Eating disorders – The silent killer

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Eating disorders, are real illnesses that don’t discriminate on race or class, have little to do with vanity and can have life-long after-effects. Anorexia nervosa, bulimia nervosa and binge-eating disorder are “silent diseases” that impact on sufferers’ physical health and quality of life, their ability to function in daily life and their relationships with family and friends. Anorexia nervosa has the highest death rate of all mental health conditions.

The spotlight has turned onto the role of social media such as photo-sharing platform Instagram, with calls from eating disorder experts and support organisations to clamp down on images and posts “glamourising” eating disorders following the company’s agreement to remove images of self-harm.

The South African Society of Psychiatrists (SASOP) said media stereotypes of beauty and “ideal” body types had long been implicated as contributing to eating disorders, especially for those already vulnerable or at-risk. SASOP member Prof Christopher Paul Szabo, a leading expert on eating disorders, said there was a “real vs ideal” disconnect between average body sizes and types in real life versus the often-unattainable ideals portrayed in the media and by social media users. This potentially creates incorrect perceptions that being underweight, meaning below healthy norms, is desirable and contributes to the unhealthy attitudes and behaviours around weight, food, dieting and body image that are central to eating disorders.

According to Prof Szabo, the causes of eating disorders were complex and their treatment was specific to each individual. While body image concerns were central, eating disorders were also “powerful indicators of distress that goes beyond food and body issues alone. Every sufferer has an individual story. Dieting should be added to the list of risky behaviours for teenagers, along with the more usual concerns of unprotected sex and abuse of drugs and alcohol, especially when there was no clear health reason for dieting.

Broadly defined as unhealthy preoccupation with eating, food, weight, exercise or body image – together with behaviours such as restriction of intake, excessive exercise, binge eating or purging – that impacts on quality of life and the ability to function in daily life, eating disorders are most prevalent in teenage and young adult women. There are also increasing concerns for pre-teens, with the physical changes of puberty such as increased body fat and girls maturing at younger ages interacting with social pressures for “thinness” and dieting, creating a risk for eating disorders to develop.

Prof Szabo’s research since the early 1990s had found that eating disorders affected both black and white young women – resulting in similar behaviours and attitudes irrespective of race – and weren’t limited to urban or “Western” settings. This mirrored findings in other African countries and other societies undergoing social and political changes. It is important for families, schools and medical professionals to be aware that eating disorders were possible in all cultures, socio-economic groups and races, so that symptoms weren’t dismissed or misdiagnosed, and sufferers could get help. The stereotype of eating disorders being limited to females is also changing – teenage boys and young men are increasingly at risk due to pressures to achieve perceived ideal male body types, usually involving exercise to lose weight and build muscle.

This leads to possibly excessive exercise and the use of nutritional supplements (or anabolic steroids, or both) to replace healthy eating habits, he said, but cautioned that there could also be underlying  medical  conditions and that medical professionals should be careful of  assuming an eating disorder diagnosis before  excluding other possibilities. The root causes of eating disorders are complex but often linked to the pressures of contemporary life and culture, with the body as the vehicle for expression of conflicts of identity. The causes are best understood as an interaction between the individual and their environment. 

Perfectionism is a personality trait associated with eating disorders but not exclusively so, he said, and combined with a preoccupation with diet and exercise regimens should be an early warning signal. The role of parents and family in the development of eating disorders has been highly controversial, and can contribute to the guilt associated with eating disorders, but Prof Szabo notes that there is no specific causal relationship had been identified.

Families should pay as much attention to healthy father-daughter relationships as to the relationship of mother and daughters. Unrealistic expectations of high achievement or perfection from either parent were associated with feelings of guilt and shame that could potentially lead to expression in eating disorders. Further possible precipitants of eating disorders can often be linked to stresses such as changes in family circumstances, abusive situations (either directly or witnessing abuse), or pressures to perform in school or sport, leading to feelings of a lack of control or disrupting the sufferer’s sense of self-esteem and self-worth.

The area of eating and body becomes the one place where the sufferer feels in control over their emotions and circumstances. With respect to concerns around weight – especially when a person’s perception of being overweight didn’t match their actual weight – and a history or preoccupation with dieting, and their weight and eating habits dominating conversation, are all warning signals of an eating disorder. On treating eating disorders, the kind of treatment generally needs the help of a specialist in eating disorders as sufferers tend to deny there is anything wrong and often resist treatment. Thus, consulting the family physician should be the starting point. 

Unlike many psychiatric conditions where medication is the primary method of treatment, eating disorders are treated with a combination of psychotherapy, usually also involving therapy sessions for parents/family, as well as nutrition or dietary counselling. Medication may be prescribed to treat related symptoms such as sleeping problems, anxiety or mood disorders. Treatment for anorexia could likely include hospitalisation, with a focus on nutrition counselling and weight restoration, which has been proven to aid also in improvement in overall psychological and emotional health. Hospitalisation may also be a requirement in certain instances for bulimia nervosa.

Professor Christopher Paul Szabo is currently the Head of Department of Psychiatry at the University of the Witwatersrand and Head of Clinical Department at Charlotte Maxeke Johannesburg Academic Hospital.