Eating Disorders: Anorexia Nervosa and Bulimia Nervosa
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Eating Disorders: Anorexia Nervosa and Bulimia Nervosa

August 17, 2019

Among the Kalabari people in southeastern
Nigeria, West Africa, abundant body fat is the beauty ideal for women. Before their wedding,
women of this tribe are sent to fattening resorts, where they gorge themselves on food,
move as little as possible, and even take drugs to increase appetite and promote weight
gain, so that they can fatten up to be admired by everyone and become more desirable in the
eyes of their future husband. Our concept of what is ‘normal’ and ‘abnormal’,
what is ‘acceptable’ and ‘unacceptable’ is first and foremost a result of our environment:
our culture, our values, what we see around us and what our parent taught us. And this
applies to body weight as well. Unfortunately, in our countries, our current
notions of ideal body shape and weight are greatly distorted, and influenced since an
early age by images from the media, advertisement and the fashion industry that promote an unrealistic
and unhealthy ideal of body type and thinness. If we were to estimate the body mass index
of the Venus of Willendorf, this sort of paleolithic Barbie sculpted more than twenty thousand
years ago, it would be around 40, which by today’s standards would be severely obese.
But by prehistoric standards, her shape represented beauty and fertility. The Venus painted by
Botticelli in 1486 had a BMI of about 26. Early Renaissance standards of beauty were
clearly different, and yet for us, a BMI of 26 represents overweight, hardly a standard
of perfection. Today we have her. With her 50 kg for an height of about 176 cm, Barbie
has a BMI of around 16. Clinically, she would be considered severely underweight and likely
diagnosed with anorexia nervosa. And yet for most of today’s girls, she sets the standard
of the ideal body shape, together with real life actresses, fashion models and winners
of beauty contests. In response to this social pressure, we sometimes respond with extreme
and unhealthy measures to achieve our desired body weight, which in some cases become pathological. Anorexia nervosa and bulimia nervosa are considered
eating disorders. Eating disorders are not just disordered eating behaviors, they are
medical illnesses which require medical attention and treatment. Anorexia nervosa is characterized by a severe
restriction of food intake to the point of self-starvation, with life-threatening consequences.
It results from a distorted self-perception of body image: despite looking emaciated and
underweight, these patients continue to see themselves as fat, or they recognize they
are underweight but are obsessed with getting rid of excess fat in specific areas of their
body. One of the worst problems with anorexia is that most patients see don’t see anything
wrong with their eating behavior and they don’t think they have a problem, making
interventions much more complicated. Some early warning signs that anorexia nervosa
may be present or may develop in the near future are eating in a painfully slow way,
such as taking an hour to eat a salad, or cutting food into tiny pieces, to the point
of cutting a pea in half, or creating lists of ‘safe’ and ‘unsafe’ foods, or complicated
bizarre rules about how foods should be associated, prepared, cooked, or at what times they should
be eaten, all attempts at exercising ‘control’. Trimming visible fat off of a chicken breast
may be a normal response to the frequent messages about the perils of excess fat, but broiling
the trimmed chicken breast on a slice of bread and then discarding the bread to eliminate
the excess fat that was absorbed from the chicken, is clearly a distorted behavior.
Although such behaviors do not warrant in themselves a diagnosis of anorexia nervosa,
they are definitely warning signs that an eating disorder may be present or may develop
in the near future. In women, amenorrhea, which is the cessation
of the menstrual cycle, as a consequence of starvation, is usually the first landmark
sign of anorexia nervosa. Bulimia nervosa is characterized by association
of two disordered eating behaviors, bingeing and purging. In bulimia nervosa patients,
compulsive bingeing episodes trigger guilt, self-contempt and anxiety, which lead to purging
practices to offset the calories introduced during the binge, often through self-induced
vomiting. Bulimia nervosa is much more difficult to detect than anorexia nervosa, because the
body weight of bulimia patients is often normal, if not slightly overweight, and bingeing and
purging behaviors are almost always hidden. Some characteristic detection signs are damaged
teeth from the acidity of vomit, and damaged knuckles from involuntarily biting them after
having induced vomiting. We are still struggling to understand what
causes eating disorders. How much of it is genetic, how much is psychological, how much
is social, what is the influence of the upbringing, and what triggers the first episode.
Everyone can develop an eating disorder, but there are segments of the population that
are more at risk. First of all, there is a strong gender bias: about 90% of eating disorders
affect women, and young women between 15 and 25 years of age are particularly at risk.
Among males, however, eating disorders occur more frequently among athletes, especially
in sports that require weight classes such as boxing or wrestling, but also dancers and
swimmers, and in male fashion models. We know that anorexia nervosa patients are
very often individuals who have a tendency toward perfectionism, high-achievers, who
set very strict standards for themselves. With regard to the influence of parenting,
anorexia nervosa patients often report having parents perceived as overly controlling, or
overly demanding, setting abnormally high achievement standards, or overly disapproving,
often critical of weight and appearance. A history of sexual abuse also increases the
risk of developing anorexia nervosa, probably because of the desperate need to feel in control,
maybe to offset the shameful feelings and the sense of guilt that their lack of control
was the cause of the abuse. The central theme of anorexia nervosa is the
need for control. Strictly controlling food intake and therefore one own’s body is a
way to exercise some control over an existence otherwise perceived as powerless. “It’s
just me versus the food. It’s my body and I can do what I want with it. I’m in control
of at least this one. And I’m going to win.” In contrast, bulimia nervosa patients are
often very impulsive persons, with low self-control as well as low self-esteem and lack of a stable
sense of personal identity. They often exhibit stress eating behaviors, and they often have
a hystory of repeated dieting with repeated weight loss and weight gain cycles.
A persistent, exaggerated concern or even fear about weight and weight gain are common
among both anorexia nervosa and bulimia nervosa patients.
Anorexia nervosa and bulimia nervosa are all about struggling with control, which manifests
as an excess of control in the case of anorexia nervosa, or in a lack thereof, in the case
of binge eating; but most often in a struggle between these two extremes, such as the purging
behavior of bulimia nervosa, a distressed, guilt-driven exaggerated attempt at exercising
control after having completely lost it during a binge. As we said, eating disorders are pathological
conditions that require medical attention, both from a nutritional and a psychological
point of view. The strict nutritional part of the treatment is rather simple, but the
dietician must take special care in trying to correct misconceptions about food and nutrition,
and to educate about the real physiological effects of semistarvation, bingeing and purging.
The use of medication is of limited help and quite controversial, while counseling to support
the patient, understand and address the underlying psychological conflicts, feelings, attitudes,
and anxieties is much more important. Cognitive restructuring of food and body image thinking,
relaxation training and stress-management techniques, self-control and stimulus control
training if triggering factors are identified, have all proved very helpful.
But it would be wrong to paint too a rosy picture: while we have cures for the most
exotic infectious diseases and incredible surgeries for heart conditions, we still do
not have a cure for anorexia nervosa. Treatment does not always work, and relapses are frequent,
and for this reason, anorexia nervosa patients should never be considered completely cured,
but constantly supported and monitored throughout their lives.

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