INTRODUCTION

There is general agreement about the criteria for diag- nosis of anorexia nervosa (AN) and bulimia nervosa (BN) as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM IV) (American Psychiatric Association (Nietzel and Wakefield 1994, Fairburn and Harrison (2005). Eating disorders are characterized by severe disturbances in eating behaviors and attitudes. Both AN and BN are characterized by weight preoccupa-

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*Corresponding Author: Received 10th March, 2016

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tion, fear of fat and a sense of self unduly influenced by weight and body shape concerns (APA 2000). When distinctions between AN and BN are drawn, it is usu- ally because of weight and associated medical compli- cations. People with AN are underweight while people with BN tend to be of average or above-average weight. In addition, the DSM–IV includes fear of becoming fat, and amenorrhea in postmenarchal women as necessary criteria for AN. Less conclusive or agreed upon is the definition and criteria for a diagnosis of Binge Eating

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Disorder (BED). However, people with BED usually suffer from binge eating episodes without the compensatory behaviors seen in BN. There seems to be agreement that eating disorders result in serious physical, psychological, and social difficulties and dysfunction (Russell-Mayhew 2007 and Mervin and Zucker 2010).

Body image is an important aspect of self-representa- tion and self-evaluation during youth and adolescence. Although body image is a multidimensional construct, it is most frequently defined as the degree of satisfac- tion with one’s current physical self (size, shape, general appearance). The importance of body image is evident in its relationship to risk status for eating disorders (Jones 2001).

Many influences have been noted as formative in the development and maintenance of eating-, shape- and weight-related disorders (Thompson et al. 1999, Mervin and Zucker 2010). These factors include, but are not lim- ited to, teasing or critical comments about one’s appear- ance from parents, peers or other significant individu- als, early pubertal maturation, sexual abuse, psychiatric disturbance, negative emotionality, poor interoceptive awareness, developmental challenges, academic pres- sures, and elevated social comparison tendencies (Leon et al. 1995, Levine et al, 1994).

Socio-cultural theory emphasizes on those ideas and beliefs that can be learned through social and cultural factors such as the media, family or history. Stice et al., (2002) stated that the social and cultural effects cause disorders in body image and eating habits.Pressure from parents to lose weight and being ridiculed because of weight or being encouraged because of weight loss are associated with negative body image and eating.

Stice et al., (2002) have also concluded that not only family pressures, but peer pressure also influence body image. Being ridiculed by friends for the weight and pressure of being thinner affects the state of being con- sent with the body. One of the most important factors related with the developing of ED is the social standard of beauty and thinness that appears in the media (Ditt- mar et al. 2000). As applied to body image disturbance and eating disorder development, researchers propose that images of models displayed prominently in the media serve as comparison others. When women com- pare themselves to models in mainstream media, they are evaluating themselves in comparison to a very specific ideal female physique, whereas media is correlated with the internalization of thin- ideal, body dissatisfaction. If women internalize these ideals but do not conform to them, and have friends and family members who do, then they would be in an upward social comparison pro- cess, and likely feel body dissatisfaction (Warren 2006).

Studies around the world confirm that a relatively large proportion of teenage girls are encountered with

eating disorders. Teens, especially girls, in most cases, pay special attention to their weight and body shape, and often in an attempt to deal with the pressures asso- ciated with changes in the critical and challenging period of puberty, adopt wrong eating habits. Therefore, this exposure may cause nutritional behavior problems (Rustaee et al. 2009).

Although exact statistics about the use of weight loss drugs are not available in Iran, according to Ham- shahri News Agency reports; Sales of weight loss drugs are high, which itself is indicative of high expenses that people undertake for these drugs. But aside from the negative side effects of these medications, the problem is lack of proper drug effect. Despite the cost of the drugs, the result is not desired. This makes people adopt wrong eating habits, and face anorexia nervosa and bulimia nervosa.

Eating disorders deserve attention for two major rea- sons (APA 2000). First, the mortality rate for those who do meet the criteria for eating disorders is between 5 and 12%, indicating that eating disorders are indeed some of the most serious mental illnesses. In general, “eating disorders have the highest levels of treatment seeking, inpatient hospitalization, suicide attempts, and mortality of common psychiatric syndromes” (Daniels 2009). In addition, eating pathology increases the risk for future onset of obesity, depressive disorders, anxiety disorders, substance abuse, and health problems (Johnson, et al. 2002,Stice et al. 1999,Stice et al. 2000).

In the meantime, no major sociological research on eating disorders and their relationship with social fac- tors has been done in Shiraz yet. Given the fact that Shiraz is one of the major metropolises in Iran, as well as ethnic and cultural diversity of the city, conducting research on factors related to body image, which can have a significant cultural dimension is important.The questions examined in this study include how much is the frequency of eating disorders among girls and young women? What are the factors affecting eating disorders and what are the direct and indirect impacts of factors affecting eating disorders through body image? Which one is more important and the most effective?

MATERIAL AND METHODS

This study has been done through survey method. The tools for data collection were self- reported question- naires. As Zhang et al explain, in self-reported method, respondents have personal place and space to remember their past events (Zhang et al. 2000). In this study body- related social comparison in 15 to 29 years old girls and women of Shiraz was considered as independent varia- ble, body image was considered as the interval variable, and eating disorder as the dependent.

The total girls and women between 15 to 29 years old of Shiraz are 36237. Based on Lin table, the sample size was 600. The method was multi-stage random sampling. In order to determine the validity and reliability of the questionnaire, the two kinds of content validity and face validity were used. For content validity, the question- naire was given to some experts and for face validity; it was given to some girls and women between 15 to 29 years old. To measure the reliability of the questionnaire items, Cronbach’s alpha technique was used.

INDEPENDENT VARIABLES

ICT use

A composite measure of weekly viewing was con- structed to account for using ICTs. Participants reported how muchthey watch television during every week, from “not at all” to “very much”. These data were weighted and combined to create an average weekly viewing.

BODY-RELATED SOCIAL COMPARISON(BRSC)

To measure likelihood to engage in comparisons with peers, family members and models, Participants answered the question how often they compare their “overall body” to members of their own sex (e.g., how often do you compare your overall body to that of peers).

PARENTAL ATTITUDES REGARDING BODY

The parental influence section from the Tripartite Influ- ence Model of Body Dissatisfaction and Eating Distur- bances with Adolescent Girls (Berg et al. 2002) with some changes was used to measure perceptions of parental atti- tudes toward weight and body shape. The index included five statements using a 7-point scalefrom“Strongly disa- gree” to“Strongly agree.” Statements included items like “My mother is on a diet to lose weight” and “My father has made comments or teased me about my appearance”.

PEER ATTITUDES REGARDING BODY

The same questions were used to measure percep- tions of peer attitudes toward weight and body shape. The index included five statements using a 7-point scalefrom“Strongly disagree” to“Strongly agree.” State- ments included items like “My friends are on diet to lose weight” and “My friends have made comments or teased me about my appearance”.

BODY IMAGE

Two measures were used for body image: body areas- satisfaction, self-discrepancies for physical characteris- tics. These measures were used to focus on perceptual

Bijan Khajrnoori and Roodabeh Dehghani

aspects of body image (i.e., what people perceive about their bodies such as weight, physical characteristics, and attractiveness).

BODY AREAS SATISFACTION

A modifed version of Body Areas Satisfaction Scale (Cash 1989) wasused to measure participants’ satisfac- tion, ranging from1 (very dissatisfied) to5 (verysatisfied), with specific areas of the body such aslower torso (e.g., hips, legs), mid torso (waist, stomach), upper torso (e.g., breasts, arms), muscle tone, weight, and height. Higher scores indicate satisfaction with most areas of the body. The internal consistency of this scale was high in this study (α = 0.93).

SELF-DISCREPANCIES FOR PHYSICAL CHARACTERISTICS

A modified version of The Body-Image Ideals Question- naire (Cash and Szymanski 1995) was used to measure weighted self-perceived discrepancies (i.e., self-discrep- ancies from internalized ideals) for multiple physical characteristics. Those physical characteristics include height, muscle tone and definition, body proportions, weight, chest size, and physical coordination. Higher scores indicate greater dissatisfaction with those physi- cal characteristics. The internal consistency revealed good reliability of this scale (α = 0.92).

EATING DISORDERS

Eating disorder symptoms has been measured by the Eating Disorder Diagnostic Scale (EDDS) in this study. The EDDS consists of a diagnostic scale and a symp- tom composite scale. The diagnostic scale can be used to diagnose AN, BN and BED. The symptom compos- ite score indicates participants’ overall level of eating pathology. The EDDS (Stice et al. 2000) contains items assessing the DSM–IV diagnostic criteria for anorexia nervosa, bulimia nervosa, and binge eating disorder. Responses can be used to generate DSM–IV diagnoses for the three eating disorders. Items can also be stand- ardized (to control for the different response formats) and summed (except the height and birth control pill use items) to create an overall eating disorder symptom composite (Stice et al. 2004). The preliminary psycho- metric study (Stice et al., 2000) provided evidence that the EDDS was reliable and valid within a sample con- taining both adolescents and adults. The eating disorder symptom composite in this study had an alpha of 0.88.

HYPOTHESES

1.There is relationship between body-related social comparison and eating disorder.

2.There is relationship between family attitudes to- ward body and eating disorder.

3.There is relationship between friends’ attitudes to- ward body and eating disorder.

4.There is relationship between body satisfaction and eating disorder.

5.There is relationship between self-discrepancy and eating disorder.

6.There is relationship between ICT use and social comparison.

RESULTS AND DISCUSSION

We used the EDDS to assess AN, BN and BED. Because most patients with eating disorders do not fulfill a full syndrome diagnosis (Fairburn & Harrison 2003), we decided to include both full and sub threshold EDDS diagnoses of AN, BN and BED, similar to (Sticeet al.2004). Sub threshold diagnoses required the presence of all of the symptoms of the disorder, but the severity

Table 1: Frequency of Anorexia, Bulimia,

and Bing Eating Disorder (N=602)

of one of these symptoms was of sub diagnostic sever- ity (e.g. binge eating only once per 2weeks or having a body mass index of less than 18.5). Based on the EDDS, the sample (N=602) included 95persons with AN, 107 persons with BN, and 60 persons with BED.

According to Table 2, the following statements can be stated:

1.There is a positive correlation between the use of information and communication technologies (ICTs) and body- related social comparison. The use of ICT makes the person involved in the pro- cess of social comparison, with models that are observed in the media and with friends, peers and family members.

2.There is a negative correlation between body- relat- ed social comparison and body satisfaction. In fact, we can say that with increasing social comparison, body satisfaction will be reduced. According to the theory of social comparison, we can say that the people involved in the media images are comparing their bodies with a perfect body. Also, according to this theory, we can say that when people do not match to these images, and they find friends and people around them are matched to those images, then they may face upward social comparison and as a result, experience body dissatisfaction.

3.There is a positive correlation between self-dis- crepancies and body- related social comparison. One can provide an explanation as above for dis- crepancies.

4.There is a positive correlation between body- re- lated social comparison and eating disorders. by increasing social comparison among individuals, eating disorders increase.

5.There is a negative correlation between attitude of parents towards the body and body satisfaction. It

Bijan Khajrnoori and Roodabeh Dehghani

well as the great difference between their physical body and their ideal.

On the other hand, dissatisfaction with body and self- discrepancy both affect eating disorders. When body dis- satisfaction and self-discrepancy increases, more symp- toms of eating disorders escalate. BRSC is also associated with components of body image, and an increase in BRSC can exacerbate eating disorders. Another result of model 2 is that there is a relation between attitude of family members to the body and component of body image. That means the more negative parental attitudes toward body, the lower body satisfaction and self-discrepancies. In addition, the parents’ attitudes towards body have the strongest effect on eating disorders among all the vari- ables. Therefore, we can see how others’ attitudes and behaviors can affect people’s eating habits. Due to the importance of the issue and its relationship to physical and mental health of individuals, debates on the body and eating disorders and paying attention to the risky factors are very important. So in light of these cases, we need to look at factors associated with them. In these cases, according to the results of this study, it can be said that, parents and their attitude toward the body should be a priority, since it has the greatest effect on eating disorders. In this regard, it is essential that attention be given to the media. The media affects body image com- ponents and eating disorders indirectly through BRSC, which should be considered.

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