INTRODUCTION

According to the World Health Organization, adolescence is the period between the ages of 10 and 19 years ¹ , when individuals leave behind childhood behaviors and acquire characteristics of adult life. During this phase, biological and behavioral changes occur, marked by intense physical growth and development, cognitive maturation and the search for social adequacy. Such conditions can favor conflicts related to physical appearance that can affect eating, with an increased risk of developing eating disorders ² .

Risk behaviors for the development of eating disorders are expressed by excessive concern with food, which can result in food restriction and episodes of binge eating, characterized mainly by the ingestion of large amounts of food in a short period of time, which occurs, above all, after a period of severe food restriction. Purgative behaviors may also be present, such as the use of laxatives, diuretics or other medications, self-induced vomiting and excessive physical exercise, in addition to body dissatisfaction and rigid behavior related to eating ³ . According to Fortes et al. ⁴ , approximately 25% of young people worldwide exhibit this type of behavior related to eating.

Eating disorders are deviations in eating behavior of a psychological nature that can lead to biopsychosocial damage, associated with increased morbidity and mortality. Dissatisfaction and distortion of body image and overestimation of weight constitute precedents for eating disorders and interfere in the individual’s interaction with their weight, body and health.

It is observed that, when there is dissatisfaction with body image, it is common to adopt attitudes to adapt to the desired appearance, at any cost. In general, individuals with eating disorders, before the pathology becomes established, already demonstrate some dysfunctions in eating behavior that signal the risk of developing eating disorders ⁵ .

The main organic complications of eating disorders are endocrine disorders, such as amenorrhea, increased cortisol levels, and decreased testosterone concentrations; metabolic disorders, such as hypercholesterolemia and hypoglycemia; bone disorders, such as osteopenia and osteoporosis; hydroelectrolytic disorders, with disorders in serum vitamin and mineral levels; hematologic disorders, such as anemia and bone marrow hypoplasia; physical disorders, such as regression of secondary sexual characteristics, as well as arterial hypotension, cardiac arrhythmia, renal failure, and pulmonary insufficiency. This condition can compromise the maturation and development process, and the organic impact of eating disorders in adolescence can cause consequences that continue into adulthood. Adolescents with eating disorders are more likely to commit suicide ⁶ .

In view of this, adolescence is the phase of greatest vulnerability to the development of eating disorders due to excessive concern with physical appearance and exacerbated susceptibility to environmental influences and information about the body, health and diet to which these individuals are exposed. This situation reinforces the relevance of studies on eating behaviors in adolescents ⁴ .

The fragility in the face of the volume of information available demonstrates the importance of the quality of information related to food and nutrition in promoting health and adequate and healthy eating. Therefore, the level of exposure of the adolescent population to sources of information about nutrition of dubious reliability is worrying. Many messages conveyed in the media are inaccurate, unstable and distorted, reinforcing ideals of beauty, promoting fad diets and generating insecurity about food, thus contributing to the adoption of risky eating behaviors that can evolve into an eating disorder ⁷ .

Thus, the objective of the present study was to identify the occurrence of risk behavior for the development of eating disorders and its association with sex, nutritional status, and sources of information on food and nutrition in adolescents.

METHODS

This is an observational, exploratory, and cross-sectional study. The approach to the data was quantitative-descriptive. The research was conducted with 191 adolescents of both sexes, aged between 15 and 19 years, enrolled in high school at a public school during the month of August 2017. The sampling was done for convenience and is not probabilistic, and was carried out among the 487 high school students enrolled in the morning and evening shifts.

For data collection, all students enrolled in high school classes who were present on the days designated for the research explanation were invited to participate in the study. Only individuals between the ages of 15 and 19, duly enrolled, and who presented the Free and Informed Consent Form (FICF) signed by adults were included. For individuals under 18 years of age, the FICF was signed by the guardian. All minors were required to sign the Free and Informed Assent Form (FICF), agreeing to participate in the study. This study was approved by the Research Ethics Committee of the State University of Western Paraná UNIOESTE, under opinion number 2,162,785.

The Eating Attitudes Test (EAT-26) was used to assess the presence of risk behavior for eating disorders. The test consists of 26 self-administered questions and was developed by Garner and Garfinkel in 1979 and validated for Portuguese by Bighetti and Ribeiro ⁸ .

The questions are divided into three scales. The first scale refers to dieting and concerns dysfunctional denial of food and excessive concern with body shape. The second scale concerns bulimia and preoccupation with food and verifies the occurrence of episodes of binge eating followed by purging behaviors to avoid weight gain. The last scale is the oral control scale, which demonstrates self-control over food and identifies environmental factors that are related to food intake ⁸ .

The response options are on a Likert scale, with six alternatives and a score ranging from 0 to 3. The alternatives never, almost never and rarely are equivalent to 0 points, sometimes are equal to 1 point, often to 2 points and always to 3 points. In question 25, this order is reversed. At the end, the score of each question is added up and if it is equal to or greater than 21 points, it indicates the presence of risk behavior for eating disorders ⁸ .

The survey of the most used sources of information was carried out using the Nutrition Information Sources Questionnaire, simplified by Ferraz (2002) ⁹ , which consists of a single question in which the sources used to obtain information on subjects related to food and nutrition must be marked. The questionnaire consists of eight options and there is no limit to the alternatives that can be marked. The options are: TV, internet, doctor/nutritionist, food packaging, books, magazines and newspapers, friends and family or other, and when the latter was selected, it was necessary to specify the source ⁹ .

Anthropometric assessment was performed by measuring weight and height, and the Body Mass Index (BMI) was obtained according to the Quetelet formula (BMI = body mass (kg) / height (m2 ⁾ ). Nutritional status was classified using the WHO AnthroPlus software to verify the percentile, which was subsequently classified according to the cutoff points proposed by the World Health Organization (WHO) ¹⁰ . The results of the study were expressed in percentiles and represented in tables and graphs, using a Microsoft Excel spreadsheet.

Descriptive statistical analysis of the data was performed using frequency, mean, minimum values, maximum values ​​and standard deviation. Tests for analytical statistics (correlation and chi-square) were performed, and there was no association between the study variables.

RESULTS

A total of 191 adolescents participated in the study, of which 60% (n=115) were female and 40% (n=76) were male. The mean age was 16.71±1.15 years (15 – 19), with the majority (31%) being concentrated in the range of 16 to 16.9 years.

Regarding the anthropometric evaluation, the mean BMI was 22.47±4.02 kg/m2 (15.79 – 40.09). Regarding the classification of nutritional status by BMI, 75% (n=143) of the adolescents evaluated presented eutrophy. Among the female participants, 74% (n=85) presented eutrophy, 17% (n=19) overweight, 8% (n=9) obese, 2% (n=2) thin and none presented severe obesity. Of the male participants, 76% (n=58) were eutrophic, 13% (n=10) were overweight, 8% (n=6) were obese, 1% (n=1) were thin and 1 (1%) was severely obese. The classification of the nutritional status of the individuals evaluated is described in Table 1.

The mean EAT-26 score was 15.40±9.77 points (0-50). Among the research participants, 28% (n=53) obtained a positive result for the presence of risk behavior (cutoff point above 21 points) and 72% (n=138) did not present a result above 21 points.

Among the female participants, 37% (n=43) were identified with risk behavior for eating disorders. Among the male individuals, 13% (n=10) expressed this behavior. Among the adolescents interviewed with the presence of risk for eating disorders, 16% (n=30) were between 16 and 17.9 years old. The prevalence of risk behavior according to sex is shown in Table 2.

Regarding the sources of information on food and nutrition used by the studied public, it was observed that 87% (n=166) reported using the internet as the main source of information, followed by TV 57% (n=109), friends and family with 48.5% (n=93), as shown in table 3.

DISCUSSION

Evidence shows that adolescence is a period of vulnerability to the development of conflicts related to eating, since at this stage nutritional needs are high and there is great susceptibility to the influence of environmental factors. The search for identity is also an important characteristic factor of this age group and can contribute to body dissatisfaction, the main risk factor for the development of eating disorders ^4,6,11 .

The prevalence of normal nutritional status in adolescents can be explained by the high nutritional demand characteristic of this phase due to the complexity of the development and maturation process. During this period, although the diet generally presents an irregular pattern and the presence of dysfunctional behaviors, the BMI of these individuals remains normal, as explained by Pinho et al. ¹² .

It is observed that female individuals appear to be more vulnerable to the development of dysfunctional eating behaviors, which can be justified by the constant effort to control body weight, especially among adolescents ^4,11,13 . This may explain why most studies investigating behaviors related to eating disorders focus exclusively on females.

Data from the National School Health Survey conducted in 2015 showed that female adolescents place an exaggerated value on physical appearance, which leads them to cultivate intense dissatisfaction with their bodies and increases the likelihood of developing body image disorders. Among males, concerns about physical appearance permeate the desire for a muscular body. The highest proportions of adolescents who took steps to lose weight were found among females ¹⁴ .

The occurrence of risk behavior for eating disorders in the present study is considered worrying, as pointed out by Cubrelati et al. ¹³ when they indicate that percentages greater than 20% deserve attention and reflect the need for intervention.

According to Fortes et al. ¹⁵ , in recent years the frequency of risk behaviors for eating disorders in males has increased, at a rate of 1 case for every 10 in females, which has stimulated more in-depth studies regarding the etiology and risk detection instruments for males. The EAT-26 questionnaire has been validated for use in females, however, with the increase in cases in men, it was found necessary to study its application for these individuals. As the studies by Fortes et al. ¹⁵, who evaluated the psychometric qualities of the EAT-26 for male adolescents. The authors concluded that the instrument has good applicability for this population, with proven internal consistency and reproducibility.

Fortes et al. ⁴ constructed an etiological model of risk behaviors for eating disorders and suggested that the media content to which adolescents are exposed has a direct relationship with these behaviors. In addition, the incorporation of ideals of thinness and dubious and subliminal messages in the media related to diets, body appearance and nutrition are associated with the triggering of inappropriate eating behaviors.

These observations reinforce the findings of the present study, with worrying evidence regarding the sources of information on nutrition most used by the public. It is noteworthy that there is little research that has investigated the sources of information used for this purpose, with the few studies being population-based and with a broad age range of audiences.

In a survey conducted in 2010 by FIESP (Federation of Industries of the State of Sao Paulo) and IBOPE (Brazilian Institute of Public Opinion and Statistics), with individuals aged 16 to 60 years of both sexes, the sources of information about food and food products were evaluated. The findings revealed that the main source used by 40% of individuals was television, followed by a doctor or nutritionist with 20% and the internet with 19%. These findings are available in a document entitled Brazil Food Trends 2020 ¹⁶ .

The population survey conducted by Pol-lard et al. ⁷ in Western Australia between 1995 and 2012 with individuals aged between 18 and 64 years, sought to evaluate the internet as a source of nutritional information. The results of this study revealed that the use of the Internet as a source of nutritional information increased from 9.1% in 2004 to 33.7% in 2012. Younger women were more likely to use the Internet as a source of information and the greatest search was related to weight control. It was concluded that the information to which the individuals in the study were exposed was inaccurate and that accurate and reliable information was provided by medical, government and university websites. However, these appeared on the second and third pages of the website searches, since they were less likely to be accessed.

The research also suggests that Internet users do not discriminate against the quality of information on food and nutrition, not checking the source and date of the content and using commercial websites to search for health information. Such findings may justify the negative impact of the excessive and indiscriminate use of the Internet as a source of information on nutrition, reinforcing beauty standards and inducing inappropriate behavior to achieve them, especially among women ⁷ .

The instrument used to verify the main sources of information on nutrition used by the public in this research was simplified from the study by Ferraz ⁹ , conducted in 2001, in which individuals aged 16 and over participated. An interesting finding that corroborates the research conducted in Australia is that at the beginning of the last decade, the main source of information found were books, magazines and newspapers, followed by television, and friends and family in third place. Thus, the implications of the growing use of the Internet as a source of health information can be observed.

Alvarenga et al. ¹⁷ clarify that suggestions that ensure quick results, extremism in considering a single food as good or bad, guidelines based on only one study or on studies that do not consider individual and population differences are signs of a lack of credibility in information about food and nutrition.

Mendonça et al. ¹⁸ point out that, in Brazil, there are no defined criteria for analyzing the quality of information on health-related topics conveyed in the media. The objective of this analysis is to ensure that the population can trust the information available and that it is possible to understand the risks related to the adoption of certain practices. The authors suggest that there should be a certification process for websites that provide health information.

In some European countries, such as Switzerland and Spain, quality seals are used on health websites on the Internet, evaluated by several criteria to verify the credibility and intangibility of the content. In these countries, there are also campaigns to educate the population, enabling them to develop critical thinking skills. An example of this is the provision of checklist models to verify the quality of information. This process is relevant, considering the current scope of information available on the Internet.

Schools, as an educational environment, have a strong influence on the health of adolescents. In their study with students from public schools, Leite et al. ¹⁹found that 40.5% of participants did not recognize moments dedicated to addressing health-related issues in the school environment. Among the participants who responded positively to the existence of these moments, only 2.3% reported that the topic of eating disorders had been addressed.

In view of the vulnerability already addressed among adolescent individuals, it is essential that the topics regarding eating disorders, body image and diet are constantly addressed in the school environment, in order to promote awareness about health in this period of life and prevent the development of eating disorders. As well as detecting positive signs early, providing a better prognosis and less impact of these dysfunctions in adult life. To this end, a joint effort between health professionals, educators and family members is necessary ¹⁹ .

CONCLUSION

This research found worrying results in relation to risk behavior for eating disorders among the adolescent population studied, proving the vulnerability of this phase to dysfunctional eating behaviors.

There was no association between risk behavior and BMI, sex or sources of information used. However, the high use of the Internet as a source of information on nutrition stands out as an important factor influencing the development of eating disorders, and the lack of reliability of this information and the propagation of beauty standards can favor the adoption of pathological habits to control body weight. Given the relevance of this issue, it is essential that actions to prevent eating disorders aimed at adolescents are developed.