|Year : 2019 | Volume
| Issue : 4 | Page : 311-317
Eating disorders: An overview of Indian research
Sivapriya Vaidyanathan1, Pooja Patnaik Kuppili2, Vikas Menon1
1 Department of Psychiatry, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
|Date of Submission||09-Nov-2018|
|Date of Acceptance||18-Jan-2019|
|Date of Web Publication||15-Jul-2019|
Dr. Pooja Patnaik Kuppili
Department of Psychiatry, All India Institute of Medical Sciences, Jodhpur, Rajasthan - 342 005
Source of Support: None, Conflict of Interest: None
| Abstract|| |
There has been sporadic research on eating disorders in India, with no published attempt to collate and summarize the literature landscape. Hence, the present narrative review aims to summarize Indian work related to eating disorders, discern current trends, and highlight gaps in research that will provide directions for future work in the area. Electronic search using the MEDLINE, Google Scholar, and PsycINFO databases was done to identify relevant peer-reviewed English language articles, in October 2018, using combinations of the following medical subject headings or free text terms: “eating disorders,” “anorexia nervosa,” “bulimia,” “treatment,” “epidemiology,” “co-morbidity,” “management,” “medications,” “behavioral intervention,” and “psychosocial intervention.” The data extracted from studies included details such as author names, year, from which of the states in India the work originated, type of intervention (for interventional studies), comparator (if any), and major outcomes. There is increasing research focused on eating disorders from India over the last decade, but it continues to be an under-researched area as evidenced by the relative paucity of original research. The cultural differences between east and west have contributed to variations in the presentation as well as challenges in the diagnosis. Hence, there is a need for the development of culturally sensitive instruments for diagnosis, as well as generating locally relevant epidemiological data about eating disorders from community and hospital settings.
Keywords: Anorexia nervosa, bulimia nervosa, eating disorder, India
|How to cite this article:|
Vaidyanathan S, Kuppili PP, Menon V. Eating disorders: An overview of Indian research. Indian J Psychol Med 2019;41:311-7
The earliest description of an eating disorder (ED)-like syndrome appears in a treatise by Morton (1694), under the section “Nervous Consumption,” where the author talks about two adolescents who presented with loss of appetite, extreme fasting, weight loss, and their treatment and outcome. Historical reports point to the existence of ED even in the 17th century, referred to as “holy anorexia.” However, one of the first scientific reports of this condition, in the late 19th century, was by William Gull who is credited with coining the term anorexia nervosa (AN). In India, the occurrence of ED was not reported until the late 20th century. Perhaps, media-related glorification of “size zero” body type and culturally sanctioned drive for thinness, body shaming, and dissatisfaction have contributed to the recent upsurge of ED cases.,, Traditionally, these parameters have been less of a concern in India than other countries. Yet, another reason for the recent increase in the incidence of ED such as bulimia nervosa (BN) and binge eating disorder (BED) is more easy access to media outlets promoting unhealthy body types and higher socioeconomic status of people.,
Notwithstanding its increasing prevalence rates, ED continues to be an area that is under-reported and under-researched. There are several reasons why ED must be given increasing focus in health care research and policy planning in today's scenario. AN, a prototype ED, has the highest mortality rate among mental health disorders., The economic and social impact of ED was estimated to be upwards of $15 billion (INR 1057.8 billion) in 2012, which is comparable to the productivity impact of anxiety and depression, estimated at $17.9 billion (INR 1262.3 billion) in 2010. Though, relatively rare in the general population, the individual impact of ED can be quite debilitating and long-term treatments are often expensive. ED have high rates of psychiatric and medical co-morbidity.,,,
Though there has been sporadic research on ED in India, there has been no attempt to collate and summarize the literature landscape. We undertook the present narrative review with the objectives of summarizing Indian work related to ED, discern current trends, and highlight gaps in research that will provide directions for future work in the area. These would potentially answer key questions on the clinical presentation and trajectories of ED in our setting.
| Methodology|| |
Search strategy and study selection
Electronic search using the MEDLINE, Google Scholar, and PsycINFO to identify relevant peer-reviewed English language articles was carried out to include articles between April 1967 to October 2018. We used random combinations of the following medical subject headings or free text terms: “eating disorders,” “anorexia nervosa,” “bulimia,” “treatment,” “epidemiology,” “co-morbidity,” “management,” “medications,” “behavioral intervention,” and “psychosocial intervention.”
This being a narrative review and because research on ED in India is relatively sparse, we included all types of research reports, including case reports, to gain a true picture of the research landscape. The initial search yielded 84 articles. From the initial search, 39 articles were relevant and therefore selected for inclusion in the review. The full text of these articles was retrieved electronically. Additionally, the reference section of all articles was manually screened to identify potentially relevant articles. We only selected articles describing research from India. There was no restriction on the date of publication. Citation indexing services and gray literature such as conference proceedings were not included in the present review.
The data extracted from studies included details such as author names, year, from which of the states in India the work originated, type of intervention (for interventional studies), comparator (if any), and major outcomes.
| Results|| |
A major part of the literature on ED from India is derived from case reports and case series (n = 24). In comparison, there are 15 original studies summarized in [Table 1].
The earliest reports of ED date back to 1966. The case was of AN in a 42-year-old female with episodes of compulsive fasting for 2 years. The patient was treated with 100 mg chlorpromazine, 100 ml of 25% glucose with vitamin C 500 mg intravenously, 10 injections of liver extract 2 ml intramuscularly biweekly, and 9 sessions of electroconvulsive treatment. After 46 days of intensive pharmacotherapy and supportive psychotherapy, she showed improvement and was kept in close follow up. Following this, there has been increasing reports of ED cases in the last two decades. Majority of the cases were of AN, especially restrictive subtype. The typical profile of cases described from India is of adolescent females,,,,,, belonging to Hindu religion,,, and coming from an upper- or middle-socioeconomic background ,,,,, In contrast, there are only four cases of male AN reported., There is a single case report of AN described in a pair of monozygotic twins too.
Cases of AN have been described in Indian adolescents belonging to Sikh religions, living in the United Kingdom. The symptoms of AN were found to flare up after being teased by peers about weight which was followed by concerns about weight gain, in the majority of cases., There is also a case of AN which had atypical features such as denial of fears of weight gain. One report of disordered eating described a young female, in whom “not eating” was conceptualized as a resistance to the patriarchal system and this highlights the role of Indian sociocultural factors for developing an ED.
Bradycardia, hypotension, anemia, and dyselectrolytemia have been reported at the time of presentation to a psychiatrist.,, Wernicke–Korsakoff syndrome was the presenting symptom for a 39-year-old female who had AN from adolescence. Surreptitious use of metformin, with episodes of hypoglycemia, was the presenting symptom in another case of AN in a 21-year-old female. Though the nature of psychiatric co-morbidity has not been described, psychiatric co-morbidity was noted in all the cases of a case series. Obsessive traits of symmetry and order, obsessive compulsive disorder (OCD), and major depressive disorder have been reported as co-morbidities. Menstrual abnormalities and poorly developed secondary sexual characteristics have been noted in the majority of cases.,,,,
There have been only five cases of BN reported till date.,,,, Two of the cases were females: one was a 22-year-old medical student, with the onset of symptoms around 13 years of age, with binging and purging with isabgol husk and consumption of orlistat., The other three cases were atypical, with an absence of concerns for body weight or body image, along with an absence of concurrent use of diuretics or laxatives in a 37-year-old male, 15-year-old female, and a 24-year-old female.
Cases of ED have been described occurring co-morbid to physical illnesses such as systemic lupus erythematosus  and secondary to traumatic brain injury  or due to an adverse drug reaction to zolpidem consumption termed as a nocturnal sleep-related ED. Further, AN has been found to mask physical illnesses such as carcinoma. Treatment described in these cases included comprehensive treatment involving mental health professionals and dieticians.,
Majority of cases were managed in the in-patient setting.,, In AN, high-calorie high-protein diet has been advised, with careful monitoring for re-feeding syndrome., In the 1960s, chlorpromazine and modified insulin therapy were the treatment options used. Cyproheptadine in combination with chlorpromazine, combination of cyproheptadine and olanzapine, mirtazapine, risperidone, trazodone, citalopram, and fluoxetine at 20 mg/day  have been used for treatment of AN. Combinations of olanzapine and fluvoxamine or olanzapine and fluoxetine have been used in cases of AN with obsessive traits and OCD, respectively., Sertraline  and fluoxetine at low dose of 20 mg/day  as well as at 80 mg/day  has been described in the management of BN, with good response.
The non-pharmacological therapy of ED included family therapy, cognitive behavioral therapy (CBT), supportive psychotherapy, contingency management, hypnotherapy, and play therapy.,,,,,,, High-frequency repetitive transcranial magnetic stimulation (rTMS) over the left dorsolateral prefrontal cortex was given as augmentation strategy in a 23-year-old female who earlier had only a partial response to antidepressants as well as atypical antipsychotics and CBT. rTMS was found to improve attitude toward body weight and body shape, with an improvement of weight.
| Discussion|| |
This review attempted to summarize the Indian research on ED. The literature is largely comprised of case reports, as noted in the previous reviews., However, there has been an increase in the number of published original research articles over the last 5–6 years. There are no studies available which determined the prevalence of ED from the community setting. There is a single hospital-based retrospective review, which reported a prevalence of 1.25% for ED. Of them, almost 85% had psychogenic vomiting and about 15% had AN. This is in contrast to the international literature, wherein the frequency of occurrence of BN and BED is more common than that of AN. A meta-analysis of 15 studies from various settings reported that the estimated lifetime prevalence of any ED was 1.01%, and those of AN, BN, and BED were 0.21%, 0.81%, and 2.22%, respectively.
BED had the highest point prevalence of ED, followed by BN and AN, among young females across China, Japan, Africa, and Latin America. In comparison, in the Indian setting, there are no cases reported of BED, and only five cases have been reported of BN.,,,, Further, the two-step assessment (initial screening by self-rated questionnaire, followed by assessment by semi-structured or diagnostic interview) is the standard procedure followed globally. However, there is a single study using the two-step procedure and found no cases. Majority of the Indian studies used only the screening, self-rated assessment. 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%., EDS refers to subsyndromal forms of AN or BN, with patients having distressing and conflicting thoughts about body shape and eating habits. EDS is characterized by strict dieting, and bingeing in a few cases, with no significant weight loss or behaviors such as resorting to severe measures of weight loss such as diet pills, starvation, purging, or vomiting. However, there has been practically no Indian research on EDS in the last 20 years.
There are several methodological issues in Indian studies which need to be addressed. Firstly, many of the studies have employed convenient sampling on medical and nursing students.,,,,, This may lead to selection bias and such samples may not be truly representative of the population at large. However, this practice of studying medical students is popular worldwide. The rationale given to support this being the “stressful” nature of medical training, which could be a risk factor for ED.,, But this may also imply that the prevalence rates obtained in these studies may be an inflated figure.
Secondly, in the measurement of the frequency of disordered eating, it was found to be higher as per the Sick, Control, One-stone, Fat, Food questionnaire (SCOFF) compared to the Eating Attitudes Test-26 item (EAT-26) questionnaire., The frequency with SCOFF ranged from 17.2% in women to 45.4% in men, and the frequency with EAT-26 ranged from 4% to 31%.,,, Thirdly, there are limitations in the translation and implementation of the questionnaires in a setting like India that has such linguistic diversity. Though the EAT-26 questionnaire has been translated into Hindi, the cut-off score for the Hindi version has not been defined. Also, the rationale for using the same cut-off of the English version in the Kannada version is not clear. Hence, due to cultural differences between the western and Indian settings, there is a definite need for the development of culturally sensitive scales for screening ED.
Culture bears a strong influence on the presentation of ED in India. One unique point noted in the Indian presentations of ED is relative lack of concern for body fat/shape. This has been termed as “Non-fat phobic” variant of AN. This has been described in Hong Kong as well. In this form, food restriction is attributed to somatic complaints such as abdominal bloating, pain, and lack of appetite, rather than concern for body fat. Similar atypical features have been noted in cases of BN too from India. Also, the concept of EDS is in accordance with this concept., Further, food restriction is culturally sanctioned in Indian culture when one is unwell, for “cleansing the bowel.” However, several recent studies show an association between perception of body shape and higher scores on EAT-26.,, This could be explained by the ongoing rapid societal transitions in India and the increasing influence of western ideals.
At least 50% of patients with an ED are known to have a psychiatric co-morbidity, with depression being the most common., In contrast, a few cases had syndromal co-morbidity., The principles of management of ED adopted in India is similar to the west. Most reports of AN and BN describe using a combination of pharmacotherapy and psychotherapy. Selective serotonin reuptake inhibitors (SSRIs), second-generation antipsychotics, and cyproheptadine have been found to be effective for AN. Patients with BN were treated with 20–80 mg/day of fluoxetine in the case reports., In contrast, globally, a higher dose of SSRIs, especially fluoxetine, has been found to be effective in cases of BN. Psychotherapeutic approaches used in the Indian setting, such as family-based therapy and CBT, therapy match global practices.
To conclude, there is increasing research focus on ED from India over the last two decades. Lower prevalence of ED could be the reason for the relative paucity of studies. But, with the increasing impact of westernization of society, ED merit renewed focus. The cultural differences between east and west have contributed to variations in presentation as well as challenges in diagnosis. Hence, there is a need for the development of culturally sensitive instruments for diagnosis as well as generating locally relevant epidemiological data about ED from the community and hospital settings.
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Conflicts of interest
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