Eating disorders and related behaviors among medical students in Rabat, Morocco

Abstract

Introduction

Medical students encounter a distinct array of stressors that can adversely affect their physical and mental well-being. Mental health problems such as eating disorders, stress, burnout and telephone addiction are prevalent among them. The presence of these disorders can damage their academic performance and hinder their ability to deliver quality healthcare. This study aims to determine the prevalence of eating disorders among medical students and to identify their associated factors.

Materials & methods

A cross-sectional study was conducted within the Faculty of Medicine and Pharmacy in Rabat, over a period from June to October 2023, among medical students. Descriptive analysis, Spearman’s rank correlation and logistic regression were performed.

Results

One hundred sixty medical students were enrolled in this study. Their mean age was 23.1 (± 0.79) years with a female predominance (52.5%). Third of participants showed signs of eating disorders (30.8%) and had body image problems (31.4%). Burnout affected 47.5% of medical students and high stress levels was experienced by 11.9% of the sample. The multivariate regression analysis revealed that moderate (p = 0.01, aOR = 9.14, CI 95% [1.71–48.8]) and high (p = 0.002, aOR = 23.24, CI 95% [3.11–173.4]) perceived stress and the presence of body image issues (p = < 0.001, aOR = 17.37, CI 95% [6.85–44.06]) were significantly associated with an increased risk of eating disorders.

Conclusion

This study reveals that medical students present high psychosocial risks. There is an urgent need to put in place supporting measures to improve their well-being, in order to guarantee the quality of care they will provide in the future and raise society’s awareness of the importance of mental health.

Introduction

Mental health

Mental health is a state of well-being in which individuals realize their own abilities, can cope with the normal stresses of life, work productively, and contribute to their communities. It encompasses emotional, psychological, and social well-being, influencing how people think, feel, and behave in daily life. Good mental health is more than the absence of mental disorders, it involves the capacity to manage stress, maintain fulfilling relationships, adapt to change, and make meaningful contributions to society. Conversely, poor mental health can lead to functional impairment, reduced quality of life, and increased vulnerability to psychological disorders [1, 2].

Eating disorders

Among mental health concerns, eating disorders (EDs) have emerged as an important yet underexplored issue within young adult populations in higher education. EDs, including behaviors such as binge eating, restrictive dieting, and body image dissatisfaction, are associated with both psychological distress and long-term physical health consequences. EDs are characterized by disturbances in eating behavior and occur worldwide, with a lifetime prevalence of 2% to 5%. They are more common among females than males and may be associated with medical and psychiatric complications, impaired functioning, and decreased quality of life [3]. Conceptually, EDs can be influenced by a range of interconnected psychological factors, including stress, burnout, body image dissatisfaction, and addictive behaviors such as excessive smartphone use. High stress and burnout may exacerbate negative body image and unhealthy eating behaviors, while permissive or authoritarian familial or social environments may further shape coping mechanisms related to food and body perception [4].Understanding these interrelationships can help identify students at higher risk and inform preventive strategies. In fact, eating disorders is a real challenge to psychiatrists due to the complexity of causes, the variety of physical, mental and social influences and the increasing risk of eating disorders (24.8%) among medical students in the MENA region [5, 6] In Morocco, 25.09% and 32.8% are the prevalences of EDs among medical students according to studies conducted in the Faculty of Medicine and Pharmacy of Casablanca and Fez, respectively [7, 8].

Medical students

Medical students, as a special group, are faced with academic, social and psychological demands that can lead to distress. In fact, the medical training is one of the most stressful programs of education. According to more than 55,000 published articles about medical students’ mental health, this journey can affects students’ well-being, damage their academic performance and hinder their ability to deliver quality healthcare [9]. These challenges not only affect their personal well-being but may also compromise professional development and the quality of patient care.

While some studies have addressed stress, burnout, or body image individually, few have examined their combined influence on ED risk within this population. Moreover, data on gender differences, mediating roles of anxiety and depression, and the interplay between multiple psychological constructs remain scarce.

Critical transitional periods in medical education, such as the shift from preclinical to clinical training and the phase just prior to beginning residency, present unique psychological challenges. Fifth-year students, in particular, navigate the increasing demands of clinical responsibilities alongside academic pressures, which may heighten their vulnerability to stress, burnout, and disordered eating. Building on this context, the present study adopts a framework examining the interrelationships between multiple psychological constructs: stress, burnout, body image perception, and eating disorder risk among fifth-year medical students. It also considers potential mediating factors providing a comprehensive assessment of mental health challenges during this critical transitional phase.

Research gap

Research into the risk factors associated with eating disorders is necessary in order to better understand the reasons why medical students develop EDs. By elucidating these patterns, the findings may inform medical education policies and the design of targeted interventions, including mental health support programs, preventive initiatives, and awareness campaigns, to promote student well-being and reduce the risk of eating disorders in Moroccan and MENA medical schools. To address these gaps, we have conducted this study to estimate the prevalence of eating disorders and to determine their associated factors among medical students.

Materials and methods

Study design and setting

We conducted a cross-sectional study for both descriptive and analytical purposes among fifth-year medical students at the Faculty of Medicine and Pharmacy of Rabat in Morocco from June to September 2023. The Faculty of Medicine and Pharmacy of Rabat was established in 1962 as a public institution affiliated with Mohammed V University. It stands as Morocco’s first faculty dedicated to medicine and pharmacy.

Participants and study size

For this survey, the inclusion criteria were being enrolled in the fifth year of medical school during the 2022–2023 academic year and being present during the data collection sessions. Students who were absent, declined participation, or did not complete the questionnaire were excluded. A convenience sampling approach was adopted in this study. All students registered in the fifth year during the academic period were approached and invited to participate through self-administered questionnaires. Participation was voluntary and anonymous, with no academic or administrative consequences for choosing to participate or decline. This study was reviewed and approved by the Medical committee of the Faculty of Medicine and Pharmacy in Rabat (Ref.553/2023). To determine the required sample size, we used the prevalence of eating disorders among the Moroccan medical students [7]. For an expected proportion of 32.8%, a type I error rate of 5% (α = 0.05) and the precision of 10% (d = 0.10), the minimum sample size of this survey was 85 participants. To overcome the problem of non-responses, we added 30% to the sample, which leads to a minimum sample size of 111 students [10, 11].

Data collection and variables

Data were collected using a self-administered paper-based questionnaire. It was developed in French language as it’s the primary language of medical studies in Morocco. At the faculty amphitheater, questionnaires were distributed in person to all 5th year medical students by the end of both the regular and retake exam sessions. All eligible students were informed about the purpose and procedures of the study, and those who agreed to participate provided informed consent prior to data collection. An informational notice was shared through the official student communication Whatsapp group to ensure that all eligible students received the invitation and were informed of the study conduct. All returned questionnaires were included in the analysis, with the exclusion of incomplete data.

The questionnaire comprised five sections. The first part of our questionnaire was covering students’ socio-demographic characteristics including age, gender, marital status and residence. Then, the others parts were represented by the following scales previously validated in French:

Cohen’s Perceived Stress Scale-10 (10-item PSS) [12, 13]

The level of stress was commonly measured by the Cohen scale (10-item PSS). The items were easy to understand and the alternative responses were simple to grasp. Moreover, the questions were relatively free of content specific to any subpopulation group. The questions in the PSS were raised about feelings and thoughts during the last month. In each case, respondents were asked how often they had a certain feeling from never to very often (0 to 4).For stress, we calculated the sum of the scores obtained for the 10 items. This enabled us to distinguish between low (≤ 13),moderate (14–26) and high (score 27–40).

Maslach Burnout Inventory - Human Services Survey for Medical Personnel - MBI-HSS (MP) [14, 15]

Burnout is a variable that continues to sustain international research interest. The most widely adopted tool measuring the burnout syndrome is the Maslach Burnout Inventory (MBI-HSS MP) with 22 items to measure the burnout levels of our participants. The use of the MBI in this study was conducted after an official license obtained from Mind Garden for the purposes of this research. It contained three dimensions or subscales:

The emotional exhaustion (EE): The feeling of being emotionally overrun and exhausted by one’s work (9 items) The depersonalization (DP): The tendency to view others as objects rather than as feeling persons (5 items) The personal accomplishment (PA): The degree to which a person perceives performing well on worthwhile tasks (8 items). The frequency of burnout symptoms was rated on a seven point Likert scale ranging from 0 to 6. In practice, the MBI produces three separate scores, one for each of the three subscales. In fact, burnout is defined by at least one pathological dimension of the MBI.This is defined by a high score for emotional exhaustion (≥ 30) or a high score for depersonalization (≥ 12) or by a low score of personal accomplishment (≥ 40).

Problematic Mobile Phone Use Questionnaire (PMPUQ) [16–18]

The Problematic Mobile Phone Use Questionnaire was created to examine if there is a relationship between impulsivity and the problematic of phone use. The PMPUQ questionnaire consisted of two sections. The first section asked 6 questions that are directed more towards general use and driver’s license status. The second section was a 30-item survey scored on a four-point agreement scale with : 1 meaning strongly disagree and 4 meaning strongly agree. The PMPUQ reported the presence of the following four factors: Prohibited use (5 items) : score ≥ 12; dangerous use (5 items): score ≥ 14; dependence (7 items) : score ≥ 21; financial problems (13 items) : score ≥ 34.

SCOFF questionnaire (Sick, Control, One stone, Fat, Food) [19, 20]

The SCOFF questionnaire uses an acronym to refer to the five main points addressed in the test (Sick, Control, One stone, Fat, Food) designed for use by non-professionals to assess the potential presence of an eating disorder. The authors aimed to create a reliable, simple, and quick scale to identify individuals at risk or suffering from eating disorders for screening and epidemiological purposes. The SCOFF questionnaire has as responses yes or no (Yes = 1; No = 0). If the score is ≥ 2 while adding items 1 to 5, we will expect an eating disorder. Besides, we will assess the presence of body image issues if the score ≥ 1 by adding item 3 to 4.

Statistical analysis

The data were collected and analyzed using Jamovi software version 2.3.26. Descriptive analysis was performed for quantitative variables with means and standard deviation and for qualitative variables with effectives and percentages. Continuous variables, such as PSS, MBI PMPUQ, SCOFF scores, were categorized into binary groups (yes/no) based on established cut-off points for analysis. We conducted a logistic regression to determine the factors associated to eating disorders. The dependent variable was the presence of eating disorders, while independent variables included socio-demographic data, body image issues, burnout stress and other mental disorders. Variables with p-values < 0.05 in univariate analysis were included in a multivariate logistic regression model to identify factors independently associated with eating disorders. Adjusted odds ratios (aOR) with 95% confidence intervals (CI) were reported. Multicollinearity was checked using the variance inflation factor (VIF), which was between 1 and 1.5 indicating the absence of any significant collinearity between explanatory variables. A Spearman’s rank correlation analysis was also performed to assess the relationship between perceived stress, burnout and eating disorder scores. A p-value of < 0.05 was considered statistically significant.

Results

From the 400 students invited to participate, consent was obtained from 160 participants, resulting in a 40% response rate.

Characteristics of the study population

The mean age of enrolled students was 23.1(± 0.79) years old. Among them, 47.5% were male and 52.5% were females, with a sex ratio M/F of 0.9. Regarding the marital status, 98.1% of students were single while 1.9% were married. The majority (68.6%) were living with their families, 21.8% were living alone and 9.6% were living in university campuses (Table 1).

Table 1.

Socio-demographic characteristics of population

Variables	Descriptives (n = 160)
Gender*
Female	84 (52.5)
Male	76 (47.5)
Age**	23.1 ± 0.79
Marital status*
Single	157(98.1)
Married	3 (1.9)
Residence*
With family	107(68.6)
Alone	34 (21.8)
University campus	15 (9.6)

*n(%); ** Mean ± SD

Prevalence of mental disorders

This study found that the prevalence of burnout, based on MBI-SS was 47.5% with CI 95% [39.8–55.2%]. High emotional exhaustion was expressed by 23.3% of students, high levels of depersonalization was experienced by 34.6% and low personal accomplishment was described by 1.3%.

The mean score of stress based on Cohen’s Perceived stress scale was 21.9 (± 4.83), with 67,5% of our sample expressing moderate stress levels.

The prevalence of eating disorders in our sample was 30.8% with CI 95% [24.1–38.4%] while body image issues were found out of 31.4% with CI 95% [24.6–39.1%].

Concerning mobile phone addiction, 40.9% exhibited prohibited usage, while 27.7% demonstrated dependency (Table 2).

Table 2.

Description of Burnout, stress and phone addiction scores among medical students in Rabat

Variables	Descriptives (n = 160)
Burnout syndrome*
Yes	75(47.5)
No	83(52.5)
Burnout subscales
Emotional exhaustion*
Low	43(27)
Moderate	79(49.7)
High	37(23.3)
Depersonalization*
Low	38(23.9)
Moderate	66(41.5)
High	55(34.6)
Personal accomplishment*
Low	2(1.3)
Moderate	26(16.4)
High	131(82.4)
PSS Total score**	21.9±4.83
Stress levels*
Low	33(20.6)
Moderate	108(67.5)
High	19(11.9)
Score SCOFF**	0.94± 1.1
Eating disorders *
Yes	48(30.8)
No	108(69.2)
Score SCOFF body image issues**	0.37± 0.59
Body image issues *
Yes	49 (31.4)
No	107 (68.6)
PMPUQ factors*
Prohibity use	65 (40.9)
Dependence	44 (27.7)
Dangerous use	30(18.9)
Financial problems	29(18.2)

*n(%); ** Mean ± SD

Factors related to eating disorders

In the univariate analysis, presence of eating disorders was associated to moderate stress level (p = 0.01, OR = 7.14, CI 95% [1.61–31.68]) and high stress level (p < 0.001, OR = 19.93, CI 95% [3.65–108.89.65.89]). As well as, the existence of burnout (p = 0.01, OR = 2.34, CI 95% [1.16–4.73]) and body image issues (p < 0.001, OR = 15.05, CI 95% [6.58–34.44]). After adjusting for the effects of potential confounders in the multivariate regression analysis, the items that were significantly associated with an increased risk of eating disorders were moderate (p = 0.01, aOR = 9.14, CI 95% [1.71–48.8]) and high (p = 0.002, aOR = 23.24, CI 95% [3.11–173.4]) perceived stress and the presence of body image issues (p = < 0.001, aOR = 17.37, CI 95% [6.85–44.06]). Extra details are presented in Table 3.

Table 3.

Associated factors related to eating disorders

	Univariate analysis			Multivariate analysis
Variables	OR	CI (95%)	p- value	Ajusted OR	CI(95%)	p-value
Age	0.65	0.39–1.09	0.102
Gender Male-Female	1.05	0.53–2.09	0.87
Residence Family – Alone University Campus – Alone	1.36 1.38	0.57–3.25 0.37–5.18	0.477 0.625
Perceived Stress Moderate – Low High – Low	7.14 19.93	1.61–31.68 3.65–108.89	0.01* < 0.001*	9.14 23.24	1.71–48.8 3.11–173.4	0.01* 0.002*
Existence Of burnout Yes– No	2.34	1.16–4.73	0.01*	2.05	0.83–5.03	0.11
Body Image Issues Present – Absent	15.05	6.58–34.44	< 0.001*	17.37	6.85–44.06	< 0.001*
Prohibity use Yes-No	1.48	0.74–2.94	0.26
Phone Dependence Yes – No	1.22	0.58–2.57	0.59
Dangerous use Yes-No	1.96	0.86–4.46	0.10
Financial problems Yes-No	1.21	0.51–2.86	0.65

OR Odds Ratio, aOR Adjusted Odds Ratio, CI Confidence interval

*significant results

Correlation between body image, perceived stress, and burnout dimensions

We investigated the relationship between body image, perceived stress, and burnout dimensions (emotional exhaustion, depersonalization and personal accomplishment). Our results revealed a statistically significant positive correlation between body image issues and perceived stress (Rho = 0.229, p = 0.004), body image and emotional exhaustion (Rho = 0.209, p = 0.009) and body image and depersonalization (Rho = 0.159, p = 0.048) (Table 4).

Table 4.

Correlation between body image, perceived stress, and burnout dimensions

Scores	Coefficient	p- value
PSS (Perceived stress scale)	0.229	0.004*
MBI (Maslach Burnout Inventory)
Emotional exhaustion	0.209	0.009*
Depersonalization	0.159	0.048*
Personal accomplishment	0.082	0.309

Rho Spearman correlation coefficient

*significant results

Discussion

Our study highlights significant impact of various factors on students’ mental health and well-being. It reveals a high prevalence of burnout among medical students and high scores of perceived stress. It also provides an in-depth comprehension of factors associated to both eating disorders and body image perception among students in a medical school. This study introduces crucial elements to understand these psychological distresses, and emphasizes urgent needs for preventive and impactful interventions to promote mental health among this specific category of youth.

According to a recent systematic review, the global prevalence of burnout in medical students is 37.23% [21], this result concurs with our findings which reported a rate of 47.5%. Indeed, in low and middle income countries, nearly one third of university students experienced burnout, with a high rate among the African region [22]. Predictors of burnout may vary, but being older and being female has been shown to be significant predictors of burnout [21]. A study carried in Casablanca revealed that emotional exhaustion was associated to enhanced workload, conflicts in both home and work and lack of social support from colleague. Learning phase and workload were also identified as factors associated with dimension of cynicism among medical students [23].

A study in Brazil noted that lack of emotional support, dropping out of school thoughts, and perceiving the academic performance as weak were associated factors of burnout syndrome among medical students [24]. Burnout was also associated to negative life events, dissatisfaction, and poor motivation [25]. These results address serious urge to develop targeted interventions to help future doctors to improve their coping mechanisms and support styles.

Eating disorders were present among one third of medical students in our study. This indicates a high prevalence compared to the overall prevalence of eating disorders risk of 10.4%, found in a global systematic review and meta-analysis [26]. Furthermore, literature shows that medical students from countries with an Arabic culture are more affected by eating disorders than those from western countries. Indeed, studies conducted in Fez [10, 27] in Tunisia [28] and Lebanon [29] reported high prevalence of eating disorders compared to studies conducted in France [30] Spain [31], UK [32] and Poland [33]. Anxiety played a meaningful role in the development or maintenance of eating disorders, especially binge-eating behaviors. The positive correlation indicates that as anxiety levels increase, the likelihood or severity of binge eating also tends to rise, supporting the idea that emotional distress and difficulties in regulating negative affect may contribute to maladaptive eating patterns [34]. Depression, in its severe form, and social anxiety were also found to be associated with an increased risk of eating disorders. Additionally, these psychological factors were found to mediate the relationship between parenting style and eating disorder risk. Higher levels of depression and anxiety were associated with greater vulnerability to disordered eating among students who reported more permissive parenting, suggesting that less structured or less emotionally regulated family environments may contribute to the development of maladaptive coping behaviors [35, 36].

We can also discuss the impact of social media as its influence increases in Arabic communities [37]. Indeed, social media induces pathways of social comparison, with body image ideal internalization, leading to poor mental health with eating disorders and body image concerns [38]. Exposure to mass media was also associated with a higher likelihood of dieting and changes in ideal body image among females [39].

Our study also underlines a significant association with increased risk of eating disorders with body image issues, burnout, and high perceived stress. Several factors were identified by literature. In Morocco multiple studies treated this topic. A study revealed that eating disorders was prevalent among medical staff that were 22 years old of age and under, obese, cannabis users, emotional eaters and living with depression [40]. Anxiety was also described as a risk factor of eating disorders among Moroccan youth [41]. High BMI and use of weight control did also multiply the risk of eating disorders among medical students [8, 42]. Likewise, violence was linked to eating disorders as well as psychological violence and sexual violence, beside history with justice and negative childhood events [43]. On another hand, regular physical activity was described as a protective factor against the development of eating disorders [41]. We notice that most of these studies were limited to the screening stage of eating disorders. Further studies need to be carried among Moroccan youth in general and medical students more specifically, with a focus on the psychiatric diagnosis and therapeutic support of these conditions in order to address it with a comprehensive approach including its co-occurring mental troubles.

This study suggests a high prevalence of body image issues among medical students, and revealed a correlation of body image issues with perceived stress, emotional exhaustion and depersonalization. Indeed, body image dissatisfaction is high among medical students, with a strong desire to become thinner [44]. Studies carried among medical students showed that majority had normal BMI, but despite that many participants didn’t believe having the ideal weight [45]. A lot of students felt in need to lose weight, and developed compensatory behaviors such as skipping meals [46], eating less in terms of quantity [47] and spending more time doing sports [48]. Media pressure was highlighted in literature [49]. Undergraduate medical students tend to be influenced by models and athletic figures, putting high standards of attractiveness [50]. Hence, negative body image perception affects the quality of life and self-esteem of medical students [51]. It ruins both their self-compassion and their self-worth [52].Quality of life seems to be better among students with less concern with their body image [53]. A recent study conducted in Morocco showed that body image perception is one of the most important predictors of self-esteem among university students [54].

The findings of this study highlight the need for targeted support strategies within medical education. Given the identified prevalence of disordered eating tendencies among students, medical schools may benefit from implementing structured wellness programs that include routine mental health screening, counseling services, and accessible nutrition education. Integrating stress management training and promoting healthy coping mechanisms may help reduce the impact of academic and clinical pressures on students’ eating behaviors. Additionally, incorporating early awareness and preventive interventions into the curriculum may contribute to fostering a healthier learning environment and supporting students’ overall well-being as they transition into clinical practice.

Limitations of the study

This study presents some limitations. The cross-sectional study design and the non-heterogeneity of the sample do not allow to confirm the causality of variables, however it identifies points at issue for further intervention studies. The data collection was in only one institution with a small sample size considering the short period of data collection, the students’ demotivation regarding participation in surveys post-Covid 19 pandemic and specifically the limitation to one specific grade. Consequently, future studies should be longitudinal with follow-ups and larger sample sizes. Additionally, although the correlation between the body image, perceived stress, and burnout dimensions reached statistical significance, the effect size was weak. This indicates that, although a relationship may exist, its clinical relevance is limited and should be interpreted cautiously.

Conclusion

This study has highlighted several challenges faced by medical students in Morocco, including stress, burnout, eating disorders, and negative body image perception. These issues remain linked to prejudice and discrimination and negatively affect both the personal and professional well-being of students, as well as the quality of care they provide. Consequently, it is essential for medical education institutions to develop targeted interventions aimed at promoting mental health, providing psychological support and counseling, and implementing innovative strategies, such as through social media campaigns, to prevent burnout, reduce eating disorders, and improve body image perception. These findings underscore the importance of integrating structured prevention programs and comprehensive student mental health support systems within medical training.

Authors’ contributions

O.BO, O.BEN, A.H, K.F and L.L contributed to the idea, study design, questionnaire design, data collection, data analysis, data interpretation and manuscript drafting. K.M contributed to manuscript drafting and study supervision. All authors revised the manuscript and approved it for publication.

Funding

The authors received no funding for this work.

Data availability

The datasets used and analyzed during the current study are available from the corresponding author upon a special request.

Declarations

Ethics approval and consent to participate

In complying with the standards of Helsinki declaration, the questionnaire, aims of the study, and confidentiality of data were clearly explained to all students. The participants gave their written informed consent before starting filling the questionnaire. This study was reviewed and approved by the Medical committee of the Faculty of Medicine and Pharmacy in Rabat (Ref.553/2023).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Clinical trial number

Not applicable.