Int J Adolesc Med Health 2016; aop
Ana Márcia Tenório de Souza Cavalcanti*, Ilma Kruze Grande de Arruda, Emilly Anne Cardoso Moreno de Lima, Waldemar Brandão Neto, Estela Maria Leite Meirelles Monteiro, Luciane Soares de Lima and Alcides da Silva Diniz
Characterization of eating behavior disorders in school-aged children and adolescents: a population-based study DOI: 10.1515/ijamh-2015-0087 Received August 14, 2015; accepted November 19, 2015
Abstract Objective: Cross-sectional study to assess the characteristics of the risk behaviors for eating disorders (EDs) in school children between 10 and 14 years of age in the city of Recife, Pernambuco, Brazil. Methods: 1405 school-aged children were assessed, using the Eating Behaviours and Body Image Test (EBBIT) to screen for EDs. The normality of the continuing variables was tested using the Kolmogorov-Smirnov test with Lilliefors correction. They were described as medians and interquartile intervals (25 and 75th percentiles). Results: The criteria that represented a condition of anorexia and/or bulimia nervosa were considered as strong indicators of risk for EDs in school-aged children who indicated the following behaviors with scores superior to the 75th percentile on the scales: “compulsive eating” 3.0% (CI95% 2.2–4.0); “dissatisfaction with body image/ restrictive eating” 1.3% (CI95% 0.8–2.0); children scoring superior to the 30th percentile, “compulsive eating” + “dissatisfaction with body image/restrictive eating”, 0.6%
*Corresponding author: Ana Márcia Tenório de Souza Cavalcanti, Nursing Department, Avenida Prof. Moraes Rego, s\n Bloco A do Hospital das Clínicas 1° Andar Cidade Universitária CEP – 50.670 – 901, Recife – PE, Brazil, E-mail: [email protected] Ana Márcia Tenório de Souza Cavalcanti and Estela Maria Leite Meirelles Monteiro: Nursing Department, Universidade Federal de Pernambuco, Brazil Ilma Kruze Grande de Arruda and Alcides da Silva Diniz: Nutrition Department, Universidade Federal de Pernambuco, Brazil Emilly Anne Cardoso Moreno de Lima and Waldemar Brandão Neto: Graduate Program in Child and Adolescent Health, Universidade Federal de Pernambuco, Brazil Luciane Soares de Lima: Nursing Department, Coordinator of Graduate Program in Child and Adolescent Health, Centre of Health Sciences, Universidade Federal de Pernambuco, Brazil
(CI95% 0.3–1.2); and superior to the 50th percentile; “compensatory behavior for hyperphagia” 6.7% (CI95% 5.4–8.1). In addition, greater vulnerability of the female gender was perceived, as well as an increase in the preliminary risk factors of EDs, such as advanced age, dissatisfaction with the body image linked to restrictive behaviors and the compulsive establishment of an eating pattern. Conclusion: This study shows the dimension of the problem in this ecological context and the urgent need for intervention programs, developed among different sectors, from the perspective of the adolescents’ empowerment to prevent and minimize the vulnerability factors of the eating disorders. Keywords: adolescents; anorexia nervosa; bulimia nervosa; child; eating behaviors; eating disorders; health promotion.
Introduction Eating Disorders (EDs) can be defined as multidimensional pathological conditions in which the interaction among biological, family, psychological and sociocultural factors determines a distorted relation between individuals and their eating behavior. The criteria of this behavioral syndrome have been studied in the past 30 years (1). The signs of EDs can be perceptible since childhood, with the possibility of early detection, consequently favoring intervention measures to act on determining factors, mainly attempting to minimize possibilities of illness and perpetuation of its s ymptoms (2–4). The classification systems of mental disorders, the International Classification of Diseases – 10th edition (ICD-10) (5) and the Diagnostic and Statistical Manual of Mental Disorders – DSM-5 (6), recognize the main types of EDs: anorexia nervosa (AN), bulimia nervosa (BN) and binge-eating disorder (BED). Despite distinct classi fications, AN and BN share the same psychopathology:
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2 Cavalcanti et al.: Characterization of eating behavior disorders in school-aged children and adolescents the excessive concern with the body weight and shape, so that the patients use inappropriate methods, such as extremely restrictive diets, out of fear of gaining weight and in search of the ideal body. These disorders mainly happen in female adolescents and young people (7) and, according to the American Psychiatric Association (8), the prevalence of anorexia nervosa ranges between 0.3 and 3.7% and the prevalence of bulimia nervosa between 1.1 and 4%. According to Wong et al. (9) and Claudino and Borges (1), the patients judge themselves exclusively based on their physical appearance and always show to be dissatisfied with that image. In addition, it is discussed that the number of cases may be even higher, as the health professionals generally discover the most severe cases of the disease in specialized hospital services. These disorders can entail physical consequences similar to those deriving from a state of chronic malnutrition. EDs usually appear in early adolescence and can cause malformations in their growth curves, delay or interruption of the adolescent development (10). On average, this delay can cause a reduction by up to 15% regarding the appropriate lower age and height limit. There is a high risk of association with other illnesses and a significant risk of mortality (11). In general, both BN and AN emerge during adolescence but, according to some authors, AN can be found as from the age of seven years (12). They also report that, in childhood, AN can cause physical development problems and that the incidence in boys is more relevant in the pre-adolescent age range. Investigating the affective-emotional, biological, physiopathological and environmental bases of AN, BN and compulsive eating disorder involves the need to attempt to understand the world of anorexic and/or bulimic patients, permitting the identification of risk factors, which increasingly arouses the need for scientific inquiries, in view of the fact that these EDs have stood out in the current society, mainly due to the high demand of adolescent girls and young adults in consultation rooms and clinics, in view of the importance the Western culture has attributed to the lean, pale and slim body (13). For a long time, EDs were considered as being exclusive to wealthy countries, affecting only young white women from the highest social class, which can partially explain the small number of studies in the area in developing countries. The association between a false belief in first-world countries and their scientific community that eating disorders are very rare in poor countries and the absence of local statistics on the theme provoked a delay
and abandonment of more systematic research on EDs in economically emerging areas. Several surveys indicate rising prevalence of EDs in the modern world, given the changes in eating habits of children and adolescents (14–16). Dissatisfaction with one’s body image should be considered one of the main precursors of EDs. Therefore, studies that identify groups with these risks around the world are relevant, aiming for the early identification of the most preponderant abnormal eating behaviors, which can interfere in their prognosis (17, 18). In Brazil, Triches and Giugliani (19), Vieira et al. (20) Vilela et al. (3). According to Ferreira and Veiga (21) and Moya and Fleitlich-Bilyk (22), studies that investigate the EDs and their precursors are relatively rare in developing countries and specifically in Brazil, which reflects the relation with this theme. This is one of the first studies in the Northeast of Brazil that involves a representative sample of younger adolescents, with the opportunity to describe the occurrence of eating behaviors and to identify risk indicators for the development of eating disorders. The objective in this study was to assess the risk behaviors for EDs in children and adolescents between 10 and 14 years of age in the city ofRecife, Pernambuco, Brazil.
Methods Study design and place The research design was cross-sectional, aiming to estimate the prevalence of eating behavior disorders at public and private schools in the city of Recife between August and December 2007.
Study population The study population consisted of school-aged children, between 10 and 14 years of age, taking the fifth to eighth year of primary education in the state and municipal public and private education networks in the city of Recife, Pernambuco.
Inclusion/exclusion criteria Students were considered eligible who were between 10 and 14 years of age, male and female and regularly enrolled in the official education network. Students were excluded who, although enrolled, were not regularly attending the classes and school activities, as well as students who needed a special diet due to a health problem or whose families adopted a special form of diet.
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Cavalcanti et al.: Characterization of eating behavior disorders in school-aged children and adolescents 3
Sampling plan A pilot test was undertaken, involving 50 male and female students from one previously drafted school, which served as the base to estimate the prevalence of eating disorders in the study population. The sampling size (n) was calculated based on the formula [n= z2.p.(1-p)/d2] Henderson and Sunderesan (23), where “z” represents the desired level of reliability (95%), “p” the estimated prevalence of overweight corresponding to 19.5% Campos et al. (24), and “d” the acceptable error margin of 3.0%. A multiple-stage sampling process was adopted, whose sampling units were the school (1st cluster), period (2nd cluster), class (3rd cluster) and student (4th cluster). The sample “n” was adjusted by the effect of the research design through the use of a correction factor corresponding to 2.1, (23), totaling a minimum number of 1403 students. To correct for possible losses or refusals, 5% was added, totaling a sample of 1473 students. Nevertheless, 1507 students participated in the study. The clusters and students were selected using a table with random numbers and respecting the maximum limit of 40 sampling units per school. To select the sample, first, the total number of public and private schools was determined that offered the fifth to eighth year of primary education in the city of Recife in 2007, totaling 674 and 256 schools, respectively. A random draft was used to select 40 schools, including 29 public and 11 private institutions, aiming for the proportionality needed in a stratified sample. In the second and third phase, the period and class from each school were selected in a simple random manner. Next, a draft was used to select a maximum of 40 students per school through the use of a table with random numbers.
Evaluation procedures and techniques Situation of risk of eating behavior disorders The Eating Behaviours and Body Image Test (EBBIT) was adopted, in view of its replicability and sensitivity for the purpose of the study proposal: early screening for risk situations (25–27). This scale is used to assess early and screen for behaviors that indicate a risk for eating behavior disorders. Candy and Fee (27) structured and validated this scale, which was translated and validated in Brazil by Galindo and Carvalho (26), maintaining the factorial structure of the original scale, with an internal consistency coefficient (Cronbach’s α) of 0.89. This test consists of 42 items with four alternative answers. Each alternative answer refers to an eating behavior, which can be scored between 0 and 3, like in the original scale. Score 0 (zero) is employed when the response is never, 1(one) when the response is once per month, that is, rarely, 2(two) once per week, frequently, and 3(three) for answers indicating every day, always.
To assess the risk factors, the EBBIT consists of three subscales, which assess dissatisfaction with the body image, binge eating habits and precursor behaviors of EDs. The maximum score is 12 for the subscale “compensatory behavior for hyperphagia”, 45 for “compulsive eating” and 69 for dissatisfaction with the body image/ restrictive eating. The subscales “binge eating” and “dissatisfaction with the body image/restrictive eating” composed a complete scale with a maximum score of 114 points. Although planned for application in female children, its validation for use in male children has been supported by studies that identify this use as statistically consistent (28).
Data collection procedure A technical team of health professionals was trained to apply the EBBIT and a questionnaire, under the supervision of a project researcher. The supervisors retested about 20% of the questionnaires to assess the consistency of the data and the replicability of the information.
Statistical analysis algorithm The data were expressed in the form of medians and interquartile intervals (IQ1–3). Due to the ordinal measuring, the Likert scale score was described in the form of percentages. The intergroup/intercategory medians were compared using Mann-Whitney’s non-parametric U test (2 groups/categories) and Kruskal-Wallis’ test (> 2 groups/ categories), using Mann-Whitney’s U test as an a posteriori test. Significance to reject the null hypothesis was set at 5%. Students who indicated a behavior with scores superior to the 75th percentile on the scales “binge eating”, “dissatisfaction with body image/restrictive eating” and scores superior to the 30th and 50th percentile for the disorders “compensatory behavior for hyperphagia” and “binge eating” + “dissatisfaction with body image/restrictive eating”, respectively, were considered as a strong indication of attending to the criteria to be considered as cases of anorexia and/or bulimia nervosa. Doubledata entry was used to type the data, which were verified using VALIDATE, a module of the software Epi-info, (Epi-info 6.04, WHO/CDC, Atlanta, GE, USA), to check the consistency and validation. SPSS for Windows, version 13.1 (SPSS Inc., Chicago, IL, USA) was used for statistical analyses.
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4 Cavalcanti et al.: Characterization of eating behavior disorders in school-aged children and adolescents Table 1: Frequency distribution of assessment scale of compensatory behavior for hyperphagia in school-aged students between 10 and 14 years old in Recife – 2007. Percentage scale Score 0 P1–P10 P10–P20 P20–P30 >P30 Total
n 1229 53 88 26 9 1405
%
87.4 3.8 6.3 1.9 0.6 100.0
CI95%a
85.6–89.1 2.9–4.9 5.1–7.7 1.2–2.7 0.3–1.2 0.3–1.2
CI, Confidence interval.
a
Ethical aspects The regulations of National Health Council Resolution 466/2012 on research involving human beings were followed (29). The research protocol received approval from the Institutional Review Board at the Center for Health Sciences of Universidade Federal de Pernambuco under CAAE (Certificate of Institutional Review Board Submission) – 0203.0.172.000-06. The students’ parents/responsible caregivers received information on the project, its objectives, the procedures and signed the free and informed consent form.
Results In total, 1405 students were assessed. The pilot study showed that the age group of interest understood the items questioned appropriately. The percentage distribution of the EBBIT scores for the eating behavior disorders has been described in Tables 1–3. It can be affirmed that the adolescents who indicated symptoms with scores superior to the 75th percentile on the scales “binge eating”, “dissatisfaction with body image/restrictive eating” and scores superior to the 30th and 50th percentile for the
disorders “compensatory behavior for hyperphagia” and “binge eating” + “dissatisfaction with body image/restrictive eating”, respectively, would be a strong indication of attending to the criteria to be considered as cases of anorexia and/or bulimia nervosa. The medians of the EDs were significantly higher in female adolescents, as can be observed in Table 4. The EDs varied as age advanced, reaching the highest medians between 13 and 14 years of age for “binge eating”, while “dissatisfaction with the body image/ restrictive eating” peaked at the age of 12–13 years. Similar results were observed for the sum of the subscales “binge eating” + “dissatisfaction with the body image/restrictive eating” (Table 5).
Discussion Intense research has been done on the psychometric characteristics, the dimension of the behavioral eating disorders and the body image. Feelings of dissatisfaction with the bodily aspect, eating restrictions, binge eating as well as the adoption of compensatory behaviors for hyperphagia are predictors used to assess children and adolescents and correspond to the criteria used in adults to diagnose anorexia and bulimia nervosa. The EBBIT is a psychometric assessment scale that serves to identify the onset of the problem in a reliable and valid manner, addressing eating and body image disorders in adolescents and dimensioning their underlying causes. The high score on the EBBIT subscales that assess the risks of EDs, observed among the students screened in Recife, shows the dimension of the problem in this ecological context and the urgent need for interventions to prevent and control these eating disorders. These results need to be interpreted with due caution though, given the need for replication in other geographic spaces. Comparing the magnitude of the EDs described in other contexts is difficult due to different methods and
Table 2: Frequency distribution of assessment scale of binge eating and dissatisfaction with the body image/restrictive eating disorders in school-aged students between 10 and 14 years old in Recife – 2007. Percentage scale ≤P25 >P25–≤P50 >P50–≤P75 >P75 Total
n
%
Binge eating CI95%a
595 599 169 42 1405
42.3 42.6 12.0 3.0 100.0
39.8 – 45.0 40.0 – 45.3 10.4 – 13.8 2.2 – 4.0
Dissatisfaction with body image/restrictive eating n
%
CI95%a
954 306 127 18 1405
67.9 21.8 9.0 1.3 100.0
65.4 – 70.3 19.6 – 24.0 7.6 – 10.7 0.8 – 2.0
CI, Confidence interval.
a
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Cavalcanti et al.: Characterization of eating behavior disorders in school-aged children and adolescents 5
Table 3: Frequency distribution of sum of subscales binge eating + dissatisfaction with the body image/restrictive eating in schoolaged children between 10–14 years of age in Recife – 2007. Percentage scale
n
770 541 94 1405
≤P25 >P25–≤P50 >P50 Total
%
54.8 38.5 6.7 100.0
CI95%a
52.2–57.9 36.0–41.1 5.4–8.1
CI, Confidence interval.
a
Table 4: Medians and interquartile intervals of the a ssessment scales of eating behavior disorders according to sex in school-aged children between 10 and 14 years of age in Recife – 2007. EDs
Sex Male (n=605) Med (IQ1–3)d
Female (n=800) Med (IQ1–3)d
12 (7–19) 8 (3–17) 23 (14–34)
14 (9–20) 13 (6–26) 29 (18–43)
Bebb Bidrec Beb + Bride
p-Valuea
0.001 0.000 0.000
Mann-Whitney’s U-test; bbinge eating; cdissatisfaction with the body image/restrictive eating; dmedian and interquartile intervals (IQ1–3).
a
Table 5: Medians and interquartile intervals of the assessment scales of the eating behavior disorders according to age in schoolaged children between 10 and 14 years of age in Recife – 2007. Age, years 10 11 12 13 14 pa
n
Bebb Med (IQ1–3)d
275 363 309 283 175
12 (7–18)e 12 (7–19)e 13 (8–20)e 14 (9–21)f 14 (9–20)f 0.019
Bidrec Med (IQ1–3)d
Beb+Bride Med (IQ1–3)d
9 (4–18)e 9 (4–21)e 12 (5–27)f 11 (4–23)e,f 11 (4–23)f 0.021
24 (16–35)e 25 (16–36)e 29 (17–44)f 28 (18–40)f 27 (16–42)f 0.006
a Kruskal-Wallis; bbinge eating; cdissatisfaction with the body image/restrictive eating; dmedian and interquartile intervals (IQ1–3); e,f different letters mean different medians at 5% (Mann-Whitney’s U-test).
tools used in this kind of inquiries. In Spanish adolescents, prevalence rates of EDs around 1% and 4.7% have been estimated (30). Fairburn and Harrison (31) reported a prevalence rate of 0.7%, while Patton et al. (32), studying Australian adolescents between 15 and 17 years of age and using at least two criteria of the DSM-IV, observed prevalence rates of 9.4% in women and 1.4% in men.
A much higher number of adolescents who are not identified in some scales, such as the Eating Disorders Inventory, may be at risk of developing eating disorders but are not identified through the use of instruments built to assess adults. In that sense, Pope et al. (33) observe that behavioural eating disorders are at least as chronic as the well-defined disorders anorexia nervosa and bulimia nervosa, and probably represent a stable symptom. The greater vulnerability of the female sex to EDs observed in this sample demonstrates the strong influence of the body image in this gender, although behavioural eating disorders among male adolescents are increasingly growing in recent decades. This information is similar to the findings in studies from Thailand, Ireland and India (9, 34, 35) in which the effect of the gender variable on the expected bodily condition could be verified, revealing that girls are more dissatisfied with their bodily shape and want a leaner and thinner body, therefore being more prone to eating disorders. Beauty standards advocated by the media and society influence behavior of dissatisfaction both girls and boys. The girls start to have excessive body checking behaviors in front of the mirror and the preoccupation with weight (36). As for the boys, studies have shown that just as in girls, body dissatisfaction is an important triggering variable of EDs in this group (37), and with increasing age, demonstrate dissatisfaction with thinness, motivated by culture to athletic and muscular body (38). Generally teenagers that eat compulsively can act as a way to break the intolerable restrictions of a diet or probably because they exhibit a permanent pattern of hyperphagia which leads to increased body weight. Therefore, adolescents who eat compulsively would be at lower risk for developing bulimia, but at greater risk for developing chronic obesity; on the other hand, teenagers who eat compulsively and make food restriction would be at greater risk of developing bulimia (39). The increase of the precursor risk factors of EDs as age advances among the students/adolescents in Recife has also been a frequent finding in other studies involving adolescents (27, 40). In students who attend the final years of primary school, dissatisfaction with their body image is clearly linked to restrictive behaviors and the use of physical exercise for the sake of weight control, but a binge eating pattern is also evident in some adolescents. In the adolescents with the highest education level, the weight control methods are more extreme, including provoked vomiting, abuse of laxatives, diuretics and appetite inhibitors (41). In adolescents, two factors can represent these problems: one is related to restrictive eating behaviors and the other to binge eating. As age advances, however, these symptoms are combined into bulimia. Based on this
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6 Cavalcanti et al.: Characterization of eating behavior disorders in school-aged children and adolescents attempted hypothesis, interventions designed to prevent unhealthy weight control strategies would be better aimed at adolescents at the end of primary school or the start of secondary school (27). Nevertheless, it should be taken into account that this research did not include any interview to reach a clinical or subclinical diagnosis. The high scores may represent very similar symptoms to the DSM-IV for the diagnostic criteria for anorexia and bulimia. It should be highlighted, however, that the official criteria for these diagnoses represent extreme problems that can be considered too severe for this age group to exhibit commonly, like the loss of the menarche in cases of anorexia nervosa. The disorders these adolescents present, in turn, should be characterized as subclinical. Due to the physical maturity stage and the potential risk of inappropriate eating, these problems impose the necessary attention. The subjective stress of children and adolescents of the study is clearly highlighted by the behaviors they referred to, including “skipping” meals; avoiding food that most teens like (e.g. dessert, chocolate) and at the other end, eating compulsively to point of discomfort or eating alone in the room. Therefore, research is needed to assess the utility of the EBBIT in tracking risks to eating behavior disorders, as well as the adequacy of existing diagnostic criteria for DSM-IV. The better understanding of the precursor risk factors of these eating disorders will greatly contribute to the design of intervention programs with prevent and control purposes. It is fundamental for these intervention programs to seek a dynamic care model that offers alternative references, within a preventive and therapeutic perspective of EDs, at all care levels, in an interdisciplinary manner, for possible use by health technicians and/or community health agents at the Family Health services. The range of the actions suggested in this model should be mediated by interdisciplinarity in care for these clients, attempting to associate the clinical interfaces of Nutrition, Mental Health, Pediatrics, Adolescent Medicine and Epidemiology. The goal is to construct a holistic understanding of these people who are suffering, aiming for the most appropriate preventive-therapeutic conduct. Nevertheless, it is known that public health services are lacking that serve as referral institutions to respect to the demands of children and adolescents, and even more to prevent mental health and psychopathological development problems. It emphasizes the fundamental importance the of creating social support and care systems in primary care and of training health professionals to be more sensitive to the problem
and manage the cases identified, avoiding inequalities in the access to treatment and in care, focused on hospitalbased services, which come with high costs and low efficiency in prevention actions. This research appoints important political implications for the public health area, including the need to develop prevention programs, supporting by health education actions, with a view to empowering the adolescents for the situations of vulnerability to inappropriate eating behaviors. In addition, the essential role of institutional partnerships among schools, health services and the family group is emphasized in the composition and action strategy of prevention programs, which encourage favorable environments to support and encourage teenagers to adopt healthy behaviors in order to reflect in improving important EDs predictors: low self-esteem, negative body image and internalization of the skinny ideal (42, 43). Finally, it is highlighted that changes in the eating behavior and awareness raising about the quality of the diet are not an easy task, and that the interventions do not cause effects in the short term. Nevertheless, health promotion practices can be established, based on intersectoral public policies in which the quality of life of the child-juvenile population is discussed on the health agenda. Study limitations: In the first place, the cross-sectional design of most studies does not permit inferences about causes and effects based on the associations established. Second, there is the fact that the response to the questionnaire was self-referred. Adolescents with disturbed eating pathologies may not be sufficiently honest in their answers to the inquiries. In addition, if the scale is used for clinical purposes, obtaining complementary data from other information sources would be highly recommendable. Finally, longitudinal studies are suggested to understand the triggering factors of EDs since childhood, as well as experimental or quasi-experimental studies to verify the effect of intervention programs aiming to change eating behaviors and perceptions on the ideal and perfect body concept. Acknowledgements and research funding: This research received funding from the Brazilian Scientific and Technological Development Council (CNPq) and the Brazilian Ministry of Science and Technology, (process numbers: 444146/2006-5 and 01.0265/2005-MCT, respectively). Acknowledgements to the Pernambuco State and Municipal Health Secretaries, Recife, Brazil. To the Union of Private Schools of the State of Pernambuco. To all Deans, Coordinators, Teachers, Parents and/or responsible caregivers who took part in this research.
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Cavalcanti et al.: Characterization of eating behavior disorders in school-aged children and adolescents 7
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8 Cavalcanti et al.: Characterization of eating behavior disorders in school-aged children and adolescents association with socio-demographic factors and nutritional status. Cien Saude Colet 2014;19:1201–8. 38. Jain N, Prasuna JG, Khandekar J. Self body image and perceived health in adolescents: a facility based study. Ind J Youth Adol Health 2015;2:8–15. 39. Williamson DA. Assessment of eating disorders: obesity, anorexia, and bulimia nervosa. New York: Pergamon, 1990. 40. McNamara C, Hay P, Katsikitis M, Chur-Hansen A. Emotional response to food, body dissatisfaction and other eating disorders features in children, adolescent and young adults. Appetite 2008;50:102–9.
41. Stephen EM, Rose J, Kenney L, Rosselli-Navarra F, Striegel Weissman R. Adolescent risk factors for purging in young women: findings from the national longitudinal study of adolescent health. J Eat Disord 2014;2:1–9. 42. Latzer Y, Spivak-Lavi Z, Katz R. Disordered eating and media exposure among adolescent girls: the role of parental involvement and sense of empowerment. Int J Adolesc Youth 2015;20:375–91. 43. Fortes LS, Meirelles JF, Neves CM, Almeida SS, Ferreira MEC. Can self-esteem, body dissatisfaction, and internalization of the thinness ideal influence risk behaviors for eating disorders? Rev Nutr 2015;28:253–64.
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Ana Márcia Tenório de Souza Cavalcanti*, Ilma Kruze Grande de Arruda, Emilly Anne Cardoso Moreno de Lima, Waldemar Brandão Neto, Estela Maria Leite Meirelles Monteiro, Luciane Soares de Lima and Alcides da Silva Diniz
Characterization of eating behavior disorders in school-aged children and adolescents: a population-based study DOI: 10.1515/ijamh-2015-0087 Received August 14, 2015; accepted November 19, 2015
Abstract Objective: Cross-sectional study to assess the characteristics of the risk behaviors for eating disorders (EDs) in school children between 10 and 14 years of age in the city of Recife, Pernambuco, Brazil. Methods: 1405 school-aged children were assessed, using the Eating Behaviours and Body Image Test (EBBIT) to screen for EDs. The normality of the continuing variables was tested using the Kolmogorov-Smirnov test with Lilliefors correction. They were described as medians and interquartile intervals (25 and 75th percentiles). Results: The criteria that represented a condition of anorexia and/or bulimia nervosa were considered as strong indicators of risk for EDs in school-aged children who indicated the following behaviors with scores superior to the 75th percentile on the scales: “compulsive eating” 3.0% (CI95% 2.2–4.0); “dissatisfaction with body image/ restrictive eating” 1.3% (CI95% 0.8–2.0); children scoring superior to the 30th percentile, “compulsive eating” + “dissatisfaction with body image/restrictive eating”, 0.6%
*Corresponding author: Ana Márcia Tenório de Souza Cavalcanti, Nursing Department, Avenida Prof. Moraes Rego, s\n Bloco A do Hospital das Clínicas 1° Andar Cidade Universitária CEP – 50.670 – 901, Recife – PE, Brazil, E-mail: [email protected] Ana Márcia Tenório de Souza Cavalcanti and Estela Maria Leite Meirelles Monteiro: Nursing Department, Universidade Federal de Pernambuco, Brazil Ilma Kruze Grande de Arruda and Alcides da Silva Diniz: Nutrition Department, Universidade Federal de Pernambuco, Brazil Emilly Anne Cardoso Moreno de Lima and Waldemar Brandão Neto: Graduate Program in Child and Adolescent Health, Universidade Federal de Pernambuco, Brazil Luciane Soares de Lima: Nursing Department, Coordinator of Graduate Program in Child and Adolescent Health, Centre of Health Sciences, Universidade Federal de Pernambuco, Brazil
(CI95% 0.3–1.2); and superior to the 50th percentile; “compensatory behavior for hyperphagia” 6.7% (CI95% 5.4–8.1). In addition, greater vulnerability of the female gender was perceived, as well as an increase in the preliminary risk factors of EDs, such as advanced age, dissatisfaction with the body image linked to restrictive behaviors and the compulsive establishment of an eating pattern. Conclusion: This study shows the dimension of the problem in this ecological context and the urgent need for intervention programs, developed among different sectors, from the perspective of the adolescents’ empowerment to prevent and minimize the vulnerability factors of the eating disorders. Keywords: adolescents; anorexia nervosa; bulimia nervosa; child; eating behaviors; eating disorders; health promotion.
Introduction Eating Disorders (EDs) can be defined as multidimensional pathological conditions in which the interaction among biological, family, psychological and sociocultural factors determines a distorted relation between individuals and their eating behavior. The criteria of this behavioral syndrome have been studied in the past 30 years (1). The signs of EDs can be perceptible since childhood, with the possibility of early detection, consequently favoring intervention measures to act on determining factors, mainly attempting to minimize possibilities of illness and perpetuation of its s ymptoms (2–4). The classification systems of mental disorders, the International Classification of Diseases – 10th edition (ICD-10) (5) and the Diagnostic and Statistical Manual of Mental Disorders – DSM-5 (6), recognize the main types of EDs: anorexia nervosa (AN), bulimia nervosa (BN) and binge-eating disorder (BED). Despite distinct classi fications, AN and BN share the same psychopathology:
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2 Cavalcanti et al.: Characterization of eating behavior disorders in school-aged children and adolescents the excessive concern with the body weight and shape, so that the patients use inappropriate methods, such as extremely restrictive diets, out of fear of gaining weight and in search of the ideal body. These disorders mainly happen in female adolescents and young people (7) and, according to the American Psychiatric Association (8), the prevalence of anorexia nervosa ranges between 0.3 and 3.7% and the prevalence of bulimia nervosa between 1.1 and 4%. According to Wong et al. (9) and Claudino and Borges (1), the patients judge themselves exclusively based on their physical appearance and always show to be dissatisfied with that image. In addition, it is discussed that the number of cases may be even higher, as the health professionals generally discover the most severe cases of the disease in specialized hospital services. These disorders can entail physical consequences similar to those deriving from a state of chronic malnutrition. EDs usually appear in early adolescence and can cause malformations in their growth curves, delay or interruption of the adolescent development (10). On average, this delay can cause a reduction by up to 15% regarding the appropriate lower age and height limit. There is a high risk of association with other illnesses and a significant risk of mortality (11). In general, both BN and AN emerge during adolescence but, according to some authors, AN can be found as from the age of seven years (12). They also report that, in childhood, AN can cause physical development problems and that the incidence in boys is more relevant in the pre-adolescent age range. Investigating the affective-emotional, biological, physiopathological and environmental bases of AN, BN and compulsive eating disorder involves the need to attempt to understand the world of anorexic and/or bulimic patients, permitting the identification of risk factors, which increasingly arouses the need for scientific inquiries, in view of the fact that these EDs have stood out in the current society, mainly due to the high demand of adolescent girls and young adults in consultation rooms and clinics, in view of the importance the Western culture has attributed to the lean, pale and slim body (13). For a long time, EDs were considered as being exclusive to wealthy countries, affecting only young white women from the highest social class, which can partially explain the small number of studies in the area in developing countries. The association between a false belief in first-world countries and their scientific community that eating disorders are very rare in poor countries and the absence of local statistics on the theme provoked a delay
and abandonment of more systematic research on EDs in economically emerging areas. Several surveys indicate rising prevalence of EDs in the modern world, given the changes in eating habits of children and adolescents (14–16). Dissatisfaction with one’s body image should be considered one of the main precursors of EDs. Therefore, studies that identify groups with these risks around the world are relevant, aiming for the early identification of the most preponderant abnormal eating behaviors, which can interfere in their prognosis (17, 18). In Brazil, Triches and Giugliani (19), Vieira et al. (20) Vilela et al. (3). According to Ferreira and Veiga (21) and Moya and Fleitlich-Bilyk (22), studies that investigate the EDs and their precursors are relatively rare in developing countries and specifically in Brazil, which reflects the relation with this theme. This is one of the first studies in the Northeast of Brazil that involves a representative sample of younger adolescents, with the opportunity to describe the occurrence of eating behaviors and to identify risk indicators for the development of eating disorders. The objective in this study was to assess the risk behaviors for EDs in children and adolescents between 10 and 14 years of age in the city ofRecife, Pernambuco, Brazil.
Methods Study design and place The research design was cross-sectional, aiming to estimate the prevalence of eating behavior disorders at public and private schools in the city of Recife between August and December 2007.
Study population The study population consisted of school-aged children, between 10 and 14 years of age, taking the fifth to eighth year of primary education in the state and municipal public and private education networks in the city of Recife, Pernambuco.
Inclusion/exclusion criteria Students were considered eligible who were between 10 and 14 years of age, male and female and regularly enrolled in the official education network. Students were excluded who, although enrolled, were not regularly attending the classes and school activities, as well as students who needed a special diet due to a health problem or whose families adopted a special form of diet.
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Cavalcanti et al.: Characterization of eating behavior disorders in school-aged children and adolescents 3
Sampling plan A pilot test was undertaken, involving 50 male and female students from one previously drafted school, which served as the base to estimate the prevalence of eating disorders in the study population. The sampling size (n) was calculated based on the formula [n= z2.p.(1-p)/d2] Henderson and Sunderesan (23), where “z” represents the desired level of reliability (95%), “p” the estimated prevalence of overweight corresponding to 19.5% Campos et al. (24), and “d” the acceptable error margin of 3.0%. A multiple-stage sampling process was adopted, whose sampling units were the school (1st cluster), period (2nd cluster), class (3rd cluster) and student (4th cluster). The sample “n” was adjusted by the effect of the research design through the use of a correction factor corresponding to 2.1, (23), totaling a minimum number of 1403 students. To correct for possible losses or refusals, 5% was added, totaling a sample of 1473 students. Nevertheless, 1507 students participated in the study. The clusters and students were selected using a table with random numbers and respecting the maximum limit of 40 sampling units per school. To select the sample, first, the total number of public and private schools was determined that offered the fifth to eighth year of primary education in the city of Recife in 2007, totaling 674 and 256 schools, respectively. A random draft was used to select 40 schools, including 29 public and 11 private institutions, aiming for the proportionality needed in a stratified sample. In the second and third phase, the period and class from each school were selected in a simple random manner. Next, a draft was used to select a maximum of 40 students per school through the use of a table with random numbers.
Evaluation procedures and techniques Situation of risk of eating behavior disorders The Eating Behaviours and Body Image Test (EBBIT) was adopted, in view of its replicability and sensitivity for the purpose of the study proposal: early screening for risk situations (25–27). This scale is used to assess early and screen for behaviors that indicate a risk for eating behavior disorders. Candy and Fee (27) structured and validated this scale, which was translated and validated in Brazil by Galindo and Carvalho (26), maintaining the factorial structure of the original scale, with an internal consistency coefficient (Cronbach’s α) of 0.89. This test consists of 42 items with four alternative answers. Each alternative answer refers to an eating behavior, which can be scored between 0 and 3, like in the original scale. Score 0 (zero) is employed when the response is never, 1(one) when the response is once per month, that is, rarely, 2(two) once per week, frequently, and 3(three) for answers indicating every day, always.
To assess the risk factors, the EBBIT consists of three subscales, which assess dissatisfaction with the body image, binge eating habits and precursor behaviors of EDs. The maximum score is 12 for the subscale “compensatory behavior for hyperphagia”, 45 for “compulsive eating” and 69 for dissatisfaction with the body image/ restrictive eating. The subscales “binge eating” and “dissatisfaction with the body image/restrictive eating” composed a complete scale with a maximum score of 114 points. Although planned for application in female children, its validation for use in male children has been supported by studies that identify this use as statistically consistent (28).
Data collection procedure A technical team of health professionals was trained to apply the EBBIT and a questionnaire, under the supervision of a project researcher. The supervisors retested about 20% of the questionnaires to assess the consistency of the data and the replicability of the information.
Statistical analysis algorithm The data were expressed in the form of medians and interquartile intervals (IQ1–3). Due to the ordinal measuring, the Likert scale score was described in the form of percentages. The intergroup/intercategory medians were compared using Mann-Whitney’s non-parametric U test (2 groups/categories) and Kruskal-Wallis’ test (> 2 groups/ categories), using Mann-Whitney’s U test as an a posteriori test. Significance to reject the null hypothesis was set at 5%. Students who indicated a behavior with scores superior to the 75th percentile on the scales “binge eating”, “dissatisfaction with body image/restrictive eating” and scores superior to the 30th and 50th percentile for the disorders “compensatory behavior for hyperphagia” and “binge eating” + “dissatisfaction with body image/restrictive eating”, respectively, were considered as a strong indication of attending to the criteria to be considered as cases of anorexia and/or bulimia nervosa. Doubledata entry was used to type the data, which were verified using VALIDATE, a module of the software Epi-info, (Epi-info 6.04, WHO/CDC, Atlanta, GE, USA), to check the consistency and validation. SPSS for Windows, version 13.1 (SPSS Inc., Chicago, IL, USA) was used for statistical analyses.
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4 Cavalcanti et al.: Characterization of eating behavior disorders in school-aged children and adolescents Table 1: Frequency distribution of assessment scale of compensatory behavior for hyperphagia in school-aged students between 10 and 14 years old in Recife – 2007. Percentage scale Score 0 P1–P10 P10–P20 P20–P30 >P30 Total
n 1229 53 88 26 9 1405
%
87.4 3.8 6.3 1.9 0.6 100.0
CI95%a
85.6–89.1 2.9–4.9 5.1–7.7 1.2–2.7 0.3–1.2 0.3–1.2
CI, Confidence interval.
a
Ethical aspects The regulations of National Health Council Resolution 466/2012 on research involving human beings were followed (29). The research protocol received approval from the Institutional Review Board at the Center for Health Sciences of Universidade Federal de Pernambuco under CAAE (Certificate of Institutional Review Board Submission) – 0203.0.172.000-06. The students’ parents/responsible caregivers received information on the project, its objectives, the procedures and signed the free and informed consent form.
Results In total, 1405 students were assessed. The pilot study showed that the age group of interest understood the items questioned appropriately. The percentage distribution of the EBBIT scores for the eating behavior disorders has been described in Tables 1–3. It can be affirmed that the adolescents who indicated symptoms with scores superior to the 75th percentile on the scales “binge eating”, “dissatisfaction with body image/restrictive eating” and scores superior to the 30th and 50th percentile for the
disorders “compensatory behavior for hyperphagia” and “binge eating” + “dissatisfaction with body image/restrictive eating”, respectively, would be a strong indication of attending to the criteria to be considered as cases of anorexia and/or bulimia nervosa. The medians of the EDs were significantly higher in female adolescents, as can be observed in Table 4. The EDs varied as age advanced, reaching the highest medians between 13 and 14 years of age for “binge eating”, while “dissatisfaction with the body image/ restrictive eating” peaked at the age of 12–13 years. Similar results were observed for the sum of the subscales “binge eating” + “dissatisfaction with the body image/restrictive eating” (Table 5).
Discussion Intense research has been done on the psychometric characteristics, the dimension of the behavioral eating disorders and the body image. Feelings of dissatisfaction with the bodily aspect, eating restrictions, binge eating as well as the adoption of compensatory behaviors for hyperphagia are predictors used to assess children and adolescents and correspond to the criteria used in adults to diagnose anorexia and bulimia nervosa. The EBBIT is a psychometric assessment scale that serves to identify the onset of the problem in a reliable and valid manner, addressing eating and body image disorders in adolescents and dimensioning their underlying causes. The high score on the EBBIT subscales that assess the risks of EDs, observed among the students screened in Recife, shows the dimension of the problem in this ecological context and the urgent need for interventions to prevent and control these eating disorders. These results need to be interpreted with due caution though, given the need for replication in other geographic spaces. Comparing the magnitude of the EDs described in other contexts is difficult due to different methods and
Table 2: Frequency distribution of assessment scale of binge eating and dissatisfaction with the body image/restrictive eating disorders in school-aged students between 10 and 14 years old in Recife – 2007. Percentage scale ≤P25 >P25–≤P50 >P50–≤P75 >P75 Total
n
%
Binge eating CI95%a
595 599 169 42 1405
42.3 42.6 12.0 3.0 100.0
39.8 – 45.0 40.0 – 45.3 10.4 – 13.8 2.2 – 4.0
Dissatisfaction with body image/restrictive eating n
%
CI95%a
954 306 127 18 1405
67.9 21.8 9.0 1.3 100.0
65.4 – 70.3 19.6 – 24.0 7.6 – 10.7 0.8 – 2.0
CI, Confidence interval.
a
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Cavalcanti et al.: Characterization of eating behavior disorders in school-aged children and adolescents 5
Table 3: Frequency distribution of sum of subscales binge eating + dissatisfaction with the body image/restrictive eating in schoolaged children between 10–14 years of age in Recife – 2007. Percentage scale
n
770 541 94 1405
≤P25 >P25–≤P50 >P50 Total
%
54.8 38.5 6.7 100.0
CI95%a
52.2–57.9 36.0–41.1 5.4–8.1
CI, Confidence interval.
a
Table 4: Medians and interquartile intervals of the a ssessment scales of eating behavior disorders according to sex in school-aged children between 10 and 14 years of age in Recife – 2007. EDs
Sex Male (n=605) Med (IQ1–3)d
Female (n=800) Med (IQ1–3)d
12 (7–19) 8 (3–17) 23 (14–34)
14 (9–20) 13 (6–26) 29 (18–43)
Bebb Bidrec Beb + Bride
p-Valuea
0.001 0.000 0.000
Mann-Whitney’s U-test; bbinge eating; cdissatisfaction with the body image/restrictive eating; dmedian and interquartile intervals (IQ1–3).
a
Table 5: Medians and interquartile intervals of the assessment scales of the eating behavior disorders according to age in schoolaged children between 10 and 14 years of age in Recife – 2007. Age, years 10 11 12 13 14 pa
n
Bebb Med (IQ1–3)d
275 363 309 283 175
12 (7–18)e 12 (7–19)e 13 (8–20)e 14 (9–21)f 14 (9–20)f 0.019
Bidrec Med (IQ1–3)d
Beb+Bride Med (IQ1–3)d
9 (4–18)e 9 (4–21)e 12 (5–27)f 11 (4–23)e,f 11 (4–23)f 0.021
24 (16–35)e 25 (16–36)e 29 (17–44)f 28 (18–40)f 27 (16–42)f 0.006
a Kruskal-Wallis; bbinge eating; cdissatisfaction with the body image/restrictive eating; dmedian and interquartile intervals (IQ1–3); e,f different letters mean different medians at 5% (Mann-Whitney’s U-test).
tools used in this kind of inquiries. In Spanish adolescents, prevalence rates of EDs around 1% and 4.7% have been estimated (30). Fairburn and Harrison (31) reported a prevalence rate of 0.7%, while Patton et al. (32), studying Australian adolescents between 15 and 17 years of age and using at least two criteria of the DSM-IV, observed prevalence rates of 9.4% in women and 1.4% in men.
A much higher number of adolescents who are not identified in some scales, such as the Eating Disorders Inventory, may be at risk of developing eating disorders but are not identified through the use of instruments built to assess adults. In that sense, Pope et al. (33) observe that behavioural eating disorders are at least as chronic as the well-defined disorders anorexia nervosa and bulimia nervosa, and probably represent a stable symptom. The greater vulnerability of the female sex to EDs observed in this sample demonstrates the strong influence of the body image in this gender, although behavioural eating disorders among male adolescents are increasingly growing in recent decades. This information is similar to the findings in studies from Thailand, Ireland and India (9, 34, 35) in which the effect of the gender variable on the expected bodily condition could be verified, revealing that girls are more dissatisfied with their bodily shape and want a leaner and thinner body, therefore being more prone to eating disorders. Beauty standards advocated by the media and society influence behavior of dissatisfaction both girls and boys. The girls start to have excessive body checking behaviors in front of the mirror and the preoccupation with weight (36). As for the boys, studies have shown that just as in girls, body dissatisfaction is an important triggering variable of EDs in this group (37), and with increasing age, demonstrate dissatisfaction with thinness, motivated by culture to athletic and muscular body (38). Generally teenagers that eat compulsively can act as a way to break the intolerable restrictions of a diet or probably because they exhibit a permanent pattern of hyperphagia which leads to increased body weight. Therefore, adolescents who eat compulsively would be at lower risk for developing bulimia, but at greater risk for developing chronic obesity; on the other hand, teenagers who eat compulsively and make food restriction would be at greater risk of developing bulimia (39). The increase of the precursor risk factors of EDs as age advances among the students/adolescents in Recife has also been a frequent finding in other studies involving adolescents (27, 40). In students who attend the final years of primary school, dissatisfaction with their body image is clearly linked to restrictive behaviors and the use of physical exercise for the sake of weight control, but a binge eating pattern is also evident in some adolescents. In the adolescents with the highest education level, the weight control methods are more extreme, including provoked vomiting, abuse of laxatives, diuretics and appetite inhibitors (41). In adolescents, two factors can represent these problems: one is related to restrictive eating behaviors and the other to binge eating. As age advances, however, these symptoms are combined into bulimia. Based on this
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6 Cavalcanti et al.: Characterization of eating behavior disorders in school-aged children and adolescents attempted hypothesis, interventions designed to prevent unhealthy weight control strategies would be better aimed at adolescents at the end of primary school or the start of secondary school (27). Nevertheless, it should be taken into account that this research did not include any interview to reach a clinical or subclinical diagnosis. The high scores may represent very similar symptoms to the DSM-IV for the diagnostic criteria for anorexia and bulimia. It should be highlighted, however, that the official criteria for these diagnoses represent extreme problems that can be considered too severe for this age group to exhibit commonly, like the loss of the menarche in cases of anorexia nervosa. The disorders these adolescents present, in turn, should be characterized as subclinical. Due to the physical maturity stage and the potential risk of inappropriate eating, these problems impose the necessary attention. The subjective stress of children and adolescents of the study is clearly highlighted by the behaviors they referred to, including “skipping” meals; avoiding food that most teens like (e.g. dessert, chocolate) and at the other end, eating compulsively to point of discomfort or eating alone in the room. Therefore, research is needed to assess the utility of the EBBIT in tracking risks to eating behavior disorders, as well as the adequacy of existing diagnostic criteria for DSM-IV. The better understanding of the precursor risk factors of these eating disorders will greatly contribute to the design of intervention programs with prevent and control purposes. It is fundamental for these intervention programs to seek a dynamic care model that offers alternative references, within a preventive and therapeutic perspective of EDs, at all care levels, in an interdisciplinary manner, for possible use by health technicians and/or community health agents at the Family Health services. The range of the actions suggested in this model should be mediated by interdisciplinarity in care for these clients, attempting to associate the clinical interfaces of Nutrition, Mental Health, Pediatrics, Adolescent Medicine and Epidemiology. The goal is to construct a holistic understanding of these people who are suffering, aiming for the most appropriate preventive-therapeutic conduct. Nevertheless, it is known that public health services are lacking that serve as referral institutions to respect to the demands of children and adolescents, and even more to prevent mental health and psychopathological development problems. It emphasizes the fundamental importance the of creating social support and care systems in primary care and of training health professionals to be more sensitive to the problem
and manage the cases identified, avoiding inequalities in the access to treatment and in care, focused on hospitalbased services, which come with high costs and low efficiency in prevention actions. This research appoints important political implications for the public health area, including the need to develop prevention programs, supporting by health education actions, with a view to empowering the adolescents for the situations of vulnerability to inappropriate eating behaviors. In addition, the essential role of institutional partnerships among schools, health services and the family group is emphasized in the composition and action strategy of prevention programs, which encourage favorable environments to support and encourage teenagers to adopt healthy behaviors in order to reflect in improving important EDs predictors: low self-esteem, negative body image and internalization of the skinny ideal (42, 43). Finally, it is highlighted that changes in the eating behavior and awareness raising about the quality of the diet are not an easy task, and that the interventions do not cause effects in the short term. Nevertheless, health promotion practices can be established, based on intersectoral public policies in which the quality of life of the child-juvenile population is discussed on the health agenda. Study limitations: In the first place, the cross-sectional design of most studies does not permit inferences about causes and effects based on the associations established. Second, there is the fact that the response to the questionnaire was self-referred. Adolescents with disturbed eating pathologies may not be sufficiently honest in their answers to the inquiries. In addition, if the scale is used for clinical purposes, obtaining complementary data from other information sources would be highly recommendable. Finally, longitudinal studies are suggested to understand the triggering factors of EDs since childhood, as well as experimental or quasi-experimental studies to verify the effect of intervention programs aiming to change eating behaviors and perceptions on the ideal and perfect body concept. Acknowledgements and research funding: This research received funding from the Brazilian Scientific and Technological Development Council (CNPq) and the Brazilian Ministry of Science and Technology, (process numbers: 444146/2006-5 and 01.0265/2005-MCT, respectively). Acknowledgements to the Pernambuco State and Municipal Health Secretaries, Recife, Brazil. To the Union of Private Schools of the State of Pernambuco. To all Deans, Coordinators, Teachers, Parents and/or responsible caregivers who took part in this research.
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Cavalcanti et al.: Characterization of eating behavior disorders in school-aged children and adolescents 7
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