The risk of developing eating disorders among students attending University of Khartoum Medical Campus, Khartoum, Sudan

doi:10.21203/rs.3.rs-3879198/v1

Background

Medical students are susceptible to various eating disorders including anorexia nervosa, bulimia nervosa and binge-eating. High prevalence rates of eating disorders have been recorded across the Europe and Africa Regions, yielding a negative impact on academic merit.

Objectives

The aim of this study is to assess the risk of developing eating disorders among medical students and examine its association with childhood trauma and self-esteem. Methodology: An observational cross-sectional study where a total of 299 students participated, 81 males and 218 females. 62 from the faculty of Dentistry, 49 from the faculty of Pharmacy and 202 from the faculty of Medicine - all in Year 3, 4 and 5. Participants filled out a pre-designed online Google survey. Descriptive statistics were used to compute means, and standard deviations for numerical variables.

Results

The study consisted of 299 participants, of which 37 students were found to be at risk of developing an eating disorder (12.4%). It was discovered in this study that emotional neglect was significantly associated with an increased risk of developing eating disorders (p = 0.028). A significant correlation was also established with childhood maltreatment and the prevalence of risk for eating disorders (p = 0.016).

Conclusion

The prevalence of medical students with eating disorders was found to be relatively high, hence it merits more campaigning to prevent its onset among university students.

Eating disorders

Medical students

childhood trauma

low self-esteem

Khartoum University

Physical or psychosocial derangements caused by abnormal eating habits are the main constituents which define eating disorders (EDs).^[1] They range from anorexia nervosa, bulimia nervosa, binge eating disorder, pica, among others. Over the past 50 years, eating disorders have become increasingly prevalent due to changes in the food industry..^[2]

Medical students are prone to various mental health issues.^[3] In accordance with an Egyptian study, it was found that over 50% of students have been victims of mental disorders, of which only a small proportion sought assistance from a medical practitioner.^[4] According to a meta-analytic study conducted, the prevalence of EDs among medical students was found to be 10.4%.^[5] In contrast, a Hungarian study established a decline in binge eating habits by almost double.^[6]

High prevalences of EDs among university students have been reported in developing countries. In Egypt, a study conducted in the University of Tanta found the risk of developing EDs was 33%.^[7] In Nigeria, a cross-sectional study demonstrated the prevalence of abnormal eating habits in University students to be 9.1%.^[9]A similar study carried out in India found a percentage risk of 13%, significantly associated with increased levels of stress.^[8]

Little light has been shed on EDs among medical students in Sudan. A study conducted recently across six medical colleges in Sudan revealed a prevalence of stress of 31.7% and students in their final years were found to have higher levels of stress.^[10] These high levels of stress can account to an increased prevalence of EDs.^[11]

Studies have revealed that LSE increases the likelihood of developing EDs. ^[12] In 1996, a study showed that those with low self esteem were 8 times more likely to develop an ED as opposed to those with higher self esteems.^[13]Another national study confirmed the assumption by using the Rosenberg Self-Esteem scale where an increased risk by 9% was seen with every 1 point decrease on the scale.^[14] Childhood abuse was also shown to render subjects more susceptible to mental disorders. ^[15] The results of a study carried out in Chile revealed that 30% of their participants with EDs were victims of childhood sexual abuse ^[16] A study conducted in Turkey showed a significant association between EDs and sexual and emotional abuse..^[17]

EDs are also proven to negatively impact medical students’ performance as they lower both individuals’ attention span, alter their memory and ability to focus.[18]

The aim of this study was to investigate the prevalence of EDs among medical and allied health students attending University of Khartoum. Also, this study sought to risk factors associated with the development of EDs and their association with childhood trauma and low self-esteem. A scarcity of data among university students in Sudan motivated the authors to perform this study.

Study design:

This study was an original, cross-sectional and institution-based study.

The study was conducted in the Medical Campus of University of Khartoum located in Al

Qasr Avenue, Khartoum, Sudan. It was established in the year 1924 where it was previously

known as Kitchener Medical School.

The Medical Campus consists of 3 faculties (Medicine, Dentistry and Pharmacy) and accommodates 3,174 students in total − 1998 medical students, 514 pharmacy students and 662 dental students.

Sampling size and technique

A minimum of 288 students were selected for this study based on a 25% prevalence rate and 95% confidence interval using the equation

$$n=z2*p*(1-P)\backslash \text{e}2$$

n = sample size

z = standard normal deviation

p = proportion of students with EDs: 25%

e = gross margin error (0.05).

A stratified random sampling technique was applied to select the participants of this study.

The total number of students within each faculty was obtained from previous records and

divided into three strata on the basis of their faculties within the University of Khartoum Medical Campus - Dentistry, Pharmacy and Medicine. Participants of ages 20–24 were then randomly selected from their respective faculties.

Strata	Total population	Number of participants
Faculty of Dentistry	662	62
Faculty of Pharmacy	514	49
Faculty of Medicine	1998	188

The number of participants 299 was reached, yielding a response rate of 100%.

Data Collection tools and methods

Tools:

A pretested, structured, self administered questionnaires with closed-ended questions

were used to collect data from respondents.

The first section of the questionnaire comprised the Eating Attitudes Test 26-item questionnaire (EAT-26), which is a standardised self-report measure of

symptoms and concerns characteristic to EDs developed by D. Garner in

1987. Options for each question were given a score from 0 to 3 (Always = 3, Often = 2,

Sometimes = 1, Rarely = 0, Never = 0). Individual scores were then added and a score of

20 or more suggested a high risk for development of EDs. The BMI was also calculated using the formula (body weight/height (m)2). A BMI of less than 18.5 for females was considered underweight, higher than 18.5 but less than 24.9 was considered normal and more than 24.9 overweight. As for males, less than 19.6 was considered underweight, a BMI lying within the range 19.6–24.9. A value higher than 24.9 was also considered overweight. There was also a second section with five behavioural questions whose aim was to find out the necessity of seeking professional medical attention.

To find the correlation between developing EDs, child abuse and neglect, the CATQ (Child Trauma Questionnaire) developed by Bernstein and Fink was implemented in this study. Its main focus was covers five aspects; sexual abuse, emotional abuse, physical abuse, emotional neglect and physical neglect. Questions on each form of abuse were given a Likert score (SA = 5, A = 4, N = 3, D = 2, SD = 1) and the total was calculated and compared to its cut-off scores (physical ≥ 10; emotional ≥ 13; sexual ≥ 8) and neglect (physical ≥ 10; emotional ≥ 15). Childhood maltreatment was described as a score which lies above the 50th percentile of the distribution ( = > 40), this was done as there was no official cut-point for the total score.

Self-esteem was assessed using a scale developed by Rosenberg in the year 1965,

publicly known as the Rosenberg Self-Esteem scale. It was a ten-item Likert-scale questionnaire

(SA = 5, A = 4, N = 3, D = 2, SD = 1) and high scores indicated high self-esteem and vice

versa.

Method of data collection:

The questionnaire was created using an online Google Form and sent to participants selected randomly (through WhatsApp and Telegram platforms) within the faculties of Medicine, Pharmacy and Dentistry. No pilot test was performed as constituents of the questionnaire were standardised scales.

After the results were submitted and the required sample size reached, the scores for each section were calculated using each component's scoring system and investigated for the presence of any correlation.

Data analysis:

Data from the online Google form was transferred into a Microsoft Excel database and

analysed using Statistical Package for Social Science (SPSS) ® version No. 23 software.

Descriptive statistics were used to compute means, and standard deviations for numerical

variables. Frequencies were calculated for nominal and ordinal variables. Appropriate

tests for significance were carried out and a significance was denoted when p < 0.05 All the results were presented in the form of graphs and tables.

Ethical Considerations:

Ethical clearance was obtained from the Department of Community Medicine, Faculty of Medicine, University of Khartoum. Written informed consent was obtained from the study subjects before they participated in this study. The participants' personal data remained confidential.

The study included 299 participants: 218 females (72.9%) and 81 males (27.1%), The mean age of participants was 22.1 years. 32 participants were 20.0 years (10.2%), 56 were 21.0 years (17.9%), 100 were 22.0 years (31.9%), 74 were 23.0 years (23.6%) and 50 of the participants were 24.0 years (15.6%). 62 students (19.8%) attended the Faculty of Dentistry, while 49 students attended the Faculty of Pharmacy (17.5%) and 188 students (62.9%) attended the Faculty of Medicine. (Fig. 1)

Fig. 1: No. of participants in the study from each faculty, Medical Campus, University of Khartoum, 2021 (n=299)

Fig No. (2): Weight status of participants according to BMI, Medical Campus, University of Khartoum, 2021 (n=299)

The BMI (Body Mass Index) fell under three categories: either normal 180 (62.5%), underweight 50 (15.1%), overweight 53 (17.1%), or obese 15 (5.1%). The mean BMI was 22.5+5.5kg/m2 (Fig. 2).

Fig No. (3): EAT-26 scores among the study participants. (n=299)

Using the EAT-26, 37 (12.4%) scored 20 or above, suggesting a high risk for development of EDs whereas 262 (87.6%) scored below 20 which suggested a low risk of developing EDs. The difference in prevalence of risk in relation to age, gender, faculty, academic year and weight status showed no statistical significance. (Fig. 3)

According to the behavioural score, 193 out of 299 (61.7%) of the participants required medical evaluation. 8.3% of the respondents in this study have experienced binge-eating at least twice monthly, whilst 4.2% have used medications (laxative, dietary medications) or fasted in order to control their weight and bodily appearance. 10.5% have exercised for over 60 minutes 2-6 times weekly to control their weight prior to this study. (Table 1) These findings have been corroborated by Table 2, demonstrating a minimum weight loss of 20lbs in approximately one-fifth of the respondents (18.5%).

Table No. (1) Responses regarding symptoms of eating disorders among Medical students in University of Khartoum 2021 (n=299)

	Never	Once monthly or less	2-3 times a month	2-6 times a week	Once weekly	Once a day or more	Total
Have you ever gone on eating binges where you feel that you may not be able to stop?	57.2%	23.6%	8.3%	3.8%	6.7%	0.3%	100%
Have you ever made yourself sick (vomited) to control your weight or shape?	92.7%	1.9%	2.6%	1.3%	1.0%	0.6%	100%
Have you ever used laxatives, diet pills, or diuretics (water pills) or fasted to control your weight or shape?	87.9%	5.4%	4.2%	-	2.6%	-	100%
Have you ever exercised more than 60 mins a day to lose or control your weight?	62.9%	12.5%	6.1%	10.5%	7.3%	0.6%	100%

Table 2: Excessive weight loss which might be among medical students in University of Khartoum. (n=299)

	Yes	No
Lost 20 pounds or more in the past 6 months ?	18.5%	81.5%

Using cross-tabulation and Pearson Chi-Square testing, the association was found to be statistically insignificant (>0.05) between the socio-demographic characteristics and risk for developing EDs. (Table 3)

Table No. (3) Relationship between EAT scores & sociodemographic characteristics among students in University of Khartoum Medical Campus.

	Chi-square value
Gender and EAT score	.424
Age and EAT score	.414
Faculty and EAT score	.843
Academic Year and EAT score	.943
Weight status and EAT score	.094
Behavioural score and EAT score	.727

2 CATQ:

Out of 299 participants, 181 did not experience emotional abuse (60.5%). 76 experienced low levels of emotional abuse (25.4%), whilst 25 experienced moderate emotional abuse (8.4%) and 17 suffered from severe emotional abuse (5.7%). (Table 4).

214 did not experience physical abuse (71.6%). 43 experienced low levels of physical abuse (14.4%), 28 experienced moderate physical abuse (9.4%) and 14 suffered from severe physical abuse (4.7%). (Table 5)

Table 4: Prevalence of emotional abuse among medical students in University of Khartoum. (n=299)

Emotional Abuse
		Frequency	Percent	Valid Percent	Cumulative Percent
	N/A	181	60.5	60.5	60.5

	low	76	25.4	25.4	86.0
	moderate	25	8.4	8.4	94.3
	severe	17	5.7	5.7	100.0
	Total	299	100.0	100.0

Table No. (5) Prevalence of physical abuse among medical students in University of Khartoum. (n=299)

Physical Abuse
	Frequency	Percent	Valid Percent	Cumulative Percent
N/A Low Moderate Severe	214	71.6	71.6	71.6
	43	14.4	14.4	86.0
	28	9.4	9.4	95.3
	14	4.7	4.7	100.0
	299	100.0	100.0

Out of 299 participants, 157 did not experience sexual abuse (52.5%), 47 experienced low levels of sexual abuse (15.7%), 53 experienced moderate sexual abuse (17.7%) and 42 suffered from severe sexual abuse (14.0%). (Table 6). Emotional neglect was also a commonality in this study, experienced by 56.1% of the study participants (Table 7). Severe levels were experienced by 13.0%.

Table No. (6) Prevalence of sexual abuse among medical students in University of Khartoum. (n=299)

Sexual Abuse
		Frequency	Percent	Valid Percent	Cumulative Percent
Valid	N/A	157	52.5	52.5	52.5
	low	47	15.7	15.7	68.2
	moderate	53	17.7	17.7	86.0
	severe	42	14.0	14.0	100.0
	Total	299	100.0	100.0

Table No. (7) Emotional neglect among medical students in University of Khartoum. (n=313)

Emotional Neglect
	Frequency	Percent	Valid Percent	Cumulative Percent
N/A	129	43.1	43.1	43.1
low	84	28.1	28.1	71.2
moderate	47	15.7	15.7	87.0
severe	39	13.0	13.0	100.0
Total	299	100.0	100.0

A high prevalence of physical neglect was present among the study participants (36.5%). 56 experienced low levels of physical neglect (18.7%), 38 experienced moderate physical neglect (12.7%) and 15 suffered from severe physical neglect (5.0%). (Table 8)

Table No. (8) shows frequency and percentage prevalence of physical neglect using the CTQ among medical students in University of Khartoum. (n=299)

Physical Neglect
		Frequency	Percent	Valid Percent	Cumulative Percent
	None	190	63.5	63.5	63.5
	Low	56	18.7	18.7	82.3
	Moderate	38	12.7	12.7	95.0
	Severe	15	5.0	5.0	100.0
	Total	299	100.0	100.0

Self-esteem using the Rosenberg Self-esteem scale:

22.4% of the students , 67 out of 299, were found to have low self-esteem while 239 (75.9%) have normal self esteem. As for a high esteem level, these scores were achieved by only 5 respondents (1.7%). (Table 9)

Table No.9: Self-esteem among the participants. (n=299)

	n	%
Low	67	22.4
Normal	227	75.9
High	5	1.7
Total	299	100

No correlation was found between emotional abuse, physical abuse, sexual abuse and physical neglect and high risk of EDs as the p-value was >.05. However, there was a correlation between it and emotional neglect (p-value=.014) and childhood trauma when the 50th percentile was used (.015). There was no signification relationship between EAT scores and self-esteem levels. (p=.109) (Table 10)

Table No. (10) The relationship between EAT scores and physical, sexual & emotional abuse, physical & emotional neglect and childhood trauma among medical students in University of Khartoum ,Faculty of Medicine 2021 (n=299)

	Chi-square value
Physical abuse and high EAT score	.573
Emotional abuse and high EAT score	.103
Sexual abuse and high EAT score	.440
Physical Neglect and high EAT score	.319
Emotional neglect and high EAT score	.014
Childhood Trauma and high EAT score	.015
Self-Esteem and high EAT score	.109

This study addresses the risk for developing ED's among medical and allied health students at the University of Khartoum and its correlation with low self-esteem, childhood abuse and neglect. The results obtained by this study were found to be slightly higher than those revealed by a global meta-analysis which involved medical students [5]. However, compared to other national studies, the risk was found to be half that deduced by the study performed in Egypt [7]. This may be attributed to the fact that the Egyptian study included medical students of a wider age group, whereas students below 20 years of age were not included in this study. Nevertheless, when compared to the study in the rural area in South Africa, the findings were four times greater. {18]. It is fair to assume that this is because those living in rural areas are less exposed to social media and other external influences which play a role in the prevalence. [19]

Medical students in the University of Khartoum were found to be at higher risk than those in France, India and China[20 ,21,22]. The fact that this percentage in the University of Khartoum surpassed that of China and France suggests that EDs are a bigger issue in developing countries and the numbers are yet to rise. This can be blamed on the unavailability of treatment facilities and the stigma associated with mental illnesses; which makes it difficult for victims to seek professional help. [23] Another factor that might have played a role is that developing countries have recently adopted Western standards and show less interest in their own customs- a direct effect of globalization. [24]

The results of a wide-scale study in a Spanish university for the risk of developing EDs was also higher compared to this study. [25] This variation might be due to differences in execution as the study in Spain used the SCOFF questionnaire which has a lower specificity (higher false-positive results) than the EAT-26 which was used in this study and most of the ones mentioned above. Even though the risk was higher among females there was no association between it and socio-demographic factors (age, gender, academic year, faculty and weight status) (Table No. 3) matching the proposition presented by the studies in the University of Tanta and France [7,20]. As for the second objective, which is the presence of an association between LSE and the risk of developing EDs, this study showed no significant association. A study in Turkey however established an association; (the p value was 0.001 when the correlation between prevalence of EDs and LSE were investigated). [17] Another paper substantiated the belief that LSE is a vital risk factor and it was found that almost a quarter of girls with a known history of EDs have LSE. [26] This can be due to the fact that in the latter studies a larger, more diverse study population was targeted. Regarding the third objective, there was no statistical significance between the risk of prevalence for EDs and sexual, physical and emotional abuse in childhood contradicting the outcome of the paper in Turkey which unveiled childhood sexual and emotional abuse in particular to be strongly correlated(p = 0.03). [17] The same can't be said about emotional neglect however which showed a statistically significant p-value. (Table No. 5) Emotional neglect can be a precipitating factor as parents' lack of concern towards children's needs will then force them to resort to other sources of comfort, an example of which is food. [54] As there is no cut-point for the total score in the CTQ used in this study, the median was used. Those who lied at or above the median ( = > 40) were considered to be victims of childhood maltreatment and those below were considered as the opposite. A strong correlation was found between childhood maltreatment using the 50th percentile and those at risk of developing an ED. (Table No. 5) The reasoning for this is the same as above, which is that children whom are maltreated might try to numb the pain caused by their parents' lack of concern through frequent episodes of bingeing and purging. [27]

Limitations

Students who were asked to participate were university years from the age of 20–24 who experienced stress mostly since they are in their final years, this is on the hypothesis that stress is a precipitating factor for the development of EDs [10,11]. The percentage prevalence might have been higher since EDs do not affect this age group exclusively, and the risk can start at a much younger age.[28] There was selection bias as students were chosen based on their ability to access the online Google forum and an online platform was the only possible method due to the restrictions caused by the current pandemic. The questionnaire used to detect the risk of EDs (EAT-26) has moderate sensitivity.[29]

The study found out that risk for developing EDs among Medical students in the University of Khartoum was 12.4% using the EAT-26. Emotional neglect and childhood maltreatment were found to be strongly correlated to the risk of developing EDs.

Recommendations

The authors of this study recommend consistent public health campaigning to address the current prevalence of EDs among university students. Also, the authors recommend the establishment of on-campus counselling services in universities as a preventive measure to curb the onset of eating disorders among students in higher institutions.

Acknowledgement

The authors acknowledge the participants for their time and efforts.

Author Contributions

Yumna Ahmed Eltayeb Mohamed Ali Magzoub conceptualised the study, collected, interpreted and analysed the data and wrote the first draft of the manuscript.

Randa Ahmed Abdalrheem Altamih and Osman Kamal Osman Elmahi remodelled the data, validated the results and edited the first draft of the manuscript.

All authors approved the final draft of the manuscript.

Conflict of Interest

None declared among the authors.

Data availability.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

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No competing interests reported.

The risk of developing eating disorders among students attending University of Khartoum Medical Campus, Khartoum, Sudan

Status:

Version 1

Abstract

Background

Objectives

Results

Conclusion

Figures

Introduction

Methodology

Study design:

Sampling size and technique

Data Collection tools and methods

Tools:

Method of data collection:

Data analysis:

Ethical Considerations:

Results

Discussion

Limitations

Conclusion

Recommendations

Declarations

References

Additional Declarations

Status:

Version 1