Journal of Nutrition Education and Behavior
Volume 42, Issue 5 , Pages 292-298, September 2010

Factors Associated with Abnormal Eating Attitudes among Greek Adolescents

  • Aggeliki Bilali, MSc

      Affiliations

    • Laboratory of Demography, Faculty of Nursing, University of Athens, Athens, Greece
    • ,
  • Petros Galanis, PhD

      Affiliations

    • Center for Health Services Management and Evaluation, Faculty of Nursing, University of Athens, Athens, Greece
    • Corresponding Author InformationAddress for correspondence: Petros Galanis, PhD, Center for Health Services Management and Evaluation, Faculty of Nursing, 123 Papadiamantopoulou St, 115 27, Ampelokipoi, Greece; Phone: 0030 210 7461471; Fax: 0030 210 7461473
    • ,
  • Emmanuel Velonakis, PhD

      Affiliations

    • Department of Public Health, Faculty of Nursing, University of Athens, Athens, Greece
    • ,
  • Theofanis Katostaras, PhD

      Affiliations

    • Laboratory of Demography, Faculty of Nursing, University of Athens, Athens, Greece

published online 01 July 2010.

Article Outline

Abstract 

Objective

To estimate the prevalence of abnormal eating attitudes among Greek adolescents and identify possible risk factors associated with these attitudes.

Design

Cross-sectional, school-based study.

Setting

Six randomly selected schools in Patras, southern Greece.

Participants

The study population consisted of 540 Greek students aged 13-18 years, and the response rate was 97%.

Main Outcome Measure

The dependent variable was scores on the Eating Attitudes Test-26, with scores ≥ 20 indicating abnormal eating attitudes.

Analysis

Bivariate analysis included independent Student t test, chi-square test, and Fisher's exact test. Multivariate logistic regression analysis was applied for the identification of the predictive factors, which were associated independently with abnormal eating attitudes. A 2-sided P value of less than .05 was considered statistically significant.

Results

The prevalence of abnormal eating attitudes was 16.7%. Multivariate logistic regression analysis demonstrated that females, urban residents, and those with a body mass index outside normal range, a perception of being overweight, body dissatisfaction, and a family member on a diet were independently related to abnormal eating attitudes.

Conclusions and Implications

The results indicate that a proportion of Greek adolescents report abnormal eating attitudes and suggest that multiple factors contribute to the development of these attitudes. These findings are useful for further research into this topic and would be valuable in designing preventive interventions.

Key Words: Greek adolescents, eating attitudes, risk factors, EAT-26, eating disorder

 

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Introduction 

In the past 3 decades, the incidence of eating disorders has risen, especially among adolescent females. Eating disorders are a major public health issue that usually occur among young people (anorexia nervosa occurs mainly among adolescents aged 15-19 years and bulimia nervosa between 15 and 25 years).1 Recovery from eating disorders can be a long, difficult process interrupted by relapses. About 50% of all patients with anorexia recover, whereas up to 20% die of complications of the disorder. Concerning bulimia nervosa, the recovery rate is slightly higher. Also, eating disorders have significant physical, psychological, and social consequences as well as high mortality and case fatality rate.2, 3 Furthermore, abnormal eating behaviors are linked with other health-compromising behaviors, such as smoking, alcohol and drug abuse, unprotected sexual activity, and suicide attempts.4, 5, 6

Epidemiological studies of eating disorders are difficult to compare and interpret because of the low incidence and prevalence of eating disorders, the different methodologies employed, differing study populations, and the diversity of criteria used for diagnosis. The prevalence of anorexia nervosa is currently estimated at 0.2%-1% and of bulimia nervosa at 0%-2%.7 The prevalence of abnormal eating attitudes among adolescents, as defined by the Eating Attitudes Test-26 (EAT-26), ranges from 5% to 30% in studies performed in several countries.8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19

The development of eating disorders is multifactorial, and several risk factors have been suggested; sociocultural, environmental, and lifestyle factors have been related to eating disorders and abnormal eating attitudes. A great number of studies has confirmed that eating disorders occur more often among females than males.8, 12, 13, 16, 17, 20, 21 Also, a greater prevalence of eating disorders in the urban setting compared to the rural one was found in Italy,22, 23 in Holland,24 and in Japan.25 Moderate exercise motivated by concern about healthful lifestyle is linked to reduction of the occurrence of eating disorders,18, 26, 27 whereas cigarette smokers and alcohol drinkers are more likely to skip meals and not notice their hunger.28 In addition, body dissatisfaction and perception of being overweight increase the risk of eating disorders.8, 9, 11, 14, 18, 26, 27, 29

There is agreement on the importance of early identification of an eating disorder. In that case, it is possible that implementation of the most appropriate therapeutic treatment from the initial stages of the disorder can result in reduction in the frequency of physical and psychological complications and even death. The sooner a person with an eating disorder gets professional help, the better the chance of recovery. Thus, it is necessary that the general practitioner have full knowledge of the early warning signs as well as the adequate tools for diagnosis. Psychometric tests like the EAT-26 have been applied in recent years for the accurate evaluation of abnormal eating attitudes.23, 29 The EAT-26 does not provide a specific diagnosis, but it is an efficient screening instrument to identify those who should be interviewed to identify a possible eating disorder. The evaluation of abnormal eating attitudes in nonclinical populations is essential to monitor and track trends and changes and to plan preventive and treatment programs.

Many epidemiological studies on eating disorders and abnormal eating attitudes among adolescents have been conducted primarily among Northern European and North American populations, with a few studies from other regions including Greece, Turkey, Australia, Israel, and South America.8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19 Studies on various populations are needed to bridge this gap. The objectives of the present study were to estimate the prevalence of abnormal eating attitudes as defined by an EAT-26 score above the cutoff of 20 in a school-based population of Greek adolescents and to identify possible risk factors associated with abnormal eating attitudes.

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Methods 

Participants 

Based on a reported prevalence of abnormal eating attitudes (14.2%) among Greek adolescents in a previous study,19 518 participants were needed to detect the estimated prevalence with 95% level of confidence, 80% statistical power, and precision of ± 3%. The study population consisted of 540 Greek students aged 13-18 years who consented to participate in a confidential, cross-sectional self-report study of eating attitudes and behavior.

The present study was conducted between April and June of 2008, on 2 samples drawn from the schools of an urban district (Patras) and a rural one (Vrachnaiika). Patras is a high-density (1,358 residents per km2) urban city surrounded by a network of suburbs and villages, with 193,843 residents at the time of study. Concerning population ranking in Greece, Patras is in third place. Vrachnaiika is a part of the Patras area, as it belongs to the network of Patras's villages, and is a low-density (137 residents per km2) rural area, with 5,049 residents in 2008. Schools in which studies were already taking place or that reported that they were short staffed were not approached. Five (out of 60) secondary schools from Patras and the only one from Vrachnaiika were therefore recruited. Two hundred sixty eight out of the 540 participants were urban residents, whereas 272 were rural residents.

Oral informed consent was received by the headmasters of all schools and by the parents of the students who participated in the study. Students were informed that this study was about eating attitudes and behavior, they were individually asked to participate and invited to complete an anonymous, self-reported questionnaire on a voluntary basis. Participants were assured of the anonymity and strict confidentiality of their responses. They were informed that the questionnaire was not an examination, that there were no right or wrong answers, and that they could withdraw from the study any time. With the assistance of teachers, the questionnaires were distributed to the students during classroom hours. The questionnaires were returned in sealed envelopes to ensure confidentiality. The questionnaires and the envelopes did not require any means of identification.

The study protocol was approved by the ethical board of the Faculty of Nursing of the University of Athens, Greece.

Measures 

The study questionnaire consisted of 3 parts: (1) demographic and lifestyle characteristics; (2) risk factors for abnormal eating attitudes; and (3) the 26-item version of the EAT-26. Participants' age, sex, place of residence (urban/rural), number of siblings, number of close friends, and status of parents' employment were collected in the study. Also, other factors closely linked with abnormal eating attitudes, such as cigarette smoking (number of cigarettes per week), watching TV/DVDs (hours per week), use of personal computer/video game consoles (hours per week), exercise outside of school (hours per week), and eating out of the home (times per week) were examined. Subjective self-image in relation to body weight (overweight or not overweight), body satisfaction, existence of a family member on a diet, recent death of a family member, and existence of a family member with an eating disorder were explored as possible risk factors for abnormal eating attitudes.

Researchers measured each participant's height and weight on standardized equipment. Weight was measured in light clothing to the nearest 0.1 kg (Seca 750, Seca Corporation, Ontario, Canada, 2007), and height was measured without shoes using an aluminum anthropometer (Seca 217, Seca Corporation, Ontario, Canada, 2007). Body mass index (BMI) was calculated by dividing body weight (kg) by height squared (m2). According to a World Health Organization expert committee recommendations, weight status for adolescents aged 10-19 years was categorized into underweight (BMI < 5th percentile), normal weight (5th percentile ≤ BMI < 85th percentile), and overweight (BMI ≥ 85th percentile).30 For purposes of statistical analysis of BMI, participants were categorized into 2 BMI groupings, those with BMI within normal range and those who were above or below normal BMI values.

The short version of the EAT-26 was used to evaluate the participants' attitudes toward eating, dieting, bulimia, food preoccupation, and oral control.31, 32 The EAT-26 is widely used to assess self-reported symptoms and has been shown to be a reliable and valid screening measure for eating disorders. The short version (26 items) is highly correlated with the original 40-item version.32 The EAT-26 is considered to be reliable and valid.32, 33 In the EAT-26, each item is answered on a 6-point Likert scale, ranging from “never” to “always.” The most symptomatic response receives a score of 3, the next most symptomatic a score of 2, and the least a score of 1. The remaining 3 choices receive a score of 0. Total scores are derived as a sum of the composite items, ranging from 0 to 78. Scores that are ≥ 20 on the EAT-26 indicate abnormal eating attitudes and behavior and may identify those with an eating disorder. The entire questionnaire was translated into Greek by an expert panel (including a psychiatrist, a psychologist, a nurse, a statistician, and 2 headmasters) with experience in the translation of psychopathology assessment instruments. The procedure involved translation into Greek, back-translation into English, and modification of the Greek version according to the back-translation.

Statistical Analysis 

The Statistical Package for Social Sciences (SPSS) program (version 13.0, SPSS, Inc., Chicago, IL, 2004) was used for statistical analysis. Continuous data were expressed as means (standard deviation), whereas categorical data were expressed as percentages of the groups. Concerning demographic data, the independent Student t test was used to examine differences between continuous variables, whereas the chi-square (χ2) test or the Fisher's exact test were used to examine differences between categorical variables.

Participants' answers on the EAT-26 were categorized into 2 groups: those with scores ≥ 20 on the EAT-26, indicating abnormal eating attitudes, and those with scores < 20. So, existence or not of abnormal eating attitudes was defined as the outcome (dependent) variable and risk factors measures as predictive (independent) variables.

Logistic regression analysis was applied for the identification of the predictive factors that were associated with abnormal eating attitudes. First, a univariate logistic regression of each potential predictive factor was carried out, and those with an independent statistically significant association (P < .05) were included in the multivariate logistic regression. The backward stepwise elimination method was used for model development in multivariate logistic regression. Multivariate analysis was applied for the control of each potentially confounding of each statistically significant factor to the others. The predictive variables were identified in terms of odds ratios (OR) with 95% confidence intervals (CI). A 2-sided P value of less than .05 was considered statistically significant.

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Results 

In the Patras sample of the 278 eligible participants, 268 (96%) agreed to participate in the study. In the Vrachnaiika sample, 279 questionnaires were distributed, 272 (98%) of which were returned filled out in a computable manner. The mean and standard deviation (SD) age of the 540 students was 15 (1.4) years. Table 1 shows the demographic and lifestyle characteristics categorized by sex. Almost half (49%) of the participants felt that they were overweight, whereas 37% declared dissatisfaction with their bodies. Also, 52% of participants had a family member who was dieting, 2% had recently lost a family member, and 9% had a family member with an eating disorder.

Table 1. Demographic and Lifestyle Characteristics of Participants Categorized by Sex
Male, n = 266 (49.3%)Female, n = 274 (50.7%)
Age (y), mean (SD)15.0 (1.4)14.9 (1.4)
Place of residence (%)
Urban48.550.7
Rural51.549.3
Number of siblings, mean (SD)1.8 (1.2)1.8 (1.3)
Number of close friends, mean (SD)∗4.7 (3.2)4.0 (2.8)
Working father (%)
Yes97.395.2
No2.74.8
Working mother (%)
Yes56.848.5
No43.251.5
Cigarette smoking (cigarettes/wk), mean (SD)∗6.8 (24.6)1.8 (8.2)
Watching TV/DVDs (h/wk), mean (SD)∗16.1 (17.7)11.5 (10.4)
Use of personal computer/video game consoles (h/wk), mean (SD)∗11.5 (14.5)5.6 (10.8)
Exercise outside of school (h/wk), mean (SD)∗7.0 (8.6)2.7 (3.9)
Eating out of home (times/week), mean (SD)1.6 (1.5)1.4 (1.5)
Weight (kg), mean (SD)∗64.3 (13.9)54.8 (9.5)
Height (m), mean (SD)∗1.7 (0.1)1.6 (0.1)
Body mass index (kg/m2), mean (SD)∗21.6 (3.4)20.4 (3.1)
Weight status (%)∗
Underweight3.03.2
Normal weight69.586.9
Overweight27.59.9

h indicates hours; kg, kilograms; m, meters; SD, standard deviation; wk, week; y, years.

∗P < .01 (χ2 test for categorical variables and t test for continuous variables).

The Cronbach α for the EAT-26 was 0.8. The mean score on the EAT-26 for the entire sample was 11.7 (SD 8.6), with a 95% confidence level of 11.0-12.5; for females, the mean score (SD) was 13.6 (8.8); for males, the mean score was 9.8 (8.1). Ninety participants (56 females and 34 males) had a total EAT-26 score equal to or greater than 20. Thus, the prevalence of abnormal eating attitudes in the study population was 16.7% (90/540).

In univariate logistic regression analysis, statistically significant predictive factors that were associated with abnormal eating attitudes were sex (females more often than males), place of residence (urban residents more often than rural ones), BMI outside normal range, perception of being overweight, body dissatisfaction, and existence of a family member on a diet (Table 2). Multivariate logistic regression analysis demonstrated that the above 6 variables were independently related to abnormal eating attitudes (Table 2). Perception of being overweight, body dissatisfaction, and urban place of residence were the most important factors for abnormal eating attitudes. Table 3 shows the EAT-26 scores of the participants with regard to the statistically significant factors that were associated with abnormal eating attitudes. On the other hand, there were no significant relationships between disordered eating attitudes and age, number of siblings and close friends, status of parents' employment, cigarette smoking, watching TV/DVDs, use of personal computer/video game consoles, exercise outside of school, eating outside of the home, recent death of a family member, and a family member with an eating disorder.

Table 2. Factors Associated With Abnormal Eating Attitudes Among Participating Greek Adolescents
Univariate modelaMultivariate modelb
FactorOR95% CIPOR95% CIP
Sex (male = 0, female = 1)1.81.1-2.8.0202.01.2-3.4.009
Place of residence (rural = 0, urban = 1)2.11.3-3.3.0022.31.4-3.8.001
BMI within normal range (no = 0, yes = 1)0.40.3-0.7.0010.50.3-0.9.030
Perception of being overweight (no = 0, yes = 1)2.81.7-4.5<.0012.11.2-3.7.007
Body satisfaction (no = 0, yes = 1)0.30.2-0.5<.0010.50.3-0.8.007
Family member on a diet (no = 0, yes = 1)2.41.5-3.8.0011.91.2-3.2.012

BMI indicates body mass index; CI, confidence interval; OR, odds ratio.

aEach line is a single model

bThe entire column is a single model.

Table 3. The EAT-26 Scores of the 540 Participants With Regard to the Statistically Significant Factors That Were Associated with Abnormal Eating Attitudes
FactorEAT-26 score
mean (SD)		EAT-26 score ≥20
n (%)		EAT-26 score <20
n (%)
Sex
Male9.8 (8.1)34 (12.8)232 (87.2)
Female13.6 (8.8)56 (20.4)218 (79.6)
Place of residence
Urban12.6 (8.6)58 (21.6)210 (78.4)
Rural10.8 (8.5)32 (11.8)240 (88.2)
BMI within normal values
Yes11.2 (8.3)58 (13.7)365 (86.3)
No13.5 (9.6)32 (27.4)85 (72.6)
Perception of being overweight
Yes13.5 (9.5)63 (23.5)205 (76.5)
No10.0 (7.3)27 (9.9)245 (90.1)
Body satisfaction
Yes9.8 (7.9)35 (10.3)304 (89.7)
No15.0 (8.9)55 (27.4)146 (72.6)
Family member on a diet
Yes13.0 (8.7)62 (22.1)219 (77.9)
No10.4 (8.3)28 (10.8)231 (89.2)

BMI indicates body mass index; EAT-26, Eating Attitudes Test-26; SD, standard deviation.

The prevalence of abnormal eating attitudes among females was 20.4% (56/274) compared to 12.8% (34/266) among males. Moreover, 58 out of 268 (22%) adolescents living in the urban area had a total EAT-26 score ≥ 20, whereas only 12% (32/272) of adolescents in the rural area presented abnormal eating attitudes.

Students with BMI outside of normal range were more likely to have disordered eating attitudes than those with BMI within normal range (27% [32/117] of the students with BMI outside of normal range compared to 14% [58/423] of those with BMI in the normal range). A large percentage (27%) of participants who were not satisfied with their bodies also had a total EAT-26 score ≥ 20, whereas the respective percentage for those who expressed body satisfaction was only 10% (35/339). Also, body perception of being overweight was a factor strongly associated with abnormal eating attitudes, with adolescents who believed that they were overweight having significantly higher EAT-26 scores (24% [63/268]) than those who believed that they were not overweight (10% [27/272]). Finally, participants with a family member on a diet had a greater percentage of total EAT-26 score ≥ 20 compared to those without a family member on a diet (22% vs 11%).

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Discussion 

The findings of this study show that the prevalence of abnormal eating attitudes among adolescents in Greece (16.7%) is comparable to the prevalence reported in Western countries and somewhat higher than the prevalence reported in other non-Western countries. In Western countries, the prevalence of disordered eating attitudes among adolescents based on EAT-26 scores ranged from 7.5% to 30%,10, 11, 12, 13, 16, 17, 18, 29, 34, 35 whereas in non-Western countries, prevalence ranged from 4.6% to 20%.8, 9, 14, 15, 36, 37 Yannakoulia et al used the EAT-26 for the assessment of abnormal eating attitudes in Greek adolescents and reported similar results (the prevalence was 14.2%).19

Despite the fact that many epidemiological studies, mostly among Northern European and North American populations, have been conducted for the identification of possible risk factors that are associated with eating disorders and abnormal eating attitudes, this is the first study referring to this topic in Greece.

Concerning demographic characteristics, sex was closely related with abnormal eating attitudes. Females were more likely to have abnormal eating attitudes than males, a finding confirmed by a great number of studies.8, 12, 13, 16, 17, 20, 21, 37, 38, 39, 40, 41, 42 Females seem to be more susceptible than males to the message sent by the media that being not just thin, but ultrathin is fashionable and desirable, creating a sense of dissatisfaction, unrealistic goals, and a negative body image. Moreover, it appears that females react differently and present less adaptability to difficult situations, which leads females, more often than males, to extreme behaviors such as anorectic and bulimic behaviors.

Also, place of residence was a factor associated with disordered eating attitudes, with urban adolescents having significantly higher EAT-26 scores than rural ones. Urban/rural differences regarding the distribution of eating disorder cases have been reported. In Holland24 and Italy,22, 23 prevalence of bulimia nervosa was higher in urban populations than rural or suburban ones, whereas in Japan25 and Italy,22, 23 urban samples had a greater prevalence of anorexia nervosa. These differences could be attributed to the different lifestyle among adolescents in urban populations as well as to the different social, economic, and cultural environment between urban and rural populations.

Participants with BMI outside normal range had a greater probability of reporting abnormal eating attitudes compared to those with BMI within normal range. This finding was consistent with data in the literature reporting a positive correlation between higher BMI and a higher EAT-26 score.14, 34, 43, 44 Overweight people may be more likely than those with weight within the normal range to develop preoccupations about body size, food, and eating, leading to eating-disordered behaviors that are typical of eating problems as well as of subclinical, subthreshold, and full-syndrome eating disorders. We hypothesize that underweight people, females in particular, may not want to gain weight but would prefer to remain underweight, which can result in negative health outcomes.

Strong associations were observed between disordered eating attitudes, perception of being overweight, and body dissatisfaction. As the authors expected from previous research,8, 11, 15, 26, 27, 29, 45, 46 the results indicate that the prevalence of abnormal eating attitudes was significantly higher among adolescents who perceived that they were overweight. Also, adolescents who were not satisfied with their body had a greater probability of developing abnormal eating attitudes. Many previous studies have also reported an association between eating attitudes and body dissatisfaction.9, 11, 14, 18, 27 In some cases, people, females in particular, perceived themselves as overweight and were dissatisfied with their body despite the fact that their weight fell within a normal range.

Finally, the results showed that adolescents with a family member who is dieting were more likely to have abnormal eating attitudes than those without a dieting family member. Although the family plays an important role in the development of eating attitudes, there is a gap in the literature about this topic. Existence of a dieting family member may indicate increased concerns about eating, dieting, and body image.

Several limitations of the present study should be noted. First, its cross-sectional design does not allow the assessment of the progression of symptoms over time or the inference of causal relationships. Second, because the study population consisted of Greek adolescents aged 13-18 years only, one should be cautious with expanding the results of the study to other groups. Third, no structured clinical interviews were performed to diagnose eating disorders, and the EAT-26 was used only as a screening instrument for the measurement of symptoms and concerns characteristic of eating disorders. Also, the self-reporting of the EAT-26 is dependent on accurate reporting by participants. Another study limitation is the absence of questions on other possible risk factors such as mass media exposure and poor family relationships.

In conclusion, the results of this study indicate that a proportion of Greek adolescents report abnormal eating attitudes. Also, females, urban place of residence, BMI outside normal range, perception of being overweight, body dissatisfaction, and a family member who was on a diet were independently associated with abnormal eating attitudes, suggesting that multiple factors contribute to the development of these attitudes. These findings are useful to guide further research into factors for abnormal eating attitudes and would be valuable in designing preventive interventions, such as health education programs focusing on healthful eating, body image, exercise, and the available types of mental health services. Thus, selected prevention programs (those aimed at higher-risk adolescents and females in particular) could focus on specific psychological and social factors like body perception and body satisfaction.

Moreover, abnormal eating attitudes can be detected early and prevented. Evaluation of these attitudes along with input from adolescents and their families and friends is the most effective approach for the early detection of the population at risk and the prevention of the health problems that underlie eating disorders. Also, primary care professionals need to be familiar with and sensitive to issues of weight, eating attitudes, and eating behaviors to detect early the subgroup of adolescents vulnerable to developing abnormal eating attitudes. Eating attitudes and habits are established at an early age, and therefore nutritional education has to begin before behaviors and attitudes become fixed. Interventions should take advantage of the ties between persons, namely, their social context and the community level dimension (family, friends, and school). Better understanding of the adolescents' environment can help health education activities to be more efficacious and effective.

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PII: S1499-4046(09)00288-7

doi:10.1016/j.jneb.2009.06.005

Journal of Nutrition Education and Behavior
Volume 42, Issue 5 , Pages 292-298, September 2010

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