|Year : 2021 | Volume
| Issue : 1 | Page : 12-17
Eating disorders in India: An overview
Shorouq Motwani1, Sagar Karia1, Bilvesh Mandalia2, Avinash Desousa1
1 Department of Psychiatry, Lokmanya Tilak Municipal Medical College, Mumbai, Maharashtra, India
2 Desousa Foundation, Mumbai, Maharashtra, India
|Date of Submission||10-Mar-2021|
|Date of Acceptance||11-Mar-2021|
|Date of Web Publication||18-Jun-2021|
Dr. Sagar Karia
Department of Psychiatry, Lokmanya Tilak Municipal Medical College and G.H, OPD 21, New OPD Building, Second Floor, Sion, Mumbai - 400 022, Maharashtra
Source of Support: None, Conflict of Interest: None
Eating disorders (EDs) are disabling, deadly, and costly mental disorders that considerably impair physical health and disrupt psychosocial functioning. Disturbed attitudes toward weight, body shape, and eating play a key role in the origin and maintenance of EDs. As EDs are under-researched, there is a great deal of uncertainty as to their pathophysiology, treatment, and management. Future challenges, emerging treatments, and outstanding research questions are addressed in this review.
Keywords: Clinical challenges, eating, eating disorders, epidemiology, India
|How to cite this article:|
Motwani S, Karia S, Mandalia B, Desousa A. Eating disorders in India: An overview. Ann Indian Psychiatry 2021;5:12-7
| Introduction|| |
Eating disorders (EDs) worldwide are associated with a significant burden on patients, huge clinical comorbidity, and significant impact on the quality of life of patients and their family members along with a high mortality rate among various psychiatric disorders. These disorders have been classically described to occur in young females, while in recent years, a subset of male patients has also emerged with the symptoms of EDs. The overvaluation of slimness, which is commonly seen in the West, has been considered to be an important contributory factor in the pathogenesis of ED. Emerging trends in urbanization and globalization have resulted in these disorders slowly spreading to India as a result of the cultural transformations that have ensued.
This article reviews the research done on ED over the past 25 years (1995–2019) and presents the salient findings of these papers. There has been research on the epidemiology and clinical features of these disorders; however, research on treatment methods, both medical and psychotherapeutic has been conspicuous by their absence. This study while being a systematic review with clear methodology has exerted laxity in its inclusion and exclusion criteria of studies due to the paucity of data on the subject from India. This review sets out to provide a synthesis of various research papers done in India on ED and represents an updated review as some reviews on the subject exist though nonsystematic in nature. The focus of this article is to present the findings of the various studies done and look at the clinical implications of these studies while trying to determine specific pathways that can be laid down for future research.
| Methods|| |
A systematic literature search was executed in Medline, PubMed, Google Scholar, and the websites of the Indian Journal of Psychiatry, Indian Journal of Psychological Medicine, and Indian Journal of Social Psychiatry from 1995 to 2019. The main search strategy was ([“eating disorders” OR “anorexia nervosa” OR “bulimia” OR “binge eating” OR “feeding disorders”] AND [“depression” OR “personality disorders” OR “eating habits” OR “body image” OR “treatment,” “psychotherapy” OR “family therapy”]). References of selected articles were also searched to identify the additional reports. We also manually searched the references of the original studies and reviews to identify any potential studies omitted by our search strategy. Recent issues of relevant publications and the reference lists of included texts and relevant review articles were searched.
We included studies of importance with sample sizes of >20 participants and that reported either mean scores or percentages with appropriate statistical analysis. This was added to review the papers that were reviewed. Case reports of relevance to this review were also included. Both the authors reviewed all of the articles and the most relevant ones were chosen for this review. A total of 63 papers were chosen for this review, and the 41 relevant papers were included in this article. Studies were excluded if they only reported on the outcomes that were not related to ED symptoms, for example, depression and self-esteem. Due to the use of samples with multiple ED diagnoses, all studies were included even if not diagnosis specific. As multiple papers are often published from one cohort, they were included, provided that each reported unique information when compared to the other.
The above was supplemented with the personal clinical experience of one of the authors (AD) who works regularly with adults, children, and adolescents with ED in a private clinic and who is attached to a tertiary general hospital where ED patients are seen. Both the authors are researchers (psychiatrists) and working in clinical settings [Figure 1].
| Results|| |
The studies described herewith are divided on the basis of ED phenomenology, psychopathology, and treatment modality covered. The selection of papers and the entire process are described in [Figure 1], while a table with the most relevant papers from India with their significant findings has also been included [Table 1].
Epidemiological and sociodemographic studies
Studies of ED among the Asian populations have increased dramatically in the last two decades and questions as to how culture, ethnicity, and ED are related for Asians. Numerous studies have investigated whether there are differences in the prevalence rates of ED in Asian countries as compared to Westernized countries.
Keel and Klump in their review of studies in non-Western countries comment that excluding the criterion of weight concerns, anorexia nervosa appears to represent a similar proportion of the general and psychiatric populations in several Western and non-Western nations nations. The authors hypothesize that bulimia is more culturally dependent than anorexia nervosa in Asian nations.
Studies have been conducted to investigate how acculturation may be related to ED for Asians. ED appears to be increasing in Arab and Asian countries in conjunction with increasing industrialization, urbanization, and globalization. Of the 306 physical and mental disorders, AN and BN combined ranked as the 12th leading cause of disability-adjusted life years in females aged 15–19 years in high-income countries.
By the close of the 20th century, disordered eating attitudes and behaviors increased dramatically across Asia's high-income populations of young females, with clinical EDs proliferating beyond Japan to Singapore, Hong Kong, Korea, and Taiwan. In sum, today, many Asian countries report EDs as these countries have grown more industrialized and globalized.,,,
In the Indian settings, there are no cases reported of BED and only five cases have been reported of BN. The frequency of disordered eating/probable ED ranged from 4% to 45.4%. It is possible that subsyndromal ED cases may not be captured by a self-rated assessment. Two studies reported the prevalence of eating distress syndrome (EDS) to be 11% and 14.8%.
It has also raised the awareness of the possibility of abuse of various anti-obesity drugs as a part of bulimic compensatory behavior is high in this population, given the easy and unsupervised access of these drugs over the counter, for example, Orlistat.
In the context of India, EDs paint a particularly complex picture both historically and at present, perhaps reflecting the enormous diversity of its populace. Early reports of EDs began appearing in the mid-1990s, including five cases of young, single, Hindu women (aged 15-22), who exhibited persistent vomiting, amenorrhea, refusal to eat, significant weight loss, and numerous somatic complaints without particular import placed on thinness or fatphobia. Alternatively, the low incidence of AN and related ED in nonwestern cultures could be artifacts of how data on ED are collected in these areas.
In a study done in India on medical students, obesity was found to be 13.2% (confidence interval: 7.84%–18.5%) with stress being one of the major factors along with increased calorie intake, lack of physical activity, consumption of tea/coffee/fruit juices, socioeconomic status, and family history of obesity having a statistically significant relationship with overweight/obesity. Medical education was also considered stressful throughout the course of training. A study on nursing students reported the prevalence of obesity and underweight to be 5% and 34%, respectively. Interestingly, all the nursing students in the current study belonged to the middle socioeconomic status.
In India, the prevalence studies of ED and anorexia nervosa began to emerge only post the 1990s. In the study, Indian patients felt that they over ate and binge ate more often than Australian patients while frequencies of food restriction, vomiting, and laxative use were similar. Many Indians were less aware of ED feelings, such as, fear of losing control over food or eating and being preoccupied with food, eating or their body. Furthermore, Indian females were less preoccupied with ED-related feelings. Fear of loss of control over eating and preoccupation with thoughts of food, eating, or body weight occurred but to a significantly lesser extent for Indian patients.
Data also suggest that Indian girls like other Asian populations have a strong orientation toward family values, collectivism rather than individualism, and hence, personal or internal control is less important to them.
In a study on adolescent girls, the rates of overweight (31%) and obesity (24.6%) were higher in students whose parents had a higher level of education.
A study done by Minu et al. 2019 suggested that high scores in AN involved a greater chance of being diagnosed with an ED in rural adolescent girls, while urban adolescent girls' educational status and family have an influence in gathering knowledge regarding anorexia nervosa. In a study on medical students, out of the total 134 study participants, 23 (17.2%) students had scores that indicated the presence of probable AN. Out of the 23 who had an ED, 19 (82.6%) made themselves sick because they felt uncomfortable, 21 (91.3%) worried that they have lost control over their eating pattern, all the participants felt they are fat, and only 9 (39.1%) said that food dominates their life.
There have thus been sporadic studies on the epidemiology of ED in India but all circumscribed by limited data sets, fixed age groups, and there are no nationwide studies that would enable us to have accurate estimates of the incidence and prevalence of ED in India. Large planned epidemiological data are sparse and warranted.
Studies focusing on etiology and pathogenesis
In a review article on ED in women, it was reported that premorbid personality appears to play an important role, with a differential predisposition for individual disorders and culture may have a pathogenic effect leading to nonconforming presentations like the nonfat phobic forms of AN, which are commonly reported in developing countries. With rapid cultural transformation, the classical forms of these conditions are being described throughout the world.
EDs are often conceptualized as culture-bound problems; however, the processes by which culture contributes to EDs have yet to be elucidated by researchers. It is hoped that the ideas presented will be used to direct efforts to further develop models of the relations between culture and ED and will be considered in the development of programs seeking to aid in the prevention and treatment of maladaptive eating patterns.
There has also been case study that has illustrated how an in-depth ethnographic approach can reveal multiple layers and the dynamic character of not eating in rural India. Socioeconomic changes have been found to play an important role in the spread of ED by leading women to experience conflicts in gender performance. A study on medical students in Chandigarh showed body shape through correlation and logistic regression analysis as the only statistically significant predictor of ED. High score on the body shape questionnaire mediated as a proximate risk factor for ED.
It has also been reported that many binge eating cases have a history of difficulties in adaptation on being separated and living independently from the caretaker. Thus, in this case, binge eating may represent a wish to merge with mother and regurgitation may unconsciously express a wish for separation from mother.
In a study on binge eating behaviors in Indian patients being treated for psychoses and other disorders, most of the binge spectrum behaviors occurred in patients on treatment for >2 years and on concomitant antidepressant medication. Patients admitted to obesogenic eating behavior more readily than actual calorie intake. A common risk factor for the development of an ED in Indians seems to be psychosocial stressors relating to family or achievement, like feelings of failure in regards to parental expectations. Another study saw the emergence of three key factors, those that were related to the constructs of compulsive activity, impulsivity/sociocentric avoidance and associated attitudinal responses, and depressive thinking with features of helplessness and feelings of failure.
A review found that in underdeveloped countries, where young children suffer from starvation due to a lack of food, it is important to consider the likelihood of these children developing AN later in life. As a matter of fact, forced starvation will rarely develop into AN. This suggests that voluntary and involuntary starvation is distinct entities having unique mechanisms. Conventionally, in India, thinness has been associated with lower attractiveness, power and social status, perhaps partly due to the high rates of poverty and other distinct cultural ideologies.
Studies that have focused on clinical features
There are many studies where patients meet all clinical criteria for anorexia nervosa except for that of amenorrhea. Most of the differences between patients with and without amenorrhea seem to reflect the nutritional status of the patient, rather than any core pathology. Hence, various authors have advocated for the removal of amenorrhea as essential criteria for the diagnosis of anorexia nervosa more so in Asian countries.
There have been reports of subsyndromal forms of ED are more common in the Indian population and researchers suggest the term “EDS” for such cases with the following criteria, namely eating habits and body shape as a source of conflict and concern with the need to change them, felt need for or sought professional help, bingeing once a week with short binges associated with guilt but no counter-binge behaviors such as starvation, vomiting, and purging. These subjects also show strict dieting, but no rigorous measures like full-day starvation or use of diet pills while slimming exercises are practiced. They also experience no significant change in body weight because of the above measures. However, this syndrome has not been studied further.
The clinical symptoms of AN in India may not be different from AN in Western countries. Conventionally, cases of AN from India surmised the lack of the fundamental characteristic, that AN is not accompanied by a “fear of fatness” or desire to be thin, but rather by a desire to fast for religious purposes or eccentric nutritional values. Although symptomatology may be similar to that of Western AN, psychosocial developmental and psychodynamic issues may not be similar as AN may develop as an unexpected crisis in response to a psychosocial stressor without any risk factors for AN.,
The only difference between AN and atypical AN is regarding OCD symptomatology. These findings clarify that obsessions (rather than compulsions) may be the specific aspect of OCD most warranting treatment intervention in AN and Atypical AN.
There has also been a study on food addiction in India, where the Yale Food Addiction Scale was administered and it was found that food addiction was significantly associated with eating-disorder psychopathology, including binge eating, depression, and health-related quality of life but was not related to body mass index or sex. These findings challenge previous notions of disordered eating as a uniquely western problem and highlight the importance of examining eating behaviors, such as addictive-like eating, across cultures. There have been reports where there has been discussed a need for raising awareness among schools, other institutions which care for adolescents, and the general public regarding the potential complications and the concept of ED in general.
Studies on the effects of eating disorders
In a meta-analysis conducted in 1995 of 42 published studies, the crude mortality rate was 5.9%. In the studies specifying the cause of death, 54% of the patients died as a result of ED complications, 27% committed suicide, and the remaining 19% died of unknown or other causes. In another meta-analysis of standardized mortality rates (SMR) in 2001, the overall aggregate SMR of anorexia nervosa in studies with 6–12 years of follow-up was 9.6 and in studies with 20–40 years of follow-up 3.7. AN comorbid with alcohol dependence is associated with up to 50 times higher and AN comorbid with insulin-dependent diabetes mellitus with up to 10 times higher mortality than each of these illnesses alone.
Studies on treatment
There are a shortage and dearth of studies that focus on the treatment in patients with ED in India. There is one study on the use of laughter therapy in AN where the beneficial effects of laughter and moderate levels of laughter were shown to promote health. There is a clear need to strengthen and/or reinforce adaptive traditional cultural beliefs and practices, especially those that enhance self-esteem and self-concept. There is an urgent need for studies that focus on medical treatments, psychotherapeutic management, family therapy, and psychoeducational approaches for ED. There is a need for randomized controlled trials, open-labeled trials, and the need for clinical experience from psychiatrists to be amalgamated through surveys to develop better treatment guidelines for the management of ED in Indian patients.
Critical clinical challenges with regard to eating disorders in India
This section of the article is devoted to highlight some of the challenges faced clinically in the diagnosis, treatment, and detection of ED in India. This is based on the authors' clinical experience in working in a tertiary general hospital where the cases of ED are diagnosed and treated as well as from their experience in a private clinic set up. Some of the major challenges faced are as follows:
- There is a lack of awareness about ED in the general population in India. A lot of psychoeducational programs about depression, schizophrenia, and child psychological issues are held for the common man, but there are no awareness programs organized in the area of ED. This may result in the people in India not realizing that AN, BN, BED, and other subclinical ED are in fact psychiatric disorders. They may view the same as medical problems and may visit physicians and gastroenterologists for the same. Even psychogenic vomiting, the most common ED seen in India presents to the pediatrician, general physician and gastroenterologist and when all organic causes are ruled, a psychiatry referral is sought
- There is very little impetus on teaching the psychodynamics, causation, and management of ED in psychiatry and psychology curriculums in India except for probable one lecture of 60 min. The topic of ED is also rarely found in psychiatric conferences held in India and there are rarely dedicated conferences and symposia for the same
- Culturally, while thinness and worry about body image are seen in teenagers in India, there is also a belief that overeating and obesity are the hallmarks of affluent households and eating well is normal. Many patients in India overeat as a means of coping and undereating or AN is seen far less than BED. Weekly binges are culturally acceptable and will never be accepted as binge eating that entails psychopathology
- We have no rating scales and psychometric measures that have been adapted for Indian patients, and most of the scales used have reliability and validity in the Western populations. The content of these scales must be Indianized to suit the symptoms seen by Indian patients. Thus, diagnosis using these measures is often difficult in the Indian populations
- ED awareness among psychiatrists and mental health professionals is present but needs further training and sprucing up to bring about an ED cognizant diagnostic culture in psychiatric clinics and hospitals. ED symptoms and diagnosis also need to weaved in regular history-taking practices, so that patients that do not mention ED symptoms due to the lack of their awareness may be diagnosed
- There is also no association or body that works for the cause of ED in India. This may also stem from a lack of interest in the area or a lack of professionals that work in the area of ED. ED associations will also need the coming together of professionals from different medical disciplines and these would need great effort.
| Conclusions|| |
The above review has tried to present and synthesize the ED literature and research done in India over the past 25 years. As seen, studies on ED are sparse, have small sample sizes, are plagued with methodological constraints and lack of scientific rigor in many areas. There are a large number of case reports which have not been included as they did not bring any new to the world ED literature from an Indian perspective. There is a dire need for further research and development of proper clinical and treatment protocols for patients with ED in India. There needs to consensus in the treatment approach and research at a hospital and community level needs to be undertaken. The review has tried to provide of ED and how it may differ from the West in India as well as basic literature on ED with research done in the Indian settings. Further efforts to add to the scientific data available are warranted.
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Conflicts of interest
There are no conflicts of interest.
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