Artigos

INTRODUCTION
In Brazil, as in other countries, anxiety disorders stand out with high prevalences among university students1,2,3,4. Just like stress and other negative emotional experiences, anxiety might also be a key factor for emotional eating, which in and of itself is a risk behavior for the development of eating disorders (ED)5.
The minority stress (i.e., factors related to prejudice against diversity) puts sexual and gender minorities (SGM) individuals, including those who identify as lesbian, gay, bisexual, transgender, queer, intersex, asexual, and others (LGBT), in particular mental health vulnerability6,7,8. According to Nagata et al.9, minority stress theory helps explain the disproportionate rates of ED behaviors and body dissatisfaction among SGM compared to heterosexual and cisgender individuals. Furthermore, the perception of tension and discrimination regarding gender and sexual orientation are among the factors associated with psychological distress in academic settings10.
Previous studies have pointed to higher prevalences of mental disorders, including anxiety and ED, in SGM individuals11,12,13,14. For instance, not identifying as male or female has a greater association with anxiety15. Cross-sectional studies have shown that sexual minority students are 1.20 to 3.16 times more likely to have elevated ED risk than their heterosexual peers, and transgender students are respectively 4.65 and 6.04 times more likely to report a past-year and a lifetime ED diagnosis14,16,17.
Considering the already known co-occurrence of ED and other mental disorders, particularly anxiety, as well as the increasing demand for studies that investigate these disorders and their determinants in minority groups, this study aimed to investigate whether anxiety is a mediator of ED risk in LGBT university students from several Brazilian federal universities. We hypothesize that anxiety mediates the relationship between LGBT university students and ED risk, given the importance of minority stress as a predictor of psychopathology18,19.
METHODS
Ethical aspects
The Research Ethics Committee of the Federal University of Alagoas (Universidade Federal de Alagoas) approved this study (protocol number: 5.163.251). Participants were required to read and accept an online informed consent form on the first page of the survey to access the questionnaire.
Study design and participants
This is an analytical, quantitative cross-sectional online study with a non-LGBT control group, conducted with undergraduate students from 28 Brazilian federal universities, ages between ?18 and <30 years old. Of those who agreed to participate in the study, only those who did not complete the survey were excluded.
For this study, SGM individuals were grouped as LGBT, adopting a broad definition similar to that adopted by Flatt et al.20 and Willenbrock and Santella21, that is: those who (1) identified themselves in the sample characteristics questionnaire, regarding their gender identity and sex assigned at birth, as “Transgender woman,” “Transgender man,” or “Non-binary,” including as of gender non-binary those who identify themselves as other specified gender identities that so fit; and/or (2) those who identified themselves regarding their sexual orientation as “Lesbian,” “Gay,” “Bisexual,” “Queer,” “Asexual” or other non-heterosexual sexual orientations specified in the “Other” alternative in the questionnaire; and/or (3) those who reported intersex status. Individuals who reported questioning or being unsure of their gender identity and/or sexual orientation were grouped as “Questioning.”
Sample size calculation
A sample of 1,452 students was estimated considering a 95% confidence level, an 80% power, a 1:1 unexposed to exposed ratio, a 10% prevalence in the unexposed group, and a 1.5 risk ratio (RR). Sample size calculation was performed using Epi Info software version 7.2.4.0 (CDC, Atlanta, USA) through the StatCalc module - Sample Size and Power.
Instruments
Sociodemographic characteristics questionnaire
Participants self-reported socioeconomic data, age, sex assigned at birth, gender identity, intersex status, and sexual orientation through a sociodemographic characteristics questionnaire previously developed by the research team.
Eating Attitudes Test (EAT-26)
One of the instruments used to assess the presence of ED risk was the Eating Attitudes Test (EAT-26). Garner et al.22 developed and validated this self-assessment questionnaire as a shortened version of the original questionnaire (EAT-40). It was originally proposed to measure symptoms of anorexia nervosa (AN) in clinical patients. However, it also proved useful in non-clinical samples, making it the most applied test for ED in general23. Although it is not enough to make a diagnosis, it may indicate ED risk due to symptoms that characterize abnormal eating patterns and might have psychosocial implications. It consists of 26 questions with six alternatives each and a score that ranges from 0-3 per question. The total score ranges from 0-78. Individuals with a score ? 21 were considered at risk for ED22,24. McDonald's ? of 0.869.
Bulimic Investigatory Test of Edinburgh (BITE)
The second instrument used to assess ED risk was the symptom scale of the Bulimic Investigatory Test of Edinburgh (BITE), developed by Henderson and Freeman25 and validated in Portuguese by Ximenes et al.26. The questionnaire has similar properties to the EAT, but it aims to identify cases of individuals who binge eat since the EAT does not contemplate these. The symptom scale consists of 30 out of the 33 test questions (questions 6, 7, and 27, relative to the severity scale, are excluded). The questions are dichotomous, and participants were instructed to answer them regarding the past three months. The total score ranges from 0-30, and it is classified as “normal” (scores 0-9), “unusual eating pattern” (scores 10-19), and “highly disordered eating pattern and presence of binge eating” (scores ? 20). Individuals with a score ? 20 were considered at risk for ED. McDonald's ? of 0.911.
Hospital Anxiety and Depression Scale (HADS-A)
The presence of anxiety was assessed using the anxiety subscale of the Hospital Anxiety and Depression Scale (HADS-A) translated and validated into Portuguese27. This is a self-assessment scale developed by Zigmond and Snaith28 to identify clinically significant cases of anxiety and depression disorders in outpatients of general hospitals; it has also been validated for use in the general population29. The anxiety subscale consists of 7 questions with a score ranging from 0-3 for each question. It classifies cases of anxiety according to the total score as "non-cases" (scores 0-7), "doubtful cases" (scores 8-10), and "definite cases" (scores 11-21). When used in research, however, an optimal cut-off point is suggested to classify “cases” and “non-cases,” 8 being the ideal adopted for greater sensitivity30. McDonald's ? of 0.858.
Procedures
The study, originally entitled “Anxiety as a mediator of the risk of eating disorder among university students: a comparison between LGBT and non-LGBT students”, used a convenience sampling strategy. Eligible participants were undergraduate students enrolled in Brazilian universities, regardless of their course or year of study. The questionnaires were unified in a single Google Forms file. Students were invited to participate in the research through forwarded emails sent by the research team to their universities, or directly by the universities, and also through social media (WhatsApp and Instagram) posts, all of which included a link to the informed consent form and the survey questionnaire. Data collection took place between December 2021 and March 2022.
Data analysis
Descriptive statistics for the sample are shown as percentages, except for the age variable, which is shown as mean and standard deviation (SD). Mediation was tested using simple mediation models, which used sum scores for the EAT-26, the BITE, and the HADS-A. The LGBT variable was used as the independent variable (X), the risk of ED as the dependent variable (Y), and anxiety as the mediator (M). Three paths are formed between these variables:
(1) The total effect of X on Y (c) without M in the model;
(2) The direct effect of X on Y (c') with M in the model; and
(3) The indirect effect of X on Y (ab) through M, which subdivides into the effect of X on M (a) and the effect of M on Y (b).
Complete mediation is when the effect of X on Y is no longer significant once M is controlled, while partial mediation is the case in which this effect decreases but does not lose its significance31.
The mediation models were tested with and without covariants (age, race/color, and family income) and had similar results; thus, only the multivariable analyses are shown in the paper. For the univariable analysis, see supplement information (Table S1 and Figure S1).
The significance of the indirect effect (mediation) was tested using a bootstrapping procedure with 5,000 samples and a 95% percentile bootstrap confidence interval. The analyses were performed using the statistical program R version 4.1.0 (R Core Team, Vienna, Austria) and the PROCESS macro v. 4.1 for mediation.
RESULTS
A total of 3,491 forms were answered, of which 660 were excluded after applying the inclusion and exclusion criteria. The final sample analyzed consisted of 2,831 individuals (Figure 1).
The mean age of the participants was 22.18 ± 2.86 years. Most of them declared themselves to be white (n = 1,255; 44.3%) or brown (n = 965; 34.1%) and reported a family income of 1 to 3 times the Brazilian minimum wage (BMW) (n = 1,139; 40.2%). The sample consisted mainly of cisgender women (n = 1,933; 68.3%). 49.6% (n = 1,405) of the participants identified themselves as part of the LGBT group. ED risk was identified in 28.5% (n = 807) of the sample by the EAT-26, and "highly disordered eating pattern and presence of binge eating" in 22.5% (n = 637), according to the BITE. As for anxiety, 65.6% (n = 1,857) of the participants were classified as “cases” by the HADS-A (Table 1).
As hypothesized, anxiety significantly mediated the relationship between LGBT students and ED risk, as observed both in the EAT-26 (A) (a1b = 2.26; 95%BootCI [1.84 — 2 .70]) and in the BITE (B) (a1b = 1.69; 95%BootCI [1.38 — 2.00]) mediation models. The same is observed regarding individuals who reported questioning their gender identity and/or sexual orientation, both in the A (a2b = 2.82; 95%BootCI [1.99 — 3.68]) and B (a2b = 2.11; 95%BootCI [1.48 — 2.72]) mediation models. These models explained 21.08% (R² = 0.2108) and 29.75% (R² = 0.2975) of the relationship between the LGBT variable and ED risk assessed by the EAT-26 and by the BITE, respectively (Table 2).
Figure 2 illustrates the paths of this relationship including the non-standardized regression coefficients of the relative total (c1 and c2) and direct (c’1 and c’2) effects, as well as the split paths that form the relative indirect effects (a1b and a2b): effect of the LGBT variable on anxiety (a1 and a2) and of anxiety on ED risk (b); both in the EAT-26 (A) and in the BITE (B) mediation models. In the first case, a complete mediation is observed, since the inclusion of the mediator removed the significance of the relationship between LGBT identities (X) and ED risk (Y) assessed by the EAT-26 (c1 = 2 .77; 95%CI [1.90 — 3.64], p < 0.0001); (c’1 = 0.51; IC95% [-0.29 — 1.31], p = 0.20); whereas in the model with the BITE, a partial mediation is observed, since the direct effect (c1 = 2.66; 95%CI [2.10 — 3.22], p < 0.0001) decreases in absolute value, but remains significant (c’1 = 0.97; 95%CI [0.48 — 1.46], p = 0.0001). When it comes to those who reported questioning their gender identity and/or sexual orientation, a complete mediation by anxiety is observed both in the model with the EAT-26 (c2 = 2.95; 95%CI [1.14 — 4.75], p < 0.001); (c’2 = 0.12; 95%CI [-1.51 — 1.76], p = 0.88) and in the model with the BITE (c2 = 2.22; 95%CI [1.06 — 3, 38], p < 0.001); (c’2 = 0.11; IC95% [-0.89 — 1.11], p = 0.83).
DISCUSSION
As hypothesized, anxiety significantly mediates the relationship between LGBT students and ED risk, as observed both in the EAT-26 and in the BITE, mediation models, the former showing a complete mediation and the latter a partial mediation. A complete mediation was also observed in the relationship between those who reported questioning their gender identity or sexual orientation and ED risk in both models.
The coefficients of the relative total effects observed in both models show that LGBT students and those who reported questioning their gender identity or sexual orientation, had significantly higher EAT-26 and BITE scores for ED risk. These data are in agreement with the findings of Lipson and Sonneville17, who observed, in 9,713 students from 12 United States (US) colleges and universities, that sexual minority men are 3.16 times more likely to have elevated ED risk than their heterosexual peers. Another study by Diemer et al.16, with data from a national sample of 289,024 students from 223 US universities, observed that men and women of sexual minorities or unsure about their sexual orientation are more likely to report a past-year ED diagnosis compared to heterosexual, cisgender women. These odds are significantly higher for transgender students, who are 4.62 times more likely to report a past-year ED diagnosis and 2.46 times more likely to report past-month vomiting or laxative use.
The prevalence of individuals with anxiety symptoms observed in our sample (65.6%) was higher than that observed in the national study by Da Silva Júnior et al.32. They observed a 43% prevalence of anxiety in a sample of 5,368 students from several public and private Brazilian universities. However, our findings are similar to those of the national survey by the National Forum of Deans of Community and Student Affairs (Fórum Nacional de Pró-Reitores de Assuntos comunitários e Estudantis) - FONAPRACE and the National Association of The Presidents of Federal Institutions of Higher Education (Associação Nacional dos Dirigentes das Instituições Federais de Ensino Superior) – ANDIFES33, which even before the COVID-19 pandemic had shown a 63.6% prevalence of anxiety among students from Brazilian Federal Institutions of Higher Education, which may indicate an anxiogenic role of the academic environment of these institutions for students. The same survey points out the level of academic demand as one of the main reasons for thinking about dropping out of the course at these institutions.
The mediating effect of anxiety in the relationship between LGBT students and ED risk consists of the positive association of the LGBT variable (X) with anxiety (M), and of anxiety (M) with ED risk (Y). The former is observed regarding both the LGBT students (a1 = 2.19; 95%CI [1.82 — 2.57], p < 0.0001) and those who reported questioning their gender identity and /or sexual orientation (a2 = 2.74; 95%CI [1.97 — 3.52], p < 0.0001); both groups scored significantly higher for anxiety when compared to the non-LGBT group.
These findings agree with the integrative review by Francisco et al.7, who point out that LGBT individuals show higher symptoms of several anxiety disorders such as generalized anxiety disorder, panic disorder, and social phobia than their peers. Particularly transgender and bisexual individuals are more affected by the disorders. The same review suggests that anxiety in this population is associated with several factors such as social and family stigma, lack of support from family and friends, and shame. Such factors can lead these individuals to hide their sexual orientation, leading to anguish, suffering, and isolation.
The literature has shown that, in addition to individual risk factors, LGBT people experience unique distal stressors, such as stigma, discrimination, and violence, and proximal stressors, such as internalized homophobia or transphobia and concealment of sexual or gender identity, which are associated with a higher risk of developing physical and mental health problems, including ED8,19. From this perspective, mediation analyses of minority stressors help to reveal the processes by which these stressors act, contributing to a better understanding of the internal psychological mechanisms to which they are linked18.
It is worth noting that both stress and anxiety are emotional responses that can lead to physical symptoms; stress, however, ceases in the absence of its trigger, while anxiety is a persistent, excessive worry that does not cease even in the absence of a stressor34.
The second positive association is between anxiety and ED risk. Students with higher scores for anxiety had also higher scores for ED risk, as seen both in the EAT-26 (b = 1.03; 95%CI [0.95 — 1.10], p < 0.0001) and with the BITE (b = 0.77; 95%CI [0.72 — 0.82], p < 0.0001) mediation models. This relationship is already known in the literature. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), anxiety disorders often co-occur with AN, are associated with an increased risk of bulimia nervosa (BN) and are among the most common comorbid disorders in binge-eating disorder (BED)34. A study by Swinbourne et al.36 investigated the comorbidity of anxiety and ED in 152 women in treatment for an ED or an anxiety disorder and observed that 65% of the ED patients met the criteria for at least one anxiety disorder and the majority of these (69%) reported that the onset of the anxiety disorder preceded the onset of the ED.
Several studies point to the relationship between anxiety or stress and emotional eating, overeating, or even food addiction32,37,38. On the other hand, considering the strong desire to control one’s environment, present mainly in AN, negative emotions such as stress, anxiety, and a feeling of lack of control could lead individuals to try and compensate for these feelings by compulsively controlling their eating35,39. ED share some of the same neural systems implicated in regulatory self-control and reward involved in substance use disorders which may explain some patterns of compulsion and cravings observed in them as well35.
This study has limitations. Firstly, despite the BITE being a widely used instrument in research, it was developed based on the old diagnostic criteria of the disorder now known as BN; however, its use is justified because it identifies an ED profile not contemplated by the EAT-26. Secondly, this is a cross-sectional mediation analysis and it is not able to determine how the mediation process develops over time, therefore, as in any observational study, causation cannot be determined. Finally, the title and aim of the research may have created a participation bias since people who identify with the theme tend to be more interested in participating.
As for the strengths, the survey questionnaire was conducted in an online and anonymous setting, which allowed students from several parts of the country to participate and to feel safe answering personal, and possibly difficult, questions (such as about their gender identity, sexual orientation, and eating behaviors) as truthfully as possible. In addition, our sample was almost twice as large as the minimum required.
Finally, this study found that anxiety significantly mediates the relationship between LGBT students and ED risk, as observed in both the EAT-26 and the BITE mediation models. We also found complete mediation in the relationship between those who reported questioning their gender identity and/or sexual orientation and ED risk in both models.
These findings reinforce the need for mental health care in universities, especially for LGBT individuals. Future studies that further investigate anxiety in these individuals, especially breaking it down by gender identity and sexual orientation and investigating specific minority stress variables are needed, as well as interventional studies with actions aimed at reducing anxiety and ED and creating an inclusive and health-promoting academic setting.


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