Anorexia nervosa in 'non-white' populations

Eating disorders in women

Eating disorders, especially anorexia nervosa and bulimia nervosa have been classically described in young females in Western population. Recent research shows that they are also seen in developing countries including India. The classification of eating disorders has been expanded to include recently described conditions like binge eating disorder. Eating disorders have a multifactorial etiology. Genetic factor appear to play a major role. Recent advances in neurobiology have improved our understanding of these conditions and may possibly help us develop more effective treatments in future. Premorbid personality appears to play an important role, with differential predisposition for individual disorders. The role of cultural factors in the etiology of these conditions is debated. Culture may have a pathoplastic effect leading to non-conforming presentations like the non fat-phobic form of anorexia nervosa, which are commonly reported in developing countries. With rapid cultural transformation, the classical forms of these conditions are being described throughout the world. Diagnostic criteria have been modified to accommodate for these myriad presentations. Treatment of eating disorders can be quite challenging, given the dearth of established treatments and poor motivation/insight in these conditions. Nutritional rehabilitation and psychotherapy remains the mainstay of treatment, while pharmacotherapy may be helpful in specific situations.

Characteristics and stability of empirically derived anorexia nervosa subtypes: towards the identification of homogeneous low-weight eating disorder phenotypes

Anorexia nervosa (AN) is characterized by within-group heterogeneity in symptom presentation, which poses problems for research on etiology and treatment. This study sought to identify homogeneous subtypes of AN, and examine their short-term stability, using empirical methods. A treatment-seeking sample with AN (n = 194) was assessed at baseline and 6- and 12-month follow-ups. Latent class analysis was used to identify homogeneous AN subgroups, and latent transition analysis was used to examine the stability of latent classes. Three low-weight eating disorder classes were identified: 1) fat-phobic restricting (AN-R-FP); 2) fat-phobic binge-eating/purging (AN-BP-FP); and 3) non-fat-phobic restricting (AN-R-NFP). Subtype membership was stable over follow-up, with .68 to .88 probabilities of remaining in the same class from baseline to 6 months, and .87 to 1.00 from 6 months to 12 months. The most common transition pattern was between AN-R-FP and AN-R-NFP (56.8% of transitions); the majority of these participants transitioned from AN-R-FP to AN-R-NFP (n = 20/21). Predictors of latent class membership included lifetime mood and substance use disorder comorbidities, negative temperament, illness duration, and body mass index at treatment presentation. Disinhibition (vs. constraint), history of overweight or obesity, and illness duration decreased the probability of latent transition. Findings support the presence of 3 low-weight eating disorder phenotypes that are highly stable over short-term follow-up. Identification of a stable non-fat-phobic AN phenotype is intriguing and highlights the importance of studying mechanisms that differentiate fat-phobic and non-fat-phobic eating disorders.

Classification of feeding and eating disorders: review of evidence and proposals for ICD-11

Current classification of eating disorders is failing to classify most clinical presentations; ignores continuities between child, adolescent and adult manifestations; and requires frequent changes of diagnosis to accommodate the natural course of these disorders. The classification is divorced from clinical practice, and investigators of clinical trials have felt compelled to introduce unsystematic modifications. Classification of feeding and eating disorders in ICD-11 requires substantial changes to remediate the shortcomings. We review evidence on the developmental and cross-cultural differences and continuities, course and distinctive features of feeding and eating disorders. We make the following recommendations: a) feeding and eating disorders should be merged into a single grouping with categories applicable across age groups; b) the category of anorexia nervosa should be broadened through dropping the requirement for amenorrhoea, extending the weight criterion to any significant underweight, and extending the cognitive criterion to include developmentally and culturally relevant presentations; c) a severity qualifier "with dangerously low body weight" should distinguish the severe cases of anorexia nervosa that carry the riskiest prognosis; d) bulimia nervosa should be extended to include subjective binge eating; e) binge eating disorder should be included as a specific category defined by subjective or objective binge eating in the absence of regular compensatory behaviour; f) combined eating disorder should classify subjects who sequentially or concurrently fulfil criteria for both anorexia and bulimia nervosa; g) avoidant/restrictive food intake disorder should classify restricted food intake in children or adults that is not accompanied by body weight and shape related psychopathology; h) a uniform minimum duration criterion of four weeks should apply.

Adolescent male with anorexia nervosa: a case report from Iraq

This is the first reported case of an adolescent male with anorexia nervosa in Iraq. This disorder is believed to be rare in males across cultures and uncommon for both genders in Arab countries. The patient met the DSM-IV diagnostic criteria for anorexia nervosa. He was hospitalized and received medical and psychiatric treatment at local facilities as discussed below and responded well to treatment.

Belief and behavior aspects of the EAT-26: The case of schoolgirls in Belize

This study investigates components of eating attitudes in a sample of Belizean schoolgirls and argues for separate analysis of eating beliefs and eating behaviors using the EAT-26 in populations undergoing rapid cultural change. The EAT-26 was utilized in a novel manner, preserving the ethnographic and empirical distinction between belief and behavior components of eating attitudes. Participants included a sample of secondary schoolgirls (n = 80) undergoing acculturative stress. Participants reported more disordered eating beliefs than behaviors. Respondents having higher belief scores than behavior scores were more likely to prefer thinner body build and to be concerned about boys' assessments of their bodies. Girls with higher behavior scores were less likely to report eating when hungry and stopping when full. In conclusion, discriminant validity was found between attitudinal and behavioral aspects of the EAT-26 as evidenced by face validity and patterns in predicting body image preference and desired weight change. Such a distinction has implications for assessing risk for disordered eating among populations undergoing acculturative stress. Among such populations, while behavioral symptoms might be absent or present in subclinical levels, disordered beliefs associated with psychological distress or potential precursors to eating-disordered behavior might be detected and should be investigated further.

Should non-fat-phobic anorexia nervosa be included in DSM-V?

OBJECTIVE

Cross-cultural data suggest that rationales for food refusal vary in anorexia nervosa (AN), and a variant, termed non-fat-phobic AN (NFP-AN), has been described. This review evaluates whether data support modification of the requirement for intense fear of weight gain to meet AN criterion B in DSM-V.

METHOD

We performed a systematic search of the Medline and PsychInfo literature and evaluated the relevant publications by Robins and Guze's (Am J Psychiatry 126, 983-987, 1970) criteria as a standard for diagnostic validity. We also performed a meta-analysis comparing the severity of eating pathology in AN to (a) NFP-AN and (b) AN with low drive for thinness (low-DT-AN).

RESULTS

A modest literature indicates that NFP-AN has wide geographic distribution and occurs in both Western and non-Western populations alongside cases of typical AN. Aggregating across eligible studies, patients with NFP-AN or low-DT-AN score at least 2/3 of a standard deviation lower on measures of eating pathology than patients with conventional AN. Transcultural comparison of drive for thinness suggests significantly lower norms in non-Western cultures.

DISCUSSION

NFP-AN occurs with wide distribution. Further research is necessary on the course and outcomes of NFP-AN to characterize its congruence with, or distinction from, conventional AN. We discuss several options for including a description of NFP-AN in DSM-V.

Anorexia nervosa in Asian-American adolescents: do they differ from their non-Asian peers

OBJECTIVE

This study reports on the clinical characteristics and phenomenology of anorexia nervosa (AN) in Asian-American adolescents, and compares them with a non-Asian sample.

METHOD

Data were obtained from a family therapy trial for adolescents with AN. Demographic details were collected and participants assessed on a series of structured interviews. Data from Asian participants were compared with that from non-Asians.

RESULTS

Asians scored lower on all the Eating Disorder Examination (EDE) subscales, significantly on the restraint subscale (1.48 vs. 2.80, p = 0.016) and weight concerns subscale (1.35 vs. 2.30, p = 0.026). They also scored higher on the Family Environment Scale achievement orientation subscale (6.50 vs. 4.81, p = 0.011).

CONCLUSION

Asians are demographically similar to their non-Asian peers but tend to come from higher-income families who were more achievement oriented. EDE scores suggest Asians tend to report fewer symptoms. The apparent lack of fat-phobia among Asians could be related to this overall under-reporting of symptoms.

Non-fat-phobic anorexia nervosa in British South Asian adolescents

OBJECTIVE

The current study investigated the clinical features of British South Asian adolescent females presenting with low weight in the absence of organic disease.

METHODS

The authors performed a retrospective case note study of South Asian British female adolescents presenting with weight loss/anorexia nervosa to psychiatric clinics and matched White English peers presenting with low weight.

RESULTS

South Asian patients presented more frequently with loss of appetite (p = .01) and less frequently with fat phobia (p = .032) and weight preoccupation (p = .001). South Asians also had significantly more satisfactory relationships with their nuclear family and peers (p = .03).

DISCUSSION

Differing symptom profiles for anorexia nervosa need to be taken into account when assessing patients from different cultures. South Asian adolescents may present with a non-fat-phobic form of anorexia nervosa. This has clinical and epidemiologic implications. Further investigation is warranted to assess the nosologic status of this group.

Television, disordered eating, and young women in Fiji: negotiating body image and identity during rapid social change

Although the relationship between media exposure and risk behavior among youth is established at a population level, the specific psychological and social mechanisms mediating the adverse effects of media on youth remain poorly understood. This study reports on an investigation of the impact of the introduction of television to a rural community in Western Fiji on adolescent ethnic Fijian girls in a setting of rapid social and economic change. Narrative data were collected from 30 purposively selected ethnic Fijian secondary school girls via semi-structured, open-ended interviews. Interviews were conducted in 1998, 3 years after television was first broadcast to this region of Fiji. Narrative data were analyzed for content relating to response to television and mechanisms that mediate self and body image in Fijian adolescents. Data in this sample suggest that media imagery is used in both creative and destructive ways by adolescent Fijian girls to navigate opportunities and conflicts posed by the rapidly changing social environment. Study respondents indicated their explicit modeling of the perceived positive attributes of characters presented in television dramas, but also the beginnings of weight and body shape preoccupation, purging behavior to control weight, and body disparagement. Response to television appeared to be shaped by a desire for competitive social positioning during a period of rapid social transition. Understanding vulnerability to images and values imported with media will be critical to preventing disordered eating and, potentially, other youth risk behaviors in this population, as well as other populations at risk.

Genes and/or Jeans?

Eating disorders are prevalent among young adult females and pose serious psychological and medical risks. Notwithstanding important advances, efforts to develop effective means of preventing and treating eating disorders have been limited by an incomplete understanding of their multifactorial etiology. Whereas epidemiologic data strongly suggest the influence of socio-cultural context in moderating risk, many hypotheses about how these effects are exerted have remained empirically unevaluated. Specifically, experimental and observational data suggest that social transition (e.g., transnational migration, urbanization, modernization), Western media exposure, and certain peer environments (involving social comparison and teasing) may all contribute to risk. With respect to genetic influences on etiology, family and twin studies have supported a genetic diathesis to eating disorders. Whereas, molecular genetic studies have generated interesting leads- with the most promising findings emerging for genes related to the function of serotonin-they have yet to identify well-replicated susceptibility loci. This paper reviews the data supporting both socio-cultural and genetic contributions for eating disorders and suggests productive future strategies for continuing to unravel their likely multiple and complex interactions.

A survey of anorexia nervosa using the Arabic version of the EAT-26 and "gold standard" interviews among Omani adolescents

OBJECTIVE

The purpose of this study was to assess the validity of the Eating Attitude Test (EAT) in identifying the presence and severity of eating pathology in male and female Omani urban adolescents and to establish cut-off scores that matched those of anorexia identified by gold standard interviews without fear of fatness criteria.

METHODS

Both females (n=126) and males (n=136) were screened using the Arabic version of the EAT-26 and interviewed using a semi-structured, Composite International Diagnostic Interview (CIDI) in order to investigate the relationship between false positives and false negatives at various EAT-26 cut-off points. A receiver operating characteristics (ROC) curve was calculated to discriminate the power of the EAT-26 for every possible threshold score.

RESULTS

The EAT-26 identified 29% of the subjects as probable anorexic cases as against 9.5% identified during the structured interview based on the anorexia gold standard (32% males and 68% females). The sensitivity and specificity of the EAT-26 were respectively 24% and 69.6%. When using the ROC curve, a cut-off score of 10 gave the best compromise between sensitivity (64%) and specificity (38%).

DISCUSSION

Although the EAT-26 is the most widely used screening instrument in cross-cultural studies, it does not appear to be reliable in identifying probable cases of anorexia among Omani adolescents. The use of a gold standard interview without fat phobia criteria indicated that the rate of anorexia nervosa may be more prevalent among males than previously estimated. This intriguingly high preponderance of males is discussed in terms of prevailing demographic trends in Oman.

Presence and severity of anorexia and bulimia among male and female Omani and non-Omani adolescents

OBJECTIVE

The population of Oman is a heterogeneous mix of nationalities providing a natural setting for studying the cross-cultural differences in the presence and severity of eating disorders as well as an opportunity for evaluating the performance of measurement instruments for these disorders.

METHOD

Disordered eating screening instruments (the Eating Attitude Test and the Bulimic Investigatory Test) were administered to Omani teenagers, non-Omani teenagers, and Omani adults.

RESULTS

On the Eating Attitude Test, 33% of Omani teenagers (29.4% females and 36.4% males) and 9% of non-Omani teenagers (7.5% of males and 10.6% females) showed a propensity for anorexic-like behavior. On the Bulimic Investigatory Test, 12.3% of Omani teenagers showed a propensity for binge eating or bulimia (13.7% females and 10.9% males). Among the non-Omani teenagers, 18.4% showed a tendency toward bulimia, with females showing a slightly greater tendency than males. In contrast, barely 2% of Omani adults showed either a presence of or a severity of disorderly behavior with food.

CONCLUSION

Omani teenagers scored significantly higher than other ethnic groups and Omani adults. This finding is discussed in the light of emerging evidence from many parts of the world suggesting that cultural transition, compounded by demographic constraints, plays a significant role in abnormal eating attitudes.

Anorexia nervosa in early adolescence in Sri Lanka

We report four cases of anorexia nervosa (AN) seen over a period of 5 months in the psychiatry unit of a general hospital. The report is unusual because two of the patients were male, all were between 13 and 15 years of age and AN is thought to be rare in Sri Lanka. All four patients had features typical of AN. There are implications for clinical practice in Sri Lanka if the prevalence of AN is rising because all these patients presented to psychiatrists late in their illness, some in an advanced state of weight loss.

Weight-related body image concerns among 18-24-year-old women in Canada and India: an empirical comparative study

OBJECTIVE

Sociocultural factors are important in the pathogenesis of eating disorders. We examined some core (DSM IV) features of eating disorders, i.e., drive for thinness and dissatisfaction with the weight of the abdomen, hips, and thighs among women in Canada and India.

METHODS

A total of 65 Canadian (mean+/-S.D. age: 21.4+/-2.0 years) and 47 Indian (mean+/-S.D. age: 18.7+/-4.1 years) women completed the Drive for Thinness (DT) and Body Dissatisfaction (BD) subscales of the Eating Disorder Inventory (EDI) and in addition rated the degree to which they believed all major regions of their body were overweight.

RESULTS

After the effects of body mass index (BMI) were partialled out statistically, the DT (EDI) and BD (EDI) scores were not significantly different between the two countries. In both groups, concerns about the weight of the abdomen, hips, thighs, and legs loaded on a factor that essentially described the 'body dissatisfaction' construct. After the effects of BMI were partialled out, however, the factor scores from this factor correlated with BD (EDI) in the Canadian but not the Indian sample.

DISCUSSION

In contrast to the Canadian women, the Indian women did not overestimate the 'fatness' of their abdomen, hips, thighs, and legs. Among the Indian women, concerns about the weight of the upper torso (i.e., face, neck, shoulders, and chest) emerged as a distinct body image construct. In conclusion, after the effect of BMI was controlled for statistically, the Canadian and Indian women scored similarly on some of the core features of eating disorders, as measured by the DT (EDI) and BD (EDI) subscales, however, the nature of the underlying body image construct was different between the two groups.