1 Background

Eating disorders (EDs) are chronic eating disturbances that compromise health or psychosocial functioning. The four most commonly diagnosed types of eating disorders named in the Diagnostic and Statistical Manual of Mental Disorders-V (DSM-V) are anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), and OSFED (other specified feeding or eating disorder) [1]. Although concerned attitudes about food, weight, and body image are crucial to their emergence and maintenance, the aetiology of EDs can be summarized as the results of complex interactions between genetic and environmental factors [2].

For several years, Western countries, particularly those with high socioeconomic status, have been the primary focus of extensive research on eating disorders (ED). Its global occurrence is now well-known, in light of the cultural and socio-demographic influences that might greatly vary through nations [3]. Globalization and cultural change, such as modernization, urbanization, and media exposure promoting the Western beauty ideal, have been linked to increased eating disorders in non-western nations [4]. Recent literature declared the prevalence of EDs at 41.9 million cases worldwide [5]. However, little is known about the prevalence in Middle Eastern countries [3].

Adolescence is a critical developmental stage marked by significant transitions in relationships, self-concept, and future aspirations. Consequently, this period poses a heightened risk for the development of eating disorders (EDs) [6]. Addressing EDs is of utmost importance as they are among the leading causes of morbidity and mortality among young adults [7]. Notably, there is a relatively high prevalence of EDs among adolescents in Arab countries, including Syria [8].

Extensive stress can disrupt eating patterns and increase the vulnerability to developing EDs [9]. A considerable body of literature has highlighted this issue among university students attending different majors [10, 11]. Notably, medical students are particularly susceptible to mental health issues, including EDs, as evidenced by research findings [12, 13]. Recent research conducted among Syrian medical students indicated that half of the students demonstrated unhealthy eating habits [14]. This heightened risk can be attributed to various factors, such as academic stress, demanding workloads, continuous learning requirements, and exposure to illnesses and death throughout their medical education [15].

Since the outbreak of the war in Syria, students have faced numerous challenges that have impacted their ability to continue their education. The conflict has resulted in severe disruptions, presenting students with several significant struggles. Those difficulties involved several aspects, such as reduced human resources, lack of a suitable environment to study, and low-income-related limitations. In addition, it has shown the huge impact of the COVID-19 pandemic on students' diet and well-being [16]. This study aims to screen for eating disorders and their associated risk factors among Syrian university students. However, limited research has been conducted on eating disorders within this specific population, especially in the context of the ongoing conflict and the COVID-19 pandemic. Therefore, this study fills an important gap in the existing literature by providing critical insights into the prevalence and risk factors of eating disorders among Syrian university students. The findings from this research can inform the development of targeted interventions to support the mental health and well-being of this vulnerable student population.

2 Methods

2.1 Study methods, and participants

A questionnaire-based cross-sectional study was conducted among university students of the Syrian Private University (SPU) in Damascus, Syria. The survey was distributed online using a convenience sampling method between December 2020 and February 2021. The sample size was 357 based on a margin of error of 5%, and a confidence interval of 95%, for a populace of 5000 students using a sample size calculator. Participants were told that their contribution was voluntary, that response to all questions was optional and were allowed exemption from the survey anytime. Objectives of the study were disclosed to students in a written form attached to the questionnaire. A formerly published study on eating habits and its related psychological factors was based on the same data [14].

2.2 Study instruments

A self-completed questionnaire on students’ eating habits, eating disorders, and psychological factors was adopted from previously published studies [17,18,19]. The questionnaire contained 3 sections:

  1. 1

    Socio-demographic information included [12] questions on gender, faculty, year of study, marital status, financial status, living status, body mass index (BMI), smoking status, alcohol consumption, and exercise. Participants were asked about their eating habits status during exam season, with 3 possible answers: “become worse”, “no change”, or “become better”, and a question regarding barriers affecting healthy eating habits. The BMI was calculated as weight in kilograms divided by height in square meters (kg/m2). Students’ BMI was split into 4 groups: ≤ 18.5 kg/m2 was categorized as underweight, 18.5—24.9 kg/m2 was categorized as healthy weight, 25–29.9 kg/m2 was categorized as overweight, and ≥ 30.0 kg/m2 was categorized as obese.

  2. 2

    Eating habits and psychological behavior towards eating were determined with 13 items. The validated Compulsive Eating Scale (CES) was used to measure uncontrolled eating patterns among university students [14].

  3. 3

    Screening for eating disorders was assessed using a 5-item scale. The Sick, Control, One Stone, Fat, and Food (SCOFF) scale is a screening tool that can only identify the potential presence of an eating disorder [19]. This is an effective screening tool for eating disorders with good psychometric properties (kappa statistic = 0.73 to 0.82) [19]. Each ‘yes’ answer to a question of SCOFF score is equivalent to one point. A score of two or more points indicates the participant may be suffering from an eating disorder.

2.3 Ethical approval

Ethical approval was obtained from the Institutional Review Board (IRB), Faculty of Medicine, SPU. Under registration number: 466.

2.4 Registration of research studies

  • 1. Name of the registry.

  • 2. Unique Identifying number or registration ID: researchregistry8935.

2.5 Statistical analysis

Data were analyzed using the Statistical Package for Social Sciences version 26.0 (SPSS Inc., Chicago, IL, United States) and reported as frequencies and percentages (for categorical variables) or means and standard deviations (SD) (for continuous variables). The chi-square analysis was applied to compare BMI distribution (≤ 18.5, 18.5–24.9, 25–29.9, and ≥ 30.0), eating habits during exams, psychological factors, and eating disorder behavior against both genders. The chi-square test was applied to compare SCOFF score categories (< 2 points, ≥ 2 points) against socio-demographic variables (age, gender, faculty, marital status, living status, BMI, and exercise), eating habits status during exams, and psychological factors. Statistical significance was considered at p-value < 0.05.

3 Results

3.1 Socio-demographic characteristics

Of the 1000 students invited to collaborate, 728 responded to the survey, with a response rate (72.8%), of which 45.3% were males and 54.7% were females. The mean age of participants is 21 (2 ±). Most participants studied medicine 32.3%, followed by pharmacy 25.7% and dentistry 17.6%. For non-medical faculties, 9.1% studied IT, 7.8% studied Business administration, and 7.6% studied Petroleum engineering. 83.2% were single, 77.5% living with family members, 53.2% non-smokers, and 81.5% never consumed alcohol. A minority of 36.8% participated in physical exercises once or twice a week and 36.5% never did so. About 81.5% of students reported getting between six and ten hours of sleep per day (Table 1).

Table 1 Socio-demographic characteristics of respondents: (n = 728)
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3.2 Dietary habits and barriers to eating healthy meals and gender deference

Merely 36% of students reported adopting a healthy diet. Approximately 60% of participants stated having breakfast daily. 64.7% and 57.6% of students stated the weekly consumption of vegetables and fruits respectively. 68.2% of the students stated drinking less than 2 litters per day. Lack of time (72.7%), not accessible 279 (38.3%), and unenjoyable 230 (31.6%) were the most frequent perceived barriers to healthy food.

The gender difference in dietary habits was analysed. Firstly, a higher proportion of females 62.7% reported consuming three or more breakfasts per week compared to males 54%, with fewer females 37.3%, and males 46.0% reporting less than three breakfasts per week. This suggests that females may be more inclined towards regular breakfast consumption (P = 0.01). Secondly, a significant difference was observed in snack frequency, with a greater percentage of females 58.8% reporting having three or more snacks per week compared to males 48.5% (P = 0.006). Thirdly, A higher percentage of females 38.8% reported consuming three or more servings of fast food per week compared to males 26.6%, while more males 73.9% reported consuming less than three servings (P < 0.001). Fourthly, more females 42.4% reported consuming two or more litters of water per day compared to males 22.9%, while a higher percentage of males 77.1% reported consuming less than two litters (P < 0.001). Finally, most of the students' eating habits became worse during exams 55.7%, while 34.3% reported no change and 9.9% became better. In addition, eating habits during exams differed across gender, females 60.6% markedly reported worse eating habits during exams compared to males 50% (P = 0.017) (Table 2).

Table 2 Dietary habits among respondents and gender deference (n = 728)
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3.3 Gender differences in psychological factors and SCOFF variables

Students reported psychological factors affecting their eating habits. In particular, female students showed a significant association with certain factors compared to their male counterparts. These factors included “eating because of feeling lonely” (47%, P = 0.006), “eating because of feeling upset” (37.7%, P ≤ 0.001), and “eating because of feeling bored” (73.4%, P < 0.001). On the other hand, males were correlated with a higher prevalence of "eating until the stomach hurts” (50.3%) compared to females (38.7%, P = 0.002).

When answering questions related to eating disorder-related behaviours, students’ responses varied by gender. Specifically, females exhibited significant associations with certain behaviours compared to males. These behaviours included “provoking sickness due to unpleasant fullness” (5.3%, P = 0.006), “worrying about losing control over the amount of eating?” (19.8%, P = 0.006), and "having a distorted perception of body shape" (40.5%, P < 0.001) (Table 3).

Table 3 Gender differences of psychological factors and SCOFF variables:
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3.4 Association between Socio-demographic variables and Scoff score

The prevalence of probable eating disorder according to positive SCOFF score was 20.3%. Among the sample with possible eating disorders, 66.9% were females, indicating a higher prevalence compared to males (33.1%) (P ≤ 0.001). Students with normal BMI (65.5%) were significantly associated with negative SCOFF scores compared to other BMI groups (P ≤ 0.001). Students who reported worse eating habits during exams (66.9%) were significantly more likely to have possible eating disorders compared to those who reported no change (27.2%) or became better (5.4%) in their eating habits during exams (P = 0.006) (Table 4).

Table 4 Association between Socio-demographic variables with SCOFF score (n = 728)
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3.5 Association between psychological factors variables and Scoff score

Surprisingly, students with probable eating disorders compared to negative Scoff scored students were significantly associated with psychological factors by the following: “eat because of feeling lonely” (58.8%) (P < 0.001), “feel out of control to food” (67.6%) (P < 0.001), “eat until stomach hurts” (66.9%) (P < 0.001), “eat because of feeling upset” (53.4%) (P < 0.001), “eat because of feeling bored” (79.7%) (P < 0.001) (Table 5).

Table 5 Association between psychological factors variables with SCOFF score (n = 728)
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4 Discussion

Deleterious eating habits, body shape dissatisfaction, and eating disorders are widespread among university [20]. The results of this study revealed a high overall prevalence of eating disorder attitudes and behaviours among Syrian undergraduate students based on the SCOFF screening test (20.3%). This was similar to reports conducted among students in Lebanon 19% [13], USA 20.4% [21], Hong Kong 26.9% [22], Spain 28.3% [23], and Palestine 31.5% [11]. Nevertheless, it is slightly lower than the findings of other research conducted in Western and European-based samples such as the UK (32%) [24], and Ukraine (36.9%) [25]. A much higher eating disorder prevalence was found among university students in India at 34.1% [26], and Turkey 41.4% [27].

The new definition of ideal body shape has affected university students’ tendency to acquire perfection traits and behaviour in body shape [3, 28]. Pursuing an impractical thin and muscular body to amaze others is common among undergraduates [3, 28]. This is present clearly in the study findings, as 32% of students worried about being fat even though their peers told them they didn’t do so, 40.5% of those were females. A long severe burden of the Syrian war, economic inflation, and agronomic sector deterioration negatively influenced the civilian’s nutritive intake, and diverse cuisine access. All of these make Syrian students a vulnerable group for psychological distress and disordered eating.

Of the 20.3% who demonstrated a higher risk of eating disorder prevalence, 66.9% were female. Likewise, previous studies thoroughly indicated female dominance in the prevalence of eating disorders. Multiple factors were suggested to point out gender differences including the fact that women are more implicated in weight and appearance concerns [23, 29, 30]. There is a higher prevalence of stress and anxiety among females compared to males. Additionally, stressed and anxious university students are at a heightened risk of developing eating disorders. [23, 31,32,33]. The school-to-college transition exposes women to a range of nutritional hazards, including extreme dieting, eating disorders, and physical dissatisfaction [34]. To investigate the causes of gender differences in eating behaviour, further research is needed in this area. Among other factors, a healthy diet is an influential predictor of BMI [35, 36]. Students reported lack of time, low access, and unsatisfying as major barriers to healthy nutrition. According to SCOFF score students with normal BMI were markedly not at risk for an eating disorder. In line with previous research among university undergraduates [37].

4.1 EDS and exams

Psychological distress has a high prevalence among Syrian university students [38]. Studies showed that individuals exhibit varying responses in food intake when subjected to stress. Around 40% of individuals increase their calorie intake by approximately 40%, while another 40% reduce their caloric intake by the same percentage. Meanwhile, approximately 20% of individuals do not alter their feeding behaviours during periods of stress. These varying results may relate to the specific type of stressor manipulated, duration of stress provocation, and variations in the satiety and hunger levels at the start of the study [9]. In the present study, Students who tested positive for probable eating disorders exhibited a deterioration in their eating habits during exams, which is known to be a stressful situation.

4.2 EDS and psychological factors

Research has shown that university students, particularly those pursuing medical degrees, have a high prevalence of probable eating disorders (EDs). A hypothesis relating stressful situations, peer pressure, and depressive episodes to behavioral changes in eating habits has been proposed [39]. The literature suggests that psychological behaviours, such as disordered eating patterns, can be exacerbated by stressful situations and may be used as a coping mechanism by students [39]. Given the findings of our study, of students with positive SCOFF score, 58% stated eating because of feeling lonely, 67.6% stated feeling completely out of control when it comes to food, and 53.4% stated eating because of feeling upset or nervous. Our study revealed multiple psychological factors associated with EDS. Thus, being upset, bored, angry, lonely, and nervous were factors determined as potential risk factors for EDS.

5 Conclusion

The high risk of EDs prevalence in Syrian private university students indicates a severe psychological burden affecting Syrian young adults. Social and psychological factors were factors significantly associated with the potential development of eating disorders. Prompt awareness strategies should be presented on university campuses to control eating behaviours and to cope with negative emotions and stressful conditions. Further research is mandated to demonstrate these putative risk factors in longitudinal studies with larger, more diverse samples. Additionally, the utilization of a validated diagnostic measure for eating disorders would strengthen the assessment of the relationship between the identified psychological factors and the presence of clinically significant eating disorder symptoms.

6 Strengths and limitations

This is the first study to reveal a significant number of probable EDs among university students and its correlation with socio-demographic factors and psychological factors in Syria. However, our work presents various limitations. Due to the nature of the study type, self-reported findings, particularly in relation to variables such as BMI and exercise where respondents may be tempted to provide more socially desirable answers, can affect the outcomes of the study. This study is a single-center cross-sectional study design that lacks the representation of the entire population affecting external validity. The use of the SCOFF score to predict probable EDs was easier to conduct but less accurate than diagnostic measurements. Finally, a cross-sectional study design may not be able to deduce causality and connections; thus, additional longitudinal studies are needed to obtain more precise results.

7 Implication

To tackle this complex problem, a comprehensive, multidisciplinary strategy is required. Universities must prioritize increasing access to mental health resources and reference specialized treatment programs to support affected students when applicable. Educational campaigns and skills-based interventions targeting positive body image, healthy eating habits, and stress management techniques should be implemented campus-wide. Peer-led support groups and mentorship programs may also foster a more nurturing environment and reduce feelings of isolation. Continued research is needed to develop and evaluate the effectiveness of targeted prevention and early intervention strategies for this high-risk population, especially those who will be future physicians. By addressing the sociocultural drivers of eating disorders among university students, institutions can work to promote overall student well-being and mitigate the negative academic and health consequences of this pressing issue.