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Research report
Eating disorder risk behavior in Brazilian adolescents from
low socio-economic level
Julia Elba de Souza Ferreira *, Gloria Valeria da Veiga
Department of Nutrition, Federal University of Rio de Janeiro, Av. Brigadeiro Trompowisky, s/n8, Ilha do Fundão,
CCS, Bloco J 28 andar, Ilha do Fundão, Rio de Janeiro, RJ CEP 21.941-590, Brazil
Received 21 August 2007; received in revised form 22 November 2007; accepted 18 February 2008

Abstract
We investigated the prevalence, by gender, age and nutritional status, of eating disorder (ED) risk behavior, using a simplified self-report
questionnaire in a probabilistic sample of 561, 12–19-year-old students from public schools in the metropolitan area of Rio de Janeiro, Brazil. Sex-
and age-specific body mass index cut-offs were used to assess nutritional status. The prevalence of overweight/obesity was 16.2% and of being
underweight was 2.5%; 37.3% of the adolescents studied presented symptoms of binge eating (BE) and 24.7% would go on a strict diet at least once
a week, both cases more frequent in females (40.8% vs. 25.3%; 31.2% vs. 10.5%, respectively). Older students were shown to be more susceptible
to binge eating and younger students more susceptible to strict dieting. Overweight adolescents were shown to be more susceptible to strict dieting
than normal-weight adolescents, regardless of sex and age. The prevalence of binge eating and strict dieting was high in low-income Brazilian
adolescents and females are at greater risk of developing eating disorders than males. The greater prevalence of strict dieting in younger students
shows they are at nutritional risk.
# 2008 Elsevier Ltd. All rights reserved.

Keywords: Eating disorders; Binge eating; Purging; Strict dieting; Adolescents

Introduction
Eating disorders (EDs) such as anorexia nervosa (AN),
bulimia nervosa (BN), and periodic binge eating disorder
(BED), are chronic diseases, difficult to treat, and may damage
the individual’s nutritional status, predisposing them to
malnutrition as well as obesity. The excuse of wanting to
have a perfect body that causes the obsession with leanness,
particularly among women, has been linked to the origin of
EDs, as this proposed ideal of leanness is not easily attained,
contributing to frequent dissatisfaction with the body and the
pursuit of mechanisms to combat it (Morgan, Vecchiatti, &
Negrão, 2002; Rodriguez et al., 2001).
Although EDs cannot be directly associated with concern
with obesity, considering such EDs have existed since ancient
times when stereotypical beauty was not centered around
thinness, one cannot ignore how the current prejudice against
* Corresponding author.
E-mail addresses: jesferreira@globo.com (J.E. de Souza Ferreira),
gvveiga@globo.com (G.V. da Veiga).
0195-6663/$ – see front matter # 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.appet.2008.02.015
obesity may provoke extreme behavior like the practices of strict
dieting, fasting, use of laxatives among others, to combat it.
Adolescence is the age range in which individuals are most
influenced by ongoing body aesthetic patterns and are therefore
more vulnerable to EDs (Alvarenga, 2004; Granillo, Jones-
Rodriguez, & Carvajal, 2005; Lahortiga-Ramos et al., 2004). In
Brazil, obesity has been on the rise in adolescents of the lower
socio-economic spectrum (Veiga, Cunha, & Sichieri, 2004;
Wang, Monteiro, & Popkin, 2002), bringing us to question
whether this population is also likely to develop extreme eating
behavior aimed at combating excessive weight and, conse-
quently, at risk of developing EDs.
The point prevalence of EDs in the general population is still
low, at between 0.5 and 1.0% for AN, and around 2 and 3% for
BN (Cordás et al., 2004). These numbers may be higher when
partial ED syndromes, characterized by behavior considered
risky, are taken into account, already observed in 15.8% of
Italian girls (Miotto, Coppi, Frezza, & Preti, 2003) and in
53.3% of Latina adolescents, evaluated in the United States of
America, who were frequently on extremely strict diets
(Granillo et al., 2005).
In Brazil epidemiological studies regarding risk behavior for
eating disorders are scarce. ED risk behavior was observed in
250 J.E. de Souza Ferreira, G.V. da Veiga / Appetite 51 (2008) 249–255
23.8% of a probabilistic sample of 513, 12–29-year-old women,
residing in a city of southern Brazil (Nunes, Barros, Anselmo,
Camey, & Mari, 2003) and in 13.3% of 1807, 7–19-year-old
students from public schools of six municipalities in the rural
area of a southeastern state (Vilela, Lamounier, Dellaretti, Neto,
& Horta, 2004). Although the magnitude of EDs among
Brazilian students from public schools in urban areas is
unknown. In this group, socio-cultural factors there could be
more favorable to development of these disorders.
In spite of the greater prevalence in females (Makino,
Tsuboi, & Dennerstein, 2004), the incidence of eating disorder
risk behavior in males has also been observed. O’Dea and
Abraham (2005) verified that 3% of 93 American male college
students presented BED, 2% presented BN and one fifth was
extremely concerned with body weight and shape, and followed
strict dietary rules to control their weight. The differences
between genders in terms of the prevalence of eating disorder
risk behavior in Brazilian adolescents are not so clear (Vilela
et al., 2004).
As a general rule, the epidemiological studies on ED use, as
an investigatory criterion, the application of long self-report
questionnaires (e.g. Eating Attitudes Test—EAT, Eating
Disorder Inventory—EDI, Bulimic Investigatory Test—BITE)
that are not easy to fill out, particularly by people from low-
income social backgrounds and low levels of education.
Brazilian students from public schools generally are behind in
their schooling and have low-income backgrounds. So, the use
of long questionnaires would hinder understanding of the
instrument. Use of simplified questionnaires in investigating
the risk of developing EDs may be an attractive alternative to
screening the problem among these youngsters.
In the revised literature, some gaps were found that could be
filled through the present study, which was developed with the
aim of fulfilling two principal objectives: (a) to verify the
magnitude of ED risk behavior, such as the habit of going on
strict diets or fasts, binge eating episodes, and the presence of
mechanisms to compensate for food intake among poor
students from public schools in the greater metropolitan area of
the state of Rio de Janeiro, Brazil, through a simplified
questionnaire; (b) to identify subgroups at greater risk by
gender, age and nutritional status.
Material and methods
The study was carried out with a probabilistic sample of 610
adolescents ranging from 12 to 19.9 years of age, studying from
the 5th grade of the elementary school (1–8) up to the final year
of high school in public schools in the city of Niterói, Rio de
Janeiro State. Niterói has approximately 450,000 inhabitants.
In 2001, the base year for calculating the sample, 25,102
students of the age covered by the study were enrolled in these
schools. In Brazil public schools are generally frequented by
students from low socio-economic backgrounds.
The sample was calculated using the prevalence of 24% of
ED risk behaviors (Nunes et al., 2003), 95% confidence
interval, the absolute precision of 5 percentile points, and the
design of cluster sampling by random class selection (Lwanga
& Lemeshow, 1991). There was an anticipated 30% non-
response according to a pilot study, in a total sample of 780
adolescents (26 classes of 30 students). As it was already
predicted there would be school classes with less than 30
students, 28 school classes were randomly selected from 13 of
the city’s 33 state public schools.
Only adolescents who were willing and obtained signed
consent from their legal guardians participated in the study. The
criteria for eligibility were: no participants with physical
disabilities rendering the anthropometrical evaluation impos-
sible, and no pregnant participants. Seven hundred and fifty
seven students met these criteria, resulting in the loss of 147 in
the anthropometrical evaluation (43 did not obtain authoriza-
tion from their legal guardians, 85 refused to participate and 19
did not come on the day of data collection), totaling 610
adolescents. The questionnaire on ED risk behavior was
answered by 562 adolescents, one being excluded for
inconsistency in filling it out. Therefore, complete data from
561 adolescents was obtained (74.1% total response rate).
Data collection took place in the period from June to
December of 2003.
The evaluation of ED risk behavior was carried out through a
self-report questionnaire, containing a set of five questions
aimed at identifying the frequency of binge eating (BE)
episodes, compensatory mechanisms like purging through the
use of diuretics or self-induced vomiting, with the intent of
controlling weight, and following a very strict diet or by fasting
within the last 3 months.
The questionnaire is the result of an adaptation of another
used by Hay (1998) in an Australian community. In developing
the questionnaire, the author used as its basis a script for a
clinical interview known as the Eating Disorder Examination—
EDE, created by Fairburn and Beglin (1994) and regarded as
the ‘‘gold standard’’ for ED screening (Freitas, Gorenstein, &
Appolinario, 2002). When the frequency of risk behavior
occurred at least once a week it was considered to be current
regular ED risk behavior, according to Hay (1998). The
questionnaire was filled out by students in the class room, in the
researcher’s presence. When a student did not understand some
question on the questionnaire the researcher read the question
to the adolescent again. In addition sentences explaining the
meaning of the words like diuretic and laxatives were used in
the questionnaire, e.g.: laxatives (medicine used to induce
diarrhea) to eliminate an excess of food ingested; diuretics
(medicine used to induce urination) to eliminate an excess of
liquid ingested.
A pilot study was carried out with 50 students who belonged
to the same age range as the present study, in a public school in
the city of Niterói, aimed at verifying the adolescents’
comprehension of the questionnaire. Modification of the
questionnaire was deemed unnecessary after the pilot study.
Weight was measured using an electronic scale accurate to
50 g and height was measured with a portable stadiometer
accurate to within 0.1 cm. The adolescents were wearing light
clothing and no shoes. Height was measured twice and a
maximum variation of 0.5 cm between the two was admitted,
and the average was obtained. The evaluation of nutritional
 J.E. de Souza Ferreira, G.V. da Veiga / Appetite 51 (2008) 249–255
status was done based on the body mass index (weight/height2),
according to Cole, Bellizi, Flegal, and Dietz (2000) criteria for
being classified as overweight and obese, and to that of the
WHO (1995) for classification as being underweight. Anthro-
pometric data was collected by a trained team.
Data analysis was performed using the Statistical Package
for Social Sciences (SPSS) software, version 13.0. The
prevalence of ED risk behavior was estimated in regards to
gender, age range and nutritional status. The chi-square test
was used to compare prevalence among the groups, and the
prevalence ratio (PR) and their respective 95% confidence
intervals (CI) were used as a measure of association. The
adjusted PR was verified through the Poisson regression model
with the parametric scale adjusted using the chi-square
statistics, in the multivariate analysis. For this analysis ED
risk behavior was considered the dependent variable and sex,
nutritional status and age range were the independent
variables, the latter being inserted into the model as a
‘‘dummy’’ variable. The p < 0.05 value was accepted for
statistical significance.
The project was approved by the Research Ethics
Committee of the Clementino Fraga Filho University Hospital
at the Federal University of Rio de Janeiro.
Results
Among the 196 adolescents who did not participate in the
study it was possible to obtain evaluation data on the nutritional
status of 151 individuals. The participant and non-participant
adolescents did not differ in prevalence of their being
overweight/obese and underweight, nor in terms of their
gender distribution. The adolescent proportion in the 12–15.9-
year-old age range was higher in the non-participants than in
the participants (88.1% vs. 74.5% p = 0.000).
Among the adolescents evaluated 37.1% were males, and
62.9% females. Most of the adolescents (62%) were in the 15–
17.9-year-old age range, 12% in the 12–14.9-year-old age range
and 26% in that of the 18–19.9-year-olds.
Table 1
Frequency of adolescents in regard to nutritional status by gender and age range
Nutritional status Male
n %
Eutrophic 142 80.0
Underweight 5 2.7
Overweight 26 14.5
Obese 5 2.8
Age range (years)
12–14.9 15–17.9
n % n %
Eutrophic 64 82.5 276
Underweight 1 0.5 11
Overweight 9 12.6 40
Obese 3 4.4 8 2.4
State public schools—Niterói, RJ, Brazil.
251
In regard to nutritional status, 13.2% were overweight, 3%
obese and 2.5% were underweight. On account of the low
prevalence of obesity for analysis of the association between
nutritional status and risk of ED, the categories overweight and
obese were grouped together to form the ‘‘overweight’’
category that corresponds with 16.2% of those studied. There
was no significant difference between females and males and
age ranges regarding nutritional status (Table 1).
Less than half the adolescents (39.7%) responded that they
had no binge eating episodes within the last 3 months. A
frequency of at least once a week (grouping once, twice or more
times) was reported by 37.3% of the adolescents. Among these,
3.4% reported having used some sort of compensatory
mechanism for binge eating episodes. The practice of strict
dieting or fasting, at least once a week, was reported by 24.7% of
the adolescents, and it was significantly more frequent in females
(31.3%) than in males (10.7%). The other risk behaviors were not
so frequent, and they were reported by less than 3% of the
adolescents at a frequency of at least once a week (Table 2).
In Table 3 the associations of each of the questions on the
questionnaire are presented with their explanatory variables.
Females presented greater frequency of binge eating episodes
(PR = 1.69; 95% CI = 1.28–2.25) and strict dieting or fast
(PR = 2.96; 95% CI = 1.66–5.30) when compared to males. An
association between binge eating episodes with age range and
nutritional status was not observed. Overweight adolescents
showed a greater risk of using diuretics (PR = 5.01; 95%
CI = 1.26–19.67) when compared to normal weight ones.
Adolescents falling into the 15-year-old age range or above
provided protection against strict dieting or fasting, compared
with the 12–14.9-year-old age range (PR = 0.53, 95%
CI = 0.38–0.73 for the 15–17.9-year-old age range, and
PR = 0.58, 95% CI = 0.38–0.88 for the 18–19.9-year-old age
range). The prevalence of strict dieting was 73% higher in
overweight adolescents than in normal weight ones (PR = 1.73;
95% CI = 1.08–2.78).
Due to the significant association between the habit of strict
dieting with all the explanatory variables in the bivariate
Female p-Value
n %
315 82.1 0.89
8 2.2
48 12.6
12 3.1
18–19.9
n %
82.5 117 78.6 0.44
3.2 2 1.4
11.9 25 16.6
5 3.4
252 J.E. de Souza Ferreira, G.V. da Veiga / Appetite 51 (2008) 249–255

Table 2
Frequency of adolescents in regard to risk behavior for eating disorders, by gender
Risk behavior Male (n = 177) Female (n = 384) p-Value Total sample
(n = 561)
n % n % n %
Binge eating
(1) Never 84 47.6 138 37.4 223 39.7
(2) Less than once a week 48 27.1 81 21.8 129 23.0
(3) Once a week 22 12.2 85 19.8 106 18.9
(4) Twice or more times a week 23 13.1 80 21.0 0.03 103 18.4
Use of laxatives
(1) Never 174 98.5 356 92.6 530 94.5
(2) Less than once a week 1 0.5 18 4.7 19 3.4
(3)) Once a week 1 0.4 5 1.4 6 1.1
(4) Twice or more times a week 1 0.6 5 1.3 0.01 6 1.0
Use of diuretics
(1) Never 173 98.0 374 97.4 547 97.5
(2) Less than once a week 3 1.5 2 0.6 5 0.9
(3) Once a week 1 0.5 5 1.3 6 1.1
(4) Twice or more times a week 0 0 3 0.7 0.17 3 0.5
Self-induced vomiting
(1) Never 175 99.1 368 95.8 543 96.8
(2) Less than once a week 2 0.9 8 2.2 10 1.8
(3) Once a week 0 0 5 1.3 5 0.9
(4) Twice or more times a week 0 0 3 0.7 0.26 3 0.5
Strict dieting/fast
(1) Never 147 82.9 226 58.8 372 66.4
(2) Less than once a week 12 6.5 38 10.0 50 8.9
(3) Once a week 6 3.6 29 7.6 36 6.3
(4) Twice or more times a week 12 7.0 91 23.6 0.00 103 18.4
State public schools—Niterói, RJ, Brazil.

Table 3
Prevalence ratio (PR) and respective 95% confidence intervals (CI) for risk behaviorsa for eating disorders in regard to gender, age range and nutritional status
Variables N n % PR 95% CI p-Value
Binge eating
Gender
Male 177 45 25.4 1.00
Female 384 165 42.9 1.69 1.28–2.25 0.001
Age range (years)
12–14.9 77 19 24.7 1.00
15–17.9 335 132 39.4 1.57 1.08–2.29 0.02
18–19.9 149 58 38.9 1.55 1.13–2.13 0.01
Nutritional status
Eutrophic 457 172 37.6 1.00
Underweight 13 3 23.1 0.61 0.21–1.74 0.36
Overweight 91 34 37.4 0.99 0.67–1.46 0.94

Purging
Gender
Male 177 2 1.1 1.00
Female 384 10 2.6 1.03 0.24–4.52 0.18
Age range (years)
12–14.9 77 0 0 1.00
15–17.9 335 5 1.5 3.4 0.38–30.37 0.28
18–19.9 149 6 3.4 9.12 0.97–85.40 0.06
Nutritional status
Eutrophic 457 12 2.6 1.00
Underweight 13 0 0.0 0.00 –
Overweight 91 0 0.0 0.15 0.02–1.17 0.08
 J.E. de Souza Ferreira, G.V. da Veiga / Appetite 51 (2008) 249–255 253
Table 3 (Continued )
Variables N n % PR 95% CI p-Value

Use of diuretics
Gender
Male 177 1 0.6 1.00
Female 384 8 2.1 3.61 0.68–19.15 0.14
Age range (years)
12–14.9 77 2 2.6 1.00
15–17.9 335 4 1.2 0.58 0.06–5.52 0.63
18–19.9 149 3 2.0 1.06 0.16–6.77 0.95
Nutritional status
Eutrophic 457 3 0.7 1.00
Underweight 13 0 0.0 0.0 –
Overweight 91 6 6.6 5.01 1.28–19.67 0.01

Self-induced vomiting
Gender
Male 177 0 0.0 1.00
Female 384 8 2.1 1.60 1.50–1.71 0.04
Age range (years)
12–14.9 77 0 0.0 1.00
15–17.9 335 6 1.8 4.16 0.43–40.4 0.23
18–19.9 149 1 0.7 1.42 0.09–22.93 0.80
Nutritional status
Eutrophic 457 5 1.1 1.00
Underweight 13 0 0.0 0.00 –
Overweight 91 3 3.3 2.50 0.34–18.55 0.37

Strict dieting/fasting
Gender
Male 177 19 10.7 1.00
Female 384 120 31.3 2.96 1.66–5.30 0.001
Age range (years)
12–14.9 77 31 40.3 1.00
15–17.9 335 72 21.6 0.53 0.38–0.73 0.0006
18–19.9 149 35 23.5 0.58 0.38–0.88 0.017
Nutritional status
Eutrophic 457 103 22.5 1.00
Underweight 13 0 0.00 0.00 –
Overweight 91 35 38.9 1.73 1.08–2.78 0.032
State public schools—Niterói, RJ, Brazil.
a
Individuals who presented risk behavior for weekly eating disorders (for at least once a week in the last 3 months).

analysis, multivariate analysis was carried out to test possible
confounding variables. In this analysis, all associations
maintained their statistical significance. Multivariate analysis
was also carried out for binge eating and the significant
associations between gender and age range were maintained
(Table 4).
Discussion
The frequency of binge eating episodes in this study, at least
once a week, was high (37.3%) when compared to that observed
by Hay (1998) who found a frequency of 3.2%. The large
difference between the two studies could be due to the broad span
of the age range in Hay’s study (15–94-year-old). On the other
hand, the fact that self-report questionnaires may overestimate
rates of binge eating episodes cannot be ignored. However, along
with to the elevated prevalence of compulsive eating behavior, a
great frequency of restrictive dieting was observed, suggesting
that restrictive dieting could be either a compensatory
mechanism for compulsive eating or a precursory factor. Taking
into consideration a frequency of twice or more times a week,
following the criteria established by the Diagnostic and
statistical manual of mental disorders, 4th ed. (APA, 1994)
for the diagnosis of BED, the proportion of adolescents reporting
to have this behavior (18.4%) in this study was similar to the one
described by Johnson, Rohan, and Kirk (2002) for American
students in the age range of 10–19 years of age.
Among adolescents reporting binge eating episodes, 3.4%
may possibly be cases of bulimia nervosa as they presented
some compensatory mechanisms for this behavior. This
frequency is similar to that reported for Latina adolescents
(3.3%) of Cuban origin living in the USA (Granillo et al., 2005).
The higher risk of EDs in females than males observed in
this study agrees with other reports (Johnson et al., 2002;
254 J.E. de Souza Ferreira, G.V. da Veiga / Appetite 51 (2008) 249–255

Table 4 progressive strict dieting. The greater frequency of strict dieting

Prevalence ratio (PR) adjusted for the habit of going on a strict diet by gender,
among younger adolescents observed in this study has already
nutritional status and age range and binge eating by gender and age
been reported (Mcvey, Tweed, & Blackmore, 2004) and shows
Variables PR S.D.a 95% CI p-Value the high risk of malnutrition to which these adolescents are
Strict dieting/fasting being exposed at the age range where the caloric-protein
Gender (female) 2.82 0.30 1.54–5.18 0.00275 demand is greater and needed for growth.
Nutritional status A longitudinal study conducted in Canada with 14,972
Overweight 1.73 0.23 1.09–2.76 0.029 adolescents, in the age range of 9–14 years, revealed that going
Age range (years) on a strict diet to lose weight was ineffective, and rather
12–14.9 1.0 contributed to weight gain (Field et al., 2003). This may explain
15–17.9 0.64 0.15 0.47–0.87 0.010 the findings of the present study that showed a greater
18–19.0 0.68 0.18 0.47–0.98 0.049 frequency of strict dieting among overweight adolescents.
Binge eating This study was not intended to diagnose EDs but to screen for
Gender (female) 1.77 0.13 1.36–2.31 0.0002 these disorders’ risk behavior. The results showed that the use of a
Age range (years) simplified questionnaire might be useful in epidemiological
12–14.9 1.0 investigations as a screening tool to identify adolescents at risk of
15–17.9 1.70 0.20 1.13–2.57 0.017 developing EDs that will need diagnostic confirmation through a
18–19.0 1.72 0.17 1.22–2.43 0.0052
subsequent clinical interview. Premature screening could serve
State public schools—Niterói, RJ, Brazil. to assist public programs geared towards the prevention and
a
Standard deviation. combat of behavior considered to be ED risk behavior, thus
preventing the syndrome from becoming fully installed.
Kjelsas, Bjrnstrom, & Götestam, 2004; O’Connor, Simmons, & Although descriptive epidemiological studies on EDs are
Cooper, 2003), particularly in regard to strict dieting and common in developed countries, the present investigation is a
purging. In Brazil, in the only epidemiological study carried out pioneering one in Brazil as it evaluates the magnitude of ED
with students of public schools residing in rural areas, a greater risk behavior by gender, age and nutritional status in an
prevalence of risk behavior for developing EDs was observed in expressive probabilistic sample of Brazilian adolescent
girls than in boys when the EAT was used as an instrument of students from public schools in an urban area. The great
investigation but differences between the sexes were not found frequency of strict dieting, and binge eating episodes, observed
when the BITE was used (Vilela et al., 2004). Even though the show that, even among Brazilian adolescents from lower socio-
EAT and BITE are used, currently, to screen for eating disorders economic backgrounds, this problem is already present.
in general, the EAT was initially created to diagnose anorexia Females and younger adolescents were the higher risk groups
nervosa, tending to identify behavior leaning towards strict for whom a more complete investigation is necessary as a
dieting, whereas the BITE tends to evaluate the severity and means to prevent further aggravation of these diseases in future.
symptoms related to episodes of compulsive eating and
bulimia. Drawing an analogy between our results and those Acknowledgement
of Vilela et al. (2004), it is likely strict dieting is the ED risk
behavior that most differentiates the sexes. We thank the Brazilian agency Conselho Nacional de
The higher frequency of strict dieting in females may be Desenvolvimento Cientı́fico e Tecnológico–CNPq for support-
explained by the fact that females are more vulnerable to the ing this research.
concept of beauty focused on leanness prevalent in con-
temporary society (Alvarenga, 2004; Assumpção, 2004; References
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