The Relationship between Disordered Eating Pathology, Sense of Coherence and Body Image among Adolescent Boys in Israel

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1 Isr J Psychiatry - Vol No 1 (2018) The Relationshi between Disordered Eating Pathology, Sense of Coherence and ody Image among Adolescent oys in Israel *Yael Latzer, DSc, 1,2 *Orna Tzischinsky, DSc, 3 Zohar Sivak-Lavi, PhD, 1 Irit Chen, MA, 3 and Sarah Weinberger-Litman, PhD 4 1 School of Social Work, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa, Israel 2 Eating Disorders Institution, Psychiatric Division, Rambam Health Care Camus, Haifa, Israel 3 Deartment of Psychology, Emek Yezreel College, Emek Yezreel, Israel 4 Det. of Psychology, Marymount Manhattan College, New York, N.Y., U.S.A. Abstract ackground: Disordered eating athology (DEP) and body dissatisfaction are well-documented risk factors for eating disorders and have become more revalent among adolescent males. Method: The samle consisted of 256 Israeli boys, in grades Particiants comleted questionnaires measuring, Sense of Coherence (SOC), ody Shae (SQ), Eating attitudes (EAT-26), and the Eating Disorder Inventory (EDI-2). Results: Findings revealed low levels of DEP among adolescent boys. Younger adolescents (grade 8-9) had higher levels of clinically relevant DEP than older adolescents (grade 10-12). SOC was negatively associated with DEP and a significant interaction for age and SOC emerged with younger age being associated with both lower levels of SOC and higher DEP. Conclusion: These results demonstrate a low overall revalence rate of DEP among adolescent boys and is consistent with the develomental literature relating to SOC and mental health and in contrast with a similar oulation of girls documented in Israel and the US. * Latzer & Tzischinsky contributed equally to this aer. Introduction An increasing body of research over the last five decades indicates a consistent rise in the revalence of eating disorders (EDs), articularly in Western society (1-3). Eating disorders are more likely to occur in females than males with the ratio increasing to aroximately 10:3 during adolescence (mainly among AN and N ) and 20:1 during young adulthood (4). In addition to full-blown eating disorders there exists a continuum of risk for the develoment of these disorders which includes disordered eating athology (DEP) and body dissatisfaction. Eating disorders and associated risk factors reresent comlex syndromes involving a multitude of biological, behavioral, sychological and social factors (5). Although female atients account for most ED diagnoses (6), recognition of eating disorder behaviors as well as associated risk factors such as DEP and body dissatisfaction in males has increased in recent years (4). It has recently been reorted that males account for 10-25% of ED cases (7, 8) including 10% with anorexia, 20% with bulimia, and 40% with binge eating disorder (9). It was found that boys aear to engage in disordered eating behavior at young ages (10) and an investigation of a large reresentative samle in the U.S. found 7.1% of boys age 9-14 engaged in some form of disordered eating behavior (11). It is likely that the rates of eating disorders and disordered eating athology (DEP) are underestimated among males due to diagnostic tools designed for women and ossible differential manifestations of symtoms between males and females (12). Address for Corresondence: latzery@gmail.com Prof. Yael Latzer, DSc, Faculty of Social Welfare and Health Sciences, University of Haifa, Haifa 31905, Israel 66

2 Yael Latzer et al. In addition, body dissatisfaction known to be a critical redictive factor for DEP that increases the risk for eating disorders (13). A recent study confirms that body dissatisfaction and eating disturbances are becoming more normative and universal, not just for women but also for men (14). This transition thought to be a result of the idealized and unrealistic images of beauty and attractiveness that ervade modern society and affect the eating behavior of both female and male adolescents (14). It was found that 36.4% of girls and 23.9% of boys lace great imortance on weight and shae in their self-evaluation (15). In females, most disordered eating behaviors geared toward thinness; however, among males there may be a desire for thinness and/or a desire for increased size and muscularity (16-18). The trend of increased DEP has also been seen in Israel (19-22). In the last three decades, large numbers of Israeli-Jewish adolescents in non-clinical settings have been found to have abnormal eating attitudes and weight concerns (21, 23, 24). One study also examined DEP among adolescent boys in communal samles of the Israeli-Arab oulation. The results indicated that 16.4% of boys were found to have disturbed eating attitudes. The results demonstrated a high revalence of DEP among Israeli-Arab adolescent boys and emhasize that boys may be at risk as much as girls to develo eating disorders (25). Engaging in DEP and related atterns (such as drive for thinness, dieting behavior, body dissatisfaction, and low body image, etc.) is the result of an interlay of a variety of biological and sychosocial factors. In recent years, the concet of sense of coherence (SOC) (26) has received renewed attention for its role in overall mental and hysical health. Sense of coherence defined as the external and internal abilities to change and coe with stress (27). According to the theory, an individual s SOC is a significant human resource that can determine mental ability to coe in stressful situations and reresents a continuum from healthy to athological behaviors. SOC also relates to choosing coing styles that are suitable for different situations (27). According to the literature, there is a ositive correlation between high SOC and various hysical and mental health conditions (28-30). etter well-being (31), better self-esteem (32, 33) and better ability to deal with emotional tension in stressful situations (34, 35) are associated with higher SOC. Peole with low SOC exressed higher levels of anxiety, deression, burnout, anger and hellessness (36). Lower SOC was also associated with adating an unhealthy lifestyle, such as smoking and alcohol consumtion (37, 38) and higher levels of somatic comlaints (30). These findings are consistently found in both adults and adolescents (39). Individuals with higher SOC have demonstrated higher levels of resilience during crisis and have better overall hysical health outcomes as well. This theoretical model has been given good emirical suort (40) However, this concet has not been widely studied with regard to its association with DEP, body dissatisfaction or eating disorders. It is likely that lower levels of SOC and higher levels sychoathology such as DEP may share core features related to natural develomental trajectories as well as cultural stressors related to adolescence. Given that SOC has strong ties to other areas of mental and hysical health it seems befitting to extend this aradigm to DEP that is observed regularly in adolescents. To the best of our knowledge only a few studies have examined the revalence of DEP among boys in Western societies. Furthermore, revalence rates among Israeli adolescent boys have not been exlored. This is of articular imortance given that a study by the World Health Organization found that dieting behaviors were higher among Israeli adolescents than any other country examined (24). Additionally, to our knowledge, there have not been any studies examining the association between SOC and DEP and body dissatisfaction among adolescents. ody dissatisfaction has consistently been shown to be one of the most roximal risk factors for DEP and is therefore imortant to exlore indeendently as well as in relation to other symtoms (12). Further, this is of articular relevance given the influence that SOC aears to have on other health behaviors and sychological outcomes. Therefore, the current study has two main goals: To examine the rate of clinically relevant Disordered Eating Pathology (DEP) among a convenience samle of Israeli adolescent boys in grades To examine the relationshi between sense of coherence, DEP and body image disturbance and to assess whether age and sense of coherence redict scores on the EAT-26, SQ and EDI subscales. Method Particiants: Two hundred fifty-six adolescent boys articiated in the study. All were fluent Hebrew seakers, from grades 8-12: 30.6% were from eighth grade, 18.1% from ninth grade, 23.8% from tenth grade, 19.8% from 67

3 Disordered Eating Pathology, Sense of Coherence and ody Image eleventh grade, 7.7% from twelfth grade. The mean age was ± The study was conducted in a ublic school and included middle and high school students who were from urban and rural areas from the northern art of Israel. Measures Demograhics: Particiants rovided demograhic data including age, grade. Height and weight were used to calculate MI, using weight (kg)/height2 (m2). The Eating Attitude Test (EAT-26) (41) is a widely used screening instrument for measuring eating attitudes in large non-clinical oulations. The EAT-26 consists of 26 items scored on a three-oint Likert scale. The EAT-26 contains a general (sum) score, and three subscales. For the uroses of this study, the total score was used. The EAT-26 has been translated and validated into Hebrew (42). Cronbach s alha for the total score has been reorted at.70 n (43), in the current samle alha for the total score =0.75. Additionally, scores 20 indicate elevated body shae and weight concerns (44) and can be used to identify those individuals at high risk for develoing an eating disorder (anorexia nervosa and bulimia nervosa). Therefore, the cutoff score for the EAT is used to identify levels of DEP that may be of clinical relevance. In the current study the EAT is used as both a categorical measure of clinically relevant DEP and a continuous measure of overall DEP. Eating Disorder Inventory (EDI-2) (43) contains 91 items rated on a six oint scale and are divided into 11 subscales. The EDI-2 has been found to be a valid and reliable instrument in a wide range of different settings and has been translated into many different languages, including Hebrew (45). In the current study we used two subscales: drive for thinness (DT) 0.84=α)) and body dissatisfaction (D) (α=0.88). The EDI has been translated and validated into Hebrew (45). The ody Shae Questionnaire (SQ) (46, 47) assesses body shae concerns, self-dereciation due to hysical aearance and the cognitive exerience of feeling fat. SQ contain 34 items on Likert scale between 1-6, the score is between Cronbach s alha for the current samle (α=0.97). Sense of Coherence (SOC) (27, 48, 49): SOC defined as a global orientation that exresses the extent to which one has a ervasive, enduring and dynamic, feeling of confidence, and that (a) the exerience of internal and external environments is structured, redictable and exlicable; (b) the resources are available to meet the demands osed by the exerience; and (c) these demands resent challenges worthy of investment and engagement. SOC includes 29 items on a 7-oint Likert-tye scale where 1 = never and 7 = always. For the uroses of this study the total score was used, Cronbach s alha for the SOC general score (α=.83). Procedure The questionnaires were aroved rior to the study by the ethics committee (equivalent to the Institutional Review oard [IR]) of the Israel Ministry of Education and by the ethics committee of the Emek Yezreel College, as well as by the school rincials. Research assistants distributed the forms during gym classes (when boys and girls are searate). Students were told that they were taking art in a survey about the tyical issues related to adolescents eating attitudes. Particiation was voluntary and anonymous. All resent students comleted the questionnaire. Data analysis Data were analyzed using SPSS version 24 for Windows. Descritive and inferential statistical outut was generated based on a -value of < 0.05 (2-sided). Age grous were classified as younger adolescents in grades 8-9 and older adolescents in grades Zero-order correlations were comuted for all measures of DEP (as measured by the EAT-26, the SQ, and EDI-drive for thinness and body dissatisfaction subscales), and MI. Further, stewise linear regression was used to examine whether age and sense of coherence significantly redicted DEP as measured by the EAT-26, the SQ, and the EDI-drive for thinness and body dissatisfaction subscales. A total of four individual regression models were run using each measure of DEP above as an outcome with age and SOC as redictors. In addition, an age and SOC interaction term was created and used as an additional redictor variable in each model. Results Particiant Characteristics: In the resent study, 256 students articiated in the study, all of them males. Mean MI for the total samle was 21.00±3.31 (ranging from ), MI for the younger grou was (SD = 3.73) and MI for the older grou was

4 Yael Latzer et al. (SD = 2.98). Indeendent t-tests indicated that MI was significantly higher in the older grou ( <.01), as would be develomentally exected: 93.4% of the students were born in Israel, from urban or rural areas. Most of the students (74.6%) identified as secular and the rest identified as religiously traditional. Most of the arents (fathers and mothers) were born in Israel (77%), and most of them had a college degree or higher (87% of fathers; 93% for mothers). Aim 1: Examine the rate of clinically relevant disordered eating athology (DEP), among a convenience samle of Israeli adolescent boys age A clinical cutoff score of 20 or above on the EAT-26 was used to identify boys in the high risk category. Those with a score below 20 were categorized as low risk. Twenty-five subjects (9.8%) were found to be at high risk of eating disorders (Eat-26-sum 20). Of these, 14% were from grades 8-9 and 5% were from grade (X 2 =5.21, <0.03). Aim 2: To examine the relationshi between sense of coherence, DEP and body image disturbance and to assess whether age and sense of coherence redict scores on the EAT-26, SQ and EDI subscales. Table 1 resents the zero-order correlations between the EAT-26, SQ, EDI-2 and SOC scores. As shown, SOC coherence is strongly correlated with all measures of DEP and body dissatisfaction. Table 1. Zero-order correlations between the EAT-26, SQ, EDI-2 and SOC scores SOC general Eat-26 sum SQ EDI2- DT EDI2- D MI SOC general * -.203*** -.399*** -.291*** -.354*** -.197** Eat-26 sum *.541***.664***.480***.265*** SQ *.689***.665***.443*** EDI2- DT *.675***.427*** EDI2- D *.486*** MI * **<0.00 Additionally, as shown in Table 2, regression analyses revealed that grade level significantly redicts scores on the total EAT-26 (<.05) and the SQ (<.01), indicating that younger age is associated with higher scores on these measures. Sense of coherence significantly redicts scores on the EAT-26 (<.01), the SQ (<.001) and the EDI-DT ( <.05) and EDI-D (<.05), indicating that lower levels of SOC are associated with higher scores on these measures. Furthermore, an interaction term between grade level and sense of coherence was calculated and significantly redicted scores on the EAT ( <.05) and the SQ (<.01) indicating that younger age is associated with lower SOC and greater disordered eating and decreased levels of body image. Discussion Disordered eating and disturbed eating attitudes and behaviors are well-documented roblems among females in Western, modern industrial countries (50-52), and have also risen among adolescent boys (6, 53-56) Thus, the aims of the resent study were to: (1) examine the rate of clinically relevant DEP, among a convenience samle of Israeli adolescent boys age 13-18, and (2) to examine the relationshi between sense of coherence, DEP and body image disturbance and to assess whether age and sense of coherence redict scores on the EAT-26, SQ and EDI subscales. To our knowledge, no revious studies have examined rates of DEP among Israeli adolescent boys. This is of articular imortance given that a survey by the World Health Organization has showed that dieting behavior is higher among Israeli adolescent girls and boys as comared to 34 other countries (24). In addition, to our knowledge, sense of coherence has not been exlored in relation to DEP and body dissatisfaction in adolescent boys, and is a articularly imortant sychological construct during this develomental eriod (57). Table 2. Regression using Age Grou, Sense of Coherence and Age Grou X Sense of Coherence Interaction as redictors of four measures of Disordered Eating Pathology EAT-26 SQ EDI-Dt EDI-d Age grou (6.0) (24.91) (3.84) SOC (2.10) (8.71) < (1.34) Age X SOC 2.72 (1.28) (5.31) (.82) Note: SOC = Sense of Coherence; EAT = Eating Attitudes Test; SQ = ody Shae Questionnaire; EDI-Dt = Eating Disorders Inventory Drive for Thinness; EDI-d = Eating Disorders Inventory ody Dissatisfaction 69

5 Disordered Eating Pathology, Sense of Coherence and ody Image Aim 1: Using a cutoff score of above 20 on the EAT-26 it was found that 9.8% of the samle was found to be at high risk for disordered eating. Younger age significantly imacted risk, with 14% of younger adolescents meeting these criteria and only 5% of older adolescent meeting these criteria. Overall, in the current samle, which reresents a limited demograhic, the rate of clinically relevant DEP is relatively low comared to adolescent girls in the same age range in Israel (21, 23) and in other Western countries (58, 59). This may suggest that even at the same develomental stage, adolescent boys are not yet influenced by the same socio-cultural standards and exectations to the same extent as adolescent girls. However, it also ossible that the low rate is a reflection of the fact that measures of disordered eating were designed to cature symtomatology among females and may be less sensitive to the cognitive and behavioral exerience of adolescent males. In addition, unexectedly, we found that revalence of clinically relevant DEP was higher among the younger grou of adolescent boys as comared to the older grou. This finding is in line with a WHO study examining adolescent behavior and sychoathology which found higher dieting behavior (but not secifically DEP) among younger adolescents. Furthermore, dieting behavior was higher in this grou than 34 other Western countries (not including the U.S.) (24). However, this finding is in contrast to the literature relating to DEP in adolescent girls that suggests higher levels of DEP in later adolescence and continual increases in eating disturbance and body dissatisfaction through late adolescence. Therefore, it is ossible that the current finding reresents a heightened sense of vulnerability during this develomental stage rather than an actual manifestation of DEP, as the rate decreases significantly during later adolescence. It is known that this early eriod of adolescence is one of articularly low self-esteem and is critical for identity formation (60), and is also one of rofound hysical and cognitive changes (61). It is therefore ossible that our observed rate is a function of normal adolescence and reflects general distress during this eriod. Aim 2: Examined the relationshi between sense of coherence, DEP, and body image disturbance and to assess whether age and sense of coherence redict scores on the EAT-26, SQ and EDI subscales. Consistent with this aim, we found that higher sense of coherence was significantly associated with lower scores on all measures of DEP and body dissatisfaction. These findings are in line with research suggesting that a solid sense of coherence is critical for overall functioning and general well-being both hysically and emotionally. Furthermore, adolescence is a fundamental develomental stage during which SOC forms and is related to self-esteem (39), social functioning and aroriate coing mechanisms (27). Secifically one s SOC is most activated during times of high stress such as war, terror (62), chronic illness (63), or other trauma (64). Socio-cultural exectations of aearance are an additional source of stress that may engender the need for a higher level of SOC which translates into lower levels of body dissatisfaction and DEP. To our knowledge, the current study is the first to highlight the imortance of SOC in coing with social stressors related to aearance that are not routinely thought to contribute to trauma. Yet, it is likely that combating these socio-cultural messages does require a level of resilience engendered by the concet of SOC. With regard to age, younger age was found to be a significant redictor of higher disordered eating symtomatology on the SQ and EAT-26 but not on either the drive for thinness or body dissatisfaction subscale of the EDI. This may be due to differences in sensitivity of these measures with regard to the cognitive and behavioral exerience of males (4) as oosed to the EAT-26 and SQ which may be less clinically oriented and more gender neutral. In addition, we also found a significant interaction between age and SOC on the EAT-26 and SQ. This indicates that according to these measures, younger age is associated with lower levels of SOC and higher levels of DEP. This is consistent with the aforementioned develomental ersective on SOC formation during this eriod of adolescence. Limitations and Future Directions These findings are limited by a small samle size with articiants from a very secific demograhic background. The articiants were all recruited from a school in one region of the country where most of the students were native Israelis. Therefore, our ability to generalize these findings is limited, and further research is required to encomass the diversity of exeriences among adolescent boys in Israeli society. However, given that this is the first study of its kind it highlights a need for further exloration an in deth assessment with more diverse and reresentative samles. Additionally, we observed what aear to be develomental differences between younger and older adolescents. In order to fully understand the role of hysical 70

6 Yael Latzer et al. and sychological maturation, both with regard to SOC and DEP, samles should also include re-ubescent boys in grades 5-7. Finally, as mentioned reviously, these measures were not initially designed for use with adolescent boys and may not best cature their actual exeriences with regard to body image and DEP. Secifically, as indicated in the literature, the body image and weight concerns of adolescent boys may be more focused on muscularity rather than thinness, and their distress may be better reflected with different terminology. Therefore, future research should include additional measurements better suited for boys. Nevertheless, the current study makes two imortant contributions. It is the first to measure DEP and body dissatisfaction among Israeli boys, and highlights a otential develomental mechanism with regard to these factors. Furthermore, it emhasizes the imortance of SOC as a otential rotective factor against the develoment of DEP. This is consistent with the critical role of SOC in other areas of mental and hysical well-being, in general and articularly among adolescents. Therefore, SOC may be an imortant interventional variable to consider when working with adolescents at risk for develoing eating disorders and related behaviors. Authors contributions YL, concetion and design, interretation of data, critical revision, final aroval. OT, concetion and design, analysis and interretation of data. ZSl concetion and design, and interretation of data, final aroval. IC, concetion and design, collection of data Interretation of data. SWL, concetion and design, analysis and interretation of data, critical revision, final aroval. Cometing Interests The authors declare that they have no cometing interests. References 1. Smink FR, van Hoeken D, Hoek HW. Eidemiology, course, and outcome of eating disorders. Curr Oin Psychiatry 2013;26: Smink FR, Hoeken D, Oldehinkel AJ, Hoek HW. 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