Section 1 Epidemiology

## **Chapter 1** The Eating Disorder's Society

*Juan José Labora González and Pablo Soto-Casás*

### **Abstract**

Feeding has been subjected to a process of medicalization throughout history that has caused its perception to be assimilated to the intake of nutrients. However, it is necessary to conceive feeding as a total social phenomenon. That is to say, a phenomenon that impregnates food and the practices that surround it with different meanings. It is therefore necessary to understand how certain social dynamics (secularization, rationalization, bureaucratization) have modified the way we feed ourselves and how we interpret food itself. This, in turn, has generated a series of negative meanings that have influenced how we perceive the body and the image of people. The calculability of nutrients and an unrealistic and unattainable image canon for people have been installed. Thus, a social food imaginary has been created based on a whole series of myths that are transmitted through social networks and that produce that the society in which we live has become an obesogenic and lipophobic society. It is therefore necessary to understand how the social imaginary of fat and fatness has been constructed in order to understand how people perceive their body image and how this can be altered.

**Keywords:** eating disorders, social imaginaries, body, feeding, society

### **1. Introduction**

*The human sciences, since a long time ago, they are insisting on the fact that the human feeding belongs to an imaginary, symbolic and social dimension (…). It is a commonplace: we are feeding ourselves from nourishment, but also from the imagination [1].*

In this chapter, we are going to understand the pacing throughout the feeding process. This process must be analyzed like a social phenomenon, which acquires identity dimensions with people, and it is affecting in a great scale by moral aspects which affect mainly how obesity and fat is understood. Therefore, in the feeding process, we should acknowledge phenomenon like the fasting, hunger, diet, food taboo, etc.

Furthermore, we will explain how the important process of medicalization of the feeding resulted into a reduction of the feeding phenomenon by the fact of acquiring necessary nourishments for surviving (diet/nutrition). This locates the symbolic power for its social evaluation again in the hands of doctors.

In fact, the food and its social uses were soon associated with different social meanings. The symbolic universe of the feeding was branding this practice from the beginning of the times. The Anthropology linked the practice of the feeding with taboo, the

totemist, and the sacrifice [2]. The taboo, at the same time, it was linked to the impurity's meaning of the soil where everyone should stand apart from it [3]. Some foods, as like Harris would say [4], they are healthy for eating, and there are others that are not. In such rules, the Sociology interprets them as part of the symbolic universe of each society and/or culture. From this perspective, the forbidden consumption of beef in India, or some specific cultures that were allowing cannibalism in different ages since the prehistorical times, like it was founded in Atapuerca, the Tupinambo in Brazil in the sixteenth century, the Yanomami on the border between this and Venezuela until practically today, the Aztecs in the sixteenth century, the Fore in the highlands of New Guinea until the end of the twentieth century, etc. [5, 6].

It was Marcel Mauss [7] who was the first to recognize feeding as the category of total social fact. This category implied, to the French sociologist that feed would be turned into a speaker of institutions: religious, legal, economic and moral (we understand that this sphere would include the politics and the family). All in all, we eat what we are. Thinking from the same framework, Herrera would say that "far from being a spectre, from the beginning, a simple sign of other fact, the feeding is the social act where memory and fashion are intertwined, arguing and practice, power and knowledge, liking and necessity; where all the references are added, where behaviours are defined, where the differences are established" [8].

This starting point imposes the necessity of performing an analysis of the social dynamics that affects feeding. In specific, the medicalization process is the same, the canon of beauty that rule with an iron hand the postmodern societies and the obesity phenomena. This is understood from the perspective that the feeding as a phenomenon that is born and produces, in specific types of moral that can allow to introduce unique meanings in social imaginaries that we share, not only with the workers that we work with people with eating disorders (onwards, ED), but also with them.

### **2. The medicalization of the feeding**

Following Fischler, the relationship between the medicine and the feeding is inseparable, hence, "feeding is the first step to access to the body, namely, a privileged instrument of medical intervention. The incarnation explains the difference between the dietetic and cooks some kind of continuum, ambiguity, may be a fundamental rivalry" [1]. From Hippocratic medicine the medical treatment seems linked to some specific ways of eating. The Hippocratic medicine was based on the necessity of achieving the mood balance and in order to, in a sickness situation -we mean, an unbalanced situation-, the food was employed as a medium or tools for the doctor's work.

Nevertheless, in the prehistory of the society of the hunter-gathering they dedicated a huge amount of daily energy for seeking food. They hunted what they could with weapons that they had. Women, however, they recollected plants and edible seeds as a way of complement the diet. They were having satiety or relativity abundance and other of famine and even starvation. This situation was the main characteristic of the nomad lifestyle that they had. After a while, agriculture emerged that, namely, allowed to evolve into a new sedentary life. However, this fact did not prevent famine, whether it was for climate reasons or for other kind (plagues, lack of insecticides, etc.) The last mayor famines in the occidental world can be situated in France between 1741 and 1742 and Ireland between 1846 and 1848 due to the lack of potatoes [1].

### *The Eating Disorder's Society DOI: http://dx.doi.org/10.5772/intechopen.106840*

In the present times, starvation continues to exist in the world, but it usually affects the majority of the population of the Third World, or the so-called undeveloped countries, as it is said in the politically correct paradigm likes to call them. Countries for known structural global causes, they do not achieve that wished development that emerged in international analysis or in macro figures that, unfortunately, are not edible and they do not redistribute, most of the times, a redistribution of the wealth which is still located in a small number of people.

Anyway, Herrera [8] points out that from the XVII in advanced it will raise the process of the blossoming of the modern nourishment. This process of modifying the feeding for the contemporary society would be characterized by the following traits: it is a process of a progressive secularization, rationality and bureaucracy. However, what it is true if that the act of feeding, always was affected by a number of tensions:


Some authors [8, 9] point out that this tension "were resolved" by gathering around the process of a progressive calculated rationalization and leaded by nutrition, for ending being assumed by the homonymous medical knowledge. If in the antiquity the argument for recommending one or other food choice were clearly biased due to moral factors linked to religion or social, moral, with the irruption of nutrition the social speeches allow to estimate what kind of food is correct for each person in specific. Or what food would be beneficial for a specific person to eat, hence it may be harmful in that case.

Using the Foucauldian terminology, Coveney [9] would say that the apparition of the nutrition was due to the fact of the rationality feeding that was produced by the workhouses and prisons. These possibilities broad up a new kind of governmentality allowed by the surge of Social Science's applied statistics and the Medicine.

Despite of this exquisite asepsis in discourses, some authors warn us that maybe behind of the façade we could find that these discourses are "equally "pastorals" in their intentions and objectives" [9]. In this sense, the author claims that "the nutrition is not only a science, but also an ethos" [9]. Diet, then, would be defined by the formula [9]:

$$\text{Diet} = \text{Health} + \text{Medicine} + \text{Lifestyle.} \tag{1}$$

Some specific social dynamics: the rising of the population, the rapid acceleration of lifestyle, the women's incorporation to the workforce, etc., it forced the necessity of acquiring food in the most rapid way (with the minimum time expended) and the minimum effort (minimum economic and energy cost); it is imposed that what it is called Fordist diet [10]. At the same time, this process leads to a *macdonalization* [11], namely, a system that responds to the population demands. A system that favors the efficiency, allowing a fasting feeding (both in relation to the raw material, as the elaboration process, as the price that is charged to the population that consume them).

Some processes or social changes can be pointed out in order to influence, the changes of the feeding habits in the contemporaneity [8]:


All these possibilities are immense which they produce "an informative cacophony where the ignorance of products and the processes of the elaborating food (…) the modern commensal it is plunged into a permanent state of insecurity and uncertainty where there are no reliable criteria or coherent rationality funding their decisions" [8].

These changes in society cause food to undergo a series of changes [8, 12, 13]:


This type of changes and dynamics created a paradoxical eating defined from two incompatible characteristics: the homogeneity of the feeding and the diet [1, 2] and the food diversity and cuisines that currently coexist [8].

### **2.1 The feeding and the risk of the ED**

Nonetheless, what is the link between the feeding with the ED? In this case, this hinge concept is the consideration from the Sociology in the contemporary societies, such as the risk society [14–17].

As far as food is concerned, the legal regulations that the food industry must respect are increasingly strict. This raises the risk perception among the population, something that was ate until it may be harmful and must be retired from the market. Secondly, new debates are emerging:

*Regarding bioethics about the genetic alteration of the foods, the environmental degradation which involves the organization of production and the technological apps or the nutritional degradation of the own food (lack of fiber, vitamins, high fat content, sugar and salt, excess questionable chemical compounds…) they are creating perceptions and risk situations to the consumers that demand the introduction of strict regulations that guarantees the food security [8].*

These kinds of characterizations produce that the health field is not only restricted to effective health and real, otherwise it enhances their limits until reaching the potential health. Now, in addition to the diseases that they suffer, it matters as well as the risk factors, the predispositions related to the risk situation, etc. The sanitary prevention just started to enter into our lives.

In the present times being sick is not the same, you have to be vigilant in order to maintain your health in a good shape. From time to time you will have to measure your vascular pressure, be aware of the glucose levels, if she is a woman, she would have to get a mammogram, if he is a man he would have to get a prostate check… This is how we enter in a long list of "mandatory" individual actions that we have to assume as responsible people. The sanitary prevention can turn into one of the monsters that threatens our individual freedom along with the internet (and the possible elimination of our privacy) or even the flexisecurity paradigm (which justify any domain measure of our bodies and our mobility freedom despite of being consecrated in almost any of existing Magna carta).

This calculability that characterized the social imaginary of nutrition opens the door to the social evaluations in another sense. Right now, each person can know what the recommended food intake is, for healthy in their specific case. That is, for me it can be 1500 calories, for another person 2000 calories, etc. If I eat more than is recommended, evaluations automatically appear that say that I do not have enough willpower, or I am an indolent person, or that I am simply fat because I decide to be (guilt), etc. Fatness becomes governed and leaded by a calculative logic [18], which frames everything in the sphere of morality.

In addition, the definition of the frameworks that sets the limits to the mentioned assessments is established by the medical staff. And they are transmitted to society due to the guarantee of medical research. Herrera reminds us that "Doctors, biologists, educators, publicists, media, national and international institutions…are now claimed as information agents and educators in the food field, becoming an integral part -and often decisive- of an agri-food system that is thus significantly enlarged in its elements" [8]. And what this sociologist calls rational superstition, that is, "a new sacredness that institutes faith in scientific rationality, and its legitimate administration by a medical priesthood" [8].

Once again Herrera will be the one who sums up in a magnificent way the situation of food in contemporary societies when they say that:

*The main consequence of the process of rationalization in culinary practices is observed in the radical change of agency that entails. The progressive extension of medical-biological rationality, and the consequent erosion of traditional religious restrictions and patterns of social distinction, of the dictates of the body and of tradition, induces a growing reversal of the agenda in the subjects of food that figures in the transition from eating to nutrition, from action to reception, from the attribution of an agent role for the diner related to a patient role [8].*

Based on the introduction of morality in the food imaginary, the question is whether this provoked some kind of consequence or influence in the field of ED. As a matter of fact, it does. Gracia-Arnáiz and Comelles [19] refer that the biological. Medical paradigm imposes a threefold look at medical practice: The medicalcentrism, that is, the use of a reductionist rationality supposedly shielded by the scientific asepsis, androcentrism and misogyny.

The process of medicalization of food takes its first steps in the famous "experiment" carried out at the spa of Battle Creek in Michigan in 1863 and that would end in an experience of creating a healthy diet for the human being, but that along the way was commodified and led to the famous cereals Kellogg's [9, 20]. This process takes off after the Second World War, guided by the attempt to reduce the levels of cholesterol, glucose, etc., but it will do so by establishing the parameter of statistical normality established by medicine. Toro notes that in the United States "By 1880 girls were conspicuously worried about not looking too thin" [20]. And Gracia-Arnáiz and Comelles qualify that "Preventing obesity was never a biomedical priority before the twentieth century. Being fat was not considered pathological, malnutrition, yes" [19].

These types of events run parallel to the change in the canon of beauty. Referents such as Marilyn Monroe or Sofía Loren are abandoned and the canon evolves towards the image of the Twiggy model [19, 20]. From that moment on, the aforementioned model will be followed by: Kate Moss, Nieves Álvarez, Cindy Crawford, etc. But perhaps it would not hurt to remember that all these women, over time, ended up

*The Eating Disorder's Society DOI: http://dx.doi.org/10.5772/intechopen.106840*

recognizing their eating disorders or, at least, dalliances with inappropriate eating behaviors.

Right now, the problem of the image is much more complex, because programs like Photoshop allow to create women and men that do not exist and will never exist. People with perfect images that only exist in the virtual reality of the computer documents in which they are stored and edited.

All this outlines a social imaginary permeated by a true mythology that, following Sanders and Bazalgette [21] would respond to the following myths:


Toro after making a tour of the investigations that studied the dissatisfaction of people with his body, concludes that "practically all citizens value his physical appearance, pays attention to it, thinks about it, worries and tries to modify it actively" [20]. In relation to this matter, Moreno finds three types of beliefs that would lay the basis of what he calls "ideologies about eating disorders" [22].


### *Recent Updates in Eating Disorders*

In his research he concludes that the social position of the individual determines in a similar way his perception that in the case of EA "the body as a possible space of a personal construction project is absent from the discourse" [22]. Moreno [22] detects the resistance of the influence of discourses in the symbolic sphere of the body in certain sectors of the population:


Compared to the above enumeration, the social sectors most likely trend to influence their body perception, like middle-aged women, around 45 years old would be [22], in specific, women who reside in small localities (less than 5000 inhabitants). Overall, according to Moreno [22] women would show a greater tendency to show perceptions of having a higher-than-normal weight.

### **3. The moralization: obesogenic and lipophobic societies**

One of the most repeated expressions in the scientific literature to describe the ED would be to define them as an epidemic of contemporary societies [23, 24]. This occurs in parallel to the consideration of current societies as societies suffering from the obesity epidemic [25]. As a result, different authors have been using the term lipophobia [1, 26, 27] to describe the current situation of hate to fat, the fear of fattening produced by the process of medicalization of the body and food.

Lipophobia would be a relatively recent phenomenon, Gracia-Arnáiz tells us that:

*Fatness was, and still is, welcomed in numerous societies. Gluttony and binge eating can be a socially accepted and even valued practice that not everyone can afford. In contexts where food shortages are not unusual, corpulent individuals were more likely to survive. While being thin was associated with fearsome diseases, being fat denoted status and often beauty and sexual appeal [26].*

What processes led us here? The truth is that some specialist [25] studying obesity, pointed out that its imaginaries were always paradoxical. In the Middle Ages, Vigarello distinguishes "between two possible looks. On the one hand, there is the fat that imposes its mass and causes an immediate respect, which provides distinction and holiness. And, on the other hand, the fatness that underlies its heaviness, which produces the grind and the weakness [25]. Thus, there would be a social imaginary of fatness, provided it does not impede the mobility of the person, characteristic of the upper classes. The nobility and the aristocracy were the social strata that enjoyed sufficient economic level to be able to afford to maintain a certain leisure and a high level of food intake, which together could produce excessive weight gain.

### *The Eating Disorder's Society DOI: http://dx.doi.org/10.5772/intechopen.106840*

But from the end of the twelfth century and the beginning of the thirteenth two relevant phenomena occur. From that moment on the pastoral work of the monks who used to live more closed in their abbeys will increase. On the other hand, the growth of cities modified sociability, and facilitated the sermon itself, which would be supported by phenomena such as that of mendicant monks [25]. You have to control the appetite for food, as well as sexual appetite, abstinence and moderation, can protect us from falling into sin. As Coveney [9] points out, Christian practices are rearranged around eating habits, examination of conscience, confession and penance.

The food itself in this sense is an ambivalent element: it is a gift of God and as such should be considered; in addition to being used as an instrument of mortification of the body and praise of the divinity through fasting; but at the same time, carries with it great opportunities to fall into sin: food as something external that could contaminate the body. Fat participated in the canon of beauty of the moment. Vigarello [25] cites some excerpts from the romances of the time in which we speak of "tender and beautiful fatties" [25] and how in the "Roman de la Rose" a "feminine and beautiful maiden (who is) quite fat" is quoted [25]. But as Vigarello [25] says, fat was present until the fifteenth century in the discourse, but it was practically absent from the iconographic representation. Even some historical personage of which there is much news of his corpulence as William the Conqueror was represented without this characteristic. The fat in the image used to be reduced to the representation of a rounded belly, but it was not usually represented in the rest of the body. Obesity was structured around the popular/distinguished distinction [25]. It was therefore a social differentiation to which moral meanings are beginning to be assigned, but which will increasingly be pointed towards the moral sphere in later times.

At the same time, we find a medical discourse still vague and without concretion, and of a low level of influence [25]. In the Renaissance we find a revaluation of the possibility of activity. In the sixteenth century the criticism of the heavy, of the enormous, of laziness was introduced. But without forgetting that thinness is also criticized, the object of search is balance [25]. This equilibrium, which is attempting to recover from the classical canon that had been established in Greece centuries ago, is embodied in the man of Vitruvius, which Leonardo elevates to classical canon through the balance of the Aurea proportion. Leonardo recovers the classical canon of the Greek proportion that had defined the ratio between the body and the head in 7 to 1. But as exemplified by Raich, Sánchez Carracedo and López Guimerà [27], although the Venus de Milo meets the requirements of the aforementioned canon of beauty and balance, it would not meet those of the current canon, since the aforementioned statue would need a size 42. And such considerations will remain throughout history. Marilyn Monroe and Sofía Loren are cited in the literature as examples of the sixties beauty canon [20, 27]. It should be remembered that Marilyn responded to the canon of the famous 90–60-90, but in reality, Marilyn wore a size 44 [27]. So, the famous triple figure still dominates the popular imaginary, the truth is that it does not respond closely to the measurements of supermodels and advertising models today. The 90–60-90 parameter, applied today, would relegate figures such as the two actresses cited to be "seen as plump, low-muscled women" [27].

Even so, fatness was preferred to thinness. Thinness with its fat removal prevented reaching the balance that was the criterion of beauty. In addition, the thinness was linked to the classic type of melancholy described by the mood model [25]. At this time there are many engravings that reflect different allegories of melancholy. This emotion had already been pointed out by Aristotle in the famous problem n° 1 in Section XXX of his Problems [28] as a possible cause of mental illness. The etymology of melancholy itself refers to mélas (black) and khôle (bile) [29]. The predominance of black bile makes people unstable, but at the same time, it makes them capable of great works of intellectual or artistic character. This kind of link between melancholy and genius was picked up by Cicero and passed through him to the entire Western culture (Seneca Plutarco Galeno Marsilio Ficino Montaigne). Until being sanctioned by Diderot through its inclusion in the Encyclopedia when, on the other hand, it was something already installed in the popular culture of the time [30]. This link reaches to the present time in which some specialist relates the high IQ with a personality structure that generates emotional difficulties that affect the patterns of functioning of people in their daily lives [31].

This process will end in melancholy swallowed up by medicine because:

*Within the process of medicalization and medicamentation of daily life, people learned to denominate as "depression" most of the problems of life (frustrations, disappointments, burdens, lack of happiness), so that the thresholds of acceptance of the "discomfort" and the ability to face life's vicissitudes normally was lost [32].*

The iconography finally begins to reflect large, greasy bodies, eager for reality and implantation in space [25]. One only must remember some of the figures painted by El Bosco. And not to mention the bodies painted by Rubens; to finish remembering the epitome of "las tres Gracias".

As usually happens in history, this moment of excess and lack of measure follows the time of the containment of bodies. This containment would occur at two levels: at the physical level with the systematization from the sixteenth and seventeenth centuries of the physical systems of containment of the female body: the corsets, the bodices, the slips, etc.; and at social level the first diets sprout from the imaginary dry mood. The fat is linked to the liquid. The diet should be carried out with the intake of meat, astringent foods, avoiding, on the contrary, typical birds of rainy climates or with stagnant waters, as well as legumes or citrus containing a lot of liquid [25]. The contemporary construction of obesity would take its first steps in the Enlightenment. It is at this time that the consideration of fatness is individualized. There will be as many fatties as individuals. Obesity becomes an object of the gaze: "This work of the gaze transformed perception: alerts were created, and fatness was noted that did not exist, concerns were displaced, the gaze was sharpened" [25].

We are at the moment when science is establishing the measures of length, weight, etc. This helped the establishment of two symbolic universes, which unfortunately still live with us today. These two universes would be concretized in particular in "two thresholds of "acceptance" of fatness. Towards 1780, the Galerie des modes points to a considerable reduction in the female size and a greater freedom of the male volume: the lightness of women opposes the density of men" [25]. The male model begins to be established on the basis of more permissive criteria, they are allowed a certain body volume, even being plump; they, on the contrary, must show stylized sizes, even exaggerated by the use of corsets.

At that time obesity was borne. The first use in French is found in the second edition of 1701 of Antoine Furetière's Dicionario, when the term was not mentioned in the first edition of 1690 [25]. The word is commented on in the medical entries of the Dictionary. The change necessary to begin the medicalization process occurs because "fat is no longer a simple quantitative excess that should prevent sobriety, but it is a disorder, an internal degradation that has progressions of his determinations" [25]. Soon after we found in the Encyclopedia obesity as a medical term.

### *The Eating Disorder's Society DOI: http://dx.doi.org/10.5772/intechopen.106840*

With the passage of time a rationalizing logic and new calculative type is introduced [25]. The nineteenth century must weigh obesity, measure it, etc., we must reduce everything to figures. This will cause the bourgeois world to give itself the swollen belly and take a step further with the sanction of the romantic prototype.

In Romanticism lapels reach impossible sizes, men had to wear belts that gird their waist, the use of vests is imposed, etc. The criterion to reach is youth full of strength and embodied in a spiky body. In the case of women, the paradigm is established fragility, often linked to a sickly appearance. The pallor of the skin, promoted by the use of different cosmetics; and care not to be exposed to the sun. The dominant values are the delicacy, passivity [25]. The subject's imaginary in Romanticism could be summed up saying that:

*Everything is sorrow, a kind of metaphysical loneliness, abysmal, in front of a strange world, more than strange, to suggest that one is out of place in his own family world, a foreigner without a homeland (…). What remains as a remedy (…) is to enjoy sorrow, that is, to turn sadness into a way of life and to recreate itself in melancholy, because, as is known, melancholy is the joy of sadness [32].*

As Lama [33] points out in the nineteenth century, the disease was introduced into the social imaginary of women. But not only did women join the disease, but this link was sometimes made with mental illness [34–36]. In literature and opera of the nineteenth century, the so-called Scenes of Madness are widespread. Scenes in which a woman tormented by circumstances and/or an impossible love fell into the nets of madness. So it happens in Hamlet de Ambroise Thomas (Á vos jeux…Partagez-vous mes fleurs…Et maintenant, ècoutez ma chanson), in Il Pirata de Bellini (¡Oh! S'io potessi…Col sorriso d'innocenza), in Anna Bolena de Donizetti (Piangete voi…al dolce guide lame casstel natío) or in Luccia di Lammermoor by the same composer (Il doce suono…Ardon gl'icensi).

Once the standardization process of the models and measures was finished, there were parameters for medical science set the goal for each. The first therapies to treat patients suffering from obesity arise: the burning of calories, spas, etc.

Everything is ready to begin the desperate and absurd race of contemporary society towards martyrdom. Vigarello writes that towards the beginning of the twentieth century there is a displacement of two stigmas:

*The fat one is first of all someone who "eludes", who rejects thinness, who despises striving to take care of himself. His defect is abandonment, and his responsibility, an intimate fault (…). Failure takes on a new form, which reinforces not only the generalization of treatments, but also the rise of psychology (…). The obese is no longer just a fat man. He is also incapable of changing: a failed identity [25].*

The medical imaginary of fat, therefore, aims to highlight the individual responsibility in the causality of this situation, forgetting the variety of influences and interactions: metabolic, genetic, and hormonal that can affect the obesity of people. All this causes a perception of obesity to be generated within medical science, which following Gracia-Arnáiz [26], is dominated by moral interpretations.

Obesity rapidly progressed from a social situation, a personal characteristic, to being considered a medical problem. This medical condition would, in turn, go from being considered a risk factor, to a disease, even an epidemic of global proportions [26]. When talking about obesity, unfortunately, we must begin by noting that this

is not an ED, it is not classified as such either in the DSM or in the CIE. As a result of this it cannot be said to be a mental disorder. The surprising thing is to find in the literature articles that question this type of assertions, and that link obesity with a deranged gesture of eating that, ultimately, puts in solfa the homeostasis of the body [37]. On the other hand, some authors, relying on the use of food to relieve moments of high anxiety that people have from time to time, raise the consideration of binge eating disorder as a subtype of obesity [38]. But the truth is that it is common to find manuals or books on the ED in which obesity is treated without making it abundantly clear that this is not a mental disorder [39].

The truth is also that the figures that reach overweight and obesity in countries such as the United States, Spain, etc. can be worrying. The Spanish Ministry of Health, Social Services and Equality reports that "the prevalence of obesity in adults reached 16.91% in 2014, maintaining the high levels achieved in 2009 (16.0%) and 2011 (17.03%), in the upward line of the last 25 years [40] and now slightly higher in men than in women. According to the same ministry, since 1987 obesity in the case of women has doubled, and in the case of men the problem is even greater, since it rose from 7 to 17%,1%; maintaining the prevalence of overweight in these same years stable around 32–35%. In 2014, if the figures for overweight and obesity were added, the figure was 52.7% (men 60.7 and women 44.7%).

Fat in medicine, according to Fischler [1], is going to be considered a useless substance, so much so that it is not considered worthy of research on it. This point would be reached through the translation of a series of social processes into the symbolic realm that dominates medicine. The social processes in which lipophobic arises would be [1]: the role of technology in today's society, the division of sexual roles and the modern conception of the individual and the relationships that the latter maintains with the collective.

This author [1] points out the decisive role of American insurance companies in the resignation of obesity as a risk factor for health. In 1890 it is noted that fatness reduces people's life expectancy, but in 1951 statistical support is given to this observation. Metropolitan Life concluded that "obesity increases mortality very dramatically" [1]. But the problem was that according to Fischler [1] this statistic lacked sufficient methodological rigor: the sample was not representative of the universe; the rigor of the data collection was not desirable (weights were made with clothes and shoes on) etc. On the basis of all this Fischler concludes that:

*Be that as it may, Metropolitan Life studies served as the basis for a vast campaign of insurance companies to incite the population to lose weight. American doctors, subjected to an intense campaign, easily adopted the conclusions and considered the duty to disseminate them and to advocate widespread weight loss [1].*

From this moment a series of processes occur that affect and increase the phobia to fat [1]:


*The Eating Disorder's Society DOI: http://dx.doi.org/10.5772/intechopen.106840*


### **4. Conclusions**

To end with, it can be said that obesity advanced vertiginously from a social situation, a personal characteristic, to be considered a medical problem. The aforementioned medical situation, in turn, would go from being considered a risk factor, to a disease, and even an epidemic of global proportions [26]. Thus, in Western societies come from two processes that intersected in the current standardization of food: the medicalization of food and the moralization of it. This produced the current dietary standardization that comes from criminalizing half of the western population labelling it as obese. From that moment on, all the dietary food imaginary linked obesity to meanings of personal weakness, lack of will of people, etc. Which can cause the typical vicious circle of so-called obesogenic societies to arise. Better not to say: "When prescribing slimming diets, many doctors consider that the carriers of the anomaly -excess fat- are responsible for their dysfunction: if you are obese, it is because you eat a lot or because you do not know or do not want to eat well" [26].

In this way it is necessary to take into account that for the explained it is possible that the stigma effects of some tide to the ED. It should be known whether it affects only the general population or whether it may also affect the perception of professionals of the persons affected by any of the disorders covered by this research.

### **Author details**

Juan José Labora González\* and Pablo Soto-Casás University of Santiago de Compostela, Santiago de Compostela, Spain

\*Address all correspondence to: juan.labora@usc.es

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

### **References**

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[3] Douglas M. Símbolos naturales (1ª reimp., e. o. 1970). Madrid: Alianza Editorial; 1988. p. 198

[4] Harris M. Bueno para comer. Madrid: Alianza Editorial; 1990. p. 400

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*The Eating Disorder's Society DOI: http://dx.doi.org/10.5772/intechopen.106840*

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### **Chapter 2**

## Disordered Eating amongst Adolescents

*Farzaneh Saeedzadeh Sardahaee*

### **Abstract**

Eating disorder, "a persistent disturbance in eating and its related behaviors" affects both "food consumption and its absorption", and the overall physical and mental wellbeing of affected individuals. ED is reported worldwide, across gender, ethnical, racial, and socioeconomic strata. Societal emphasis on gender based body-ideals puts extra pressure on adolescents to achieve or maintain unattainable weigh or body shapes, at the cost of them becoming unwell. ED has a complex etiology where an interplay between genetics and environment brings about the onset of symptoms as early as prepubertal years. With their fluctuating and chronic nature, ED may affect perception, emotions, cognition, and behavior. The interface between ED, overeating and obesity, as well as the recent surge in reported cases of ED during Corona pandemic, has focused much attention on eating pathology amongst adolescents. Many adolescents (particularly boys) specially in a prodromal phases of ED, do not yet meet diagnostic thresholds for ED and hence do not receive timely or appropriate professional help. In the current chapter, we aim to 1- address the issues surrounding early recognition of ED symptoms in adolescents under a general umbrella term, "Disordered Eating", and 2- highlight the importance of societal influence on vulnerable individuals.

**Keywords:** eating disorder, disordered eating, adolescents, suicidal ideation, mental distress, body ideal, body size overestimation, genetic risk score

### **1. Introduction**

Eating is an integral part of multifaceted human survival behavior, but its importance reaches far beyond human physiological necessities. Eating has helped shape human culture throughout history, by the way of food gathering, its preparation or consumption, as well as through its many symbolic attributes, as evident in fasting, either through spiritual rituals or forced by natural forces such as famine [1]. Some historical accounts of fasting practices date back a few centuries, of which the infamous case of Saint Catherine of Siena, would be considered as eating pathology in more modern times [1, 2].

Overweight and obesity have been known phenomena since prehistoric times [3]. Cases of overeating and consequent purging of food (bulimia) amongst the wealthy are recorded as far back in time as the Middle Ages. Scientific recognition of bulimic practices as a pathology started in the early 1900s; however, the first published scientific article on this condition emerged decades later, in 1979, when the possible link between periodic bulimia and pathological undereating was speculated [4].

Earlier scientific speculations on a link between hunger, varying patterns of food consumption from undereating to bulimia and overweight on one hand and emotional state on the other hand were based on, amongst other observations, coexisting history of some adverse childhood experiences in many cases [5]. A wealth of scientific evidence has been since collected on the complex link between physical and psychological aspects of eating behavior in both general and clinical contexts.

Parallel to an increase in the prevalence of both overweight/obesity and overeating/undereating in the past few decades, adolescents seem to be increasingly concerned with their food consumption, weight, or body size. Although in the past few decades, genetic studies have provided ample evidence for the link between obesity, undereating, and overeating, the current understanding of this link stops short of fully explaining the exact mechanisms underlying a pathological change in eating, from a natural physiological response to hunger/satiety to a disturbed state that can be defined as a medical condition with possible lifelong consequences. Although many times, such disturbing states reach their peak presentation during adolescence and may cause significant health problems for the affected individuals, they may yet not meet the diagnostic criteria for a clinical diagnosis of eating disorder [6, 7].

Eating disorder (ED), as explained extensively elsewhere in this book, refers to a wide range of disturbances in eating and feeding that may vary in their nature, severity, or frequency over the lifespan. In the "Diagnostic and Statistical Manual of Mental Disorders," fifth edition (DSM-V) [8], eating disorders are defined as conditions "*characterized by a persistent disturbance of eating or eating-related behavior that results in the altered consumption or absorption of food and that significantly impairs physical health or psychological functioning*." DSM-V provides diagnostic criteria for an array of ED subtypes: pica, rumination disorders, avoidant/restrictive food intake disorder, anorexia nervosa (AN), bulimia nervosa (BN), binge-eating disorder, other specified feeding or eating disorder (OSFED), and unspecified feeding and eating disorder.

Prevalence, demographics, etiology, and comorbidities in ED are discussed elsewhere in this book and will not be included here. Instead, in this chapter, the author will try to shift readers' attention from ED to a set of similar presentations under an umbrella term, disordered eating (DE) that due to an array of reasons may go unnoticed by clinicians but is nevertheless associated with several biopsychosocial complications.

As an introduction to the subject, the author will first define DE with special attention paid to its common features with ED, before moving on to give a summarized account on prevalence, comorbidities, and burden of disease in DE, followed by a section on etiology on DE, with focus on the importance of societal weight and body ideals, which together with a digitized modern world with an exponential increase in exposure to images portraying such ideals, seem to have created a healthcare dilemma where individuals are advised to maintain a healthy weight, but repeatedly fail to attain societal body ideals that are not necessarily in line with the definition of healthy weight. Treatment in DE follows the same principles employed in treating ED, which is covered in other book chapters and will not be covered here.

Please note in this chapter, the terms ED and DE are not used interchangeably. The term "eating pathology" is used where the author refers to symptom(s) shared between ED and DE.

### **2. Definition and diagnosis in disordered eating**

Over the lifespan of affected individuals, clinical presentations of ED may greatly fluctuate, for instance from anorexia nervosa (AN) to much milder conditions where a diagnosis of ED would no longer apply [9]. Current classification systems, such as the latest edition of WHO's classification system for mental and behavioral disorders, ICD-11 [10], and DSM-V [8], do not match the observed scope of eating problems and their related traits in general adolescent populations, resulting in a considerable proportion of adolescents with an array of eating problems left out with no treatment available to them [11]. On the other hand, heterogeneity, both within and across different subtypes of ED, makes conducting research on ED more challenging and less generalizable, hence the introduction of the umbrella term, disordered eating [12, 13].

Similar to eating disorders, DE is manifested through symptoms such as individuals' concern about their body weight and shape, excessive or unnecessary use of weight reduction methods such as dieting or exercise, self-induced vomiting, inappropriate use of laxative or diuretic, or in some cases periodic binge eating, under- or overweight [14, 15].

Like eating disorders, DE has been associated with varying factors such as "biological" (BMI, puberty), "sociocultural" (socioeconomic status and exposure to media pressure), and "psychological" (early life adverse events, concerns about the body image, self-esteem, and negative affect) [16]. Interestingly, subthreshold symptom constellations observed in DE are associated with similar levels of functional impairment and emotional distress seen in ED [17, 18]. Recognition of impaired function in adolescents with DE is important since, many times, what brings a person to a clinician is their lack of function and not the mere presence or absence of certain symptoms directly taken from medical textbooks.

In clinical settings, the diagnosis of ED is made based on comprehensive clinical interviews and tests, which is a usually lengthy process that requires good training [19, 20]. Self-reported questionnaires [21] are used with the advantage of being quicker and easier to administer than semi-structured diagnostic clinical interviews [19, 22]. One other advantage of self-reported questionnaires is their more accurate reporting of symptoms, such as binge eating, when compared to clinical interviews [19]. Validation studies of self-reported questionnaires in adolescents have shown mixed results, and they are rendered less suitable for screening of eating pathology in overweight adolescents [22, 23].

Attempts have been previously made at making a more robust identification of DE by researchers [11, 22], by using standard screening tools available for ED [23, 24]. These tools are developed on the basis of observations of individuals with more severe presentations than those observed in general populations [25], and they neither seem to have sufficient reliability in the identification of earlier manifestations of ED nor are they fully suitable for the detection of disordered eating [25]. Generally, diagnostic thresholds for DE are either set lower than that for ED, or only a subset of ED symptoms are included in the screening process.

It is important to point out that currently, neither the definition nor identification of DE is fully agreed upon by the scientific community. The author is of the opinion that further identification of more reliable and validated screening tools for DE is important considering that 1 – prevalence of DE is higher than ED [13, 16, 26–28]; 2 – shared symptomatology between ED and DE makes studying the symptoms on their own of value and relevance to a wider group of individuals, independent of their diagnoses; and 3 – a sound understanding of factors attributing to the emergence

of symptoms in DE seems pertinent for their prevention. Furthermore, given time, a proportion of adolescents with DE may evolve eating disorders, which makes the development of reliable identification tools for early detection of DE even more important [29].

### **3. Prevalence and demography in disordered eating**

As mentioned earlier, ED and DE have a set of shared symptoms. Previous studies have shown that these symptoms seem to occur worldwide and across many ethnical, racial, and socioeconomic strata [30–32]. Prevalence of these symptoms is reportedly higher than that of clinically diagnosed cases of EDs [31, 33, 34]. Binge eating, purging, and dieting are present across adolescence and adulthood [26, 35–37]. Compared to extreme weight loss or fasting in adolescents that are more commonly flagged up to healthcare services, some prevalent and potentially harmful symptoms such as frequent binge eating and purging may go unreported and hence untreated [16], inadvertently also in populations with DE.

Existing scientific literature has shown that only a small proportion of individuals with ED come to the clinicians' attention [38, 39] partly due to the vigorous application of current diagnostic criteria for ED [39, 40]. On the other hand, the validity of many epidemiological studies on ED has been scrutinized by the scientific community due to their selection bias for younger and fit female populations [38]. This makes research findings derived from clinical populations with ED less generalizable to the general population where targeted preventive methods are meant to be applied [38]. For similar reasons, DE in male adolescents is still understudied [41, 42], hence it is important to have a fresh look at symptoms in a population representing samples, rather than a sole focus on groups with evident clinical diagnoses of ED that have female over-representation.

Although compared to eating disorders, DE is generally milder in its symptomatology, it is more common amongst adolescents than ED [13, 16, 26–28, 43], especially amongst adolescents with higher BMI [44], making DE easier to identify and research in population-based studies.

Similar to ED [19], the symptom constellation in DE may vary based on gender [11]. Both ED and DE are generally more common in females than males [16, 26, 43], but one needs to also bear in mind that 25–30% of preadolescents who attend special ED clinics in Australia and UK are younger males [16, 26]. Moreover, prevalence of binge eating disorder, a subtype of ED with overlapping symptoms with DE, is equal in females and males [45].

### **4. Comorbidities and burden of disease**

The burden of disease in eating pathology remains relatively high since it is associated with poor physical, poorer social relationships and quality of life, lower productivity, higher rates of substance use, anxiety, and depression, as well as increased self-harming behavior, suicidal ideation, suicidal attempts, suicide, and higher mortality [46–53]. Adolescents with overweight, obesity, or those who are unhappy with their weight or shape also show an increase in mental distress. These incremental risks were observed independent of sex, age, BMI, and socioeconomic status, but adolescent boys with DE showed a stronger vulnerability to mental distress [11, 43].

*Disordered Eating amongst Adolescents DOI: http://dx.doi.org/10.5772/intechopen.107302*

Studies of temporal trends in the burden of disease have shown a considerable increase in the prevalence of binge eating and extreme dieting. Current scientific literature points at a considerable proportion of youth in the USA and Canada reporting high levels of functional impairment due to their attitudes toward eating [7, 27, 38].

Eating pathology may be associated with poor concentration and decision making, as well as with rigidity in thoughts, hence may reducing individuals' mental capacity to recognize their problems or consent to necessary treatments [16]. Lack of timely and effective interventions for EDs can have devastating effects on the lives of sufferers, their families, and wider society. Early detection and timely intervention for eating pathology are vital considering the early age of onset, which is reportedly as low as 10 years old [54], and their possible debilitating effects on the physical and mental wellbeing that can pave the way for a range of unwanted long-term effects. Previous research suggests that increasing treatment coverage could substantially reduce ED-related mortality [32].

### **5. Etiology in disordered eating**

Much of what is known about etiology in DE stems from studies done on symptoms of ED, as previously discussed in this book. The etiology of DE has been difficult to study partially due to its fluctuating and chronic course, and in parts because of its several biopsychosocial determinants. The issues surrounding etiological studies in DE are further complicated by the lack of consensus as how to define DE or classify its subtypes.

The symptom constellation in DE constitutes a range of areas; such as altered perception of weight or body size, negative emotion, changed cognition and behavior such as purging, dieting, extreme or unnecessary exercise, use of diuretics or anabolic steroids as seen in binge eating [8]. Human perception, emotion, cognition, and behavior are shaped and governed by a set of mechanisms that are themselves regulated by the combined effects of genetic and environmental factors, as well as by epigenetics [55–57]. The following subsections briefly look at these factors amongst adolescents with DE, before moving on to expand on the body ideals.

### **5.1 Genetic factors associated with disordered eating**

Identification of heritable patterns in developing DE is important for designing interventions that can detect or modify DE presentations in affected persons, some of whom may develop ED later on in life or see similar presentations in their offspring.

There is a sound scientific ground for generating hypotheses on whether eating pathology, be it a part of ED or DE, shares biopsychosocial determinants with other prevalent public health issues, such as overweight/obesity. Abnormal weight and DE seem to share more than just their phenotypic traits. Family, twin, and adoption studies provide some evidence in favor of a set of common predisposing factors that regulate satiety, appetite, and reward systems in the human brain in both eating pathology and under- or overweight [58–66], for example, through the involvement of dopaminergic and opioid neurotransmitters [67]. A notable observation is the shared genetic susceptibility (FTO, MC4R, BDNF [63, 64], and OPRD1 [28, 60, 65]) between obesity and mechanisms underlying eating pathology. Synaptic plasticity and glutamate receptor activity are pathways that respond to the changes in feeding

pattern, such as fasting. Interestingly, these pathways seem to be regulated by obesityrelated molecules such as BDNF and MC4R [63, 68–71].

Inheritance studies on subtypes of ED, such as anorexia nervosa, have not identified a single gene with a large effect [72–76]. When no single genetic marker shows a significant effect on the existence of a trait, genetic risk scores (GRSs) have been instead used to study a possible additive effect of several genes on that trait [77]. GRSs have been useful in the identification of shared underlying mechanisms between eating behavior, obesity, ED [78, 79], and satiety [80]. Likewise, GRSs have been used in studying inheritance amongst sex-stratified populations of adolescents with DE [11] where results showed an association between obesity-related genes and DE, as well as observing sex-specific differences in how genes seem to associate with DE symptoms. However, in the absence of a clearer classification of DE symptoms and larger genetic studies, drawing further conclusions on this matter seems premature. Whether these risk factors aggregate in families of individuals with DE is not yet fully understood and needs further research.

### **5.2 Other factors associated with disordered eating**

Investigating the collective effect of biopsychosocial factors in DE at the adolescent age is important since it can help identify individuals at higher risk for developing negative long-term health consequences of eating pathology.

### *5.2.1 Psychiatric comorbidities*

There are reports on a link between negative emotion and regulatory systems involved in food intake [61]. Comorbidity between eating pathology and a wide range of mental disorders, such as anxiety, depression, substance misuse, and personality disorders, is well documented [81–88]. Early life adversities, such as childhood neglect and physical and sexual abuse, have significantly higher prevalence amongst adolescents with eating pathology [35].

### *5.2.2 Overweight and obesity*

Obesity is recognized as a major health problem across the world, also amongst adolescents [89, 90]. In the past few decades, human lifestyle, eating habits, and physical activity together with a subsequent imbalance between food consumption and energy expenditure have undergone major changes [91]. Overweight and obesity have overarching unwanted, yet preventable consequences for both physical and mental health across the lifespan [92]. Like ED and DE, abnormal weight can impair both physical and mental health [92, 93].

The association between weight status, eating pathology and other psychiatric disorders is complex. Both unhealthy weight change and ED are, as shown in animal models, associated with some degree of altered food consumption or absorption [94]. On the other hand, change in eating style has been associated with being overweight or obese, ED, and depressed mood, pointing to the possible association between eating pathology and psychiatric disorders [95]. Moreover, both abnormal weight and ED have a higher prevalence of clinical depression [96, 97], anxiety [98, 99], bipolar affective disorder [100, 101], and substance use disorders [102, 103]. Interestingly, some weight-loss treatment regimens are also known to help improve psychosocial outcomes in obese children with disordered eating [104, 105]. A recent systematic

### *Disordered Eating amongst Adolescents DOI: http://dx.doi.org/10.5772/intechopen.107302*

review has shown that the link between obesity and ED is stronger than the link between obesity and depression, anxiety, or substance use disorder [106].

Overweight and obesity were more prevalent in adolescents with DE who show patterns of uncontrolled appetite/overeating compared to those who have poor appetite/undereating. Underweight seems to be more prevalent in adolescents with DE and poor appetite/undereating compared to those who show uncontrolled appetite/ overeating [11].

However, it is interesting that despite ample scientific evidence for a close link between abnormal weight and eating pathology, having abnormal weight is not a necessary diagnostic criterion for any ED, or for that matter DE, other than in anorexia nervosa (AN). Neither it is necessary for an individual with abnormal weight to have suffered from any form of DE.

National percentile growth charts show the spread of distribution of weight by height, weight by age, and height by age in a given population of a certain age, gender, and race [107] and are widely used as an indicator of physical development and health from infancy throughout adolescence. Body mass index (BMI), another measure of weight status, has also been used to categorize individuals into underweight, normal weight, overweight, or obese groups [108]. BMI, as originally called Quetelet's Index (QI) [109], is a value derived by quantification of the proportion of mass to height in each individual and is calculated by dividing the body weight in kilograms to the square of the body height in meters (kg/m2 ). Use of BMI as an indicator for eating pathology can be particularly misleading amongst adolescent males who may, due to higher muscular volumes and intake of certain supplementary nutrients, have normal BMI even in more debilitating instances of eating pathology.

### *5.2.3 Societal body ideals*

It is also vital to study disordered eating in the context of increasingly more appearance-focused societies, keeping in mind the possible negative effects of unattainable societal body ideals on younger individuals during their formative adolescent years. Societal emphasis on physical appearance may put pressure on adolescents to attain or maintain a certain body type, the so-called body ideals. Many adolescents try to achieve their body ideals by restricting the frequency or content of what they eat, or by vigorous physical exercise, which at times comes at the cost of them neglecting their other needs. Societal stigma about having an eating pathology may prevent adolescents from reporting their problems [110]. It is difficult to identify and costly to treat eating pathology, in part due to a lack of subjective insight into ill-fated consequences of unreported or untreated eating pathology [110, 111].

Body image, a subjective perception of the human body, is a complex construct based on comparisons made between the perception of an individual's body size or shape to that of others. "Size," the magnitude or dimension of a thing, is determined by comparisons drawn between various objects on their magnitude of a quantity, such as mass and length, which could then be expressed either relative to a measuring unit or by assigning adjectives such as smaller/bigger or heavier/smaller.

Mass, weight, or length are separate concepts. In physics, mass is loosely referred to by the amount of "matter" in any given object. Weight, however, refers to something different and more dynamic than the fixed amount of matter in a mass at any given time. Weight is the force that is "experienced" by an object due to gravity. Hence, body image may be considered both "relative" and "subjective," as it may also be dynamic and seen as "amenable to change" [112]. However, human body image seems to be a

more complex concept than only a mental picture of dimensions, but rather a multifaceted construct made of neurological, psychological, and sociocultural elements [113].

First scientific studies of body image date back to the 1900s and emerging clinical reports of altered body perception after brain injury in the parietal lobe or phantom limb in amputees. Krueger thought of body image as the representation of identity derived from internal and external body experiences [114]. Schilder attempted at defining body image by combining known concepts of the "somatopsyche," postural model of the body, and the more recent Freudian understanding of ego [113]. In his book, "The Image and Appearance of the Human Body," Schilder suggested that body image plays a fundamental role in individuals' relation to themselves, to their fellow human beings, and to the world around them [113].

Body image is dynamic and may change with individuals' age, mood, or even type of clothing. People with the same body size might have different body weights due to differences in their body composition or muscular and bone density [56, 115]. Discrepancy between subjective body image and actual body size is common in the general population and is a shared feature in many conditions, such as body dysmorphic disorder, obesity, or some types of ED [6]. Besides, human perception is not just a passive reception of sensory information but is also formed by the percipient's cognition that in turn is dependent upon learning, memory, and attention, as well as on pre-learned concepts or expectations (body ideals) [116, 117].

Mismatch between body image and body ideals may lead to unnecessary concern. Concerns about weight or body size are present in various subtypes of ED [8]. Being dissatisfied with one's body is known to associate with changes in affect, lower selfesteem, and social dysfunction [118]. Interestingly, weight underestimation has been associated with less symptoms of anxiety/depression in both adulthood [119] and preadulthood [120].

Individuals with weight or body size concerns may unnecessarily resort to ways to change their appearances, such as dieting or exercise. Many dieting regimes are advertised and endorsed by the society as effective ways to "look better," despite, at times, their questionable effectivity. Subjective body dissatisfaction arising from discrepancy between one's body image and body ideals, combined with individuals' perceived inability to change their appearance by dieting or exercise, can cause or worsen mental distress and may lead to other negative health outcomes [121].

Considering selective mechanisms such as "attention" also influence human perception [122], one can postulate whether focus on body size, may by itself, shape as well as distort, individuals' body image, alter their behavior (dieting) or even mental state.

Societal body ideals are gender based [119], which makes it interesting to examine gender differences in exhibiting weight concern, body size perception, and mental distress. It is also tempting to postulate that pre-learned expectations of how a body should look like (body ideals), as represented in visual clues available through social media or fashion industry, can hypothetically affect individuals' body image.

Association studies between adolescents' BMI, weight concern, body size perception, or dieting and their mental health have provided some answers to these questions [43]. For example, having weight concern has been associated with increased odds of mental distress amongst adolescent boys and girls, to a greater degree than actually being overweight/obese. Similarly, body size overestimation at adolescence has shown a greater impact on mental distress amongst adolescents, than weight concern. Male adolescents who overestimate their body size were shown to be at particularly high risk for having mental distress, compared to their female counterparts [43].

### **6. Conclusions**

Disordered eating at adolescence is prevalent but understudied. The importance of research in the field, especially amongst adolescent males, cannot be overemphasized as these adolescents may suffer from both physical and psychiatric consequences of their eating pathology.

The underlying molecular biology in disordered eating is still understudied. Genetics cannot fully explain the variation in the formation, severity, and course of disordered eating amongst individuals with similar faulty genes. The use of the polygenetic risk score (PRS) in future genetic studies may help quantify the actual genetic risk in each individual carrying these faulty genes.

Furthermore, variation in individuals' response to standard medical and nonmedical interventions for disorders of feeding and eating underscores the importance of taking a holistic approach to studying the combined effect of genetic and environmental factors. Epigenetic studies can shed light on resilience factors that may protect young adolescents against developing disordered eating in the first place. Besides, by identification of environmental factors that act as trigger for developing disordered eating, epigenetic studies can help introduce timely and appropriate preventive measures in young adolescents.

Likewise, developing novel intervention methods that can address both disordered eating and comorbid disorders requires studying these disorders together. However, relative lower prevalence of some forms of ED would translate to fewer potential research participants from clinical settings where treatment is sanctioned for more severely affected individuals. Whilst international consortia and multicenter studies are useful ways to overcome this problem, they may introduce other issues such as heterogeneity in study population that may potentially affect study findings and their interpretations.

Future longitudinal studies that focus on traits rather than clinical diagnoses may offer a methodological solution by increasing the number of research participants in any given category of ED symptoms and traits. Findings of population-based studies are more generalizable to nonclinical populations and may better help design preventive measures that fit young adolescents who have not yet reached the disease threshold.

Scientific literature provides evidence for the relative importance of subjective weight concern, rather than being overweight/obese in adolescent mental health. Body size overestimation is associated with mental distress, especially in boys. Body size overestimation and weight concern seemed associated with mental distress, the former playing a greater part. Body size overestimation may be related to increasingly unattainable societal body ideals. Lack of effective weight control methods combined with easy access to relatively cheaper fattening food and overeating has led to an increase in overweight as well as dissatisfaction with own body. The use of compensatory weight reduction behaviors, such as dieting, extreme exercise, and use of anabolic steroids, has also been on the rise amongst adolescents. A change of societal body ideals to a set of more attainable and population representative size or shape may help prevent negative consequences of unnecessary weight concerns or dieting.

Despite showing higher mental health vulnerabilities, male adolescents with DE are an overlooked group. A more thorough examination of DE traits in formative adolescent age is necessary for the early identification of vulnerable adolescents.

*Recent Updates in Eating Disorders*

### **Author details**

Farzaneh Saeedzadeh Sardahaee1,2

1 National Unit for Mandatory Care, St. Olav University Hospital, Trondheim, Norway

2 Center for Research and Education in Security, Prison and Forensic Psychiatry, St. Olav University Hospital, Trondheim, Norway

\*Address all correspondence to: farzaneh.sardahaee@googlemail.com

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### **Chapter 3**

## Prevalence and Determinants of Obesity in Children in Algeria

*Nasreddine Aissaoui, Lamia Hamaizia, Said Khalfa Mokhtar Brika and Ahmed Laamari*

### **Abstract**

Our objectives through this paper are multiple: to measure the prevalence of overweight and obesity in children between 5–11 years; highlight the main causes that lead children under 12 years old to become overweight or obese, especially by highlighting the cause and effect relationship between eating disorders "bulimia nervosa" and obesityoverweigh; highlight the risk factors associated with overweight or obese children; and finally, the strategies to be planned and the policies to be applied to curb the phenomenon of obesity in this age group. This is a descriptive and cross-sectional survey which aims to study and analyze a representative sample of children under the age of 12 who attend a municipal swimming pool during the month of July 2018. The sample is made up of 509 children from less than 12 years old; the majority of children are regulars at the municipal swimming pool during the summer located in the department of Constantine, a department in the North-East of Algeria. Overweight affects 14% of children aged 5–11 years old, while moderate obesity affects 4% of children in this age category, frank obesity affects 1% of this age group. The percentage of boys and girls with a BMI3, 4 or 5 are around 13% and 23%, respectively, of the entire sample.

**Keywords:** overweight and obesity, bulimia nervosa, prevalence of obesity, factors associated with obesity, risk factors for obesity, Algeria

### **1. Introduction**

The prevalence of overweight and obesity has risen at an alarming rate in recent decades, particularly among children and adolescents, becoming one of the greatest public health challenges of the twenty-first century [1, 2]. Childhood and adolescent obesity is a global problem, affecting both developed and low- and middle-income countries, particularly in urban areas [3–5].

In 2019, an estimated 38.2 million children under the age of 5 years were overweight or obese. Once seen as specific problems of high-income countries, overweight and obesity are now on the rise in low- and middle-income countries, particularly in urban settings. In Africa, the number of overweight or obese children has increased

by almost 24% since 2000. Almost half of overweight or obese children under 5 years lived in Asia in 2019. More than 340 million children and adolescents aged 5 to 19 years were overweight or obese in 2016 [1].

Overweight and obesity are becoming a serious public health problem; one in two Algerians and one in three Algerian women are overweight [6]. The phenomenon hardly spares children; the tendency to overweight is rather on the rise in a society inclined to a sedentary lifestyle and excessive consumption of fast-food products. Globally, the number of obese children and adolescents aged 5 to 19 years has increased 10-fold over the past four decades. If current trends continue, by 2022 there will be more obese children and adolescents than moderately or severely underweight children [7].

Through a questionnaire, we conducted a survey of children under 12 years old. This survey aims to study and analyze the causes and consequences of overweight or obesity on a sample of children aged 5 to 11 years old.

### **2. Patients and methods**

This was a descriptive cross-sectional study on a representative sample of 509 children between 5 and 11 years old, the survey was conducted during the month of July 2018.

### **2.1 Study type and population**

The study population consisted of 509 children aged 5 to 11 years old, who visit a public swimming pool during the summer holidays. The children are selected by chance, during the 4 weeks of July 2018.

### **2.2 Study variables**

We studied age, sex, height, weight and BMI. The weight, expressed in kilograms, was measured in a lightly dressed, barefoot subject, standing on a SECA digital medical scale (Seca 703 digital column scale with measuring rod, Germany).

BMI was calculated by dividing the weight expressed in kilograms by the square of the height expressed in meters. We used the definition of the International Obesity Task Force/ IOTF [8], which is based on the recommendations of the European Childhood Obesity Group for epidemiological studies of Rolland-Cachera [9].

In 2000, the Childhood Obesity Working Group of the International Obesity Task Force (IOTF), a working group under the aegis of the WHO, developed a new definition of childhood obesity with curves for boys and girls aged 2 to 18 according to the thresholds proposed by Cole et al. [8]. This definition has the specificity of coordinating the characteristics of childhood obesity and adult: it uses the same index (BMI) and refers to the same thresholds. Body mass index (BMI) was calculated by dividing weight by height squared BMI = Weight/Height2 (kg/m2). The International Obesity Task Force (IOTF) proposes 5 BMI groups [9]:


*Prevalence and Determinants of Obesity in Children in Algeria DOI: http://dx.doi.org/10.5772/intechopen.106197*


In children and adolescents, curves have been developed to take into account the specificity of sex and age.

### **2.3 Statistical analysis**

Using a standardized questionnaire, respecting confidentiality, anonymity and after informing the families. We recorded a few refusals, since we distributed 600 copies of questionnaires, and we recovered only 509, thus a percentage of recovery which is around 84.83%. Most uncollected copies are those of children accompanied by adults who are not their parents. According to the questionnaire, two types of data were collected: information on the parents of the children, and others on the children themselves who were the subject of the study.

Data were analyzed using SPSS 21.0 software. Quantitative variables were represented as mean, standard deviation (SD), 95% confidence interval (95% CI), while qualitative variables were represented as numbers (n) and percentage (%). The p value <0.05 was considered statistically significant and a two-tailed test was used.

### **3. Results**

### **3.1 Prevalence of overweight and obesity in children by gender**

The study sample consists of 509 children aged between 5 and 11 years old, among them 235 males and 274 females. By referring to the thresholds of the International Obesity Task Force/IOTF, we obtained the following results (**Table 1**).

The normal body mass index/BMI2 is around 86.8% in boys and 76.7% in girls. Girls had a significantly higher BMI than boys in all age groups, whether overweight (BMI3) or obese (BMI4 and BMI5). By comparing the two sexes, we can see that the difference between the two sexes in BMI becomes more visible with age. The average weight was 31.61 ± 10.33 kg (i.e. 30.23 ± 10.22 kg for boys and 32.46 ± 11.24 kg for girls) in children aged between 5 and 11 years, that of height was 116.23 ± 15.43 cm (i.e. 115.70 ± 12.68 cm for boys and 118.79 ± 9.68 cm for girls) and that of BMI was 19, 39 ± 4.12 kg/m2 (i.e. 18.96 ± 3.85 kg/m2 for boys and 19.97 ± 4.06 kg/m2 for girls). Overweight affects 14% of children aged between 5 and 11 years old, moderate obesity affects 4% of children and frank obesity affects 1% in this age group. The percentage of boys and girls with a BMI of 3, 4 or 5 is around 13% and 23% respectively of the entire sample. The prevalence of overweight in our study was respectively 14.5% (including 18.2% in girls against 10.2% in boys) and that of obesity was 4.1% (including 5.1% in girls against 3.0% in boys). By comparing the prevalence of overweight between the two sexes, the Pearson test shows quite significant differences in girls than boys, on the other hand the same test shows few differences between the two sexes among those who suffer from obesity (**Table 1**).

### *Recent Updates in Eating Disorders*


*\*\*p-value: comparison of prevalence of obesity between boys and girls.*

#### **Table 1.**

*Prevalence of overweight and obesity in children by gender.*

### **3.2 Factors associated with overweight and obesity according to the study sample**

Four main questions have been asked to locate the risk factors responsible for overweight or obesity in children under 12: We have not recorded a relationship between the socioeconomic situation of the family and the BMI of the child; on the other hand, other factors can constitute a major risk for these young people gaining extra pounds (**Table 2**).

We can clearly see that overweight and obesity are indeed present in girls more than in boys; since 68% of those who are overweight (group 1) and 67% of those who suffer from obesity (group 2) are female; i.e. two thirds of those who have


*Group 2: those who are obese (BMI4 and BMI5).*

### **Table 2.**

*Factors associated with overweight and obesity in children.*

(BMI3, BMI4 and BMI5). Two out of three of the parents questioned have a medium or high level of education. Weight gain begins early in 85% of children, where the family history is pointed out. We found an absence of a food culture in 53% of the families of children in both groups and an insufficient culture in 32% of the families of children in the two groups. What is worrying in both groups; it is the non-taking of breakfast which is around 58% in children of the two categories, the non-taking of breakfast at home is responsible for the multiple snacks before and after lunch, thus the majority of the children of the two groups have tendency to snack all the time, in other words to have one or more snacks during the day. We noticed that 78% of the children in two groups admitted: never or rarely practicing physical activity during the week outside of school. The majority of "never" or "rarely" answers are those of girls of the two groups, who admit that they never or rarely practice a physical activity outside the school establishment, this percentage is close to 100% among girls aged 10 and 11 years, in the same wake 89% of children admit to spending more than an hour in front of an electronic device for entertainment daily, even during school days.

### **4. Discussion**

In our study, the prevalence of overweight including obesity is 18% in children between 5 and 11 years old, according to the international IOTF thresholds corresponding to BMI4 and 5 in adulthood. We arrived at the following results: 14% of the children in the study sample are overweight, while moderate and frank obesity concerns 4% of this age group. Girls are the most affected by overweight and obesity with 18 and 5% respectively, compared to 10 and 3% for boys. The proportions of overweight and obese children are close to those found in the national literature [4, 5, 10, 11]. However, the situation is changing from 1 year to year, since in 6 years: the prevalence of overweight including obesity is 18% after it was 13.1%; if overweight only affected 10% of children before, now it affects 14%; obesity only affected 3.1% of this age category at the beginning of this decade, now it affects 4% globally according to the most recent study on this age category [4, 5, 12]. The prevalence of overweight including obesity is 24% according to IOTF international thresholds. According to a study conducted in 2013 by the Algerian Nutrition Society (SAN), 13% of adolescents aged 10 to 17 are overweight [6]. Globally, the obesity rate among children continues to rise from 1 year to the next, as this rate has risen from less than 1% in 1975 (i.e. 11 million children), to more than 6% (i.e. 124 million) in 2016. So these figures show that the number of obese children aged 5 to 19 in the world is multiplied by 10. We must not forget that the number of overweight children is very worrying; we recorded 213 million in 2016. Fortunately, obesity in Algeria is below world averages, but measures must be taken to counter this scourge [1].

The prevalence of overweight is higher in girls than in boys of children between 5 and 11 years old. Thus, girls between the ages of 4 and 11 are 2.08 times more likely to be overweight and twice to become obese, which is consistent with the results of published research [13, 14]. In the present study, we found age to be a factor associated with overweight and obesity. Thus, 14% of children between 5 and 11 years old are overweight, and 4% are obese. Therefore, over the years, weight gain seems inevitable, which is consistent with the results of published research [4, 15]. According to our survey, the birth weight of the child and the BMI of the parents are risk factors for overweight or obesity. Thus, 85% of parents of children who have extra pounds admit that they still have curves. In addition, 52% of children suffering from excess weight have overweight or obese parents; which is consistent with the results of published studies [16–18]. The results of this survey showed that 85% of families ignore or neglect the nutritional content of the meals consumed by their children [19]. In the same vein, 53% of parents of overweight or obese children admit that the nutritional culture of food is not taken into consideration at home, which is consistent with the results of published studies. According to this survey, few children respect the recommended number of meals (i.e. 3–4 meals per day). What is worrying is that 58% of the subjects in the sample do not have breakfast at home in the morning. For those who are overweight or obese, the majority of them take at least two snacks a day, which is consistent with the results of published studies [18, 20, 21]. In the present study, we arrived that 78% of the children do not practice, or rarely, a sports activity outside the school establishment, to tell the truth apart from the 2 hours of physical activity within the school; they have no other sporting activity, which consistent with the results of published studies [4, 18, 22]. Most surprisingly, for those who do not practice any physical activity or rarely outside school, it is the percentage of girls between the ages of 10 and 11 which is close to 100%. This is mainly due to social taboos and the absence of stadiums or sports halls reserved for girls and teenagers. If the non-practice of sporting activity is quite visible, sedentary lifestyle is becoming more and more accentuated among young people. Our results show that 37% of children spend more than 2 hours in front of an electronic entertainment device, so overweight or obese children suffer more from this scourge, who over time become dependent on this kind of leisure.

### **5. Conclusion**

Overweight and obesity have progressed rapidly over the past 5 decades; children are not immune to this phenomenon which affects all age groups, which has become a serious public health problem throughout the world. Algeria is not an exception, since the plural transition that has known this country for the last 4 decades has generated profound changes and bad habits among Algerians, in this case among the children of this country. Since the 1990s, Algeria has experienced an economic transition towards a market economy, and that after more than 30 years of socialism, this economic opening has allowed an abundance of goods on the shelves of supermarkets, among these goods those which do not are not necessarily

### *Prevalence and Determinants of Obesity in Children in Algeria DOI: http://dx.doi.org/10.5772/intechopen.106197*

healthy (sweets, sodas, fast food, etc.). A marked improvement in purchasing power; enabled Algerians to direct their spending towards the impulsive purchase of energy products, fast foods, and fatty meals. Children do not escape this new life, which promotes a sedentary lifestyle and cheap unhealthy meals. The results of our survey confirm the significant increase in overweight and obesity among Algerian children. Our results converge with the majority of results from national and international research, which have sounded the alarm about the dangerousness of the phenomenon and its rapid progression. The responsibility is shared between: parents, schools, media, food industry, etc. In order to fight against the consequences of obesity on our children, in this case chronic diseases, several preventive solutions can be sought: early food education must be taken into consideration in textbooks from primary school; make manufacturers aware of reducing the levels of the three whites (sugar, salt, white flour) in food; encourage homemade meals that protect our dear health; children must be made aware of the reduction of the time devote in front of an electronic entertainment device; encourage young people to devote more time to physical activity outside of school. It is the responsibility of local elected officials and non-profit associations to devote a few hours during the week to girls, adolescents and adult women in stadiums, sports halls and municipal swimming pools, to initiate a strategy to counteract overweight and obesity among women.

Our study is arguably limited by several aspects of design and analysis. Based on our small sample size, our findings may not generalize to all obese or overweight children in this country. Interest, the strength lies in the results which open the way to larger studies on children who live in large cities, or those who are confined during the long months of COVID-19.

### **Acknowledgements**

The authors would like to thank the anonymous reviewers and the editor for their insightful comments and suggestions.

### **Conflict of interest**

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

### **Author contributions**

NA and LH authors contributed equally to the ideas presented. SKMB and AL wrote the draft of the paper. All authors contributed to editing the final version and approved the submitted version.

*Recent Updates in Eating Disorders*

### **Author details**

Nasreddine Aissaoui1 \*, Lamia Hamaizia1 , Said Khalfa Mokhtar Brika<sup>2</sup> , and Ahmed Laamari3

1 Faculty of Economics, Department of Finance Sciences, Business and Management Sciences, Oum El Bouaghi University, Algeria

2 Departement of Administrative Sciences, AppliedCollege, University of Bisha, Bisha, Saudi Arabia

3 Faculty of Science and Art in Al-Namas, University of Bisha, Bisha, Saudi Arabia

\*Address all correspondence to: aissaoui.nasreddine@univ-oeb.dz

© 2022 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### Section 2
