الفهرس 
IntroductionOnly 14 pages are availabe for public view
 |  | from | 293 |  |  |
| | | from | 293 | | |
Abstract
There are three diagnostic categories of eating disorders, according to what was described in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV); they are anorexia nervosa, bulimia nervosa, and eating disorder not otherwise specified (American Psychiatric Association, 1994) whereas Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition that is currently available for diagnosis of eating disorders expanded to include: (1) anorexia nervosa; (2) bulimia nervosa; (3) binge-eating disorder; (4) avoidant/restrictive food intake disorder; (5) pica; (6) rumination disorder; (7) other specified feeding or eating disorder; and (8) unspecified feeding or eating disorder (American Psychiatric Association, 2013).
Eating disorders significantly impact the health and well-being of many adolescents (Hudson et al., 2007) and Ackard et al. (2007) & Culbert et al. (2011) found that adolescents are considered a group of population at risk for the development of eating disorders beside the disturbed eating attitudes and dieting behaviours among adolescents are widespread. Approximately, 36.4% of adolescent females and 23.9% of adolescent males put a great importance of both body weight and shape on self-evaluation.
Also, adolescents experience the development of both primary and secondary reproductive characteristics which may impact body image (Herpertz-Dahlmann et al., 2013) and this disturbance of body image has been found to be a potent risk factor for eating disorders (Jacobi and Fittig 2010). Furthermore, adolescents’ overestimation of body weight may be linked to harmful eating disorders which are health issues of particular interest during adolescence (Zipfel et al., 2015).
Moreover, these disorders have a serious consequence on physical and mental health of adolescents and adults. They often have a variety of medical complications and significant psychiatric comorbidity, some of them are irreversible and life threatening (Klump et al., 2009; Johnson, 2003).
In addition, eating disorders have not only an elevated mortality risk; anorexia nervosa is the most remarkable (Smink et al., 2012; Ohlmer et al., 2013), but also, they have the highest mortality rate of any mental illness (Trent et al., 2013).
The medical complications occurring in individuals with an eating disorder are largely related to the effects of starvation, malnutrition, and weight-control behaviors such as vomiting and laxative abuse. The consequences of nutritional deprivation and metabolic impairment on the growing and developing adolescent body also depend on the length, severity, and number of episodes of restriction and, the timing of those episodes in relationship to normal periods of growth and physical development (Eisenstein, 1997; Rome, 2003).
Furthermore, the medical complications of eating disorders in adolescents are different from that in adults; as they are potentially irreversible include growth retardation if the disorder occurs before closure of the epiphyses (15–18 years); pubertal delay or arrest (Nussbaum et al.,1985; Pfeiffer et al., 1986; Nussbaum et al., 1990); and impaired acquisition of peak bone mass during the second decade of life that increases the risk of osteoporosis in adulthood (Nussbaum et al.,1985; Biller et al., 1989; Kreipe et al., 1993).
Also, eating disorders have psychiatric complications that include depression, anxiety, repeated self harm, impaired relationships, and limitations on social functioning. Perhaps the most distressing fact about eating disorders is that they are the most deadly of all psychopathologies; 20% of people with an eating disorder diagnosis die from their medical sequelae (Maines, 1999; Birmingham et al., 2005).
The incidence and prevalence of disordered eating attitudes are increasing and eating disorders are considered the most prevalent diseases among adolescent girls next to obesity and bronchial asthma (Golden, 2003; Klein and Walsh, 2004). Adolescent females are at high risk for disordered eating attitudes (Golden, 2003) and for example these disorders became the third leading chronic illness among adolescent girls in the United States and other developed countries (World Health Organization [WHO], 2005).
The period-prevalence estimates of eating disorders have varied dramatically across studies (Hay et al., 2015; Solmi et al., 2016). This variability across studies may be due to sample size, differences in study design, and a focus on a certain age group such as adolescents or young adults only or focus on a certain culture and for example, Treasure and his colleagues found that eating disorders have a prevalence of about 5 % in the general population (Treasure et al., 2010) while Mitchison and his colleagues found that the prevalence of eating disorders is doubled during the last two decades in Western societies (Mitchison et al., 2012).
Risk factors for eating disorders arise from interplay of various factors such as biological and familial characteristics, the socio-cultural context as well as psychological factors (Emmett, 2013; Culbert et al., 2015).
The psychiatric comorbidity is common and can represent a rule rather than exception among individuals with eating disorders. Clinical and community studies have reported that between 55% and 98% of individuals with anorexia nervosa and between 88% and 97% of individuals with bulimia nervosa have another Axis I disorder (Brewerton et al., 1995; Blinder et al., 2006 & Swanson et al., 2011).
Rationale of the study:
Conduction of this study may help to give an important idea about the magnitude of the problem among a sample of adolescent students in one of Egyptian cities, Tanta, the Eastern area.
Hypothesis:
The eating disorders are underestimated problem among adolescents and that they would be highly prevalent among the studied sample; and some specific socio-demographic and clinical characteristics would be expected as risk factors for the development of eating disorders among this population.
Aim of the work:
To determine the prevalence of eating disorders in a sample of secondary school students in Eastern area of Tanta and to study the different socio-demographic and clinical characteristics of eating disorders.
Subjects and Methods:
Study design: It is a cross-sectional descriptive study.
Site and date of the study: Secondary schools in Tanta, the Eastern area. The study was conducted during the academic year 2016/2017.
Subjects, sample design and sample size: The sample size was calculated and the sample was allocated to be representative: Stratified random sampling was used in this study for random choice of schools, random choice of classes and the random choice of students to obtain the representative sample to the total study population. The sample size is 407 secondary school students aging 16-18 years and it was statistically calculated by considering the total society size = 12784, error percentage = (0.05), percentage of availability of the character and objectivity = 70% and the corresponding standard class of significance = 95%.
Allocation of the sample:
The study sample was allocated to ensure suitability of chosen sample to the total number of students; 300 students from governmental secondary schools and 107 students from private secondary schools. from each type of the schools, stratification was done, where two schools were selected by random sampling, then from each selected school, classes were selected also by random sampling and from the selected class, students were also selected by simple random sampling.
Inclusion criteria:-
1 - Secondary school students who were agreed on sharing in the study.
2 - Age: 16 - 18 years.
3 - Both male and female sex.
Exclusion criteria:-
Age below 16 or above 18 years.
Tools:
(1) A designed questionnaire (Appendix-1).
(2) Eating Attitudes Test (EAT40) (Appendix-2).
(3) Body Shape Questionnaire-Revised-10 (BSQ-R-10;Mazzeo 1999)-Arabic version- (El desouky, 2004) (Appendix-3).
(4) Self-esteem Scale (El Dereni et al., 1982) (Appendix-4).
(5) Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I-R) (First et al., 1996)-Arabic version-Revised (El-missiry et al., 2003) (Appendix-5).
Ethical consideration:
A written informed consent was obtained from the school manager for all included subjects who agreed to participate in the study. All subjects were informed about the questionnaires being used in the study and students who accepted to share in the study were included. Interviews with the students were done at each school in private places that were determined by the school manager.
Procedure:
1- A written consent was obtained from Directorate of Education and its related security office.
2- A written consent was obtained from Educational Administration of Eastern Tanta and its related security office.
3- Official letters were obtained from Educational Administration of Eastern Tanta and forwarded to the previously selected schools by random sampling.
4- A written informed consent was obtained from the school manager for all included subjects who agreed to participate in the study.
5- Socio-demographic data were reported and height & weight were measured for all students who agreed to participate in the study. The household crowding index was calculated, EAT40, BSQ-R-10 and Self-esteem Scale were done for all students who agreed to participate in the study.
6- SCID-I was done for the students with EAT40 score ≥ 30 in private places that were determined by their school manager.
Statistical analysis:
The collected data were organized, tabulated and statistically analyzed using SPSS software (Statistical Package for the Social Sciences, version 19, SPSS Inc. Chicago, IL, USA). The statistical significance was adopted at p<0.05 for interpretation of results of tests of significance (Dawson and Trapp, 2001).
Results:
In this current study, the socio-demographic data of the study sample include the mean age of the students is 16.05 ± 0.23 years. 39.8% of the fathers have university education, 41.3% and 44% of the fathers are semi-professional and professional, respectively. 55.8% of the fathers have enough incomes, 83% of the fathers are kind with their children. 39.6% of the mothers have university education, 53.3% of the mothers have no job, 40.8% of the mothers have enough special income and 89.4% of the mothers are kind with their children. The household crowding index for 80.8% of the students is two and 49.6% of them have warm home atmospheres.
As regards the comparison of clinical characteristics of eating disorders between male and female secondary school students in Eastern Tanta, we found that the mean body weight (68.37±15.54) and height (169.63±6.76) of the males are significantly higher than that of the females (weight =61.64±13.28 and height =160.49±5.25) and the mean students’ body mass index is 23.72 ± 4.72 kg/m2 without significant difference between males and females. The mean score of EAT-40 of females (20.71±10.14) is highly significant higher than that of males (16.41±7.76) but both scores indicate normal eating attitude and behavior (below 30 the cut-off point). 28.5% of the females and 12.6% of the males are highly preoccupied with their body shape with significant difference between them. Females are significantly more preoccupied with their body shape (BSQ-R-10 = 31.68±13.81) than males (BSQ-R-10 = 25.63±11.60), 3.4% of the students (14 students) have low self-esteem without significant difference between males and females. Males (mean self-esteem score = 40.70±8.54) have significant higher self-esteem than females (mean self-esteem score = 38.55±9.32).
Whereas the prevalence of eating disorder among secondary school students is 9.3% (38/407) and the prevalence of anorexia nervosa is 3.2% (13/407) while that of bulimia nervosa is 6.1% (25/407). Moreover, we found that 82% (31/38) of the students with eating disorders and 46% (169/369) of the students without eating disorders are females with highly significant difference between them.
In addition, the current study revealed that there is a significant statistical difference between students with and without eating disorders as regards their mother job as students with eating disorders having a semi-professional mother job (36.9%) are more than those without eating disorders (28.7%) while students without eating disorders having a professional mother job (16.5%) are more than those with eating disorders (10.5%).
Regarding the comparison between students with and without eating disorders as regards the clinical characteristics, we found that the mean body height of the students with eating disorders (162.68 cm ± 6.32) is significantly lower than that of the students without eating disorders (165.39 cm ± 7.67) while the mean body weight of the students with eating disorders is 63.47 kg ± 22.22 and the mean BMI of the students with eating disorders is 23.79 kg/m2 ± 7.7 with insignificant difference between eating disorder and non-eating disorder students as regards either body weight or BMI.
The mean body weight of anorexia nervosa students (41.08±3.28) is highly significant lower than that of bulimia nervosa students (75.12±18.52) and the mean BMI of anorexia nervosa students (15.72 kg/m2 ± 0.23) is highly significant lower than that of bulimia nervosa students (27.99 kg/m2 ± 6.14).
We also found that the mean score of EAT-40 among students with eating disorders (38.08 ± 8.40) indicating abnormal eating attitudes and behaviors (above 30 the cut-off point) is significantly higher than that of students without eating disorders (16.51 ± 6.62).
In addition, we have found that 68.4% of the students with eating disorders and 15.4% of the students without eating disorders are highly preoccupied with their body shape with highly significant difference between them. Students with eating disorders are significantly more preoccupied with their body shape (BSQ-R-10 = 47.31 ± 9.66) than students without eating disorders (BSQ-R-10 = 26.68 ± 11.80). Whereas, 23.7% (9/38) of the students with eating disorders and only 1.4% (5/369) of the students without eating disorders have low self-esteem with highly significant difference between them and students with eating disorders (mean self-esteem score = 25.92 ± 5.97)) have highly significant lower self esteem than students without eating disorders (mean self-esteem score = 41.06 ± 8.00).
Regarding the comparison between anorexia nervosa students and bulimia nervosa students as regards socio-demographic data, we found insignificant difference between them. While, regarding the comparison between anorexia nervosa students and bulimia nervosa students as regards clinical characteristics, we found that the mean body weight of anorexia nervosa students (55.46±8.92) is significantly lower than that of bulimia nervosa students (75.12±18.52) and there is insignificant difference between the mean body height of anorexia nervosa students (161.46±6.13) and those of bulimia nervosa students (163.32±6.45). The mean BMI of anorexia nervosa students (21.13 kg/m2 ± 2.48) is highly significant lower than that of bulimia nervosa students (27.99 kg/m2 ± 6.14) and the mean score of EAT-40 among anorexia nervosa students (40.46±10.44) and among bulimia nervosa students (36.84±7.04) indicate abnormal eating attitudes and behaviors (above 30 the cut-off point) without significant difference between them. And, there is insignificant difference between secondary school students with anorexia nervosa and those with bulimia nervosa as regards body shape preoccupation and self-esteem.
Furthermore, we found that the predictive factors of eating disorders and their types are: (1) Female gender: Female gender is a predictive factor for eating disorders either anorexia nervosa or bulimia nervosa. (2) Body shape preoccupation: Body shape preoccupation is a predictive factor for eating disorders either anorexia nervosa or bulimia nervosa. (3) Low self-esteem: low self-esteem is a predictive factor for eating disorders either anorexia nervosa or bulimia nervosa. (4) Abnormal eating attitude and behavior: Abnormal eating attitude and behavior is a predictive factor for eating disorders either anorexia nervosa or bulimia nervosa. (5) Overweight: Overweight is a predictive factor for eating disorders and bulimia nervosa. (6) Underweight: Underweight is a predictive factor for anorexia nervosa.
We also found that 94.7% of the eating disorder students have psychiatric comorbidities and there is insignificant difference between anorexia nervosa students and bulimia nervosa students as regards the comorbid psychiatric disorders except for the major depressive disorder which is significantly higher among anorexia nervosa students than among bulimia nervosa students what could be explained by the effects of starvation in anorexia nervosa students which may contribute to a depressive‐like state or even to major depressive disorder and it was reported that depression improves with weight restoration.
In addition, we found the following psychiatric disorders comorbid with eating disorders which include depressive disorders, anxiety disorders and somatoform disorders: (1) Specific phobia: the most common psychiatric comorbidity among eating disorder students is specific phobia (30/38 – 78.9%) {10/13 (76.9%) anorexia nervosa students and 20/25 (80%) bulimia nervosa students}. 7/38 (18%) eating disorder students suffer from specific phobia only; 2/13 (15.4%) anorexia nervosa students and 5/25 (20%) bulimia nervosa students suffer from specific phobia only, whereas 8/13 anorexia nervosa students (61.5%) anorexia nervosa students and 15/25 (60%) bulimia nervosa students suffer from additional psychiatric disorders beside the specific phobia.
(2) Generalized anxiety disorder: more than the half eating disorder students suffer from generalized anxiety disorder (21/38 – 55.3%) {8/13 (61.5%) anorexia nervosa students and 13/25 (52%) bulimia nervosa students}. 2/25 (8%) bulimia nervosa students suffer from generalized anxiety disorder only, whereas, 8/13 (61.5%) anorexia nervosa students and 11/25 (44%) bulimia nervosa students suffer from additional psychiatric disorder beside the generalized anxiety disorder. (3) Major depressive disorder: less than the half eating disorder students suffer from major depressive disorder (18/38 – 47.9%) {9/13 (69.2%) anorexia nervosa students and 9/25 (36%) bulimia nervosa students; with significant difference between them}. All of them suffer from additional psychiatric disorders beside the major depressive disorder. (4) Dysthymic disorder: more than the quarter of eating disorder students suffer from dysthymic disorder (11/38 – 28.9%) {4/13 (30.8%) anorexia nervosa students and 7/25 (28%) bulimia nervosa students}. All of them suffer from additional psychiatric disorders beside the dysthymic disorder. (5) Social phobia: more than the quarter of eating disorder students suffer from social phobia (11/38 – 28.9%) {6/13 (46.2%) anorexia nervosa students and 5/25 (20%) bulimia nervosa students}. All of them suffer from additional psychiatric disorders beside the social phobia. (6) Posttraumatic stress disorder: 13.2% (5/38) of eating disorder students suffer from posttraumatic stress disorder {3/13 (23.1%) anorexia nervosa students and 2/25 (8%) bulimia nervosa students}. One from 13 (7.7%) anorexia nervosa student suffers from posttraumatic stress disorder only, whereas, 2/13 (15.4%) anorexia nervosa students and 2/25 (8%) bulimia nervosa students suffer from additional psychiatric disorders beside the posttraumatic stress disorder. (7) Panic disorder without agoraphobia: 10.5% (4/38) of eating disorder students suffer from panic disorder without agoraphobia {One/13 (7.7%) anorexia nervosa student and 3/25 (12%) bulimia nervosa students}. All of them suffer from additional psychiatric disorders beside the panic disorder without agoraphobia. (8) Somatization disorder: 7.9% (3/38) of eating disorder students suffer from somatization disorder {One/13 (7.7%) anorexia nervosa students and 2/25 (8%) bulimia nervosa students}. All of them suffer from additional psychiatric disorders beside the somatization disorder.
(9) Body dysmorphic disorder: 7.9% (3/38) of eating disorder students suffer from body dysmorphic disorder {2/13 (15.4%) anorexia nervosa students and one/25 (4%) bulimia nervosa student}. All of them suffer from additional psychiatric disorders beside the body dysmorphic disorder. (10) Panic disorder with agoraphobia: one anorexia nervosa student (2.6% from the eating disorder students and 7.7% from the anorexia nervosa students) suffers from panic disorder with agoraphobia with other additional psychiatric disorders. (11) Agoraphobia without history of panic disorder: one bulimia nervosa student (2.6% from the eating disorder students and 4% from the anorexia nervosa students) suffers from agoraphobia without history of panic disorder with other additional psychiatric disorders. (12) Obsessive-compulsive disorder: one bulimia nervosa student (2.6% from the eating disorder students and 4% from the anorexia nervosa students) suffers from obsessive-compulsive disorder with other additional psychiatric disorders. (13) Hypochondriasis: one anorexia nervosa student (2.6% from the eating disorder students and 7.7% from the anorexia nervosa students) suffers from hypochondriasis with other additional psychiatric disorders.