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.
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