Eating disorders are profoundly neglected in Indonesia due to cultural taboos, lack of public awareness, and limited mental health resources. This study is a breakthrough for several reasons:Breaking the “Invisible” Barrier: On average, individuals with EDs experience a delay of 5.28 years before seeking treatment, heavily exacerbated by healthcare workers failing to recognize the signs.Focusing on Unique Micro-environments: Islamic boarding schools (pesantren) have regimented communal eating habits and distinct religious structures. Investigating EDs here proves that body dissatisfaction crosses all socioeconomic, geographic, and religious boundaries—it is not merely a “Western” problem.
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Factors associated with eating disorders among
Indonesian adolescents at boarding schools
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Abstract
Objectives
Eating disorders (EDs) are a significant global issue among adolescents, including those in boarding schools; however, this population remains under-researched. This study investigated the factors associated with EDs among Indonesian boarding school students.
Methods
Using a cross-sectional approach, 1,400 adolescents were selected through purposive sampling. The study examined factors such as body mass index (BMI), body image, mood, loneliness, and weight loss using a modified combination of questionnaires. Data analysis was performed using logistic regression in SPSS 21 with a significance level of 0.05.
Results
Four factors significantly influenced the risk of developing ED. A lower BMI (underweight or normal) decreased the risk (OR=0.2 and 0.3, respectively; CI: 0.140–0.360 and 0.231–0.524, respectively). A lower drive for leanness reduced the likelihood of EDs (OR=0.49; CI: 0.347–0.713). Lower levels of muscularity-oriented eating also decreased ED risk (OR=0.39; CI: 0.273–0.573). Conversely, unhealthy weight loss experiences significantly increased ED risk (OR=8.9; CI: 6.728–11.827).
Conclusions
These findings highlight the complex factors contributing to EDs risk, emphasizing the need for targeted interventions to address body image concerns, nutritional practices, and weight loss experiences to promote the well-being of students in boarding schools. The implementation of structured health education programs that emphasize balanced nutrition, positive body image, and healthy weight management is recommended to address eating disorders. Nursing and health professionals play key roles in the development and delivery of these programs.
Introduction
Eating disorders (EDs) among adolescents constitute a significant issue, not only nationally but also globally [1]. The EDs can lead to various aspect of adolescents’ physical (such as short-term effects including weakness, injuries and stress fractures) [2], psychological and social well-being (like bullying, emotional dysregulations, and other mental health related issues) [3], 4]. Furthermore, the long impacts of EDs can be even worse alarming, encompassing cardiovascular issues, gastrointestinal problems and metabolic disturbances [5]. A recent systematic review encompassing 32 studies disclosed an overall prevalence of eating disorders at 22.36 %, highlighting the substantial impact of these conditions within the analyzed populations. The findings from a recent comparative analysis indicate a marked gender disparity in the prevalence of ED behaviors, with girls reporting a significantly higher rate of 30.03 %, in stark contrast to boys, who manifested a lower prevalence of 16.98 % [6]. A study in Taiwan reported an estimated mean annual incidence of 11.11 per 100,000 residents and a 1-year prevalence rate of 20.87 per 100,000 residents, with these conditions predominantly affecting females [7]. EDs are also present among young adults; for instance, a study conducted in China revealed that 2.5 % of this group displayed attitudes indicative of being at risk for eating disorders [8]. A study in Indonesia, conducted among girls students in a health sciences school, showed that 17.11 % of participants were at high risk for eating disorders [9]. Another studies also mentioned that the prevalence of EDs in Indonesia is quite higher which reached 23.9–37.3 % [10]. Additionally, these behaviors can adversely affect both physical and mental health, potentially leading to conditions such as depression [11].
The prevalence of EDs among adolescents continues to rise, characterized by significant alterations in metabolism and associated with psychiatric comorbidities, underscoring the need for updated knowledge on these disorders [12]. EDs can be serious and often develop into chronic conditions, especially when not addressed promptly. A recent investigation into the experiences of individuals with EDs highlighted that, on average, patients experienced a significant delay of 5.28 years from the first symptoms to seeking treatment [13]. One contributing reason for this delay may be the insufficient awareness among health professionals about the signs of disordered eating, resulting in a failure to recognize EDs in patients [13]. Proactively identifying risk factors for EDs can provide a critical chance for targeted education among healthcare workers. This education could enhance their ability to spot various psychosocial, biological, and genetic predispositions for disordered eating, regardless of explicit weight or dietary issues [14].
An understanding of the risk factors associated with EDs presents an opportunity for the early detection of individuals at high risk, leading to prompt, customized interventions through strategies like the development of public policies or the launch of targeted prevention initiatives [15]. Programs that intervene early and are informed by models of the origins of EDs may hinder the progression from being at risk to the development of a full-blown disorder [16]. Additionally, eating disorders are intricate psychiatric conditions, and there is a somewhat limited selection of effective, evidence-based treatments available [17], 18]. Moreover, a considerable portion of patients with EDs show resistance to the available evidence-based treatments [19], [20], [21]. Therefore, there is an acute need for enhanced understanding of how risk factors contribute to the etiology and causation of EDs, which is essential for advancing more sophisticated conceptualizations of these disorders.
Islamic boarding schools play great significance in the education of young adults in Indonesia, yet they deal with notable health challenges. Students are required to live in dormitories located in the school and separate from their family, while this type rule make them different from general school which students might live with their family [22]. The stereotype of poor clean and unhealthy behavior in some Islamic boarding school had become common phenomenon among people as it is rooted in their habit [23]. Some of poor clean and unhealthy behavior are including consuming the modest food without nutritional consideration, sharing belonging with friends (such as clothes, towels, and prayers set [24], and utilizing poor quality of waters for shower, of which these all cause particular common skin diseases, namely scabies, diarrhea, typhus and dyspepsia [23], 24]. Moreover, nutritional risk data highlights a worrisome prevalence of both undernutrition and overnutrition among students in these schools [25]. Unlike general boarding schools, Islamic boarding schools often have specific structures regarding communal eating arrangements, regimented meal schedules, dietary restrictions due to religious teachings, and gender-specific practices, all of which can contribute uniquely to patterns of eating behavior, body perception, and nutritional intake [25]. In South Tangerang City, a study revealed that nearly 30 % of Islamic boarding school students were overweight or obese, while almost 20 % exhibited abnormal mental health scores [26]. Contributing to these challenges are Clean and Healthy Life Behavior (CHLB) practices, influenced by cultural and religious factors, which are widespread among Islamic boarding school students. These practices include modest food consumption without nutritional consideration as they believe that foods are gift from the God, of which they have to accept any food they receive without any doubt [23]. While existing literature on eating disorders in public schools and general boarding schools is more extensive, there is a notable gap regarding Islamic boarding school populations. Addressing these multifaceted challenges necessitates a comprehensive approach that considers the cultural context mentioned before and actively promotes healthy behaviors and nutritional practices among students. Despite the growing concerns surrounding health issues in these settings, research on EDs among adolescents at Islamic boarding schools in Indonesia remains notably scarce.
Encouraging Islamic boarding school students to adopt a healthy lifestyle is paramount. A previous study showed evidence of a lack of awareness of CHLB among Islamic boarding school managements, providing meals without any guidelines for health standard meals, and students, and limited engagement of students in food preparations and dietary choice involvement [27]. Despite this urgency, a critical research gap exists concerning about the factors related to eating disorders specifically among Islamic boarding school students. Thus, this study primarily aimed to investigate the factors associated with eating disorders among Indonesian boarding school students.
Methods
Design
This study adopted a cross-sectional survey approach conducted across three Islamic boarding schools in the East Java province of Indonesia.
Sample and sampling
The sample for this study consisted of students from three Islamic boarding schools located in Gresik, Jombang, and Bojonegoro in East Java. A purposive sampling strategy was employed to ensure that the selected institutions would provide meaningful insights into the phenomena under study, particularly eating disorders (EDs) in the context of Islamic boarding schools. East Java comprises 38 districts and cities, each with varying levels of urbanization, infrastructure, and access to resources, which can influence students’ dietary habits and health behaviors. The selected boarding schools represent a diverse cross-section of these environments: Gresik, a highly industrialized area with greater access to modern infrastructure and food markets; Jombang, a more traditional and religiously centered region with strong cultural influences on dietary practices; and Bojonegoro, a predominantly rural area where students may experience different food availability and lifestyle patterns. Including institutions from these distinct locations would allow for a broader understanding of how environmental factors contribute to ED prevalence among students in Islamic boarding schools.
Meanwhile, for the participants we selected young adults who are currently living and receiving education in Islamic boarding schools. The inclusion criteria require participants to have been enrolled in boarding school at least six months and to possess clear understanding and effective communication skills to ensure reliable data collection. The exclusion criteria consisted of students who were not attending an Islamic boarding school or those who had not reached six months living in an Islamic boarding school, refusing to participate in the study, and inability to communicate clearly. A purposive sampling was applied to recruit a total of 1,400 students across three Islamic boarding schools. To ensure the accuracy of reflected population under study, this sampling method is focused on individuals who are most likely to exhibit the phenomena related to eating disorder (EDs) within this educational and cultural settings.
Variables
This study investigated factors associated with EDs risk in adolescents categorized into lower and higher levels of EDs risk. The categorization of these groups is determined by the cut-off score for global score result. Scores falling below the midpoint are classified as low risk of EDs, while those above the midpoint are classified as high risk of EDs. EDs are defined as unhealthy habits related to food, weight, and body image which negatively affect physical and mental health. the habits might include restrictive eating, binge eating, extreme preoccupation with body image, or compensatory behaviors (such as: purging or overexercising) that deviate from healthy eating and weight-management practices [28]. The risk of ED was assessed based on the Eating Disorder Examination Questionnaire (EDE-Q) [29], that evaluates eating attitudes and behaviors across four subscale: restrain, eating concerns, weight concerns, and shape concerns.
The independent variables in this study consisted of nutritional status which measured by Body Mass Index (BMI) and classified as Overweight, Underweight, and Normal based on WHO criteria [30]. The participants’ exercise attitudes were assessed, exploring perceptions of exercise frequency, intensity, and purpose, categorized into lower and higher levels which higher scores reflected more positive attitudes toward regular and structure physical activity. Body image was evaluated across four dimensions: [1]: Desire for leanness: the extent to which participants wished to reduce body fat; [2]: Desire for Muscularity: the level of aspiration for muscle mass; [3]: Muscle dysmorphic disorder: a pathological preoccupation with perceived muscular inadequacy; [4]: Muscularity-Oriented eating: Eating behaviors aimed at achieving a more muscular physique. Each dimension was categorized as either low or high. The categorization of these groups was determined using a cutoff score for each variable. Scores below the midpoint were classified as having low body image concerns, while those above the midpoint were classified as having high body image concerns [31].
Additionally, participants’ well-being, with a focus on three dimensions, namely anxiety, depression, and emotional stability, was measured using a mood index. The Mood Index measured participants’ overall emotional well-being. Higher scores indicate positive emotional states, whereas lower scores are associated with increased negative emotions, such as sadness, stress, and irritability. The loneliness index assesses subjective feelings of social isolation and a lack of meaningful connections. Higher scores reflect greater levels of loneliness, whereas lower scores indicate stronger feelings of connectedness and social support. Finally, Weight Loss Experience (WLE) was examined participants’ experience with weight loss, categorized into healthy weight loss (referring to health guidelines and promoted sustainable weight managements involving behaviors such as portion control, balanced diets, and regular exercise) and unhealthy weight loss (posing risks to physical and mental health behavior that include extreme or harmful practices such as skipping meals, fasting, using laxatives or diuretics, purging, or exercise beyond recommended limits) The measurement of these variables was conducted through a detailed questionnaire, as further elaboration on specifics scales and scoring systems in the subsequent section.
Instruments
The research employed a comprehensive instrument that amalgamated various questionnaires to probe into the diverse aspects of participants’ variables associated with eating disorders. The first section concentrated on demographics, collecting data on age, gender, educational background, and other factors that potentially influence physical and psychological well-being. The second part evaluated attitudes toward exercise using the Exercise Addiction Inventory (EAI), a succinct six-item tool that identifies the risk of exercise addiction. It examines participants’ exercise habits and potential addictive tendencies [32]. Section 3 observes eating disorder risk tendencies with a modified EDE-Q comprising 21 questions [29]. It evaluated primary behavioral and psychological features, yielding severity scores and self-control behaviors related to eating habits.
Section 4 employed four questionnaires to assess the body image of students. Body image assess based on Drive for Leanness Scale (DLS), The Drive for Muscularity Scale (DMS), Muscle Dysmorphic Disorder Inventory (MDDI), and Muscularity Oriented Eating (MOET). The DLS measured the desire for a slim physique, utilizing a six-item unidimensional scale [33]. The DMS gauged the inclination for a muscular body, utilizing a 15-item self-report tool that assesses an individual’s desire for a more muscular physique through attitudinal and behavioral prompts [34]. The MDDI assisted in identifying symptoms linked to an obsessive focus on perceived flaws in muscle size, comprising a 13-item measure that assessed symptoms of muscle dysmorphia [35]. Additionally, the MOET was a single-factor, 15-item scale designed to assess eating attitudes and behaviors associated with the pursuit of muscularity [36]. Together, these questionnaires provided a comprehensive understanding of motivations, perceptions, and potential disorders related to body image among the participants. Items were rated on a six-point Likert scale, ranging from 1 (Never) to 6 (Always), with higher overall scores indicating greater attitudes toward body image of students.
Section 5 focused on personal experiences of weight loss, inspired by the Three-Factor Eating Questionnaire (TFEQ) [37]. It comprised four yes/no questions, offering insights into individuals’ self-initiated weight loss journeys. Section 6 introduces the “Mood Index,” modeled after the Hospital Anxiety and Depression Scale (HADS) [38]. It examines specific dimensions of mood to understand emotional well-being comprehensively. Section 8 measured loneliness using the Revised University of California Los Angeles (R-UCLA) Loneliness Scale [39]. It assesses feelings of social isolation and the need for social support.
The final set of questionnaires underwent pilot testing with a sample of 30 participants to ensure clarity, understandability, and effectiveness. Feedback and performance data collected during the pilot testing phase were instrumental in validating the questionnaires. Additionally, a Cronbach’s alpha statistical test was conducted to assess the reliability and validity of the results. The Cronbach’s alpha coefficients for each questionnaire were as follows: EDEQ (0.955), EAI (0.709), DLS (0.891), DMS (0.927), MDDI (0.748), MOET (0.944), TFEQ (0.731), HADS (0.713), and R-UCLA (0.926). These results affirm the reliability and validity of the tested questionnaires.
Data collection
Data collection was conducted through a self-administered questionnaire. The data collection process involved administering printed questionnaires directly at three Islamic boarding schools located in East Java, Indonesia. Before participation, individuals received a brief overview of the study, its associated risks, and information on how confidentiality would be maintained. Following this, participants completed and signed an informed consent, expressing their willingness to take part in the study. They then independently completed the distributed questionnaires. To ensure the confidentiality of participant data, no personal identifiers such as names or specific information that could be linked to participant identities were included. Completing the questionnaire took approximately 15–20 min for each participant.
Data analysis
The data analysis employed logistic regression using the Statistical Package for the Social Sciences (SPSS). The dataset was input into SPSS, and logistic regression models were constructed to evaluate the predictive power of the independent variables with a significance level set at 5 % or p-value 0.05. The results, inclusive of odds ratios and their corresponding confidence intervals, were interpreted to gain valuable insights into the factors under examination.
Ethical clearance and inform consent
This research received approval from the Ethical Board of the Faculty of Nursing, Universitas Airlangga with number 2965-KEPK. Participants received comprehensive information about the study before joining, ensuring that participation was voluntary. Individuals aged above 18 years old who agreed to participate willingly signed a consent form by themselves, while those who below 18 years old should be accompanied by their parents or legal guardians in signing the inform consents. This document outlined the study’s objectives, procedures, and confidentiality measures. All collected data were treated with strict confidentiality, and the identities of participants were carefully safeguarded. No personal information has been disclosed in any publications. The study adhered to ethical guidelines to ensure the rights and well-being of the participants were prioritized and respected.
Results
Table 1 provides a comprehensive overview of demographic characteristics in relation to the eating disorder, distinguishing between lower and higher levels of eating disorders among the study participants. Analyzing the incidence of eating disorders in 1,400 people, different trends show up for different attributes. Adolescent girls show a higher prevalence of eating disorders than adolescent boys with a prevalence of 73.0 %. Age appears to have a complex effect; eating disorders are more common in 71.0 % of people 17 years of age and older. 72.2 % of part-time workers show a higher risk for eating disorder. Financial allowance also influences, with a larger risk identified in persons getting more than IDR 500,000–IDR 1,000,000 per month (71.3 %). Individuals who are overweight (88.9 %) exhibit increased risks. Both individuals with higher and lower tendency towards exercise have same risk to higher eating disorder risk. The importance of body image is highlighted by the considerable correlation between higher risks and the urge for muscularity (67.9 %) and leanness (72.5 %). Elevated risks were also associated with lower moodiness (72.1 %) and loneliness (76.9 %), underscoring the significance of emotional wellbeing. Those with an unhealthy weight loss experience (89.4 %) are more prone to eating disorders.
Demographic characteristic of islamic boarding school student (n=1,400).
| Characteristics | Eating disorder risk | Total | |||
|---|---|---|---|---|---|
| Lower level of eating disorder | Higher level eating disorder | ||||
| n | % | n | % | ||
| Gender | |||||
| Male | 153 | 40.6 % | 224 | 59.4 % | 377 |
| Female | 276 | 27.0 % | 747 | 73.0 % | 1,023 |
| Age, years | |||||
| ≤16 | 271 | 31.7 % | 585 | 68.3 % | 856 |
| ≥17 | 158 | 29.0 % | 386 | 71.0 % | 544 |
| Working status | |||||
| Part time working | 74 | 27.8 % | 192 | 72.2 % | 266 |
| Not working | 355 | 31.3 % | 779 | 68.7 % | 1,134 |
| Allowance per month | |||||
| <IDR 500,000 | 163 | 32.9 % | 333 | 67.1 % | 496 |
| IDR 500,000–IDR 1,000,000 | 201 | 28.7 % | 500 | 71.3 % | 701 |
| >IDR 1,000,000 | 65 | 32.0 % | 138 | 68.0 % | 203 |
| BMI categories | |||||
| Underweight | 145 | 50.7 % | 141 | 49.3 % | 286 |
| Normal | 245 | 32.1 % | 519 | 67.9 % | 764 |
| Overweight | 39 | 11.1 % | 311 | 88.9 % | 350 |
| Exercise attitude | |||||
| Lower level of exercise attitude | 144 | 30.2 % | 333 | 69.8 % | 477 |
| Higher level of exercise attitude | 285 | 30.9 % | 638 | 69.1 % | 923 |
| Body image: drive for leanness | |||||
| Lower level of DLS | 111 | 45.3 % | 134 | 54.7 % | 245 |
| Higher level of DLS | 318 | 27.5 % | 837 | 72.5 % | 1,155 |
| Body image: drive for muscularity | |||||
| Lower level of DMS | 258 | 29.7 % | 610 | 70.3 % | 868 |
| Higher level of DMS | 171 | 32.1 % | 361 | 67.9 % | 532 |
| Body image: muscle dysmorphic disorder inventory | |||||
| Lower level of MDDI | 358 | 33.9 % | 697 | 66.1 % | 1,055 |
| Higher level of MDDI | 71 | 20.6 % | 274 | 79.4 % | 345 |
| Body image: muscularity oriented eating | |||||
| Lower level of MOET | 366 | 39.1 % | 569 | 60.9 % | 935 |
| Higher level of MOET | 63 | 13.5 % | 402 | 86.5 % | 465 |
| Mood index | |||||
| Higher level of moodness | 135 | 38.9 % | 212 | 61.1 % | 347 |
| Lower level of moodness | 294 | 27.9 % | 759 | 72.1 % | 1,053 |
| Loneliness index | |||||
| Lower level of loneliness | 294 | 36.0 % | 522 | 64.0 % | 816 |
| Higher level of loneliness | 135 | 23.1 % | 449 | 76.9 % | 584 |
| Weight loss experience, WLE | |||||
| Unhealthy WLE | 75 | 10.6 % | 635 | 89.4 % | 710 |
| Healthy WLE | 354 | 51.3 % | 336 | 48.7 % | 690 |
| Total | 429 | 30.6 % | 971 | 69.4 % | 1,400 |
- DLS, drive for leanness; DMS, drive for muscularity; MDDI, muscle dysmorphic disorder inventory; MOET, muscularity oriented eating; WLE, weight loss experience.
The logistic regression analysis in Table 2 reveals that certain variables significantly influence the likelihood of an Eating Disorder among respondents. Among the BMI categories, both underweight (OR=0.225; 95 % CI=0.140–0.360) and normal BMI (OR=0.348; 95 % CI=0.231–0.524) are associated with a significantly reduced likelihood of elevated eating disorder risk. In terms of body image, a lower drive for leanness also significantly reduces the likelihood (OR=0.498; 95 % CI=0.347–0.713), while muscularity-oriented eating behaviors, when at a lower level, significantly lessen the risk (OR=0.395; 95 % CI=0.273–0.573). Notably, unhealthy weight loss experiences significantly increase the risk, with an OR of 8.920; 95 % CI=6.728–11.827, indicating the risk is approximately 9 times higher compared to those with healthy weight loss experiences. The constant of the model, which represents the baseline risk of an eating disorder, is also significant, thereby emphasizing the complexity of factors that contribute to this mental health issue.
Multivariate analysis result.
| Variables | p-Value | OR | 95 % CI | |
|---|---|---|---|---|
| Lower | Upper | |||
| BMI categories | ||||
| Overweight | 0.000a | 1 | 1 | 1 |
| Underweight | 0.000a | 0.225 | 0.140 | 0.360 |
| Normal | 0.000a | 0.348 | 0.231 | 0.524 |
| Exercise attitude | ||||
| Lower level of exercise attitude | 0.175 | 1.233 | 0.911 | 1.669 |
| Higher level of exercise attitude | 1 | 1 | 1 | 1 |
| Body image: drive for leanness | ||||
| Lower level of DLS | 0.000a | 0.498 | 0.347 | 0.713 |
| Higher level of DLS | 1 | 1 | 1 | 1 |
| Body image: drive for muscularity | ||||
| Lower level of DMS | 0.306 | 1.206 | 0.843 | 1.726 |
| Higher level of DMS | 1 | 1 | 1 | 1 |
| Body image: muscle dysmorphic disorder inventory | ||||
| Lower level of MDDI | 0.074 | 0.707 | 0.483 | 1.035 |
| Higher level of MDDI | 1 | 1 | 1 | 1 |
| Body image: muscularity oriented eating | ||||
| Lower level of MOET | 0.000a | 0.395 | 0.273 | 0.573 |
| Higher level of MOET | 1 | 1 | 1 | 1 |
| Mood index | ||||
| Higher level of moodness | 0.327 | 0.852 | 0.618 | 1.174 |
| Lower level of moodness | 1 | 1 | 1 | 1 |
| Loneliness index | ||||
| Lower level of loneliness | 0.065 | 0.755 | 0.559 | 1.018 |
| Higher level of loneliness | 1 | 1 | 1 | 1 |
| Weight loss experience | ||||
| Unhealthy WLE | 0.000a | 8.920 | 6.728 | 11.827 |
| Healthy WLE | 1 | 1 | 1 | 1 |
- ap-Value <0.05 (significant). DLS, drive for leanness; DMS, drive for muscularity; MDDI, muscle dysmorphic disorder inventory; MOET, muscularity oriented eating; WLE, weight loss experience.
It’s also worth mentioning that some variables such as exercise attitude, drive for muscularity, muscle dysmorphic disorder inventory, mood index, and loneliness index are not statistically significant at the p<0.05 level, suggesting that within this analysis, they do not have a significant impact on the risk of an eating disorder.
Discussion
Our study reveals a significant association between nutritional status (based on BMI) and eating disorder risk in boarding school students, with lower risk observed in normal and underweight students compared to overweight students. The high prevalence of eating disorder risks among overweight students can attributed to societal standards and body image perceptions in boarding school environments, along with psychological factors like stress [40]. Supporting studies emphasize the complex BMI-eating disorder relationship. A 2022 meta-analysis showed obesity as a common co-morbidity for bulimia nervosa and binge eating disorder [41]. A 2020 study found positive associations between eating disorder behavior and BMI, suggesting higher BMI relates to increased eating disorder risk [42]. Conversely, normal BMI is generally associated with lower eating disorder risk and healthier relationships with food and body image [43]. A 2023 study suggests normal weight BMI, combined with lower parental weight concern and more frequent family meals, may protect against disordered eating in adolescents from low-income backgrounds [44].
Our research found a statistical positive correlation between the “drive for leanness” and muscle-oriented eating, which are aspects of body image, and the risk of eating disorders among Islamic boarding school students. In contrast to our findings, previous studies have indicated that the “drive for leanness,” involving the control of a low body fat percentage and muscle visibility, is not always associated with an increased risk of developing eating disorders, particularly binge eating [45]. However, internalizing ideals of lean bodies is linked to eating disorder symptomatology, especially among males [46]. In our results, students with lower levels of “drive for leanness” had a lower risk of eating disorders. One possible explanation is the social and cultural pressure promoting specific beauty or fitness standards, triggering efforts to achieve “leanness” or muscle tone through extreme diet practices or unhealthy eating habits which can lead to the risk of eating disorders [47]. However, within the confines of the Islamic boarding school community, possessing a leanness body is not necessarily regarded as a point of esteem by the students. They prioritize the significance of competing to enhance their religious knowledge and devotion within the Islamic context, emphasizing activities such as Quranic memorization, recitation of prayers, and others [48]. This underscores the influence of cultural values and social norms in the boarding school environment on students’ body perceptions and the risk of eating disorders.
In previous studies, muscle-oriented eating patterns have been identified as significant predictors of long-term issues, such as problematic eating attitudes leading to a risk of developing eating disorders [49]. Other research has also underscored the association between muscle-oriented eating patterns and various adverse outcomes, including symptoms of depression and other irregular eating behaviors [50]. In our research within the Islamic boarding school context, we observed that students with lower levels of muscle-oriented eating patterns showed a decreased risk of developing eating disorders. This observation may be rooted in the Islamic boarding school environment’s meal selection, where the concept of the boarding school provides meals for the students, limiting their freedom to choose their food, especially muscle-oriented ones. Student in the Islamic boarding school, they have received a schedule and portioned meals that are predetermined and tailored to the students’ needs, ensuring that they feel adequately satisfied with the portions and menu provided. Additionally, students are also taught to always feel grateful for what they currently have. Consequently, students tend to accept and consume what is provided by the school without specifics orientation towards specific types of food [51], 52]. Meanwhile, mental health and body image perceptions are closely intertwined, as body image is a psychological construct that significantly influences an individuals’ mental well-being. A contributing factor to mental health issues, such as eating disorders, depression, and anxiety, can be triggered by body image perceptions, particularly dissatisfaction or excessive preoccupation with achieving a specific body shape. Ultimately, students with lower levels of muscle-oriented eating patterns can maintain their eating behavior, reducing the risk of developing eating disorders. However, it is always crucial to ensure and promote the mental health of students, particularly concerning their body image perceptions, to prevent excessive orientation towards specific body shapes that could potentially impact their eating behavior and lead to the risk of developing eating disorders.
Experiencing unhealthy weight loss in boarding schools significantly increases the risk of eating disorders among students. The extent of negative experiences related to weight loss in the past directly correlates with the likelihood of developing eating disorders in the future. These practices, including extreme dieting and restrictive eating habits, heighten vulnerability and impact mental health [53]. A study in Oregon (2010) found that adolescents engaging in unhealthy weight loss practices were more prone to eating disorders, depression, and substance abuse [54]. The widespread prevalence of disordered eating and unhealthy weight control practices among adolescents poses a concerning health issue, potentially leading to eating disorders [55]. Research on fad diets in female adolescents suggests a link to unhealthy weight loss practices and the development of eating disorders [56]. The school food environment may contribute to weight-related issues and unhealthy weight loss behaviors among students [57]. Boarding schools, by providing meals, limit students’ control over dietary choices, potentially leading to dissatisfaction and resorting to unhealthy weight loss measures [52]. Insufficient awareness and education about healthy weight management can result in misguided or extreme weight loss attempts [58]. Mitigating these risks involves promoting healthy eating habits, providing nutritious options, and implementing school-based programs. School staff play a crucial role in fostering healthy habits and identifying signs of eating disorder among students.
Eating disorders are multifaceted, arising from genetic, psychological, environmental, and sociocultural factors [59]. Boarding school life, especially for adolescent females, heightens body image concerns. Limited control over food choices in boarding schools may contribute to negative body image and health concerns. Negative body image, characterized by dissatisfaction with one’s physical appearance, is often a contributing factor to the development of eating disorders [60]. Our findings highlight the importance of addressing nutritional disparities among boarding school students to reduce the risk of eating disorders. Implementing targeted interventions to encourage healthy eating behaviors and providing adequate nutritional support and knowledge can contribute to creating an environment that supports student well-being.
While this study provides valuable insights, it is essential to acknowledge its limitations. Firstly, the cross-sectional design employed does not establish causation, and a more comprehensive understanding of the observed relationships could be obtained through longitudinal studies. Furthermore, the study’s reliance on self-reported data introduces the potential for bias, as participants may underreport sensitive information concerning eating behaviors and mental health. Despite these constraints, the findings contribute essential knowledge that can inform targeted interventions and support systems within Islamic boarding schools.
Conclusions
This study of Indonesian Islamic boarding school students has identified key factors that impact the risk of eating disorders. Nutritional status is significant: being underweight or maintaining a normal BMI notably reduces this risk. Furthermore, a lower drive for leanness and a lesser focus on muscularity-oriented eating are linked to a decreased likelihood of eating disorders. On the other hand, experiences with unhealthy weight loss methods substantially increase the risk. These findings highlight the complex nature of this mental health issue. By recognizing these factors, Islamic boarding schools can develop targeted interventions, including nutrition education programs, mental health and body image workshops, collaboration with parents and guardians ensuring the support of healthy eating habits, providing menu improvements and meals variety, training for school staffs, and physical activity programs. These interventions aim to reduce the prevalence of eating disorders by addressing contributing factors such as poor nutrition knowledge, body image dissatisfaction, and mental health challenges while promoting a supportive and health-oriented school environment. Risk mitigation involves encouraging healthy dietary habits, offering nutritious food options, and instituting comprehensive school-based programs. School staff play a vital role in nurturing healthy habits and in the early detection of disordered eating behaviors among students.
- Ethical approval: This research received approval from the Ethical Board of the Faculty of Nursing, Universitas Airlangga with number 2965-KEPK.
- Informed consent: Participants received comprehensive information about the study before joining, ensuring that participation was voluntary. Individuals who agreed to participate willingly signed a consent form. This document outlined the study’s objectives, procedures, and confidentiality measures. All collected data were treated with strict confidentiality, and the identities of participants were carefully safeguarded. No personal information has been disclosed in any publications. The study adhered to ethical guidelines to ensure the rights and well-being of the participants were prioritized and respected.
- Author contributions: All authors made a significant contribution to the work reported, whether that is in the conception, study design, execution, acquisition of data, analysis and interpretation, or in all these areas; took part in drafting, revising or critically reviewing the article; gave final approval of the version to be published; have agreed on the journal to which the article has been submitted; and agree to be accountable for all aspects of the work.
- Use of Large Language Models, AI and Machine Learning Tools: None declared.
- Conflict of interest: Authors state no conflict of interest.
- Research funding: This research was supported by a grant from Universitas Airlangga for supporting funding (Satu Joint Research Scheme) with grant number 1614/UN3.LPPM/PT.01.03/2023. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
- Data availability: The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.
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