1. Introduction

Eating disorders are a major problem worldwide. They mainly affect young people and teenagers, but older people are not excluded. At the same time, while eating disorders are used to refer to women, in recent decades an increase in symptoms has also been observed in men [1].

Eating disorders can be defined as “eating habits that are detrimental to a person’s health.” They revolve around food and weight issues and can be life threatening.

The most common eating disorders are four and they are anorexia nervosa (AN), bulimia nervosa (BN), orthorexia nervosa (ON), and binge eating disorder (BED).

It is worth mentioning that orthorexia is not yet an official eating disorder, despite the fact that it is frequently observed by clinicians [2]. It is not listed in the official ICD-11 and DSM-V classifications of mental disorders, as there is still no officially accepted definition of ON, or standardized criteria of its diagnosis [3].

2. Anorexia nervosa

Anorexia nervosa is a mental illness characterized by intense weight loss, intense fear of gaining weight even if the patient is underweight, distorted body image, and amenorrhea [4].

Although it is difficult to measure as it varies depending on the population studied and the diagnostic criteria used, the prevalence of AN is 0.1–3.6% for women and 0–0.3% for men [5].

It usually starts at a young age or in adolescence, although it can appear at any age. The sex ratio in adults is 1:8, with a predominance of women, while the gender distribution in children is smaller. Disparities differ between age groups, with higher rates of complete recovery and lower mortality in adolescents than in adults (median mortality 2 vs. 5%) [6].

In addition to the psychological effects, other effects of anorexia nervosa are:

Iron deficiency anemia
Reduced function of the immune system
Intestinal problems, for example, abdominal pain, constipation, diarrhea
Loss or disturbance of menstruation in girls and women
Increased risk of infertility in men and women
Renal failure
Osteoporosis
Heart problems (e.g., heart abnormalities, sudden cardiac arrest)
Death [7]

3. Bulimia nervosa

Bulimia nervosa or bulimia nervosa is a mental illness characterized by repeated episodes of binge eating that are followed by compensatory behaviors. A person with bulimia nervosa usually eats large amounts of food in a short period of time, during which they feel a loss of control and may not be able to stop even if they want to.

There are two types of bulimia. In the first, the person regularly induces vomiting, uses laxatives, enemas, or diuretics to compensate for the amount of food consumed. In the second, the individual engages in regular fasting or excessive exercise but does not demonstrate purging behaviors such as vomiting or laxative abuse [8].

In adults, prevalence estimates of full-threshold BN are 1%–1.5%, 2.12 to 0.1–2% in youth [9]. However, community studies that assessed disordered eating behavior instead of applying strict diagnostic criteria for bulimia found that the prevalence was much higher, that is, 14–22%, than the respective strict criteria [10].

The most common health complications that bulimia nervosa can cause are:

Dental erosions due to self-induced vomiting and gastroesophageal reflux
Gastrointestinal disorders, which are one of the first symptoms
Liver and pancreatic problems, such as hepatic steatosis and acute pancreatitis
Metabolic and electrolyte complications due to prolonged fasting, vomiting, and excessive use of diuretics
Cardiovascular complications
Skin problems such as dryness and dermatitis [11]

4. Orthorexia

The word “orthorexia” comes from the Greek words “Ortho” meaning “right” and “appetite.” Orthorexia nervosa means “correct appetite” and is a pathological condition in which there is an obsession with healthy eating. It has been aptly described as a “disease masquerading as a virtue” [12]. Although, as already mentioned [3], not formally recognized as a psychiatric diagnosis, orthorexia is often associated with significant obsessions, such as embarking on a quest to achieve optimal health through attention to diet, which can lead to malnutrition, loss of relationships, and poor quality of life [2].

Since it is not recognized as a psychiatric disorder and since there are no diagnostic criteria yet, it becomes difficult to estimate its prevalence [2].

The existing literature estimates the prevalence of orthorexia to be around 6.9% [13].

In terms of consequences, orthorexic individuals may experience nutritional deficiencies. In long-term empirical studies, there is evidence that such dietary extremism can lead to the same medical complications seen in severe anorexia: osteopenia, anemia, hyponatremia, metabolic acidosis, testosterone deficiency, and bradycardia [14].

Psychologically, orthorexic individuals experience intense frustration when their food-related practices are disrupted or prevented, disgust when the purity of food is seemingly compromised, and guilt when they commit dietary violations [15].

In addition, orthorexic individuals are at risk of social isolation as they believe they can maintain a healthy diet while alone and may adopt a position of moral superiority regarding their eating habits so that they do not wish to interact with others [2].

5. Binge eating disorder

Binge eating is characterized by episodes of uncontrollable and impulsive overeating, beyond the point of feeling “satisfactorily full.” Not infrequently, these episodes are accompanied by guilt and resentment. The condition differs from bulimia nervosa in the fact that the episodes are not by balancing-compensating behaviors, such as fasting or the use of laxatives. Binge eating episodes occur on average 2 days per week for 6 months or more.

To date, there have been few epidemiological studies examining the prevalence of episodic binge eating in the general population. For example, Spitzer et al. have conducted two studies where they found that the prevalence was 3.3% in the first study and 2% in the second study [16].

6. Study design

From May to August 2018, a correlation study was carried out in dietetic offices all over Greece in order to investigate eating disorders in the country, the behavior of people who have some kind of disorder toward food, various weight management practices, and finally the peculiarities and the socioeconomic characteristics of people with eating disorders.

Sampling was done through anonymous questionnaires in dietitian offices, which were given to clients to complete by their first two appointments. The anonymity of the sample and the use of its answers for the specific task were explicitly mentioned in these. In addition, the possibility of withdrawing—refusing to participate at any time from the research was mentioned.

Thus, 625 people were collected, of which 80.8% were women and 19.2% were men. The people answered a total of 47 questions. The first 11 questions were about behaviors and practices they might follow to control their weight and about their relationship with food in general. These are a combination of behavioral questions related to eating symptoms and weight loss, that someone is requested to answer supplementary when they fill in the EAT-26 questionnaire, and some other questions that dietitians in dietary offices reported as important and wanted to be investigated. The next 26 questions were the questions of the internationally recognized EAT-26 questionnaire. Finally, the remaining 10 questions were about personal information such as gender, age, marital status, monthly income, education, occupation, place of living, frequency of physical activity, weight, height of individuals, and other relevant questions.

The procedure followed after receiving the 625 questionnaires, was their processing in the SPSS Statistics 25.0 program.

The EAT-26 test is perhaps the most widely used standardized symptom measure and is specific to eating disorders. The original EAT appeared in 1993 and is highly reliable and valid [17]. The EAT-26 alone does not provide a specific diagnosis of an eating disorder.

The EAT-26 items consist of three subscales: (1) dieting, (2) bulimia and food preoccupation, and (3) oral control. Its main objective is to determine the presence of extreme weight control behaviors, as well as to estimate their frequency by collecting a lot of information from a questionnaire [18].

The answers people can choose are: “always,” “usually,” “often,” “sometimes,” “rarely,” and “never.”

Each answer is scored respectively and finally, the scores are added up and the total score of the questionnaire is obtained [19].

Because refusing to answer many of the questions and hiding the truth can be a problem and wrong answers may be given, a low score should also be taken as a possible eating disorder.

In addition to the EAT-26 questions, identification in body mass index (BMI) and behavioral symptoms reflect an eating disorder.

7. Study results

As already mentioned, 625 people aged 12 and over participated in the study, with the largest percentage, 32.2%, being between 25 and 35 years old.

54.88% of the respondents were single and even more, 44.48%, had a higher education.

Particularly significant was the finding that 24.96%, or 1 in 4, of people who visit a dietitian’s office and attend nutrition sessions have some kind of eating disorder, a result that could be considerably higher if we consider that stricter criteria were used (Figure 1).

Figure 1.
The percentage of respondents who had an eating disorder.

In point of fact, it was found that there is a strong correlation between these people with various behaviors around food.

Specifically, there was a significant correlation (Pearson’s correlation coefficient > 0.3 and P value < 0.001) between people who have an eating disorder with the influence of the scale number on their psychology as well as their self-belief as overweight/obese, even though their circle thinks they are not.

Furthermore, various food-related behaviors were positively correlated with the likelihood of the individual having an eating disorder.

These behaviors were: the number of times someone has dieted in the past, the number of times someone has had a binge eating episode in which they feel they cannot stop, and the number of times they have lost >9 kg through dieting and caused vomiting.

Regarding the knowledge of the existence of an eating disorder among the Greek respondents, it was found that 64.32% did not know if they have or had an eating disorder, 29.44% knew that they have an eating disorder in the presence, and the remaining 6.24% knew that they had an eating disorder in the past (Figure 2).

Figure 2.
Percentages of respondents who did not know if they have an eating disorder, those who knew they had an eating disorder, and those who knew they had in the past.

Among those who stated that they had an eating disorder in the past, only 37% of them actually have, which demonstrates the insufficient information and as a consequence the ignorance on the part of nutrition and its disorders.

Furthermore, the percentages of respondents who exhibit various behaviors related to eating disorders were high.

For example, the number on the scale affects the way they see themselves for about 7 out of 10 people who visited dietetic offices (68.8%) (Figure 3).

This could also be the main reason why more than 25% of each dietitian’s clients stop after less than 2 months of trying or at the first indication that the result is not worthy of their—usually overestimated—expectations.

Figure 3.
Percentage distribution of the sample affected by the number shown on the scale.

Additionally, 62.08% of respondents weighed themselves more than once a month, which shows a strong concern about body weight and scale numbers. In fact, 27.2%, that is, about 1 in 3 people, weigh themselves 2–4 times a week, reinforcing this indication (Figure 4).

Figure 4.
Percentage distribution of the sample for the question “how often do you weigh yourself”?

Regarding binge eating episodes, only 33.44% stated that they had not had one in the last 6 months. So the vast majority have had at least 1 episode of this kind. More specifically, 19.68% stated that they do it 2–3 times every month in the last 6 months (Figure 5).

Figure 5.
How often have you had a binge eating episode in the last 6 months?

8. Conclusions

The findings from this study offer a view into the intricate landscape of eating disorders and their correlation with various behavioral patterns, self-perception, and awareness levels among people who seek nutritional guidance.

The study’s demographic breakdown, with the highest percentage (32.2%) within the 25 to 35-year age range, signifies the potential willingness of this age group to control its weight and diet and ask for experts’ help. This is crucial because it probably demonstrates the different importance that individuals place on their weight and diet depending on their age and therefore the different types of interventions that need to be made in each age group.

The identification that a substantial proportion (24.96%) of individuals visiting dietitian’s offices grapple with eating disorders underscores the urgent need for dietitians to be vigilant in recognizing signs of eating disorders and providing appropriate interventions.

Moreover, the positive correlation between disordered eating and behaviors such as frequent dieting, binge eating episodes, and extreme weight loss through vomiting underscores the importance of a comprehensive approach that addresses both psychological and behavioral aspects of these disorders. For this reason not only dietitians but also all healthcare providers, such as psychologists and psychiatrists, should be well-informed and educated in the field.

To conclude, the significant proportion (64.32%) of participants uncertain about their condition highlights the pressing need for improved education and awareness campaigns. It is meaningful accurate information be disseminated to the public, enabling individuals to recognize potential signs of eating disorders and seek appropriate help in a timely manner.

9. Suggestions

Based on the above results and conclusions, it is very important to early detect and intervene, but also inform and educate people about eating disorders.

There are various strategies that would help to raise awareness among the people.

First of all, the state could organize educational campaigns that would include the provision of information by specialized professionals about the signs, symptoms, and effects of eating disorders. These will be addressed to schools, universities, and workplaces, both public and private.

Corresponding educational campaigns could also be organized through television and social media for mass information and the approach and awareness of the general public.

Furthermore, it would be helpful to create structures staffed with qualified health professionals, doctors, psychologists, and nutrition experts, where every citizen can visit and discuss issues related to nutrition and body image that concern them.

To serve the entire population and people living in remote areas, it would also be beneficial to establish a toll-free telephone line through which people who feel the need can contact experts on such matters.

For this purpose, it is considered necessary to organize special seminars for additional education and training of the health professionals who will deal with the specific incidents.

These professionals could also provide educational materials to teachers and educators so they know how to raise issues of nutrition, body image, and self-esteem with students, recognize unhealthy eating behaviors, and reach out to relevant agencies for help.

In order to financially support the above actions and also to make them known to the general public, walks, road races and other sporting and cultural events can be organized at regular intervals. The money collected will be allocated to the structures and organizations for the prevention and treatment of eating disorders that will have been created.

Finally, the establishment of an annual preventive check in schools, workplaces, and sports clubs would contribute to the early diagnosis of children, adults, and athletes who suffer.

Conflict of interest

The authors declare no conflict of interest.

Appendix A

Questionnaire.

You can only choose one (1) answer.

Do you know that you have an eating disorder or that you had in the past?

Yes, I have
No, I have not
I had an eating disorder in the past

Have you ever lost and regained >9 kg through diet?

One time
Two times
Three times
Never

Does the weight on your scale affect your mood and how you see yourself during the day?

Yes
No

How often do you weigh yourself?

>1 time per day
1 time per day
5–7 times per week
2–4 times per week
<1 time per month
Never

Do you consider yourself overweight despite others telling you that you are not?

Yes
No

How many times have you been on a diet in the past?

Never
1 time
2 times
3 times
>3 times

During the last 6 months:

How many times have you had a binge-eating episode, during which you felt that you could not stop eating?

Never
<1 time per month
2–3 times per month
1 time per week
2–6 times per week
6 or > 6 times per week

How many times have you vomited to control your weight or your body image?

Never
<1 time per month
2–3 times per month
1 time per week
2–6 times per week
6 or > 6 times per week

How many times have you used laxatives, pills or diuretics to control your weight or your body image?

Never
<1 time per month
2–3 times per month
1 time per week
2–6 times per week
6 or > 6 times per week

How many times have you done exercise to lose or control your weight?

Never
<1 time per month
2–3 times per month
1 time per week
2–6 times per week
6 or > 6 times per week

Have you lost 10 kg or more?

Yes
No

EAT - 26 Questionnaire.

I am terrified about being overweight.
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I avoid eating when I am hungry
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I find myself preoccupied with food
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I have gone on eating binges where I feel that I may not be able to stop
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I cut my food into small pieces
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I aware of the calorie content of foods that I eat
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I particularly avoid food with a high carbohydrate content (i.e. bread, rice, potatoes, etc.)
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I feel that others would prefer if I ate more
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I vomit after I have eaten
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I feel extremely guilty after eating
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I am occupied with a desire to be thinner
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I think about burning up calories when I exercise
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
Other people think that I am too thin
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I am preoccupied with the thought of having fat on my body
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I take longer than others to eat my meals
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I avoid foods with sugar in them
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I eat diet foods
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I feel that food controls my life
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I display self-control around food
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I feel that others pressure me to eat
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I give too much time and thought to food
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I feel uncomfortable after eating sweets
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I engage in dieting behavior
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I like my stomach to be empty
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I have the impulse to vomit after meals
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never
I enjoy trying new rich foods
- Always
- Usually
- Often
- Sometimes
- Rarely
- Never

Personal Information:

Gender:

Man
Woman

Age:

12–17
18–25
25–35
36–45
46–55
56–65
>66

Weight: __ (kg).

Height: __ (cm).

How many hours do you do physical activity during the week?

0 hours
<2 hours
2–4 hours
5–9 hours
>10 hours

Marital status:

Married
Unmarried
Divorced

Monthly income

<500 €
501–800 €
801–1000 €
1001–2000 €
>2000 €

Educational level:

Basic/Compulsory Education - Junior High School
High School
Vocational Training
Bachelor degree
Master degree
Ph.D. degree

Job:

Student
Private Employee
Public employee
Freelancer
Farmer
Unemployed
Household

Living region:

Epirus
Thessaly
Thraki
Creta
Makedonia
Islands of Aegean Sea
Islands of the Ionian Sea
Peloponnese
Central Greece (not Attica)
Attika

Appendix B. Conclusion

So despite the fact that Greece belongs to the Mediterranean countries that promote the Mediterranean diet model, which is linked to mental health, it seems that many of its inhabitants have a disturbed relationship with food. One in four people are found to have some kind of eating disorder, while a very large percentage do not know if they have an eating disorder. The latter confirms and intensifies the concern that Greeks have no idea of the meaning and importance of eating disorders and their effects.

It is therefore considered important to strengthen the planning of interventions, such as those mentioned above, to raise awareness among people who are at risk of developing an eating disorder and to support those who already have one.

Alla Boshchenko

Chapters authored

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