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Eating Disorders Research Initiative (EDRI)

 

The purpose of eating disorder research initiative is to produce evidence-based data on prevalence and management of eating disorders in Pakistan. This initiative also includes designing and implementation of clinical trials/research studies for developing innovative pharmacologic or behavioral interventions for the screening, treatment and prevention of eating disorders. The initiative also focuses on developing strategic alliances with International partners to secure sustainable funding and increase the range and quantity of effective eating disorder support. Moreover, developing national and international partnerships for promoting equity in research and program funding for screening, treatment and prevention of eating disorders are also part of this initiative.

Research on Eating Disorders in Asia: A Need to Address the Critical Gaps 

In the past, eating disorders were characterized as illnesses that affected only young, White, affluent women. Recently, however, research has begun to demonstrate that the syndromes and symptoms of anorexia nervosa (AN), bulimia nervosa (BN), and binge eating disorder (BED) are present in men and women of diverse racial/ethnic, cultural, and socioeconomic backgrounds. They are among the most lethal of psychiatric illnesses, with estimated mortality rates ranging from 0.3% to as high as 20.0% and interventions that occur earlier in the course of certain eating disorders have been related to improved outcomes. 




Research on Eating Disorders in Middle East

A study conducted in Kuwait highlighted that approximately 28% of the sample was at risk for eating pathology. Thin-ideal internalization was also found to significantly predict eating pathology (Zainal etal, 2020). Another study revealed that majority of individuals were dissatisfied with their current muscle mass and body fat. Individuals dissatisfied with their muscularity and body fat had significantly higher risk of disordered eating attitudes (Ebrahim etal, 2019). Another study highlighted that Kuwaiti students with overweight and obesity were at high risk of disordered eating compared to students who were at a normal weight or underweight. Women with normal and underweight had higher chances of developing restrictive oral control behaviors associated with anorexia nervosa. Distorted weight perception was found in all weight categories (Al Kazemi etal, 2018).

A study conducted in Jordan revealed that majority of students believed that young women struggled with body image and 72% of students believed that young women struggled with eating disorders. Additionally, 14% reported that they have or currently are suffering from an eating disorder. Professionals suggested that the media, lack of education, lack of resources, and culture are the major reasons why eating disorders and low self-body image are an issue and that these need to be improved (Gable, 2014).

A study conducted in Turkey highlighted that majority of the students had orthorexia. In the male students, there was a statistically significantly higher tendency for orthorexia and there was a statistically significant difference between the age groups for tendency for orthorexia (Fidan etal, 2010). Another study highlighted that EDs were higher in females and those with history of trauma (Unal e 2017). Another study in Turkish students revealed that females also had more negative body image and higher depression levels. Individuals with abnormal eating attitudes had higher depression levels (Tayfur and Evrensel, 2020).

A study was conducted among school counselors which highlighted that counselors correctly identified target case in over half of cases with anorexia nervosa being the most frequently correctly identified compared to depression or Diabetes. Diagnostic knowledge of anorexia nervosa was lower compared to other eating disorders, although not significant (Ogutlu etal, 2021) . A study conducted among healthcare professionals highlighted that  mental health professionals from Turkey perceive the causes of eating disorders on the microsystemic level, whereas U. S. practitioners perceive the causes on the macrosystemic level (Erguner etal, 2010).

Another study in Turkey concluded that problematic internet use is significantly correlated with eating disorders and that variations arise in problematic internet use depending on the faculty attended (Celik etal, 2015). Another study conducted among Turkish nursing students concluded that [psychological status, self-esteem, economic level, and place of residence of nursing students may be the potential factors for eating disorders (Celik etal, 2015).

A study conducted in Saudi Arabia highlighted that high risk eating disorders was significantly higher among females, among those aged ≤22 years, among those who had a GPA more than 2.49 ( and among those who are obese compared to underweight (Alhazmi etal, 2019). Another study highlighted that the highest rate of eating disorder  was reported among underweight students whereas the lowest rate was reported among obese students. EDs are more prevalent in females who believe that others are comparing them with slimmer people; media has an impact on their efforts toward slimness and world fashion and style has a role on their trial to lose weight (Allihaibi, 2015). Another study highlighted that frequencies of eating disorder symptoms increased with an increase in the body mass index of the participants. In addition, more than half of the participants who were pressured by social media to be slim and perceived that social media influencers motivated them to go to the gym had eating disorders' symptoms (Al jumayan etal, 2021).

A study in UAE highlighted that about 33% of the sample had mild to marked concerns about their body shape. Women students were significantly more concerned about their shape, and more influenced by media than men (Hasan etal, 2018). Another study in feale students showed that 24% of the sample were indicative of disordered eating attitudes and possible eating disorder. Additionally 74.8% of the participants were dissatisfied with their current estimated body image, furthermore disordered eating attitudes were positively correlated with body image dissatisfaction, and negatively correlated with body image ideals (Thomas etal, 2010).

Research on Eating Disorders in South East Asia

A study conducted in Malaysia highlighted that the results showed that 6.3% were susceptible to eating disorders. There was a significant positive relationship between depression and eating disorders and a negative relationship between body image and depression as well as between body image and eating disorder (Manaf etal, 2016). Another study showed that students with low selfesteem had higher anorectic eating concerns. Young students with low self-esteem are more vulnerable to anorectic eating concerns than older students (Talwar, 2012).  Another study reported that majority of medical undergraduates were under stressed and there was a risky trend toward eating disorders in such students (Ngan etal, 2017).

A study in Thailand revealed that medical students were reported to have atypical attitudes towards eating, and displayed abnormal eating behaviors. There was no statistically significant correlation of attitude towards eating, and their current eating behaviors according to the medical students’ gender, year of studying and Grade Point Average. However, their eating attitudes and behaviors were, associated with Body Mass index (Pitanupong etal, 2017).  Another study conducted in ASEAN countries revealed that 11.5% of the students across all countries were classified as being at risk for an eating disorder, ranging from below 10% in Indonesia, Thailand and Vietnam to 13.8% in Malaysia and 20.6% in Myanmar (Pengpid etal, 2021).

A study in Taiwan reported that sisturbed eating attitudes and behaviors were found in 10.4 % of participants. Disturbed eating attitudes and behaviors were associated with weight/shape-related teasing experiences and dissatisfaction with body weight. The reported intakes of energy, protein, fat, carbohydrate, cholesterol, zinc and vitamins B-6, B-12, were significantly lower in participants with disturbed eating patterns than in participants without disturbed eating. Conversely, participants with disturbed eating patterns had higher dietary and crude fiber intake than participates without disturbed eating (Tsai etal, 2011).

Research on Eating Disorders in East Asia

A study is South Korea highlighted that disturbed eating attitudes and behaviors were found in 7 percent of students. Disturbed eating attitudes and behaviors were associated with the passive coping strategies, fear of being overweight, total behavioral difficulties, fourth grade, and high socioeconomic status (SES) (Yang etal, 2010). Another study highlighted that the total treatment prevalence of eating disorders in South Korea was 12.02 people (per 100,000) in 2010, and 13.28 in 2015. The cost of medical expenditures due to eating disorders increased from USD 1229724 in 2010 to USD 1843706 in 2015. The total economic cost of eating disorders was USD 5455626 in 2015. In 2015, the economic cost and prevalence of eating disorders was the highest in the 20–29 age group (Lee atal, 2021).

Research on Eating Disorders in South Asia

A study conducted in Chinese students revealed that the students at risk for eating disorders were 2.17%. Eating disorder risk was more frequent in students with poor parent’s relationship, students with poor relationship with parents, students with high body mass index, students who were excessive focus on slimming propaganda, and students whose relatives have a diet. Also, the mean scores for the psychological factors of depression and anxiety were higher in students with eating disorder risk (Chang etal, 2015).

Another study conducted in China revealed a high prevalence rate of disordered eating behavior among rural adolescents and associated factors among school students. Perceived overweight, negative affect, body dissatisfaction, and watching TV were significantly associated with DEB (Feng and Abebe,2017).

Another study highlighted that symptoms of eating disorders were more prominent in individuals living in urban residence and with higher education levels. Scores on shape concerns and weight concerns were all higher for individuals in urban versus village locations (Yao etal, 2021).

A study conducted in Iran focused on assessing prevalence of eating disorders in adolescents. The results highlighted that 24.2% were at risk of ED  with 14 cases of anorexia nervosa, 18 bulimia nervosa, and 19 eating disorder not otherwise specified diagnosed (Raouf etal, 2015). Another study revealed that  the prevalence of eating disorders was 11.5% that included 0.8% anorexia nervosa, 6.2% full threshold bulimia nervosa, 1.4% sub threshold anorexia nervosa and 30% sub threshold binge eating disorder. Symptoms of bulimic syndrome were greater in males (Garrushi and Baneshi, 2013). A study revealed that Eating disorder behaviors (EDBs) were common among college students in Iran. Binge eating was the most common EDB, followed by extreme dietary restriction. Most EDBs were equally common among male and female students (Sahlan etal, 2020).

A study in India higlighted inadequate knowledge regarding eating disorders among adolescent girls. The history of abnormal eating had significant association with level of knowledge on eating disorders and age, educational status, family history of eating disorders & source of information (Mallick & Mukhopadyay, 2014). Other studies conducted in India revealed higher prevalence of eating disorders in adolescents with increased BMI but age and gender did not have a significant influence (Babu etal, 2017; Kumar etal, 2016; Shashank etal, 2016).

A study conducted in Nepal revealed that more than fifty percent of the students had inadequate knowledge regarding eating disorders. Almost quarter of the students were screened to have eating disorders (Subedi etal, 2018).

Eating Disorders in Pakistan: The Missing Link

Eating disorders have been misunderstood, under reported and misdiagnosed in Pakistan. It is rarely considered as a mental illness. Weigh and body appearance are seen as social taboos in the country. There is lack of specialized services for management of eating disorders with inadequate experts. Limited research data is available on the issue of eating disorders and only seventeen studies have been conducted to the best of my knowledge till date. Most of the studies conducted are based on prevalence of eating disorders. Abideen et al in 2011 highlighted that the increasing prevalence of eating disorders and rising number of young females employed in weight loss endeavors. Memon et al in 2012 and Haroon et al in 2016 reported significant number of medical students in Karachi and Islamabad at higher risk for developing eating disorders, respectively. Females were found more prone than males. The earlier these disorders are diagnosed and assessed, the better the chances are for enhanced treatment and fuller recovery. Similarly, Mahmood et al in 2014 and Jamali et al in 2020 highlighted higher prevalence of eating disorders among management sciences and engineering students, respectively. A considerable number of students particularly females and individuals from lower age groups were also found more susceptible to develop eating disorders. Moreover, Waris et al in 2020 reported rising prevalence of anorexia nervosa among female university students in Lahore. Anorexia was found higher among hostilities as compared to day scholars. Furthermore, Malik et al in 2019 highlighted moderate prevalence of binge eating disorder (BED) among overweight/obese in two major cities of Pakistan. Although, moderate binge eating disorder was seen among most of the obese individuals but BED in most of the cases goes undiagnosed. Binge eating disorder was found more common among students and non-smokers. Early detection and evidence-based treatment strategies can help the patients to recover at initial stages and prevent from further complication of binge eating disorder. Additionally, Warsi et al in 2020 reported high prevalence of eating disorders was observed in diabetics, more commonly among Type II diabetic patients. Non-significant fluctuated anthropometric indicators were observed among diabetics type I and II and patients with eating disorders.

As far as the role of life style and dietary habits are linked with eating disorders, Asim et al in 2021 highlighted nutritional status of reproductive age women in Pakistan as poor, with 14 % being underweight (BMI < 18·5) and 42 % experiencing iron deficiency anemia. Moreover, Hussain et al in 2020 highlighted that health behavior is linked with gender, marital status, age, physical activity, and educational qualification of adults whereas stress was associated with physical activity and qualification of adults. Females had unhealthy eating habits where males had bad sleep patterns. The stress factor has an inverse relationship with qualification and physical activity. Healthcare professionals should design innovative interventions to improve healthy eating behavior and reduce depression and stigma associated with obesity.

Low self-esteem and fear of negative evaluation were reported as negative predictors of eating habits among young overweight women by Javed et al in 2021. Fear of negative evaluation might be a helpful factor in reducing the weight and changing the unhealthy eating habits of overweight women. Zaidi et al in 2020 reported that the night eating syndrome as a common practice which was found correlated to depression among medical students. Moreover, Saleem et al in 2014 highlighted interdependence between eating disorder risks (Dieting, Bulimia & Oral Control) and prevalence of depression among undergraduate university students. Females had more eating disorder and depression as compared to males. Zahid et al in 2021 highlighted that social media has been known to influence eating habits especially amongst young children and adolescents. Excessive use of social media was associated with an increased risk of eating pathology. Evidence based research is required for identifying more barriers related to social taboo of eating disorders in Pakistan in order to develop effective strategies for addressing the challenges of low screening and appropriate treatment of eating disorders in Pakistan.