East Asian Arch Psychiatry 2012;22:70-4


Body Shape and Eating Attitudes among Female Nursing Students in India


YPS Balhara, S Mathur, DK Kataria

Dr Yatan Pal Singh Balhara, MD, DNB, Department of Psychiatry and De- addiction, Lady Hardinge Medical College and SSK Hospital, New Delhi, India.
Dr Shachi Mathur, MA, CHt, Jamia Millia Islamia, New Delhi, India.
Prof Dinesh Kumar Kataria, MD, Department of Psychiatry and De-addiction, Lady Hardinge Medical College and SSK Hospital, New Delhi, India.

Address for correspondence: Dr Yatan Pal Singh Balhara, Department of Psychiatry (NDDTC), All India Institute of Medical Sciences, New Delhi, India 110029.
Tel: (91) 9868976365; email: ypsbalhaar@gmail.com

Submitted: 28 July 2011; Accepted: 13 December 2011 

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Objectives: Eating disorders have been associated with body image disturbances, disordered eating attitudes, and other psychiatric difficulties. There is limited published literature on body shape and eating attitudes from non-western settings. This article presents the findings of a study of eating attitude and body shape concerns among female nursing students in India.

Methods: A cross-sectional observational study was conducted at a government nursing college associated with a tertiary-level multi-specialty hospital. Instruments used included semi-structured proforma, Eating Attitudes Test–26 (EAT-26), and the Body Shape Questionnaire (BSQ). Correlations of age and body mass index with EAT-26 and BSQ scores were carried out using Pearson’s correlation statistics. The level of statistical significance was accepted at p < 0.05.

Results: A total of 97 nursing students returned the completed study questionnaire. There was a significant positive correlation between body mass index and BSQ score. However, body mass index was not found to be correlated with EAT-26 score.

Conclusions: The findings from the current study bring some interesting insights into body shape and eating attitudes of female nursing students from India.

Key words: Body image; Body mass index; Eating disorders; Nursing students








Eating disorders have been associated with body image disturbances, disordered eating attitudes, and other psychiatric difficulties. 1,2 Dissatisfaction with body shape has been found to be a predictor of depression in a prospective study.3 Increased psychological problems and low self-esteem could be the possible connecting link between dissatisfaction with body image and abnormal eating behaviour.4 Female college students have been reported to be more keen to have a thinner figure than their male counterparts, in both western and Asian settings.5,6

There is limited published literature on body shape and eating attitudes from non-western settings.7 In fact, it has been argued that eating disorders are culture-bound disorders specific to western societies.8 Consequently, these conditions remain understudied in most non-western settings.

Literature from India on both anorexia nervosa and bulimia nervosa is restricted to a few case reports.9,10 Similarly, issues such as eating attitudes and body shape dissatisfaction remain unexplored in the Indian setting. One prior study conducted among Indian adult females explored the role of teasing and internalisation in mediating the effect of body mass index (BMI) on body dissatisfaction.11

However, with increased globalisation and consequent westernisation of many Asian societies, it becomes imperative to study eating attitudes and body shape concerns in these populations. In fact, preliminary studies from Asian countries have found high rates of body shape dissatisfaction and eating attitude distortions.4,12,13

The current study aimed at exploring eating attitudes and body shape concerns among female nursing students in India. The issue remains unexplored among nursing students in India.


The study was conducted at a government nursing college associated with a tertiary-level multi-specialty hospital.


All the undergraduate nursing students who were enrolled in the institute at the time of study constituted the sampling frame. Those who were being enrolled in the undergraduate nursing course at the college, being female, and consented to participate in the study were included. The nursing students were approached immediately after their lectures. They were informed about the voluntary and anonymous nature of the survey. No information that could identify the study subjects was collected. Students giving informed consent to participate in the study were given the questionnaires.


A semi-structured proforma was used to collect information on age, gender, professional year of training, socio-economic status, height, current weight, lowest and highest weight during the past 3 years, and self-perceived ideal weight. The BMI (in kg/m2) was categorised as severely underweight (< 17.0), underweight (17.0-19.9), normal (20.0-24.9), overweight (25.0-29.9), moderate obesity (30.0-39.9), and severe obesity (≥ 40.0).

Eating Attitudes Test–26

The Eating Attitudes Test–26 (EAT-26)14 is a 26-item self- administered test that evaluates attitudes, feelings and preoccupations in relation to food, weight, and exercise. Each item can be rated as 1 of the 6 responses ranging from ‘never’ to ‘always’. The cut-off point used is 20. Those scoring more than 20 were advised to seek consultation with health professional for possible eating disorder problem.

Body Shape Questionnaire

The Body Shape Questionnaire (BSQ)15 is also a self- administered questionnaire. It has 34 items used to evaluate fear of putting on weight, feelings of low self-esteem because of one’s appearance, the desire to lose weight, and body dissatisfaction. The scores are classified into 4 categories: not worried about body shape (< 81), slightly worried (81- 110), moderately worried (111-140), and extremely worried (> 140).16 Conditions of anonymity and confidentiality as specified in the ethical guidelines were strictly adhered to during the study and data reporting.

Data Analysis

Statistical analysis was carried out using the SPSS Windows version 17.0. Descriptive analyses of socio-demographic variables and scores in the questionnaires were carried out. Correlations of age with EAT-26 and with BSQ scores, as well as BMI with EAT-26 and BSQ scores were carried out using Pearson’s correlation statistics. Between-group comparisons were made using the independent sample t test. The level of statistical significance was accepted at p < 0.05 for all tests.


A total of 97 nursing students returned the completed study questionnaire (response rate, 90%). Among them, 14 failed to provide information on either height or weight, so only 83 were included in the final analysis. The mean (standard deviation [SD]) age of the study subjects was 20 (1) years. The socio-demographic and anthropometric profile of the study subjects across different professional years are shown in Table 1.

In all, 31 study subjects (37%) reported a normal BMI; 6 (7%) and 37 (45%) subjects reported being severely underweight and underweight, respectively, whereas 8 (10%) reported being overweight and 1 (1%) having moderate obesity. Besides, 3 (4%) of the study subjects exceeded the cut-off EAT scores of 20. Around 81% (n = 67) of the study subjects had a BSQ score of < 81, indicating that they were not worried about their body shape. Moreover, 8 (10%) subjects were worried slightly and another 8 (10%) moderately about their weight (Table 2).

For those reporting a normal BMI, their mean (SD) EAT-26 score (9 [7]) and BSQ score (67 [29]) were both lower than the corresponding thresholds.

There was no significant correlation of age with BMI (r = –0.001, p = 0.99), as well as with scores on EAT-26 (r = –0.13, p = 0.23) and BSQ (r = –0.01, p = 0.90).

A significant positive correlation between BMI and BSQ score (r = 0.40, p < 0.001) was found. However, the BMI did not correlate significantly with the EAT-26 score (r = 0.11, p = 0.32). Additionally, EAT-26 and BSQ scores were found to be positively correlated (r = 0.58, p < 0.001) [Table 3].

Between-group comparisons were made for students scoring ≥ 81 and < 81 on the BSQ. The 2 groups did not differ in terms of age and height. However, students scoring higher than the cut-off value had significantly higher weight (t = 3.69, p < 0.05) and BMI (t = 4.05, p < 0.05) than those scoring lower (Table 4).


This study reports findings of body shape and eating attitudes among female nursing students from an Indian city with a strong western influence. The survey-based methodology employed for the study had a high response rate. Literature on body shape and eating attitudes among nursing students is limited.

The mean BMI of 20.6 reported in the current study was lower than that reported by Szweda and Thorne (22.0).17 Also, the respective BMIs of ≥ 25.0 (overweight) and > 30.0 (obesity) reported in 10% and 1% of our participants were higher than that reported among Chinese6 and Japanese13 female university students. However, these rates were significantly lower than the reported rate of 35% for being overweight or obese among university students in the United States.18

We observed that less than 40% of the nursing students reported a normal BMI. A study from India among nursing students reported the prevalence of obesity and underweight to be 5% and 34%, respectively.19

Interestingly, all the nursing students in the current study belonged to the middle socio-economic status. Moreover, being related to health care they must have been aware of the importance of a normal BMI. Nevertheless, a small proportion of the students were found to have normal BMI. The finding of high rates of malnutrition (underweight as well as overweight) among nursing students is a concern. Interestingly, those with a normal BMI were found to score below the cut-off score on both EAT-26 and BSQ scales. Hence, the eating and body shape attitudes in this sub-group were well in keeping with BMI scores.

A study among nursing students from Thailand reported rates of underweight and overweight of 5% and 2%, respectively.20 Another study by Zabut21 reported that 24% of female nursing students from Gaza Strip were overweight and 4% were underweight based on BMI findings. Rasheed22 observed that 31% of the subjects from Saudi Arabia were overweight and 27% were underweight, based on a study of female medical and nursing students.

In the current study, about 4% of the study subjects had the EAT-26 score higher than the cut-off, which was much lower than those noted in previous studies from Asian and western countries. Studies on Japanese females found that 7% (aged 12-15 years)4 and 11% (aged 15-17 years)13 of the subjects scored more than 20 on the EAT-26. Studies from Korea reported rates of 7% and 10% among high school girls,7,12 whilst in European countries the rates in women varied from 7 to 11%.23,24 Studies conducted among Brazilian university students found the rate of abnormal eating attitudes to vary from 8 to 8.5%.25,26 Another study conducted among Puerto Rican college students reported the rate to be 9.6%.27 In a study from Pakistan, anorexic behaviour was noted in 22% of the female nursing students as assessed by EAT-26.28

Similarly, the mean EAT-26 score of 7.9 in the present study was lower than that reported in European and American studies.14,23,24,29-32 The study of Szweda and Thorne17 reported the mean EAT score to be 4.9. While majority of the nursing students in the current study were comfortable with their body shape, about 20% reported being slightly or moderately worried about it.

In the present study, a significant correlation between distorted eating attitudes and body shape dissatisfaction was found, however, only BMI scores correlated significantly with BSQ scores. A positive correlation between EAT-26 scores and the scores on the scale for assessing body shape distortion has been reported in various studies in different cultural settings.26,32 Correlation between BMI and EAT-26 scores has also been reported in previous studies in western and Asian settings.7,33

In an ethnically diverse group of adolescent females attending secondary schools in Trinidad, 51% of them had a negative body image perception as assessed by the BSQ; the EAT-26 score was also correlated with BSQ score.34 A similar association between disturbed eating attitudes and body image dissatisfaction was reported by Thelen et al.35

In a study among female university students in Greece, the choice of a leaner ideal female figure was found to be a predictor of scores on the EAT-26 scale.36

It has been found that Asian American and native American girls tend to report similar weight-related concerns and behaviours.37,38 These observations have been attributed to the influence of westernisation on people from Asia.

The findings of the current study suggest that the BMI along with the body shape concerns might be better screening tools for detecting eating disorders among nursing students in an Indian setting. The use of eating attitude screening scales only is likely to miss most cases.

Prevalence rates of underweight in adult women are considerably higher in South Asia than other regions of the world,39 where malnutrition among women has long been recognised as a serious problem. Such malnutrition has been associated with reduced productivity, slow recovery from illnesses, increased susceptibility to infections, and a heightened risk of adverse pregnancy outcomes.40

One limitation of this study was that it was a cross- sectional assessment only. Follow-up evaluation could be interesting, but may be a logistically difficult option. Since the study was carried out at a single site, it may not be appropriate to extrapolate its findings to the whole country. A multi-site study including students from different cities is recommended.


The findings from the current study achieved a high response rate and apply to body shape and eating attitudes of female nursing students in India. By using well-validated, standardised instruments, we were readily able to make comparisons with different studies. Additionally, students from all professional years were included in this study. A low proportion of female nursing students were found to have BMI in normal range. It is recommended to assess BMI along with the body shape concerns while screening for eating disorders among nursing students in the Indian setting.


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