Int J Adolesc Med Health 2015; 27(1): 93–100
Supa Pengpid, Karl Peltzer* and Gias Uddin Ahsan
Risk of eating disorders among university students in Bangladesh Introduction
Abstract Objective: As there is a lack of information on eating disorders in Bangladesh, the aim of this study was to explore the eating disorder attitudes and behaviors among undergraduate university students in the country. Materials and methods: A cross-sectional questionnaire survey and anthropometric measurement were conducted with undergraduate students who were recruited randomly from classes. The Eating Attitudes Test (EAT26) was used to determine the prevalence of disordered eating attitudes. The sample included 800 university students (56.6% men and 43.4% women), with a mean age of 21.0 years (SD = 32.5). Results: Using the EAT-26, 37.6% of the students were classified as being at risk for an eating disorder. In multivariate analysis, being a late adolescent (17–19 years), high religious involvement, overweight body perception, low body appreciation, having had cosmetic surgery, and current binge drinking were found to be associated with an eating disorder risk. Discussion: Very high rates of eating disorder risk were found. This result calls for increased awareness and understanding of eating disorders, and related risk factors and interventions in university students in Bangladesh. Keywords: Bangladesh; EAT-26; eating attitudes; eating behavior; university students. DOI 10.1515/ijamh-2014-0013 Received March 1, 2014; accepted May 13, 2014; previously published online August 12, 2014
*Corresponding author: Prof. Karl Peltzer, ASEAN Institute for Health Development, Madidol University, Salaya, Phutthamonthon, Nakhonpathom 73170, Thailand, E-mail: [email protected]; University of Limpopo, Turfloop Campus, Sovenga, South Africa; and HIV/AIDS/STI/and TB (HAST), Human Sciences Research Council, Pretoria, South Africa Supa Pengpid: ASEAN Institute for Health Development, Madidol University, Salaya, Phutthamonthon, Nakhonpathom, Thailand; and University of Limpopo, Turfloop Campus, Sovenga, South Africa Gias Uddin Ahsan: Department of Public Health, North South University, Bashundhara, Dhaka, Bangladesh
Recent studies demonstrate that eating disorders and disordered eating behaviors occur in non-Western countries, including South Asian societies (1, 2). Among university students, the following prevalences of eating disorders were found: in China (3.2%–9.9% in females and 1.2%– 2% in males) (3, 4), India (female nursing students, 4%) (5), Malaysia Sarawak (13.7% females, 5.6% males) (6), Pakistan (17%–22.75%) (7, 8), and Turkey [17.2% of the underweight and 21.2% of the overweight (9), and 7.9% in Turkish students (10)]. Filipino students were 10.9 times more likely to have eating disordered attitudes and behaviors than their American counterparts (11). Factors identified to be associated with eating disorders include (i) sociodemographic variables, including adolescent age, female sex, and married status (11); greater exposure to Western culture (8); cultural transition and globalization, including modernization, urbanization, and media exposure promoting the Western beauty ideal (2, 12–14); and lack of religiosity (15, 16); (ii) body-related variables including body mass index (BMI) (3), body shape concern (3, 8), desire for thinness (17), and cosmetic surgery (18); and (iii) mental distress and substance misuse, such as perceived stress (19) and mental distress (social anxiety, depression) (3, 19), and substance use disorders often co-occur with eating disorders in female populations (20). As there is a lack of information on eating disorders in Bangladesh, the aim of this study was to explore eating disorder attitudes and behaviors in a university student population in Bangladesh.
Methods Sample and procedure A cross-sectional survey design was used. An anonymous, selfadministered questionnaire was used to collect data. Concerning the sampling procedure, the simple random sampling method was used in this survey. Undergraduate classes of North South University in Dhaka were selected randomly during day classes; then, from the randomly selected classes based on the class attendance/sampling
Unauthenticated Download Date | 4/16/16 9:58 AM
94 Pengpid et al.: Eating disorders among students in Bangladesh frame, every alternative undergraduate student was selected as a respondent after taking their informed consent. A presurvey half-day orientation training was conducted for 10 faculty members/teachers and 10 research fellows on survey methods and data collection technique, including physical assessment that was supervised and cross-checked by the selected faculty members. Ten percent of the collected questionnaire was cross checked for correctness and missing data, and then returned to the students for correction; however, unfortunately, we did not find all of the students as there were no classes for all sections. The study protocol was approved by the North South University research Ethics Committees, and permission was obtained from the university management. The cover pages of the questionnaires briefly explained about the study and provided instructions to the respondents on how to fill it up. It also provided information about the researchers. It also mentioned that anonymity and confidentiality would be maintained and that the participation of students was voluntary. It specified that data would be used only for research purposes. The study was conducted from December 2013 to January 2014.
of your body”? Response options ranged from 1 (extremely dissatisfied) to 5 (extremely satisfied). The Body Appreciation Scale (BAS) (28, 29) has 13 items rated on a five-point scale (1 = never, 5 = always), and are averaged to arrive at a total score (higher scores reflect greater body appreciation); sample items include, “I feel good about my body” and “I do not focus a lot of energy being concerned with my body shape or weight”. The Cronbach α reliability coefficient of this 13-item scale was 0.93 in this study. Tobacco use was assessed with the question, “Do you currently use one or more of the following tobacco products (cigarettes, snuff, chewing tobacco, cigars, etc.)”? Response options were “yes” or “no” (30). Alcohol consumption was measured by asking participants which of the following terms best described them: non-drinker, special occasions drinker, occasional drinker, and regular drinker (27) Occasional and regular drinkers were asked, “How often do you have (for men) five or more and (for women) four or more drinks on one occasion”?
Centres for Epidemiologic Studies Depression Scale (CES-D)
Measures The Eating Attitude Test-26 (EAT-26) is a validated self-administered questionnaire widely used to measure symptoms and features of eating disorders (21). It comprises 26 questions for which scoring is done on a six-point scale, from always to never. The total sum of EAT-26 scores ranges from 0 to 78. The EAT has a three-factor structure: dieting, food preoccupation, and oral control. The EAT-26 had a Cronbach α of 0.89 in the current study. The cutoff score for the EAT-26 is a total score of ≥ 20, indicating a risk for disordered eating attitudes and behaviors, and the need to be evaluated further by a mental health professional.
We assessed depressive symptoms using the 10-item version of the CES-D (31). While the CES-D 10-item survey has not been directly compared with clinical diagnosis of major depression, the sensitivity and specificity of the CES-D 20-item survey has been reported to average 80% and 70%, respectively, compared with formal diagnostic interview (32). Scoring is classified from 0 to 9 as having a mild level of depressive symptoms, 10 to 14 as moderate depressive symptoms, and ≥ 15 representing severe depressive symptoms (33). The Cronbach α reliability coefficient of this 10-item scale was 0.76 in this study.
Posttraumatic stress disorder (PTSD)
Anthropometric measurements Students were weighed and measured by trained researchers using standardized procedures (22). Waist circumference (WC) was measured around the waist through a point one-third of the distance between the xiphoid process and the umbilicus, using a non-stretchable tape measure (23). BMI was calculated for each participant by dividing weight in kilograms by the square of height in meters (24). BMI was used as an indicator of obesity ( ≥ 27.5 kg/m2), and overweight was defined as BMI ≥ 23–27.4 (25). Central obesity was defined as WC ≥ 90 cm in men and ≥ 80 cm in women, according to World Health Organization (26) South Asian criteria.
A seven-item screener was used to identify PTSD symptoms in the past month (34, 35). The items asked whether the respondent had experienced difficulties related to a traumatic experience (e.g., “Did you begin to feel more isolated and distant from other people?”, “Did you become jumpy or get easily startled by ordinary noises or movements?”). Consistent with epidemiological evidence, participants who answered affirmatively to at least four of the questions were considered to have a positive screen for PTSD (34, 35). The Cronbach α reliability coefficient of this seven-item scale was 0.62 in this study.
Duke University Religion Index (DUREL)
Body image assessment Body weight perception was assessed with the question, “Do you consider yourself to be very overweight, slightly overweight, about right, slightly underweight, and very underweight?” (27). In the analysis, “very” and “slightly” overweight and “very” and “slightly” underweight, respectively, were collapsed. Body size and shape perception were assessed with the question, “How satisfied are you at this moment with the size and shape
Religiousness was assessed with the five-item DUREL (36). The instrument assesses the three major dimensions of religiosity: organized religious activity, non-organized religious activity, and intrinsic religiosity (or subjective religiosity) (37). The DUREL measures each of these dimensions by a separate “subscale”, and correlations with health outcomes are analyzed by subscale in separate models (37). The Cronbach α for the intrinsic religiosity scale was 0.76 for this sample.
Unauthenticated Download Date | 4/16/16 9:58 AM
Pengpid et al.: Eating disorders among students in Bangladesh 95
Socioeconomic background was assessed by rating their family background as wealthy (within the highest 25% in Bangladesh, in terms of wealth), quite well-off (within the 50%–75% range for their country), not very well-off (within the 25%–50% range from Nigeria), or quite poor (within the lowest 25% in their country, in terms of wealth) (27). We subsequently divided the students into poorer (not very well-off and quite poor) and wealthier (wealthy, quite well-off) categories.
Data analysis The data were analyzed using IBM-SPSS for Windows, version 20 (Chicago, IL, USA). Descriptive statistics were used to calculate the frequency of sample characteristics of the study population. Multivariable logistic regression analysis was performed with eating disorder risk (EAT-26 scores ≥ 20) as the dependent variable. Sociodemographic characteristics, body-related variables, substance use, and mental distress variables were taken as independent variables. p
Supa Pengpid, Karl Peltzer* and Gias Uddin Ahsan
Risk of eating disorders among university students in Bangladesh Introduction
Abstract Objective: As there is a lack of information on eating disorders in Bangladesh, the aim of this study was to explore the eating disorder attitudes and behaviors among undergraduate university students in the country. Materials and methods: A cross-sectional questionnaire survey and anthropometric measurement were conducted with undergraduate students who were recruited randomly from classes. The Eating Attitudes Test (EAT26) was used to determine the prevalence of disordered eating attitudes. The sample included 800 university students (56.6% men and 43.4% women), with a mean age of 21.0 years (SD = 32.5). Results: Using the EAT-26, 37.6% of the students were classified as being at risk for an eating disorder. In multivariate analysis, being a late adolescent (17–19 years), high religious involvement, overweight body perception, low body appreciation, having had cosmetic surgery, and current binge drinking were found to be associated with an eating disorder risk. Discussion: Very high rates of eating disorder risk were found. This result calls for increased awareness and understanding of eating disorders, and related risk factors and interventions in university students in Bangladesh. Keywords: Bangladesh; EAT-26; eating attitudes; eating behavior; university students. DOI 10.1515/ijamh-2014-0013 Received March 1, 2014; accepted May 13, 2014; previously published online August 12, 2014
*Corresponding author: Prof. Karl Peltzer, ASEAN Institute for Health Development, Madidol University, Salaya, Phutthamonthon, Nakhonpathom 73170, Thailand, E-mail: [email protected]; University of Limpopo, Turfloop Campus, Sovenga, South Africa; and HIV/AIDS/STI/and TB (HAST), Human Sciences Research Council, Pretoria, South Africa Supa Pengpid: ASEAN Institute for Health Development, Madidol University, Salaya, Phutthamonthon, Nakhonpathom, Thailand; and University of Limpopo, Turfloop Campus, Sovenga, South Africa Gias Uddin Ahsan: Department of Public Health, North South University, Bashundhara, Dhaka, Bangladesh
Recent studies demonstrate that eating disorders and disordered eating behaviors occur in non-Western countries, including South Asian societies (1, 2). Among university students, the following prevalences of eating disorders were found: in China (3.2%–9.9% in females and 1.2%– 2% in males) (3, 4), India (female nursing students, 4%) (5), Malaysia Sarawak (13.7% females, 5.6% males) (6), Pakistan (17%–22.75%) (7, 8), and Turkey [17.2% of the underweight and 21.2% of the overweight (9), and 7.9% in Turkish students (10)]. Filipino students were 10.9 times more likely to have eating disordered attitudes and behaviors than their American counterparts (11). Factors identified to be associated with eating disorders include (i) sociodemographic variables, including adolescent age, female sex, and married status (11); greater exposure to Western culture (8); cultural transition and globalization, including modernization, urbanization, and media exposure promoting the Western beauty ideal (2, 12–14); and lack of religiosity (15, 16); (ii) body-related variables including body mass index (BMI) (3), body shape concern (3, 8), desire for thinness (17), and cosmetic surgery (18); and (iii) mental distress and substance misuse, such as perceived stress (19) and mental distress (social anxiety, depression) (3, 19), and substance use disorders often co-occur with eating disorders in female populations (20). As there is a lack of information on eating disorders in Bangladesh, the aim of this study was to explore eating disorder attitudes and behaviors in a university student population in Bangladesh.
Methods Sample and procedure A cross-sectional survey design was used. An anonymous, selfadministered questionnaire was used to collect data. Concerning the sampling procedure, the simple random sampling method was used in this survey. Undergraduate classes of North South University in Dhaka were selected randomly during day classes; then, from the randomly selected classes based on the class attendance/sampling
Unauthenticated Download Date | 4/16/16 9:58 AM
94 Pengpid et al.: Eating disorders among students in Bangladesh frame, every alternative undergraduate student was selected as a respondent after taking their informed consent. A presurvey half-day orientation training was conducted for 10 faculty members/teachers and 10 research fellows on survey methods and data collection technique, including physical assessment that was supervised and cross-checked by the selected faculty members. Ten percent of the collected questionnaire was cross checked for correctness and missing data, and then returned to the students for correction; however, unfortunately, we did not find all of the students as there were no classes for all sections. The study protocol was approved by the North South University research Ethics Committees, and permission was obtained from the university management. The cover pages of the questionnaires briefly explained about the study and provided instructions to the respondents on how to fill it up. It also provided information about the researchers. It also mentioned that anonymity and confidentiality would be maintained and that the participation of students was voluntary. It specified that data would be used only for research purposes. The study was conducted from December 2013 to January 2014.
of your body”? Response options ranged from 1 (extremely dissatisfied) to 5 (extremely satisfied). The Body Appreciation Scale (BAS) (28, 29) has 13 items rated on a five-point scale (1 = never, 5 = always), and are averaged to arrive at a total score (higher scores reflect greater body appreciation); sample items include, “I feel good about my body” and “I do not focus a lot of energy being concerned with my body shape or weight”. The Cronbach α reliability coefficient of this 13-item scale was 0.93 in this study. Tobacco use was assessed with the question, “Do you currently use one or more of the following tobacco products (cigarettes, snuff, chewing tobacco, cigars, etc.)”? Response options were “yes” or “no” (30). Alcohol consumption was measured by asking participants which of the following terms best described them: non-drinker, special occasions drinker, occasional drinker, and regular drinker (27) Occasional and regular drinkers were asked, “How often do you have (for men) five or more and (for women) four or more drinks on one occasion”?
Centres for Epidemiologic Studies Depression Scale (CES-D)
Measures The Eating Attitude Test-26 (EAT-26) is a validated self-administered questionnaire widely used to measure symptoms and features of eating disorders (21). It comprises 26 questions for which scoring is done on a six-point scale, from always to never. The total sum of EAT-26 scores ranges from 0 to 78. The EAT has a three-factor structure: dieting, food preoccupation, and oral control. The EAT-26 had a Cronbach α of 0.89 in the current study. The cutoff score for the EAT-26 is a total score of ≥ 20, indicating a risk for disordered eating attitudes and behaviors, and the need to be evaluated further by a mental health professional.
We assessed depressive symptoms using the 10-item version of the CES-D (31). While the CES-D 10-item survey has not been directly compared with clinical diagnosis of major depression, the sensitivity and specificity of the CES-D 20-item survey has been reported to average 80% and 70%, respectively, compared with formal diagnostic interview (32). Scoring is classified from 0 to 9 as having a mild level of depressive symptoms, 10 to 14 as moderate depressive symptoms, and ≥ 15 representing severe depressive symptoms (33). The Cronbach α reliability coefficient of this 10-item scale was 0.76 in this study.
Posttraumatic stress disorder (PTSD)
Anthropometric measurements Students were weighed and measured by trained researchers using standardized procedures (22). Waist circumference (WC) was measured around the waist through a point one-third of the distance between the xiphoid process and the umbilicus, using a non-stretchable tape measure (23). BMI was calculated for each participant by dividing weight in kilograms by the square of height in meters (24). BMI was used as an indicator of obesity ( ≥ 27.5 kg/m2), and overweight was defined as BMI ≥ 23–27.4 (25). Central obesity was defined as WC ≥ 90 cm in men and ≥ 80 cm in women, according to World Health Organization (26) South Asian criteria.
A seven-item screener was used to identify PTSD symptoms in the past month (34, 35). The items asked whether the respondent had experienced difficulties related to a traumatic experience (e.g., “Did you begin to feel more isolated and distant from other people?”, “Did you become jumpy or get easily startled by ordinary noises or movements?”). Consistent with epidemiological evidence, participants who answered affirmatively to at least four of the questions were considered to have a positive screen for PTSD (34, 35). The Cronbach α reliability coefficient of this seven-item scale was 0.62 in this study.
Duke University Religion Index (DUREL)
Body image assessment Body weight perception was assessed with the question, “Do you consider yourself to be very overweight, slightly overweight, about right, slightly underweight, and very underweight?” (27). In the analysis, “very” and “slightly” overweight and “very” and “slightly” underweight, respectively, were collapsed. Body size and shape perception were assessed with the question, “How satisfied are you at this moment with the size and shape
Religiousness was assessed with the five-item DUREL (36). The instrument assesses the three major dimensions of religiosity: organized religious activity, non-organized religious activity, and intrinsic religiosity (or subjective religiosity) (37). The DUREL measures each of these dimensions by a separate “subscale”, and correlations with health outcomes are analyzed by subscale in separate models (37). The Cronbach α for the intrinsic religiosity scale was 0.76 for this sample.
Unauthenticated Download Date | 4/16/16 9:58 AM
Pengpid et al.: Eating disorders among students in Bangladesh 95
Socioeconomic background was assessed by rating their family background as wealthy (within the highest 25% in Bangladesh, in terms of wealth), quite well-off (within the 50%–75% range for their country), not very well-off (within the 25%–50% range from Nigeria), or quite poor (within the lowest 25% in their country, in terms of wealth) (27). We subsequently divided the students into poorer (not very well-off and quite poor) and wealthier (wealthy, quite well-off) categories.
Data analysis The data were analyzed using IBM-SPSS for Windows, version 20 (Chicago, IL, USA). Descriptive statistics were used to calculate the frequency of sample characteristics of the study population. Multivariable logistic regression analysis was performed with eating disorder risk (EAT-26 scores ≥ 20) as the dependent variable. Sociodemographic characteristics, body-related variables, substance use, and mental distress variables were taken as independent variables. p
