Eating-Disordered Behavior in Adolescents: Associations with Body Image, Body Composition and Physical Activity

The use and misuse of the SCOFF screening measure over two decades: a systematic literature review

PURPOSE

The SCOFF questionnaire was designed as a simple, memorable screening tool to raise suspicion that a person might have an eating disorder. It is over 20 years since the creation of the SCOFF, during which time it has been widely used. Considering this, we wish to review the use of the SCOFF in peer-reviewed scientific journals, and to assess whether it is being used appropriately in the manner in which it was originally devised and tested.

METHODS

The Preferred Reporting Items for a Systematic Review and Meta-analysis (PRISMA) guidelines were followed, and all search strategies and methods were determined before the onset of the study. PubMed and Wiley Online Library were searched using the terms SCOFF and eating. Two reviewers were involved in the reviewing process. Criteria for appropriate use of the SCOFF were formalised with the tool's original authors.

RESULTS

180 articles were included in the final review. 48 articles had used the SCOFF appropriately, 117 articles inappropriately and 15 articles had been mixed in the appropriateness of their use.

CONCLUSION

This systematic review highlights the inappropriate use of the SCOFF in diverse languages and settings. When used correctly the SCOFF has made a significant contribution to the understanding of eating disorders and its simplicity has been applauded and led to widespread use. However in over two-thirds of studies, the use of the SCOFF was inappropriate and the paper highlights how and in what way it was misused, Guidelines for the appropriate use of the SCOFF are stated. Future validation and avenues of research are suggested.

LEVEL OF EVIDENCE

Level I.

Body Weight Satisfaction, Comments, Nutrition and Injury Risk in 489 Adolescent Elite Athletes

Exposure to critical body weight comments in youth athletes could lead to decreased self-esteem, affect body image, and increase the risk of eating disorders and cause depressive symptoms. The aim was to explore differences between sex, body mass index, sports type, with regards to body weight satisfaction, exposure to critical body weight comments from their coach and nutrition status in adolescent elite athletes. A questionnaire about body weight, critical body weight comments and nutrition was distributed to 489 adolescent elite athletes and injury prevalence was monitored across 20 weeks. The results showed that almost one in four athletes (n=116, 24%) was not satisfied with their weight and 12% (n=59) had received critical body weight comments from their coach. Of the athletes who were unsatisfied with their body weight (n=116), 47% wanted to lose weight (n=55). A significant (p<0.05) higher proportion of ice hockey players and swimmers used nutritional supplements, were unsatisfied with their body weight, and were more exposed to critical body weight comments compared to athletes from other sports. Adolescent elite athletes as young as 15-16 years old are exposed to critical body weight comments from their coach and experience challenges with body weight satisfaction that is partly dependent on the sport-specific context.

Parental Pressure on Child Body Image, BMI, Body Image Dissatisfaction Associated with Eating Disorders in School-Age Children in China: A Path Analysis

Background

Children's eating behaviors, body shape and body image cognition may be more susceptible to the influence of their parents, but these influences may be weakened with age. There may be different association pathways between parental pressure on children's body image (PPCBI), body mass index (BMI), body image dissatisfaction (BID) and eating disorders (EDs) among children and adolescents at different developmental stages.

Methods

The stratified cluster sampling method (Stratified by grade, and took the classes as clusters) was used to select 486 students aged 8-15 years in two 9-year schools. Children's body height, weight, testicular volume and breast development were measured. PPCBI, BID, and EDs were investigated using the Appearance-related Social Stress Questionnaire, Body Size Questionnaire (BID-14), and EDI-1 scale, respectively.

Results

The boys before puberty initiation had significantly higher EDs score (182.3±50.8) than girls before puberty initiation (164.1±58.1) (P<0.05). There were significant association pathways of PPCBI→BMI→BID→EDs and PPCBI→BID→EDs in boys before puberty initiation (β=0.035, P<0.01; β=0.059, P<0.01), in boys after puberty initiation (β=0.032, P<0.01; β=0.175, P<0.001), and in girls after puberty initiation (β=0.026, P<0.01; β=0.172, P<0.001). There was a positive association pathway of PPCBI→EDs in boys before puberty initiation (β=0.30, P<0.001) and PPCBI→BID→EDs in girls before puberty initiation (β=0.176, P<0.01).

Conclusion

Parental pressure on children's body image may positively associate with children's eating disorders through BMI and body image dissatisfaction in boys and girls after puberty initiation and directly associate with eating disorders in boys before puberty initiation; however, it may indirectly associate with eating disorders only through BID in girls before puberty initiation.

The global prevalence of screen-based disordered eating and associated risk factors among high school students: systematic review, meta-analysis, and meta-regression

OBJECTIVE

Estimate the prevalence, and associated risk factors, of high school students who are considered at risk for an eating disorder based on screening measures.

METHODS

An electronic search of nine databases was completed from their inception until 1st September 2022. A random-effects meta-analysis was conducted, and confounder (moderator) analyses and meta-regressions examined whether the overall prevalence estimate for of screen-based disordered eating (SBDE) was moderated by student age, BMI, or gender, as well as culture and type of SBDE assessment.

RESULTS

The mean estimate of the prevalence of SBDE among high school students (K = 42 (66 datapoints), N = 56282] in the sample of 25 countries was 13% ([95% CI] = 10.0-16.8%, I2 = 99.0%, Cochran's Q p = 0.001). This effect was not moderated by features of the samples such as gender, BMI, or age. Among cultures, non-Western countries had a higher prevalence of SBDE prevalence than Western countries, but the difference was not significant. There was considerable variability in the prevalence estimates as a function of the assessment measure, but no meaningful pattern emerged.

CONCLUSION

The estimated figure of 1 in 8 high school students with SBDE-unmoderated by gender and BMI-stands out as a problem in need of attention from public health officials, psychologists, psychiatrists, pediatricians, parents, and educators. There is a great need for innovative, integrated policy and program development all along the spectrum of health promotion and universal, selective, and indicated prevention. Further research is also needed to validate and refine this estimate by (a) conducting basic research on the accuracy of eating disorder screening measurements in samples ages 14 through 17; (b) examining representative samples in more countries in general and Latin American countries in particular; (c) clarifying the relationships between SBDE and age throughout the different phases of late childhood, adolescence, and emerging adulthood; and (d) investigating whether there are meaningful forms of disordered eating and whether these are associated with variables such as gender, ethnicity, and BMI.

Height and subjective body image are associated with suicide ideation among Korean adolescents

Introduction

Suicide is the leading cause of death among Korean adolescents. Suicide has been found to be associated with body mass index (BMI), height, and subjective body image among adults, but investigations of these associations among adolescents are limited. Thus, we aimed to examine to what extent suicide ideation is associated with height, BMI, and subjective body image among Korean adolescents.

Methods

This study examined the data of 6,261 adolescents, selected from a nationally representative survey. The participants were divided into subgroups by sex, suicide ideation, and subjective body image. Logistic regression analyses were performed to examine the association of suicide ideation with height, BMI, and subjective body image.

Results

The proportion of perceived obesity was high in the total sample; the height Z-score was lower for the group with suicide ideation than the group without suicide ideation; the height Z-scores were also lower for female participants with suicide ideation than those female participants without suicide ideation. The proportions of depressed mood, suicide ideation, and suicide attempts were higher among the total sample and female participants with perceived obesity than among those with a normal body image. On logistic regression, perceived obesity was positively associated with suicide ideation even after adjusting for age, height Z-score, weight Z-score, and depressed mood, whereas height Z-score was negatively associated with suicide ideation. These relationships were more prominent among female participants than among male participants.

Conclusion

Low height and perceived obesity, not real obesity, are associated with suicide ideation among Korean adolescents. These findings indicate that the need for an integrated approach to growth, body image, and suicide in adolescents is warranted.

Global Proportion of Disordered Eating in Children and Adolescents: A Systematic Review and Meta-analysis

Importance

The 5-item Sick, Control, One, Fat, Food (SCOFF) questionnaire is the most widely used screening measure for eating disorders. However, no previous systematic review and meta-analysis determined the proportion of disordered eating among children and adolescents.

Objective

To establish the proportion among children and adolescents of disordered eating as assessed with the SCOFF tool.

Data Sources

Four databases were systematically searched (PubMed, Scopus, Web of Science, and the Cochrane Library) with date limits from January 1999 to November 2022.

Study Selection

Studies were required to meet the following criteria: (1) participants: studies of community samples of children and adolescents aged 6 to 18 years and (2) outcome: disordered eating assessed by the SCOFF questionnaire. The exclusion criteria included (1) studies conducted with young people who had a diagnosis of physical or mental disorders; (2) studies that were published before 1999 because the SCOFF questionnaire was designed in that year; (3) studies in which data were collected during COVID-19 because they could introduce selection bias; (4) studies based on data from the same surveys/studies to avoid duplication; and (5) systematic reviews and/or meta-analyses and qualitative and case studies.

Data Extraction and Synthesis

A systematic review and meta-analysis was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline.

Main Outcomes and Measures

Proportion of disordered eating among children and adolescents assessed with the SCOFF tool.

Results

Thirty-two studies, including 63 181 participants, from 16 countries were included in this systematic review and meta-analysis. The overall proportion of children and adolescents with disordered eating was 22.36% (95% CI, 18.84%-26.09%; P < .001; n = 63 181) (I2 = 98.58%). Girls were significantly more likely to report disordered eating (30.03%; 95% CI, 25.61%-34.65%; n = 27 548) than boys (16.98%; 95% CI, 13.46%-20.81%; n = 26 170) (P < .001). Disordered eating became more elevated with increasing age (B, 0.03; 95% CI, 0-0.06; P = .049) and body mass index (B, 0.03; 95% CI, 0.01-0.05; P < .001).

Conclusions and Relevance

In this systematic review and meta-analysis, the available evidence from 32 studies comprising large samples from 16 countries showed that 22% of children and adolescents showed disordered eating according to the SCOFF tool. Proportion of disordered eating was further elevated among girls, as well as with increasing age and body mass index. These high figures are concerning from a public health perspective and highlight the need to implement strategies for preventing eating disorders.

Risk of eating disorders, changes in salivary cortisol concentrations and nutritional status of adolescents

PURPOSE

The imposition of the thin body as an ideal of beauty and the changes that occur in adolescence lead to a constant concern with adolescents' body weight, putting them at risk for eating disorders. Thus, the study sought to investigate associations between eating disorders and salivary cortisol concentrations, nutritional status and depressive symptoms in female adolescents with bulimia.

METHODS

A cross-sectional study was carried out with 1435 adolescents aged 10-19 years. The Bulimic Investigatory Test of Edinburgh (BITE) and Body Shape Questionnaire (BSQ) questionnaires were used. A follow-up study was conducted from a random selection of female adolescents diagnosed with Bulimia Development and Well-Being Assessment-(DAWBA) to assess associations with salivary cortisol concentrations and nutritional status.

RESULTS

The prevalence of body dissatisfaction among adolescents with symptoms of bulimia was 37%. There was a significant difference between salivary cortisol and bulimia (Risk Group = 0.33 ± 0.20 μg/100 ml, Diagnostic Group = 0.44 ± 0.21 μg/100 ml p = 0.040), and correlation positive between the risk of bulimia with symptoms of depression (0.355 p = 0.002) and with Body Mass Index (0.259 p = 0.028). High concentrations of salivary cortisol in bulimic adolescents may be associated with hyperactivity of the hypothalamic-pituitary-adrenal axis and depressive symptoms.

CONCLUSIONS

Nutritional status indicators cannot be used alone for the diagnosis of bulimia, since cortisol levels seem to be a reliable parameter in the identification of bulimia, provided they are used with other diagnostic criteria.

LEVEL III

Evidence obtained from cross-sectional study.

Physical fitness and disordered eating among adolescents: Results from the EHDLA study

The aim of this study was to examine the association between a comprehensive spectrum of physical fitness components and disordered eating symptoms in a sample of Spanish adolescents. This cross-sectional study analysed a representative sample of 741 adolescents (55.1% girls) from the Eating Healthy and Daily Life Activities (EHDLA) study (Valle de Ricote, Region of Murcia, Spain). Objective physical fitness (i.e., cardiorespiratory fitness, upper body strength, lower body strength, speed-agility, and flexibility) was assesed by the ALPHA-FIT Test Battery for a young population. Disordered eating symptoms were assessed with the Sick, Control, One, Fat, Food (SCOFF) questionnaire. An incremental inverse association was found in participants with low cardiorespiratory fitness (OR = 2.33; 95% CI: 1.56-3.50), low handgrip strength (OR = 1.99; 95% CI: 1.33-2.97), low lower body strength (OR = 1.91; 95% CI: 1.28-2.86), low speed-agility (OR = 1.75; 95% CI: 1.17-2.62), and low global physical fitness (OR = 2.03; 95% CI: 1.37-3.01) and disordered eating symptoms, compared to participants with a high level of each of these physical fitness components. Our study provides evidence that, in Spanish adolescents, disordered eating symptoms are inversely associated with a comprehensive set of physical fitness components. Hence, it could be relevant to promote physical fitness, e.g., by a multifactorial approach, since it seems to be related to lower disordered eating symptoms in adolescents.

The prevalence and nutritional status of adolescent Saudi girls with disordered eating

This study on adolescents was intended to assess the prevalence of disordered eating attitudes and the nutritional status of adolescent girls in Saudi Arabia. Disordered eating attitudes and behaviour were assessed using the EAT-26. The type of eating disorder (ED) was determined using Diagnostic statistical manual of mental disorders, fifth edition. The nutritional status of the adolescent girls was determined by measuring their weight and height twice using standard protocols. The BMI-for-age and height-for-age were defined using WHO growth charts. Comparisons between adolescent girls with and without EDs were conducted using SPSS version 26. Eating disorders (EDs) were prevalent among 10⋅2 % of these girls. Other specified feeding or EDs were the most prevalent ED (7⋅6 %), followed by unspecified feeding or eating disorder (2⋅4 %). Anorexia nervosa was common among 0⋅3 % of the girls. The eating disordered adolescents were either overweight (7⋅7 %), obese (10⋅3 %), stunted (7⋅7 %) or severely stunted (2⋅6 %). ANOVA revealed that the BMI-for-age was influenced by age (P = 0⋅028), the type of ED (P = 0⋅019) and the EAT-26 (P < 0⋅0001). Pearson's correlation showed that the EAT-26 score increased significantly with the BMI (r 0⋅22, P = 0⋅0001), height (r 0⋅12, P = 0⋅019) and weight (r 0⋅22, P = 0⋅0001). The early detection of EDs among adolescents is highly recommended to reduce the risk associated with future impaired health status. Nutrition professionals must target adolescents, teachers and parents and provide nutritional education about the early signs and symptoms of ED and the benefits of following a healthy dietary pattern.

Eating Disorders in Top Elite Beach Handball Players: Cross Sectional Study

(1) Background: The preoccupation with the increasing appearance of eating disorders (ED) in athletes continues to grow, especially in athletes who practice team sports. ED severely affects the eating habits of the athletes, who tend to use unhealthy approaches to control their body weight. The development of nutritional education and early interventions by training staff is essential, and these factors are widely perceived as beneficial in sports medicine. This study evaluates the frequency at which beach handball (BH) players develop ED, also comparing the differences by sex and age (junior: adolescents vs. senior: young adults). In addition, the relation between body composition variables and ED was studied. (2) Methods: A descriptive and cross-sectional study was carried out in 69 top elite handball players (36 males and 33 females) from the Spanish National BH Team; who were separated by age (junior: adolescents and senior: young adults). The athletes completed the Eating Attitudes Test in its 26 item version (EAT-26). (3) Results: The prevalence of ED indicated that 11% of females had a high possibility of developing an ED, and 3% of males. Regarding the EAT-26 total score and subscales, no significant differences were found between female and male participants, or between the junior and senior categories. The correlations showed an association between body composition, in terms of body mass index, and the EAT-26 total score in both males and females. In the case of males, the correlation was negative. (4) Conclusions: Although there are no significant differences between sex or categories, it has been found that elite athletes are a population that is at high risk of developing ED.