Received: 13 February 2022 Revised: 13 July 2022 Accepted: 15 July 2022

DOI: 10.1002/eat.23790

ORIGINAL ARTICLE

The prevalence and correlates of bulimia nervosa, binge-eating

disorder, and anorexia nervosa: The Saudi National Mental
Health Survey

Ahmad N. AlHadi MD1,2 | Amani Almeharish BSc3 | Lisa Bilal MPH2,3,4 |

Abdulhameed Al-Habeeb MBBS5 | Abdullah Al-Subaie MBBS2,4,6 |
Mohammad Talal Naseem MSc2,3,4 | Yasmin A. Altwaijri BSc, MSc, PhD2,3,4

1
Department of Psychiatry, College of
Medicine, King Saud University, Riyadh, Abstract
Saudi Arabia
Objective: Limited studies have been conducted in the Kingdom of Saudi Arabia on
2
SABIC Psychological Health Research &
Applications Chair (SPHRAC), College of
eating disorders (EDs). This study presents national epidemiological survey data on
Medicine, King Saud University, Riyadh, the prevalence and correlates of anorexia nervosa (AN), bulimia nervosa (BN), and
Saudi Arabia
3
binge-eating disorder (BED) and their association with other mental health disorders,
Biostatistics, Epidemiology and Scientific
Computing Department, King Faisal Specialist impairment in role functioning, and individual help-seeking behaviors in the Saudi
Hospital and Research Centre, Riyadh,
National Mental Health Survey (SNMHS).
Saudi Arabia
4 Method: A face-to-face survey was conducted in a nationally representative house-
Research Department, King Salman Center
for Disability Research, Riyadh, Saudi Arabia hold sample of Saudi citizens aged 15–65 (n = 4004). The Composite International
5
National Center for Mental Health Diagnostic Interview (CIDI 3.0) was used to produce estimates of lifetime and
Promotion, Ministry of Health, Riyadh,
Saudi Arabia 12-month prevalence and treatment of common DSM-IV mental disorders.
6
Department of Psychiatry, Edrak Medical Results: Twelve-month prevalence of any of the three EDs was 3.2%; the overall life-
Center, Riyadh, Saudi Arabia
time prevalence was 6.1%. Education and marital status were significantly associated
Correspondence with both 12-month and lifetime EDs prevalence. Significant mental health comor-
Yasmin A. Altwaijri, Biostatistics, Epidemiology
bidities associated with 12-month EDs were anxiety, mood, and impulse-control dis-
and Scientific Computing Department, King
Faisal Specialist Hospital and Research Centre, orders, while lifetime EDs were significantly related to all disorders. A similar
MBC 03, PO Box 3354, Riyadh 11211,
percentage of respondents that reported having ED-related treatment at some point
Saudi Arabia.
Email: yasmint@kfshrc.edu.sa in their lifetime utilized healthcare and nonhealthcare sector. There was a significant
relationship between body mass index category, and lifetime BED and BN.
Funding information
King Salman Center for Disability Research, Discussion: The 12-month prevalence of EDs in the Saudi population was higher
Grant/Award Number: KSRG-2022-048
than the EDs rates reported worldwide. These findings can help healthcare experts,
Action Editor: Ruth Striegel Weissman and policymakers in the implementation of initiatives for raising awareness of EDs
among the Saudi population, and the development of a country-wide plan for the
[Corrections added on 10 August 2022, after
first online publication: Affiliation and Author prevention of EDs.
Contributions details for Amani Almeharish
Public Significance Statement: The study presents data on the prevalence, correlates,
have been corrected in this version.]
and help-seeking behaviors of AN, BN, and BED, in the Saudi National Mental Health
Survey (SNMHS). Obtaining information on this underrepresented region is essential
due to the large differences in cross-national data in addition to cultural beliefs about
mental illness and treatment seeking to exert an important influence on eating disor-
ders. Such knowledge could provide a better understand of mechanisms underlying

Int J Eat Disord. 2022;1–12. wileyonlinelibrary.com/journal/eat © 2022 Wiley Periodicals LLC. 1

2 ALHADI ET AL.
the development of eating disorders and thereby improve prediction, prevention, and
treatment.
KEYWORDS
anorexia nervosa, binge-eating disorder, bulimia nervosa, eating disorders, Saudi Arabia,
treatment
1 | I N T RO DU CT I O N
Three primary EDs are currently recognized in the Diagnostic and Sta-
tistical Manual of Mental Disorders (DSM-5)—anorexia nervosa (AN),
bulimia nervosa (BN), and binge-eating disorder (BED) (APA, 2013).
For individuals with these EDs, the associations with body mass index
(BMI) depend on the ED type (Kessler et al., 2013; Scott et al., 2018;
Udo & Grilo, 2018). In addition, EDs are frequently associated with
role impairment and other mental disorders, such as mood disorders,
substance abuse, and anxiety disorders (Hudson et al., 2007; Keski-
Rahkonen & Mustelin, 2016; Kessler et al., 2013; Scott et al., 2018).
According to a recent meta-analysis and systematic review of stud-
ies from across the world, the lifetime prevalence of AN, BN and BED
are 0.16%, 0.63% and 1.53%, respectively (Qian et al., 2021). Prevalence
in the European population specifically ranges between 0.2% and 0.5%
for AN and 0.1% and 0.9% for BN (Wittchen et al., 2011). Moreover,
according to a community-based study conducted in Germany, the
cumulative incidence of DSM-IV AN is 1.7%, and 1.1% for BN among
young women; and overall, EDs affect 0.3% of men (Nagl et al., 2016).
Similarly, a 2018 report on data from 15 countries—under the World
Mental Health (WMH) Survey Initiative—indicates that the lifetime prev-
alence of EDs in the general population is on average 1.0% for BN, and
1.8% for BED (Scott et al., 2018); and the 12-month prevalence esti-
mates are on average 0.4% for BN, and 0.8% for BED (Scott
et al., 2018). The WMH results also indicate a relatively early age-of-
onset for EDs, where the median age-of-onset (i.e., 21; range 19–24) for
BN is earlier than that for BED (i.e., 24; range 21–31) (Scott et al., 2018).
Globally, EDs treatment rates are low (Kessler et al., 2013; Scott
et al., 2018). About 47.4% of BN, and 38.3% of BED lifetime cases are
reported to receive or seek treatment (Kessler et al., 2013; Scott
et al., 2018). And about 25.9% and 9.8% of individuals with BN and BED,
respectively, have received treatment in the preceding 12 months (Kessler
et al., 2013). Although EDs prevalence estimates seem comparatively
lower in the general population, the burden imposed by these disorders on
affected individuals is high, given the increase in mortality and morbidity
rates (Crow et al., 2009; Hudson et al., 2007; Smink et al., 2012). Further-
more, this burden extends to the caretakers of the individuals suffering
from EDs, and the community in general (Raenker et al., 2013).
Research on EDs in the Kingdom of Saudi Arabia (KSA) has been
conducted in local settings (Alhazmi & Al Johani, 2019;
Aljomaa, 2018; AlShebali et al., 2021; Alsulaiman & El Keshky, 2019;
Alwosaifer et al., 2018; Anitha et al., 2019; Fatima et al., 2018;
Hussein et al., 2016; Taha et al., 2018), mostly focusing on university
students, and using screening instruments such as Eating Attitude
Test-26 (EAT-26; Garner et al., 1982), and the Eating Disorder Diag-
nostic Scale DSM-5 (EDDS; Stice et al., 2000). There is a need for
research studies aimed at determining the prevalence of EDs in repre-
sentative population samples, using standardized assessments.
The Saudi National Mental Health Survey (SNMHS) was implemen-
ted to address the research gaps in psychiatric epidemiology within the
context of the KSA, including the lack of studies involving national
representation, and using standardized methodology as part of the
WMH Survey Consortium. Under the World Health Organization
(WHO)-WMH Survey Initiative (Alonso et al., 2013; Kessler & Üstün,
2008; Scott et al., 2018), psychiatric epidemiological surveys of common
mental disorders in various countries across the world are coordinated.
Standardized design and methods are used in WMH surveys to ensure
valid data on the prevalence, burden, and treatment of mental disorders.
This strategy provides insights for policy makers to better understand
EDs, their associated burden, as well as data related to treatment (Hark-
ness et al., 2008; Heeringa et al., 2008; Pennell et al., 2008).
The SNMHS is a nationally representative population household
survey conducted across various regions of the KSA, to establish the
prevalence of lifetime and 12-month mental disorders, including the
three EDs diagnoses (AN, BN, and BED). The survey also provides
data on age-of-onset distributions, duration, and association with
sociodemographic factors (Altwaijri, Al-Habeeb, et al., 2020; Altwaijri,
Al-Subaie et al., 2020) of AN, BN, and BED
2 | METHODS
2.1 | Sample
The SNMHS relied on a multistage clustered area probability sampling
design, involving 4004 male and female Saudi respondents, aged
between 15 and 65 years old, living in the KSA (Al-Subaie et al., 2020;
Mneimneh et al., 2020). Fieldwork was conducted between 2014 and
2016, with pauses for Ramadan and summer months (due to very high
temperatures), across 11 administrative areas of the country. Two
administrative areas (Jazan and Najran) were excluded because of a
political conflict at the time of the survey. Face-to-face interviews
were held with respondents in their homes to administer the survey.
The response rate was 61%. Further details of the survey procedures
can be found elsewhere (Aradati et al., 2019; Hyder et al., 2017;
Kessler et al., 2020; Shahab et al., 2017).
The interviews were administered in two parts. Part I included a
core diagnostic assessment and was administered to all respondents
ALHADI ET AL.
(n = 4004), while Part II included questions about the risk factors, con-
sequences, other correlates, and assessments of additional disorders.
Part II was administered to all Part I respondents with any core disorder,
and to a 25% probability sub-sample of other Part I respondents
(n = 1981). All respondents provided informed consent prior to the
interview. The field procedures and the consent form were approved
by the Institutional Review Board committee at the KFSH&RC, Riyadh.
2.2 | Measures
2.2.1 | Diagnostic assessment
Psychiatric diagnosis was based on the WHO Composite International
Diagnostic Interview 3.0 (WMH-CIDI; Kessler & Üstün, 2004)–a fully
structured interview administered by trained lay interviewers that
generates diagnoses based on the criteria of both the ICD-10 and
DSM-IV diagnostic system. The computerized version of CIDI (CAPI)
was translated into Arabic and adapted to the local context
(Mneimneh et al., 2018; Shahab et al., 2019).
In the SNMHS, the DSM-IV criteria were used to allow compari-
son with previous WMH epidemiological surveys. Disorders were
grouped as follows: anxiety disorders (panic disorder, generalized anx-
iety disorder, agoraphobia without panic disorder, social phobia, post-
traumatic stress disorder, obsessive–compulsive disorder, separation
anxiety disorder), mood disorders (major depressive disorder, bipolar
disorder I or II), impulse control disorders (conduct disorder, attention-
deficit/hyperactivity disorder, intermittent explosive disorder), sub-
stance use disorders (alcohol and drug abuse and dependence), and
the EDs of AN, BN, and BED. The DSM-IV organic exclusion rules and
diagnostic hierarchy rules were applied to all diagnoses except sub-
stance use disorders, where misuse was defined with or without
dependence.
The EDs diagnostic algorithm, and the details of the assessment of
age of onset, and clinical validation studies can be found in Appendix
Table A. For BN and BED diagnosis, the symptom questions were closely
matched to the DSM-IV criteria with two exceptions. First, DSM-IV BED
requires 6 months of regular BN; only 3 months were adopted in the
CIDI, in line with the proposed DSM-5 criteria (Hudson et al., 2012; Keel
et al., 2012; Trace et al., 2012), and DSM-IV BN criteria (Wilson &
Sysko, 2009). Second, for BED, DSM-IV requires loss of control, and dis-
tress. Rather than addressing these symptoms directly, the CIDI probes
into the attitudes and behaviors indicative of loss of control and distress
(upset at out-of-control eating; feeling guilty, upset, or depressed after
binging; continued eating after full; eating until uncomfortably full; eating
alone because of embarrassment about volume eaten). These differences
are outlined in Appendix Table B.
2.2.2 | Socio-demographic data
Variables that describe the sociodemographic characteristics were
extracted for all respondents from the survey data. This included
3
gender (male/female), age (categorized as 15–24 years, 25–34 years,
35–49 years, and 50+ years), completed years of education (catego-
rized as 0–6 years, i.e., low; 7–9 years, i.e., low average; 10–15 years,
i.e., high average; and 16+ years, i.e., high), and income (below aver-
age, high average, high). Family income was defined as the household
income divided by the number of household members. A case was
assigned a category on a scale based on the per capita income of
the respondent's household divided by the median income for the
country, where it was categorized as low if it was less than 50% of
the median value, low-average if equal to the median, high-average if
up to twice the median, and high if greater than twice the median.
Socioeconomic status was measured using neighborhood observa-
tion records (low, medium, and high). This is a subjective measure,
where interviewers recorded their assessment of the neighborhood for
each household. Finally, urbanicity (rural and urban), and region (Central,
Eastern, Northern, Southern, and Western) based on the administrative
areas were extracted from the sample frame (2010 Census) provided by
the General Authority for Statistics in Saudi Arabia.
2.2.3 | Seeking treatment
In Part II of the interview, respondents were asked if they had
sought treatment from any of the 14 professionals listed for “prob-
lems with their emotions or nerves or use of alcohol or drugs” in
the past 12 months. Further questions were asked to ascertain the
age when treatment was first obtained, types of treatment, and
number of visits to each of these types of professionals. Summary
measures of treatment were created separately for the healthcare
sector, and the nonhealthcare sector. Healthcare sector treatment
was further divided into treatment in the general medical sector,
and the mental health specialty sector. Nonhealthcare sector was
classified into human services and complementary-alternative med-
icine (CAM).
Several treatment questions were also administered at the end
of each diagnostic section, where respondents were asked whether
they had ever sought help from a medical doctor or any other pro-
fessional about the disorder assessed in the interview and, if so, at
what age they first sought treatment for the disorder. Responses to
these disorder-specific questions and the more general treatment
questions were combined in the descriptive analyses of treatment
prevalence.
Respondents that reported having AN, BN, or BED within the pre-
ceding 12 months were asked to assess the severity of recent eating
problems based on the Sheehan Disability Scale (SDS; Leon
et al., 1997). The modified SDS requires responses on a 0–10 visual
analogue scale, ranging from none (0) to very severe (10), to character-
ize the severity of impairment in each of four areas of living (work,
home management, social life, and relationships). The SDS has excellent
internal consistency reliability, and good concordance with the objective
measures of role functioning (Hambrick et al., 2004; Leon et al., 1997;
Ormel et al., 2008; Pallanti et al., 2006). For calculating the BMI, respon-
dents were asked to self-report their height and weight.
4 ALHADI ET AL.

TABLE 1 Sociodemographic correlates of 12-month and lifetime ED diagnosis (AN, BN, or BED) in the Saudi National Mental Health Survey

12 month disorders (N = 91) Lifetime disorders (N = 169)

Sociodemographic characteristics OR 95% CI OR 95% CI

Gender
Female 1.52 (0.88–2.62) 1.04 (0.7–1.54)
Male 1.00 — 1.00 —
χ 21 2.27 0.04
Age
Age 15–24 4.33 (0.59–32.02) 2.44 (0.79–7.51)
Age 25–34 6.30 (0.94–42.37) 2.46 (0.88–6.89)
Age 35–49 2.82 (0.42–18.78) 1.26 (0.46–3.49)
Age 50+ 1.00 — 1.00 —
χ 23 7.21 7.02
Education
Low 1.00 — 1.00 —
Low average 3.43 (0.67–17.49) 2.88 (0.96–8.66)
High average 2.14 (0.42–10.86) 2.19 (0.75–6.42)
High 5.16 (1.08–24.73) 5.05 (1.76–14.44)
χ 2
3 9.78 a
18.50 b

SES
Low 0.80 (0.31–2.1) 0.69 (0.34–1.4)
Middle 0.88 (0.43–1.8) 0.91 (0.54–1.53)
High 1.00 — 1.00 —
χ 2
2 0.21 1.18
Marital status
Married 1.00 — 1.00 —
Separated/widowed/divorced 3.29 (1.32–8.17) 1.93 (0.92–4.06)
Never married 0.94 (0.44–2.01) 0.78 (0.44–1.39)
χ 22 7.46a 4.65
Urbanicity
Urban 1.00 — 1.00 —
Rural 1.68 (0.86–3.28) 1.02 (0.58–1.78)
χ 2
1 2.32 0.00
Region
Central 1.00 — 1.00 —
Eastern 0.67 (0.31–1.48) 0.77 (0.42–1.42)
Northern 0.51 (0.12–2.07) 0.62 (0.23–1.67)
Southern 1.42 (0.65–3.09) 1.16 (0.61–2.21)
Western 0.51 (0.24–1.11) 1.08 (0.66–1.77)
χ 24 6.95 2.55
Income
Low 0.83 (0.42–1.62) 1.11 (0.68–1.82)
Low average 0.35 (0.09–1.33) 1.72 (0.92–3.24)
High average 1.55 (0.77–3.14) 1.28 (0.73–2.26)
High 1.00 — 1.00 —
χ 2
3 5.87 3.22

Note: Part II weights were used (N = 1981). Anorexia nervosa (AN) was not included in 12-month disorders due to no cases.
a
p value <.05.
b
p value <.001.
ALHADI ET AL. 5

TABLE 2 Mental health comorbidity among respondents with an ED (AN, BN, or BED)

12-month ED Lifetime ED

Point 95% Wald Point 95% Wald

Disorders N Estimate Confidence limits N Estimate Confidence limits
Anxiety disorders 39 4.29a 2.24 8.23 100 4.81b 2.62 8.83
a b
Mood disorders 22 5.18 2.43 11.04 53 5.73 3.15 10.41
Impulse disorders 16 5.09a 2.17 11.92 56 3.41a 1.86 6.26
a
Substance disorders 7 2.25 0.69 7.37 23 4.73 1.91 11.70
Any disorders 54 5.98b 3.03 11.81 131 5.31b 2.56 11.03

Note: Part II weights were used. Anorexia nervosa (AN) was not included in 12-month disorders due to no cases. 12-month eating disorder (ED i.e., AN,
BN, or BED) (N = 91) and Lifetime ED (n = 169).
a
p value <.05.
b
p value <.001.

2.3 | Analysis 3.2 | Socio-demographic correlates of EDs

The SNMHS used a complex sample design that required weights
to be assigned to Part I and Part II sample (Mneimneh et al., 2020).
These weights were created to adjust for the population distribu-
tion by gender, age and region, according to the 2010 census data.
Since the data analyzed in this study included variables from only
Part II, all the sample-related information and weights pertain to
Part II. The data were analyzed using SAS 9.4 (SAS Institute Inc.,
Cary, NC, USA) for Windows. The PROC SURVEYFREQ procedures
were adopted to create cross-tabulations of 12-month and lifetime
disorder prevalence, mental health comorbidities, role impairment,
number of days out of role, BMI-related risk factors, and treatment.
Lifetime and 12-month treatment prevalence were calculated
across the treatment sectors based on the information provided by
the respondents, who obtained treatment for at least one disorder
during their lifetime and within the preceding 12 months. Logistic
regression models were applied to the 12-month and lifetime EDs
data to generate odds ratios (ORs) with 95% confidence intervals
for socio-demographic variables, using the PROC LOGISTIC proce-
dures. The significance was calculated using the Wald chi-squared
test with p < .05.
(i.e., AN, BN, or BED)
As shown in Table 1, education and marital status were significantly asso-
ciated with both 12-month and lifetime EDs prevalence. Respondents
with high level of education were significantly more likely than respon-
dents with lower levels of education to have had an ED (AN, BN, or BED)
in the preceding 12 months. In addition, those who were separated/
widowed/divorced (OR 3.29) were more likely than those who were mar-
ried or never married to have an ED in the preceding 12 months.
3.3 | Mental health comorbidities
As shown in Table 2, there was an overall significant association between
EDs and almost all other DSM-IV disorders. In particular, 12-month ED
prevalence was significantly related to anxiety disorders (OR 4.29), mood
disorders (OR 5.18), and impulse-control disorders (OR 5.09). Lifetime
EDs were also significantly related to all DSM-IV disorders.
3.4 | Role impairment

As shown in Table 3, role impairment was assessed only for respon-

3 | RESULTS dents who reported AN, BN, or BED in the last 12 months. Some role
impairment (mild, moderate, or severe) was reported in at least one role
3.1 | Prevalence of EDs domain (36.4%–64.8%) irrespective of the ED type. However, only
3.5%–20.7% of individuals with any ED reported severe role impair-
The 12-month prevalence of any of the three EDs was 3.2%, ment, compared to those with BN (3.0%–19.7%) or BED (3.8%–21.1%).
where 2.1% was attributed to BED and 1% to BN. Overall life-
time prevalence of any of the EDs was 6.1%, including 2.6%
respondents with BED, 2.8% with BN and 0.6% with AN. The 3.5 | Body mass index
mean age-of-onset was 19.73 years (IQR 20.0 [16.0–23.0]) for
BN, 21.32 years (IQR 20.0 [17.0–24.0]) for BED, and 14.4 years As shown in Table 4, there was a statistically significant relationship
(IQR14.0 [14.0–14.0]) for AN. between BMI category and lifetime diagnosis of BED or
6 ALHADI ET AL.

TABLE 3 Impairment in role functioning

Any bulimia nervosa or binge-eating

Bulimia nervosa Binge-eating disorder disorder

N % 95% CI N % 95% CI N % 95% CI

Impairment (mild, moderate, severe)
Home 16 57.37 33.41 81.32 34 64.42 39.62 89.21 50 62.34 43.81 80.86
Work 13 36.48 12.74 60.21 28 52.25 28.84 75.67 41 47.59 29.83 65.36
Relationships 13 33.68 10.35 57.01 21 37.62 16.21 59.04 34 36.46 19.90 53.02
Social 11 24.12 3.90 44.34 24 41.48 19.52 63.43 35 36.35 19.83 52.87
Any 21 63.77 41.11 86.42 36 65.28 40.35 90.21 57 64.84 46.10 83.57
Severe impairment
Home 4 6.18 0.00 13.08 7 14.44 1.81 27.08 11 12.00 2.92 21.09
Work 3 12.59 0.00 28.67 6 5.67 0.05 11.29 9 7.71 1.33 14.10
Relationships 3 2.99 0.00 6.97 5 3.76 0.00 8.19 8 3.53 0.20 6.86
Social 5 6.31 0.00 12.87 8 6.23 0.51 11.96 13 6.26 1.78 10.73
Any 9 19.74 2.34 37.14 15 21.09 6.74 35.45 24 20.69 9.38 32.01

Note: Part II weights were used. Anorexia nervosa (AN) was not included because no cases were diagnosed in 12-month disorders.

T A B L E 4 Current body mass index class among respondents with bulimia nervosa and binge-eating disorder in the Saudi National Mental
Health Survey

12-month Lifetime

Binge-eating disorder Bulimia nervosa Binge-eating disorder Bulimia nervosa

OR 95% CI OR 95% CI OR 95% CI OR 95% CI

Underweightb 0.26 0.01 5.17 — — — 0.30 0.04 2.48 0.28 0.03 2.32
Normal c
1 — — 1 — — 1 — — 1 — —
Overweightd 3.38a 1.47 7.77 2.21 0.72 6.76 1.66 0.81 3.41 2.17a 1.11 4.21
e a a
Obese 2.51 1.05 5.98 2.02 0.65 6.25 2.04 1.03 4.06 1.64 0.81 3.29

Note: Anorexia nervosa (AN) was not included due to low case numbers; low cases for lifetime (n = 5) and no cases for 12-month disorders (n = 0).
12-month disorders: binge-eating disorder (n = 51) and bulimia nervosa (n = 40). Lifetime disorders: binge-eating disorder (n = 86) and bulimia
nervosa (n = 78).
a
p value <.05.
b
BMI: <18.5.
c
BMI: 18.5–24.9.
d
BMI: 25–29.9.
e
BMI: >30.

BN. Respondents classed as overweight or obese were more likely to
be diagnosed with BED, compared to underweight individuals or
those with normal weight. Overweight individuals were more likely to
be diagnosed with BN, compared to those in the underweight, normal,
or obese BMI categories. Similarly, individuals with overweight or
obese classification were significantly more likely to be diagnosed
with BED in the preceding 12 months.
The majority relied on human services (50.9% for BN, and 49.2% for
BED), followed by general medical care (40.6% for BN, and 38.3% for
BED), mental health specialists (44.5% for BED, and 23.7% for BN),
and the CAM sector (30.8% for BED and 6.5% for BN).
4 | DI SCU SSION

The aim of the present study—which marks the first attempt to

3.6 | Seeking treatment
As shown in Table 5, a similar percentage of respondents, who
reported seeking ED treatment at some point in their lifetime, utilized
healthcare and nonhealthcare sector (59.6% and 54.4%, respectively).
use nationally representative household probability samples in the
KSA—was to assess the prevalence of AN, BN, and BED in
Saudi Arabia. Our findings revealed that 6.1% of the analyzed sample
had experienced one of these EDs during their lifetime, and 3.2% in
the last 12 months. These estimates could not be compared with the
 ALHADI ET AL.

TABLE 5 Proportional lifetime treatment among respondents with bulimia nervosa and binge-eating disorder in the Saudi National Mental Health Survey

Healthcare treatment Non-healthcare treatment

Complementary-alternative
Mental health specialty General medical Total Human services medicine Total

% 95% CI % 95% CI % 95% CI % 95% CI % 95% CI % 95% CI Na

Binge-eating disorder 44.51 21.02 68.00 38.32 17.26 59.39 62.23 37.44 87.02 49.22 25.28 73.15 30.76 7.71 53.81 55.80 32.33 79.28 34
Bulimia nervosa 23.65 3.71 43.60 40.62 9.14 72.11 54.70 19.90 89.50 50.86 17.48 84.25 6.50 0.00 15.43 51.86 18.71 85.01 23
Totalb 37.22 19.41 55.02 39.13 21.52 56.73 59.60 39.24 79.96 49.79 30.30 69.28 22.28 5.78 38.78 54.43 35.33 73.52 57

Note: Part II sample, prevalence calculated using part II weights. CAM includes internet use, self-help groups, any other healer, such as an herbalist, a chiropractor, or a spiritualist, and other alternative therapy.
Human Services includes social workers or counselors in any setting other than a specialty mental health setting, and religious or spiritual advisors, such as a Shaikh or Imam. Some respondents were treated in
multiple sectors; thus, the sum exceeds 100%. Anorexia nervosa (AN) was not included because of the low cases for lifetime disorders (n = 5).
a
Number of respondents with lifetime disorder who had any treatment.
b
Total includes both binge-eating disorder and bulimia nervosa.
7
8 ALHADI ET AL.
EDs prevalence reported in previous studies because our study did
not include the EDs not otherwise specified (EDNOS) diagnosis, which
can potentially represent the majority of EDs cases, as diagnosed by
the DSM-IV (Qian et al., 2021).
In a large study that included 24,124 participants from 14 coun-
tries and used the same assessment tool, the worldwide lifetime prev-
alence for BN was 1% (ranging from 0% in Romania to 2% in Brazil)
(Kessler et al., 2013), compared to 2.8% in the KSA, as indicated in our
study. As for the 12-month BN prevalence in Saudi Arabia, the esti-
mate was 1%, compared to 0.4% at the global level, ranging from 0%
in Romania and Italy to 0.9% in Brazil (Kessler et al., 2013). These
prevalence estimates were slightly higher, but comparable to findings
of a recent meta-analysis of studies from across the world, where the
lifetime prevalence of BN was reported as 0.63% (Qian et al., 2021).
For BED, the lifetime prevalence in Saudi Arabia was 2.6%,
compared to 1.9% globally (ranging from 0.2% in Romania to 4.7% in
Brazil), and the 12-month prevalence in Saudi Arabia was 2.1%,
compared to 0.8% worldwide, ranging from 0.1 in Romania to 1.8%
in Brazil (Kessler et al., 2013). These findings were in line with the
meta-analysis of global studies, which indicated that BED lifetime prev-
alence was 1.53% (Qian et al., 2021). Furthermore, in a recent study
based in the United States (US) with a nationally representative sample
of 36,309 adults using DSM-5 criteria, BN, and BED lifetime prevalence
were 0.28%, and 0.85%, respectively (Udo & Grilo, 2018). The lower
percentage of BN in this study was explained as being potentially due
to methodological issues, such as the placement of ED-related ques-
tions at the end of the interview which may have resulted in fatigue
(Udo & Grilo, 2018). Similarly, a European study based on data obtained
from six countries (with 21,425 respondents in total)–published in
2009–yielded 0.48%, 0.51%, and 1.12% as lifetime prevalence esti-
mates for AN, BN, and BED, respectively (Preti et al., 2009). Our find-
ings were additionally supported by a recent systematic review and
meta-analysis of data related to EDs in Western Asia (including
Saudi Arabia), where relatively higher prevalence estimates (1.59%,
2.41%, and 3.51%) were reported for AN, BN, and EDNOS, respec-
tively. These high percentages were also likely due to the methodologi-
cal differences among studies, wherein screening questionnaires and
semi-structured diagnostic interviews were used (Alfalahi et al., 2021).
Altogether however, it is difficult to pinpoint an explanation, or the
causes of BN and BED and their high prevalence estimates in
Saudi Arabia, given the lack of published literature in this regard. This is
a knowledge gap that needs to be addressed by the future studies.
In our study, only five cases of AN (for lifetime; and 0 cases for the
past 12 months) were identified. Consequently, correlates of AN were
not reported in detail. This finding concurred with the results of a local
study conducted by AlShebali et al. (2021) including female university stu-
dents, where no AN cases were identified. Similarly, AN lifetime preva-
lence was reported to be as low as 0.16% in a meta-analysis of global
studies on EDs (Qian et al., 2021). In the US, AN lifetime prevalence was
reported to be 0.8%, according to the DSM-5 (Udo & Grilo, 2018). More-
over, a European study–that used the DSM-IV diagnostic criteria–
reported AN lifetime prevalence as 0.48% (Preti et al., 2009). Our results
showing a very small number of AN cases were also supported by other
studies that suggested potential issues related to assessment of AN spe-
cifically using the CIDI (Lu et al., 2015; Thornton et al., 1998). Further-
more, using DSM-5 diagnostic criteria for disorder assessments may be
related to increased prevalence estimates for EDs, compared to estimates
generated using the DSM-IV (Flament et al., 2015; Lindvall-Dahlgren
et al., 2017; Mancuso et al., 2015; Qian et al., 2021).
According to our findings, age was not associated with a greater
risk of developing ED, in contrast to previously published data; and
unlike other authors that reported greater ED prevalence among
females than males, we found no gender-based differences (Hudson
et al., 2007; Kessler et al., 2013; Nagl et al., 2016; Preti et al., 2009).
This could be due to analyzing the three EDs (AN, BN, and BED) as a
group vs. individually. Our findings on gender were also in line with a
systematic review of extant research on the impact of social media on
body image and disordered eating outcomes, which found that sex
was not a moderating factor in this relationship (Holland &
Tiggemann, 2016). Moreover, higher education and being separated/
divorced/widowed (but no other demographic factors) were associ-
ated with higher risk for an ED in our sample.
Having other mental disorders was associated with a seven-fold
increase in the lifetime EDs prevalence, with the strongest association
among individuals with a history of mood disorders (6-fold), and the
weakest for those with impulse control disorders (4-fold), in line with
the available evidence (Hudson et al., 2007; Preti et al., 2009). Role
impairment related to any of the three EDs was also high in our study
(65%), and was associated with severity, consistent with previously
reported results (Hudson et al., 2007; Kessler et al., 2013; Preti
et al., 2009). Increased body weight was associated with BN and BED,
concurring with previously reported findings (Hudson et al., 2007;
Kessler et al., 2013; Preti et al., 2009). Indeed, obesity prevalence in
Saudi Arabia is among the highest worldwide, as indicated by a recent
study with 25% of the sample–comprising of 4709 participants
recruited from all 13 regions in the country–falling in the BMI range
of ≥30 (Althumiri et al., 2021). Based on this finding, screening for BN
and BED in larger-bodied individuals is suggested.
Even though all EDs are observed to onset at a young age, in our
sample, age of onset for BN was slightly younger (19.73 years old)
than that for BED (21.32 years old), concurring with the worldwide
findings reported for 14 countries (Kessler et al., 2013). About 60% of
our sample sought treatment for BN or BED from mental health ser-
vices or the general medical sector. This was in line with previous
global studies (Bohrer et al., 2017; Coffino et al., 2019; Kessler
et al., 2013), but differed with a European report (Preti et al., 2009),
likely due to growing awareness about EDs and seeking treatment in
the KSA. Moreover, almost half of the individuals with BN or BED in
our sample sought human services. This was consistent with previous
studies, which observed that patients with psychiatric symptoms–in
the Arabian Gulf region–visited faith-healers before seeking medical
treatment. For example, in a study from the United Arab Emirates,
about 60% of individuals with mood disorders visited a faith-healer
before visiting medical facilities (Sherra et al., 2017). Another local
study found that the majority (>70%) of faith-healer visitors had psy-
chiatric diagnoses (Alosaimi et al., 2014). Stigma and young age have
ALHADI ET AL.
been reported to be the main barriers to seeking treatment for EDs, in
addition to the finding that individuals seek/receive treatment for BN
and BED later, compared to AN (Hamilton et al., 2022).
5 | RECOMMENDATION
For future studies, we recommend the use of DSM-5 diagnostic cri-
teria to assess the prevalence and correlates of EDs in Saudi Arabia.
Prospective studies must also bear in mind that our findings cannot
be compared with studies that yielded estimates using 6-months
duration as a diagnostic criteria for BED.
6 | L I M I T A T I O NS
Our findings should be interpreted with caution, given that recall
bias may have affected the respondents' answers, especially if they
experienced the symptoms a long time ago (Cannell et al., 1977).
However, we attempted to address this by using 3-months duration as
diagnostic criteria for EDs, rather than 6-months duration for reporting
symptoms. Additionally, for binge eating, the CIDI probes into the atti-
tudes and behaviors indicative of loss of control and distress, in contrast
to DSM-IV, which focuses on the actual loss of control and distress.
Therefore, the CIDI may have introduced some imprecision into the
assessment of binge eating in our study. With regard to blind clinical
reappraisals with the Structured Clinical Interview for DSM-IV (SCID)
for EDs, these were not done in the SNMHS. This was because prior
clinical appraisal studies have consistently found good concordance
between diagnoses based on the CIDI, and those based on blinded
SCID clinical reappraisal interviews (Kessler et al., 1998;
Wittchen, 1994; Wittchen et al., 1995; Wittchen et al., 1996). Finally,
the questions in the CIDI do not cover other possible disorders within
the EDNOS category provided in DSM-IV (APA, 2000). As such, our
prevalence data pertain only to AN, BN, and BED, and do not reflect
the full extent of ED pathology in Saudi Arabia.
7 | C O N CL U S I O N
The 12-month prevalence of EDs (AN, BN, BED) in the Saudi popula-
tion was higher than the worldwide rates; and was greater among
younger respondents in the KSA. Moreover, mental disorders were
associated with EDs lifetime prevalence as well as serious impairment
in psychosocial functioning. More than half of the individuals with
EDs sought treatment, where mental health services were typically
provided for BN, and BED was treated in the general medical sector.
These crucial findings can help the healthcare experts, and policy-
makers in Saudi Arabia to accelerate the implementation of initiatives
aimed at raising the awareness of EDs in general population, and
developing a country-wide plan for reducing the EDs prevalence. Early
detection and treatment focusing on children and adolescents should
be the main priority of healthcare professionals.
9
AUTHOR CONTRIBU TIONS
Ahmad Nayef AlHadi: Conceptualization; supervision; writing – original
draft; writing – review and editing. Amani Almeharish: Conceptualiza-
tion; data curation; resources; writing – original draft; writing – review
and editing. Lisa Bilal: Conceptualization; project administration; supervi-
sion; writing – original draft; writing – review and editing. Abdulhameed
Al-Habeeb: Data curation; funding acquisition; project administration;
writing – review and editing. Abdullah Al-Subaie: Conceptualization; pro-
ject administration; writing – review and editing. Mohammad Talal
Naseem: Data curation; formal analysis; methodology; writing – review
and editing. Yasmin Altwaijri: Conceptualization; data curation; method-
ology; resources; supervision; writing – review and editing.
ACKNOWLEDG MENTS
The SNMHS team thanks the following local institutions for their col-
laboration, and support for this project: King Abdulaziz City for Sci-
ence and Technology (KACST), Ministry of Health (Saudi Arabia),
Saudi Basic Industries Corporation (SABIC), and King Saud University,
King Faisal Specialist Hospital and Research Centre and Research
Center, and the Ministry of Economy and Planning, General Authority
for Statistics. The SNMHS is carried out in conjunction with the World
Health Organization World Mental Health (WMH) Survey Initiative.
We thank the staff of the WMH Data Collection Coordination Centre
in the Survey Research Center at the University of Michigan, and the
WMH Data Analysis Coordination Centre in the Department of
Health Care Policy at Harvard Medical School for assistance with the
design, instrumentation, fieldwork, and consultation on data analysis.
A complete list of all WMH publications can be found at https://
www.hcp.med.harvard.edu/wmh. We also acknowledge the work and
dedication of the current and previous SNMHS staff, and thank them
for their contributions to the study.
FUNDING INF ORMATI ON
The SNMHS is funded by King Salman Center for Disability Research,
Grant Number: KSRG-2022-048. The funder had no role in study
design, data collection, data analysis, data interpretation, or writing of
the report. All authors had full access to the data of the study, and
were responsible for the final decision to submit for publication.
DATA AVAILABILITY STAT EMEN T
A public use dataset is not available because of restrictions in the
informed consent language used to recruit respondents and WMH
consortium agreements. However, a de-identified minimal dataset for
quality assurance can be obtained by contacting the corresponding
author at: yasmint@kfshrc.edu.sa.
OR CID
Ahmad N. AlHadi https://orcid.org/0000-0002-2298-3509
Yasmin A. Altwaijri https://orcid.org/0000-0001-8826-3224
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