The study, conducted by researchers at Jahangirnagar University and the Centre for Medical Research and Development, was published in the Journal of Eating Disorders. It offers one of the first systematic looks at how eating behavior phenotypes manifest among adolescents in a low- and middle-income country, a context in which eating disorders have often been assumed to be rare or primarily a phenomenon of high-income Western societies. The findings challenge that assumption and suggest that prevention efforts in rapidly urbanizing countries may need to focus sharply on the dangers of restrictive dieting during adolescence.

Eating behavior researchers typically distinguish three phenotypes. Restrained eating refers to the deliberate attempt to limit food intake in order to control body weight, often through skipping meals, avoiding certain food groups, or rigid calorie counting. Emotional eating describes the tendency to eat in response to negative emotional states such as stress, sadness, or anxiety, rather than in response to hunger. External eating, meanwhile, is the tendency to eat in response to external food-related cues—the sight or smell of appetizing food, for example, or the sight of others eating—regardless of internal hunger signals. Decades of research in Western populations have linked all three patterns to disordered eating outcomes, but their relative importance appears to vary across cultural and economic contexts, making locally grounded studies essential.

To fill this gap, the research team carried out a cross-sectional survey between February and August 2025 among students aged 12 to 17 years enrolled in selected secondary schools in the Dhaka South City Corporation area. Participants were recruited using a multistage cluster random sampling design, a technique in which schools are first randomly selected and then students within them are sampled, helping to reduce selection bias and improve the representativeness of the sample. In total, 428 adolescents completed a structured questionnaire that combined socio-demographic and lifestyle questions with two internationally validated instruments: the Dutch Eating Behavior Questionnaire, which measures restrained, emotional, and external eating, and the Eating Attitudes Test-26, a widely used screening tool for eating disorder symptoms.

The researchers defined eating disorder risk as a score of 20 or higher on the EAT-26, the conventional threshold indicating clinically concerning attitudes and behaviors around food and weight. Group differences were tested with independent-samples t-tests and chi-square tests, and the team then used logistic regression to estimate both crude and adjusted odds ratios. Crucially, the adjusted models controlled for a range of potential confounders, including age, sex, body mass index category, breakfast skipping, sleep duration, screen time, physical activity, and household income. This statistical approach allowed the researchers to isolate the independent contribution of each eating behavior pattern to eating disorder risk, rather than attributing to dieting what might actually be explained by sleep, income, or sedentary lifestyle.

The results were sobering. Of the 428 adolescents surveyed, 123—or 28.7 percent—met the criteria for eating disorder risk, meaning nearly one in three urban school-going adolescents in the sample screened positive. The risk was significantly higher among girls than boys, with 33.3 percent of female participants at risk compared with 24.2 percent of males, a statistically significant difference. Two lifestyle factors also stood out: adolescents who skipped breakfast and those who slept for shorter durations were significantly more likely to screen at risk, with breakfast skipping showing a particularly strong association.

But it was the analysis of eating behavior phenotypes that produced the study’s most striking result. Adolescents at risk of eating disorder had substantially higher restrained eating scores than those not at risk, averaging 2.38 on the Dutch Eating Behavior Questionnaire scale compared with 1.84 among low-risk peers, a highly significant difference. In the multivariable analysis, each unit increase in restrained eating score was associated with roughly two and a half times the odds of eating disorder risk, with an odds ratio of 2.42 and a 95 percent confidence interval of 1.85 to 3.16. When the researchers divided participants into tertiles of restrained eating, the contrast became even more dramatic: adolescents in the highest tertile had nearly six times the odds of eating disorder risk compared with those in the lowest, with an odds ratio of 5.84 and a confidence interval of 3.25 to 10.50.

Emotional eating, by contrast, showed only a weak association with eating disorder risk after statistical adjustment, and external eating was not significantly related to risk at all. This hierarchy of effects is scientifically meaningful. It suggests that in this urban Bangladeshi adolescent population, the psychological drive to restrict food intake—a behavior often socially rewarded and even encouraged as “discipline” or “healthy eating”—is a far more powerful correlate of disordered eating than eating in response to emotions or food cues. The finding aligns with a substantial body of international evidence indicating that dietary restraint can initiate a cascade of psychological and physiological processes, including heightened preoccupation with food, binge-restrict cycles, distorted body image, and metabolic adaptation, that collectively increase vulnerability to clinical eating disorders such as anorexia nervosa and bulimia nervosa.

The authors also note that restrained eating among adolescents frequently arises in response to weight-related concerns, teasing, social media exposure, and cultural ideals of thinness—pressures that are intensifying in urban Bangladesh as globalized media and consumer culture expand. Dhaka, one of the world’s most densely populated megacities, has seen rapid lifestyle change over the past two decades, including increased consumption of ultra-processed foods, reduced physical activity, longer screen time, and altered sleep patterns. The study’s finding that breakfast skipping and short sleep were independently associated with eating disorder risk fits within this broader picture of lifestyle disruption, and suggests that multiple everyday behaviors could serve as accessible red flags for parents, teachers, and clinicians.

For a country like Bangladesh, where adolescent mental health services remain limited and eating disorders are rarely diagnosed, the study has clear public health implications. Screening for restrained eating behaviors in school settings could identify adolescents at heightened risk long before the onset of full clinical syndromes, when intervention is most effective. The authors argue that early identification of unhealthy eating behaviors—particularly rigid dieting—should be integrated into prevention strategies targeting adolescent populations. School-based programs that promote balanced nutrition without moralizing about weight, discourage meal skipping, and address body image pressures may offer a practical and scalable route to prevention.

The study does have limitations typical of cross-sectional research. Because data were collected at a single point in time, the analysis cannot establish whether restrained eating causes eating disorder risk or whether early disordered eating drives restrictive behavior; the relationship is likely bidirectional. The EAT-26 is a screening instrument rather than a diagnostic tool, so the 28.7 percent figure represents risk, not confirmed clinical diagnoses. The sample was drawn from urban Dhaka schools only, meaning the findings may not generalize to rural adolescents or to out-of-school youth. Self-reported questionnaires are also subject to recall and social desirability biases, particularly around sensitive topics like food restriction and body image.

Even with these caveats, the study represents a significant addition to the global evidence base on eating disorders in low- and middle-income countries, where epidemiological data remain sparse despite growing concern among researchers. By demonstrating that the same behavioral phenotype—restrained eating—that predicts eating disorder risk in high-income settings also exerts the strongest association in urban Bangladesh, the findings underscore that eating disorders are not culturally bounded phenomena. As urbanization, digital media exposure, and thinness ideals continue to spread across South Asia, the researchers warn that unhealthy eating behaviors among adolescents are likely to intensify unless met with early, culturally informed prevention efforts. For the nearly one in three Dhaka adolescents screening at risk, the message from this research is unambiguous: the dieting behaviors society often applauds may be the most important early warning signs of all.

The numbers behind the proposal are sobering. The point prevalence of eating disorders in the general population has more than doubled in roughly two decades, climbing from 3.5 percent between 2000 and 2006 to 7.8 percent between 2013 and 2018, and an estimated 20 million people in Europe alone now live with these conditions. The rise has been global and became particularly evident during and after the COVID-19 pandemic. Although anyone can be affected regardless of age, gender or background, incidence peaks in young women aged 15 to 19, with the sharpest spike at age 16—and clinicians report an alarming emergence of cases in progressively younger children. Within this vulnerable demographic, athletes carry an exceptionally high risk compared with non-athletes, and the burden escalates sharply in aesthetic disciplines, endurance sports and weight-class competition, where leanness and body control are effectively written into the sport itself.

At the center of the framework sits a phenomenon the authors call maladaptive exercise: physical activity that is excessive, compulsive and driven by weight or shape control rather than by health, enjoyment or performance. Where adaptive training flexes around illness, rest and life circumstances, maladaptive exercise is rigid and rule-bound, persists through injury and sickness, and produces acute distress when a session is missed. Its footprint in clinical populations is enormous: estimates cited in the Comment put lifetime prevalence at 88 percent among people with eating disorders, with a point prevalence of 48 percent, and the behavior is strongly associated with anorexia nervosa, bulimia nervosa and muscle dysmorphia. Because training hard is socially celebrated, it hides in plain sight while its physiological toll accumulates, from cardiovascular, renal and musculoskeletal complications to a heightened risk of suicide. By the time most cases reach clinical attention, the disease is already advanced.

Physical activity and sport professionals occupy a paradoxical position in this landscape. Across Europe, the workforce is heterogeneous—kinesiologists, personal trainers and fitness coaches in sport settings, physical education teachers in schools, and sports medicine physicians—but all share one defining characteristic: regular, close contact with at-risk individuals in their training environments. In 2020, the Australian Institute of Sport issued a position statement calling on coaches and support staff to participate in early identification. A year later, the American Academy of Pediatrics urged teachers, coaches and athletic trainers to promote healthy nutrition and exercise, avoid weight stigmatization and recognize warning signs. In 2023, the International Olympic Committee’s consensus on relative energy deficiency in sport, known as REDs, called for engaging coaches, parents and managers, and prioritizing education over body weight. Yet these recommendations targeted elite athletes surrounded by multidisciplinary medical teams, sports dietitians and mental health specialists. The epidemiological reality is nearly inverted: most people engaging in maladaptive exercise are recreational exercisers and amateurs training in commercial fitness centers, community sports clubs or school programs—settings with no internal medical or psychological support at all. No European consensus has yet addressed this role for non-elite populations.

The only European proof of concept comes from Norway, where a one-year educational intervention studied by Martinsen and colleagues significantly improved coaches’ knowledge of eating disorders. But the study also exposed a limitation that shapes the entire new framework: better knowledge among coaches did not automatically translate into earlier identification of affected athletes in everyday practice. Education, in other words, must reduce the practical and psychological barriers to recognition and referral, not merely transfer facts. Well-intentioned but misguided practices by inadequately trained professionals—inappropriate comments about weight or body shape, the prescription of non-evidence-based nutritional plans, the minimization of clinical red flags and the inadvertent reinforcement of compulsive training patterns—can themselves cause iatrogenic harm, a concern the American Academy of Pediatrics has raised explicitly. Any system pushing non-medical professionals toward detection must pair opportunity with strict boundaries.

My Fit Friend was designed to fill that vacuum. Coordinated from Italy with partners in Portugal, Spain and Turkey, and supported by the Erasmus+ Sport Programme (EU project number 101184114), the initiative adapts elite-sport recommendations to recreational and youth sport, targeting young people aged 11 to 18. Its architecture rests on two complementary pillars. The first is structured education: a minimum of six hours of in-person training, with optional online participation, delivered by physicians specialized in sports medicine and child and adolescent neuropsychiatry. The curriculum covers the physiology of nutrition and physical activity, the epidemiology and clinical features of eating disorders and body dysmorphic concerns, practical guidance on approaching suspected cases and project-specific procedures, with pre- and post-training questionnaires tracking what actually sticks. Communication receives particular attention: participants practice non-judgmental language and open questions for exploring sensitive topics, and are coached in empathy, active listening and clarity about their role to reduce blaming and stigmatization.

To scale beyond a single cohort, the project invested heavily in a train-the-trainer model, preparing master trainers who can sustain standards within their organizations and cascade knowledge across the sport ecosystem. The second pillar is the My Fit Friend diary, an observational tool built around eight key domains: training frequency, patterns and setting; the psychological dimensions of training; food habits; self-perception and body image; social engagement; and social media influence. The developers grounded the instrument in a systematic review of the eating disorder literature, then analyzed eating-disorder-related content on social media to align the questions with colloquial, easily understandable language, before refinement through expert consensus among specialist physicians. Crucially, the diary is not a diagnostic instrument. It exists to help professionals document concerning behaviors over time—including details such as extra training performed elsewhere, social media content or eating patterns outside sport settings, which only surface if the individual discloses them—so that patterns that would otherwise evaporate from memory are preserved for referral conversations.

The project’s most technologically ambitious component is its avatar-based simulation training. Avatar-based interventions and immersive virtual reality are a promising frontier in eating disorder care, and recent evidence shows they can train healthcare professionals to assess mental health disorders with outcomes comparable to or better than traditional methods. In the My Fit Friend protocol, participants interact in real time with an avatar operated by trained medical personnel, through live question-and-answer exchanges built around two prototypical cases: an adolescent female showing early-onset eating disorder behaviors such as dietary restriction and excessive training, and a young adult male with body dysmorphic concerns focused on muscularity. Each one-hour session ends with a facilitated debriefing, creating a safe space to practice risk recognition and difficult communication with no risk to real individuals. The format matters psychologically: research indicates avatar-based training reduces communication barriers, encourages exploration of challenging situations and lets facilitators control the learning stimuli, whereas conventional role-play can heighten evaluation anxiety because the counterpart’s identity is known. Because the system relies on standard videoconferencing technology, it can be adapted to other recreational settings at relatively contained cost, with in-person role-play as a fallback.

What should a sentinel actually watch for? The framework catalogs the behavioral signatures of maladaptive exercise: a progressive increase in load through duration, intensity or frequency, accompanied by shrinking flexibility in scheduling; distress when workouts are missed; insistence on exercising despite illness or injury; and “extra” or “secret” sessions beyond the prescribed plan—compulsive patterns rather than goal-oriented commitment. Context adds further cues: a move from group to solitary training, avoidance of situations where the body might be visible, or exercising at unusual hours to evade observation. Although exercise professionals are explicitly barred from conducting nutritional assessments, they can observe food-related behaviors such as avoiding team meals, strict dietary rules beyond sports nutrition, or preoccupation with food timing, composition or calories. Body image red flags include frequent body-checking, baggy clothing used for concealment and persistent dissatisfaction despite objective evidence; in males, concern often fixates on muscularity and leanness, with rigid “bulk and cut” cycles that can resemble binge-purge patterns. Social media compounds the pressure: constant checking of fitness content and comparison with influencers are warning signs themselves. The referral logic is graduated: when multiple warning signs persist over time, professionals are encouraged to refer; ambiguous situations are monitored first; and clearly severe cases warrant prompt medical evaluation through local health pathways, with parents or legal guardians involved for anyone under 18.

The authors are emphatic about where the sentinel’s job ends. The goal is to monitor a “fracture” in global functioning—a shift, for instance, from exercise as enjoyment to rigid, compulsive obligation—and to serve as a bridge for communication, never to diagnose or treat. The position draws its power from trust rather than clinical authority: for many children and adolescents, the coach is an approachable, non-judgmental figure outside the family, especially when the coach is a current or former athlete whose habits are read as a standard. Scaling the model is a question of policy. The team proposes making eating disorder awareness and systematic observation tools mandatory components of European professional certifications, and building fast-track referral pathways between community fitness centers and local mental health services. They are candid about the obstacles: professional qualifications range from brief course certificates to university degrees across the continent, curricula prioritize biomechanics and performance over mental health literacy, and health systems differ radically in organization, funding and access. Where trainers are mostly privately employed, such pathways would need formal agreements between private providers and public services; municipal centers could integrate more easily, though sustainable funding remains a constraint. Pilot projects backed by national health systems or European funding, the authors argue, are a pragmatic first step. If they succeed, the ordinary gym could be recast as what the project envisions: a protective environment that catches the earliest fractures in a young person’s functioning, long before those fractures become the reason a clinician finally sees them.