Social Health and Behavior

: 2019  |  Volume : 2  |  Issue : 4  |  Page : 127--132

Eating disorder risk, sleep status, and anthropometric indices among teenage female students

Ahmadreza Rasouli1, Maryam Javadi2, Sara Mohiti1, Saeed Shahsavari3, Koorosh Kamali4, Mohammad Reza Shiri-Shahsavar2,  
1 Department of Nutrition; Student Research Committee, School of Health, Qazvin University of Medical Sciences, Qazvin, Iran
2 Department of Nutrition, School of Health; Children Growth Research Center, Qazvin University of Medical Sciences, Qazvin, Iran
3 Food Hygiene and Safety, School of Health, Qazvin University of Medical Sciences, Qazvin, Iran
4 Department of Public Health, School of Public Health, Zanjan University of Medical Sciences, Zanjan, Iran

Correspondence Address:
Dr. Mohammad Reza Shiri-Shahsavar
Department of Nutrition, School of Health, Qazvin University of Medical Sciences, Qazvin


Introduction: Eating disorder (ED) is characterized by a persistent disturbance of eating or eating-related behavior that results in significantly impaired physical health and psychosocial functioning. It has been revealed that ED patients had significantly lower sleep efficiency. The purpose of this study was to evaluate the prevalence of ED risk and its possible relationship with body mass index (BMI) and sleep status among primary high school girls in Zanjan, Iran. Methods: Teenage girl students (12–15 years old, n = 370) participated in a descriptive study with a cross-sectional design and completed the Eating Attitude Test-26 and Pittsburgh Sleep Quality Index questionnaires. Cluster random sampling method was applied. Disordered eating attitudes, recent sleep quality, and anthropometric measures were extracted. Statistical analysis was performed using SPSS software version 24.0. Results: A statistically significant relationship was found between sleep quality score and ED risk in this study (P < 0.001). No significant relationship was found between waist circumference, weight, and BMI with the risk of ED (P > 0.05). Conclusion: The high prevalence of ED risk was found among school students in this study. Further studies are needed to evaluate the correlation between ED risks and sleep quality as well as BMI.

How to cite this article:
Rasouli A, Javadi M, Mohiti S, Shahsavari S, Kamali K, Shiri-Shahsavar MR. Eating disorder risk, sleep status, and anthropometric indices among teenage female students.Soc Health Behav 2019;2:127-132

How to cite this URL:
Rasouli A, Javadi M, Mohiti S, Shahsavari S, Kamali K, Shiri-Shahsavar MR. Eating disorder risk, sleep status, and anthropometric indices among teenage female students. Soc Health Behav [serial online] 2019 [cited 2020 May 30 ];2:127-132
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Full Text


A growing prevalence of eating disorder (ED) is expected as countries progress, particularly in teenagers.[1],[2] ED is a psychiatric disease with abnormal eating habits, inappropriate control of body weight, disturbances in the perception of body shape, and seriously disturbed eating behavior. Based on the diagnostic guide and statistics for psychiatric disorders of the American Psychiatric Association, ED is classified into the following four major groups: anorexia nervosa (AN), bulimia nervosa (BN),[3] ED not otherwise specified, and binge ED (BED).[4] The complications are nutritional, psychiatric, and physical health disturbances.[5] Although ED is more common at the age of 25 or below and mainly occur among females,[6],[7],[8],[9] studies have shown that ED is increasing in young males.[10],[11] The fact that women usually care more about themselves appearance and slimness leads to higher prevalence of rigid dieting among them.[12],[13] Various physical and psychological consequences may occur due to disruption in eating and/or sleeping behavior.[14] In Delvenne et al.'s study, cases with AN had lower sleep times, low-quality sleep, and rapid eye movement sleep compared to healthy controls.[15]

It has been found that women have more complaints about sleep disturbances.[16] Higher Pittsburgh Sleep Quality Index (PSQI) score indicates poor sleep quality. Women have higher PSQI scores than men, and female gender is independently associated with the global PSQI score.[17] Women with AN reported more sleep disturbances and poorer global sleep on the PSQI scale.[18] It has been reported that sleep disorder in BN cases was observed to be less than those with AN, due to lack of malnutrition.[14] Sleep latency and lower sleep quality were more common in patients with obesity and BED in compared to non-BED patients with normal body weight.[18] Kim et al.'s study showed that patients with overeating disorders (such as BN and BED) have more sleep disorder than those with nonovereating disorders (such as AN and limiting type).[19] In another study in Sweden (n = 3790), an increased risk of ED was associated with short or poor sleep, even after controlling depression and obesity. In BED, it was established that women are 5.5 times more predisposed to suffer from disordered sleep quality than men.[20] Yeh and Brown's study found that BED is part of the relationship between body mass index (BMI) and poor sleep quality.[21] Obesity and short sleep duration have been associated with each other in both adolescents and adults, based on meta-analysis studies.[22],[23]

Short-term and low-quality sleep have been reported to be associated with obesity or overweight in youth.[17] Other studies have confirmed that stress caused by current weight, poor sleep, depression, and anxiety may be associated with weight gain and delay in diet patterns called night eating syndrome (NES).[21],[22] It seems that NES is associated with stress caused by current weight, poor sleep quality, and high BMI among students.[22],[23],[24] People use eating to relax and better sleep due to effectiveness of eating in sleep. The digestive process may slow down the process of biological and cognitive processes, which may be beneficiary at night. However, people might experience reflux and other negative health effects.

Regarding the complications of ED in adolescents and the adverse effect of ED in girls, especially in adolescence, the present study was aimed to investigate the possible relationship between ED risks with anthropometric measures and sleep status among primary high school girl students in Zanjan.


Participants and procedures

This cross-sectional descriptive study was carried out in 2018 in Zanjan on 12–15-year-old primary high school girl students. Students were selected using two-stage random cluster sampling. Zanjan city was divided into five sections (north, south, east, west, and center). Two schools were randomly selected from each section, and two classes were randomly selected from each school. After explaining the project, students who were willing to participate in the project were selected, and an informed consent form was signed by the students. Because the students were under legal age, in all of the selected schools, during a meeting that teachers and students' parents have been attended, the project was fully explained and at the end of the meeting, an informed consent form was signed by the students' parents. Finally, 370 students participated in the study (approximately 7% of all primary high school girl students in Zanjan). After ethic comity approval (code: IR.QUMS.REC.1396.364), data collection began. All participants received informed consent, and those with physical, mental, or chronic complications as well as pregnant females were excluded from the study. In addition to completing the questionnaire, trained experts performed anthropometric assessments and unnamed questionnaires were completed and recorded confidentially.


The questionnaire consisted of sections including demographic information, Eating Attitudes Test-26 (EAT-26), and PSQI.

Demographic questionnaire was used to obtain basic personal and demographic data including age, educational level, number of family member, birth rank, menstrual status, pain status during menstruation, stress caused by current weight, fast-food consumption frequency, and any specific disease. The level of stress caused by current weight was determined using a Likert-scale self-report question, and fast-food consumption status was also self-reported and was obtained by selecting one of the following options: no, daily, weekly, monthly, seasonal, or annual consumption.

Eating Attitude Test-26

The EAT-26 questionnaire was used to assess ED behaviors. It is a valid tool with 26 cases to assess risk factors for ED such as food restriction, eating, cleaning, and environmental effects on food intake.[24] This Likert scale has 6 scores for each question. For questions 1–25, the terms “always,” “usually,” and “often” are valued 3, 2, and 1, respectively, and three other scales (never, rarely, and sometimes) as 0. For question 26, “never,” “rarely,” and “sometimes” are scored 3, 2, and 1, respectively, and the other three scales were scored as 0, while the total score range was 0–78. We defined score ≥20 as inappropriate eating attitudes and considered as at risk of ED. The Persian version of EAT-26 has been confirmed in numerous studies.[25],[26]

Sleep quality

The PSQI questionnaire was applied as a standard tool for determining the quality of sleep. The Persian version of this questionnaire has been approved in Farrahi et al.'s study.[27] The PSQI questionnaire has seven components and evaluates Subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, using sleep medications, and daily dysfunction. The total scores for these seven components give the global score as a sleep quality score. Each question gets a score of 1–3, and the total score of the questionnaire is in the range of 0–21. Higher scores show lower sleep quality. For each component, score 0 indicates no sleep problem, 1 indicates mild problem, 2 indicates serious problem, and 3 indicates a very serious sleep problem. The total scores of sleep quality are classified as lower or higher grade 5 and are labeled as normal and poor, respectively.[18] PSQI was translated in Iran by Yazdi et al.[28] The high values of validity and reliability (94% and 72%, respectively) and the Cronbach's alpha coefficient of 0.77 for this questionnaire were assessed by Farrahi Moghaddam et al.[29]

Weight status

Body weight was measured using Seca scale with lightweight clothing and no shoes. Height was measured using the Seca meter (range: 0–220 cm) in the standard position, without shoes and hats. BMI was calculated based on the following formula: weight (kg)/height (m2) and using the age- and sex-specific WHO percentiles reference data 2007. Based on the WHO 2007 Growth Indicators, adolescents were divided into low-weight, normal, overweight, and obesity category.[30],[31]

Statistical analysis

Data analysis was carried out using 24.0 /Released in March 15, 2016, Developer: IBM Corporation, New York, U.S.A. Descriptive analysis was done, calculating the mean and standard deviation for continuous variables and proportions for the categorical variables. Chi-square test was applied to investigate the relationship between categorical variables (stress caused by current weight, sleep quality, sleep disorder, birth rank, father's job, mother's job, fast-food consumption, and ED). In order to investigate the relationship between continuous variables (age, weight, height, BMI, waist circumference, sleep quality score, sleep duration, eating score, and number of family members) and ED, independent t-test was applied. In addition, multivariate linear regression was applied to assess the linear relationship between the ED score and family member, fast-food consumption, stress caused by current weight, sleep quality, and BMI variables. Confidence interval (95%) was calculated for each variable, and P < 0.05 was considered statistically significant.


Female high school students, (n = 370) aged 12–15 years, participated in this study. According to the WHO age- and sex-specific BMI percentiles, 56.6% of students were within the normal range, 35.8% were underweight, 7.3% were overweight, and 0.3% were obese. The results of study revealed that 37.3% (n = 138) of the students had intermediate level of stress caused by current weight. It was shown that 20.7% of those with very high level of stress caused by current weight reported eating score ≥20; totally, stress caused by current weight in students with the eating score ≥20 was high than that of others (P < 0.001). The results showed that 75.6% (n = 258) of students had weak sleep disorder and 36.9% (n = 38) of those with intermediate level of sleep disorder reported eating score ≥20, while 10.5% (n = 25) of students with intermediate level of sleep disorder reported eating score <20 (P < 0.001). It was shown that fast-food consumption of 43.9% (n = 162) of students was seasonal. The frequency of eating fast food weekly in students with eating score ≥20 was high than those who had eating score <20 (5.4% vs. 1.2%), (P < 0.007) [Table 1]. In this study, no significant differences were found in those with and without the risk of ED in terms of other qualitative variables.{Table 1}

[Table 2] compares the continuous variables between healthy controls and those with disordered eating attitudes. Statistically significant differences were reported in the mean sleep quality score (P < 0.039) and mean number of family member (P < 0.033) between the two groups. Thus, students with an eating behavior score of 20 or above had statistically higher mean sleep quality score and mean family member than their healthy counterparts [Table 2].{Table 2}

Multivariate linear regression results based on dependent variable of eating score and independent variables of family member, fast-food consumption, stress caused by current weight, sleep quality, and BMI showed that only stress caused by current weight level variable significantly increased eating score [Table 3].{Table 3}


This study investigated the possible relationship between ED and sleep status and anthropometric indices in teenage girls. According to the results, 28.2% of the individuals were at risk of ED, which is higher than previous reports in Iran [26] and other countries.[32],[33] The present data are in accordance with similar studies in the USA [34] and Japan.[35] However, a significant relationship between sleep quality score and ED was detected. Soares et al. revealed a relationship between eating and sleep disorder, particularly with malignant behavior and social pressure to eat.[36] In another study in 2017, students with night ED had less sleep time duration and lower sleep quality, although it was not clear whether overnight fasting was a response to sleepiness or contrariwise.[37] Bos et al. found that people with severe ED experience significant sleep disturbance in starting and maintaining sleep.[38] Kim et al.'s study showed that patients with overeating disorders (such as BN and BED) have more sleep disorder than those with nonovereating disorders (such as AN and limiting type).[19] In another study in Sweden (n = 3790), poor or short sleep was associated with an increased risk of ED, even after controlling for depression and obesity. In BED, it was observed that women are 5.5 times more predisposed to suffer from disordered sleep quality than men.[20] Yeh and Brown's study found that BED is part of the relationship between BMI and poor sleep quality.[21] According to past studies, short sleep duration is associated with high BMI in adolescents.[22],[23]

Our study found no significant relationship between ED, BMI, and waist circumference. Our results were in contrast to other results.[36],[39] This difference can be due to cultural and social differences, levels of physical activity, as well as stress caused by current weight levels and other factors.

Our results showed a significant difference between the mean score of sleep quality, in people with ED and those without ED. Hao-Chang et al. reported that overweight and obesity (40% and 60%, respectively) were more associated with sleep disturbances than normal weight and obese/overweight cases who had higher PSQI scores. Nolan and Geliebter also reported lower sleep quality in students with NES, compared to others.[40]


Cross-sectional design was the main constraint of this study. Hence, longitudinal studies are suggested for a more accurate analysis of causal relationships between the variables.


In the present study, individuals with ED had a higher PSQI score and lower sleep quality score than others. Hence, it is essential to expand strategies for prevention, early detection, and treatment of these problems from a broad perspective.


The authors gratefully acknowledge Qazvin University of Medical Sciences, Education Department of Zanjan, and the adolescents who participated in this study. This research is part of a thesis project.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


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