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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 39  |  Issue : 3  |  Page : 119-126

Subclinical eating disorders in a sample of secondary school girls and comorbidity with depression in Sharkia Governorate, Egypt


Department of Psychiatry, Faculty of Medicine, Zagazig University, Zagazig, Egypt

Date of Submission22-Aug-2016
Date of Acceptance18-May-2016
Date of Web Publication11-Oct-2018

Correspondence Address:
Nagda M Elmasry
Department of Psychiatry, Faculty of Medicine, Zagazig University, Zagazig
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-1105.243024

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  Abstract 


Background Eating disorders are complex psychiatric syndromes in which cognitive distortions related to food and body weight and disturbed eating patterns can lead to significant and potentially life-threatening medical and nutritional complications.
Aim of the work The aim of this study was to evaluate the frequency of subclinical forms of eating disorders and the association between it and depression in school girls in Sharkia Governorate, Egypt.
Patients and methods In this two-stage cross-sectional study, we screened 2000 secondary school girls using eating disorder test. Those scoring 30 or less (n=415) and a control group randomly selected from those scoring 30 or more (N=215) were assessed using the eating disorder module of the Structured Clinical Interview for Diagnostic and statistical manual of mental disorders, 4th ed. (DSM-IV) axis-I disorders (SCID-I). SCID-I positive patients from stage 2 were screened for depressive symptoms using Beck Depression Inventory and diagnosed as having major depressive disorder according to DSM-IV criteria.
Results The prevalence of subclinical eating disorders was 25.5% (subthreshold anorexia 3.5%, subthreshold bulimia nervosa 3.0%, SWC 10.0%, and subthreshold binge-eating disorder 9.0%), and the prevalence of major depressive disorder in SEDS patients was 10.8%.
Conclusion Subclinical eating disorders are more frequent than typical eating disorders. Subclinical forms of eating disorders may represent a high-risk group for developing serious eating disorders; identifying this group will give an opportunity of prevention. Depressive disorder is frequent in patients with subclinical eating disorders.

Keywords: depression, eating disorder test, eating disorders, subclinical eating disorders


How to cite this article:
Elmasry NM, Khali DM. Subclinical eating disorders in a sample of secondary school girls and comorbidity with depression in Sharkia Governorate, Egypt. Egypt J Psychiatr 2018;39:119-26

How to cite this URL:
Elmasry NM, Khali DM. Subclinical eating disorders in a sample of secondary school girls and comorbidity with depression in Sharkia Governorate, Egypt. Egypt J Psychiatr [serial online] 2018 [cited 2018 Oct 21];39:119-26. Available from: http://new.ejpsy.eg.net/text.asp?2018/39/3/119/243024




  Introduction Top


Eating disorders (EDs) are complex psychiatric syndromes in which cognitive distortions related to food and body weight and disturbed eating patterns can lead to significant and potentially life-threatening medical and nutritional complications (American Dietetic Association, 2007). Although EDs are rare in the general population, they are relatively common in teenagers and young women. EDs represent the third most common chronic illness (after asthma and obesity) in adolescent girls (Swanson et al., 2011).

EDs are the third largest causes of morbidity among teenagers and young people. Much of the interest in learning more about subclinical ED/AEDs is related to the clinical course of these disorders and the possibility of early detection and prevention of EDs (Garcia et al., 2011).

Five ED diagnoses were ascertained: anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder (BED), subclinical anorexia nervosa (SAN), and subthreshold binge-eating disorder (SBED). The rates of AN, BN, BED, SAN, and SBED were 0.3, 0.9, 1.6, 0.8, and 2.5%, respectively (Merikangas et al., 2009).

Psychiatric comorbidity appears to be greater overall among adolescents than among adults (Rohde, 1997). Some authors reported a higher rate of suicide attempts and self-harm in AED patients than in typical ED patients.

Subclinical EDs are more frequent than the full syndromes, and there is a shift between diagnostic groupings (clinical end subclinical) over time (Hesse-Biber, 1992).

We expect a relatively high prevalence of subclinical eating disorder (SED) in adolescent girls because more than 50% of adult outpatients with an ED do not meet DSM criteria for either AN or BN and given the eating disorder not otherwise specified diagnosis. It has been proposed that depression and anxiety co-occur with ED because of the neuroendocrinal disturbances induced by starvation (Fairburn et al., 2007). In adolescence, EDs are significantly more frequent among depressive or anxiety disorders than among those without depressive or anxiety disorders (Stein et al., 2012). To our knowledge, the understanding of mood and anxiety disorders among individuals suffering from SED is very scarce in the adolescent population (Eddy et al., 2008). Assessing the presence of mood and/or anxiety disorders among girls suffering from SED may inform on the severity of their psychological distress and could decrease the onset of ED symptoms in early adulthood (Johnson et al., 2002). Finally, early detection of SED was associated with better clinical outcome (Steinhausen et al., 2002) and a decrease in the risk of mortality (Lindblad et al., 2006).


  Aim of the work Top


The aim of the current study was to evaluate the prevalence of subclinical forms of EDs and the association between it and depression among adolescent girls in Sharkia Governorate.


  Patients and methods Top


Design and procedures

A cross-sectional study was conducted during two academic years 2013/2014 and 2014/2015, which included 2000 adolescent girls from secondary schools in Sharkia Governorate. The study was approved by the Ethics Committee. Informed consent was taken from the students after discussing with them the aim of the study. The identification of cases was performed in two stages. In the first stage, all participants were asked to complete the demographic and anthropometric measures to estimate the BMI and the eating disorder test (EDT) questionnaires administered in a single session during their class breaks. A total of 150 participants were dropped. In the second stage, from all the remaining participants (1850) the one who scored at or above the cutoff point of 30 on the EDT (EDT positive) was examined face to face by a psychiatrist with the EDs module of the Structured Clinical Interview for Diagnostic and statistical manual of mental disorders, 4th ed. (DSM-IV) axis I disorders (SCID-I) for EDs. A control group was selected randomly from students who scored lower than 30 on the EDT (EDT negatives) and negative SCID-I for EDs. SCID-I positive patients from stage 2 were screened for depressive symptoms using the Beck scale for depression and diagnosed according to the DSM-IV criteria of depression.

Participants

The studied sample was divided into two groups: patient group and control group.

The patient group included 471 female students who were positive EDT and positive SCID-I for subclinical EDs, and the control group included 215 participants with no current or past EDs (negative EDT, negative SCID-I for subclinical EDs), matched for age, sex, and educational level.

Measures

A constructed questionnaire was used to collect information from self-reported data on age, education level, birth order, residence, parental education, occupation, as well as family ownership.

Eating disorder test

This test was used as a diagnostic test for AN nervosa, but nowadays it is frequently used to detect ED in general. It contains 40 questions with six graduated answers in Likert style. The score varies between 0 and 120. Patients who obtained 30 points or over were considered at high risk of having EDs. Higher scores from the items indicated that the severity of pathology could get worse; EDT has been validated and found to discriminate well between patients with ED and normal female individuals (Marshall, 1998). The Arabic version was used (Shokaire, 2002).

Anthropometry

Girls’ heights and weights were measured following the questionnaire. Weight was taken to the nearest 0.1 kg and height was measured to the nearest 0.1 cm. The BMI was calculated by dividing the weight (kg) by the height (m) squared.

ED module of the SCID-I (First et al., 1997).

In Egypt, SCID-I has been adapted and successfully used by psychiatric patients and nonpatient community patients. The diagnosis of partial syndromes (eating disorder not otherwise specified) Thomas et al., (2010) was applied to cases that met all the DSM-IV criteria for AN and/or BN, with one exception.

Beck Depression Inventory (BDI-II-Arabic version) (Beck et al., 1996):

The Beck Depression Inventory Second Edition (BDI-II) was a 1996 revision of the BDI. It is a self-report rating scale translated to Arabic by Ghareeb Abd El-Fatah, measuring the emotional, cognitive, and motivational symptoms of depression. It is a 21-item self-report instrument intended to assess the existence and severity of symptoms of depression, as listed in the American Psychiatric Association (1994).

Each of the 21 items corresponding to a symptom of depression is summed to give a single score for the BDI-II. There is a four-point scale for each item ranging from 0 to 3. On two items (16 and 18) there are seven options to indicate either an increase or a decrease of appetite and sleep. A total score of 0–13 is considered minimal range, 14–19 is mild, 20–28 is moderate, and 29–63 is severe.

Statistical analysis

Data were collected, verified, and analyzed using the SPSS for windows (version 20.0; SPSS Inc., Chicago, IL, USA). Data were expressed as mean±SD for quantitative variables, number, and percentage for categorical variables.

The association among variables was evaluated by correlation coefficients. Cronbach’s α, which is a measure of how well each individual item in a scale correlates with the sum of the remaining items, was used to measure the internal consistency of EDT. Cronbach’s α values of 0.90 or greater are considered excellent, values of 0.7–0.90 are acceptable/good, and values below 0.5 are unacceptable.

To estimate the sample size, we used the index: n= (z/e) 2 [p (1−p)], where z is the statistical coefficient for the established confidence level (0.05), p is the prevalence of ED in the population, and e is the precision F1%. This is in agreement with the data provided by DSM-IV and previous studies in the Egyptian secondary school-girl population (Nasser, 1994; Okasha and Mahmoud, 1998). We included 2000 students to allow dropouts (because of refusal to participate, absenteeism from school, and so on). Probabilities below 0.05 were regarded as significant (Paececock and Paececock, 2011).


  Results Top


Of the 2000 students who originally approached, 1850 completed the study. [Table 1] demonstrates the demographic data.
Table 1 Characteristics of the studied sample

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The whole sample comprised 2000 student girls with an age range of 15–18 years and a mean age of 16.3±13 years. Their BMI ranged from 16 to 40 with a mean of 24.7±5.4. A total of 736 (26.8%) lived in rural areas and 1264 (63.3%) lived in urban areas. Fathers of 224 (11.2%) students were illiterate, those of 608 (30.4%) students had average education, and those of 1168 (58.4%) had high education. With regard to occupation of father, those of 32 (1.6%) students were unemployed and those of 1968 (98.4%) were working. Mothers of 208 (10.4%) students were illiterate, those of 944 (47.2%) students had average education, and mothers of 848 (42.4%) students had high education level. Mothers of 800 (40%) students were employed. Birth order more than third n=320 (16%) relation between father and mother.

[Table 2] shows that the number of students who scored positive in EDT (susceptible to ED) was n=215 (11.6%), and the number of students who scored negative EDT (not susceptible to ED) was n=1635 (88.4%).
Table 2 Frequencies of eating disorders detected in the sample in stage 1 (screening stage)

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[Table 3] shows the distribution of EDs among the studied sample (1850): BN, 0.6%; subclinical AN nervosa, 3.5%; subclinical bulimia nervosa, 3.0%; subclinical weight concern, 10.0%; and SBED, 9.0%.
Table 3 Distribution of eating disorders in stage 2 (psychiatric interview)

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[Table 4] shows that subclinical BN has the most severe depressive symptoms (3.6%) ([Figure 1],[Figure 2],[Figure 3]).
Table 4 Severity of depressive symptoms among the subclinical eating disorder groups according to Beck Depression Inventory

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Figure 1 There is a statistically significant difference between the four groups of subclinical eating disorders regarding BMI. SAN group has the lowest BMI. SAN, subthreshold anorexia; SBED, subthreshold binge-eating disorder; SBN, subthreshold bulimia nervosa.

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Figure 2 There is a positive correlation between subthreshold bulimia nervosa and depression. MDD, major depressive disorder.

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Figure 3 There is a positive correlation between subthreshold binge-eating disorder and depression. MDD, major depressive disorder.

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  Discussion Top


A number of people suffer from EDs that closely resemble AN nervosa and BN but which are considered atypical and subthreshold, as they do not meet the precise diagnostic criteria for these conditions (Turner and Bryant-Wough, 2003).

As subclinical forms may represent a ‘high-risk group’ for developing more serious EDs, identifying this group will give an opportunity of prevention. Subclinical EDs may negatively influence health and psychosocial functioning (Pearson et al., 2002).

ED symptoms were also associated with the presence of mood and anxiety disorders (Stein et al., 2012).

In our study, females were included, as they show more abnormal eating behaviors, which makes them more at risk for EDs. Several studies show that sex differences in eating styles indicate that adolescent girls have been socialized to eat in a more feminine manner. Women are more dissatisfied with their body weight and shape than men, in addition to the sociocultural and psychological factors that may be important in the etiology of EDs, which are much more prevalent in women (American Psychiatric Association, 2010).

By using the EDT in the screening stage of this study, we found that 11.6% of the sample of secondary school girls, from Sharkia Governorate, had a score above the cutoff point of 30.This was in agreement with the study by Fawzi et al. (2010). Using a similar scale and a similar cutoff point of EDT-40 on a population of secondary school girls in Sharkia Governorate, they found that 11.2% of school girls had a score above the cutoff point.

In addition, Nasser (1994) using a similar cutoff point of the same screening tool on a population of secondary school girls in Cairo showed a very close figure of 11.4%. The rate that we obtained is also broadly concordant with the results of studies in other Arab countries (Eapen et al., 2006; Thomas et al., 2010).

In addition, Sepulveda et al. (2008) reported that in Western societies the prevalence of university students at high risk for developing an ED was 11.6–18%.

In the second stage of the present study, the prevalence of current ED meeting all DSM-IV criteria for EDs was 0.0% for AN nervosa and 0.6% for BNs. This was in agreement with the study by Fawzi et al. (2010) in which a similar scale SCID-I structured interview was used on a population of secondary school girls in Sharkia Governorate. They found that the prevalence of AN was 0.0%. In addition, Szabó and Túry (1995) reported that the prevalence of AN was 0.0% and that of BN was 0.7%.

Hoek (2006) and Fairbum and Beglin (1990) found that the prevalence of BN was 1.0% among young girls. Hay and Bacaltchuk (2003) found that the prevalence of BN was 0.5–1.0%, which was in accordance with our results, as the study was concerned with adolescent girls. In contrast, in the study by Roberts et al. (2007), 13.8% of the college students had EDs; Touchette et al. (2011) and Johnson et al. (2002) showed that the prevalence of ED meeting all clinical criteria was 0.6% for AN and 0% for BN. The different results declared in various research studies can be derived from different use of different screening methods, age of the study groups, and cultural background.

We found that the prevalence of SED in the present study was 25.5%. In agreement with our results, Touchette et al. (2011) reported that the prevalence of SED was 31.1% by using the same criteria for the diagnosis of subclinical EDs and SCID-I. The small difference may be because of the difference in cultural background and the difference in age, as their study was concerned with children of a younger age (6–12 years).

DiGioacchino DeBate et al. (2002), in their study, reported that the prevalence of subclinical EDs was 28% for triathlete females; the study included female individuals of the same age as in our study, and this is in agreement with our results.

The prevalence of SAN was 3.5% and that of subclinical bulimia nervosa (SBN) was 3.0% in adolescent girls included in our study.

Touchette et al. (2011) reported that the prevalence of SAN was 3.5% and that of SBN was 3.8% of adolescent girls; Szabó and Túry (1995) reported that the prevalence of subclinical AN was 6.7% and that of subclinical BN was 5.3%. These results are in agreement with our study, but there was a difference in the Szabó study related to the difference of age of the sample, as their study was concerned with college girls.

In contrast, Daniel et al. (2012) found that the prevalence of SAN nervosa among adolescent girls was 19.99%; these data were collected from the national comorbidity survey replication adolescent supplement.

In contrast, Arnold et al. (2008) found that the prevalence of partial syndrome of AN nervosa was 21% and partial syndrome of BN was 14%; the study used different scale BET (Branched eating disorders test) in evaluating partial syndromes of AN and BN.

From our findings, the prevalence of SBEDs was 9.0%.This is in agreement with the study by Touchette et al. (2011), who found that the prevalence of SBEDs was 10.8%; Striegel-Moore et al. (1999) reported that the prevalence of SBED of high-school girls was 6.8%, as their study involved adolescent girls.

Daniel et al. (2012), in their study, reported that the prevalence of SBED was 29.60% in adolescent girls; these data were collected from the national comorbidity survey replication adolescent supplement.

Our results showed that the prevalence of subclinical weight concern was 10.0%. Researches concerned with subclinical weight concern (SWC) are limited, and thus there are a few studies to be compared. In agreement, Touchette et al. (2011) reported that the prevalence of subclinical weight concern was 13%. Field et al. (2001) reported that 33% of adolescent girls thought frequently about wanting to be thinner; this is in contrast to our findings, as the study uses self-reporting scales for girls and their mothers.

The BMI for girls suffering from SAN was low compared with other subgroups. In agreement with our result, Touchette et al. (2011) reported that girls suffering from SAN had lower BMI as compared with other subgroups. Data of the present study suggested that girls with SBED and subclinical BN have a significant difference compared with the control group in BMI; this is in agreement with the study by De Zwaan et al. (1994), who proposed that the BMI in binge eating was two-fold.

The present study showed that there is a significant difference between subclinical BN (P=0.02), BED (P=0.017), and control group regarding the relationship between the mother and the father − tense relations were reported to be more liable to produce subclinical BN and subclinical BED. John Wiley and Sons Inc. (2001) reported that, as might be expected, the poorer the marital relationships, the greater the chance that the offspring would have subclinical BN and that conflictual and distinct marital relationship can at least partially act as an environmental risk factor. Our results are consistent with those of Stein et al. (2012), who found that there are certain family dynamics that leave young people more susceptible to developing problems with food, weight, and body image. Similarly, Blouin et al. (2005) found that families of bulimic patients appear to indicate patterns of chaotic type of disturbance; also, bulimic females perceive their families as less cohesive, less encouraging of independent behavior, less expressive, and less oriented toward relational purists than cases of families in which there are no ED symptoms.

In our study, mother’s occupation has a significant difference in SWC and SBED; however, no difference was found regarding father’s occupation. Studies concerned with mother’s occupation and subclinical EDs are very limited to be compared. Maor et al. (2008) stated that the scores of eating attitude tests are not different between the students whose mothers have jobs and the students whose mothers do not; however, they declared that the scores of eating attitude tests were higher among the students whose fathers were unemployed. This difference can be explained by the difference in the culture background. In contrast to our results, Wang et al. (2001) and Tozun et al. (2008) found that there was no difference between the students whose mothers have jobs and the students whose mothers do not.

We found that prevalence of depressive disorder among subclinical groups was 10.8%. This result is supported by previous research indicating that adolescents with abnormal eating attitudes and behaviors frequently report high levels of depression (Stein et al., 1997). This finding is consistent with that of Touchette et al. (2011), who found that the prevalence of depressive disorder among subclinical EDs was 10.2%. This is in agreement with the study by Katz et al. (1984), who examined depression in women with varying degrees of severity of EDs symptomatology. In agreement with our results, Zaider and Cockell (2000) in their study concerned with psychiatric comorbidity associated with ED symptomatology among adolescents found that the prevalence of mood disorders was 9.7% and that of major depressive disorder (MDD) was 10.0%. In contrast, Randy and Patterson (2008) found that the partial syndrome group had a 56.5% rate of depression comorbidity. This difference can be explained by the fact that the study was concerned with adults.Subclinical BN has the highest prevalence of depressive disorder followed by SWC and SBED and the lowest prevalence in SAN.

Similarly, Davis et al. (1985) monitored eating behavior and mood and found that bulimic patients experienced significant depression hours before bulimic bouts; studies have found that the patients were most likely to binge eat when they experienced unpleasant emotions or feelings, particularly anxiety or feelings of unhappiness, depression, and hostility.

Lewinsohn et al. (2000) reported that MDD or dysthymia was more strongly correlated with bulimic symptoms in an adolescent and young adult sample; this is in agreement with our results (the study included patients from the same age group).

SBED has a positive significant correlation with mood (MDD). Depressed people in binge-eating disorder are less likely to cope with negative moods and are therefore more likely to engage in ineffective coping strategies, such as binge eating (Dingemans et al., 2009). In addition, depressive symptoms such as increased appetite, hopelessness, or feelings of failure may contribute to increased caloric intake (Presnell et al., 2008), and this is in line with our results.


  Conclusion Top


From the results, we can conclude that subclinical EDs are more frequent than typical EDs. They represent a high-risk group for developing serious EDs; identifying this group will give an opportunity of prevention. Depressive symptoms are more frequent in subclinical EDs. There is an urgent need for early detection of subclinical EDs for treatment and better prognosis, especially in the high-risk groups. There is a need to study the comorbidity of psychiatric disorders with subclinical EDs and treatment of both disorders concurrently. Instructional programs should be designed for the population at risk to detect abnormal eating behaviors and concerns to prevent maladaptive behaviors used for weight control.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

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