Watch out! ED no longer western malady

By Smriti Daniel

We’re used to thinking of eating disorders (ED) as a purely western malady, but Consultant Dietician Sigrid S. De Silva has noticed a disturbing trend in recent years. Some of her youngest patients have been diagnosed as having anorexia or bulimia, while others complain of compulsive overeating. In many cases, the condition has gone unnoticed for a considerable length of time.

There is a real danger here, says Sigrid. Describing children from wealthy backgrounds who have such poor diets that they are malnourished, she emphasises that an eating disorder is something that could wreak havoc on a child’s growth and development. If neglected, it could even prove fatal. Though it is a family who must first identify the problem, it takes a team of a physician, a dietician, and a psychologist to treat the patient.

This week, in the first instalment of a two part series, we look at the effects of anorexia and bulimia.

The Migration of ED

Anorexics typically display an aversion to food and a corresponding obsession with weight loss. Self induced starvation and excessive exercising become their chosen strategies to reach that elusive ideal weight. A person with bulimia will actually indulge in episodes of binge eating, and then find themselves overwhelmed with guilt and self loathing. In order to prevent weight gain, bulimics will typically induce vomiting, use laxatives or fast. Along this spectrum, are many other ‘not specified’ food disorders that display a combination of symptoms.

ED has long been considered the province of Western countries. “A lot of people are totally oblivious to the fact that there are people with eating disorders in urban and sub-urban Sri Lanka,” says Sigrid, revealing that she is yet to personally come across a case of someone from a rural area being so affected. What could be driving the phenomenon? The images of ‘perfect’ bodies that proliferate across the mass media have ensured that children know exactly what constitutes ‘attractive’. Across South Asia, that ideal of beauty is becoming increasingly generic – where we once prized voluptuousness in our actresses, we now look for slender limbs and flat stomachs. For a young person looking to meet that standard, the internet is populated with websites that advocate harmful strategies and diets.

However, an even more potent force lurks in the schoolyard. “Most eating disorders have a psychological basis, and some of it of course has to do with peer pressure,” says Sigrid, explaining that some of her patients describe the stringent diet their friends have adopted. Ignorant of the important role that certain components essential for life -such as fatty acids- play in maintaining health, such self imposed imbalanced, nutritionally inadequate diets take a heavy toll on young bodies.

Challenging preconceptions

In some cases, you’ll be surprised by how young. As with the assumption of this being confined to the West, one assumes that ED is primarily the province of teenagers. However, Sigrid has seen patients younger than 10 years and older than 30. While the majority do fall between 14 -18, she says there seems to be no age limit on developing ED.

Referring to photographs of famous mothers who are back to their normal weight mere weeks after delivering their babies, Sigrid notes that very few of us are spared the pressure to be beautiful. While social factors are well publicised (physical, sexual and/or emotional abuse has also been linked to the development of ED), the genetic component is less well known. In one study, doctors at the Maudsley Hospital in London suggested that people with anorexia were twice as likely to have variations in the gene for serotonin receptors. Reported by BBC, the study linked the overproduction of serotonin in these patients with their being in a continual state of acute stress and anxiety. (Genetic clues to eating disorders; BBC News). Other studies have also identified abnormal serotonin levels in some people with bulimia with bulimia. (Brain Chemicals May Cause Bulimia; BBC News).

Model on the ramp: Young people here are influenced by images such as this of what
constitutes 'attractive'

“Eating disorders affects people of all sizes,” says Sigrid, emphasising that even if a person is of a normal weight it doesn’t rule out an eating disorder. It’s also a common belief that women overwhelmingly comprise the majority of ED patients. “More girls is what it used to be,” says Sigrid, adding that “more and more I see it happening in males as well.” Unfortunately, since there is so little awareness of ED in Sri Lanka, she says there’s no way to gauge either the incidence of ED or its distribution across gender. In the end, cases of ED are believed to be the result of the interaction of multiple social, environmental, and biological factors

Spotting the problem

How do you know that your child has an eating disorder? “Though children may be making selective or weird dietary choices or over exercising, it often goes unnoticed for a very long time because people are just so busy and self involved,” says Sigrid. “The later you detect it, the longer it takes to cure, if you don’t cure it, it can even lead to death,” she says.

Many of the signs are not obvious – while dramatic weight loss is the most common symptom, it does not always occur in every patient with anorexia or bulimia. “There are signs if you watch carefully,” says Sigrid. The person will not want to eat in public or with the rest of family. Parents say they will find their child sitting in front of the computer or on a video game. The child promises to eat later, but does not, or claims to have already had something to eat at school, says Sigrid. With bulimia, she says there is one sign that’s hard to miss – the acrid smell of vomit is hard to wash off completely.

Sigrid recommends the website as a good site for those wanting to understand more. On it you will find a long list of other signs to watch out for. Included among them are an obsession with weight and complaining of weight problems (even if ‘average’ weight or thin), frequent trips to the bathroom immediately following meals (sometimes accompanied with water running in the bathroom for a long period of time to hide the sound of vomiting), use or hiding use of diet pills, laxatives, ipecac syrup or enemas, flushing uneaten food down the toilet (can cause sewage problems), hair loss and a pale or ‘grey’ appearance to the skin.

The long term consequences

“In most cases, it’s not about a lack of food provided, but the diet is so imbalanced that they’re actually malnourished,” says Sigrid of the cases she’s seen among well to do youngsters. Such a clampdown on essential nutrition at such a young age can have a profound impact on the growth and development of the body. “Some girls will not reach puberty, while in others who have, the menstrual cycle will stop,” warns Sigrid, explaining that not enough is known on how this affects men (or boys?).

Suffice to say that haemoglobin levels drop and essential fatty tissue disappears, the hormonal balance is thrown into flux. “For sure, growth will be stunted,” says Sigrid, adding “the expected height will no longer be achievable.”

With the immune system so undermined, patients become vulnerable to a range of other problems from frequent infection to heart disease. The latter (which famously claimed Karen Carpenter, an anorexic) is the most common medical cause of death in people with severe anorexia. Since it would not occur to many patients to take supplements, it makes them additionally vulnerable to conditions like osteopenia (loss of bone minerals) and osteoporosis (more advanced loss of bone density).

The less the patient weighs, the more severe the bone loss. Unsurprisingly, anemia is also a common result of anorexia.

In bulimia, the regular purging brings with its own set of problems. Tooth erosion, cavities, and gum problems are caused by the gastric acids coming into the mouth. Water retention, swelling, and abdominal bloating are common as is acute stomach distress. Patients become dehydrated and low potassium levels can lead to extreme weakness, near paralysis, or lethal heart rhythms along with irregular periods and damage to the esophagus.

However, the long-term outlook becomes considerably brighter with prompt diagnosis and treatment, says Sigrid.

In recovery

“The longer one has had a eating disorder, the more firmly it has manifested,” says Sigrid, emphasising that it takes the combined efforts of a physician, a dietician and a psychologist to combat the disease. Though health issues are very real, she says the psychologist might be the most important person there.

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