Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 13 nº 4 - Oct/Dec - 2016

Original Article Imprimir 

Páginas 42 a 48

Risk Behaviors for the Development of Eating Disorders associated to Body Image and Nutritional Status of Adolescents in a Public School

Comportamientos de Riesgo para el Desarrollo de Trastornos Alimenticios asociados a la Imagen Corporal y el Estado Nutricional en Adolescentes de una Escuela Pública

Comportamentos de Risco para o Desenvolvimento de Transtornos Alimentares associados à Imagem Corporal e o Estado Nutricional em Adolescentes de uma Escola Pública

Autores: Vanessa Mayana Alves Baad1; Michelle Vance de Figueiredo Fulco2; Ana Carolina Rodarti Pitangui3; Marianne Louise Marinho Mendes4; Cristhiane Maria Bazílio de Omena Messias5

1. Master's Degree student in Adolescent Medicine. Bachelor's Degree in Nutrition, Pernambuco University (UPE). Petrolina, Pernambuco State, Brazil
2. Graduand in Nutrition, Pernambuco University (UPE). Petrolina, Pernambuco State, Brazil
3. PhD in Sciences, São Paulo University (USP). São Paulo, São Paulo State. Professor, Physiotherapy Course, Pernambuco University (UPE). Petrolina, Pernambuco State, Brazil
4. PhD in food Science and Technology, Paraíba Federal University (UFPB). João Pessoa, Paraíba State, Brazil. Professor, Nutrition Course, Pernambuco University (UPE). Petrolina, Pernambuco State, Brazil
5. PhD in Chemistry and Biotechnology, Alagoas Federal University (UFAL). Maceió, Alagoas State, Brazil. Professor, Nutrition Course and Teacher Training and Interdisciplinary Practices Graduate Studies Program (PPGFPPI), Pernambuco University (UPE). Petrolina, Pernambuco State, Brazil

Cristhiane Maria Bazílio de Omena Messias
Universidade de Pernambuco (UPE) - campus Petrolina, Curso de Nutrição
BR 203 KM2 S/N. Campus Universitário, Vila Eduardo
Petrolina, PE, Brasil. CEP: 56328-903;

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Keywords: Adolescent, feeding and eating disorders, body image, nutritional status.
Palabra Clave: Adolescente, trastornos de la alimentación y de ingestión de alimentos, imagen corporal, estado nutricional.
Descritores: Adolescente, transtornos da alimentação e da ingestão de alimentos, imagem corporal, estado nutricional.

OBJECTIVE: Identify the prevalence of risk behaviors for eating disorders, dissatisfaction with body image and nutritional status in adolescents.
METHODS: The sample consisted of 418 female teenagers with 10 to 17 years old from a Public School. Were applied questionnaires for the diagnosis of the population, perception of body image, body satisfaction and to the risk of developing eating disorders. We also assessed the nutritional status by anthropometric measures. The relationships between anthropometric measurements were performed by means of the Pearson correlation coefficient. For the data from the satisfaction questionnaire, we used the chi-square test with a significance level of 1% and the other descriptive statistics data.
RESULTS: Most of the study population was eutrophic through anthropometric assessment and satisfy with their current body structure. But the research showed a high percentage of adolescents at risk of having some type of eating disorder.
CONCLUSION: The perception of the adolescent's body image is appropriate to actual nutritional situation. However, even satisfied with their body image, the rates of risk for developing eating disorders found in the study were high.

OBJETIVO: Identificar la prevalencia de comportamientos de riesgo para trastornos alimenticios, insatisfacción con la imagen corporal y el estado nutricional en adolescentes.
MÉTODOS: La muestra fue compuesta por 418 adolescentes del sexo femenino entre la franja etaria de 10 a 17 años de una escuela pública. Fueron aplicados cuestionarios para diagnóstico de la población, percepción de imagen y satisfacción corporal y para el riesgo de desarrollo de trastornos alimenticios. El estado nutricional fue evaluado a través de medidas antropométricas. La relación entre las medidas antropométricas fue realizada por intermedio del coeficiente de correlación de Pearson. Para los datos provenientes del cuestionario de satisfacción se utilizó la prueba del Chi-cuadrado con el nivel de significancia del 1% y para los demás datos, estadística descriptiva.
RESULTADOS: La mayoría de la población se encontraba eutrófica a través de la antropometría y satisfechas con sus estructura corporal actual. Sin embargo se observó un alto porcentaje de adolescentes con riesgo de presentar algún tipo de trastorno alimenticio.
CONCLUSIÓN: La percepción de la imagen corporal de las adolescentes está adecuada a su real situación nutricional. Sin embargo, mismo satisfechas con su imagen corporal, los índices de riesgo para el desarrollo de trastornos alimenticios encontrados en el estudio fueron altos.

OBJETIVO: Identificar a prevalência de comportamentos de risco para transtornos alimentares, insatisfação com a imagem corporal e o estado nutricional em adolescentes.
MÉTODOS: A amostra foi composta por 418 adolescentes do sexo feminino entre a faixa etária de 10 a 17 anos de uma escola pública. Foram aplicados questionários para diagnóstico da população, percepção de imagem e satisfação corporal e para o risco de desenvolvimento de transtornos alimentares. O estado nutricional foi avaliado através de medidas antropométricas. A relação entre as medidas antropométricas foram realizadas por intermédio do coeficiente de correlação de Pearson. Para os dados provenientes do questionário de satisfação utilizouse o teste do qui-quadrado com o nível de significância a 1% e para os demais dados, estatística descritiva.
RESULTADOS: A maioria da população encontrava-se eutrófica através da antropometria e satisfeitas com suas estruturas corporais atual. Porém observou-se um alto percentual de adolescentes com risco de apresentar algum tipo de transtorno alimentar.
CONCLUSÃO: A percepção da imagem corporal das adolescentes está adequada a sua real situação nutricional. No entanto, mesmo satisfeitas com sua imagem corporal, os índices de risco para o desenvolvimento de transtornos alimentares encontrados no estudo foram altos.


Adolescence is the stage in life between 10 and 19 years of age,1 constituting a time of transition between childhood and adulthood. This is an extremely vulnerable group with higher nutritional needs, particularly in view of eating patterns, lifestyles and susceptibility to the influences around them2.

Consequently, adolescents end up by yielding to the current body aesthetic, which favors a slim figure2. The conflict between the quest for adult identity, which implies autonomy and the wish to remain dependent, characteristic of children, may appear through dissatisfaction with their bodies. Consequently, body dissatisfaction among adolescents is characteristic of feelings of anxiety and oddness, when dealing with the changes that arrive with puberty3.

Body dissatisfaction may lead to serious body image distortions. Body image may be defined as the mental representation of the body and the way it is perceived by each person, whereby this image encompasses meanings, ideas and feelings related to the body4.

Due to the lack of data in Brazil on eating disorders, dissatisfaction with body image and its associated risk factors justifies studies conducted to extend core knowledge of these aspects for Brazilian adolescents. The objective of this study was to analyze the prevalence of risk behaviors leading to the development of eating disorders associated with body image dissatisfaction and nutritional status.


A cross-sectional study was conducted between May 2011 and November 2012 with a sample consisting of 418 teenage girls between 10 and 17 years old, enrolled at a government school. This study was conducted with the approval of the Ethics Committee at Pernambuco University (UPE) under Protocol Nº 244/2010, with Deeds of Informed Consent signed by their parents or guardians.

The following variables were analyzed: eating habits, self-perception of current weight, body image perception and body satisfaction; anthropometric measurements were taken through the Body Mass Index (BMI), Waist Circumference (WC) and Body Fat Distribution (BFD).

Body image perceptions were obtained through self-assessment, using a body silhouette scale (1 to 9), in order to establish four categories: underweight (1), eutrophic (2 to 5), overweight (6 to 7), and obese (8 and 9)5,6. In order to analyze body satisfaction, the Body Shape Questionnaire (BSQ)7, was applied, which is a self-completed test consisting of 34 questions to be answered through a key, in the version translated into Portuguese by Cordás & Castilho8, with a scoring scale: < 80 = Dissatisfied; 80 - 110 = Slightly Dissatisfied; 111 - 140 = Somewhat Dissatisfied; and > 140 = Very Dissatisfied.

In order to assess the presence of eating disorders, the Eating Attitudes Test (EAT-26) questionnaire was completed, with 26 questions on eating attitudes and body image9. This rest is rated as a risk indicator for developing eating disorders, when the total score of the positive replies reaches 21 or more. The EAT lists 26 closed questions exploring eating attitudes, with the reply options being: Always (5 points), Very Frequently (4 points), Frequently (3 points), Sometimes (2 points), Rarely (1 point) and Never (0 points). Scores of 20 points or more indicate people who might be more likely to develop eating disorders or abnormal eating patterns, although not disclosing the possible psychopathology that might underlie such behavior10.

The Bulimic Investigatory Test Edinburgh (BITE) is a questionnaire with 33 questions, 30 of which explore bulimic symptomology, with scores varying from 0 to 30 points. A Yes reply indicates the presence of the symptom, worth one point, while a No reply indicates its absence (0). A score of 10 points or less was rated as normal11.

Nutritional status assessments were conducted through anthropometric measurements: weight, height, waist circumference and skin folds (triciptal and subscapular). The BMI classification was based on the system proposed by the World Health Organization (WHO)12, measuring waist circumference by the standards established by this organization12. Relative body fat percentages (% Fat) were estimated through the equations proposed by Slaughter et al.13 using the sum of the skin folds (triciptal and subscapular), which may be used for boys and girls between 8 and 17 years old14.

Lean body mass (LBM) values were determined through subtracting absolute fat quantities from body mass. The fat percentages were classified according to the adiposity categories proposed by Ronque et al.15.

A statistical analysis was conducted through the Statistical Package for the Social Science (SPSS), version 10.0 and Epi Info, version 6.0 software. The ratio between the BMI classification, Waist Circumference and Body Fat Percentage was found through the Pearson´s correlation coefficient (p > 0.0001). The Pearson´s correlation coefficient test was used to analyze the continuous variables, with p values of more than 0.0001 were considered as statistically significant. The data from the satisfaction questionnaire were analyzed through the chi-squared test with a 1% significance level. The other data were analyzed and presented by frequency and percentage distributions, using descriptive statistics.


Knowing that the number of meals eaten is directly and / or indirectly related to body image perception and body satisfaction, these adolescents were asked about their eating habits and the number of meals eaten each day. Only 12.44% ate six meals a day. For breakfast, 42.58% stated that they always ate breakfast, with the reasons for skipping this meal being a lack of appetite and waking up late, with a lower percentage wishing to lose weight.

In terms of body image using the silhouette scale (Table 1), most rated themselves as eutrophic. For the scale showing the body image that these adolescents would like to have, most of them opted for eutrophic followed by overweight. There is a significant difference between observed and expected proportions found through the c2 test (p<0.01) for each category.

In terms of body satisfaction, shown in Table 2, it was noted that most of them felt that their weight was ideal, although this figure was not as high as the eutrophic percentage in the population.

In the EAT-26 test used to identify eating disorder risks, 80.14% presented positive signs, with higher percentages found among adolescents between 10 and 13 years old. According to the BITE test, 67.22% posted negative values for this test, while 32.77% had positive results. These figures were assessed separately by series, in order to ensure better monitoring of the population. It was noted that the positive results for both the EAT and BITE tests were found to a greater extent among younger girls, in the sixth to ninth grades.

Through anthropometric assessments of the adolescents, a mean weight of 49.14 ± 10.14 Kg was found, with a height of 130.42 ± 0.07 cm. Comparing the weight mentioned by the adolescents previously (50.79 ± 7.31 Kg) the values found in the anthropometric assessment and the self-reported figures. The BMI and body fat values (Table 3) fell largely into the eutrophic category, with a significant difference between the observed proportions and the expected figures found through the c2 test (p<0.01) for each category assessed.

Analyzing the BMI and the self-classifications obtained through the silhouette scale, overestimation by some adolescents was noted (Table 4), in terms of the thinness, overweight and obesity classifications.


The use of globally validated tools such as the EAT and BITE questionnaires is a recommended approach for detecting the risk of developing these disorders. Compared to the study conducted by Chiodini and Oliveira16 in a government school in São Paulo/Rio Claro to analyze eating attitudes among adolescents, the EAT test was used, with the inadequate eating figures found in this study higher than those mentioned by them. According to Lowe et al.17, women particularly, when subject to chronic efforts to control their diets, become more vulnerable to purportedly forbidden foods and inadequate eating behaviors.

A study conducted by Appolinário and Claudino18 in government schools in Minas Gerais State with boys and girls between 7 and 19 years old found only 19 pupils (1.1%, mainly girls) presenting positive diagnoses for bulimia nervosa according to BITE. This figure is lower than the findings of this study.

When assessing adolescents between 12 and 20 years old, Mariath and Grillo19 found figures of 20.60 ± 2.50kg/cm2 with 92.9% eutrophic and 7.1% overweight. The results noted in this study were lower for eutrophic and higher for overweight, compared to the above-mentioned study. Few studies focus on the links between weight perception and self-esteem or BMI and positive body image.

Prompted by their rapidly changing bodies and appearances, concern and self-rejection among adolescents underscore the positive link between this dissatisfaction and eating disorders. A study of adolescents between 14 and 19 years old in São Paulo reported that 39% of the eutrophic adolescents felt they were overweight, while 47% believed they were obese, indicating a difference when compared with this study20.


The results showed that the body image perceptions of adolescent girls are well-attuned to their actual nutritional status. The eutrophic level found in the anthropometric assessments was rated as high for the population. This suggests that the characterizations of these adolescents by the lifestyle of this population is very different from that found in the State capital, perhaps still following healthier eating standards. Most of the adolescents felt they were satisfied with their body image, although at high risk for the development of eating disorders.


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