Underweight — the other side of the coin continue…

Causes and treatments

A full discussion of the causes and treatment of these serious eating disorders have filled books of their own.

A team consisting of a psychologist and/or a psychiatrist, a dietitian and a medical doctor should be involved in the treatment of a patient with an eating disorder. It is also important to bear in mind that treatment could stretch over many months before it has any significant effect and that even then the results are not always positive.

Generally speaking, the outlook for both anorexia nervosa and bulimia is not encouraging. In the case of the former, the outcome may vary from sudden recovery with little or no treatment, to death. Someone may be a victim of it for a few months or for a lifetime and it appears that only 40-60% of significantly ill patients make a good physical and psychosocial recovery. The mortality rate is estimated at between 5% and 18%, with the most frequent causes of death being suicide and the effects of starvation. Although not much literature has been published on bulimia, it is estimated that only 40-50% of treated bulimics can eventually be regarded as cured. Some are cured with relatively little effort, while others seem to return to normal eating habits and discontinue their purging behaviour after intensive treatment, only to relapse during periods of stress.

Serious medical complications - including death - are more likely to occur in bulimics and prugers, due to excessive losses of essential body fluids and electrolytes (such as potassium and sodium).

The risk of suicide is also believed to be higher, possibly because bulimia is often associated with depression.

Preventing the preventable

Because these eating disorders so often have a negative outcome, it is vital to either prevent their development or at least take action as soon as warning signals appear. You can help to guard against the development of anorexia nervosa and bulimia in a young person by following these guidelines:

1. Make a practice of discouraging restrictive dieting, meal-skipping and fasting.
2. Avoid unnecessary emphasis on and talk about figures, being fat and food which is 'fattening'.
3. Carefully phrase any weight-related recommendations or comments.
4. Try to correct misconceptions about nutrition, normal body weight and encourage a healthy approach to weight loss.
5. Place the 'ideal' female portrayed by the media into perspective.
6. Provide information about the normal physical changes which occur during puberty.
7. Refer an adolescent who appears to have a problem - or is at risk of developing one - to a physician, a mental health professional (psychologist/psychiatrist) or a dietitian skilled in working with patients who have eating disorders.

Reading the signs

Clearly, it is very important to identify someone who is at risk of developing - or already suffering from - an eating disorder in good time, so that treatment can be effective. But how would you know if your daughter or an acquaintance was in clanger of becoming a victim? The possible warning signals for anorexia nervosa and bulimia are summarised in the table

In conclusion, it must be said that in man the control of food intake is a very complex and delicate process. Unfortunately, the primitive reflexes which control our need for food - and thus our hunger - have become buried under so many layers of conditioning and social factors that we are hardly aware of them anymore. Perhaps the time has come for modern man to realise once more that the primary reason for food intake is to support life and encourage good health. All the other reasons - whether to do with the emotions, society, taste or simply habit - are secondary. Or, in the well-known words of the famous French playwright, Jean Moliere, which are as apt today as they were in the 17th century: 'One should eat to live and not live to eat'.

Underweight — the other side of the coin

It was Coco Chanel who once said that you can never be too thin or too rich, but she was undoubtedly wrong on at least the first count! The belief that the thinner an individual is, the better, is in fact a dangerous misconception, because research has shown that just as mortality rises along with weight, it also rises with excessive decrease in weight. It is therefore essential to prevent unnecessary weight loss and to be realistic about one's optimal weight for height.

In our society with its ideals of unrealistic thinness, the problem of underweight is often not taken seriously, yet it can cause as much distress as its opposite. The basic cause of underweight is an inadequate energy intake and/or excessive burning up of energy. People who suffer from it are generally very active, tense or nervous get very little rest, smoke, or eat poorly and irregularly. It can of course also affect those whose food intake is low and energy expenditure high due to illness, fever, gastro-intestinal disturbances, cancer or hormonal imbalances.

In recent years, however, there has been an alarming increase in an entirely different cause of excessive thinness, namely self-induced starvation and purging (laxative abuse, vomiting). Otherwise known as anorexia nervosa and bulimia, these serious eating disorders are confined almost exclusively to adolescent girls and young women.

Many researchers maintain that the incidence of eating disorders has increased significantly over the past two decades. Anorexia nervosa used to be a relatively rare condition, but is now said to occur at a rate of one new case per year for every 100-200 middle- and upper-class adolescent and young adult women (between 0,5 and 4% of the population). The incidence of bulimia is estimated to be somewhat higher (5-19%). Anorexia nervosa occurs throughout adolescence and young adulthood with peaks in early adolescence (12-13 year olds) and at about 18 years old. Bulimia sometimes appears as a complication of anorexia nervosa (also called bulimia nervosa) in middle adolescence, or as an isolated phenomenon during adolescence or young adulthood.

Anorexia nervosa

The American Psychiatric Association has defined the following criteria for the diagnosis of anorexia nervosa:

• Refusal to maintain a body weight which is above a minimal normal weight for age and height - for example, weight loss or failure to gain; weight during a period of growth, resulting in a maintained body weight which is 15% below normal.
• Intense fear of gaining weight or becoming fat, even though underweight.
• Disturbances in the way in which one's body weight, size or shape is perceived; for example, the person claims to feel fat even when emaciated or believes that one area of the body is too fat even when obviously underweight.
• In females, absence of at least three consecutive menstural cycles when there is no other underlying cause.

Bulimia nervosa

Criteria for the diagnosis of bulimia have been defined as:

• Recurrent episodes of binge-eating (rapid consumption of a large amount of food in a short period of time).
• A feeling of lack of control over eating behaviour during the eating binges.
• Regular self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise, in order to prevent weight gain.
• A minimum average of two bingeing episodes a week over a period of at least three months.
• Persistent over-concern with body shape.