The prevalence of eating disorders among
university students and the relationship
with some individual characteristics
Nesim Kugu, Gamze Akyuz, Orhan Dogan, Erdal Ersan, Ferda Izgic
Objective: The purpose of this study was to determine the prevalence of eating disorders
(EDs) among university students in a rural area of Turkey and to compare groups based
on the sociodemographic data, history of child abuse and neglect, family roles and selfesteem with a normal control group regarding EDs.
Method: Subjects who were chosen by simple random sampling method were consisted
of 980 Cumhuriyet University students who agreed to participate out of the 1003 total
students and were given a sociodemographic information form and an Eating Attitudes
Test (EAT). Students who scored above a cutoff level on the EAT were interviewed using
the Structured Clinical Interview for DSM-IV axis I Disorders (SCID-I), Clinical Version. The
Rosenberg Self-Esteem Scale, Family Assessment Device (FAD) and Childhood Abuse
and Neglect Questionnaire Form were given to subjects in the control and study groups.
Results: Seventy-one of the 951 students (492 female, 459 male) who correctly filled
out the EAT had a score above the cutoff level of 30 or higher. Of these 71 students,
21 (2.20%) were found to have an eating disorder based on the SCID-I. No subjects
were found to have anorexia nervosa. Eighteen of the 21 subjects were female. Of these
18 female students, 15 (1.57%) were found to have bulimia nervosa and three (0.31%)
were found to have binge eating disorder (BED). All of the three male subjects were
diagnosed with BED (0.31%). The self-esteem of those in the study group was lower than
those in the control group (p < 0.001). Subjects in the study group had more frequent
histories of sexual and emotional abuse in childhood (p < 0.05). Also, in the study group
scores showing communication in FAD families, unity and emotional attachment were
statistically significantly lower than the control group (p < 0.001).
Conclusions: It has been observed from the results of this research that the frequency
of bulimia nervosa and BED in this sample is so similar to Western samples. Besides that,
self-esteem, child abuse and neglect, and family functions must be examined in detail
because they are risk factors for EDs and affect the course of treatment.
Key words: childhood abuse and neglect, eating disorders, family, self-esteem, university
students.
Australian and New Zealand Journal of Psychiatry 2006; 40:129–135
Orhan Dogan, Professor and Chief (Correspondence); Nesim Kugu, Assistant Professor; Gamze Akyuz, Assistant Professor; Erdal Ersan, Psychiatrist;
Ferda Izgic, Psychiatrist
Department of Psychiatry, Cumhuriyet University School of
Medicine, Hastanesi Psikiyatri ABD, 58140, Sivas, Turkey. Email:
[email protected]
Received 20 June 2003; revised 10 February 2005; accepted 22 February
2005.
C 2006
Under the heading of eating disorders, DSM-IV specifies three diagnoses: anorexia nervosa (AN), bulimia nervosa (BN) and eating disorders not otherwise specified
(EDNOS) of which binge eating disorder (BED) is one
of them. AN’s typical characteristics include refusing to
maintain a minimal body weight, serious fear of gaining weight, important problems with thinking about their
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130
PREVALENCE OF EATING DISORDERS
body type and size, and, in female patients, the presence of amenorrhoea after the menarche. Patients with
BN have the strong perception that they cannot control
their eating or overeating during binge episodes. BN is
characterized by repeated episodes of binge eating followed by inappropriate compensatory behaviours such
as self-induced vomiting; misuse of laxatives, diuretics,
or other medications; fasting; or excessive exercise. In
DSM-IV BED there are binge eating episodes but not
compensatory behaviours [1].
For many years AN has been known as one of these
disorders but an answer is still being sought for whether
or not BN is a newly emerged disorder or if not an old disorder defined in a new way or its reflection or a different
manifestation of AN.
In adolescence and young adulthood the incidence of
AN among women is 0.5–1% and the incidence of BN
is 1–3% in Western countries [1]. In a university in the
eastern US it was reported that in a study of 1965 students the incidence of BN among girls was 1.3% and
among boys was 0.1% according to DSM-III or DSM-IV
criteria [2]. In another study with Texas University students 1.3% of girls and 0.2% of boys were found to have
BN [3]. In a study to determine the frequency of AN in
five different groups of young people in three different
countries, the frequency of AN seen among young girls
living in Munich was 1.1%, in one region of Greece the
frequency among girls was 0.41% and in another region
0.35%. In the same study there was no AN found among
Greek boys and girls or Turkish boys [4].
In research conducted in Western societies, the lower
self-esteem [5–7], child abuse [8–11] and poor family
functioning [12–14] have been identified as risk factors
for EDs. But it is not clear that these are also risk factors
for EDs in non-Western societies.
There are important cultural and social factors in the
aetiology of EDs. It is known that these disorders are
characteristic of Western societies and rarely seen in
other societies [15,16]. In Western societies it is observed
that sociocultural pressures, the value placed on physical
appearance in women’s sexual role, the presentation of
extremely thin women as the ideal body image and the
emphasis on the importance of a woman’s physical appearance for social success are risk factors for the development of EDs [17]. These values are not different from
Western societies for women in urban areas of Turkey
and these are also increasing among women in rural
areas through TV and mass media.
The diagnosis of AN is easy after the first stage because
the physical changes in AN is clear. However, in BN the
patient may have a normal weight or may be overweight,
and contrary to AN it is difficult to recognize and diag-
nose. In addition, the percentage of the cases of BN that
admit for treatment is very low. This situation, also the
case for BED, which is more prevalent among obese people than the general population, increases the importance
of epidemiological studies [18].
Although there are a large number of studies in Western
societies on the characteristics and frequencies of EDs,
there are very few studies in developing societies or emigrants to the west and in the rural areas of these societies.
This situation makes it hard to understand the cultural
aspect of EDs and to compare the societies with each
other.
The purpose of this study was to determine the frequency of EDs among university students in a rural area
(Sivas City) of Turkey, and to compare the groups based
on the sociodemographic data, history of child abuse and
neglect, family functions and self-esteem with a healthy
control group regarding EDs, and also to compare the
results based on the results of studies done both in the
west and in our country.
Method
Research population and sampling
The subjects for the research were selected from students enrolled
in university programs on the Cumhuriyet University campus. The
Cumhuriyet University Student Services Director selected students according to faculty, university program and class. Medical students in
the 5th and 6th year and students in the county professional university
programs were not included in the study. In our study the target was to
achieve 10% of the total number of students. When the students were
identified and placed into sample groups, the plan was to reach the
1st, 2nd, 3rd and 4th year classes of every program to represent every
university program and every class. The sample included 10% of the
total of students from all of the classes. The total number of students on
the Cumhuriyet University campus was 11 275. Of these students 4125
were female and 7151 were male. Of this total number of students, 691
students who were in the county professional schools and 289 students
in the 5th and 6th years of medical school were not included in the
study. Our study population was made up of 11 275 students. Our goal
was to reach 1127 students.
Permission for the study was obtained in writing from the office of
the rector of Cumhuriyet University. Simple random sampling method
was used to obtain a sample representative of the university population
of 1003 students who were informed about the study. Twenty-three
students (2.29%) declined to accept to participate in the study.
Data collection tools
1. Sociodemographic Information Form: A sociodemographic questionnaire was developed for this study that assessed: name, age, sex,
economic situation, height (metres), weight (kg), body mass index
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N. KUGU, G. AKYUZ, O. DOGAN, E. ERSAN, F. IZGIC
2.
3.
4.
5.
6.
(BMI) obtained by the formula weight divided by height squared,
and for girls, the presence of menstrual irregularity.
Eating Attitudes Test (EAT): This is a tool developed by Garner and
Garfinkel for the purpose of screening eating disorders in adolescent
girls and young women. It can be used for people over 11 years of
age, which contains 40 questions with six graduated answers in
Likert style [19]. In 1989, Erol and Savaşır confirmed the validity
and reliability of this tool in Turkey [20].
Rosenberg Self-Esteem Scale (RSES): This is a measure of selfevaluation using 63 multiple-choice questions [21]. The scale has 12
subcategories. The first 10 subcategories were used to measure selfesteem for our research goal. The scale’s reliability and validity in
our country was tested by Cuhadaroglu [22] and the level of internal
reliability was found to be r = 0.71 and test–retest reliability was
r = 0.75.
Structured Clinical Interview for DSM-IV axis I Disorders (SCIDI), Clinical Version: Fist et al. developed this form in 1997 [23].
Özkürkçügil et al. adapted the form for Turkish and checked its
reliability in 1999 [24]. There was 98% agreement among the interviewers for all the diagnoses and a kappa number of 0.86 was
found. The kappa number for all the diagnostic categories varied
between 0.52 and 1.00 and all were at a statistically significant level
(p < 0.0001).
Childhood Abuse and Neglect Questionnaire Form (CANQF): This
form examines childhood abuse and neglect with incidents of physical, sexual and emotional abuse, neglect and incest. Brown and
Anderson’s definitions were used for physical abuse, sexual abuse
and incest [25].
Childhood physical abuse is defined as physical violence against
a person under 16 years old, by someone at least 5 years older or
by a family member at least 2 years older than the victim. Close
confinement, such as being locked in a closet is also included. The
victim perceives it severe, but should not consider this maltreatment
as sibling rivalry. Quarrels between friends that do not include any
physical contact are not accepted as physical abuse.
Childhood sexual abuse is defined as involvement of a person
younger than 16 years old in any kind of sexual activities, such
as genital fondling, an adult exhibiting his or her genitalia to a child,
forcing the child to exhibit himself or herself to the adult or the
child to have sexual intercourse with someone at least 5 years older
or with a family member (incest) at least 2 years older than the
victim.
Questions about emotional abuse and neglect were based on the descriptions of Walker et al. [26]. Emotional abuse involves the use of
excessive verbal threats, ridiculous and personally demeaning comments, derogatory statements and threats against the young person
to the extent that a child’s emotional and mental wellbeing will be
jeopardized. Neglect refers to acts of omission in which the child is
not properly cared for physically (nutrition, safety, education, medical care etc.) or emotionally (failure to bond, lack of affection, love,
support, nurturing or concern).
Family Assessment Device (FAD): This self-report device was developed by Gülerce [27] for the purpose of measuring a family’s
internal relationships, needs, family structure and total functioning.
There are 36 items that comprise seven subtests: communication,
unity, management, perfection, emotional attachment, individuality and satisfaction. Answers are marked on a separate form us-
131
ing a 10-step Likert scale that ranges between ‘just like ours’ and
‘exactly opposite ours’. The lowest score for each question is 1
and the highest is 5. A high FAD score means ‘good and healthy
adjustment’.
The device was tested on 100 university students by 1-month interval and the Pearson’s product–moment correlation was 0.79, Stanley
correlation coefficient was 0.85. Kuder–Richardson 20-coefficient test
of internal stability total score was approximately 0.70. The correlation
between the FAD scores and the Beaver Timber Lawn family assessment scores was found as 0.78 (statistically significant) and also the
correlation between the FAD scores and the Minnesota Multiphasic
Personality Inventory (MMPI) family relationships subtest scores was
0.69 (statistically significant) [27].
Procedure
This research was carried out on the campus of Cumhuriyet University. Subjects were selected using the simple random sampling method.
Previously identified university classrooms were entered. The sociodemographic information form and EAT were given to 980 students who
agreed to participate and gave informed consent. The SCID-I was used
to interview the students who scored higher than the cutoff score of
30 on the EAT for diagnosis. The control group was matched with the
students having ED in respect of the number and sex and was consisted of classmates who had a score on the EAT below the cutoff score
and did not have an eating disorder using SCID-I. The control group
was selected by using simple random sampling method. The control
group was consisted of 18 females and three males. The difference
among characteristics such as gender, age, BMI and income level was
not found to be statistically significant (p > 0.05). Both groups were
given RSES, FAD and CANQF. The data obtained were evaluated using the SPSS statistical package program. Quantitative data evaluation
was done with Mann–Whitney U-test and qualitative data were evaluated with chi-squared test. Results at the p < 0.05 level were considered
statistically significant.
Results
Seventy-one of the 951 students (492 female, 459 male) who correctly
filled out the EAT had a score above the cutoff level of 30 or higher.
Of these 71 students, 21 (2.20%) were found to have an eating disorder
based on the SCID-I. No subjects were found to have AN. Eighteen of
the 21 subjects were female. Of these 18 female students 15 (1.57%)
were found to have BN and three (0.31%) were found to have BED.
All of the three male subjects were diagnosed with BED (0.31%). The
age range for the study and control group was 18–24 years old and the
mean age for the study group was 20.0 ± 1.60 and for the control group
was 21.1 ± 1.72.
Sociodemographic data
A statistically significant difference (p > 0.05) was not found between the study and control groups regarding age, sex and economic situation. The study group had significantly higher menstrual irregularity
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PREVALENCE OF EATING DISORDERS
Table 1.
Sociodemographic data, history of childhood abuse and neglect in the study and control group
Characteristics
Age
18–21 years
21–24 years
Income levels
Low
Medium
High
Menstrual irregularity
Present
Absent
CANQF
Physical abuse
Emotional abuse
Sexual abuse
Neglect
Incest
∗ Statistically
Study group
n
%
Control group
n
%
19
2
90.5
9.5
18
3
85.7
14.3
2
18
1
9.5
85.7
4.8
0
19
2
0
90.5
9.5
4
14
22.2
77.8
0
18
3
8
6
5
3
14.3
38.1
28.6
23.8
14.3
2
1
1
2
1
0
100
9.5
4.8
4.8
9.5
4.8
χ2
p
OR
1.53
0.90
1.41
2.36
0.30
Undefined
4.50
0.03∗
Undefined
0.22
6.92
4.28
1.54
1.10
0.63
0.00∗
0.03∗
0.21
0.29
1.58
12.31
8.00
2.97
3.33
95% CI
0.22 < OR < 9.61
0.18 < OR < 15.69
1.26 < OR < 294.75
0.78 < OR < 196.12
0.41 < OR < 25.94
0.26 < OR < 91.44
significant. CANQF, Childhood Abuse and Neglect Questionnaire Form; CI, confidence interval; OR, odds ratio.
for females (χ 2 = 4.50, p = 0.03). The data for both groups are shown
in Table 1.
The mean scores of child abuse and neglect for both groups are shown
in Table 1.
Physical measurements
Family roles
There was no statistically significant difference between the study
(21.02 ± 2.62) and control groups (20.86 ± 2.63) regarding mean
height, weight, and BMI, which is determined by the formula weight,
divided by height squared (p > 0.05).
When the scores for study group and control group were compared
for the FAD’s seven subtests, the scores for communication in the
family, family unity and emotional attachment in the family were found
to be statistically significantly lower in the study group (z = −3.91,
p < 0.001; z = −2.72, p < 0.001; z = −5.59, p < 0.001 respectively).
The scores for both groups on the FAD subtests are shown in Table 2.
Self-esteem
The self-esteem scores of the study group were found to be significantly lower than those of control group (χ 2 = 33.4, p < 0.001).
History of childhood abuse and neglect
The incidence of physical, emotional and sexual abuse in the study
group was 14.3% (n = 3), 38.1% (n = 8) and 28.6% (n = 6) respectively; however, the incidence in the control group was 9.5% (n = 2),
4.8% (n = 1) and 4.8% (n = 1) respectively. The incidence of neglect
was 23.8% (n = 5) in the study group and 9.5% (n = 1) in the control group; the incidence of those in the study group subjected to
incest was 14.3% (n = 3) and 4.8% (n = 1) in the control group. Although 4.8% (n = 1) of the study group had attempted suicide, there
was no history of suicide attempts in the control group but the difference between the two groups was not found to be statistically significant
(χ 2 = 0.35, p = 0.54). The frequency of childhood emotional and sexual abuse was significantly higher in eating disorder group than the
control group (χ 2 = 6.92, p = 0.00; χ 2 = 4.28, p = 0.03 respectively).
Discussion
In our study, the frequency of EDs was found to be
2.20% in university students in a rural area of Turkey. Of
this, the percentage of BN was 1.57% and the percentage
of BED was 0.31% for females. The particularly interesting aspect of this research is the BN frequency so similar
to Western countries. No cases of AN was not found.
Similar to our study two other studies done in our country did not find any AN [4,18]. AN occurs approximately
1–2 in a thousand in Western samples, so not detecting
AN in small epidemiological samples is the norm in the
Western samples. The results in our study are similar to
those of studies done both in Western societies and in
our country [3,18,28–33]. In Western societies the physical appearance of women is emphasized in their sexual
role and being excessively thin is the ideal for acceptance and success in society. Although earlier having a
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Table 2.
The FAD’s subtests mean scores of study and control groups
Mean ± SD
The FAD’s subtests
Communication
Unity
Management
Perfection
Emotional attachment
FAD satisfaction
FAD individuality
∗ Statistically
133
Study group
26.42 ± 8.57
28.52 ± 7.30
34.33 ± 1.52
34.04 ± 1.53
14.42 ± 1.12
20.66 ± 1.79
134.19 ± 9.51
Control group
34.42 ± 1.32
34.38 ± 1.20
33.90 ± 1.30
32.76 ± 1.09
21.23 ± 1.70
21.24 ± 2.07
137.04 ± 3.51
z-value
−3.91
−2.72
−1.34
−1.65
−5.59
−1.50
−0.21
p-value
0.00∗
0.00∗
0.17
0.09
0.00∗
0.13
0.83
significant. FAD, Family Assessment Device; SD, standard deviation.
thin body appearance has been evaluated as unhealthiness
and weakness especially in rural areas of Turkey, in the
last decades this idea has been changed by the increasing
effect of the media so that being thin is accepted as the
sign of the beauty. Furthermore, it is not surprising that
the prevalence of ED even in rural areas of Turkey is the
same as Western countries.
Low self-esteem has been identified as an important
risk factor for EDs [5]. Silverstone suggested that low
self-esteem is a frequent finding in BN, and EDs might be
the result of chronic low self-esteem [6]. Low self-esteem
is also an important sign that shows the bad prognosis of
ED [7]. In this study, the self-esteem of the study group
was found to be significantly lower than the control group.
Body image is important for a woman’s self-perception
and determining self-esteem [34]. Men, however, are at
lower risk for EDs because they do not define their selfesteem and self-worth by external appearance [35]. In this
study neither AN nor BN was found in men. Moreover,
18 of the 21 subjects in the study group were female and
the study group had lower self-esteem than the control
group supports this theory.
There are a number of studies in Western societies on
the subject of whether or not a history of childhood abuse
and neglect is a risk factor for EDs [8–11,36–38]. It has
been reported that the history of childhood sexual abuse
can be a risk factor for bulimic behaviours [9,36,37]. In
2000, a study by Kent et al. showed that the influence of
childhood emotional abuse on EDs is more than that of
sexual and physical abuse [10].
In this study, a history of childhood sexual and emotional abuse was found significantly more frequently in
the study group than in the control group. The findings
obtained in this study regarding childhood abuse and neglect correspond with studies done in Western societies,
which has found this relationship [8–11,39]. Because in
our country there are no other studies available on this
subject, it is very difficult to make a good evaluation.
Nevertheless, it can be said that it is necessary to study
the history of childhood abuse and neglect as the risk
factors for EDs in these subjects.
It is reported that there is a disorder of family functioning in people with EDs [12–14,40]. It has been observed that compared to healthy families in families of
patients with BN there is more enmity between parents
and daughters, less love, more blaming, rejection and neglect in relationships. On one side the patient lives with
conflict and from the other side a compulsory relationship that does not allow clarification of conflict [41].
In another study, it was reported that the relationships in
families of bulimic patients have unmet needs for interest,
empathy and support and thus vomiting is the result of
the feelings of enmity, rejection and restriction against
own family [42].
In 1999, Tachi et al. studied family roles in patients
with BN and BED as diagnosed according to DSM-III-R
criteria. Relationships were found between disengaged,
rigid family environment and purging type of BN; rigid
and chaotic family environment and purging symptoms
in BED [43]. In our country a recent study with high
school students found that study group subjects had a
higher frequency of having criticism in the family, blaming, incompatibility history in the family and witness to
physical violence in the family [18].
In our study, the scores, which show FAD communication, unity and emotional attachment, were significantly
lower in the study group than the control group. These
results reveal that the students in the study group perceive their family more problematic regarding expressing
themselves in the family freely, enmeshing or irrelevancy
of the family members, and the feelings of love, peace
and sympathy within the family environment, compared
to the control group. The findings of this study related
to family roles are consistent with the results of other
studies, which shows that there is a disorder in family
roles of patients with BN [12,13,18,40–43]. But because
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PREVALENCE OF EATING DISORDERS
there is very limited number of studies on this subject in
our country, we think that is necessary to approach these
results with precaution.
9.
Conclusions
10.
Eating disorders are seen more frequently in Western
societies than in other societies. However, in this study
the rate of incidence that was found did not show a clear
difference from the incidence in Western societies. Research carried out that shows EDs are particular to the
culture should be examined again, and it is necessary
to study the risk factors in those with EDs of low selfesteem, childhood abuse and family roles. There is very
limited research in our country about the frequency and
characteristics of EDs. This situation limits the possibility
of making good evaluations of research.
In Turkey, there is a need to expand research using
wider samples from the general population in different
regions of the country, outpatient and inpatient patients,
and adolescents and young adults identified as at risk.
Such research would assist in identifying the frequency
and characteristics of these disorders, increase the awareness of these disorders and improve methods of treatment.
However, the results of this study show that it is necessary
to pay attention to levels of self-esteem, family functioning and a history of childhood abuse in the treatment of
EDs. It is thought that it is correct to consider the factors
that are able to affect treatment.
11.
12.
13.
14.
15.
16.
17.
18.
19.
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