Articles Section

Journal of Cognitive and Behavioral Psychotherapies,

Vol. 10, No. 1, March 2010, 77-86.

AN EPIDEMIOLOGICAL STUDY OF EATING

DISORDERS AMONG HIGH SCHOOL STUDENTS IN
ROMANIA
Tímea KRIZBAI (KOVÁCS)*
University of Debrecen, Debrecen, Hungary
Sapientia-Hungarian University of Transylvania, Targu-Mures, Romania

Abstract
The present paper is an epidemiological study of eating disorders in
Romania that analyses the prevalence of eating disorders in the
Transylvanian high school population. We surveyed 2396 high school
adolescents (1140 male, 1256 female), of which 1312 were Hungarian and
1084, Romanian. The prevalence of anorexia nervosa (AN) was 0.6% in the
Romanian female sample; no clinical cases of AN were found in the
Hungarian female sample. The prevalence of subclinical AN was 0.4% in
the Hungarian female sample and 1.9% in the Romanian sample. The
prevalence of bulimia nervosa (BN) was 1% in the Hungarian and 1.3% in
the Romanian female samples. The prevalence of subclinical BN was 0.8%
in the Hungarian female sample and 0.7% in the Romanian female sample.
We have not found clinical or subclinical AN in the male sample but the
prevalence of BN was 0.2% in the Hungarian male sample. The prevalence
of subclinical BN was 0.3% in the Hungarian male sample and 0.5% in the
Romanian male sample. Our results draw attention to the presence of eating
disorders in Romanian adolescents, possibly due to the internalization of
Western values and beauty ideals.

Keywords: eating disorders, epidemiology, Romania, Eastern-Central

Europe, high school students

Eating Disorders (ED) have often been considered culture–bound

syndromes (Di Nicola, 1990; Prince, 1985; Swartz, 1985). In general, a lower
prevalence of ED and disturbed eating attitudes and behaviors has been found
among non-Caucasian subjects and among developing countries than in Western
industrialized countries (Dolan, 1991). Several studies on this topic have been
conducted in Eastern and Central Europe, particularly in Hungary, the former
Czechoslovakia, Slovakia, Poland and Bulgaria, indicating that EDs are also
wide-spread in this part of Europe.

*
Correspondence concerning this article should be addressed to:
E-mail: kovacstimea@yahoo.com

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A study conducted in Hungary by Túry, Szabó and Szendrey (1990) has

shown that the prevalence of bulimia nervosa (BN) was 0.8% among males and
1.3% among females. Eating Attitudes Test (EAT) results indicated that 1.5% of
the females and 3.6 % of the males had scores above the cutoff point. Tölgyes and
Nemessúri (2000) found anorexia attitudes (EAT> 29) in 3% of a high school
female sample, but no participants met anorexia nervosa (AN) criteria. The
prevalence of BN, based on the Bulimia Investigatory Test (BITE) was 0.6%.
Szumska (2001) analyzing a representative sample (n=3615) of young females
from Hungary (15-24 years of age) found AN prevalence scores of 0.03% and BN
prevalence scores of 0.41% . The prevalence of sub clinical AN was 1.09%, while
the prevalence of sub clinical BN was 1.48%. Data from the former
Czechoslovakia (Krch & Drábková, 1996) collected in a high school sample (n=
981) records a prevalence of AN of 0.14%, and a prevalence of BN of 5.7% in the
female population (no AN or BN was found in males). Researches conducted in
Poland (Wlodarczyk-Bisaga, Dolan, McCluskey, & Lacey, 1995; Wlodarczyk-
Bisaga & Dolan, 1996) on girls 14-16 years of age, did not identify individuals
meeting the criteria for AN or BN, but the prevalence of sub clinical EDs was 2.
34%.
In Bulgaria, Boyadjieva and Steinhausen (1996) studied the prevalence of
eating disorders on a small sample, and found a prevalence of 0.94% in the case
of AN and of 5.66% in the case of „atypical” AN.
Very few epidemiological studies comparing different countries have
been conducted. In a study by Fichter, Elton, Sourdi, Weyerer and Koptagel-Ilal
(1988) Turkish teenagers from Turkey and Greek teenagers from Greece were
compared to Greek teenagers from Western Germany, and a higher prevalence of
anorexia nervosa was found in the latter sample, indicating that the social
circumstances in Western Germany must have influenced these teenagers who
had similar upbringing and cultural background. The only factor that differed
between the Greek teenagers from Greece and the Greek teenagers from Western
Germany was their social milieu, and it is probable that the increase in ED
prevalence has to do with this factor.
Rathner, Túry, Szabó and Geyer (1995) conducted a cross-cultural study
comparing the prevalence of eating disorders and minor psychiatric morbidity in
Central Europe before the political changes of 1989. In females, the prevalence of
BN was 0.6% in the Austrian population, 1% in the Hungarian and 0% in Eastern
Germany. Subclinical BN rate in Hungary was 3.8%, twice as high as in Austria
or Eastern Germany. Hungarian participants indicated more psychiatric problems
than their Eastern German and Austrian counterparts. In the United States the
prevalence of EDs is more infrequent in Caucasian females than in non-
Caucasians (Dolan, 1991). In a sample of students studying in London and Cairo,
the prevalence of AN was much higher in the female sample who were studying
in London versus the female sample studying in Cairo (Nasser, 1988). These
results may reflect the role of cultural changes, which are important factors in the

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development of eating disorders. Another such example is offered by the data of

Raich, Rosen, Deus, Perez, Requena and Gross (1992) who compared a sample of
Spanish and USA students and found a higher prevalence of EDs in the USA
sample.
In Romania, only few studies have been conducted in the field of EDs. A
study by Túry, Birt and Antal (1998) on a group of 553 university students in
Cluj-Napoca (Romania), reports no individuals meeting the criteria for anorexia
nervosa or bulimia nervosa. The prevalence of subclinical problems were
relatively high, with subclinical anorexia nervosa occurring in 2.5% of the female
and in 0.6% of the male subjects. Subclinical bulimia nervosa was found in 3.8%
of female and 2.5% of male subjects.
Alongside the Romanian majority several large minorities live in
Romania (e.g., Hungarian, Gipsy, Saxon). We believe it is very important and
informative to make ethnical comparisons in our country between the Romania
majority and these minorities (e.g., Hungarian). In the past decades, Romania
underwent many political and social changes and these changes may have created
a proper ground for the development of eating disorders.
The purpose of this study was to conduct an epidemiological research
among Romanian and Hungarian adolescents in Romania and to assess possible
differences concerning the prevalence of eating disorders between these two
cultures.

Method

Participants
A total of 2396 female and male high school students were questioned in
the year 2006. The sample was composed of 1140 males and 1256; 1312 of those
surveyed were Hungarian and 1084, Romanian. The selection of the participants
was based on school type and age. The proportion of different types of schools
(e.g., high school, skilled worker school) was in line the National School Registry
and with the number of students in these schools. Schools in a given region were
selected randomly from a list of all regional schools. High school students from
each grade were selected randomly from the student register. Questionnaires were
filled out simultaneously by the participants, and a trained surveyor supervised
the completion of the questionnaires.

Measures
The instruments included: 19 items referring to demographic and
anthropometric data (e.g., age, height, weight, desired weight, periods), the Eating
Attitudes Test (EAT, Garner & Garfinkel, 1979) and the Eating Behaviour
Severity Scale (EBSS, Yager et. al., 1987).
The EAT is a self-report questionnaire that was developed to measure the
symptoms of AN in adolescents and it consists of 40 items. Each item is rated on

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a 6-point Liker scale ranging from “never” to “always”. The most symptomatic
answer receives a score of 3, the next adjacent a score of 2, and so on.
The EBSS is a self-report instrument and that assesses the frequency of
disturbed eating and purging behavior in the last two weeks to 6 months.
Simulated DSM-IV diagnoses of ED were generated according to the
following:
A simulated diagnosis of AN required a body mass index (BMI=kg/m2) <
17.5. Female adolescents had to report the absence of at least three consecutive
menstrual cycles. For a diagnosis of BN, two binge eating episodes a week for at
least 2 weeks (EBSS) and at least one counter regulative behavior to prevent
weight gain (e.g., vomiting, use of laxatives, diuretics, diet pills, strict dieting
according to the EBSS), suggested the presence of the disorder. To approximate
eating psychopathology (i.e., anorexia nervosa and bulimia nervosa), the
suggested cutoff scores for the EAT total score were used (EAT>29).
For subclinical syndromes we used the following classification: a BMI
below 19, either irregular menstruation or amenorrhea and at least sub-threshold
test scores for AN. Subclinical BN was diagnosed if binge eating episodes
occurred at least once a week over a 4 week period, a counter regulative behavior
occurred at least twice a month and a sub-thresholds test score on EAT was
obtained.
It is a limitation of the study that only simulated diagnosis is provided.

Results
Anthropometrical characteristics are presented in Table 1.

Table 1. Anthropometric characteristics

Male Female
N = 1086 N = 1256
mean ±SD mean±SD
Hungarian Romanian Hungarian Romanian
N= 593 N = 547 N = 719 N = 537
Age 16.1 16.5 16.1 16.4
(±1.5) (±1.2) (±1.5) (±1.3)
Height 172 cm 173.3cm* 163.9 164.08
(±9.8) (±8.4) (±7.3) (±7.2)
Weight 61.3kg 63.3kg* 54kg 53.7kg
(±11.3) (±10.5) (±7.5) (±7.8)
Desired weight 64.7kg 67.8kg* 52.1kg 51.2kg†
(±12.5) (±11.8) (±5.6) (±5.8)
Body mass 20.68 20.9 20.11 19.9
index (BMI) (±2.8) (±2.7) (±2.4) (±2.4)
*There are significant differences between the Romanian and Hungarian males (p<.05)
†There are significant differences between the Romanian and Hungarian females (p<.05)

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These data indicate that men would like to gain an average of 3 kilograms
(kg) on top of their current weight. Women, on the other hand, would like to lose
2 kgs of their current weight. Romanian male’s height and weight are
significantly higher than the height and weight of the Hungarian males, and they
would like to gain significantly more weight than Hungarian males. In the female
sample there are also significant differences between Romanians and Hungarians:
on average, Romanian females would like to lose more weight than Hungarian
females even if they are taller and thinner and their BMI is lower than that of the
Hungarians.
The EAT scores of the participants are presented in Table 2.

Table 2. Mean EAT scores and the percentage of participants scoring high on the EAT

Male Female
N = 1086 N = 1256
Hungarian Romanian Hungarian Romanian
N= 593 N = 547 N = 719 N = 537
EAT(n) 16 16 50 48
(2.7%) (2.9%) (7%) (8.9%)

Mean±SD 12.3 11.6 14.4 15.2

(±6.5) (±6.06) (±9.1) (±9.3)
†There are significant differences between males and females (p<.05)

There were significant differences between males and females regarding

EAT test scores. The percentage of the females reporting disordered eating habits
is significantly higher than that of males. There were no significant differences
between the two cultures regarding disordered eating habits. The frequencies of
binge eating and counter regulative behaviors to prevent weight gain (e.g.,
vomiting, use of laxatives, diuretics, diet pills, strict dieting - according to the
EBSS) in the two groups are presented in Table 3.
The prevalence of binge eating episodes in the male sample is fairly high,
with 5.5% of the Hungarian boys and 4% of the Romanian boys reporting weekly
binge eating episodes. There are no significant differences between the two
samples regarding binge eating. Romanian boys use significantly more laxatives
and diuretics than Hungarian boys. The most frequent counter regulative behavior
in males is physical exercise. These values are between 44.2%-54.1%. Taking
into account that participants in our sample are adolescents, exercise can be
regarded as a normal process.

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Table 3. Binge eating and counter regulative behaviors in males

Male
Hungarian Romanian
anytime monthly weekly anytime monthly weekly
Binge-eating 19% 11.5% 5.5% 22.1% 15.2% 4%
(%/n) (107) (65) (12) (115) (79) (21)
Dieting 11.9% 8.8% 2.2% 12.3% 8.7% 2.6%
(%/n) (67) (50) (12) (62) (44) (13)
Physical exercising 54.1% 24.4% 20.3% 44.2% 19.2% 15.7%
(%/n) (309) (139) (116) ( 228) (99) (81)
Vomiting 13% 12.3% 0.7% 10.5% 8.5% 1.8%
(%/n) (74) (70) (4) (54) (44) (9)
Laxatives 3.5% 2.5% 0.6% 5.3%* 3.1% 1.8%
(%/n) (16) (14) (3) (27) (16) (9)
Diuretics 2.3% 1.2% 0.4% 5.7%* 3.3% 1.6%
(%/n) (13) (7) (20) (29) (17) (8)
*There are significant differences between Romanian and Hungarian males (p<.05)

Table 4. Binge eating and counter regulative behaviors in females

Female
Hungarian Romanian
anytime monthly weekly anytime monthly weekly
Binge eating 25.5% 19.1% 5.4% 28.9%† 20.9% 5%
(%/n) (183) (137) (39) (153) (111) (26)
Dieting 42.1% 26% 11% 45.3%† 23.9% 14.6%
(%/n) (303) (187) (79) (239) (126) (77)
Physical exercising 50.5% 30.5% 20% 74.9% 29.1% 33.7%
(%/n) (407) (219) (143) (396) (154) (178)
Vomiting 14% 12.5% 1.3% 13.1% 11.9% 1.2%
(%/n) (100) (89) (9) (69) (63) (6)
Laxatives 4% 2.9% 0.4% 5.6% 4.4% 0.8%
(%/n) (29) (21) (3) (29) (23) (4)
Diuretics 2.8% 1% 0.5% 8.5% 6.3% 1%
(%/n) (20) (7) (4) (44) (33) (5)
†There are significant differences between Romanian and Hungarian females (p<.05)

Binge eating is the central symptom in BN, and dieting combined with
physical exercise is the most frequent counter regulative behavior in the female
sample. Binge eating is more frequent in the Romanian female sample than in the
Hungarian one, with 28.9% of the Romanian girls reporting binge eating behavior
anytime during the past three months. Romanian females engage in significantly
more physical exercise than Hungarians, with 74.9% of Romanian girls exercising

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weekly. Binge eating episodes and counter regulative behaviors are more
common in the female population than in the male population.
The point prevalence of simulated subclinical and clinical EDs diagnosis
is summarized in Table 5.

Table 5. The prevalence of simulated subclinical and clinical eating disorders

Male Female Total

Hungarian Romanian Hungarian Romanian N=2393
(N=593) (N=547) (N=719) (N=534)
Anorexia - - - 0.6% 0.1%
(3) (3)
Subclinical - - 0.4% 1.9%† 0.5%
anorexia (3) (10) (13)
Bulimia 0.2% - 1% 1.3%† 0.6%
(1) (7) (7) (15)
Subclinical 0.3% 0.5% 0.8% 0.7% 0.6%
Bulimia (2) (3) (6) (4) (15)
†There are significant differences between Romanian and Hungarian females (p<.05)

The prevalence of AN was 0.6% in the Romanian female sample; no

clinical cases of AN were found in the Hungarian female sample. Concerning
subclinical AN, the rate was 1.9% in the Romanian sample and 0.4% in the
Hungarian sample (the difference is statistically significant using the χ2 test;
p<.05). The prevalence of BN was 1.3% in the Romanian and 1% in the
Hungarian sample (the difference is statistically significant using the χ2 test;
p<.05). The prevalence of subclinical BN was 0.8% among Hungarian girls, and
0.7% among Romanian girls. No clinical or subclinical AN was observed in the
male sample, but the prevalence of BN was 0.2% in the Hungarian male sample.
The prevalence of subclinical BN was 0.5% in Romanian boy and 0.3% in
Romanian boys.

Discussion and conclusions

The present study compares the prevalence of eating disorders in a

sample drawn from two cultures that have different traditions and speak different
languages, but live in the same country, occupy the same land, and have similar
economic and social structures. During the past decades, Romania, a post-
communist country, has undergone major economic, social, political and cultural
changes. The strong influence of Western ideals has led to a process of
Westernization (an over-identification with Western ideals), which may have
acted as a trigger to foster the development of culture-change syndromes, EDs
being one such manifestation.

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A comparison of our results with data published in other Eastern

European countries indicates similarities in the prevalence of EDs. Our data show
a higher prevalence of disturbed eating than data collected by Wlodarczyk-Bisaga
and Dolan (1996) in Poland. The authors have not found clinical cases of AN or
BN in their research sample. The prevalence of AN in our sample is the same as
found in Czechoslovakia, but the prevalence of BN is higher in the
Czechoslovakian group (Krch & Drábková, 1996). In a study conducted by Túry
et al. (1991) the prevalence of AN is higher than in our sample, but the
prevalence of BN is higher in the Romanian sample (Túry et al., 1991; Szabó &
Túry, 1991).
Besides the important epidemiological information, our data are also
valuable as they compare the prevalence of EDs in two ethnical groups that live
together in the same country. In Romania these ethnic groups have coexisted for
centuries, but they come from different historical and religious backgrounds,
speak different languages, and different habits. The role of cultural factors in the
development of EDs is well documented and the prevalence of these disorders
shows an interesting rate in different social contexts. Very few epidemiological
studies comparing different countries have been conducted.
Nasser et al. (1988) compared the eating habits of Egyptian students
studying in London with Egyptian students studying in Cairo. The prevalence of
disordered eating attitudes was higher in the group of students studying in London
(22%) than those in Cairo (12 %). The authors explained these differences by
culture change induced stress. Raich, Rosen, Deus, Perez, Requena and Gross
(1992) compared Spanish and USA students regarding their eating habits using
the EAT. The prevalence of eating disorders was higher among USA students
(m=12.1) than the Spanish ones (m=10.0).
Rathner et al. (1995) compared students studying in three different
countries: Hungary, East-Germany and Austria, and found significant differences
among the three countries. The prevalence of BN was 0.6% in Austria, 1% in
Germany and 0% in Hungary. The prevalence of sub clinical bulimia was twice
higher in the Hungarian sample (3.8%) than in the Austrian (1.9%) and the
German sample (1.7%). Neumarker, Dudeck, Vollrath and Steinhausen (1991)
compared students studying in East and West Berlin; their results showed that
students in East Berlin had higher EAT scores (12.6) than those studying in West
Berlin (11.0).
In our study, the prevalence of disordered eating habits is significantly
higher in the Romanian sample than in the Hungarian group. The weekly
prevalence of binge eating behaviors and counter regulative behaviors reported in
the female sample for the past three months ranges between 5%-5.4%. In the male
sample the percentage ranges between 4-5.5%. The prevalence of dieting and
exercising is higher. In a meta-analysis of studies using self-report questionnaires,
Fairburn and Beglin (1990) concluded that the most common weight control
method was strict dieting or fasting, which occurred in more than a quarter of

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respondents; 15.7% of respondents reported binge eating at least weekly, 2.4%

reported self-induced vomiting at least weekly, and 2.7% reported laxative use at
least weekly.
Interestingly, the analysis of EAT scores and of the frequency of binge
eating episodes and counter regulative behaviors in the two ethnical groups shows
more eating-related concerns and symptoms in the Romanian female group,
despite the fact that women in this group had lower BMI and were taller than
women in the Hungarian group. These results may be due to a more pronounced
identification with Western norms and values. Hungarians from Romania are also
influenced by the West but, as a minority, they might also be trying harder to
preserve their traditions.
Overall, our results show that EDs are a problem in Romania, at least as
common as in Western countries and other Central and Eastern European
countries. They also draw attention to the need of developing strategies for
dealing with eating disorders in our country, such as prevention programs,
identifying unreported cases and treating them properly.

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