.6% of students never made themselves vomit to control weight. 88.4% never used laxatives, slimming pills or diuretics (water pills) to control your weight but only 3.5% use it once or twice daily. Only 7% play sports for more than an hour to lose or control weight once a day or more, 14.3% once a week, 18.2% 2- 6 times a week and 9.3% once a month. 23.6% of participants lost 9 kg or more in the past 6 months. Table 5 shows losing body significant weight in the past 6 months. 23.6% lost 9 kg or more in the past 6 months. Table 6 shows a significant correlation between risk for ED with male gender (P= 0.001), BMI (P= 0.02) and
current smoking status (P= 0.001) but not with age, working status, and social status.
Table 4 Frequency of eating problems over a period of time for students
Once a day
or more
once a
week
2 – 6 times
a week
once a
month
2 – 3 times a
month
Never
You ate so hard you feel like you
can’t stop
26
5.0%
72
14.0%
38
7.4%
118
22.9%
74
14.3%
188
36.4%
You made yourself vomit to control
weight
12
2.3%
10
1.9%
10
1.9%
14
2.7%
18
3.5%
452
87.6%
Using laxatives, slimming pills or
diuretics to resistor your bodyweight
or shape?
18
3.5%
12
2.3%
6
1.2%
14
2.7%
10
1.9%
456
88.4%
Playing sports for more than an hour
to lose or control weight
36
7.0%
74
14.3%
94
18.2%
48
9.3%
56
10.9%
208
40.3%
Table 5 Losing body significant weight in the past 6 months
Yes No
Lost 9 kg or more in the past
6 months
122
23.6%
394
76.4%
Table 6 Significant correlation between EAT-26 score and sociodemographic characters of participants
Risk for ED
Total (N=1020) P value
At high risk for ED At low risk for ED
Gender
Male 148 176 324
0.001 100.0% 47.8% 62.8%
Female 0 192 192
0.0% 52.2% 37.2%
28.60%
71.40%
At high risk for ED At low risk for ED
MEDICAL SCIENCE l ANALYSIS ARTICLE
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Page3013
Social status Single
140 338 478
0.28
94.6% 91.8% 92.6%
Married
8 30 38
5.4% 8.2% 7.4%
Working status
work
44 82 126
0.075
29.7% 22.3% 24.4%
not work
104 286 390
70.3% 77.7% 75.6%
BMI
under
weight
2 28 30
0.020
1.4% 7.6% 5.8%
normal
weight
86 208 294
58.1% 56.5% 57.0%
over
weight
34 86 120
23.0% 23.4% 23.3%
obesity
class I
17 40 57
11.5% 10.9% 11.0%
obesity
class II
5 4 9
3.4% 1.1% 1.7%
obesity
class III
4 2 6
2.7% 0.5% 1.2%
smoking status
non
smoker
100 308 408
0.001
67.6% 83.7% 79.1%
current
smoker
33 37 70
22.3% 10.1% 13.6%
ex-
smoker
15 23 38
10.1% 6.3% 7.4%
4. DISCUSSION
Eating disorders are some of the most under-researched and difficult to diagnose psychiatric conditions, with a high mortality rate. The current study reported that responds and score for EAT-26 questionnaire as 28.6% of participating student were at great threat for ED while 71.4% were at low risk for ED. A previous study of college students in Taif, Saudi Arabia found that 35.4% of students were rated at danger for ED (Taha et al. 2018). ). A higher prevalence of ED risk was reported in EAT26 (Pengpid et al., 2015), and
37.6% of students were classified as at hazard for ED. The prevalence of ED in ANNU students at EAT26 was 21.2% (17.1% for men and 23.8% for women), which was higher than that reported in Palestine (Damiri et al., 2021). Another study in South India reported a low proportion of 13% of students at high risk of eating disorders (Iyer & Shriraam, 2021). The prevalence of positive
screening was 13.5% in women and 3.6% in men, so a narrow number was reported among freshmen (Eisenberg et al., 2011).
Pakistani data reported an incidence of 23% (EAT26) in a sample of medical students in Karachi (Memon et al., 2012). In Pakistan’s highest value was 17.1%, which estimated a pooled prevalence of ED risk by country, close to these estimates (Jahrami et al., 2019).
In the present study, 87.6% of students never made themselves vomit to control weight. 88.4% never used laxatives. In the American College Health Association’s National College Health Assessment (ACHA-NCHA), 3% of females and 0.4% of males reported ever receiving a diagnosis of anorexia; 2% of females and 0.2% of males reported a previous history of bulimia; then 4% of women and 1% of males stated vomiting or using laxative tablets to mislay weight in the precedingmonth (ACHA, 2008). In our results, there was a significant correlation between risk for ED with male gender (P= 0.001), BMI (P= 0.02) and current smoking status (P= 0.001) but not with age, working status, and social status. ED carries a number of biotic and psychic threat influences, comprising inherited and ecological factors (Jacobi et al., 2004).
Eating disorder forms and weight concerns, dietary restrictions, and family history are one of the most established risk factors for partial and complete symptomatic eating disorders (Stice et al., 2008). In most previous studies, women were at significant risk for ED than men, with a female-male ratio of ED prevalence of approximately 1.5 to 1 on both scale tests, which is noticeably lower than the global female to male ED prevalence (2.6 to 1) (Damiri et al., 2021) this finding steady with various further Arab and worldwide nations (Memon et al., 2012; Reyes-Rodríguez et al., 2010; Madanat et al., 2006; Fath Al Alim et al., 2012) but gender differences in Egypt Was observed (Shehata, 2020). One explanation for this small gap may be that men in this study were more overweight and obese (42.9%) than women (18.7%), (Damiri et al., 2021).
Risk for ED was increased among medical and obese students as they attained the uppermost substantial EAT scores (Taha et al., 2018). Another study reported increased risk of ED among obese students in Palastine (Damiri et al., 2021). In contrast to one study, an increased risk of ED correlated to great stress and unadorned body form anxieties was reported (P<0.001), but there was a substantial correlation amongst BMI and eating disorders. It didn’t matter. Other influential factors included a history of behavioral
symptoms such as counseling, peer pressure, excessive exercise, and taking laxatives and diet medications (p <0.001) (Iyer & Shriraam, 2021).
5. CONCLUSION
In conclusion, the reported risk of ED among university students in this study was among reported figures but relatively high when compared to global figures. This study highlights an underrated health problem among Saudi university students. Further research is needed exploring risk factors for better understanding of ED. Follow up studies should assess caffeine, nicotine, or stimulant use which may be appetite suppressants.
Limitations of the study
In this study we face some limitations, because some students refuse to participate in the study.
Acknowledgements
Our appreciation and thanks to the people who helped us in our study and participated with the data collection, our doctors who guide us throw this research and Al Majmaah University for giving us this opportunity to learn.
Informed consent
Informed consent was obtained from all participants included in the study.
Ethical considerations
Prior to the start of the study, ethical approval was obtained from the Deanship of Scientific Research with approval No. MUREC Dec.24/COM-2018/13.
Author Contributions
All the authors contributed evenly with regards to data collecting, analysis, drafting and proofreading the final draft.
Funding
This study has not received any external funding.
Conflict of Interest
The authors declare that there are no conflicts of interests.
Data and materials availability
All data associated with this study are presented in the paper.
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Page3015
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