feliz
feliz
  • Users Online: 901
  • Print this page
  • Email this page

 
ORIGINAL ARTICLE
Ahead of print publication  

Trends in the burden of eating disorders in Pakistan over the past three decades: A joinpoint regression analysis


1 Department of Environmental Design, Health and Nutritional Sciences, Allama Iqbal Open University, Islamabad, Pakistan
2 Department of Community Medicine, Institute of Medical Sciences, Banaras Hindu University, Varanasi, Uttar Pradesh, India
3 Department of Food Science, Government College University, Faisalabad, Pakistan
4 Institute of Food Science and Nutrition, University of Sargodha, Sargodha, Pakistan

Date of Submission22-Jan-2022
Date of Decision18-May-2022
Date of Acceptance07-Jun-2022
Date of Web Publication28-Nov-2022

Correspondence Address:
Mahpara Safdar,
Department of Environmental Design, Health and Nutritional Sciences, Allama Iqbal Open University, Islamabad (44310)
Pakistan
Muhammad Zubair Khalid,
Department of Food Science, Government College University, Faisalabad 38000
Pakistan
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aip.aip_8_22

  Abstract 


Background: Eating is one of the most and foremost necessities of life. Eating is necessary for a being for growth, development, and maintenance of body and body system. However, a variety of problems are associated with eating, in which eating disorder is of the most common. Anorexia nervosa and bulimia nervosa are two most potential eating disorders mostly prevailing in youth of developing countries like Pakistan. A better understanding of its incidence is a basic requirement for improving its management. However, the temporal trend of eating disorder incidence in Pakistan is still unknown. Methods: The age- and gender-specific incidence and prevalence rates of eating disorders and their subtypes, anorexia nervosa and bulimia nervosa, from 1990 to 2019 were collected from the Global Burden of Disease Study 2019 database. The annual percentage change and average annual percentage changes were calculated using joinpoint regression analysis to observe the trends in the incidence and prevalence rates of eating disorders and their subtypes in Pakistan over the past three decades. Results: From 1990 to 2019, age-standardized incidence rates (ASIRs) and age-standardized prevalence rates (ASPRs) of eating disorders continued to increase in both males and females, and similar trends were observed in anorexia nervosa and bulimia nervosa. ASIR of eating disorders and bulimia nervosa was higher among males as compared to females, during mentioned time frame, but it was reversed in the case of anorexia nervosa where ASIR was higher among females as compared to males. However, ASPRs of eating disorders including both the anorexia nervosa and bulimia nervosa, was higher among females as compared to males. Joinpoint regression analysis showed that the incidence rates and prevalence rates have increased in all age groups. 15–19 and 20–24 years' age groups are having the highest incidence rates of eating disorders, anorexia nervosa and bulimia nervosa, for both males and females. Conclusion: Eating disorder burden continues to rise in Pakistan, particularly among adolescents and young adults. Further etiological studies are required to explain these increases and to facilitate the early identification of high-risk individuals.

Keywords: Anorexia nervosa, bulimia nervosa, eating disorders, incidence, joinpoint regression analysis, Pakistan, prevalence



How to cite this URL:
Zahra SM, Jha RP, Safdar M, Khalid MZ, Khalid W, Ali Nawaz Ranjha MM. Trends in the burden of eating disorders in Pakistan over the past three decades: A joinpoint regression analysis. Ann Indian Psychiatry [Epub ahead of print] [cited 2023 Feb 3]. Available from: https://www.anip.co.in/preprintarticle.asp?id=362052




  Introduction Top


Eating disorders adversely affect a person's physical, emotional, and social well-being.[1] Out of the major eating disorders, bulimia nervosa and anorexia nervosa are the two most significant and majorly patent in adolescences.[2] It has been reported that these disorders are likely to be three times more prevalent in females than males.[3]

Most eating disorders involve focusing too much on body weight, body shape, and food, leading to certain dangerous eating behaviors. These behaviors can significantly impact the body's ability to get appropriate nutrition. Eating disorders can harm the heart, digestive system, bones, and teeth and mouth and may lead to other diseases as well.[4]

Anorexia nervosa is a diet disorder marked by a refusal to achieve a balanced body weight, a skewed view of the body, and an excessive fear of weight gain. This disorder makes one so obsessed by their beauty and the need to be slim that ultimately affects all facets of their life, directly or indirectly.[5]

Bulimia Nervosa may lead to life-threatening situation, because individuals suffering from this disease, may consume vast quantities of food in an uncontrollable manner, seeking to discard calories with little intention of feeling satisfied, but may nevertheless be secretly hide food somewhere to deal with their feelings of fullness. After taking too much extra calories, the bulimia affectants try to lose them in a very unhealthy way.[6]

Historically, eating disorders have been regarded as a Western culture-specific health issue. However, a growing body of research has investigated the rising prevalence of eating disorders in Asian countries, especially in developing countries such as Pakistan. An increased understanding of the epidemiology of eating disorders is a fundamental prerequisite for improvements in the diagnosis and management of eating disorders, as well as the rational distribution of health-care services. As a result, the prevalence of eating disorders and potential improvements has consequences for mental health programs.[7]

There is a dearth of empirical statistics on incidence and prevalence of different eating disorders in Pakistan. Although a number of different surveys have been conducted to assess the eating disorders in Pakistan, Mumford et al.,[8] Choudry and Mumford,[9] Suhail and Nisa,[10] Latif et al.,[11] Memon et al.,[12] Shaikh and Kayani,[3] and Jamali et al.,[13] there is a dire need to see the trends in the burden of eating disorders in Pakistan.

Eating disorders put a great burden on a country in a number of ways.[14] Reporting incidence and prevalence of a disorder is very crucial for better understanding.[15] Hence, there is a dire need to report the incidence and prevalence of eating disorders in Pakistan to help the policy maker better understand and deal with their burden.

The Global Burden of Diseases (GBD) is a valuable reserve for understanding the changing health issues that people face around the world in the twenty-first century. The GBD research, led by the Institute for Health Metrics and Evaluation (IHME), is the most rigorous global observational epidemiological study to date. GBD is a valuable platform for informing physicians, scholars, and policymakers, promoting transparency, and improving lives around the world by monitoring change within and across countries.[16]

Over the last two decades, the IHME has evolved a framework for quantifying the burden of injures, illnesses, risk factors, and diseases to guide health service and policy development bodies to take suitable actions. GBD offers equivalent assessments of primary metrics of disease burden measurement including the incidence and prevalence rate of eating disorders, on regular basis.[16]

The present study was designed to utilize the GBD 2019 database to systematically summarize and analyze the incidence and prevalence of eating disorders, bulimia nervosa and anorexia nervosa, and their fluctuations since 1990–2019 for Pakistan.


  Material and Methods Top


Data sources

GBD 2019 has calculated each epidemiological quantity of interest, i.e., incidence, prevalence, deaths, years lived with disability (YLDs), years of life lost (sYLLs), and disability-adjusted life-years for 23 age categories, in 204 countries divided into seven superregions and 21 regions.[17]

The Cause of Death Ensemble model and Spatiotemporal Gaussian Process Regression were used to calculate the cause-specific death rates and cause fractions, as previously stated.[18],[19],[20],[21] Cause-specific deaths were adjusted to match the total all-cause deaths calculated as part of the GBD population, fertility, and mortality estimates. YLLs were calculated by multiplying deaths by standard life expectancy at each age. “A Bayesian meta-regression modeling tool, DisMod-MR 2.1, was used to ensure consistency between incidence, prevalence, remission, excess mortality, and cause-specific mortality for most causes. Prevalence estimates were multiplied by disability weights for mutually exclusive sequelae of diseases and injuries to calculate YLDs. Uncertainty intervals (UIs) were generated for every metric using the 25th and 975th ordered 1000 draw values of the posterior distribution.”

In the GBD 2019, EDs were defined according to the Diagnostic and Statistical Manual of Mental Disorder (DSM) and International Classification of Disease (ICD) criteria. Different versions of the DSM (DSM-III, DSM-III-R, DSM-IV, DSM-IV-TR, and DSM-5) and ICD (ICD-9 and ICD-10) were accepted. The latest DSM-5 criteria, which was released in 2013, had included three ED subtypes: AN, BN, and BED along with it also incorporated a residual category, i.e., Other Specified Feeding and Eating Disorders (OSFEDs). OSFEDs embraces clinically significant ED that doesn't meet the full criteria given for AN, BN, or BED. However, the GBD 2019 included only two ED subtypes, AN and BN. The ICD-10 codes used by GBD for eating disorders, AN and BN, are F50-F50.9, F50.0-F50.1, and F50.2-F50.5, respectively. We have extracted the age-standardized as well as age- and sex-specific incidence and prevalence rates from 1990 to 2019 from a publicly available online tool provided by the IHME known as the (Global Health Data Exchange). This query tool is used to quantify the temporal trends of ED, AN & BN incidence and prevalence rates and can be availed at: http://ghdx.healthdata.org/gbd-results-tool.[22] Percentage change and annualized rate of change of the estimates were reported. Moreover, crude rates and the 95% UIs were used to compare ED's secular trend between age groups.

Joinpoint regression analysis

The identification of changes in the secular trend is critical to the analysis of disease incidence and prevalence data. To determine the magnitude of the time trends in incidence and prevalence rates of eating disorders, anorexia nervosa and bulimia nervosa, the average annual percentage change (AAPC) and corresponding 95% confidence interval (CI) was evaluated using joinpoint regression analysis. The logarithmic transformation of the incidence and prevalence rates was conducted and the standard errors were taken as constant.[23] AAPC was calculated by taking geometrically weighted average of various annual percentage change (APC) values from the regression analysis.[24] The average APC (AAPC) was estimated using best model considering maximum 5 joinpoint, i.e., 6 segments for the full range of our study periods.

To estimate the APC, the following model is used:

log(Yx )=b0+b1x, where log (Yx) is the natural logarithm of the rate in year x.

Then, the APC from year x to year x + 1 is:



This analysis was performed using 'joinpoint' software (Joinpoint Regression Program, version 4.7.0.0, NCI) from the Surveillance Research Program of the US National Cancer Institute.


  Results Top


Descriptive analysis

Gender-wise trends in the age-standardized incidence rate (ASIR) for eating disorders, anorexia nervosa and bulimia nervosa, from 1990 to 2019 of Pakistan are depicted in [Figure 1]. For all year's ASIR of eating disorders and bulimia nervosa was higher among males as compared to females, but it was reversed in the case of anorexia nervosa where ASIR was higher among females as compared to males.
Figure 1: The trends in the age-standardized incidence rates of (a) eating disorders, (b) anorexia nervosa and (c) bulimia nervosa by sex in Pakistan (1990 – 2019)

Click here to view


The ASIRs of eating disorders, anorexia nervosa and bulimia nervosa, for both males and females in Pakistan have been increased over the period 1990–2019. For males, the ASIR of eating disorders has largely increased in 2019 (194.59 new cases/100,000 males) as compared to 1990 (171.22 new cases/100,000 males); similarly, ASIR of eating disorders among females had also increased in 2019 (86.84 new cases/100,000 females) from 77.71 new cases/100,000 females in 1990 [Figure 1]a. For males, the ASIR of anorexia nervosa had increased in 2019 (7.73 new cases/100,000 males) as compared to 1990 (6.86 new cases/100,000 males); similarly, ASIR of anorexia nervosa among females had also increased in 2019 (17.53 new cases/100,000 females) from 15.91 new cases/100,000 females in 1990 [Figure 1]b. For male, the ASIR of bulimia nervosa had increased in 2019 (186.86 new cases/100,000 males) as compared to 1990 (164.37 new cases/100,000 persons); similarly, ASIR of bulimia nervosa among females had also increased in 2019 (69.32 new cases/100,000 persons) from 61.80 new cases/100,000 persons in 1990 [Figure 1]c.

Gender wise trends in the age-standardized prevalence rate (ASIR) for eating disorders, anorexia nervosa, and bulimia nervosa from 1990 to 2019 of Pakistan are depicted in [Figure 1]. ASIR of eating disorders and bulimia nervosa was higher among males as compared to females, during mentioned time frame.

The ASPRs of eating disorders, anorexia nervosa and bulimia nervosa for both males and females in Pakistan has been increased over the period 1990–2019. For male, the ASPR of eating disorders has increased from 74.73 cases/100,000 males in 1990–91.09 cases/100,000 males in 2019; Similarly, ASPR of eating disorders among females had also increased in 2019 (152.60 cases/100,000 females) from 126.80 cases/100,000 females in 1990 [Figure 2]a. For male, the ASPR of anorexia nervosa had slightly increased in 2019 (18.69 cases/100,000 males) as compared to 1990 (16.44 cases/100,000 males); Similarly, ASPR of anorexia nervosa among females had also increased in 2019 (51.97 cases/100,000 females) from 44.85 cases/100,000 females in 1990 [Figure 2]b. For male, the ASPR of bulimia nervosa had increased in 2019 (72.96 cases/100,000 males) as compared to 1990 (59.63 cases/100,000 persons); Similarly, ASPR of bulimia nervosa among females had also increased in 2019 (101.36 cases/100,000 persons) from 82.61 cases/100,000 persons in 1990 [Figure 2]c.
Figure 2: The trends in the age-standardized prevalence rates of (a) eating disorders, (b) anorexia nervosa and (c) bulimia nervosa by sex in Pakistan (1990 – 2019)

Click here to view


Joinpoint regression analysis

[Figure 3] and [Table 1] show APC of ASIRs of eating disorders, anorexia nervosa, and bulimia nervosa in Pakistan from 1990 to 2019 for both males and females. The regression model showed a significant increasing pattern in the ASIR of eating disorders between 1990 and 2019 for both males and females for all trends; however, a nonsignificant declining trend was observed in case of males between year 1994 and 2001 (APC = −0.10; 95% CI: −0.20–0.00; P > 0.05) [Figure 3]a and [Figure 3]b. A significant increasing trend has been observed in the ASIRs of anorexia nervosa between 1990 and 2019 for both males and females for all trends except between 1995–2000 among males (APC = −0.15; 95% CI: −0.23 to − 0.08; P < 0.05) and 2017–2019 among females (APC = −0.10; 95% CI: −0.19 to −0.00; P < 0.05) where a significant declining trend was observed [Figure 3]c and [Figure 3]d. A similar increasing trend was observed in the ASIRs of bulimia nervosa between 1990 and 2019 for both males and females for all trends; however, a nonsignificant declining trend was observed in case of males between year 1994 and 2001 (APC = −0.10; 95% CI: −0.20–0.01; P > 0.05) [Figure 3]e and [Figure 3]f.
Figure 3: Joinpoint regression analysis in sex-specific age-standardized incidence rates of eating disorders, anorexia nervosa, and bulimia nervosa in Pakistan from 1990 to 2019. (a) Eating disorders in males; (b) eating disorders in females; (c) anorexia nervosa in males; (d) anorexia nervosa in females; (e) bulimia nervosa in males; (f) bulimia nervosa in females. *annual percentage change is statistically significantly different from zero at the α = 0.05 level

Click here to view
Table 1: Sex-specific temporal trends in incidence of eating disorders, anorexia nervosa, and bulimia nervosa in Pakistan based on the Joinpoint regression analysis (1990-2019)

Click here to view


[Figure 4] and [Table 2] shows APC of ASPRs of eating disorders, anorexia nervosa, and bulimia nervosa in Pakistan from 1990 to 2019 for both males and females. The regression model showed a significant increasing pattern in the ASPR of eating disorders between 1990 and 2019 for both male and female for all trends; however, a nonsignificant increasing trend was observed in case of males between year 1993–2001 (APC = 0.01; 95% CI: −0.08–0.09; P > 0.05) [Figure 4]a and [Figure 4]b. A significant increasing trend has been observed in the ASPRs of anorexia nervosa between 1990 and 2019 for both male and females for all trends except between 1995–2000 among males (APC = −0.21; 95% CI: −0.28 to − 0.15; P < 0.05) and 1994–2001 among females (APC = −0.10; 95% CI: −0.13 to −0.07; P < 0.05) where significant declining trend was observed [Figure 4]c and [Figure 4]d. Similar increasing trend has been observed in the ASPRs of bulimia nervosa between 1990 and 2019 for both male and females for all trends; however, a nonsignificant increasing trend was observed in case of males between year 1994 and 2001 (APC = 0.04; 95% CI: −0.08–0.15; P > 0.05) and 1994–2001 among females (APC = 0.08; 95% CI: −0.02–0.19; P > 0.05) [Figure 4]e and [Figure 4]f.
Figure 4: Joinpoint regression analysis in sex-specific age-standardized prevalence rates of eating disorders, anorexia nervosa, and bulimia nervosa in Pakistan from 1990 to 2019. (a) Eating disorders in males; (b) eating disorders in females; (c) anorexia nervosa in males; (d) anorexia nervosa in females; (e) bulimia nervosa in males; (f) bulimia nervosa in females. *annual percentage change is statistically significantly different from zero at the α = 0.05 level

Click here to view
Table 2: Sex-specific temporal trends in prevalence of eating disorders, anorexia nervosa, and bulimia nervosa in Pakistan based on the Joinpoint regression analysis (1990-2019)

Click here to view


The incidence rates of eating disorders, anorexia nervosa, and bulimia nervosa by age group in Pakistan in 2019 are shown in [Table 3]. In 2019, the ASIRs of eating disorders in Pakistan were 194.59 (95% UI: 129.54–275.07) and 86.84 (95% UI: 60.87–121.43)/100 000 population of males and females, respectively. The ASIRs were 7.73 (95% UI: 5.44–10.65) in males and 17.53 (95% UI: 12.34–24.38) in females for anorexia nervosa, and 186.86 (95% UI: 121.90–268.18) in males and 69.32 (95% UI: 44.35–103.46) in females for bulimia nervosa, respectively, per 100 000 population.
Table 3: The sex- and age-specific rates of eating disorders, anorexia nervosa, and bulimia nervosa in Pakistan in 2019 and their average annual percentage change from 1990 to 2019

Click here to view


The AAPCs of age–sex-specific incidence rates of eating disorders and their subtypes from 1990 to 2019 are also depicted in [Table 3]. From 1990 to 2019, the ASIRs of eating disorders in Pakistan has been increased by 0.45% (95% CI: 0.37–0.53) in males and 0.39% (95% CI: 0.35–0.43) in females. The ASIRs of anorexia nervosa rose by 0.41% (95% CI: 0.39–0.43) in males and 0.33% (0.32–0.35) in females, whereas the ASIRs of bulimia nervosa rose by 0.45% (95% CI: 0.37–0.54) in males and 0.40% (0.36–0.45) in females.

The highest incidence rates of eating disorders among males and bulimia nervosa among both males and females were observed in the group aged 15–19 years, followed by the groups aged 20–24 and 25–29 years. For anorexia nervosa, among both males and females and eating disorders among females, the group aged 10–14 years had exhibited the third highest sex-specific incidence rates, which were lower than the estimates of the groups aged 15–19 and 20–24 years. Significant increases in the gender specific incidence rates were also observed in eating disorders, anorexia nervosa, and bulimia nervosa irrespective of the age group. Moreover, the increments in ASIRs of eating disorders, anorexia nervosa and bulimia nervosa were more pronounced after 2000s as they were in the 1990s.

The prevalence rates of eating disorders, anorexia nervosa, and bulimia nervosa by age group in Pakistan in 2019 are shown in [Table 4]. In 2019, the ASPRs of Eating disorders in Pakistan were 91.09 (95% UI: 62.20–123.89) and 152.60 (95% UI: 113.56–195.69) cases/100 000 population of males and females, respectively. The ASPRs were 18.69 (95% UI: 12.85–26.33) in males and 51.97 (95% UI: 36.55–73.99) in females for anorexia nervosa, and 72.96 (95% UI: 46.27–103.05) in males and 101.36 (95% UI: 68.18–140.36) in females for bulimia nervosa, respectively, per 100 000 population.
Table 4: The sex- and age-specific prevalence rates of eating disorders, anorexia nervosa, and bulimia nervosa in Pakistan in 2019 and their average annual percentage change from 1990 to 2019

Click here to view


The AAPCs of age–sex-specific rates of eating disorders and their subtypes from 1990 to 2019 are also depicted in [Table 4]. From 1990 to 2019, the ASPRs of eating disorders in Pakistan increased by 0.69% (95% CI: 0.63–0.75) in males and 0.64% (95% CI: 0.59–0.70) in females. The ASPRs of anorexia nervosa rose by 0.44% (95% CI: 0.42–0.46) in males and 0.51% (0.49–0.54) in females, whereas the ASPRs of bulimia nervosa rose by 0.71% (95% CI: 0.62–0.80) in males and 0.72% (0.64–0.79) in females.

The highest prevalence rates of eating disorders among males and bulimia nervosa among both males and females was observed in the group aged 30–34 years, followed by the groups aged 25–29 years. The highest prevalence rates of eating disorders among females was observed in the age group 20–24 years followed by the groups aged 25–29 and 30–34 years. For anorexia nervosa, among both males and females, the group aged 25–29 years exhibited the third highest sex-specific prevalence rates, which were lower than the values of the groups aged 15–19 and 20–24 years. Significant increases were observed in the gender specific prevalence rates of eating disorders, anorexia nervosa, and bulimia nervosa irrespective of the age group. Moreover, the increments in ASPRs of eating disorders, anorexia nervosa and bulimia nervosa, were more pronounced after 2000s as they were in the 1990s.


  Discussion Top


Eating disorders are major problem among the people of developing as well as developed countries.[25] Prevention of eating disorders is one of the key public priority. It has been reported that about 80% of the people affected with eating disorders do not go through a formal treatment and interestingly the available 'evidence based treatments' are effective for <50% of the affectants.[26] The major problem is that a very often research studies are conducted on the incidence and prevalence of eating disorders. Furthermore, the estimation of the prevalence of eating disorders is also very difficult as by the WHO statistics; the data of eating disorders are included in the category of mental disorders.[27] Hence, this makes very difficult for the governmental, decision-making, and nongovernmental bodies to work on the minimization and treatment of people affected with eating disorders. In short, there is a dire need to report the prevalence and incidence of eating disorders for such decision-making bodies. The current study utilizes the GBD database to analyze the incidence of eating disorder, anorexia nervosa and bulimia nervosa, in a period of 1990–2019. The current study is unique to its kind to explore the trends in burden of eating disorders from 1990 to 2019; no such comprehensive study has previously been published.

Most of the previous studies conducted to screen the eating disorders in Pakistan could not give substantial information to report the incidence and prevalence of eating disorders in Pakistan as such studies are usually based on self-describing questionnaires and face-to-face interviews. These studies may add a value to identify the eating disorders but these studies cannot define the main features and some times may over or under estimate the eating disorders.[7] Examples of such studies in Pakistan include Zahid et al.,[28] Javed and Rafique,[29] Jamali et al.,[13] Warsi et al.,[30] Memon et al.,[12] Larif et al.,[11] Suhaild and Nisa,[10] Muford et al.,[8] and Choudry and Mumford.[9]

It has been articulated in the finding of current study that the ASIR of eating disorders and bulimia nervosa is higher among the males comparing to females from 1990 to 2019, but in case of anorexia nervosa ASIR was higher among the females comparing to males from 1990 to 2019. ASIR is a summary measure of the rate that a population would have if it had a standard age structure. Age-standardization is very essential in comparing populations that could differ with respect to age.[31] The current study also articulate that the ASIR of eating disorders, anorexia nervosa and bulimia nervosa, for both the males and females in Pakistan have been increasing over the time (from 1990 to 2019). Furthermore, the raise in ASIR of eating disorders, anorexia nervosa and bulimia nervosa were more obvious from 2000 to 2019 as they were from 1990 to 2000.

From 1990 to 2019, the ASIRs of eating disorders in Pakistan increased by 0.45% (95% CI: 0.37–0.53) in males and 0.39% (95% CI: 0.35–0.43) in females. The ASIRs of anorexia nervosa rose by 0.41% (95% CI: 0.39–0.43) in males and 0.33% (0.32–0.35) in females, whereas the ASIRs of bulimia nervosa rose by 0.45% (95% CI: 0.37–0.54) in males and 0.40% (0.36–0.45) in females. The current reported AAPCs of age-sex specific rates of eating disorders are alarming. Greater changes could be observed among the males than the females for the eating disorders from 1990 to 2019, i.e., 0.45/0.39 for eating disorders, 0.41/0.33 for anorexia nervosa, and 0.45/0.4 for bulimia nervosa among males/females. Interestingly, the current study also found that the age group 15–19 years possesses the highest incidence rates of eating disorders among the males and bulimia nervosa among both males and females.

As per the latest DSM-5 criteria, the eating disorders have been divided in to four categories that include anorexia nervosa, bulimia nervosa, binge eating disorders, and OSFEDs.[32] However, the GBD has did not follow the latest DSM-5 classification and divided the eating disorders in only two categories as anorexia nervosa and bulimia nervosa. This may be a possible factor that the incidence of eating disorders is higher in males as compared to females. Very similar results have been observed by Wu et al.,[7] in their study on trends and burden of eating disorders in China in past three decades.

It was seen in the current study that from 1990 to 2019 the ASPR of eating disorders, anorexia nervosa and bulimia nervosa, was higher among the females then comparing to males. However, a significant increase in the ASPR for eating disorders, bulimia nervosa and anorexia nervosa, was observed for both the genders from 1990 to 2019. ASPR was seen to increase from 74.73 cases/100,000 males to 91.09 cases/100,000 males and from 126.80 cases/100,000 females to 152.60 cases/100,000 females (from 1990 to 2019, respectively).

The cause in hike of eating disorders, bulimia nervosa and anorexia nervosa, are complex. The results of the existing literature on eating disorders point multifactor determination, i.e., environmental and generic factors.[33] As by a number of the epidemiological studies, women are reported to be more prone to the development of eating disorders.[34] There could be a number of different reasons for the said outcome; the increased impact of media and social media on women could be a contributing factor in women to develop eating disorders greatly compared to men.[35] The trend of women digest magazines (which are very common in Pakistan), radio, and TV programs, especially morning shows could also be significant contributors for women. Another possible reason is the celebrity influence and body image to develop eating disorders. Very similar justifications have been reported by Ioannidis et al.,[36] Brown and Tiggemann,[37] Jiotsa et al.,[38] Jurczak et al.,[27] Siew[39] Constructed,[40] Jordan et al.,[41] Shoger,[42] and Field et al.,[43]

Studies also report that teenage years are more likely to develop the eating disorders,[27] and very similar results were obtained in current study. The possible aspect influencing young people's perceptions in leading to eating disorders today could be their quest for longevity. Furthermore, now, many people see the need of a balanced lifestyle and participating in activities such as athletics, consuming foods that are healthy, and equipment that help track it, or even purchase, to sustain a healthy level of activity.[27] This is plausible, considering the large number of young males to develop eating disorders. Ioannidis et al.[44] reported that young people go for over exercise that ultimately lead to development of eating disorders. Jurczak et al.[27] articulated that young students in lower grades are more prone to eating disorders.[45] The study says that 14th year is the lower age limit for the occurrence of anorexia nervosa. Abebe et al.[46] articulated that the peak period of incidence of bulimia nervosa among girls is the 14th–16th life year. However, Stice et al.[47] in their study determined that the peak incidence of bulimia nervosa falls on 16–20th year while that of anorexia nervosa falls on 19–20th.

Very similar reasons could be given for the development of eating disorders among young people as were for the females, that include celebrity influence,[37] body image,[48] and last but not the least social media.[36],[49]


  Conclusion Top


A continuously increasing trend was observed in the incidence and prevalence rates of eating disorders and their subtypes, i.e., anorexia nervosa and bulimia nervosa, in Pakistan from 1990 to 2019 regardless of sex and age group. This predicts that the relative burden caused by eating disorders in Pakistan will continue to increase in the future and further etiological studies should be required in this area. Furthermore, adolescents are seen to have the highest incidence rates of eating disorders followed by young adults, which suggests that age is playing a crucial role. An enhanced understanding of high-risk groups and onset patterns in eating disorders among those groups could facilitate the early identification of individuals who are at risk of developing the disease that will help in timely interventions leading to the reduction in the eating disorders burden in Pakistan. It is recommended by the authors that future studies should be planned to discuss trends and burden of eating disorders around the globe in past three decades.

Acknowledgement

Authors would like to thank Global Burden of Disease Study and Institute for Health Metrics and Evaluation.

Availability of data and materials

All data were obtained from the public open database: Global Health Data Exchange (GHDx) query tool (http://ghdx.healthdata.org/gbd-results-tool).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jenkins PE, Hoste RR, Meyer C, Blissett JM. Eating disorders and quality of life: A review of the literature. Clin Psychol Rev 2011;31:113-21.  Back to cited text no. 1
    
2.
Talmon A, Widom CS. Childhood maltreatment and eating disorders: A prospective investigation. Child Maltreat 2022;27:88-99.  Back to cited text no. 2
    
3.
Shaikh MA, Kayani A. Detection of eating disorders in 16-20 year old female students-perspective from Islamabad, Pakistan. J Pak Med Assoc 2014;64:334-6.  Back to cited text no. 3
    
4.
Ellis JM, Essayli JH, Zickgraf HF, Rossi J, Hlavka R, Carels RA, et al. Comparing stigmatizing attitudes toward anorexia nervosa, binge-eating disorder, avoidant-restrictive food intake disorder, and subthreshold eating behaviors in college students. Eat Behav 2020;39:101443.  Back to cited text no. 4
    
5.
Treasure J, Oyeleye O, Bonin EM, Zipfel S, Fernandez-Aranda F. Optimising care pathways for adult anorexia nervosa. What is the evidence to guide the provision of high-quality, cost-effective services? Eur Eat Disord Rev 2021;29:306-15.  Back to cited text no. 5
    
6.
Monteleone AM, Marciello F, Cascino G, Cimino M, Ruzzi V, Pellegrino F, et al. Early traumatic experiences impair the functioning of both components of the endogenous stress response system in adult people with eating disorders. Psychoneuroendocrinology 2020;115:104644.  Back to cited text no. 6
    
7.
Wu J, Lin Z, Liu Z, He H, Bai L, Lyu J. Secular trends in the incidence of eating disorders in China from 1990 to 2017: A joinpoint and age-period-cohort analysis. Psychol Med 2022;52:946-56.  Back to cited text no. 7
    
8.
Mumford DB, Whitehouse AM, Choudry IY. Survey of eating disorders in English-medium schools in Lahore, Pakistan. Int J Eat Disord 1992;11:173-84.  Back to cited text no. 8
    
9.
Choudry IY, Mumford DB. A pilot study of eating disorders in Mirpur (Pakistan) using an Urdu version of the eating attitudes test. Int J Eat Disord 1992;11:243-51.  Back to cited text no. 9
    
10.
Suhail K, Nisa ZU. Prevalence of eating disorders in Pakistan: Relationship with depression and body shape. Eat Weight Disord 2002;7:131-8.  Back to cited text no. 10
    
11.
Latif A, Khan S, Farooq W. Impact of media on development of eating disorders in young females of Pakistan. Int J Psychol Stud 2011;3:122.  Back to cited text no. 11
    
12.
Memon AA, Adil SE, Siddiqui EU, Naeem SS, Ali SA, Mehmood K. Eating disorders in medical students of Karachi, Pakistan-a cross-sectional study. BMC Res Notes 2012;5:84.  Back to cited text no. 12
    
13.
Jamali YA, Memon SF, Lagahri ZA, Shaikh SA, Warsi J, Arain AA. Prevalence of Eating Disorders among Students of Quest University, Nawabshah, Pakistan; 2020.  Back to cited text no. 13
    
14.
Dahlgren CL, Stedal K, Wisting L. A systematic review of eating disorder prevalence in the Nordic countries: 1994–2016. Nordic Psychol 2018;70:209-27.  Back to cited text no. 14
    
15.
Kreisel KM, Spicknall IH, Gargano JW, Lewis FM, Lewis RM, Markowitz LE, et al. Sexually transmitted infections among US women and men: Prevalence and incidence estimates, 2018. Sex Transm Dis 2021;48:208-14.  Back to cited text no. 15
    
16.
Dhamnetiya D, Jha RP, Shalini, Bhattacharyya K. India's performance in controlling Visceral Leishmaniasis as compared to Brazil over past three decades: findings from global burden of disease study. Journal of Parasitic Diseases 2021;45:877-86. Available from: https://pubmed.ncbi.nlm.nih.gov/34789968/.  Back to cited text no. 16
    
17.
Vos T, Lim SS, Abbafati C, Abbas KM, Abbasi M, Abbasifard M, et al. Global burden of 369 diseases and injuries in 204 countries and territories, 1990–2019: A systematic analysis for the Global Burden of Disease Study 2019. The Lancet, 2020;396:1204-222. Available from: https://pubmed.ncbi.nlm.nih.gov/33069326/.  Back to cited text no. 17
    
18.
Lozano R, Naghavi M, Foreman K, Lim S, Shibuya K, Aboyans V, et al. Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2095-128.  Back to cited text no. 18
    
19.
Foreman KJ, Lozano R, Lopez AD, Murray CJ. Modeling causes of death: An integrated approach using CODEm. Popul Health Metr 2012;10:1.  Back to cited text no. 19
    
20.
Murray CJ, Ezzati M, Flaxman AD, Lim S, Lozano R, Michaud C, et al. GBD 2010: Design, definitions, and metrics. Lancet 2012;380:2063-6.  Back to cited text no. 20
    
21.
Murray CJ, Ortblad KF, Guinovart C, Lim SS, Wolock TM, Roberts DA, et al. Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990-2013: A systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014;384:1005-70.  Back to cited text no. 21
    
22.
IHME, Global Burden of Disease Collaborative Network. Global Burden of Disease Study 2016 (GBD 2016) Results. Institute for Health Metrics and Evaluation Seattle; 2017.  Back to cited text no. 22
    
23.
Kim HJ, Fay MP, Feuer EJ, Midthune DN. Permutation tests for joinpoint regression with applications to cancer rates. Statistics in Medicine 2000;19:335-51. Available from: https://pubmed.ncbi.nlm.nih.gov/10649300/.  Back to cited text no. 23
    
24.
Clegg LX, Hankey BF, Tiwari R, Feuer EJ, Edwards BK. Estimating average annual per cent change in trend analysis. Statistics in Medicine 2009;28:3670-82. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2843083/.  Back to cited text no. 24
    
25.
Potterton R, Austin A, Flynn M, Allen K, Lawrence V, Mountford V, et al. “I'm truly free from my eating disorder”: Emerging adults' experiences of FREED, an early intervention service model and care pathway for eating disorders. Journal of Eating Disorders 2021;9;1-14.  Back to cited text no. 25
    
26.
Ghaderi A, Stice E, Andersson G, Enö Persson J, Allzén E. A randomized controlled trial of the effectiveness of virtually delivered Body Project (vBP) groups to prevent eating disorders. J Consult Clin Psychol 2020;88:643-56.  Back to cited text no. 26
    
27.
Jurczak A, Bażydło M, Karakiewicz B. The incidence of eating disorders among upper secondary school female students. Psychiatr Pol 2020;54:253-63.  Back to cited text no. 27
    
28.
Zahid I, Jamali M, Alam SN, Hassan WU, Zafar O, Waseem HF. Is eating pathology prevalent among social media users of Karachi, Pakistan? A cross-sectional study. 2021. Available from: https://www.researchsquare.com/article/rs-322288/v1.  Back to cited text no. 28
    
29.
Javed Z, Rafique R. Predictors of eating habits of overweight young woman in Pakistan. PalArch's J Archaeol Egypt Egyptol 2021;18:246-65.  Back to cited text no. 29
    
30.
Warsi J, Mahar B, Ansari S, Shah T. Screening of eating disorders by using SCOFF questionnaire in diabetic male patients of District Hyderabad, Sindh, Pakistan. Pakistan Journal of Physiology 2020;16:41-4.  Back to cited text no. 30
    
31.
Ahmad OB, Boschi-Pinto C, Lopez AD, Murray CJ, Lozano R, Inoue M. Age Standardization of Rates: A New WHO Standard. Geneva: World Health Organization; 2001. p. 9.  Back to cited text no. 31
    
32.
Widiger TA, Costa PT, American Psychological Association, editors. Personality disorders and the five-factor model of personality. Washington, DC: American Psychological Association; 2013. Available from: https://awspntest.apa.org/buy/2012-10423-001.  Back to cited text no. 32
    
33.
Culbert KM, Racine SE, Klump KL. Research review: What we have learned about the causes of eating disorders – A synthesis of sociocultural, psychological, and biological research. J Child Psychol Psychiatry 2015;56:1141-64.  Back to cited text no. 33
    
34.
Uri RC, Wu YK, Baker JH, Munn-Chernoff MA. Eating disorder symptoms in Asian American college students. Eat Behav 2021;40:101458.  Back to cited text no. 34
    
35.
Keel P. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR). Washington, DC: American Psychiatric Association; 2000.  Back to cited text no. 35
    
36.
Ioannidis K, Taylor C, Holt L, Brown K, Lochner C, Fineberg NA, et al. Problematic usage of the internet and eating disorder and related psychopathology: A multifaceted, systematic review and meta-analysis. Neurosci Biobehav Rev 2021;125:569-81.  Back to cited text no. 36
    
37.
Brown Z, Tiggemann M. Celebrity influence on body image and eating disorders: A review. J Health Psychol 2022;27:1233-51.  Back to cited text no. 37
    
38.
Jiotsa B, Naccache B, Duval M, Rocher B, Grall-Bronnec M. Social media use and body image disorders: Association between frequency of comparing one's own physical appearance to that of people being followed on social media and body dissatisfaction and drive for thinness. International Journal of Environmental Research and Public Health 2021;18:2880. Available from: https://pubmed.ncbi.nlm.nih.gov/33799804/.  Back to cited text no. 38
    
39.
Siew CY. Predictors of Eating Behavior Disorder in Adolescent Girls and the Mediational Effects of Body Image. Universiti Putra Malaysia; 2009.  Back to cited text no. 39
    
40.
Hogan MJ, Strasburger VC. Body image, eating disorders, and the media. Adolesc Med State Art Rev 2008;19:521-46, x-xi.  Back to cited text no. 40
    
41.
Jordan AB, Kramer-Golinkoff EK, Strasburger VC. Does adolescent media use cause obesity and eating disorders. Adolesc Med State Art Rev 2008;19:431-49.  Back to cited text no. 41
    
42.
Shoger WM. The Unattainable “Reality”: How Media Affects Body Image in Men and Women and the Moderating Effects of Social Support. Illinois Institute of Technology; 2008.  Back to cited text no. 42
    
43.
Field AE, Austin SB, Camargo CA Jr., Taylor CB, Striegel-Moore RH, Loud KJ, et al. Exposure to the mass media, body shape concerns, and use of supplements to improve weight and shape among male and female adolescents. Pediatrics 2005;116:e214-20.  Back to cited text no. 43
    
44.
Ioannidis K, Hook RW, Grant JE, Czabanowska K, Roman-Urrestarazu A, Chamberlain SR. Eating disorders with over-exercise: A cross-sectional analysis of the mediational role of problematic usage of the internet in young people. J Psychiatr Res 2021;132:215-22.  Back to cited text no. 44
    
45.
WHO. Prevention of Mental Disorders: Effective Interventions and Policy Options: Summary Report. Geneva: World Health Organization; 2004.  Back to cited text no. 45
    
46.
Abebe DS, Lien L, von Soest T. The development of bulimic symptoms from adolescence to young adulthood in females and males: A population-based longitudinal cohort study. Int J Eat Disord 2012;45:737-45.  Back to cited text no. 46
    
47.
Stice E, Marti CN, Rohde P. Prevalence, incidence, impairment, and course of the proposed DSM-5 eating disorder diagnoses in an 8-year prospective community study of young women. J Abnormal Psychol 2013;122:445.  Back to cited text no. 47
    
48.
Artoni P, Chierici ML, Arnone F, Cigarini C, De Bernardis E, Galeazzi GM, et al. Body perception treatment, a possible way to treat body image disturbance in eating disorders: A case-control efficacy study. Eat Weight Disord 2021;26:499-514.  Back to cited text no. 48
    
49.
Jarman HK, Marques MD, McLean SA, Slater A, Paxton SJ. Motivations for social media use: Associations with social media engagement and body satisfaction and well-being among adolescents. J Youth Adolesc 2021;50:2279-93.  Back to cited text no. 49
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

 
Top
 
 
  Search
 
     Search Pubmed for
 
    -  Zahra SM
    -  Jha RP
    -  Safdar M
    -  Khalid MZ
    -  Khalid W
    -  Ali Nawaz Ranjha MM
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Material and Methods
Results
Discussion
Conclusion
References
Article Figures
Article Tables

 Article Access Statistics
    Viewed445    
    PDF Downloaded9    

Recommend this journal