Eating disorders are severe and potentially life-threatening illnesses affecting people throughout the life span, with a specific influence on both the physical and psychological development of the young population (1, 2). Because of the serious consequences of untreated eating disorders (3), early identification and therapeutic intervention play a key role in minimizing their impacts. An increased prevalence of eating disorders in adolescents has been observed (4), which has spiked since 2020 due to the effects of the COVID-19 pandemic on eating habits and social behavior in this age group (5). Adolescence is an age phase that usually involves an increased risk of harmful behaviors that can have undesirable consequences for health status (6), such as eating disorders. However, although the epidemiology of eating disorders in European countries has been examined in adults (7, 8), an accurate estimate of the prevalence of these disorders in this risky age phase is still underaddressed in European countries.

The prevalence rate for eating disorders differs according to the population studied and the criteria applied to establish an eating disorder (9). A systematic review of prevalence studies (from 1994 to 2013) found broadly varied estimates in the lifetime prevalence of eating disorders, ranging from 0.3% to 0.6% for men and 1.0%–22.7% for women (10). Despite this, eating disorders are often poorly detected in the general population, resulting in delayed treatment (11). A cross-sectional study including more than 10,000 US adolescents aged 13–18 years reported lifetime prevalence estimates of anorexia nervosa, bulimia nervosa, and binge-eating disorder of 0.3%, 0.9%, and 1.6%, respectively (12). Moreover, the mean age of onset for eating disorders was 12.5 years (12).

In addition to diagnosed eating disorders, there are disordered eating, which can include weight-loss dieting, self-induced vomiting, self-induced vomiting, excessive exercise, binge eating, and use of diuretics or laxatives (13). Although disordered eating (e.g., unhealthy weight-control behaviors) predict outcomes linked with eating disorders (and obesity) in adolescents five years later (14), it is important to distinguish disordered eating from eating disorders (15). As such, these types of behaviors cannot be categorized as full-blown illnesses and should be carefully assessed since they may lead to eating disorders (13). In Spain, previous studies have described a prevalence of adolescents with disordered eating (measured by the Sick, Control, One stone, Fat, Food (SCOFF) questionnaire) ranging from 12% to 21% (16–18).

Specific causes of eating disorders have not been identified, but the potential etiology includes emotional and cognitive vulnerability, genetic predisposition, environmental and social factors, and weight stigma (19, 20). In relation to the factors associated with disordered eating, previous studies have shown associations with sex (21, 22), excess weight (18, 21–23), socioeconomic status (24), immigrant status (25, 26), screen time (23, 27), substance use (26), nutritional issues (28, 29), and family meals (30). However, most of these studies analyzed these relationships in isolation rather than including a broad spectrum of possible associated factors from a socioecological approach (31). This approach assumes that appropriate changes in the social environment will produce changes in individuals and that the support of individuals in the population is essential for implementing environmental changes (31). The socioecological approach may help to identify opportunities to prevent disordered eating by recognizing the individual (e.g., sex, attitudes), interpersonal (e.g., family, peers) and organizational (e.g., home, sports clubs) factors, among others, that could be associated with this condition.

Knowing the prevalence of disordered eating among adolescents and, especially, its associated factors could be useful to subsidize public policies and intervention programs for the prevention of these behaviors and, probably, of future eating disorders. Thus, the aim of this study was twofold: a) to establish the prevalence of adolescents with disordered eating and b) to determine the factors associated with this prevalence (i.e., age, sex, race/ethnicity, immigrant status, body mass index status, physical activity, sedentary behavior, sleep duration, muscle-strengthening activities, adherence to the Mediterranean diet, tobacco consumption, alcohol consumption, cannabis consumption, educational level of parents/guardians, socioeconomic status, type of schooling, area of residence, attending a sports club, dog owner, TV in bedroom, type of family, and number of siblings) in a representative sample of adolescents from the Valle de Ricote (Region of Murcia, Spain).

Table 1 shows the descriptive information of the study participants globally and stratified by disordered eating. Participants included in this study were from CE El Ope (20.4%), IES Vicente Medina (53.5%), and IES Pedro Guillén (26.0%). The prevalence of disordered eating was 30.1% (95% CI 26.8–33.4). The prevalence of disordered eating was higher among adolescent girls, immigrants, and those with excess weight (p < 0.001 for all). Furthermore, the number of Caucasian participants was lower in the disordered eating group (p = 0.002). A greater number of adolescents reporting cannabis use was found in those with disordered eating (p = 0.022). Last, a lower number of adolescents with parents/legal guardians with university studies was found in those with disordered eating (p < 0.05 for all).

Figure 1 displays the prevalence of the different behaviors evaluated in the SCOFF questionnaire among the sample of adolescents analyzed. The disordered eating behavior most reported was related to “weight loss” (28.5%). Conversely, “lack of control” was the lowest disordered eating behavior reported by adolescents (13.4%).

Table 2 describes the associated factors maintained in the last step of the binary logistic regression model. Backward logistic regression analysis included 16 steps, in which the least statistically significant correlation was removed from the model in each step. Female sex (OR = 2.60; 95% CI, 1.81–3.73), immigrant status (OR = 2.22; 95% CI, 1.51–3.25) and excess weight (OR = 2.74; 95% CI, 1.93–3.89) were associated with disordered eating. Furthermore, for each additional hour slept, the odds of having disordered eating were lower (OR = 0.81; 95% CI, 0.67–0.98).

Overall, our findings showed that three out of 10 participants reported disordered eating. This result is slightly higher than previous studies performed in Spain, including samples of adolescents (17, 18, 47). The highest disordered eating behavior reported by adolescents was related to weight loss. One possible explanation for this greater prevalence is that excess weight and disordered eating behaviors usually coexist (48). Given that the Region of Murcia has been identified as the region of Spain with the highest prevalence of excess weight in young people (49) and the high prevalence of excess weight found in our study, this finding seems to be justified. Furthermore, in the bivariate analyses, the prevalence of disordered eating was significantly different according to sex, race, immigration status, BMI status, sleep duration, cannabis use, FAS–III (score) or educational level (parents/legal guardians). Notwithstanding, when a socioecological approach was applied, some individual-level factors, such as sex, immigrant status, excess weight and sleep duration, were significantly associated with disordered eating, which suggests that fundamental disparities exist in relation to this worrisome condition among the sample of Spanish adolescents analyzed.

Our findings indicated that female sex was linked with disordered eating. This result agrees with previous studies (2, 21, 22) but disagrees with others (23, 47). Although sex differences in disordered eating are relatively minor in adolescence (50), these disorders are known to predominate among girls (2, 51). Traditionally, studies have focused predominantly on the female sex, but currently, this has no longer been considered a girl-specific issue (51). Similarly, eating disorders and disordered eating in boys may present differently than in girls, specifically with muscle-oriented disordered eating (52). The reasons for sex differences in prevalence are not well known (50). It has been noted that disordered eating are frequently unobserved among boys (53). Boys are presumed to underreport the problem because of the stigma of female sex eating disorders (54), and disordered eating are considered specific to girls/women (53). Additionally, it has been advised that the current diagnostic criteria of eating disorder (55) fail to detect disordered eating behaviors unique to boys (i.e., behaviors aimed at increasing muscle mass and weight to counteract body image dissatisfaction (53)).

Our results also indicated that immigrant status was associated with disordered eating. This result is in line with a previous longitudinal study in Spain carried out by Esteban-Gonzalo et al. (25), who found in adolescents that immigrant populations, mainly boys, seem to be more susceptible to disordered eating than non-immigrant boys. Similarly, Hölling and Schlack (26) found that the prevalence of German adolescents with disordered eating was approximately 50% higher among immigrants than among non-immigrants. In fact, our understanding of and capacity to treat eating disorders among ethnic and racial minority groups continues to improve (56). One possible reason explaining this result could lie in the acculturative stress and ethnic minority position, since most of the evidence suggests a substantial link between this condition and eating disorder psychopathology (57). Another possible justification is that marriages including a foreign-born and a native-born partner could lead to greater levels of unsolved family agreements, a variable associated with increased disordered eating (58). However, why marriage including a foreign-born and a native-born partner is related to increased disordered eating for offspring is still an open question (59).

On the other hand, we found that excess weight was linked with disordered eating. This result matches the scientific literature (2 López-Gil et al.). For instance, a previous study by D’Anna et al. (21), reported that the prevalence of disordered eating among Italian adolescents was greater in the higher BMI categories. Similarly, Feng and Abebe (23) found that perceived excess weight was associated with disordered eating in their study among Chinese adolescents. Gutiérrez et al. (22) also found that a higher body mass index was linked with disordered eating. There are some potential reasons for this result. For instance, adolescents who have excess weight may adopt disordered eating behaviors while trying to lose weight, and early efforts to lose weight by eating healthy may progress to skipping meals, severe dietary restriction, prolonged periods of starvation, the use of laxatives, diet pills, or self-induced vomiting (60). In addition, as previously mentioned, excess weight and disordered eating frequently overlap (48). Thus, the high prevalence of excess weight found in the sample of Spanish adolescents analyzed could explain this result. In accordance with this finding, the need to consider eating disorders and excess weight as part of a continuum of weight-related disorders has been highlighted (61, 62).

Another interesting finding was that sleep duration was inversely linked with disordered eating. It has been suggested that disturbed sleep is a frequent complaint among individuals with a broad range of psychopathology and may be a particularly important factor in the development and course of eating disorders in adolescence (63). However, the literature on sleep and disordered eating is still scarce. Supporting this idea, variations in sleep duration may affect the susceptibility to losing control over eating after experiencing negative affect in a young population, and variations in sleep duration may impact susceptibility to losing control over eating after experiencing negative feelings in a young population (64). Furthermore, chronic sleep restriction may increase the likelihood of suboptimal dietary behavior in adolescents with excess weight (65). This is because they do not experience an increased inhibition-related neural response to counter the potential increase in reward-related neural response after sleep restriction (i.e., neural processes may be deficient in neutralizing increases in reward responding to mitigate excessive food intake) (65).

The present study has certain limitations that must be acknowledged. First, because of the cross-sectional nature of this study, a causal relationship cannot be established. Second, due to the inclusion of binge eating disorder and other specified eating disorders in the DSM-5, there is not enough evidence to support the use of SCOFF in primary care and community-based settings for screening the entire range of eating disorders. However, a meta-analysis by Kutz et al. (66) including 25 validation studies demonstrated that the SCOFF is a useful and simple screening tool for some of the most prevalent eating disorders (i.e., bulimia nervosa, anorexia nervosa). Third, we used self-report questionnaires to assess disordered eating and consequently, both social desirability and recall bias are possible. Conversely, this study has some strengths. For instance, we included a representative sample of adolescents from Valle de Ricote (Spain), which provides substantial external validity to our results. Similarly, these findings offer additional cross-sectional evidence of several understudied factors associated with disordered eating among adolescents from a socioecological approach.

In conclusion, almost one-third of Spanish adolescents from the Valle de Ricote (Region of Murcia, Spain) showed disordered eating, which could severely influence their general health. The associations found according to female sex, immigrant status and excess weight underline that there are fundamental individual disparities in having disordered eating among Spanish adolescents. Furthermore, these results suggest that longer sleep duration could help prevent disordered eating. Our findings point to the relevance of providing specific intervention programs to decrease the prevalence of disordered eating, mainly for adolescent girls, immigrants, and those with excess weight.