Nutrition transition and globalization have affected the diet and body composition of all life stages including adolescents. This study aims to compare body weight status, psychological distress and disordered eating (DE), and to compare the association between BMI-for-age z-score (BAZ) and psychological distress with DE among Indonesian and Malaysian urban female adolescents. The adolescents’ weight and height were measured and a self-administered questionnaire was completed by each adolescent. A total of 713 girls (Indonesia = 47.8%, Malaysia = 52.2%), aged 12–19 years from Bekasi, Indonesia and Kuala Lumpur, Malaysia, participated in this study. The prevalence of overweight and obesity was not significantly different between Indonesian and Malaysian girls (18.2% vs 21.2%). Malaysian girls have a significantly higher prevalence of DE (23.9% vs 3.2%), depression (51.9% vs 26.1%), and stress (41.7% vs 29.6%) than Indonesian girls. However, the prevalence of anxiety in Indonesian girls was significantly higher compared to Malaysian girls (77.7% vs 66.4%). For Indonesian girls, BAZ and stress were significantly positive associated with DE, dieting, and bulimia and food preoccupation. For Malaysian girls, BAZ, anxiety and stress were significantly positive associated with DE. BAZ and stress were significantly positive associated with dieting. Depression and anxiety were significantly and positively associated with bulimia and food preoccupation. For both Indonesian and Malaysian girls, stress was significantly positive associated with oral control. Therefore, future intervention programme on promoting healthy eating among female adolescents should consider the psychological well-being component.
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BMI-for-age z-score and
psychological distress associated
with disordered eating: A
comparative study among
Indonesian and Malaysian urban
female adolescents
Highlights
Prevalence of overweight and obesity were similar in Indonesian and Malaysian girls.
Malaysian girls had higher prevalence of disordered eating, depression, and stress compared to Indonesian girls.
Indonesian girls had higher prevalence of anxiety compared to Malaysian girls.
Both Malaysian and Indonesian girls showed a significant association between BMI-for-age z-score and psychological stress with disordered eating.
Abstract
Nutrition transition and globalization have affected the diet and body composition of all life stages including adolescents. This study aims to compare body weight status, psychological distress and disordered eating (DE), and to compare the association between BMI-for-age z-score (BAZ) and psychological distress with DE among Indonesian and Malaysian urban female adolescents. The adolescents’ weight and height were measured and a self-administered questionnaire was completed by each adolescent. A total of 713 girls (Indonesia = 47.8%, Malaysia = 52.2%), aged 12–19 years from Bekasi, Indonesia and Kuala Lumpur, Malaysia, participated in this study. The prevalence of overweight and obesity was not significantly different between Indonesian and Malaysian girls (18.2% vs 21.2%). Malaysian girls have a significantly higher prevalence of DE (23.9% vs 3.2%), depression (51.9% vs 26.1%), and stress (41.7% vs 29.6%) than Indonesian girls. However, the prevalence of anxiety in Indonesian girls was significantly higher compared to Malaysian girls (77.7% vs 66.4%). For Indonesian girls, BAZ and stress were significantly positive associated with DE, dieting, and bulimia and food preoccupation. For Malaysian girls, BAZ, anxiety and stress were significantly positive associated with DE. BAZ and stress were significantly positive associated with dieting. Depression and anxiety were significantly and positively associated with bulimia and food preoccupation. For both Indonesian and Malaysian girls, stress was significantly positive associated with oral control. Therefore, future intervention programme on promoting healthy eating among female adolescents should consider the psychological well-being component.
1. Introduction
Indonesia and Malaysia are countries located in the Southeast Asia, where diverse ethnicities lived in both countries. Both countries share similar values such as geographical location, culture, colonialized experience in the past, and have similar interests in economic, social culture, security, and politics. As developing countries, Indonesia and Malaysia are experiencing a rapid nutrition transition, and the concurrent shift in diet, physical activity and body composition.
This nutrition transition and globalization have affected all life stages, including adolescents. Adolescence is a stage of life between childhood and adulthood, and this life stage is more susceptible to the development of psychological distress. Psychological distress refers to a state of emotional suffering, resulting from being exposed to a stressful event that poses a threat to one’s physical or mental health [1]. Elevated levels of psychological distress are the indicator of impaired mental health and may reveal common mental disorders, like depressive and anxiety disorders [2]. Psychological distress such as depression, anxiety, anger, stress, sadness and other moods have been known to influence food choices and diet patterns [3], as well as have a negative impact on eating behaviors [4].
The nutrition-related problem, specifically overweight and obesity were shown to be increasing by time. In Indonesia, the prevalence of obesity among adolescents as reported in regional studies ranged from 2.7% to 8.0% in years 2002–2007, and the prevalence of overweight and obesity among adolescents was 9.8% in a national study in the year 2010 [5]. Higher prevalence was noted by the 2018 Indonesia Basic Health Survey that estimated the prevalence of overweight and obesity among 13–15 years old was 16% and among 16–18 years old was 13.5% [6]. The prevalence of overweight and obesity among Malaysian adolescents had increased about 10% within a decade, which was 18.1% in 2006 [7] to 27.8% in 2018 [8]. The recent Malaysian National Health and Morbidity Survey (NHMS) 2019 reported the higher prevalence of 29.8% of the children and adolescents aged 5–17 years old were having overweight and obesity problems [9].
Disordered eating behaviours could be defined as troublesome eating behaviors, such as purgative practices, bingeing, food restriction and other inadequate methods to lose or control weight, which occur less frequently or are less severe than those required to meet the full criteria for the diagnosis of an eating disorders [10]. In Indonesia and Malaysia, there are limited studies reporting on the prevalence of disordered eating. Existing regional studies showed that the prevalence of disordered eating, as well as eating disorders among adolescents in several areas in Indonesia were high. In a study by Tantiani and Syafiq (2008), the prevalence of eating disorders was 37.3%, in which 11.6% was anorexia nervosa and 27% was bulimia nervosa [11]. Furthermore, study by Syah and Asna (2018), observed 26.1% girls had eating disorders risk [12]. Several studies in Malaysia also reported the high prevalence of disordered eating among Malaysian adolescents. In a study by Soo, Zalilah and Mohd. Nasir (2008), the prevalence of restrained eating and binge eating behaviour was 36.0% and 35.4%, respectively [13]. The following studies demonstrated the prevalences of disordered eating at 27.8% [14], 18.5% [15] and 19.8% [16] in different locations throughout Malaysia. Recently, Gan, Normasliana and Law (2018) reported that the prevalence of binge eating was 14.0% among adolescents, in which 12.6% was of moderate binge eating behaviour and the rest was of severe binge eating behavior [8].
The continuation of disordered eating behaviours from adolescence to young adulthood was demonstrated in a prospective study, whereby they found that the prevalence of dieting and disordered eating behaviours remained constant or increased from adolescence to young adulthood. Those who engaged in dieting and disordered eating behaviours during adolescence were at increased risk of these behaviours 10 years later [17]. This shows that early use of dieting and disordered eating behaviours may be predictive of continued use in the future. Thus, there is a need to determine the possible factors that contributed to disordered eating behaviour, so that early prevention efforts can be carried out to avoid these behavioural patterns to continue over time.
Double burden of malnutrition was known as a public health nutrition problem in both Indonesia and Malaysia. In this regard, it is important to consider the bidirectional relationship between obesity and disordered eating, where the presence of one of these conditions increases the risk of developing the other [18]. As neighbouring countries, Indonesia and Malaysia share mutuality and differences in many aspects, including dietary habits and food environment that may affect the nutritional outcome of the respective population. Among adolescents in particular, when eating is mainly psychologically governed, its correlation to disordered eating is seemingly overlooked by researchers. Yet, it is important to be investigated since adolescents undergo the second growth spurt. Recognizing similarities and differences across these two neighbouring countries, Indonesia and Malaysia can help in understanding the factors that may influence current eating behaviour and health outcomes of adolescents in both countries. By having a comparative study, we may capture a bigger scope on gaps that need to be filled by each other country. In a view of paucity, there are still limited studies comparing adolescent nutritional outcomes by putting attention to their psychological aspects. The findings also may guide the development of interventions to prevent a progression to these problems. Thus, the aim of this study is to compare body weight status, psychological distress and disordered eating between Indonesian and Malaysian urban female adolescents. This study also aimed to compare the association between BMI-for-age z-score and psychological distress with disordered eating among Indonesian and Malaysian urban female adolescents.
2. Methods
2.1. Study design and participants
The current study consisted of two cross-sectional studies involving urban female adolescents aged 12–19 years (n = 713), in which 341 (47.8%) in Indonesia and 372 (52.2%) in Malaysia. The study samples of both countries were recruited from a total of twelve selected secondary schools, which included six secondary schools from the urban areas in Bekasi, Indonesia, and Kuala Lumpur, Malaysia, respectively. For both samples, female adolescents who were physically or mentally disabled were excluded from the current study, with the response rate of 94.0%. The similar questionnaires that assessed socio-demographic characteristics, anthropometric measurements, psychological distress and disordered eating were used in both countries.
Ethical statement
The current study was conducted based on the Declaration of Helsinki guidelines and was approved by the (blind for peer review) and (blind for peer review). Signed informed consents were obtained from both female adolescents and their parents or guardians before data collection.
2.2. Socio-demographic characteristics
Socio-demographic information was self-reported using a structured questionnaire, which included age and parental educational level. The parental educational level was determined by asking the participants to select their parent’s highest educational level from the following choices: no formal education, primary education, secondary education, and tertiary education.
2.3. Anthropometric measurements
The body weight and height of the participants were measured by using a standardised method. The weight was measured to the nearest 0.1 kg using a digital scale, while height was measured to the nearest 0.1 cm using a portable stadiometer. The BMI-for-age z-score (BAZ) was calculated using the WHO AnthroPlus software version 1.01. To classify participants, the cut-off points of ≤+1SD for non-overweight and obesity and >+1SD for overweight and obesity were used according to WHO (2007) Growth Reference.
2.4. Psychological distress
The psychological distress (depression, anxiety and stress) of the participants was assessed using the 21-item Depression, Anxiety, and Stress Scale-21 (DASS-21) [19]. Each of the depression, anxiety and stress subscales had 7 items and were rated on a 4-point Likert scale rating from 0 (did not apply to me at all), 1 (applied to me to some degree, or some of the time), 2 (applied to me to a considerable degree, or a good part of the time) and 3 (applied to me very much, or most of the time). The total score for each of the psychological distress ranged from 0 to 21. Participants were classified into two categories according to the severity of “Yes” (mild, moderate, severe, and extremely severe) and “No” (normal). The internal consistency reliability of the depression (Indonesia = 0.70; Malaysia = 0.80), anxiety (Indonesia = 0.70; Malaysia = 0.72) and stress (Indonesia = 0.72; Malaysia = 0.75) subscales of the current study was calculated and appeared to be acceptable.
2.5. Disordered eating
The 26-item Eating Attitudes Test-26 (EAT-26) was used to identify disordered eating among participants [20]. The dieting (13-item), bulimia and food preoccupation (6-item) and oral control (7-item) subscales were rated on a 6-point Likert scale rating from “always (3)”, “usually (2)”, “often (1)”, “sometimes (0)”, “rarely (0)”, and “never (0)” except for item 26. Item 26 was scored reversely. The total score of EAT-26 ranged from 0 to 78. A higher score reflects a greater eating-related pathology. A score equal to or greater than 20 was classified as disordered eating, while a score less than 20 was classified as non-disordered eating. The Cronbach’s alpha for the EAT-26 of the study was 0.73 for Indonesia and 0.87 for Malaysia, indicated that the instrument was reliable.
2.6. Statistical analysis
Data were analysed using IBM SPSS Statistics version 26.0. Descriptive data were presented in mean and standard deviations (SD) for continuous variables, while in frequency (n) and percentage (%) for categorical data. Independent-samples t-test and chi-square test were used to compare the difference between Indonesian and Malaysian girls. Pearson’s product-moment correlation test was used to determine the correlations between age, BAZ and psychological distress (depression, anxiety, and stress) with different types of disordered eating. All variables with p < 0.25 were included in the multiple linear regression (stepwise method) to determine the factors associated with the types of disordered eating among Indonesian and Malaysian girls. The statistical significance level was set at p < 0.05.
3. Results
3.1. Socio-demographic characteristics
Characteristics of the participants are shown in Table 1. Indonesian girls showed significantly higher mean age and height than Malaysian girls. Both paternal and maternal education levels were significantly different between Indonesian and Malaysian girls, with the majority attained secondary education. The prevalence of overweight and obesity was not significant difference between Indonesian and Malaysian girls. Malaysian girls showed a significant higher prevalence of disordered eating, depression, and stress than Indonesian girls. However, the prevalence of anxiety in Indonesian girls was significantly higher compared to Malaysian girls.
Table 1. Comparison of characteristics between Indonesian and Malaysian urban female adolescents (n = 713).
Characteristics | Indonesian girls (n = 341) | Malaysian girls (n = 372) | t/χ2 value | p-value |
---|---|---|---|---|
Mean ± SD/n (%) | Mean ± SD/n (%) | |||
Age (years) | 16.35 ± 1.03 | 13.81 ± 1.32 | 28.848 | <0.001*** |
Paternal education level | 36.798 | <0.001*** | ||
No formal education | 22 (6.4) | 5 (1.3) | ||
Primary education | 50 (14.7) | 17 (4.6) | ||
Secondary education | 228 (66.9) | 289 (77.7) | ||
Tertiary education | 41 (12.0) | 61 (16.4) | ||
Maternal education level | 43.361 | <0.001*** | ||
No formal education | 20 (5.9) | 5 (1.3) | ||
Primary education | 68 (19.9) | 24 (6.5) | ||
Secondary education | 226 (66.3) | 297 (79.8) | ||
Tertiary education | 27 (7.9) | 46 (12.4) | ||
Weight (kg) | 51.3 ± 10.7 | 49.7 ± 12.7 | 1.833 | 0.067 |
Height (m) | 154.6 ± 5.6 | 155.7 ± 6.4 | −2.390 | 0.017* |
BMI-for-age z-score | −0.01 ± 1.24 | −0.05 ± 1.36 | 0.368 | 0.713 |
Body weight status | 1.046 | 0.306 | ||
Overweight and obesity | 62 (18.2) | 79 (21.2) | ||
Non-overweight and obesity | 279 (81.8) | 293 (78.8) | ||
Total score of EAT-26 | 7.25 ± 4.99 | 13.76 ± 11.44 | −9.993 | <0.001*** |
Disordered eating | 63.215 | <0.001*** | ||
Yes | 11 (3.2) | 89 (23.9) | ||
No | 330 (96.8) | 283 (76.1) | ||
Dieting subscale | 3.98 ± 2.90 | 8.51 ± 7.10 | −11.318 | <0.001*** |
Bulimia and food preoccupation subscale | 1.00 ± 1.55 | 1.72 ± 2.78 | −4.347 | <0.001*** |
Oral control subscale | 2.26 ± 2.09 | 3.52 ± 3.63 | −5.717 | <0.001*** |
Depression subscale | 6.42 ± 5.67 | 10.24 ± 7.68 | −7.589 | <0.001*** |
Depression category | 49.465 | <0.001*** | ||
Yes | 89 (26.1) | 193 (51.9) | ||
No | 252 (73.9) | 173 (48.1) | ||
Anxiety subscale | 12.41 ± 7.17 | 11.40 ± 7.18 | 1.882 | 0.060 |
Anxiety category | 11.252 | 0.001** | ||
Yes | 265 (77.7) | 247 (66.4) | ||
No | 76 (22.3) | 125 (33.6) | ||
Stress subscale | 10.78 ± 6.82 | 13.47 ± 7.67 | −4.927 | <0.001*** |
Stress category | 11.222 | 0.001** | ||
Yes | 101 (29.6) | 155 (41.7) | ||
No | 240 (70.4) | 217 (58.3) |
*Significant difference at p < 0.05,**Significant difference at p < 0.01,***Significant difference at p < 0.001.
3.2. Correlations of age, BMI-for-age z-score, psychological distress and disordered eating
The correlations of age with disordered eating (EAT-26), dieting, bulimia, and food preoccupation, as well as oral control subscales were not significant for both Indonesian and Malaysian girls (Table 2). BAZ was significantly correlated with disordered eating (EAT-26), dieting, as well as bulimia and food preoccupation subscales in Indonesian girls. For Malaysian girls, BAZ was significantly correlated with EAT-26 and dieting subscale. Depression, anxiety, and stress were significantly associated with disordered eating (EAT-26), dieting, bulimia, and food preoccupation, as well as oral control subscales in Malaysian girls. For Indonesian girls, depression was associated with disordered eating (EAT-26), while anxiety was associated with disordered eating (EAT-26), dieting, and oral control subscales. However, stress was significantly associated with disordered eating (EAT-26), dieting, bulimia, and food preoccupation, as well as oral control subscales in Indonesian girls.
Table 2. Correlations of age, BMI-for-age z-score, psychological distress, and disordered eating by country (n = 713).
Characteristics | Disordered eating (Total score of EAT-26) | |||
---|---|---|---|---|
Indonesian Girls (n = 341) | Malaysian Girls (n = 372) | |||
r | p | r | p | |
Age | −0.063 | 0.248 | −0.031 | 0.553 |
BMI-for-age z-score | 0.272 | <0.001*** | 0.219 | <0.001*** |
Depression | 0.107 | 0.049* | 0.262 | <0.001*** |
Anxiety | 0.160 | 0.003** | 0.269 | <0.001*** |
Stress | 0.195 | <0.001*** | 0.314 | <0.001*** |
Characteristics | Dieting | |||
---|---|---|---|---|
Indonesian Girls (n = 341) | Malaysian Girls (n = 372) | |||
r | p | r | p | |
Age | −0.068 | 0.210 | −0.046 | 0.381 |
BMI-for-age z-score | 0.406 | <0.001*** | 0.396 | <0.001*** |
Depression | 0.103 | 0.057 | 0.209 | <0.001*** |
Anxiety | 0.119 | 0.029* | 0.210 | <0.001*** |
Stress | 0.152 | 0.005** | 0.287 | <0.001*** |
Characteristics | Bulimia and food preoccupation | |||
---|---|---|---|---|
Indonesian Girls (n = 341) | Malaysian Girls (n = 372) | |||
r | p | r | p | |
Age | −0.067 | 0.217 | −0.008 | 0.881 |
BMI-for-age z-score | 0.166 | 0.002** | 0.002 | 0.970 |
Depression | 0.070 | 0.196 | 0.266 | <0.001*** |
Anxiety | 0.102 | 0.059 | 0.258 | <0.001*** |
Stress | 0.116 | 0.032* | 0.238 | <0.001*** |
Characteristics | Oral control | |||
---|---|---|---|---|
Indonesian Girls (n = 341) | Malaysian Girls (n = 372) | |||
r | p | r | p | |
Age | −0.006 | 0.917 | −0.002 | 0.968 |
BMI-for-age z-score | −0.038 | 0.484 | −0.085 | 0.103 |
Depression | 0.060 | 0.273 | 0.214 | <0.001*** |
Anxiety | 0.141 | 0.009** | 0.238 | <0.001*** |
Stress | 0.167 | 0.002** | 0.245 | <0.001*** |
*Significant correlation at p < 0.05, **Significant correlation at p < 0.01, ***Significant correlation at p < 0.001.
3.3. Associations of BMI-for-age z-score and psychological distress with disordered eating
The results from the multiple linear regression for Indonesian girls in Table 3 revealed that BMI-for-age z-score and stress were significantly positive associated with disordered eating (total score of EAT-26), dieting as well as bulimia and food preoccupation subscales. Stress was significantly positive associated with the oral control subscale.
Table 3. Associations of BMI-for-age z-score and psychological distress with disordered eating in Indonesian girls (n = 341).
Characteristics | Disordered eating (Total score of EAT-26) | ||||||
---|---|---|---|---|---|---|---|
B | SE | β | t | p | R2 | Adjusted R2 | |
Constant | 9.214 | 4.129 | 2.232 | 0.026* | 0.115 | 0.102 | |
BMI-for-age z-score | 1.078 | 0.208 | 0.268 | 5.184 | <0.001*** | ||
Stress | 0.141 | 0.038 | 0.193 | 3.720 | <0.001*** |
Characteristics | Dieting | ||||||
---|---|---|---|---|---|---|---|
B | SE | β | t | p | R2 | AdjustedR2 | |
Constant | 5.043 | 2.279 | 2.213 | 0.028* | 0.203 | 0.191 | |
BMI-for-age z-score | 0.934 | 0.115 | 0.399 | 8.143 | <0.001*** | ||
Stress | 0.060 | 0.021 | 0.141 | 2.864 | 0.004** |
Characteristics | Bulimia and food preoccupation | ||||||
---|---|---|---|---|---|---|---|
B | SE | β | t | p | R2 | AdjustedR2 | |
Constant | 2.196 | 1.332 | 1.649 | 0.100 | 0.049 | 0.035 | |
BMI-for-age z-score | 0.203 | 0.067 | 0.162 | 3.031 | 0.003** | ||
Stress | 0.029 | 0.012 | 0.126 | 2.340 | 0.020* |
Characteristics | Oral control | ||||||
---|---|---|---|---|---|---|---|
B | SE | β | t | p | R2 | AdjustedR2 | |
Constant | 1.879 | 1.803 | 1.042 | 0.298 | 0.031 | 0.020 | |
Stress | 0.053 | 0.017 | 0.172 | 3.167 | 0.002** |
Note: All models are adjusted for age, paternal and maternal education levels.
*Significant correlation at p < 0.05, **Significant correlation at p < 0.01, ***Significant correlation at p < 0.001.
As shown in Table 4, the multiple linear regression analysis for Malaysian girls illustrated that BMI-for-age z-score, anxiety and stress were significant positive associated with disordered eating (total score of EAT-26). Similarly, BMI-for-age z-score and stress were significant positive associated with the dieting subscale. Both depression and anxiety were significantly positive associated with bulimia and food preoccupation subscale, while only stress was significantly positive associated with the oral control subscale.
Table 4. Associations of BMI-for-age z-score and psychological distress with disordered eating in Malaysian girls (n = 372).
Characteristics | Disordered eating (Total score of EAT-26) | ||||||
---|---|---|---|---|---|---|---|
B | SE | β | t | p | R2 | AdjustedR2 | |
Constant | 15.769 | 6.302 | 2.502 | 0.013* | 0.165 | 0.151 | |
BMI-for-age z-score | 1.901 | 0.407 | 0.227 | 4.665 | <0.001*** | ||
Anxiety | 0.248 | 0.106 | 0.156 | 2.347 | 0.019* | ||
Stress | 0.321 | 0.098 | 0.215 | 3.256 | 0.001** |
Characteristics | Dieting | ||||||
---|---|---|---|---|---|---|---|
B | SE | β | t | P | R2 | AdjustedR2 | |
Constant | 10.207 | 3.714 | 2.748 | 0.006** | 0.243 | 0.233 | |
BMI-for-age z-score | 2.020 | 0.238 | 0.388 | 8.480 | <0.001*** | ||
Stress | 0.271 | 0.042 | 0.293 | 6.393 | <0.001*** |
Characteristics | Bulimia and food preoccupation | ||||||
---|---|---|---|---|---|---|---|
B | SE | β | t | P | R2 | AdjustedR2 | |
Constant | 1.923 | 1.589 | 1.210 | 0.227 | 0.092 | 0.079 | |
Depression | 0.062 | 0.022 | 0.170 | 2.763 | 0.006** | ||
Anxiety | 0.064 | 0.024 | 0.166 | 2.689 | 0.007** |
Characteristics | Oral control | ||||||
---|---|---|---|---|---|---|---|
B | SE | β | t | p | R2 | AdjustedR2 | |
Constant | 3.755 | 2.096 | 1.791 | 0.074 | 0.064 | 0.053 | |
Stress | 0.118 | 0.024 | 0.250 | 4.916 | <0.001*** |
Note: All models are adjusted for age, paternal and maternal education levels.
*Significant correlation at p < 0.05, **Significant correlation at p < 0.01, ***Significant correlation at p < 0.001.
4. Discussion
In the present study, the prevalence of overweight and obesity was not significant difference between Indonesian (18.2%) and Malaysian (21.2%) girls. The prevalence found in this study were consistent with several previous studies for both Indonesian and Malaysian girls. As in a previous Indonesian national study, National Basic Health Surveys (Riskesdas) 2018, the prevalence of overweight and obesity for adolescent aged 13–15 years was 16% [6]. Another study reported that the prevalence of overweight and obesity among Indonesian adolescent girls aged 12–18 years old was 10.9% [21]. Meanwhile, in Malaysia, Tan et al. found the prevalence of overweight and obesity was 23.4% in 11–16 years old Malaysian adolescents based on the drawn from the Malaysia Global School-based Student Health Survey (GSHS) 2012 [22]. In addition, the recent National Health and Morbidity Survey (NHMS) 2019 also reported about 29.8% of the children and adolescents aged 5–17 years old were having overweight and obesity problems [9].
Malaysian girls showed a significant higher prevalence of disordered eating compared to Indonesian girls (23.9% vs 3.2%). The difference in the prevalence of disordered eating between Indonesian and Malaysian girls was illustrated in the previous study among university students in the Association of Southeast Asian Nations (ASEAN), in which the prevalence were 5.1% and 13.9% in Indonesian and Malaysian university female students, respectively [23]. Recently, a high prevalence of disordered eating among adolescents was also reported (30%) in a study in Terengganu, Malaysia [24]. These findings are consistent with previous research that has identified female university students had higher levels of disordered eating behaviours compared to male university students [25]. This suggests that disordered eating behaviours may be a significant public health concern in Malaysia, particularly among young women. It is important to identify the factors that contribute to these behaviours and to develop culturally appropriate interventions that address this important public health issue.
When psychological distress is concerned, in the present study, Malaysian girls showed a significantly higher prevalence of depression (51.9% vs 26.1%) and stress (41.7% vs 29.6%) than Indonesian girls. However, the prevalence of anxiety in Indonesian girls was significantly higher compared to Malaysian girls (77.7% vs 66.4%). In a systematic review and meta-analysis study, South Asian countries have a high disease burden of psychiatric illnesses, in which the prevalence of common mental disorders was 14.2%, higher than worldwide pooled prevalence of mental disorders (13.4%) [26]. In Malaysia, based on the NHMS 2019, 7.9% of children aged 5–15 years old were having mental health problem, mainly due to poor interaction with their peers [9]. Among Indonesian girls, the prevalence of depression, anxiety and stress found in the current study were not really different from a previous finding in an Indonesian study that reported the prevalence of depression was 21.2%, anxiety (72.7%) and stress (41.0%) among Indonesian girls aged 15–18 years in Pekanbaru [27]. The variation in the prevalence of mental disorders in different South Asian countries was ventured to be due to different levels of psychosocial, cultural and political stressors [26].
BAZ was significantly correlated with disordered eating (EAT-26), dieting, as well as bulimia and food preoccupation subscales in Indonesian girls. For Malaysian girls, BAZ was significantly correlated with EAT-26 and dieting subscale. Many cross-sectional studies reported the co-occurrence of eating problems, namely overweight and disordered eating. In Malaysia, BMI was shown to be significantly associated with disordered eating [14,15], as well as dietary restraint and binge eating [13] among Malaysian adolescents. Furthermore, the prevalence of disordered eating in Malaysian adolescents was shown to be higher in overweight (26.5%) and obese adolescents (19.8%) compared to their normal weight (20.8%), thin (13.4%) and too thin (9.9%) counterparts [16]. In a study among ASEAN university students, obese students were more likely to report the disordered eating behaviour compared to normal weight students [23]. In a study in Indonesia, Sulistyan et al. found that among girls who were trying or had tried to lose weight, 92% of girls were using unhealthy dieting (fad diets) [28].
In a systematic review on eating behaviour of Indonesian adolescents by Rachmi et al., they found the consistent patterns in all studies reviewed that overweight or obese adolescents tend to skip breakfast and snack more than their normal-weight counterparts [29]. Furthermore, in a Malaysian nationwide study, breakfast skipping (defined as consuming breakfast <3 days/week) was found to be associated with a higher BMI-for-age z-score and about 1–2 times greater likelihood of being overweight and obese, in both children and adolescents [30].
Overweight individuals are expected to engage in dieting with the intention to lose weight. Indeed, strict diets do not necessarily result in thinness. Rather, strict diets can consequently put them at greater risk of binge eating that arises following repeated excessive food restriction, which describes binge eating behaviours [31,32]. Furthermore, stigmatisation of obese children and adolescents is a common event and is probably increasing. Thus, the societal pressure to be slim might increase dieting behaviours and reduce self-esteem. There is also prospective evidence that binge eating in childhood or adolescence increases the likelihood for subsequent obesity [33]. In line with these findings, a study found that children with obesity who engage in dieting behaviors are more likely to experience loss of control eating, a form of disordered eating characterized by cycles of excessive food restriction followed by episodes of overeating [34]. This highlights the potential negative impact of strict diets intended for weight loss on overweight children and emphasizes the importance of addressing disordered eating behaviors in this population.
Depression, anxiety, and stress were significantly associated with disordered eating (EAT-26), dieting, bulimia, and food preoccupation, as well as oral control subscales in Malaysian girls. For Indonesian girls, depression was associated with disordered eating (EAT-26), while anxiety was associated with disordered eating (EAT-26), dieting, and oral control subscales. However, stress was significantly associated with disordered eating (EAT-26), dieting, bulimia, and food preoccupation, as well as oral control subscales in Indonesian girls. The relationship between psychological distress and disordered eating have been reported in several studies. Previous studies have found that disordered eating among adolescents was independently associated with emotional problem [24] and students with depressive symptoms were more likely to report eating disorder risk than students who did not have depressive symptoms [23]. In a longitudinal study from the Australian Temperament Project (ATP), they found that adolescents meeting the criteria for subthreshold disordered eating have higher levels of anxiety in adulthood compared to the non-disordered eating group [35]. High impairment in anxiety or depression was associated with more severe eating disorder symptoms in a sample of 12- to 25-year-old females [36]. Apart from the relationship between BAZ and disordered eating, a study found the significant association between psychological distress and obesity, in which significant association found between depression with obesity (p = 0.003; OR = 0.219), and stress with obesity (p = 0.044, OR = 0.028) [26].
There are some factors that can be relate to disordered eating, depression and stress. In a recent meta-analysis by Azrimaidaliza et al., among Indonesian adolescents, those who had negative body image distortion or feel themselves fat have an eating disorder risk of 3.40 times greater than adolescents who do not experience positive body image distortion or adolescents who do not feel fat [37]. In addition to negative body image distortion and feeling fat, parental comments on body weight and shape have been identified as a contributing factor to the development of disordered eating behaviors among adolescents [38]. Specifically, comments related to weight control, negative comments, and teasing have been shown to have a significant association with disordered eating behaviors in this population. Therefore, both negative body image and parental comments on body weight and shape should be considered in the prevention and intervention of disordered eating among adolescents.
Disordered eating behaviour, specifically breakfast skipping was closely associated with dieting practices in girls, because of concerns about body weight and dissatisfaction with their body shapes. In a study among Malaysian adolescents, almost half of the adolescent girls reported skipping breakfast because of concerns about becoming fat [39]. They believed that skipping breakfast was an effective method of dieting to lose weight and reduce daily energy intakes. Social media and internet use have emerged as mental health research area possibly affecting body image concerns and interaction with peers [40]. Body dissatisfaction mediating the effects of sociocultural pressures, BMI and weight perception on unhealthy weight control behaviors. Weight perception also had direct effects on unhealthy and extreme weight control behaviors in a sample of adolescent girls in Surabaya, Indonesia [41].
The strengths of this study is this is the first study that determine and compare the body weight status, psychological distress and disordered eating between Indonesian and Malaysian urban female adolescents, as well the association between BMI-for-age z-score and psychological distress with disordered eating among Indonesian and Malaysian urban female adolescents. Thus, this study gives new insights in the studied problems among female adolescents in Southeast Asia. The limitations of this study also need to be acknowledged. This study utilized cross-sectional study design, thus the causation relationships between the variables cannot be concluded. Secondly, the female adolescents in this study were only drawn from urban area which are Bekasi, Indonesia and Kuala Lumpur, Malaysia. Therefore, the results were not appropriate to be generalized for all adolescents in both countries. Last but not least, the questionnaire used in this study was self-reported and this may exposed to the bias and socially desirable response from the adolescents.
5. Conclusion
As this study found the association between BAZ and psychological stress with disordered eating, it is suggested for future nutritional intervention among female adolescents to also address the psychological aspects in the planning and implementing an intervention programme, instead of just including the knowledge on body weight status. With the additional knowledge on mental health literacy and its relation to eating behaviour, the adolescents might get early detection and seek help for their psychological problem. Thus, this might prevents them from getting worse and involve in any unhealthy eating behaviour. Neglecting to address disordered eating can lead to other complications, such as hypertension and other cardiovascular risks [42]. Hence, it is crucial to recognize and address disordered eating behaviours as early as possible. Besides, other adiposity indexes should be considered for comprehensive assessment of disordered eating behaviours in the future [43].
Author statement
Conceptualization: all authors; Data curation: CWT, MNHS; Formal analysis: CWT; Funding acquisition: YSC, MNHS; Investigation: all authors; Methodology: all authors; Project administration: all authors; Resources: all authors; Supervision: YSC, MNHS; Validation: all authors; Visualization: all authors; Writing–original draft: SIZSI; Writing–review & editing: all authors.
Fundings
This research was funded by Japfa Foundation (Indonesia) (Grant number: No. 08/PKS-JF/PROG/09/2018) and the Ministry of Higher Education of Malaysia under the Exploratory Research Grant Scheme (ERGS) (Grant number: 5527042). The funders had no role in the design, analysis or writing of this article.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
The authors sincerely thank the schools, teachers and students who participated in this study. We are also grateful for the support and cooperation received from the (blind for peer review).
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