Prevalence of Eating Disorders and Their Association with Perceived Stress and Body Shape Concerns among Medical Students in Bengaluru, India -A Cross-sectional Study

Introduction

Mental health has long been an overlooked aspect of medicine, only receiving the attention it deserves in the past decade. Today, the situation in India is particularly concerning. According to the World Health Organization (WHO), mental health conditions in the country are responsible for an estimated 2,443 disability-adjusted life years (DALYs) per 100,000 people. Alarmingly, India’s age-adjusted suicide rate stands at 21 per 100,000 -one of the highest in the world.1 The National Mental Health Survey of India (2015-16) highlighted that nearly 15% of Indian adults require active mental health support, with approximately one in every 20 individuals experiencing depression. Mental illnesses now make up a significant portion of the overall disease burden, and India shoulders a major share of the global load of mental, neurological, and substance use disorders. These figures serve as a stark reminder of the urgent need to prioritize mental health at every level of society.2

Eating disorders refer to behavioural conditions characterized by persistent disruptions in eating patterns and accompanying distressing thoughts and emotions. These disorders greatly affect physical, psychological, and social functions, often involving intense concerns about body weight and shape. They represent serious health issues affecting individuals of diverse ages, although they are predominantly observed among adolescents and students.3 Studies on eating disorders have been less common in South Asia and India compared to those in Western countries. But in the last decade, studies from Asian countries have reported high rates of eating attitude distortion.4 These represent serious, potentially life-threatening conditions that affect both emotional and physical health.5

Among students, stress, anxiety, and depression are more prevalent compared to other mental disorders. These students frequently face various stress-inducing factors, including academic pressure from universities and educational institutions, high expectations from their families regarding grades and achievements, uncertainty about their future, and the emotional strain of being separated from their families due to studies. These issues collectively contribute to mental health concerns experienced by most students. Increasing Western influence, along with the high levels of stress faced by medical students, predisposes them to burnout and mental health problems, including eating disorders.6 Research and awareness efforts are crucial to understand and support the specific challenges faced by these students. Early diagnosis is the key to reduce the prevalence and complications of these illnesses.7 This study was conducted to provide insight into the magnitude of the problem locally and to facilitate early interventions to prevent associated complications. It assessed the prevalence of eating disorders and their association with perceived stress and body shape concerns among medical students.

Materials and Methods

Study design and setting

A cross-sectional study was conducted at a government medical college in Bengaluru, between June 2023 and September 2023.

Study participants

The study participants were MBBS students from the first to fourth year of medical school.

Sampling and sample size calculation

Assuming that 13% of the subjects in the population have the factor of interest (eating disorder), based on a study conducted by Iyer S et al. and an expected response rate of 90%, the study required a sample size of 194 for estimating the expected proportion with 5% absolute precision and 95% confidence.3 The final sample size was rounded off to 200. A stratified random sampling strategy was employed to recruit 50 participants from each year of MBBS with a female to male ratio of 1:1, until the calculated sample size of 200 was achieved.

Data collection tools

A validated, semi-structured electronic questionnaire was used for data collection, which was administered through a Google Form. The questionnaire consisted of four sections.

Section 1:

Sociodemographic details

Section 2: The Eating Attitudes Test-26 (EAT-26) 

The EAT-26 is the first step in the screening process for eating disorders.8 The questionnaire includes 26 items, each scored as follows: "Always" = 3 points, "Usually" = 2 points, "Often" = 1 point, and "Sometimes," "Rarely," and "Never" = 0 points. A total score of 20 or above on the EAT-26 indicates a high risk for an eating disorder, whereas a score below 20 suggests a lower risk.3

Section 3: Perceived Stress Scale (PSS) 

The PSS is designed to assess how often individuals felt overwhelmed or lacking control in their lives. It focuses on thoughts and experiences from the past month. Based on the total score, stress levels are categorized as follows: 27-40 indicates high stress, 13-26 reflects moderate stress, and scores below 13 suggest low stress.3

Section 4: Body Shape Questionnaire (BSQ-16B)

The BSQ-16B is a validated self-assessment tool designed to evaluate an individual’s level of concern regarding their body shape. It captures emotional and cognitive responses related to body image experienced over the preceding four weeks. The questionnaire has a maximum possible score of 204, with higher scores reflecting greater dissatisfaction and distress about body shape. Scores above 140 indicate severe concern, scores between 111 and 140 suggest moderate concern, 80 to 110 reflect mild concern, while scores below 80 indicate little to no concern.8

Permission to use the scales was obtained from the respective authors.

Data collection methods

The electronic data collection tool, developed in Google Forms, was sent to 400 MBBS students from the first year to fourth year. The form was locked in for further entry once the required sample size was achieved in each stratum.

Data analysis

The collected data were entered into Microsoft Excel and subsequently cleaned and analysed using STATA version 18 (StataCorp. 2023. Stata Statistical Software: Release 18. College Station, TX: StataCorp LLC). The continuous variables were described by mean (SD) and categorical variables by proportions (%). The prevalence was calculated as prevalence proportions (%) with 95% confidence intervals (95% CI). Chi-square test was used to assess the association between groups. A multivariable logistic regression model was used to identify the determinants of high level of concern regarding body weight, shape, and eating among medical students. A P value less than 0.2 in the univariable model, plausible biological association and previous evidence were used to input predictor variables into the multivariable model. All statistical associations were considered significant at a two-tailed P value less than 0.05.

Ethics

The study was approved by the Institutional Human Ethics Committee of Bangalore Medical College and Research Institute. Informed electronic consent was obtained from all the participants. All data were coded and anonymised before the analysis.

Results

The mean (SD) age of the study participants was 21.5 (2) years. Most of the participants belonged to the upper middle socioeconomic class [121 (60.5%)], followed by lower middle class [73 (36.5%)]. The majority were from urban background [149 (74.5%)], and most resided in hostels [128 (64%)]. Table 1 presents the characteristics of the study participants.

A total of 28 participants (14%; 95% CI: 9.8%-19.5%) exhibited severe concerns regarding body weight, body shape, and eating habits, while 11 (5.5%; 95% CI: 3%– 9.6%) reported concerns specifically related to body image. Among the study participants, 75.5% (95% CI: 69%–81%) experienced moderate stress, while 13.5% (95% CI: 9.4%–19%) experienced severe stress (Table 2).

In terms of nutritional status, 31 students (15.5%) were underweight, 32 (16%) were overweight, and 3 (1.5%) were classified as obese. Individuals with higher perceived stress and greater body shape concerns were significantly more likely to exhibit high eating concerns. High eating concerns were most prevalent among overweight individuals, while those with normal or underweight BMI showed lower levels (Table 3).

A positive correlation between body shape dissatisfaction and concerns related to eating disorders was observed (Figure 1).
On univariable analysis, perceived social media influence on eating and body shape, being overweight, and belonging to the BSQ category with mild body shape concern were identified as significant predictors of high concern regarding eating disorders (Table 4). On multivariable analysis, perceived social media influence (aOR 3.4; 95% CI: 1.1-10.7) and mild body shape concern (aOR 8.5; 95% CI: 1.6-46.7) were found to be significant factors (Table 5).

Discussion

This study evaluated the prevalence of eating disorderrelated concerns in medical students and examined how these concerns are linked to perceived stress, body shape dissatisfaction, BMI, and the impact of social media. The prevalence of high-level concern regarding eating disorders in our study was 14%, consistent with findings from similar Indian studies such as Iyer et al., which reported a prevalence of 13% in South Indian medical colleges. This reiterates that a significant subset of the student population is at risk and necessitates early identification and intervention.3

A major finding of our research was the strong link identified between perceived stress levels and the risk of developing eating disorders. Students with high perceived stress were more likely to have disordered eating attitudes (P=0.049). This echoes the findings reported by Tomy et al., who also highlighted psychological stress as a major contributor to unhealthy eating behaviours.4 Medical students, especially in demanding academic environments, experience stress due to academic expectations, future uncertainty, and social pressures, which may predispose them to maladaptive coping mechanisms such as disordered eating.

Interestingly, social media influence was a statistically significant predictor of eating disorder concerns (Adjusted OR 3.4). This is consistent with global and Indian literature that shows a growing impact of social media on body dissatisfaction and unhealthy eating behaviours, particularly among youth who are vulnerable to internalizing idealized body images.9 The role of platforms promoting unrealistic body standards and diet culture cannot be overstated in this context.

Contrary to some expectations, BMI alone was not a significant independent predictor in multivariate analysis, although univariate analysis showed higher eating concerns among overweight students (P=0.021). This suggests that subjective dissatisfaction with body shape might be more relevant than actual body mass in triggering eating concerns, a point supported by both Indian and international research.10

Notably, factors such as gender, socioeconomic status, and family structure did not show significant associations in multivariable analysis. While some studies have reported higher prevalence among females, our study did not reveal a statistically significant gender difference, possibly due to equal representation of both sexes and cultural or contextual differences in body image perceptions.5

Our study underscored the multifactorial nature of eating disorder patterns among medical students, with psychological stress, body image dissatisfaction, and social media influence emerging as key contributors. These findings have important implications for medical institutions, which must prioritize mental health interventions, awareness campaigns, and counselling services to foster healthier coping strategies and body image resilience among students. 

Conclusion
Eating disorder issues are common among medical students, highlighting the importance of early detection and prevention efforts in this high-risk group. The results show a strong correlation between disordered eating attitudes and variables like social media influence, perceived stress, dissatisfaction of body shape. Psychological and perceptual characteristics were important, while demographic factors like gender and socioeconomic position were not predictive on their own. These findings suggest that when addressing eating disorders in student populations, the emphasis should be shifted from strictly physical measures like BMI to more comprehensive psychosocial variables.

Recommendation

To promote early identification of vulnerable individuals, it is recommended that medical institutions implement regular screening programs targeting eating disorders and mental health concerns. Strengthening existing psychological counselling services or establishing new oneswithin campuses, with trained professionals specializing in these areas, is essential for effective support. Encouragement and facilitation of peer-led support initiatives can help combat stigma, promote open conversations about stress, coping skills, and body image, and foster resilience among students. Furthermore, there is a pressing need for longitudinal, multicentre studies across diverse academic institutions in India to gain deeper insight into risk factors and evolving trends related to these issues.

Conflict of Interest

Nil