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. Author manuscript; available in PMC: 2022 Jan 1.
Published in final edited form as: Int J Eat Disord. 2020 Dec 3;54(1):19–23. doi: 10.1002/eat.23420

Eating disorder symptoms among adolescent boys and girls in Iran

Reza N Sahlan 1, Jessica F Saunders 2, Jonathan M Mond 3,4, Ellen E Fitzsimmons-Craft 5
PMCID: PMC8006449  NIHMSID: NIHMS1681392  PMID: 33270255

Abstract

Objective:

Few studies of eating disorder (ED) symptoms among young people in Iran have been conducted. This cross-sectional study examined ED symptoms, assessed by the Eating Disorder Examination Questionnaire (EDE-Q).

Method:

Adolescent boys (n = 498) and girls (n = 607) aged 12-19 years, recruited from schools in four different regions of Iran, completed a survey that included the EDE-Q. ED symptoms, namely, EDE-Q global scores and the occurrence of specific ED behaviors, were compared between boys and girls.

Results:

Girls had higher global scores and were more likely to report regular extreme dietary restriction than boys (16.6% vs. 12.0%). The effect sizes for these differences were small. The regular occurrence of other behaviors (girls vs. boys - binge eating: 21.1% vs. 18.8%; self-induced vomiting: 3.3% vs. 5.4%; laxative misuse: 6.1% vs. 7.6%; excessive exercise: 5.3% vs. 4.4%) did not significantly differ by gender. Twelve percent of boys and 12.9% of girls met criteria for an operational definition of “probable ED case.”

Conclusion:

ED symptoms appear to be relatively common among Iranian adolescent boys and girls. Programs designed to reduce the occurrence and adverse impact of these symptoms may therefore be increasingly important.

Keywords: Eating disorder symptoms, gender differences, adolescents, EDE-Q, Iran

Introduction

Evidence suggests that eating disorders (EDs) are increasingly common in a broad range of non-Western societies (Pike, Hoek, & Dunne, 2014; Pike & Dunne, 2015; Smink, van Hoeken, & Hoek, 2012). Information concerning the occurrence of ED symptoms among young people in Iran is scarce, despite this information being important from a public health perspective (Bentley et al., 2015). Existing studies have either focused on the prevalence of EDs meeting formal diagnostic criteria (e.g., Garrusi & Baneshi, 2013; Mohammadi et al., 2020; Nobakht & Dezhkam, 2000) or have used measures that do not allow for the assessment of the frequency of occurrence of these features and behaviors (e.g., Garrusi & Baneshi, 2013; Jalali-Farahani et al., 2015; Rauof et al., 2015; Mohammadi et al., 2020; Nobakht & Dezhkam, 2000). Further, most studies recruited participants from three major cities, thereby limiting the generalizability of the findings to the country at large. The goal of the current research was to examine the occurrence of ED symptoms, and gender differences in the occurrence of these symptoms, in a sample of adolescent boys and girls recruited from across Iran. Our only a priori hypotheses were that most ED symptoms would be 1) relatively common among both boys and girls attending schools in Iran; and 2) more common among girls than boys. We conducted exploratory analyses of the occurrence of ED symptoms as a function of age.

Method

Study Design and Recruitment of Participants

Participants were recruited from the Tabriz (North-Western), Kurdistan (West), and Rasht (North) regions. School and regional administrators approved the research procedures and parental consent was obtained prior to their child’s participation. Adolescents provided assent and filled out the scales without financial remuneration. The project was approved by Ethical Board of the Iran University of Medical Sciences. Boys (n = 498) ranged in age from 12-18 years (M = 15.37, SD = 1.43), their BMI ranged from 11.10 to 34.89 kg/m2 (M = 21.20, SD = 3.81). Girls (n = 607) ranged in age from 12-19 years (M = 15.71, SD = 1.70), their BMI ranged from 12.02 to 34.48 kg/m2 (M = 21.09, SD = 3.46). Girls were older than boys (t = 3.59, p <.001, d = .22); BMI did not differ by gender (t = 0.48, p >.05, d =.03; see Supplementary Figure 1 for the study’s full participant flow).

Demographic characteristics.

Adolescents reported their age, gender, height and weight, from which body mass index (BMI, kg/m2) was calculated.

Disordered eating measures.

ED symptoms were assessed using the Persian version of the Eating Disorder Examination Questionnaire (P-EDE-Q; Mahmoodi et al., 2016), a self-report measure that assesses the occurrence and frequency of key ED features in the past 28 days and which has been validated among Western adolescent boys and girls (Mond et al., 2014). Mahmoodi and colleagues (2016) assessed the measure for validity, reliability, and cultural and linguistic equivalency and appropriateness in their scale translation and validation study and found the scale metrics to be acceptable among college students.

Given that a Farsi version of the EDE-Q has not yet been used in adolescents, in addition to calculating the internal consistency of the EDE-Q, we administered two other measures of disordered eating, the Farsi Preoccupation with Eating, Weight, and Shape Scale (F-PEWS; Sahlan, 2016) and Farsi Eating Disorder Inventory-2 (F-EDI-2; Shaygian & Vafayi, 2010) in order to provide an index of concurrent validity. Our results showed low-to-large correlations between the F-EDE-Q with the F-PEWS (Sahlan, 2016) and F-EDI-2-Bulimia subscale (Shaygian & Vafayi, 2010) in both boys and girls (Table 1).

Table 1.

Correlations Between Measures in Boys (n = 498) and Girls (n = 607).

Global score Binge eating Dietary restriction Self-induced vomiting Laxative misuse Excessive exercise
Boys
PEWS, total score .64*** .40*** .34*** .25*** .31*** .42***
EDI-Bulimia .41*** .41*** .24*** .29*** .27*** .29***
Girls
PEWS, total score .61*** .36*** .29*** .22*** .21*** .32***
EDI-Bulimia .42*** .42*** .18*** .23*** .22*** .25***
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Note. We used Pearson (i.e., Global score) and Spearman correlations (i.e., Disordered eating behaviors). PEWS, total score: (i.e., combined eating, weight, shape subscales). EDI-Bulimia: Eating Disorder Inventory, Bulimia subscale.

***

p <.001.

A global F-EDE-Q score, indicating overall levels of ED symptoms, was derived from 22 items assessing core cognitive features. Scores on these items range from “0” to “6”, with higher scores indicating higher symptom levels. Cronbach alpha values for the F-EDE-Q global score in the present study were 0.90 for boys and 0.92 for girls.

Remaining items of the F-EDE-Q assess the occurrence and frequency of key ED behaviors. Only regular (as opposed to any) occurrence of ED behaviors was considered because the assessment of any occurrence of these behaviors is more likely to be unreliable (Mond et al., 2004) (see Table 2). The proportion of participants likely to have a clinically significant ED was derived using an operational definition of probable eating disorder case employed in previous research, namely, the presence overvaluation of weight or shape (i.e., score of 5 or 6 on either of the two EDE-Q items assessing this construct) in conjunction with the regular occurrence of any eating disorder behavior (Gratwick-Sarll et al, 2016; Mond et al, 2009). Using this definition, 12.9% and 12.0% of adolescent boys and girls, respectively, met the operational criteria for a probable ED.

Table 2.

Gender Differences of Eating Disorder Symptoms among Iranian adolescent boys (n = 498) and girls (n = 607).

Eating disorder symptoms Regular occurrencea (%)
Boys Girls X2 p NNTb
Binge eating 18.8 21.1 0.83 0.36 43.5
Dietary restriction 12.0 16.6 4.63 0.03 21.7
Self-induced vomiting 5.4 3.3 3.04 0.08 47.6
Laxative misuse 7.6 6.1 1.02 0.31 76.9
Excessive exercise 4.4 5.3 0.43 0.51 111.1
Boys Girls
Mean (SD) Mean (SD) d F
(1,1102) 		p Partial ƞ2
Global score 1.26 (1.06) 1.66 (1.22) 0.35 30.57 <0.001 0.03
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Note. Results are shown after controlling for age on Analysis of variance (ANOVA).

a

Binge eating, self-induced vomiting, laxative misuse: ≥ 4 times during the past 28 days; dietary restriction: ≥ 14 days during the past 28 days; excessive exercise: ≥ 20 times during the past 28 days (i.e., Lavender, De Young, & Anderson, 2010; Mond et al., 2006; 2014; Quick & Byrd-Bredbenner, 2013).

b

Number needed to take. An NNT<4 is considered a “strong” effect, an NNT between 4 and 9 is considered a “moderate” effect, and an NNT > 9 is considered a “weak” effect (i.e., Kraemer & Kupfer, 2006). Cohen’s d: 0.2 considered a “small” effect size, 0.5 a “medium” effect size, and 0.8 a “large” effect size (Cohen, 1988).

Statistical Analysis

All analyses were conducted using IBM SPSS Statistics 25. Pearson and Spearman correlation coefficients were used to examine the concurrent validity of the F-EDE-Q with the F-PEWS and F-EDI-2 Bulimia subscale. Analysis of variance (ANCOVA) was used to compare EDE-Q global scores between Iranian adolescent boys and girls, controlling for age, while chi-square tests were used to examine gender differences in the occurrence of each eating disorder behavior assessed. Regression models that included age as a quadratic term and F-EDE-Q global score as the dependent variable were used to assess for possible u-shaped age effects in ED symptomology. A significance (alpha) level of .05 was used for all two-tailed tests.

Results

As displayed in Table 2, Iranian girls (16.6%) were more likely to report extreme dietary restriction than boys (12.0%) while the occurrence of other ED behaviors did not differ by gender. Additionally, Iranian girls had higher global F-EDE-Q scores than Iranian boys, controlling for age. However, the effect sizes for each of these differences indicate the gender effect was minimal. Regression analysis indicated that age was not a linear (B = .49, SE = .65, t = 1.04, p = .45) nor quadratic predictor (B = −.05, SE = .02, t = −.71, p = .45) of F-EDE-Q global scores for boys. Age was not a linear predictor of F-EDE-Q global scores for girls (B = .02, SE = .03, t = .82, p = .42), though the quadratic (u-shaped) model was approaching significance (B = .03, SE = .02, t = 1.84, p = .06).

Discussion

We examined the occurrence of ED symptoms, as assessed by the F-EDE-Q, among adolescent boys and girls in Iran. Extreme dietary restriction was more common, and global F-EDE-Q scores were higher, in girls than in boys, although effect sizes for these differences were small. It also is notable that the proportion of participants with probable EDs was similar among boys (12.9%) and girls (12.0%). With respect to girls, prevalence of probable EDs were comparable between Iranian and Australia (12.0% in the current study vs. 12.20% in Australia in Gratwick-Sarll et al, 2016). However, prevalence of probable EDs among boys in the current study (12.9%) is strikingly high compared to Australian boys (1.70% in Australia in Gratwick-Sarll et al, 2016). A u-shaped age trend in global F-EDE-Q scores was approaching significance in girls, while these scores were not associated with age in boys. The upside-down u-shaped trend for girls indicated that global EDE-Q scores peak in middle adolescence and are lower in early and late adolescence.

The gender differences found in the current study were inconsistent with previous published studies in Iranian adolescents, which found a higher prevalence in girls than boys (i.e., Jalali-Farahani et al., 2015; Mohammadi et al., 2020; Rauof et al., 2015). This may be reflective of measurement differences, as prior adolescent studies did not use the F-EDE-Q. Adolescent girls in the current study reported higher EDE-Q global scores than Iranian college women (Sahlan, Taravatrooy, Quick, & Mond, 2020), and adolescents of both genders reported higher regular occurrence of most ED behaviors than Iranian university students (Sahlan, Taravatrooy et al., 2020). This finding is inconsistent with Australian samples in which higher age is correlated with higher ED symptoms (Mond et al., 2014). Machado and colleagues (2014) found that more adolescent girls than college women reported regular occurrence of subjective and objective binge eating episodes, aligning with the current findings. Although further research is needed, these findings suggest that ED symptoms are especially common among adolescents in Iran and that the inclusion of this population in health promotion and prevention programs may therefore be increasingly important.

The finding that girls had higher scores on the EDE-Q global scores than boys is consistent with studies of adolescents in both Western and other non-Western nations (Mond et al., 2014; White et al., 2014; Yucel et al., 2011). Iranian boys in the current study had higher EDE-Q global scores than those of adolescent boys in European and Asian countries (Baceviciene & Jankauskiene, 2020; Isomaa et al., 2016; Musa et al., 2016; Nakai et al., 2015). Adolescent boys also reported higher frequencies of ED behaviors compared to a Finnish study (Isomaa et al., 2016). These high scores may be early developmental indicators of Iranian men’s high drive for muscularity (Sahlan, Akoury, & Taravatrooy, 2020). In contrast, global scores and behavior frequencies were comparable between Iranian and European and Asian adolescent girls (Baceviciene & Jankauskiene, 2020; Isomaa et al., 2016; Machado et al., 2014; Musa et al., 2016; Nakai et al., 2015).

Adolescent boys in the current study may have reported relatively high frequencies of ED behaviors but relatively low F-EDE-Q global scores for several possible reasons. The F-EDE-Q global score items may be less sensitive to muscularity and muscle building concerns likely to be observed among young men (Mitchison & Mond, 2015; Mond et al., 2014; Sahlan, Akoury, & Taravatrooy, 2020), artificially deflating global scores. Further research, including qualitative research, would be helpful in elucidating both the relatively high frequency of occurrence of purging behaviors and the relatively low global F-EDE-Q scores observed among adolescent boys in the current study.

This is the first study to examine the occurrence of a broad range of ED symptoms among adolescent boys and girls in Iran. The relatively large sample size and the recruitment of participants from several different regions and ethnic groups are notable strengths of the study. However, several limitations of the current research need to be considered when interpreting the findings. First, though response rate within classes was high, only one quarter of classes approached agreed to participate. It is possible that students from participating classes were not representative of the total population of students in one or more respects related to the occurrence of ED symptoms. Second, to the extent that the EDE-Q is in fact “female-centric,” levels of ED symptoms among males may have been underestimated. Inclusion of a measure specifically designed to assess muscularity-oriented eating disorder symptoms (e.g., Murray et al., 2019) would be welcome in future research. Third, since there was no assessment of distress, disability, or other measure of impairment potentially associated with ED symptoms in the current study, any conclusions concerning the public health significance of these symptoms are necessarily tentative (Bentley et al., 2015). Fourth, while the current findings provide preliminary evidence for the concurrent validity of the F-EDE-Q in adolescent boys and girls, further research will be needed to establish test-retest reliability and factor structure. Given inherent limitations of self-report assessments and the fact that it is not known whether adolescents understood the intended meaning of the EDE-Q, findings should be regarded as preliminary and future studies should consider employing clinical interviews. This is important given research that finds low agreement between certain translations of the EDE-Q and EDE (Pliatskidou et al., 2015). The present study also provides preliminary information about concurrent validity of the scale. Future validation studies should be conducted in Iranian adolescents.

To conclude, the current findings suggest that EDs symptoms are relatively common among adolescents. These symptoms may warrant greater attention in prevention and health promotion programs. The findings also suggest that the inclusion of boys in such programs is important. In these respects, the findings converge with those of recent studies in both Western and non-Western populations.

Supplementary Material

supplementary figure 1

Acknowledgments

This research was supported in part by the National Institute of Mental Health grant K08 MH120341.

Footnotes

Conflicts of Interests

Authors have no conflict of interests.

Data Availability Statement

The data that support the findings of this study are available from the corresponding or first author upon reasonable request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Supplementary Materials

supplementary figure 1
NIHMS1681392-supplement-supplementary_figure_1.docx (300.7KB, docx)

Data Availability Statement

The data that support the findings of this study are available from the corresponding or first author upon reasonable request.

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