Karachi’s future doctors at high risk of eating disorders

Eating disorders refer to a group of conditions characterised by abnormal eating habits. They involve either insufficient or excessive food intake that is detrimental to an individual’s physical and emotional health.
Binge eating disorder, bulimia nervosa and anorexia nervosa are considered to be the most common forms of eating disorders.
They are among the potentially lethal psychiatric illnesses, and are predominately represented by a mental effect of preoccupation with body weight, shape and diet.
In addition, eating disorders frequently occur with other psychiatric disorders such as depression, substance abuse, and anxiety disorders.
People with anorexia have an extreme fear of gaining weight, which propels them to maintain a weight far less than normal.
Bulimia is characterised by a cycle of binge eating, followed by attempts to remove unwanted calories.
People with binge eating disorders often eat an uncontrollable, large amount of food during the binges.
The exact cause of eating disorders is unknown; however, it is believed to be due to a combination of biological, psychological and/or environmental abnormalities.
A common phrase in such conditions is that “genetics loads the gun, environment pulls the trigger”.
Various studies have reported prevalence of eating disorders. In Western countries, the population-based and clinical-based assessments have reported prevalence of anorexia nervosa to range from 0.1 percent to 5.7 percent, while bulimia nervosa ranged from 0.3 percent to 7.3 percent in female subjects.
A study conducted on college students reported 3.8 percent prevalence of bulimia nervosa in females and 0.2 percent in males.
Another study diagnosed 4.7 percent of female college students with eating disorders.
Medical students are associated with high levels of stress that stands as a critically important causative factor of eating disorders.
Thus, it is quite important to analyse all such instabilities in medical students who are an asset for the future of this country.
Studies have been conducted in the Western scenario to assess eating disorders in medical students.
A study from the US showed that 15 percent of the female medical students had a history of eating disorders.
In Pakistan, a study conducted in Lahore among 369 school girls and another study conducted in Mirpur among 271 school girls revealed one case of bulimia and no cases of anorexia.
Although, five girls from Lahore also suffered from partial syndrome bulimia nervosa.
Another survey from Lahore among 111 volunteers showed an occurrence of two cases of bulimia nervosa and another two cases of eating disorders not otherwise specified.
While eating disorders are characterised as a mental health condition, they have the potential to lead to other serious physical health problems.
Keeping such ominous medical consequences in view, it is naturally alarming that the future physicians of Karachi, prone to such stressful conditions, might be at significantly high risk of contracting eating disorders that would hamper the availability of dependable medical services in the future.
The earlier these disorders are diagnosed and assessed, the better the chances are for enhanced treatment and better recovery.
Therefore, we intend to undertake a descriptive study to assess the incidence of high-risk of eating disorders among medical students of Karachi.
METHODS: This was a descriptive cross sectional study conducted in three renowned medical colleges of Karachi, namely Dow Medical College, Sindh Medical College and Aga Khan University, between January 1 and June 30, 2011.
The study included 495 undergraduate medical students. Random sampling method was acquired.
Participants from first to final year of medical school were approached directly within the college timings.
The Ethical Review Board of Dow University of Health and Sciences approved the study.
All participants completed a self report screening package that included the eating attitude test (EAT-26) and SCOFF questionnaire.
English versions of both the questionnaires were used. No translated versions were adopted.
Written consent was also obtained from all participants. Body mass index (BMI) was calculated based on self reported height and weight.
EAT-26 is a validated self-administered questionnaire widely used to measure eating disorders.
It comprises 26 questions, for which scoring is done on a six-point scale from always to never. Total sum of EAT-26 scores range from 0 to 78.
SCOFF is another highly accurate self-administered questionnaire widely used as a screening tool for eating disorders.
It comprises five questions, for which scoring is done on a two-point scale, namely ‘Yes’ or ‘No’.
The data was entered and analysed using the Statistical Package for the Social Sciences (SPSS) version 16.
Relevant frequency and percentages were calculated for qualitative variables, whereas means ± standard deviations were calculated for quantitative variables.
P-values were also obtained by Pearson Chi Square Test to determine the significance of the results.
FINDINGS: Out of 495 individuals, 435 returned the complete questionnaires giving a response rate of 87.8 percent. Out of 435 individuals, 342 were female, while 93 were male.
The mean age of the population was 20.5 years ± 1.67 years, while mean BMI ratio was 20.1 years ± 3.3 years.
Mean age of male participants was 20.24 years ± 1.89 years, while it was found to be 20.65 years ± 1.60 years in females.
The average BMI, EAT-26 score and SCOFF score was 21.57 kg/ m2, 11.86/78 and 1.18/5 in male participants, with standard deviation of 4.01, 1.18 and 1.19, respectively.
Mean (SD) was 19.80 (3.08), 13.55 (9.71) and 1.29 (1.22) in females, respectively.
Based on the data, two new derivatives were produced using the 75th percentile and named as the empirically derived cut-off.
Hence, the cut-off value for EAT-26 was found to be more than 18, while cut-off for SCOFF was found to be more than 2.
Thus, out of 435 individuals who were screened through the two questionnaires, EAT-26 questionnaire detected 99 (22.75 percent) individuals with high risk of eating disorders, while SCOFF questionnaire detected 74 (17 percent) at high risk.
EAT-26 FINDINGS: Out of the reported 99 high-risk individuals, 87 (87.9 percent) were females and 12 (12.1 percent) were males.
Medical students of younger age group were found to be more susceptible. Sixty-five (65.65 percent) were from age group 18 to 21, while only 34 (34.34 percent) were from age group 22 to 25.
BMI ratio of majority (n = 53, 53.5 percent) of the individuals screened by EAT-26 to be at high-risk eating disorders fell into normal category (18.5 to 25 kg/m2).
Out of the 99 high-risk individuals, 76.76 percent (n = 76) were terrified of being overweight, while 68.68 percent (n = 68) were preoccupied with the desire to be thinner.
The number of those engaged in dieting behaviour was 55 (55.56 percent); however, only 9 percent (n = 9) vomited after eating, while 73.7 percent (n = 73) displayed self-control around food.
All the questions of EAT-26 were divided into the three subscales, namely ‘dieting’, ‘bulimia and food preoccupation’, and ‘oral control’.
SCOFF FINDINGS: Out of the reported 74 high-risk individuals, 58 (78.4 percent) were females and 16 (21.6 percent) were males.
Fifty-three (71.6 percent) were from age group 18 to 21, while only 21 (28.4 percent) were from age group 22 to 25; thus, SCOFF reports younger age group to be more at risk.
MODELS: To find the eating disorder using EAT-26 questionnaire, we used binary logistic backward method.
In the first step, the covariate age played a role insignificantly; therefore, it was eliminated from the model, and the final model is given as EAT-26 disorder (Yes) = -3.320 – 1.077 (Male) + 0.112 BMI.
The model explain us that the odds of a person with eating disorder was 0.341 in male as compared to female, with 95 percent confidence interval (0.676, 0.172), and a unit change in BMI will increase the odds for disorder 0.112 time on average, with 95 percent confidence interval (1.199, 1.043).
When the same method was performed for the SCOFF questionnaire, we get that only BMI played a significant role for eating disorder, and the computed model was SCOFF eating disorder (Yes) = -4.657 + 0.148 BMI.
This explains us that the unit change in BMI will increase the odds for disorder 0.148 times on average, with 95 percent confidence interval (1.247, 1.078).
DISCUSSION: Our study reports that significant proportion of medical undergraduates are at high-risk of suffering from eating disorders, with 99 (22.75 percent) individuals scoring above the threshold for EAT-26 questionnaire, while 74 (17 percent) scoring above the threshold for SCOFF questionnaire.
This is higher than recently reported eating disorder symptoms in 9.59 percent among Latino college students in the US.
This strengthens the fact that eating disorders are a mounting concern in our region in relation to other parts of the world.
We reported a significant majority of females being at high-risk of eating disorders as compared to males.
A study reported a similar ratio between male and female students wherein a high proportion of female subjects (anorexia = 1 percent to 4.2 percent or bulimia = 6.5 percent to 18.6 percent) suffered from eating disorders, while none of the male subjects was reported positive.
Another study reported females (binge eating, n = 49 percent; bulimia, n = 4 percent) at a greater risk to develop eating disorders.
As also seen in our study with universities located in urbanised locations, females in such settings, as avid media followers, are particularly more prone to developing eating disorders.
Various studies in different settings have highlighted the role of media exposure and its psychological effect, particularly on females, with the resultant development of body dissatisfaction culminating in eating disorders.
In a setting like Pakistan, the increasing drive of particularly females to emulate European culture as viewed via media has led to an unhealthy stringent dieting and exercising regime.
Interestingly, our study showed that of the individuals with normal BMI values, 29.6 percent still suffered from eating disorders as diagnosed by EAT-26 (n = 53/179), while according to SCOFF, 23.5 percent (42/179) of normal individuals were suffering from eating disorders.
Overweight individuals were found to be more likely to have eating disorders in relation to underweight individuals.
According to SCOFF, 21.2 percent (7/33) of the overweight and 12.2 percent (22/180) of the underweight individuals scored above the cut-off score; thus, they were likely to have eating disorders.
Similarly, in accordance with EAT-26, 18.2 percent (6/33) of the overweight individuals and 15.6 percent (28/180) of the underweight individuals were likely to have eating disorders.
The plausible explanation for our finding that underweight individuals are less likely to have eating disorders in relation to overweight individuals can be provided by elucidating that eating disorders are morbidities with psychological basis. Even individuals with normal BMI can have the likelihood of these disorders.
Thus, it depends only in part on the actual body mass. One debatable reason can be the psychological satisfaction attained after achieving the desired body shape.
Therefore, the causative factor that propelled them to have eating disorders was now resolved.
Further studies must be carried out in the future to find out if eating disorders resolve after a person achieves the desired lean body image.
Other possible reasons for low-weight individuals can be the genetic factors as well as undernutrition. Another study has also reported a high rate of undernutrition in the Pakistani population.
Also, for each particular class of BMI, SCOFF diagnosed more than twice individuals as likely to have eating disorders as compared to EAT-26. This can be seen clearly in normal, underweight and overweight individuals.
Eating disorders, particularly anorexia nervosa, is reported to derange several systems with resultant complications ranging from purpura, liver dysfunction, osteoporosis, diabetic complications to acrocyanosis.
Particularly, anorectic patients have been reported to die at a premature age possibly from one of the above-stated medical complications.
This disconcerting information should come in the knowledge of such individuals suffering from the disorder or at a high risk of developing one, who involve grossly in unhealthy dieting or purging cycle, particularly females.
The limitations of our study includes that we have focused only on medical students in colleges from the urban set-up. Further studies should be carried out that check the pattern of eating disorders in the rural set-up.
Furthermore, the most important limitation is the furtiveness and disagreement attributed to many of the subjects suffering from eating disorders. This is common in almost all the studies on eating disorders.
Further surveys need to be conducted that will co-relate socio economic group, ethnicity and relationship status (divorced, married or single) with the development of the disorder, which in other studies have been reported to be highly associated with the types of eating disorders.
Early detection of such factors causing eating disorders is important as having a significant impact in treatment of such disorders at an early stage with resultant greater efficiency of performance by future physicians.

Extracted from ‘Eating disorders in medical students of Karachi, Pakistan: a cross-sectional study’ authored by Akhtar Amin Memon, Syeda Ezz-e-Rukhshan Adil, Efaza Umar Siddiqui, Syed Saad Naeem, Syed Adnan Ali and Khalid Mehmood