The relationship between the risk of eating disorder and meal patterns in University students

Abstract

PurposeThis study was carried out to evaluate the relation between meal patterns and the risk of eating disorders in university students.Methods
The study was conducted on a total of 331 volunteer students with a mean age of 22.08 ± 1.80 years, 56.5% female. Participants’ sociodemographic characteristics, health information and eating habits like meal skipping and dieting were questioned. Sick, Control, One stone, Fat, Food (SCOFF) Eating Disorders Scale and Eating Disorder Examination Questionnaire (EDE-Q) were used to determine eating behavior disorders, with face to face interviews by the researches.ResultsA significant correlation was found between dieting and skipping meals and the risk of eating disorders in both genders (p < 0.05). In addition, when the reasons for skipping meals were questioned, a significant relationship was detected between skipping meals and eating behaviour disorders by 3.285 times (p = 0.000). Also, every unit of increase in body mass index (BMI) values of individuals who participated to the study led to an increase in eating disorders by a factor of 1.262 (p = 0.000).Conclusions
Our findings support concerns about the negative health effects of increasing overweight among university students in accordance with the data that the increase in BMI values led to an increase in eating disorders. Notably a significant correlation was found between dieting, skipping meals and the risk of eating disorders in both genders it is highlighting the need for monitoring and early diagnosis of eating disorders in youth with simple scales like SCOFF.Level of evidenceLevel V, cross-sectional descriptive study.

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Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
https://doi.org/10.1007/s40519-021-01179-4
ORIGINAL ARTICLE
The relationship betweentherisk ofeating disorder andmeal patterns
inUniversity students
MemnuneKabakuşAykut1 · SaniyeBilici2
Received: 2 December 2020 / Accepted: 22 March 2021
© The Author(s), under exclusive licence to Springer Nature Switzerland AG 2021
Abstract
Purpose This study was carried out to evaluate the relation between meal patterns and the risk of eating disorders in uni-
versity students.
Methods The study was conducted on a total of 331 volunteer students with a mean age of 22.08 ± 1.80years, 56.5%
female. Participants’ sociodemographic characteristics, health information and eating habits like meal skipping and dieting
were questioned. Sick, Control, One stone, Fat, Food (SCOFF) Eating Disorders Scale and Eating Disorder Examination
Questionnaire (EDE-Q) were used to determine eating behavior disorders, with face to face interviews by the researches.
Results A significant correlation was found between dieting and skipping meals and the risk of eating disorders in both
genders (p < 0.05). In addition, when the reasons for skipping meals were questioned, a significant relationship was detected
between skipping meals and eating behaviour disorders by 3.285 times (p = 0.000). Also, every unit of increase in body
mass index (BMI) values of individuals who participated to the study led to an increase in eating disorders by a factor of
1.262 (p = 0.000).
Conclusions Our findings support concerns about the negative health effects of increasing overweight among university stu-
dents in accordance with the data that the increase in BMI values led to an increase in eating disorders. Notably a significant
correlation was found between dieting, skipping meals and the risk of eating disorders in both genders it is highlighting the
need for monitoring and early diagnosis of eating disorders in youth with simple scales like SCOFF.
Level of evidence Level V, cross-sectional descriptive study.
Keywords Eating behaviors· Eating disorder· Meal pattern
Introduction
Eating disorder (ED) is a psychiatric disorder that includes
deterioration in eating attitudes and behaviors and has nega-
tive effects on the physical and mental health of the person
[1]. ED is often characterized by an unhealthy relationship
with food or eating behavior, which includes restrictive eat-
ing, self-induced vomiting, binge eating, or compensatory
behaviors [2]. In the United States, at least 30 million people
of all ages, regardless of gender, are reported to have eat-
ing disorders [3]. Serious emotional and physical problems
related to eating disorders are seen in both genders, mainly
in female [4]. In a study evaluating the risk status of a poten-
tial eating disorder among university students 16.2% (n:48)
of them had a risk and this risk was significantly higher in
female [5]. The prevalence of eating disorders among Euro-
pean female was < 1–4% in anorexia nervosa (AN), < 1–2%
in bulimia nervosa (BN) and 1–4% in binge eating disorder,
respectively. The prevalence of eating disorders in males is
0.3–0.7% [6]. In a study conducted among 800 university
students (56.6% male and 43.4% female) with the mean age
of 21 in Bangladesh, 37.6% of the students were found to be
at risk of eating disorders [7]. Eating disorders are observed
to have become more common in western cultures in the
second half of the twentieth century in young women, at a
time when beauty icons became even more thin and women’s
* Saniye Bilici
sgbilici@gmail.com
Memnune Kabakuş Aykut
m_kabakus@hotmail.com
1 Department ofNutrition andDietetics, Faculty ofHealth
Sciences, Gümüşhane University, Gümüşhane, Turkey
2 Department ofNutrition andDietetics, Faculty ofHealth
Sciences, Gazi University, Çankaya, Ankara, Turkey

Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
1 3
magazines published more articles on weight loss methods.
[8].
Genetic, environmental and psychological factors, per-
sonality traits and family are among the factors that cause
eating disorders [9]. According to the results obtained from
family and twin studies, there may be a familial predisposi-
tion in eating disorders; It is thought to be one of the com-
mon etiological factors due to cross-over between genetic
and environmental factors. Considering that individuals with
relatives diagnosed with eating disorders carry 7–12 times
more risk, it is seen that genetics have an important place
among etiological factors [10]. The perfectionist personal-
ity structure of the individual in his/her inner world, low
self-respect and negative affect and emotional imbalance are
considered as psychological factors causing eating disorder
[9]. A study conducted on a total of 401 university students
as 156 male and 245 female who study in different fields, it
was stated that those who eat less or more than normal in
negative emotions and situations have more risk for eating
disorder [11]. It is stated that the efforts of the perfection-
ist individuals to keep their eating, body shapes and body
weights under control, as in many other subjects, constitute
a risk for the development of eating disorders [12]. The pres-
ences of psychiatric disorders in mother and father, prenatal
maternal stress, various family factors, and childhood weight
increase the risk of eating disorders [6]. In particular, the
expectation of parents and the requirement for approval and
appreciation, and their strict critical attitude can be effective
in the development of eating disorder [13].
The change in the understanding of beauty in society and
the perception of rail thin in the media put pressure on ado-
lescents and young adult individuals, encourage them to diet
unconsciously and pave the way for development of eating
disorders by infusing some negative behaviors such as exces-
sive restriction of food intake, excessive eating, vomiting,
laxative/diuretic use to reach their ideal weight [4]. It was
reported that although most university students had a normal
body mass index (BMI) value, they dieted 60–80% in the last
5years [14]. In several studies it was determined that those
who mostly dieted have more risk of eating disorders than
those who dieted sometimes or never [15–17].
Young adulthood, including the university students is
considered to be a risky period in terms of eating disorders
due to lifestyle changes (nutrition, housing, social relations,
etc.) adaptation problems experience loneliness, disagree-
ments within the group [18]. Research suggests that young
adults engage in poor eating behaviours, such as low fruit
and vegetable consumption, high consumption of energy-
dense snack foods, frequently fail to consume regular meals
and skipping meals [19]. The value placed on eating regular
meals is evidenced in population health, dietary guidance
and inclusion in scientific research without defining “regu-
lar” [20]. Establishing a definition for mealtime regularity
highlights the question of how “meals” themselves are
defined [21] and differentiated from snacks, since most
studies use a participant-defined approach [22]. In Western
culture, it is a common idea that the daily food intake should
be divided into three square meals: breakfast, lunch, and
dinner. However, the number of meals is not a universal
standard [23]. The regular omission of meals, particularly
the breakfast meal, has been associated with poorer diet
quality, lower intakes of total energy, vitamins and miner-
als, increased risk of central adiposity, markers of insulin
resistance and cardio metabolic risk factors [24–28]. Meal
skipping is the omission or lack of consumption of one or
more of the traditional main meals (breakfast, lunch or din-
ner) throughout the day [21]. While much of the research
is focused on breakfast skipping exclusively, a recent sys-
tematic review reported that meal skipping (any meal) rates
in young adults (18–30years) ranged between 5 and 83%,
with rates for skipping specific main meals varying: break-
fast (14–89%), lunch (8–57%), dinner (5–47%) [19]. When
Turkey in the 15 and over age group is considered the main
meal consumption of individuals, 15% of the breakfast in the
morning, it was reported that 24.7% of the noon meal and
skip the evening meal of 3.7% [29]. Despite the significant
health implications of meal skipping and its higher preva-
lence among young adults, limited research has investigated
correlates of this unhealthy eating behavior [19].
In this point of view meal frequency and meal pattern is
thus a variable that is important to assess in the young adult
population, in the obese population and patients with eating
disorders. It is essential to understand the relation between
the BMI, eating disorders and meal pattern in young peo-
ple to create effective nutritional strategies in these group.
The purpose of this study is to present data that contributes
to understanding the factors that influence eating disorders
such as skipping meals and to determine the risk of eating
disorder in university students and to evaluate its relation-
ship with meal patterns.
Participants andmethod
Research method andsample selection
This study was conducted on a total of 331 volunteer uni-
versity students aged 18 and above who are studying at the
Central Campus of Gümüşhane University in Turkey. Indi-
viduals with diagnosed chronic disease and those who use
appetite-affecting drugs (antidepressant, metformin, etc.)
were not included in the study. The datas of meal pattern and
eating habits were obtained by a questionnaire applied by
the researchers using face to face interview technique. Sev-
eral socio-demographic characteristics, health status, dieting
status, meal skipping and reasons were questioned. To get

Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
1 3
information related to nutrition, the participants were asked
whether they were on a diet, whether they skipped meals,
the name of the skipped meal, and the reason for skipping
meal. Meal skipping was captured via differing methodolo-
gies; including food diaries, 24-h recalls and surveys. Data
on meal patterns have been derived from dietary assessment
methods such as 24h recalls and food records. These meth-
ods provide detailed information on the types and quantities
of food/beverages consumed and, usually, time of consump-
tion. Sick, Control, One stone, Fat, Food (SCOFF) Eating
Disorders Scale and Eating Disorder Examination Question-
naire (EDE-Q) were used to determine eating behavior dis-
orders, with face to face interviews by the researches.
Sick, control, one stone, fat, food (SCOFF) eating
disorders scale
The scale was first developed by Hill etal. [30] and letters
selected from each question were associated and developed
as SCOFF. Its validity and reliability were tested by Aydemir
etal. [31]. A questionnaire which interrogate eating control,
vomiting, and body dissatisfaction consists of 5 questions.
An individual who scores 2 or more on the scale given 1
score per item is considered to be at risk for eating disor-
ders [31]. Although it was originally designed only for the
detection of AN and BN, has recently been used frequently
in general health research and epidemiological studies to
detect irregular eating behaviour [32]. This scale was found
to be able to distinguish 81% of previously undefined eat-
ing disorder cases due to it is easy to apply because of its
shortness and its reliability (Cronbach α internal consistency
coefficient 0.74) was used in the study [33].
Eating Disorder Examination Questionnaire (EDE‑Q)
The Turkish version [34] of the Eating Disorders Examina-
tion Questionnaire (EDE-Q) which is accepted as the “gold
standard” in the examination of eating disorders, was first
developed by Fairburn and Beglin in 1994 [35]. It examines
the eating habits and self-satisfaction of the participants in
the last 28days with 4 sub-scales reflecting the severity of
the psychopathology of eating disorder. These subscales are
restraint, eating concern, shape concern, and weight con-
cern. The subscale scores are calculated by adding the scores
of the relevant items and dividing them by the total number
of items in the subscale. The scale is used to compare dif-
ferent groups or to determine the general eating behavior
profile of the population, due to a cut-off score for the Turk-
ish population of EDE-Q has not yet been determined. In
the original study, the internal consistency coefficient of the
scale was between 0.78 and 0.93 in factors [35]. In the valid-
ity and reliability study in Turkey, the internal consistency
coefficient of the scale was found to be 0.93 in the total
score. [34]. The reliability coefficient in our study was found
to be 0.75.
Anthropometric measurements
Anthropometric measurements were measured according to
standard protocols. Participants’ weight was measured to
the nearest 0.1kg using a digital scale. Height measurement
was recorded to the nearest 0.1cm, without any shoes in a
standing position using a portable stadiometer. Body mass
index (BMI) (kg/m2) was calculated by dividing the body
weight (in kilograms) by the square of height (in meters)
and the result was evaluated according to the World Health
Organization classification. According to this classifica-
tion, students with a BMI of < 18.5 were underweight, those
with a range of 18.5–24.9 were normal, those with a BMI
of 25–29.9 were overweight, and those with a BMI of ≥ 30
were obese [36].
Statistical analyses
The data obtained from the research were evaluated by SPSS
for Windows version 20 (Statistical Package for Social Sci-
ences, Chicago, IL, USA) program on computer [37]. When
data were not normally distributed, the Mann–Whitney U
Test (Z-table value) was used for comparisons between
groups. The Spearman Correlation Analysis was used to test
whether there was a relationship in the proportional data,
and the Pearson Chi-square Test was used in the categori-
cal data p values less than 0.001 and 0.05 were considered
statistically significant.
Research ethics
Written consent forms get signed to individuals to partic-
ipate in the study voluntarily and E41399 numbered and
20.03.2017 dated “Ethical Commission Approval” was
obtained from Gazi University Ethics Commission for the
study.
Results
Demographics analyses
This study was conducted on 331 students aged 18 and
above, 144 (43.5%) of them are males and 187 (56.5%)
of them are females. The mean age of the participants is
22.08 ± 1.80years. 91.7% of males stay in student houses
or dormitories, 6.9% of them stay in with family; 95.2% of
female live in student houses or dormitories, 4.3% of them
live with family. 91.5% of the students did not have any
disease diagnosed by the doctor.

Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
1 3
When the meal patterns of the students were exam-
ined, 73.6% of males and 64.7% of females stated that they
skipped meals. In total, the frequency of skipping meals is
measured as 68.6%. It was determined that the highest num-
ber of meals skipped by male students was morning (55.2%)
and noon (37.8%), while female students ranked it as noon
(57.5%) and morning (41.3%), respectively (Table1). The
lack of time was the main reason to skip meal for the most
participants. (M: 37.8%; F: 41.3%) (table was not given).
While body weight was 76.30 ± 12.52kg, height was
177.00 ± 7.0cm and mean BMI was 24.27 ± 3.76kg/ m2 for
male students, these values were found as 58.26 ± 9.06kg,
163.00 ± 6.0cm and 21.99 ± 3.20kg/m2 for female students,
respectively (table was not given).
Comparison ofSCOFF scores bygender
The distribution of the risk of eating disorders (by SCOFF
score) by gender is shown in Table2. A statistically signifi-
cant relationship was found between gender and eating dis-
order risk (p < 0.05). It was determined that 33.3% of male
students and 47.6% of female students were at risk of eating
disorders.
Comparison ofsome variables according torisk
ofeating disorder
Distribution of participants’ BMI and diet status according
to the risk of eating disorder is given in Table3. There was
a statistically significant relationship between BMI and diet
status and eating disorder risk for both genders (M:p < 0.05;
F:p < 0.001). Accordingly, male and female students at risk
of eating disorders according to BMI were classified as
54.1% and 76.4% of them are “normal”; 29.2% and 19.1%
of them are “overweight” and 16.7% and 3.4% of them are
“obese”, respectively. In addition, 39.6% of male and 49.4%
of female with eating disorders stated that they were dieting.
Comparison ofmeal patterns according torisk
ofeating disorder
Distribution of participants’ main meal skipping status and
causes according to the risk of eating disorder is given in
Table4. Accordingly, a statistically significant relationship
was found between those who skipped meals and sometimes
skipped meals, and the risk of eating disorders (p < 0.05). In
addition, when considering the reasons for skipping meal, a
significant relationship was found between those who skip
meals in order not to gain weight and the risk of eating dis-
orders (p < 0.05).
Table 1 Socio-demographic characteristics and eating habits of the
participants
Mann–Whitney U test and Pearson Chi-square test were used for
numerical data and categorical data, respectively
General Information Male (n:144) Female
(n:187)
p
n % n %
Marital status
Married 1 0.7 – – 0.254
Single 143 99.3 187 100.0
Housing shape
With family 10 6.9 8 4.3
Alone 2 1.4 1 0.5 0.401
Government/private
dorm + Student house
132 91.7 178 95.2
The average age: 22.08 ± 1.80
Disease diagnosed by doctor
Yes 8 5.6 20 10.7 0.089
No 136 94.4 167 89.3
Dieting status
Yes 33 22.9 55 29.4 0.146
No 111 77.1 132 70.6
Main meal skip status
Yes 106 73.6 121 64.7 0.207
No 1 0.7 8 4.3
Sometimes 37 35.7 58 31.0
Skipped meal
Morning 79 55.2 74 41.3 0.264
Noon 54 37.8 103 57.5
Evening 10 7.0 2 1.2
Table 2 Distribution of
participants’ risk of eating
disorder by gender (according to
SCOFF score)
SCOFF Sick, Control, One stone, Fat, Food Eating Disorders Scale, SCOFF + = “yes” to 2 or more of 5
questions, likely case of eating disorder; SCOFF– = “yes” to < 2 of 5 questions, not likely case of eating
disorder
* p < 0.05
Risk of Eating Disorder Male (n:144) Female (n:187) Total (n:331) p
n%n%n%
SCOFF
SCOFF + 48 33.3 89 47.6 137 41.4 0.009*
SCOFF− 96 66.7 98 52.4 194 58.6

Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
1 3
Correlations analyses betweensome variables
The relationship between the gender and BMI values of the
participants with the risk of eating disorder is given in Table5.
The risk of developing eating disorders was 3.285 times higher
in female than male (p = 0.000). In addition, it is seen that the
risk of developing eating disorders increased by 1.262 times
in each unit increase of BMI (p = 0.000).
Comparison ofEDE‑Q scale scores bygender
The mean (
−
x
), standard deviation (SD), median (M) and IQR
values of the participants’ EDE-Q subscale and total score by
gender are given in Table6. When the statistical difference
between the genders was examined, it was found that restraint,
eating concern and shape concern scores, which were the sub-
scales of EDE-Q, were significantly lower in males than in
females (p < 0.05).
Comparison ofBMI values according toEDE‑Q scale
scores
The relationship between the BMI values of the participants
and the EDE-Q scale scores is given in Table7. According to
this, there was a positive and statistically significant relation-
ship between BMI values of both male and female students
and EDE-Q subscales (restraint, eating concern, shape con-
cern, weight concern) and total score scores (M: p < 0.05)/F:
p < 0.001).
Table 3 Distribution of
participants’ BMI and diet
according to the risk of eating
disorder
BMI Body mass index, SCOFF Sick, Control, One stone, Fat, Food Eating Disorders Scale
SCOFF + = “yes” to 2 or more of 5 questions, likely case of eating disorder; SCOFF– = “yes” to < 2 of 5
questions, not likely case of eating disorder
* p < 0.05, **p < 0.001
Variable Male (n:144) pFemale (n:187) p
SCOFF + (n:48) SCOFF–
(n:96)
SCOFF + (n:89) SCOFF–
(n:98)
n%n%n%n%
BMI classification
Underweight - - 3 3.1 1 1.1 19 19.4
Normal weight 26 54.1 66 68.8 0.006* 68 76.4 72 73.5 0.000**
Overweight 14 29.2 25 26.0 17 19.1 7 7.1
Obese 8 16.7 2 2.1 3 3.4 - -
Dieting status
Yes 19 39.6 14 14.6 0.001* 44 49.4 12 12.2 0.000**
No 29 60.4 82 85.4 45 50.6 86 87.8
Table 4 Distribution of participants’ risk of eating disorder by main
meal skip status
SCOFF Sick, Control, One stone, Fat, Food Eating Disorders Scale,
SCOFF + = “yes” to 2 or more of 5 questions, likely case of eating
disorder; SCOFF– = “yes” to < 2 of 5 questions, not likely case of eat-
ing disorder
* p < 0.05
Risk of eating disorder SCOFF + (n:137) SCOFF–
(n:194)
p
n%n%
Main meal skip status
Yes 98 71.5 129 66.5 0.023*
No 7 5.1 2 1.0
Sometimes 32 23.4 63 32.5
Meal skip reason
Shortage of time
No 78 60.0 117 60.9 0.866
Yes 52 40.0 75 39.1
No habit
No 98 75.4 156 81.3
Yes 32 24.6 36 18.7 0.206
Get up late
No 100 76.9 144 75.0 0.693
Yes 30 23.1 48 25.0
For not preparing
No 114 87.7 174 90.6 0.401
Yes 16 12.3 18 9.4
Not to gain weight
No 123 94.6 191 99.5 0.025*
Yes 7 5.4 1 0.5
Stomachless
No 113 86.9 155 80.7 0.191
Yes 17 13.1 37 19.3

Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
1 3
Discussion
Unhealthy diet choices and behaviors, body dissatisfaction,
dieting and eating disorders are quite common among uni-
versity students [38]. Sex was the most frequently assessed
correlate of meal skipping, with males being more likely
to skip breakfast, and females being more likely to skip the
lunch or dinner meal [39, 40]. In the study a significant
correlation was found between skipping meals and the risk
of eating disorders in both genders (p < 0.05). In addition,
when the reasons for skipping meals were questioned, a
significant relationship was detected between skipping
meals in order not to gain weight and the risk of eating
disorders (p < 0.05). It is thought that the students’ early
starting course hours, intensive course and exam weeks,
lack of distribution of food in the dormitory or school,
lack of financial possibilities and lack of desire to prepare
meals may cause skipping meals. It has been reported that
people with eating disorders display various meal patterns
for weight control. Among these meal patterns, skipping
meals in order not to gain weight is also included [4]. This
is important as previous literature documents sex differ-
ence in correlates such as the likeliness to use meal skip-
ping as a weight control technique, with increased rates
seen in males compared to females.
Early diagnosis and treatment of eating disorders is cru-
cial as eating disorders are very common on university stu-
dent’s; however, the most important obstacle is that the diag-
nosis cannot be made easily among university students [41].
The use of scales such as SCOFF that can be easily used in
the field and that allows taking the necessary precautions
before any risk of eating disorder develops is very important
for early diagnosis and treatment. In a screening of 1863
young adults in Finland made using the SCOFF question-
naire, the risk of eating disorder incidence was found to be
9.7% [42]. In a study conducted by Tavolacci etal. [43] in
France to determine the prevalence of eating disorders at the
University of Normandy, 3457 students were screened with
the SCOFF questionnaire and 20.5% of them were found
to be at risk for eating disorders. In our study, SCOFF and
EDE-Q scale were used together to determine the risk of
eating disorder and the risk of eating disorder in students
was found to be 41.4%.
Eating disorders are 20 times more common in female
compared to male [44]. It is thought that this may be due to
physiological changes experienced by female adolescents
Table 5 Relationship between
gender and BMI of the
participants with the risk of
eating disorder
BMI Body mass index OR Odds ratio, SD Standard deviation
* For gender, reference category ‘Male’ students were selected
** p < 0.001
Parameters ΒStandard error Wald SD pOR 95% Confidence Range
Lower Limit Upper Limit
Gender* 1.189 0.275 18.758 1 0.000** 3.285 1.918 5.627
BMI 0.233 0.041 31.9771 0.000** 1.262 1.164 1.368
Stable −6.374 1.034 37.962 1 0.000** 0.002
CCR = 72.1% χ2(8) = 2.535, p = 0.960
Table 6 Mean (
−
x)
, standard deviation (SD), median (M) and IQR val-
ues of the EDE-Q subscale and total score scores of the participants
according to gender
EDE-Q Eating Disorder Examination Questionnaire, M Median, IQR
Interquartile range
*p < 0.05. Independent sample t test was used for tests
Variable Male (n:144) Female (n:187) p
−
x
±SS M [IQR]
−
x
±SS M [IQR]
Restraint 0.91 ± 1.20 0.4 [1.6] 1.13 ± 1.39 0.6 [1.6] 0.048*
Eating con-
cern
0.68 ± 0.88 0.2 [1.2] 0.99 ± 1.18 0.4 [1.8] 0.026*
Shape con-
cern
1.41 ± 1.26 1.1 [5.1] 1.83 ± 1.57 1.4 [2.4] 0.031*
Weight
concern
1.25 ± 1.15 1.0 [1.6] 1.57 ± 1.45 1.2 [2.0] 0.097
Total score 1.06 ± 0.95 0.8 [1.5] 1.38 ± 1.25 0.9 [1.9] 0.064
Table 7 Relationship between the BMI values of the participants and
the EDE-Q scale scores
EDE-Q Eating Disorder Examination Questionnaire, BMI Body mass
index
*p < 0.05, **p < 0.001. Spearman correlation analysis was used
Variables Male (n:144) Female (n:187)
r p r p
Body Mass Index
EDE-Q
Restraint 0.189 0.023* 0.442 0.000**
Eating concern 0.293 0.000** 0.464 0.000**
Shape concern 0.394 0.000** 0.462 0.000**
Weight concern 0.375 0.000** 0.429 0.000**
Total score 0.347 0.000** 0.481 0.000**

Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
1 3
during adolescence period. In a study that investigated eat-
ing disorders on 2822 university students using the SCOFF
questionnaire, it was found that 3.6% of males and 13.5%
of females were at risk [45]. In this study, the risk of eating
disorder in male students was found to be 33.3%, 47.6% in
female and 41.4% in total. There is a 3.285 times higher
risk of eating disorders in female compared to male. It was
considered that female have more desire to be liked and give
more importance to appearance.
EDE-Q is a screening tool that focuses on the last 28days
and is widely used to assess the frequency of the basic
behavioral characteristics of eating disorders [46]. In a study
consist total of 532 students as 250 males and 282 females in
Norway, whose ages ranged from 15 to 30years and study
in high school and university, it was reported that males
(0.44) had lower EDE-Q scores than females (1.41) and that
although there was a significant relationship between BMI
values and EDE-Q in both genders, this relationship was
weaker in male [47]. In this study, all sub-scales and total
scores of the EDE-Q were found to be lower in males com-
pared to female students; however, significant relationship
were found in only three sub-dimensions (restraint, eating
concern, and shape concern) (p < 0.05). In addition, a sta-
tistically significant positive correlation was found between
BMI values and subscale and total scores of EDE-Q. It is
thought that the risk of eating disorders and restraint behav-
iors are more common in female compared to male.
There are studies reporting that body mass index is a risk
factor in the development of eating disorder. In one of these
studies that was conducted by Musaiger etal. [48] with the
participation of 530 university students as 203 male and 327
female it was concluded that the risk of eating disorders
was twice as high in individuals with a BMI value of 25 and
above. According to the results of another study conducted
on a total of 610 university students as 338 male and 272
female whose ages ranged between 17 and 23years, there
was a positive relationship between BMI and eating disorder
risk [49]. According to the results of some studies, there was
a positive relationship between BMI and eating disorder risk
[50, 51]. In our study, it was found that the risk of eating
disorder increased 1.262 times in each unit increase of BMI.
The data points out the importance of a health concern that
may be the cause of obesity, which is still a global health
threat.
Body perception disorder and diet in parallel with this, is
another risk factor for eating disorders and is usually the first
step in the development of eating disorder pathology [5].
In our study, a significant relationship was found between
dieting status and eating disorder risk (p < 0.05). This result
suggests that weight-related concerns and behaviors can be
an independent indicator of eating disorder symptoms, but
also serve as the mediator between BMI and eating disorder
symptoms. Unconsciously and frequently repeated dietary
practices, excessive restriction in food intake, and constant
occupation with body shape can trigger hunger or stress can
lead to the development of eating disorders in the long term.
The current study has some limitations. Firstly, we could
only assign the relations not the causal connection between
variables. Second, this study cannot represent the total
population as it is only carried out on university students.
In addition, no clinical examination for measurable eating
disorders, no standard measure and cut off score of eating
disorders and uneven gender distribution are the other limi-
tations of this study.
Conclusion
The university environment is a risky environment in terms
of the opportunity to benefit from wide and diverse nutri-
tion services, more fast food consumption opportunities
and school/social demands which reduce the time allocated
for physical activity. In addition, young people try to cope
with responsibilities such as adapting to the new environ-
ment away from the family because of university education,
being sociable in social relations, passing classes, finding
jobs after graduation and providing their own living. These
factors lead the individual to bad habits, malnutrition and
even to eating disorders in the future. In this study, it was
concluded that the number of students with risky behaviors
but without definite diagnosis was quite high and the general
diet of the students were mostly unhealthy and irregular. For
this reason, university students should be supported during
the adaptation process and should be informed about healthy
life and nutrition and their behavioral changes should be
followed.
Students should be supported on strategies to control
eating behaviors and cope with stress under negative emo-
tions and conditions. We considered that this study adds to
the literature by identifying potential targets for interven-
tions aimed at reducing meal skipping and control eating
behaviors in university students. Further research is required
to examine these factors in longitudinal studies with large
sample.
What isalready known onthis subject?
Nowadays, many individuals with eating disorders do not
seek treatment, since they tend to hide the disease, and
therefore, the diagnosis become difficult. Unhealthy eating
behaviors especially meal skipping is a precursor of eating
disorders for many young people and early identification of
these behaviors could increase the quality of public polices
to prevent the rise in eating disorders incidence.

Eating and Weight Disorders - Studies on Anorexia, Bulimia and Obesity
1 3
What this study adds?
This is a cross-sectional descriptive study. The research
addressed the scales used to determine the risk of eating
disorders. It is important in terms of suggesting the pres-
ence of students who have not yet been diagnosed but are
at high risk, and that the risk may be reduced by modula-
tion in dietary habits. The reliability of the scales that can
be used in early diagnosis with the use of simple scales
that can be used in the field has been tested once again
and it has been revealed that as well as what people eat,
daily meals are also an important impact on eating disor-
ders. Adoption of an unhealthy lifestyle after becoming a
university student is due to such factors as moving away
from home, poor cooking skill, low income, preference for
snack foods and skipping regular meals. We investigated
that skipping meal habits in this population and whether
they were associated with eating disorders.
Authors’ contributions All authors have made significant scientific
contributions to this manuscript. All authors reviewed the manuscript.
All authors read and approved the final manuscript.
Funding This research was not funded by any Foundations. The
authors declare that it does not report financial support.
Declarations
Conflict of interest The authors declare that they have no conflict of
interest.
Ethics approval Written consent forms get signed to individuals to par-
ticipate in the study voluntarily and E41399 numbered and 20.03.2017
dated “Ethical Commission Approval” was obtained from Gazi Uni-
versity Ethics Commission for the study.
Consent to participate All participants provided informed consent
prior to their participation.
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