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Submitted by Mangala R on 5 March 2019
Eating Disorder awareness

There is a significant increase in young people with eating disorders from developing countries who take concerns about food and body weight to dangerous extremes. Dr. Mangala of SCARF, Chennai shares how you can spot an eating disorder such as anorexia, bulimia and binging and seek timely assistance to save precious lives.

Eating disorders are behavioural disorders characterized by abnormal eating habits, causing psychological and physiological disturbances. These persistent abnormal eating behaviours cause serious negative impact on health, emotions and functioning. The body is deprived of adequate nutrition affecting all vital organs and leading to other diseases.

The commonest eating disorders are:

  1. Anorexia Nervosa
  2. Bulimia Nervosa
  3. Binge Eating Disorder

The primary focus in all eating disorders remains preoccupation with weight, body shape and food.

In comparison with the West, the developing world has a lesser prevalence of eating disorders. But this seems to be changing in recent times. There is a significant increase in the number of people seeking treatment for eating disorders in developing countries too. Awareness about these disorders is gradually increasing but is still not adequate.

These disorders usually start in early teens or young adults but can develop in other age groups too. More common in girls, it usually starts after menarche.

Like most other psychiatric conditions, eating disorders are also multifactorial with contribution from biological, environmental and psychological factors.

1.    Anorexia Nervosa (AN)

This is a potentially life-threatening eating disorder. It is characterized by a morbid fear of becoming obese, distorted body image perception, and an abnormally low body weight (at least 15% less than lower limits of normal weight)

To achieve the “ideal body” people with AN use extreme efforts to control their weight which can significantly affect their health. These include:

  • Excessive limitation of intake of calories, sometimes to the point of starvation
  • Excessive exercise
  • Using laxatives to facilitate purging
  • Vomiting after eating

Persons suffering from AN remain obsessed with dieting, avoiding foods they perceive as fattening, calorie-counting, and checking their weight. They can either have restricted intake or binge-purge cycles. The latter involves episodic overeating, followed by guilt, self-blame and purging.

In addition, these persons can be found to perform certain peculiar rituals when dealing with food. This can involve rituals related to preparation of food, or handling of food like breaking food into small portions, hiding food, etc.

When left untreated, AN can lead to serious medical complications. These include:

  1. Dry skin
  2. Brittle hair
  3. Anemia
  4. Wasting of muscles
  5. Lethargy/ Weakness
  6. Hypothermia (low body temperature)
  7. Constipation
  8. Thinning of bones and bone fractures
  9. Lack of menstruation in girls and women
  10. 10.Reduced fertility
  11. Ovarian atrophy (indicative of ovarian failure)
  12. Joint related problems (result of excessive high impact exercise)
  13. Death from starvation

AN is usually associated with other psychiatric conditions like depression, substance abuse, or anxiety disorders. It significantly impacts psychosocial functioning and interferes with one’s ability to maintain interpersonal relationships. Impact on cognitive functioning causes damage to education and vocational performance. When the illness continues for prolonged periods of 10-20 years, about 20% will not be able to function independently.

Management:

  • Nutritional rehabilitation with good medical monitoring during refeeding is a key factor in the treatment of AN.
  • Restoration of body weight to healthy levels and treatment of physical complications.
  • Psychological interventions to help change their maladaptive thoughts, attitudes and feelings
  • Medication to help cope with depression, anxiety or other comorbid psychiatric problems, if necessary.

With proper treatment, one can return to healthier eating habits and most complications can be reversed.

2.   Bulimia Nervosa (BN)

While persons with bulimia share the belief with anorexics that “thin is ideal” they are not underweight. They are either normal in weight or overweight.

This is also a disorder starting in the teens or early twenties affecting girls more than boys. It has become more common in the last few decades and is more prevalent in the higher socioeconomic groups and in the developed countries.

What begins as a dieting behavior aimed at weight control gradually goes out of control and becomes a predominant binge-purge cycle. They start starving all the time till they are overcome by a strong desire to eat when they invariably binge on high calorie foods like chocolates, sweets, biscuits etc. Once they start eating they have little or no control over themselves and eat enormous amounts of food in short periods.

They usually eat in secret, tend to steal food, and are ashamed of their behavior. The binge is inevitably followed by guilt and shame which is followed by vomiting that is self induced. They may also use or rather misuse laxatives, diuretics, enemas and appetite suppressants.

They also develop medical complications when the condition remains untreated for long.
The complications include:

  1. Ulceration /excoriation of the oesophagus (food pipe) due to acid regurgitating from the stomach during vomiting
  2. Rupture of the oesophagus
  3. Erosion of the dental enamel (from stomach acids)
  4. Abrasions of knuckles (putting the hand in the throat to induce vomiting)
  5. Constipation
  6. Electrolyte disturbances in the body
  7. Cardiac arrhythmias

Management:

Management of Bulimia is also multipronged. A combination of behavior therapy, cognitive behaviour therapy (CBT), psychotherapy along with medication will help address bulimia and the comorbid psychiatric problems present. Psychoeducation for patients and families and group therapies play an important role in the treatment of BN.

3.   Binge Eating Disorder (BED)

Consuming large quantities of food in a relatively short period of time followed by severe discomfort and shame is the key feature of Binge Eating Disorder.

There is a tendency to eat large amounts of food throughout the day (no planned meal times), and feel depressed and guilty at the end of the binge. Due to a lack of control over eating there is a tendency to continue eating even after a sense of fullness sets in causing discomfort. Though there is marked guilt and shame following the binge as in bulimia, unlike Bulimia Nervosa, there are no compensatory acts like vomiting or purging. These people choose to eat alone most of the time, to hide the binging. Binging can occur at least once a week. Persons with binge eating may be normal or overweight or obese.

Depression is a very common comorbid condition associated with bingeing and bingeing on comfort foods like chocolates, sweets and other carbohydrate rich foods is usual.

Binge Eating Disorder (BED) is the most common eating disorder and has been identified as an important worldwide public health problem by the World Health Organization. However, it remains very much under-recognized and ignored, even while its complication obesity receives adequate attention and treatment.

Though women are more affected, the ratio of women to men is better balanced. This is the commonest eating disorder in men. Oestrogens and progesterones have been identified as factors contributing to binge eating in women. Women are also more likely to eat in response to negative emotions like anger, frustration and anxiety (emotional eating.)

Women with early menarche, menstrual dysfunctions, those who delivered babies with higher birth weights and those with Polycystic Ovarian Syndrome (PCOS) are found to have association with binge eating disorder.

BED has been found to affect glycemic control in women with type 2 Diabetes. Men are more likely to have comorbid substance dependence and are more likely to develop metabolic syndromes.

Management:

Management of Binge eating involves pharmacotherapy combined with psychotherapy, CBT and treatment of associated medical problems including obesity.

Avoidant/Restrictive Food Intake Disorder (ARFID)

This refers to an eating pattern where there is a failure to meet minimum daily requirements due to a person’s personal preferences. Certain foods are avoided for characteristics like color, smell or taste or due to fear of unpleasant consequences (e.g. choking). There is no fear of gaining weight or preoccupation with body shape. This can lead to significant nutritional deficiencies, weight loss or failure to gain weight in childhood. The important features of other eating disorders are absent here.

Other eating disorders

Though most eating disorders begin in the teens, some types are found in childhood too. Pica and rumination disorder are two such conditions.

Pica

This refers to repeated ingestion of nonfood items, such as soap, chalk, talcum powder, mud, sand or charcoal over a prolonged period of time. Eating such substances is not appropriate for the person's developmental level and not part of a specific cultural or social practice. This can result in medical complications such as poisoning, intestinal problems or infections. Pica often occurs along with other disorders such as Autism Spectrum Disorder (ASD) or intellectual disability. When it occurs due to certain conditions like anemia, it goes away when the underlying problem is corrected.

Rumination disorder

A common problem in infancy, this disorder is characterized by repeated regurgitation of food after eating. Swallowed food is brought back up into the mouth without nausea or gagging. The food thus regurgitated is rechewed and reswallowed or spit out. The disorder may result in malnutrition if the food is spit out or if the person eats significantly less to prevent the behavior.

Previously considered a syndrome limited to the Western culture, eating disorders are prevalent in the non-Western countries as well. While sociocultural and environmental factors play an important role in the etiology of eating disorders, genetics, biological and psychological factors have a very significant role too. The interactions between all the various factors are responsible for the development of eating disorders.

Some of the socio cultural factors identified in the West can be true in non-Western cultures too, but may manifest differently.

Overprotective parenting styles (where parents are overly involved in all aspects of their children’s lives) can contribute to development of eating disorders in children. These children feel completely dependent and believe they have no control over their lives and try to gain control over what is possible for them like their eating habits.

Globally, comments from friends family and peers on body appearance, weight and shape have played a significant role is affecting eating habits. Unlike their Western counterparts, Indian girls feel the impact of eating and exercise is more on medical health rather than social life and relationships.

To summarize:

Eating disorders refer to a spectrum of attitudes and behaviours centred around body weight and shape, leading to preoccupation with food restriction, dieting, binging and vomiting. They can range from mild forms to serious conditions like Anorexia Nervosa and Bulimia Nervosa. They are associated with a wide range of physical, psychological and social adverse effects. They are treatable medical illnesses. They coexist with other psychiatric conditions like depression, anxiety disorders and substance use disorders. They usually start in teenage or young adulthood and are more common in girls. Eating disorders are associated with one of the highest rates of mortality among psychiatric disorders. The methods of treatment include medical, nutritional, educational, psychotherapeutic, behavioral, and pharmacological components.

Behaviours that may indicate an eating disorder include:

  • Skipping meals or making excuses for not eating
  • Excessive focus on healthy eating
  • Making own meals rather than eating what the family eats
  • Withdrawing from normal social activities
  • Persistent worry or complaining about being fat and talk of losing weight
  • Frequent checking in the mirror for perceived flaws
  • Repeatedly eating large amounts of sweets or high-fat foods
  • Use of dietary supplements, laxatives or herbal products for weight loss
  • Excessive exercise
  • Calluses on the knuckles from inducing vomiting
  • Problems with loss of tooth enamel that may be a sign of repeated vomiting
  • Leaving during meals to use the toilet
  • Eating much more food in a meal or snack than is considered normal
  • Expressing depression, disgust, shame or guilt about eating habits
  • Eating in secret

The broad treatment goals for all eating disorders:

  • Achieving normal body weight and maintaining it
  • Stopping all abnormal eating patterns and behaviors, such as food restricting, binge eating, or purging, compulsive exercise etc
  • Changing thought distortions which focus on body weight and shape to healthy balanced views about self
  • Treating the comorbid medical and psychiatric conditions, appropriately.
  • Psychoeducation for patients, families to prevent relapses.

 

Updated on 05 March 2019 with the poster and keywords tags