Body Image and Disturbed Eating Attitudes Among Adolescents

Received 11 Feb, 2021

Accepted 04 Aug, 2021

Published 30 Sep, 2021

, Among all the psychiatric conditions, eating disorders has the highest mortality rates and most of the sufferers are adolescents. As the standards for beauty and attraction are changing and creating a bigger gap between actual and ideal body images resulting in dissatisfied, striving individuals to attain ideal body weight and shape. The current study is intended to explore the impact of closely related but discrete aspects of body image on disturbed eating attitudes among adolescents in Pakistan. Schools and universities were selected through convenient sampling, based on cross sectional research study involved 300 students of 15-20 years (M = 17.23, SD = 1.42) who completed the Eating Attitudes Test and Multidimensional Body-Self Relations Questionnaires. Analyses revealed that the adolescents with disturbed eating attitudes had scored significantly more on cognitive and affective components of body image that is overweight preoccupation and dissatisfaction with their body parts when compared to adolescents with normal eating patterns. Findings of this study are consistent with the existing literature in western culture that suggests that Preoccupation with weight and shape and body dissatisfaction is a risk factor for disturbed eating attitudes among adolescents.

Eating disorders (EDs) are marked by persistent and severe disturbances in eating or eating patterns, related cognitions which causes hindrance in individual’s daily functioning. The current Diagnostic and Statistical Manual of Mental Disorders - 5^th edition (American Psychiatric Association, 2013) includes three eating disorder diagnosis: Anorexia Nervosa (AN), Bulimia Nervosa (BN) and Binge eating disorder (BED). Eating disorders are not commonly reported group of disorders but it is a most serious group of disorders with profound psychological and physical impact along with the heightened risk for chronicity and mortality. A meta-analysis of literature from 1966 to 2010 showed that as compared to other psychiatric illnesses, highest death rate has been found in patients of anorexia nervosa(Arcelus, Mitchell, Wales, & Nielsen, 2011).

Initially in 1970s, Eating Disorders (EDs) were considered specifically limited to the western countries (Hoek et al.,2005). Since the 1980s, however, EDs are becoming truly global. Numerous countries reported rising incidences of EDs particularly in South Asian regions (Chisuwa & O’Dea, 2010; Pike, Dunne, & Grant, 2015; Pike, Hoek, & Dunne, 2014). The epidemiological data reflected that representation of insufficient number of symptoms of eating disorders (Otherwise Specified eating disorder) in clinical setting is more prevalent than full blown eating disorders (Machado, Machado, Gonçalves, & Hoek, 2007; Micali, Hagberg, Petersen, & Treasure, 2013). Studies conducted in different cities of Pakistan concluded females in adolescents age groups are found to be suffering from dysfunctional eating behaviors thus, are more vulnerable to develop eating disorders as compared to males and older age group population (Babar et al.,2002; Zulfiqar et al.,2014). Similarly, Mahmood and Bibi (2014) conducted a survey at private sector hospital in Karachi and found that about two fourth of the female nurses were suffering from partial anorexic syndrome. Noticeably the reported prevalence percentage is much higher when compared to the earlier reported percentages from Asia.

Since the Pakistan has entered period of transition of increasing industrialization and urbanization it brings radical changes into dynamics of socio cultural norms and values. Thin body ideals have never seen part of Pakistani society but with the media advancements and westernization; it has become a focal point of beauty standards (Jalees, & de Run, 2014; Swami, 2015). It has been reported that the fascination towards thinner body in Pakistani women is similar as in western women (Bardwell & Choudary, 2000).

Body image disturbance is highly prevalent among adolescents (Voelker, Reel, & Greenleaf, 2015). Studies conducted in Pakistan have found that on average 40-50% of adolescent boys and girls report marked dissatisfaction with their bodies (Khan, Khalid, Khan, & Jabeen, 2011; Najam & Ashfaq, 2012; Saleem, 2017). Negative body image has been consistently predicted as the most significant risk factor for developing and maintaining disordered eating and unhealthy weight control practices among adolescents (Dakanalis et al.,2017; Rohde, Stice, & Marti, 2015; Stice, Marti, & Durant, 2011; Stice, & Shaw, 2002). The same patterns have been reported in studies conducted in Pakistan (Jan, 2018; Suhail, 2002).

Most often body image is measured by calculating the gap between ideal and real body weight and level of satisfaction associated with it. However, body image not merely limited to the one’s feeling of satisfaction and dissatisfaction towards body weight whereas, it is a multidimensional concept comprises of affective, perceptual, cognitive, and behavioral components (Neagu, 2015). Likewise, disturbances in these distinctive aspects of body image will manifest through certain set of clinical or sub clinical symptoms such as distortion of body size such as self-classified weight (perceptual component), body image satisfaction/dissatisfaction (affective component), preoccupation with fear of gaining weight (cognitive component) and weight monitoring and controlling practices (behavioral component).

Self-classified weight is defined as the categorization of one’s weight from very underweight to overweight on the basis self-perception rather than measured weight. Whereas dissatisfaction with body weight is defined as the negative thoughts and feelings regarding one’s weight and/or shape. Preoccupation with weight is explained as the excessive thinking about the weight/shape. Among all aspects of body image, preoccupation with weight/shape is the least discussed in Pakistan. Whereas its significance in predicting the onset of disordered eating behaviors in adolescents has been showed by a longitudinal study conducted in west (Sharpe et al., 2018). These facets seem to be closely related but each has distinctive association with the eating pathology. Self-classified weight/ shape and dissatisfaction with weight/shape has been explored simultaneously by number of studies in Pakistan.

A study conducted by Suhail (2002) showed prevailing trends of body dissatisfaction and disturbed eating attitudes along with two diagnosed bulimia nervosa cases and another two for eating disorders not otherwise specified (EDNOS) among women. Furthermore, his study results depicts fairly common phenomenon of self-classification of weight that is 59% of normal weight and 21% of underweight women in his study classified themselves to be overweight, which could be a risk factor for depression. Similarly other studies conducted in Karachi (Saleem, Ahmed, Mulla, Haider, & Abbas, 2013; Sirang, et al., 2013) showed that about 30-43% of the sample of male and female university students misclassifying their weight status.

Further, recent studies (Alkazemi, Zafar, Ebrahim, & Kubow, 2018; Almenara, Fauquet, López-Guimerà, Massana, & Sánchez-Carracedo, 2014) have shown associations between distorted weight perceptions and unhealthy dieting and weight control behaviors in adolescents. However, in Pakistan this has to be explored yet.

Despite its significance, as eating disorders are the emerging field in our Asian countries (Pike, Dunne, & Grant, 2015), literatures on risk factors of disordered eating among adolescents of Pakistan is limited. Most of the studies done are regarding the prevalence rates. Therefore, studies dealing with the interaction between these variables are hard to find. However, it has been indicated from past studies that consequences of body image disturbance can be severely damaging for adolescents from both physical and psychological aspects. Hence the aim of the study was to examine the risk factors for disturbed eating attitudes among adolescents. More specifically present study focused on the association between cognitive, affective, and behavioral aspects of body image with the disturbed eating attitudes. This will provide opportunity to distinguish the relative importance of each component as a risk factor for developing disordered eating attitudes to develop better and effective strategies. The objectives for the study are:

1. To see the differences on facets of body image between groups with disturbed eating attitudes and normal eating attitudes.
2. To see association and contribution of satisfaction with weight/shape, preoccupation with weight/shape and self-classified weight on disturbed eating attitudes in adolescents.

METHOD

Sample
Convenient sampling strategy was used for sample selection. Three hundred adolescents (150 male and 150 females) of age ranged from 15-20 years (M = 17.23 and SD = 1.42) from different private sector school, colleges and universities of Karachi, Pakistan participated in this study. G power 3.1 was used to reckon the estimated sample size of 138, with confidence interval of 95%. To deal with the refusals and biases 60% more population was added to the sample size. Total 320 survey forms were administered. After discarding 20 incomplete forms, 300 forms were included in quantitative analysis. The average age of 300 participants was 17.23 ±1.42 (standard deviation SD) years. Participants were asked to report their height and weight (measured in last 6 months) to calculate BMI (kg/m²). This is considered as a valid measurement (Moreira et al., 2018; Olfert et al., 2018). BMI ranged from 12 to 37.70 (M = 20.9, SD = 3.69) kg/m2. Total 60.3% of sample population was normal weight which included 30.3% males and 30% females. Individuals with body weight below their expected age range fall in the category of underweight. There was total 20.3% under- weight individuals (males 12%, females 8.3%). There were total 1.6% females with severe underweight. Rest of the 17.6% data population (males = 7.6%, females = 10%) were overweight. Regarding the prevalence rate of disturbed eating attitudes in adolescents, there were 22.66% individuals who found with disturbed eating patterns. Among them 10.66% were males and 12% were females.

Measures
The Eating Attitudes Test (EAT-26). (Garner, Olmsted, Bohr, & Garfinkel, 1982) “Eating Disorder Risk” was assessed by using the English version of EAT 26 questionnaire. It covers the attitudinal and affective aspects of disturbed eating patterns. The three subscales i.e. Dieting, Bulimia and Food Preoccupation, and Oral Control consist of 13, 6 and 7 items respectively. Participants rated their response on each item from 3 (always) to 0 (never). A total score 20 or higher in the questionnaire indicates heightened probability of having or acquiring eating disorder.

The Multidimensional Body-Self Relations Questionnaire-Appearance Scales (MBSRQ-AS). This scale is developed by Cash (2000) and is a validated self-report questionnaire for the assessment of body image. English version has been used to assess the five facets of body image. It consists of 5 subscales and 34-items which attempted to measure the discrete aspects of body image that is Appearance Evaluation (AE), Appearance Orientation (AO), Overweight Preoccupation (OWP), Self-Classified Weight (SCW), and the Body Areas Satisfaction Scale (BASS). For item 1-22 scoring is done on 5 points likert scale, assessing the level of agreement from 1= definitely disagree to 5 = definitely agree. Item 23-25 has five options and item 26-34 again rated on 5 points likert scale assessing the level of dissatisfaction, 1 = very dissatisfied to 5 = very satisfied. The MBSRQ-AS has internal consistency Cronbach’s alpha = .73 to .89 on the subscale level and test-retest reliability (r = .74 to .91).

PROCEDURE

First, authorities of different school, colleges and universities were approached to get permission to conduct the study. Written informed consent was taken from people above 18 years and for below 18 years consent was taken from their parents prior to approaching the students. Researcher explained the intent of the study and written consent was taken from students as well. They were assured the confidentiality and anonymity of the data. Following this, participants filled the questionnaire. Questionnaires were administered with the group of 15 students at a time. Researcher was present during the administration to supervise the process. Participants were instructed to ask any questions regarding the questionnaire during the administration procedure. Average time taken by the groups to complete the procedure was 40 minutes. The overall process of pooling the data of 300 participants took 4 months.

RESULTS

Statistical analyses were calculated using SPSS Statistics (SPSS, v.23). Prevalence of disturbed eating patterns in adolescent i.e., participants who scored ≥ 20 on EAT-26 questionnaire. There were 22.66% individuals (n = 68) with disturbed eating patterns and rest of sample (n = 232) had score less than 20 considered having normal eating attitude. To compare the level of body image disturbance between participants with disturbed eating attitude and normal eating, Welch’s test was used for the purpose of analysis. Welch's t-test is designed for unequal population variances, while the assumption of normality is maintained. Linear regression was employed to assess the association and contribution of facets of body image onto disturbed eating attitudes.

Table 1:	Welch’s t-values on Facets of Body Image for Groups of Adolescents with Disturbed Eating and Normal Eating Attitudes
Note. Eat-26 = Eating Attitude Test-26; MD = Mean Difference; Skew = Skewness; Kurt = Kurtosis; AE = Appearance Evaluation; AO = Appearance Orientation; BASS = Body Area Satisfaction Scale; OWP = Over Weight Preoccupation; SCW = Self-Classified Weight

Table 1 illustrates the skewness and kurtosis for normality of variables. As the unequal variances can influence the Type 1 error rate from the nominal alpha level therefore, Welch’s t test was applied to calculate the mean difference between the appearance evaluation, appearance orientation, body area satisfaction, overweight preoccupation and self-classified weight. Participants were divided into two groups according to their eating attitude test (Group 1: EAT26 < 20 and Group 2: EAT26 > 20). Participants with disturbed eating attitudes had lower appearance evaluation scores, higher overweight preoccupation scores, lower body area satisfaction scale scores and lower self-classified weight score. There were significant mean differences between groups and body area satisfaction scale scores and overweight preoccupation scores and were highly associated as p-value < .05.

Table 2:	Summary of Linear Regression Analysis wit Five Facets of Body Image as Predictor of Disturbed Eating Attitudes
Note. AE = Appearance Evaluation; AO = Appearance Orientation; BASS = Body Area Satisfaction Scale; OWP = Over Weight Preoccupation; SCW = Self-Classified Weight

Table 2 shows the association and contribution of facets of body image on to disturbed eating attitudes of adolescents. Regression analysis indicates of five facets of body image on the body area satisfaction and overweight preoccupation were found to be significant predictors of disturbed eating attitude and explained 2% (F = 0.023, p = .008) and 7 % (F = 0.070, p = .000) variance respectively. The body area satisfaction was found to be negatively (β = -.152, p = .008) associated with disturbed eating attitudes whereas positive (β = .266, p = .000) association is evident between overweight preoccupation and disturbed eating attitudes. The remaining three predictors that is appearance evaluation, appearance orientation and self-classified were found to be insignificant predictors of disturbed eating attitude (p > 0.05).

Table 3:	Welch’s t-values on Eating Disorder Tendencies and Facets of Body Image Among Male and Female Adolescents
Note. Eat-26 = Eating Attitude Test-26; MD = Mean Difference; AE = Appearance Evaluation; AO = Appearance Orientation; BASS = Body Area Satisfaction Scale; OWP = Over Weight Preoccupation; SCW = Self-Classified Weight

Table 3 illustrates that there was nonsignificant difference in the scores for male (M = 14.13, SD = 10.63) and female (M = 13.36, SD = 9.15) and p > 0.50. These results suggest that disturbed eating attitudes has been equally found in males and females both. Furthermore on the five facets of body image significant gender difference was found only on the variable of self classified weight; for male (M = 2.750, SD = 0.848) and female (M = 3.036, SD = 0.797) and p < 0.50. Suggesting that as compare to males; females have more inclination to perceive themselves as overweight. On the contrary, males perceived themselves as underweight. On the remaining four facets of image that is appearance evaluation, appearance orientation, body area satisfaction and preoccupation with weight/shape no significant gender difference was found (p > 0.05).

DISCUSSION

Recent studies highlighted that eating disorders are not just limited to the western culture instead its now became a current growing area of concern in Asian regions as well (Babar et al., 2002; Memon et al., 2012). To cease its further escalation our current study intended to explore the contribution of discrete components of body image on disturbed eating attitudes in adolescents. Number of researches have been investigated these constructs but those researches are mainly conducted on western population which means that their relative importance in Asian population has so far not been discovered, thus warrants attention. The findings of the current study reveals the contribution of different aspects of body image in manifestations of eating disturbances in adolescents.

Our study results indicate that there is a significant difference in adolescents with normal eating and disturbed eating attitudes on cognitive (over weight preoccupation) and affective aspects (body satisfaction/dissatisfaction) (Table 1). In general adolescents show concerns about weight and shape but adolescents with disordered eating patterns (scored ≤ 20 on EAT 26) were seemed to be more fearful of gaining weight or becoming “Fat” and dissatisfaction with the certain body part such as abdomen, buttocks and thighs; which are accounted as the important markers in DSM-5 (American Psychiatric Association, 2013) for diagnosing Anorexia Nervosa.

Further clarifying the role of distinct components of body image in developing eating attitude among adolescents, Regression analysis was applied on data (table 2). Results indicates that cognitive and affective factor of body image that is overweight preoccupation was found as the strongest variable for predicting disturbed eating patterns in adolescents. Mirroring the outcomes of Mitchison et al. (2017) study which also indicates preoccupation with the concerns of weight as the strongest independent predictor of disturbed eating behaviors such as dietary restrains. Similarly Sharpe et al. (2018) in their longitudinal study highlighted that preoccupation with the fear of gaining weight and losing desired body shape was the strongest factor in female adolescents’ inclination towards weight reduction plans such as fasting, pills consumptions and excessive workouts. This may attributed to the societal and cultural factors. Social and culture’s strong emphasis on the importance of physical beauty and unrealistic beauty ideals inculcate body image issues resulting in escalation of body dissatisfaction in male and females both. Initially eating disorders was considered as the risk factors only for the females whereas recent researches suggests that body dissatisfaction and eating pathologies also prevail in males too (Baker et al., 2019). A study conducted in Pakistan with obese/overweight individuals reported that binge eating disorder is commonly found in males and females both. 15.7% participants had moderate binge eating disorder while 14.9% was having severe binge eating disorder. But unfortunately in most of the cases binge eating disorder goes undiagnosed (Malik, Shaukat, & Hussain, 2019). Our study results are also in line with the current findings and showed disturbed eating attitudes were found in both genders equally (Table 3).

Overall majority of the study participants showed most dissatisfied feeling towards the lower torso (buttocks, hips, thighs and legs), Middle torso (waist and stomach) and muscle tone. Interestingly, along with the overweight adolescents; adolescents falling in the categories of “normal” and “underweight” showed dissatisfaction towards their stomach, waist, hips, thighs and legs. Diagnostic and Statistical Manual of Mental Disorders, fifth edition (American Psychiatric Association, 2013) define dissatisfaction with the certain body parts as the significant markers for diagnosing disordered eating. Our study results further indicate that dissatisfaction with certain body area may have a tendency to prone individual towards disturbed eating patterns (Table 3). From the lenses of cognitive theories of eating disorder the maladaptive appearance related schemas are responsible for directing individuals attentions towards weight and shape related stimulus and to process information in biased fashion. Thus, this misinterpretation of one’s body parts, overall weight and shape may result in maintenance of negative body image, high alertness (hypervigilence) towards the body parts which are considered to be flawed by one own self. This misinterpretation evoke negative emotions such as depression and anxiety, to get rid out of this aversive state resulting in indulgence of individual in disturbed eating patterns for example restricted dieting, purging and other unhealthy weight control behaviors (Tuschen-Caffier et al., 2015; Williamson, White, York-Crowe, & Stewart, 2004).

Other plausible explanation through which body image conflicts develop and trigger unhealthy eating is the advancements in media and technology broaden the ways for individuals to get interconnected with each other, increased exposure to the western culture results in adoption and idealization of their ideas of physical attraction and beauty ideals which in turn cultivate body dissatisfaction. The link between westernization and increased vulnerability of Asian population for eating pathology is highlighted by researches (Mumford, Whitehouse, & Choudry, 1992; Ung 2003). As the media influence has been increasing day by day, developing stereotypes about body types that ultimately effects body preferences (Groesz, Levine, & Murnen, 2002). Literature from a qualitative research suggested that a large body size triggers complex and consistently negative stereotype such as lazy and ugly. Whereas thinness triggers more positive associations such as smart, intelligent and beautiful (Puhl & Brownell, 2001). The association of positive characteristics with thinness and perfectly shaped bodies works as reinforcer for social acceptance/approval, resulting in constant body concerns and related practices. Our study population is comprised of adolescents, which is marked by the time period when identity formation takes place.

Adolescents with the fragile sense of self, shows conformity with the external sources to bring balance to their pseudo identity. One such external source is society’s standards of beauty and attractiveness (i.e., thinness for women, muscularity for men). Striegel (1993) supported the idea and explained that focus on physical appearance is actually a strategy of an adolescent with fragile sense of self for identity affirmation. This is an adaptive response to cope with the challenges faced during the developmental stages of adolescence. Kamps and Berman (2011) and Verschueren et al. (2018) further reported identity distress as a significant predictor of appearance evaluation, body areas satisfaction, and overweight preoccupation. Thus idealization of societal standards of beauty and attractiveness leads to increased body focus anxiety, resulting young people to compulsively engage in disturbed eating patterns as a response to preoccupation (obsession) with body image.

This characteristic closely relates eating disorders with the other psychological disorders such as obsessive compulsive disorder (OCD) and body dysmorphic disorder (BDD). Therefore, the role of preoccupation in developing eating pathology must be explored in future researches. Moreover, preoccupation with body, weight and shape as a risk factor for eating disorders has not been incorporated in majority of eating disorder models. This component of body image would be beneficial in designing interventions for clients

In addition, interestingly underestimation of weight among over weight individuals has been found in our study results. According to BMI measures, there were 17.66% adolescents falling in the category of “overweight” whereas only 3.6% individuals identify themselves as overweight. Failure to identify oneself as overweight or obese the condition which is tentatively known as Fatorexia (Granese, Pietrabissa, & Mauro Manzoni, 2018). It could be attributed to the cultural factor. According to WHO (2016) statistical analysis, 20.8% of the population of Pakistan isoverweightand 4.8% isobese indicating, overweighing has become endemic to Pakistani society, from the visual normalization theory (Robinson, 2017) it increases the visual threshold for defining the criteria of “overweight” thus resulting in biased self-classification of weight and higher rates of obesity. Further attention is needed to explore this phenomenon.

Like most of the studies, current piece of work has also its strengths and weaknesses. Considering the first part; majority of the studies dealt with body image as a whole construct whereas the current study explores the associative relationship of different aspects of body image with heightened risk of developing eating disorders. Furthermore, following factors are accountable for the limitations. First, the cross-sectional design of the study does not permit testing causal hypothesis. Noticeably there are some researchers concluded the direct impact of body image in development and continuation of eating disorders (Dakanalis et.al 2017). A meta-analysis of longitudinal and experimental studies shows consistency with finding that body image disturbance is mainly the putative risk factor in developing clinical and sub clinical symptoms of eating disorder (Stice & Shaw, 2002). Moreover, Mitchison et al., 2017 study reported the contribution of three facets of body image that is preoccupation with the fear of gaining weight, dissatisfaction and self-classification of body weight and shape in developing eating disorder in longitudinal study with adolescents. However, longitudinal and experimental studies with the clinical population are required for testing directionality and possible interaction with other intermediate factors which may lead to disturbed eating patterns.

LIMITATIONS AND SUGGESTIONS

Like most of the studies, current piece of work has also its strengths and weaknesses. Considering the first part; majority of the studies dealt with body image as a whole construct whereas the current study explores the associative relationship of different aspects of body image with heightened risk of developing eating disorders. Furthermore, following factors are accountable for the limitations. First, the cross-sectional design of the study does not permit testing causal hypothesis. Noticeably there are some researchers concluded the direct impact of body image in development and continuation of eating disorders (Dakanalis et al., 2017). A meta-analysis of longitudinal and experimental studies shows consistency with finding that body image disturbance is mainly the putative risk factor in developing clinical and sub clinical symptoms of eating disorder (Stice & Shaw, 2002). Moreover, Mitchison et al. (2017) study reported the contribution of three facets of body image that is preoccupation with the fear of gaining weight, dissatisfaction and self-classification of body weight and shape in developing eating disorder in longitudinal study with adolescents. However, longitudinal and experimental studies with the clinical population are required for testing directionality and possible interaction with other intermediate factors which may lead to disturbed eating patterns.

IMPLICATIONS

These findings may help mental health professionals better understand the multifaceted aspects of body image with regard to the adolescents who are struggling with unhealthy and disturbed eating patterns such as dietary restraint, and binge eating. Body satisfaction influences one’s self esteem, thus professionals working with adolescent; self acceptance should be taken into consideration while working with this age group. Furthermore, I advocate for including eating related difficulties, body image related preoccupation and dissatisfaction in the treatment planning of adolescents suffering from disturbed or unhealthy eating attitudes. I also recommend a major shift in policy making about what should be portrayed as appropriate and body shaming and dehumanization should be discouraged on media also. Instead healthy lifestyle and self acceptance should be encouraged.

CONCLUSION

By testing the association and contribution of facets of body image in developing disturbed eating attitudes in adolescents, this study established that preoccupation with weight/shape and body satisfaction have a significant effect on manifestation of disturbed eating attitudes, with a strong correlation between the preoccupation with weight/shape, dissatisfaction with weigh/shape and disturbed eating attitudes. On literary grounds, I believe this study is a major contribution in the area of eating disorders especially in adolescents as most of the work is around body image related issues and how does that impact one's mental health. However, the current study explores preoccupation and dissatisfaction with body weight and shape and we know this from existing literature that teens are very sensitive about their self image and how they are perceived physically. So if teen agers supposedly don't perceive themselves fitting the criteria for almost unattainable standards for body sizes and beauty standards projected by social media and main stream media, that would definitely reflect on their self esteem, self perception and overall mental wellbeing.

REFERENCES

1. Alkazemi, D., Zafar, T. A., Ebrahim, M., & Kubow, S. (2018). Distorted weight perception correlates with disordered eating attitudes in Kuwaiti college women.International Journal of Eating Disorders.
2. Almenara, C. A., Fauquet, J., López-Guimerà, G., Massana, M. P., & Sánchez-Carracedo, D. (2014). Self-perceived weight status, dieting and unhealthy weight-control behaviors among Spanish male adolescents. Nutricionhospitalaria.
3. American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5^th ed.). Arlington, VA: Author.
4. Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders: A meta-analysis of 36 studies.Archives of General Psychiatry.
5. Babar, N., Alam, M., Ali, S. S., Ansari, A., Atiq, M., Awais, A.,&Israr, S. M. (2002). Anorexic behaviour and attitudes among female medical and nursing students at a private university hospital.Journal of Pakistan Medical Association,52(6), 272-276.
6. Baker, J. H., Higgins Neyland, M. K., Thornton, L. M., Runfola, C. D., Larsson, H., Lichtenstein, P., & Bulik, C. (2019). Body dissatisfaction in adolescent boys. Developmental psychology.
7. Bardwell Mumford, D., & Choudry, I. Y. (2000). Body dissatisfaction and eating attitudes in slimming and fitness gyms in London and Lahore: A cross-cultural study. European Eating Disorders Review, 8(3), 217-224.
8. Cash, T. F. (2000). The Multidimensional Body-Self Relations Questionnaire. Retrieved from http://www.body-images.com.
9. Chisuwa, N., & O’Dea, J. A. (2010). Body image and eating disorders amongst Japanese adolescents: A review of the literature.Appetite.
10. Dakanalis, A., Clerici, M., Bartoli, F., Caslini, M., Crocamo, C., Riva, G., & Carrà, G. (2017). Risk and maintenance factors for young women’s DSM-5 eating disorders. Archives of Women's Mental Health.
11. Garner, D. M., Olmsted, M. P., Bohr, Y., & Garfinkel, P. E. (1982). The Eating Attitudes Test: Psychometric features and clinical correlates. Psychological Medicine.
12. Granese, V., Pietrabissa, G., & Mauro Manzoni, G. (2018). Do subjects with obesity underestimate their body size? A Narrative review of estimation methods and explaining theories. Psychology, Society, and Education.
13. Groesz, L. M., Levine, M. P., & Murnen, S. K. (2002). The effect of experimental presentation of thin media images on body satisfaction: A meta‐analytic review.International Journal of Eating Disorders.
14. Hoek, H. W., van Harten, P. N., Hermans, K. M., Katzman, M. A., Matroos, G. E., & Susser, E. S. (2005). The incidence of anorexia nervosa on Curacao. American Journal of Psychiatry.
15. Jalees, T., & de Run, E. C. (2014). Body image of Pakistani consumers. Journal of Management Science.
16. Jan, M. J. (2018). The body image in media and its impact on female adolescents in Pakistan. Retrieved from https://academicrepository.khas.edu.tr/bitstream/handle/20.500.12469/2192/0103501MalikJahangirJan.pdf?sequence=1&isAllowed=y.
17. Kamps, C. L., & Berman, S. L. (2011). Body image and identity formation: The role of identity distress.Revista Latinoamericana de Psicología, 43(2), 267-277. Retrieved from http://www.scielo.org.co/scielo.php? script=sci_arttext&pid=S0120-05342011000200006.
18. Khan, A. N., Khalid, S., Khan, H. I., & Jabeen, M. (2011). Impact of today's media on university student's body image in Pakistan: a conservative, developing country's perspective.BMC Public Health,11(1), 1-8. Retrieved from https://link.springer.com/article/10.1186/1471-2458-11-379.
19. Machado, P. P., Machado, B. C., Gonçalves, S., & Hoek, H. W. (2007). The prevalence of eating disorders not otherwise specified.International Journal of Eating Disorders.
20. Mahmood, A., & Bibi, Z. (2014). Eating disorders among MBA students in a Business School of Karachi.Journal of Nutrition & Food Sciences.
21. Malik, M., Shaukat, W., & Hussain, A. (2019). Binge eating disorder among obese/overweight in Pakistan: Under-diagnosed, undertreated and misunderstood. Clinical Investigation, 9(2), 75-80.
22. Memon, A. A., Adil, S. E. E. R., Siddiqui, E. U., Naeem, S. S., Ali, S. A., & Mehmood, K. (2012). Eating disorders in medical students of Karachi, Pakistan-a cross-sectional study. BMC Research Notes, 5(1), 84. Retrieved from https://bmcresnotes.biomedcentral.com/articles/10.1186/ 1756-0500-5-84.
23. Micali, N., Hagberg, K. W., Petersen, I., & Treasure, J. L. (2013). The incidence of eating disorders in the UK in 2000–2009: Findings from the general practice research database.BMJ open.
24. Mitchison, D., Hay, P., Griffiths, S., Murray, S. B., Bentley, C., Gratwick‐Sarll, K., ...& Mond, J. (2017). Disentangling body image: The relative associations of overvaluation, dissatisfaction, and preoccupation with psychological distress and eating disorder behaviors in male and female adolescents.International Journal of Eating Disorders,50(2), 118-126. Retrieved from https://onlinelibrary.wiley.com /doi/full/10.100 2/eat. 22592.
25. Moreira, N. F., Luz, V. G., Moreira, C. C., Pereira, R. A., Sichieri, R., Ferreira, M. G., ... & Rodrigues, P. R. M. (2018). Self-reported weight and height are valid measures to determine weight status: Results from the Brazilian National Health Survey (PNS 2013).Cadernos De Saudepublica.
26. Mumford, D. B., Whitehouse, A. M., & Choudry, I. Y. (1992). Survey of eating disorders in English‐medium schools in Lahore, Pakistan. International Journal of Eating Disorders.
27. Najam, N., & Ashfaq, H. (2012). Gender differences in physical fitness, body shape satisfaction, and body figure preferences.Pakistan Journal of Psychological Research, 187-200. Retrieved from https://www.pjprnip. edu.pk/index.php/pjpr/article/download/272/224/476.
28. Neagu, A. (2015). Body image: A theoretical framework. The Publishing House of Romanian Academy, 17(1), 29-38. Retrieved from https:/ /acad.ro/sectii2002/proceedingsChemistry/doc2015-1/Art04Neagu. pdf.
29. Olfert, M., Barr, M., Charlier, C., Famodu, O., Zhou, W., Mathews, A., ...& Colby, S. (2018). Self-reported vs. measured height, weight, and BMI in young adults.International Journal of Environmental Research and Public Health.
30. Pike, K. M., Dunne, P. E., & Grant, A. (2015). Prevalence and incidence of eating disorders in Asian societies. Handbook of eating disorders (pp. 64-78). Hoboken, New Jersey: John Wiley & Sons.
31. Pike, K. M., Hoek, H. W., & Dunne, P. E. (2014). Cultural trends and eating disorders.Current Opinion in Psychiatry,27(6), 436-442.
32. Puhl, R., & Brownell, K. D. (2001). Bias, discrimination, and obesity.Obesity Research.
33. Robinson, E. (2017). Overweight but unseen: A review of the underestimation of weight status and a visual normalization theory. Obesity Reviews.
34. Rohde, P., Stice, E., & Marti, C. N. (2015). Development and predictive effects of eating disorder risk factors during adolescence: Implications for prevention efforts. International Journal of Eating Disorders.
35. Saleem, M. D., Ahmed, G., Mulla, J., Haider, S. S., & Abbas, M. (2013). Weight misperception amongst youth of a developing country: Pakistan-a cross-sectional study.BMC Public Health.
36. Saleem, T. (2017). Body Dissatisfaction and Social Comparison among Pakistan University Students. Paper presented at National Conference of Psychology (NCP 2017): Emerging Social and Mental Health Issues in Society,Lahore Garrison University, Lahore.
37. Sharpe, H., Griffiths, S., Choo, T. H., Eisenberg, M. E., Mitchison, D., Wall, M., & Neumark‐Sztainer, D. (2018). The relative importance of dissatisfaction, overvaluation and preoccupation with weight and shape for predicting onset of disordered eating behaviors and depressive symptoms over 15 years. International Journal of Eating Disorders.
38. Sirang, Z., Bashir, H. H., Jalil, B., Khan, S. H., Hussain, S. A., Baig, A., ... &Kadir, M. M. (2013). Weight patterns and perceptions among female university students of Karachi: A cross sectional study.BMC Public Health.
39. Stice, E., & Shaw, H. E. (2002). Role of body dissatisfaction in the onset and maintenance of eating pathology: A synthesis of research findings. Journal of Psychosomatic Research.
40. Stice, E., Marti, C. N., & Durant, S. (2011). Risk factors for onset of eating disorders: Evidence of multiple risk pathways from an 8-year prospective study.Behaviour Research and Therapy.
41. Striegel-Moore, R. H. (1993). Etiology of binge eating: A developmental perspective. Retrieved from https://psycnet.apa.org/record/1993-98750-008.
42. Suhail, K. (2002). Prevalence of eating disorders in Pakistan: Relationship with depression and body shape.Eating and Weight Disorders-Studies on Anorexia, Bulimia and Obesity
43. Swami, V. (2015). Cultural influences on body size ideals.European Psychologist.
44. Syed, A., Din, Z., Zeb, F., Ghaffar, F., Khan, S., Iqbal, M., & Ali Khan, B. (2017). Eating attitude related to the nutritional status of university girls in Peshwawar Khyber Pakhtunkhwa.Pakistan. Journal of Clinical Nutrition and Dietetics.
45. Tuschen-Caffier, B., Bender, C., Caffier, D., Klenner, K., Braks, K., & Svaldi, J. (2015). Selective visual attention during mirror exposure in Anorexia and Bulimia Nervosa.PLoS One.
46. Ung, E. K. (2003). Eating disorders in Singapore: A review.Annals of the Academy of Medicine Singapore,32(1), 19-24. Retrieved from https:// europepmc.org/abstract/med/12625093
47. Verschueren, M., Claes, L., Bogaerts, A., Palmeroni, N., Gandhi, A., Moons, P., & Luyckx, K. (2018). Eating disorder symptomatology and identity formation in adolescence: A cross-lagged longitudinal approach. Frontiers in Psychology.
48. Voelker, D. K., Reel, J. J., & Greenleaf, C. (2015). Weight status and body image perceptions in adolescents: Current perspectives.Adolescent health, Medicine and Therapeutics.
49. Williamson, D. A., White, M. A., York-Crowe, E., & Stewart, T. M. (2004). Cognitive-behavioral theories of eating disorders. Behavior Modification.
50. World Health Organization. (2016). [online] [cited 2016 Dec 22]. Retrieved from https://www.who.int/diabetes/country-profiles/pak_en.pdf.
51. Zulfiqar, A., Laghari, Z., Warsi, J., Memon, M., Lashari, K., & Muhammad, S. A. (2014). Detection of eating disorders in university students using Scoff questionnaire. International Journal of Development Research, 4(8) 1634-1637.