The weight of thinness

4 min read
23 Dec 2017
4 min read
1960 words
Eating disorders, which disproportionately affect young women, need serious intervention

One emerging mental health issue that is often swept under the rug in Nepal is eating disorders. Eating disorders are serious health issues characterised by a person’s having irregular eating habits and harbouring unhealthy preoccupation with body-shape and weight. “Eating disorders not only affect a person’s appetite and behaviour, but also lead to severe clinical consequences,” says Dr Sagun Pant, a psychiatrist at Tribhuvan University Teaching Hospital.

There are several types of eating disorders; the three most common ones are anorexia nervosa, bulimia nervosa and binge-eating disorder. Patients with anorexia nervosa have an unrealistic and unhealthy perception of their body image. They cannot maintain a healthy body weight, fiercely limit the amount of food they consume and are often severely underweight. Patients with bulimia nervosa repeatedly binge-eat, and then indulge in problematic behaviours (such as self-induced vomiting, over-exercising and using diuretics or laxatives) to compensate for the overeating. Patients with binge-eating disorders binge repeatedly without feeling guilty. They lose control over their eating, and as a result are often overweight or obese.

Signs and symptoms

These eating disorders start off as habits before the illnesses manifest completely. For anorexia nervosa, sufferers restrict their food intake, leading to substantial reduction in their body weight. Another sign is that patients keep compulsively checking their weight. For bulimia nervosa patients, one main symptom would be recurrent episodes of binge-eating, and then recurrent inappropriate compensatory behaviours in order to prevent weight gain. They indulge in these behaviours at least once a week, for three months. 

“Bulimia often goes unnoticed because victims suffering from the disorder look completely normal. With anorexia, there are noticeable physical changes, but with bulimia, we don’t know what happens behind closed doors. It’s an eating disorder that takes place in isolation,” says Dr Udip Shrestha, registered physician and a certified sports nutritionist. 

To identify eating disorders, families and friends need to look out for these sign in people they suspect are suffering from an eating disorder: lack of proper eating habits, avoidance of family dinners and social gatherings and excess weight loss. Once patients progress and have already developed an eating disorder, other serious changes that start being noticeable are hair loss, skin changes and swollen feet as well as severe dehydration.

Eating disorders in Nepal: why it is increasing 

Mental illnesses are often mediated by culture and the society an individual is part of. What may be considered normal in one society may not be considered so in another. Conversion disorders (a neurological condition in which patients present with symptoms like blindness, numbness, paralysis, fits that cannot be explained by medical evaluation) are quite common in Nepal, but they aren’t so in the US. Similarly, while eating disorders are prevalent in the Western world, they aren’t as recognised here in Nepal. A major reason is that Nepali society did not prefer to be thin or bony. In fact, skinny people used to be frowned upon. Most Nepalis associated beauty with healthy-looking and slightly plump women, as these qualities signified a family’s being able to afford more than three square meals a day. However, owing to the Western media’s, Bollywood’s and fashion industries’ penetration in the local market, today’s generation of young Nepali women (especially those between the ages of 12 and 25) regard skinny bodies as the ideal body type.

Although the actual cause of eating disorders is still unknown, many studies reveal genetic predisposition and psychological as well as environmental influences as being the probable reasons. But one of the most important reasons is cultural pressure. From teenagers to middle-aged people, everyone wants to be attractive, and they think that focusing on improving their looks and physique is the way to go about it. And these people often become so engrossed in wanting to look good that they tend to overdo it. They go on diets without consulting dietitians or exercise at the gym for four to five hours. “This obsession with prioritising looks over health is where we’re going wrong,” explains Dr Shrestha. “While first impressions are important in the world that we live in today, especially with regards to job interviews and first dates, it is equally, if not more, important to strike a right balance between beauty and health.”

Misconceptions and diagnosis

Besides the general lack of awareness about eating disorders in Nepal, there is also great misconception regarding them. Here, most people falsely assume that having an eating disorder means being a picky eater. “We have so many parents coming to us saying that their child has an eating disorder just because the child doesn’t eat properly,” says Dr Pant. “They don’t even know that eating disorder is a mental illness.”

Although Teaching Hospital only receives around 10 to 12 cases per year, Dr Pant says that they’re all referrals by the gastroenterologists. Because of the lack of awareness, most patients in Nepal don’t even know that they are suffering from eating disorders. They come in because they believe there is something wrong with their abdomen or their digestive system and are quite taken aback when they get referred to a psychiatrist, as the last person they would want to see about a supposed “gastric” problem is a psychiatrist.

According to Dr Shrestha, when it comes to eating disorders, taking the patient’s history is often the best method for diagnosis. “Sometimes, patients ask us for a diagnosis for repeated vomiting, and when we probe deeper, after ruling out all other medical causes, we find out that it is actually self-induced vomiting,” he says. Patients never downright come out and say that they have a problem with eating habits, and they sometimes don’t even accept the diagnosis given to them. They’ll make excuses, saying that they are dieting or trying to lose weight. So the initial referral to a psychiatrist and the final diagnosis are not accepted easily by the patients. However, educating them about the nature of the illness and its high comorbidity with other psychiatric illnesses help doctors eventually convince the patients. 

Other psychiatric illnesses and their health implications

Although eating disorders are classified as independent mental disorders, they usually never occur in isolation. They usually occur together with other psychiatric problems like obsessive-compulsive disorder (OCD), anxiety, depression and substance-abuse problems. Depression and OCD are much more common in patients with anorexia, and those with bulimia often have suicidal tendencies and substance-abuse problems. Furthermore, bulimia patients also often undergo personality changes. Besides being impulsive eaters, they are also likely to indulge in self-harm, are cavalier about sex and often experiment with drugs. They tend to be very moody and make a lot of hasty decisions.

Eating disorder can also have serious physical impacts on sufferers. Eating disorders can lead to cardiovascular diseases, cancer, bone deformities, amenorrhea, infertility issues and miscarriage, and muscle atrophy, among others. In fact, anorexia even has the highest mortality rate among all mental illnesses. 

Treating eating disorders

According to Dr Pant, properly diagnosing eating disorders is the first step to treating sufferers of the disease. The diagnostic criteria for eating disorders have to be met and all other medical causes have to be ruled out before a doctor can conclude that the patient has an eating disorder. After that, health professionals use a combination of different types of treatment. Although the treatment differs according to the type and severity of the eating disorder, the basic approach is to resort to multidisciplinary management conducted by nutrition experts, gastroenterologists and psychologists and psychiatrists. 

First, the doctors need to educate patients and their family about eating disorders. They are made aware of the problem, how unhealthy it is and what clinical consequences it can have, and they are presented with stories and statistics regarding their disease. The doctors then set goals, depending on the person. Most patients get admitted to hospitals because they need to be under observation, as they could revert to their old tendencies once they get home. Because anorexia is the most common eating disorder in Nepal, the usual goal in most cases would be to stabilise the patients and get their BMI within the ideal range. Nutritional supplements are given in slow doses so appetite is increased. Then, this is followed up by Cognitive Behavioural Therapy (CBT), for behavioural management, so they learn to challenge their immediate cognitions and slowly start changing their behaviour. Over the next couple of months, CBT is followed up by regular check-ups and treatment.

How to make Nepalis more aware

Nepalis still have a long way to go in terms of accepting and addressing problems like eating disorders. The first task should be to make people realise that this is actually a health problem. Most people don’t know what eating disorders are, or that they even exist. We therefore
have to change that perception, for which we need to intervene at the school level, say health experts. Eating disorders mostly start during a person’s teenage years, so in high school, a short curriculum on nutrition and health, and eating disorders should be introduced. “Apart from that, teachers and parents should be looking out for signs as well,” says Dr Pant. “Children spend half their time in schools. So even if parents miss out on signs, teachers might notice them.”

Dr Sagun Pant

Furthermore, say doctors, we as a society should stop emphasising being thin and on having the ideal body. Things like telling someone that they look good because they are thin are what keep perpetuating the eating disorder, as disorder victims are more likely to want to keep receiving compliments. Rather, we should emphasise being healthy, and for those wanting to lose weight, we should focus on healthier weight-loss protocols, say doctors. We can, for starters, say the doctors, propagate these notions through mental-health programmes in schools and through the media.