If you were to take a walk into any public area in the country, you cannot help but notice the size and shapes of Malaysians vary. There are some who are overweight, and there are some who are thin. Some of the latter are suffering from anorexia nervosa, which is an eating disorder.
Those who have anorexia are very concerned about their weight and they keep it as low as possible by strictly controlling what they eat. They may also exercise very vigorously to lose weight.
Anorexics are anxious about their weight for various reasons. It may be because they think they are overweight or fat, are fearful of being fat, or desire to be thin. Although anorexics are underweight, they have a compulsion to lose some more weight.
Anorexics may be obsessed about eating and dieting. They may go on eating binges, ie eat a lot of food in a short time and then use various methods to get rid of it, eg laxatives.
The onset of anorexia is often innocuous with mild attempts at dieting initially. These frequently get of hand rapidly.
Although anorexia is not as common as other mental health conditions like anxiety or depression, it is the leading cause of death in patients with mental health conditions.
There is insufficient data on anorexia in Malaysia. However, it is generally accepted that its prevalence is no different from Singapore's, which is not different from that of developed countries. Its prevalence is about one in 200 women in developed countries.
Most studies suggest that it is 10 to 20 times more common in females than in males and that there has been an increase in incidence in the last two decades.
Most anorexics are adolescent girls and young women. Although it usually develops in teenagers, it can occur at any age, including childhood. The sufferer is disabled severely but the condition stops short of killing her, although anorexia nervosa does carry a 10% to 15% risk of premature death.
The cause of anorexia is not known. However, it is believed that a combination of biological, environmental and psychological factors sets the person on the pattern of such behaviour.
It is believed that anorexics have certain personality characteristics which increase their likelihood of developing the condition. Environmental factors, like cultures where being thin is preferred, cause the person to commence a pattern of dieting and weight loss for the long term.
The absence of a normal diet affects the brain and reinforces the obsession and behaviour, leading to a vicious cycle in which the more dieting there is, the greater the desire to lose weight.
Everyone's brain needs a nutritious diet for normal functioning. The extreme dieting in anorexia affects these functions and the body's hormonal balance, which in turn, also affects the brain's normal functions. The theories on the mechanisms involved include an increase in the brain's sensitivity to tryptophan and a disruption of the body's system controlling appetite.
As most anorexics develop the condition during puberty, it is likely that puberty is a significant environmental factor. It may be that a combination of pubertal hormonal changes, stress, and anxiety sets off anorexia during puberty. Other environmental factors are media messages that being thin is "cool" and beautiful, stressful life events, problematic relationships and physical or sexual abuse.
Most anorexics have certain personality traits like difficulty handling stress, a tendency to anxiety and depression, obsessive-compulsive feelings and perfectionism.
Anorexia has both psychological and physical components with significant morbidity and mortality. Many of its clinical features are secondary to a starvation state and the body's adaptation to this.
The cardinal feature of anorexia is deliberate losing of a lot of weight by eating as little as possible, excessive exercising and induced vomiting.
The anorexic's objective is to get her or his weight as low as possible, to a level that is below the norm for the anorexic's height and age. If anorexics do eat, they attempt to get rid of food by making themselves vomit it out or by increasing its passage out of the body. The methods used include sticking the fingers down the throat for the former, and the consumption of laxatives, to empty the bowels, and/or diuretics, to pass larger amounts of urine more frequently, for the latter.
Anorexics manifest themselves in different ways, eg pretending they have eaten earlier, lying about what they are not eating.
They control their food intake by strict dieting, eating low calorie and/or small pieces of food, fasting and taking appetite suppressants.
The anorexic's perception is that other people will view them positively the thinner they are. They have a distorted body image in which they perceive that they are fat when they are actually thin. Their behaviour may involve repeated and persistent weighing and measuring themselves, with the mirror their constant companion.
Anorexics often do not have self confidence, with consequent effects on relationships, social life, schooling and/or work. They may have difficulty concentrating.
Their circulation may be impaired due to slow or irregular heart beats and the blood pressure may be low, either of which can lead to dizziness. There may be swelling of the face, hands and feet, and fatigue associated with altered sleep patterns.
Untreated anorexia results in severe complications, which include thinning of the bones, electrolyte imbalance, low blood sugar levels, heart failure, kidney failure, liver damage, and anaemia.
Electrolyte imbalance is common, but is often not diagnosed early because of their non-specific symptoms. Low potassium levels can lead to dehydration, fatigue, kidney damage, irregular heartbeats and fits.
Low sodium levels can lead to confusion and, if severe, fits.
Low calcium levels can lead to painful and tight muscle contractions. Low calcium and vitamin D levels can lead to bone damage.
There may be dental decay due to the stomach's acid acting on the teeth, caused by frequent vomiting.
Anorexic children have impaired growth and delayed puberty.
Adolescent and young females may cease having periods and/or have infertility.
Anorexia in pregnancy increases the risks of miscarriage, premature birth and baby of low birth weight.
There may be loss of libido and impotency in men.
Anorexia can lead to bulimia nervosa, in which there is binge eating followed by immediate attempts at vomiting and/or laxative use to get rid of the food consumed.
Serious complications secondary to bingeing are rare but can be catastrophic when they occur, eg rupture of the oesophagus or stomach.
The doctor will ask questions about a person's weight and eating habits, eg if a lot of weight was lost recently or quickly, how one feels about one's weight, and if there are concerns about it, if one makes oneself vomit regularly, and if the periods have stopped, and if so, for how long.
Weight will be checked and the body mass index (BMI) calculated. Most adults have a BMI of 20 to 25 but anorexics have a BMI below 17.5. An electrocardiogram (ECG) and blood tests of the body's chemistry may also be done.
A referral may be made to a specialist.
Prior to commencement of treatment, an assessment of the patient's medical and social needs, risks and severity of the condition will be made.
Depending on the severity of the condition, treatment can be done as an outpatient (this is most common), or in a day unit, or as in inpatient in hospital.
It is important to commence treatment as soon as possible, especially if there is substantial weight loss.
Treatment involves psychological treatment, advice on eating and nutrition to help in gaining weight safely, and treatment of other health problems. A combination of treatments works better.
Healthy eating habits, ie eating more healthy food with increasing nutrients and calories have to be developed gradually as the body cannot cope with normal amounts. Supplements may be necessary. The objective is to reach a minimum healthy weight.
The psychological treatment involves cognitive analytic therapy (CAT), cognitive behavioural therapy (CBT), interpersonal therapy (IPT), focal psychodynamic therapy (FPT) and family therapy (FT).
CAT is based on the theory that anorexia is due to unhealthy patterns of behaviour and thinking, which the patient has developed in the past, usually in childhood. It involves reformulation, ie looking for past events that may explain why the unhealthy patterns developed, recognition of how these patterns are contributing towards the anorexia, and revision, ie identifying the changes to break these unhealthy patterns.
CBT is based on the theory that thoughts about a situation affect a person's actions. Similarly, actions impact on how one thinks and feels. Hence, it is necessary to change the act of thinking and behaviour concomitantly.
IPT is based on the theory that relationships with other people have a significant effect on a person's mental health.
FPT is based on the theory that anorexia may be associated with unresolved past conflicts, usually in childhood, which are being reenacted in adult life.
FT involves the anorexic and close family members discussing how anorexia has affected them, and the positive changes the anorexic and family can make.
There is limited research on the effectiveness of the psychological treatments for various reasons. However, FT and CBT have been shown to be effective.
The type of treatment chosen may be based on personal preference and the availability of the services.
Medication is usually only prescribed for associated symptoms like obsessive-compulsive disorder or depression. By itself, medication is not effective in reducing symptoms. It has to be used in combination with nutritional and psychological treatments.
There is no response to treatment in 20% to 30% of anorexics and about 5% will die prematurely from the complications of malnutrition.
Dr Milton Lum is a member of the board of Medical Defence Malaysia. This article is not intended to replace, dictate or define evaluation by a qualified doctor. The views expressed do not represent that of any organisation the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader's own medical care.