Prevalence of Eating Disorders Among Nutritional Sciences Students and Dietitians in Saudi Arabia


 Background: Eating disorders (EDs) involve persistent disturbed eating and related behaviors that result in altered consumption or absorption of food with potential physical or psychological function impairment. EDs have four major types: anorexia nervosa, bulimia nervosa, binge eating disorder, and eating disorder not otherwise specified. The investigation aimed to study the prevalence of EDs by assessing nutritional status for nutrition students and dietitians from multiple provinces in Saudi Arabia.Methods: A cross-sectional study comprising 175 male and female nutrition students or dietitians. EDs were diagnosed using EAT-26 and DSM5. Dietary intake was estimated by repeated 24-hr recall records. Diet was analyzed using food processor nutrition and fitness software. Intakes were compared with the recommended dietary allowances. Results: According to EAT-26 diagnostic criteria, the prevalence of EDs was 15.4%. The mean age was 24.96 ± 4 years. ED subjects had normal BMIs. The diet analysis showed that these subjects had a lower intake of energy, macronutrients, and some micronutrients, and other micronutrients were high as compared to the RDA. Conclusion: EDs were more prevalent among dietitians than students. The EDs comprised a high number of OSFED and UNFED cases. Subjects with an ED had an unbalanced diet with poor nutrition.


Background
Eating disorders (ED) are illnesses that are de ned as persistent disturbed eating and eating-related behaviors that result in altered consumption or absorption of food and potential physical or psychological function disruption. EDs have four major types as described by The Diagnostic and Statistical Manual of Mental Disorders (DSM-5): anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and eating disorder not otherwise speci ed (EDNOS) [1] .
AN is de ned as a psychological illness or syndrome. It is characterized by an intense fear of fatness or seeking low body weight. The body mass index (BMI) is reported to be very low at less than 17.5 kg\m2. Affected individuals restrict their high-fat food intake and participate in excessive exercise [2] . AN and BN each 0.1%, and BED 0.3. In Switzerland, among females, AN was 1.9%, and among males 0.2%. In Germany, AN was found to be 0.3%, BN 0.4%, and BED 0.5%. In Sweden, for females, BN was 1.6% and BED 0.4%. In Australia, ED was reported to be 16.3%, AN 0.46%, BN 0.66%, and BED 5.58%. In the United States, AN among females was found to be 1.37% and BED 1.7%, and BED among males was 0.8%. In Canada, female EDs were reported to be at a level of 4.46%, AN 0.06%, BN 2.01%, and BED 0.68%; among males, ED was 2.21%, BN 1.31%, and BED 0.16% [12].
The prevalence of EDs in the Middle East and North Africa (MENA) region was found to be 16.9% in the UAE (for BED, speci cally). Egypt had a 65.0% prevalence of EDs. In Saudi Arabia (Dammam), 29.4% of females had an ED, whereas this gure was 35% and 23.3% for Taif and Arar cities, respectively [13,14,15,16] 2.0 Literature Review 2.1 Literature review Another study aimed to determine the frequency of AN and EDs among dietitians. The study was performed with a 2500 sample size. Participants were asked to complete two types of questionnaires-the Orthorexia Nervosa Questionnaire (ORTO-15) and the Eating Disorder Examination Questionnaire (EDE-Q)-and their anthropometrics were measured. The authors reported that 49.5% of participants were at high risk for AN and 12.9% at high risk for ED. 8.2% of the participants reported that they had been previously treated for an ED, and 44.6% had been treated for AN. The limitation of this study was that the response rate was only 26%, the sample size was low relative to the total, and those at high risk could be recovering from any illness that made them at risk for an ED [17] .
In another study, the objective was to assess ED behavior and addiction to food among nutrition and nonnutrition students. There were 967 participants included. The study was performed by sending questionnaires by e-mail to the students, enquiring about demographic data such as age, sex, race, height, and weight. For ED screening, the Eating Attitude Test (EAT-26) was used; as a self-assessment tool to measure three dimensions of eating behaviors, the Three-Factor Eating Questionnaire (TFEQ-R18) was employed, and the Yale Food Addiction Scale (YFAS) was used as a tool to model to DSM-5. 10% of the participants were found to be of high concern regarding an ED, and 10.3% had a food addiction. According to the observed EAT-26 scores, 8.8% of respondents were underweight or normal, and 12.9% were overweight or obese. The limitations of this study were that it was biased because of the self-report approach; the authors did not assess for general psychopathology, they only included undergraduate students, and they excluded graduate students [18] .
The previous two studies were conducted in the United States. In a study performed in Brazil, the authors aimed to determine the number of risk behaviors of EDs and body image satisfaction among nutrition students and dietitians; 743 female participants were analyzed. Data were collated using an online questionnaire-the Body Shape Questionnaire (BSQ)-to evaluate individuals' satisfaction with their own body; EAT-26 was also used. 10.1% of undergraduate students reported having an ED, whereas among dietitians, this gure was 7.9%. 5% of dietitians were underweight, 72.3% normal, 16.4% overweight, and 6.3% obese. For undergraduate students, 11% were underweight, 73.3% normal, 10.5% overweight, and 5.2 obese. The limitations of this study are that the participants were all female, the authors only used EAT-26 to diagnose EDs, and the research was biased due to the use of the self-report online questionnaire [19] .
Accordingly, our investigation aimed to study the prevalence of EDs by assessing nutritional status for nutrition students and dietitians from multiple provinces in Saudi Arabia.

Research hypothesis
Eating disorder tendencies are prevalent in both the nutrition students and dietitians. However, nutrition students will score higher on the EAT-26, that because they are gaining new knowledge about diets and food that could affect them in terms of losing or gaining weight potentially indicating higher level of ED tendencies.

Study type and duration
An epidemiological, descriptive, cross-sectional study was conducted in Saudi Arabia between October 2020 and March 2021.

Study setting and sampling
Nutrition students and dietitians from different nutrition colleges and hospitals aged 18 to 55 years were the target group. Subjects with chronic diseases such as diabetes, hypertension, hypo/hyperthyroidism, as well as pregnant and lactating woman were excluded from the study. Only subjects in a dietetic school at any academic level and dietitians were eligible for inclusion.

Data collection
Participants were screened using a form translated into the Arabic language of the Eating Attitude Test (EAT-26). EAT-26 is a widely used tool for screening EDs following a 6-point Likert scale (always, usually, often, sometimes, rarely, never). The original version of the EAT-26 was published in 1982. A score of above 20 is indicative of a possible ED. Table (1) shows the scoring system for EAT-26. Scores between 20-24 indicate mild ED, 25-30 moderate to severe ED, and more than 31 very severe ED [20] . The questionnaire was distributed to the participants in the form of an electronic online questionnaire using Google forms distributed via social media consisting of three parts: 1) consent form, 2) personal informationname, age, gender, province, college, academic level, weight, and height, and 3) the translated EAT-26. All participants whose scores indicated possible EDs were included, and they underwent further diagnosis by DSM-5.

Diagnostic criteria
DSM-5 was used to identify the types of ED (pica, rumination disorder, avoidance\restriction disorder, AN, BN, BED, OSFED and UFED) by telephone-calling the participants with ED, asking whether they had symptoms recorded in the DSM-5 to identify its type [21] .

Anthropometric Measurements
Weight and height were asked in the electronic questionnaire as a self-reported measurement. BMI was calculated using the Quetelet equation:

Ethical considerations
Ethical permission to conduct the current study was obtained from the local committee for bio-medical ethics to conduct scienti c research at Umm Al-Qura University. Participants had provided their consent prior to the beginning of the project, and they were assured that all their information would be treated with privacy and that they had the right to withdraw from the study at any time without any problem.

Pretesting of questionnaires
The data collection tools were pretested on 5 subjects not included in the study to con rm the clarity of the questions and any necessary changes before the main project was conducted.

Data analysis
Microsoft Excel was used to initially enter and analyze the data. The recall records were analyzed using food processor nutrition and tness software by ESHA research version 11.9.13. Intake values were compared with the recommended dietary allowance (RDA) for energy, macronutrients, and micronutrients and were obtained from the National Institutes of Health (NIH) [22] . Descriptive and inferential data were analyzed using statistical for social science software (IBM SPSS statistics version 26). A P-value of ≤ 0.05 was set as the signi cance level.

Background information
A total of 186 participants (14 males and 172 females) were recruited from different provinces in Saudi Arabia.
Two participants were excluded because they were not nutrition students or dietitians, and for 9 participants, contact was lost. The nal total number of participants included in the study was, therefore, 175; thus, the completion rate was 94%. The mean age of participants was 24.62 ± 4.7 years, the minimum age was 19 years, and the maximum age was 53 years. Participants who had been previously treated for an ED accounted for 3.4% (n=6), and 96.6% had never been treated for an ED (n=169). Regarding participants' academic level, 5 subjects (18.5%) were in the fth academic level, 1 (3.7%) in seventh, 2 (7.4%) in eighth, 1 (3.7%) was an intern, and 18 (66.7%) had graduated.

4.3Anthropometric measurements
Subjects' anthropometric measurements with ED mean values are listed in Table (2). The mean height was 159 ±6.8 cm, mean weight 59.6 ± 8.7 kg, and the mean BMI was 23.6 ± 3.47 for participants with an ED. Hence, there were signi cant differences regarding weight and BMI-the p. value was 0.036 and 0.016, respectivelywithin those with ED as compared to participants without ED.
Moreover, the reference data of BMI categories indicated a higher prevalence of normal weight among ED cases rather than underweight, overweight, and obesity, as noted in Table (3). there was a slight reduction from the RDA for vitamin B 6 , K, and selenium. However, the consumption of iron, manganese, and sodium was higher than the RDA, as illustrated in Table (4 & 5). Results from 24-hr recall records. Mean ± SD, RDA, and % of RDA. Results from 24-hr recall records. Mean ± SD, RDA, and % of RDA.

Correlation between EAT-26 and nutrient intake
The obtained data showed signi cant correlations for ED parameters according Eat-26 scores. There was a value=0.368), as outlined in Table (6). Data illustrated as p-value and Pearson correlation.

Discussion
Our investigation aimed to study the prevalence of EDs by assessing the nutritional status of nutrition students and dietitians from multiple provinces in Saudi Arabia.

Prevalence of eating disorders
Our results showed that the percent was 6.9% and 93.1% of males and females, respectively, suffered from an ED. These results agreed with [18], who found that 15.6% and 84.4% of males and females, respectively, had an ED, from a total of 147 nutrition students. In the present study, EDs were more prevalent between 19 and 30 years and less prevalent in 31-50-year-olds, with only 3 participants affected by an ED, whereas the age group >50 years old recorded no ED incidence. The mean age was 24.96 years, agreeing with [19], who recorded a mean age for students of 22.5 years and, for dietitians, 31.2 years. Meanwhile, those who have been treated previously from ED in the current study count for 3.4%, and 8.2% of 636 participants were found to be treated from an ED in [17].
In our study, the prevalence of ED (15.4%) was high for OSFED and UNFED compared to other EDs. A similar study conducted in Brazil that included 745 female participants showed an ED prevalence of 9.10%; the study included only females due to Brazilian female dietitians comprising more than 90% of the total [19].
[18] included 147 participants only as students in the United States and found an ED prevalence of 9.5%. Meanwhile, [23] analyzed 97 participants in Australia and reported an ED prevalence of 14.5% for nutrition students. [24] also carried out research in Australia that included 137 nutrition students and dietitians and found this prevalence to be 13.25%. [15] investigated 35 participants in Wisconsin, United States, reporting this value for nutrition students and dietitians to be 22.2%. Furthermore, the ED rate variance between studies re ected the difference of ED prevalence among nutrition students and dietitians with respect to geographic regions worldwide; the variation might have been due to differences in socioeconomic status, and knowledge about EDs could affect and lead to an ED. Notably, all studies have used EAT-26 to measure EDs.
According to our data, EDs were more prevalent (40.7%) in Medina province despite the percent of participants from Medina and Mecca provinces being equal. Moreover, ED was high (22.2%) in the Eastern province as compared to the number of participants included. Some provinces did not declare an ED because the participants were few in number when compared to the total population in other provinces. Two of the provinces (Al-Jowf and Najran) were not included in the study because no participants completed the questionnaire in these provinces, and only one participant was included from Asser province. In other provinces, the study did not detect ED, and the number of participants who completed the questionnaire was slightly low.
Further research is required to include more participants from those provinces with low sample numbers.
For the current study, students (n=9) compared to dietitians (n=18) had less incidence of EDs. A study in Brazil disagreed with these ndings; students with an ED comprised 43 participants and dietitians 25 participants [19]. In the present study, for those with an ED, 5 participants were in their third academic year, 4 in their fourth, and no participants were reported in their rst/second academic year. In another study, 4 participants were in their rst/second academic year, and 10 participants were in their third/fourth academic Greek study investigating 215 undergraduate students found this AN incidence to be 68.2% [27]. In the United States, 44.6% of 636 subjects had AN [17], indicating that most of them included only AN of the ED types. In Australia, a 23% BN prevalence was found [23], and in Brazil, using 179 nutrition students, the BN rate was reported as 6.1%, with BED being 2.8% [28]. Unfortunately, no study included OSFED and UNFED among nutrition students and dietitians.

Anthropometric measurements
Our research demonstrated that participants with ED had a normal BMI (average 23.6 kg/m 2 ). Only one case was underweight, 19 were normal, ve were overweight, and two were obese ( They also included one micro nutrient the sodium and the intake were 2260.4 mg (i.e., higher than the RDA). In our study, sodium intake was 2421.3 mg (i.e., higher than the RDA). Unfortunately, no study has investigated other nutrients, and research has yet to be performed to include all types of ED and macro-micronutrient intake among nutrition students and dietitians. There were signi cant differences between EAT-26 and intake of energy and carbohydrates, whereas there was an insigni cant difference between EAT-26 and protein and fat intake.

Strength and limits
This study has some limitations because it used a self-report online questionnaire and had a low number of participants. However, due to limited time and resources, it was not possible to include larger numbers of nutrition students and dietitians. Biomarkers would have given strong inferences to the results of the current study. Further studies are necessary to conduct biochemical analyses.
Strength points our study is the rst in Saudi Arabia to investigate the prevalence of EDs among nutrition students and dietitians.

Conclusion
Our investigation may conclude that the prevalence of eating disorders in Saudi Arabia to be 15.4% among nutrition students and dietitians. The EDs comprised a high number of OSFED and UNFED cases. Moreover, eating disorders were more prevalent in some Saudi provinces. Energy, macronutrient, and some micronutrients were low, and other micronutrients were high compared to the recommended dietary allowances (RDA).

Recommendations
According to the ndings of this study, the following recommendations are suggested: 1. Further research with a larger sample size must be performed to support the study's ndings and investigate other types of ED that this study did not include.
2. Assessment of people with EDs should be comprehensive and include physical, psychological, and social needs. Analysis of various biochemicals must be carried out in future research because they are surrogate measures for dietary intake.
3. Education and counseling should be provided for those with an ED regarding the impact of these disorders on their health, nutritional behavior, and nutrition misinformation. This approach could involve conducting nutrition campaigns, providing education to participants. 4. Pamphlets with information about the seriousness of EDs and health consequences should be distributed to limit the prevalence of EDs among this group.

Declarations
What is already known on this subject The prevalence of EDs among nutrition students and dietitians in different countries worldwide, and the dietary intake of those with EDs. The study needs to be done to investigate the number of dietitians and nutrition students with EDs in Saudi Arabia.
What your study adds The percentage of dietitian and nutrition students with EDs in Saudi Arabia from different provinces and their dietary intake.

Funding
The authors declare that no funds, grants, or other support were received during the preparation of this manuscript. Figure 1 Participants with/without eating disorders