Kiev State Linguistic University
Like their counterparts in the United States, these students worked in groups and wrote focus discipline projects.
Their teacher was Konstantin Krasnolutsky.
Yevgeniya Timofeyeva and Oleg Bastrykin
Department of Interpreters
Kiev State Linguistic University
Culture and Eating Disorders
Culture has been identified as one of the etiological factors leading to the development of eating disorders. Rates of these disorders appear to vary among different cultures and to change across time as cultures evolve. Additionally, eating disorders appear to be more widespread among contemporary cultural groups than was previously believed.
Anorexia nervosa has been recognized as a medical disorder since the late 19th century, and there is evidence that rates of this disorder have increased significantly over the last few decades. Bulimia nervosa was only first identified in 1979, and there has been some speculation that it may represent a new disorder rather than one that was previously overlooked (Russell, 1997).
However, historical accounts suggest that eating disorders may have existed for centuries, with wide variations in rates. Long before the 19th century, for example, various forms of self-starvation have been described (Bemporad, 1996). The exact forms of these disorders and apparent motivations behind the abnormal eating behaviors have varied.
The fact that disordered eating behaviors have been documented throughout most of history calls into question the assertion that eating disorders are a product of current social pressures. Scrutiny of historical patterns has led to the suggestion that these behaviors have flourished during affluent periods in more egalitarian societies (Bemporad, 1997). It seems likely that the sociocultural factors that have occurred across time and across different contemporary societies play a role in the development of these disorders.
Sociocultural Comparisons Within America
Several studies have identified sociocultural factors within American society that are associated with the development of eating disorders. Traditionally, eating disorders have been associated with Caucasian upper-socioeconomic groups, with a "conspicuous absence of Negro patients" (Bruch, 1966). However, a study by Rowland (1970) found more lower- and middle-class patients with eating disorders within a sample that consisted primarily of Italians (with a high percentage of Catholics) and Jews. Rowland suggested that Jewish, Catholic and Italian cultural origins may lead to a higher risk of developing an eating disorder due to cultural attitudes about the importance of food.
More recent evidence suggests that the pre-valence of anorexia nervosa among African-Americans is higher than previously thought and is rising. A survey of readers of a popular African-American fashion magazine found levels of abnormal eating attitudes and body dissatisfaction that were at least as high as a similar survey of Caucasian women, with a significant negative correlation between body dissatisfaction and a strong black identity (Pumariega et al., 1994). It has been hypothesized that thinness is gaining more value within the African-American culture, just as it has in the Caucasian culture (Hsu, 1987).
Other American ethnic groups also may have higher levels of eating disorders than previously recognized (Pate et al., 1992). A recent study of early adolescent girls found that Hispanic and Asian-American girls showed greater body dissatisfaction than white girls (Robinson et al., 1996). Furthermore, another recent study has reported levels of disordered eating attitudes among rural Appalachian adolescents that are comparable to urban rates (Miller et al., in press). Cultural beliefs that may have protected ethnic groups against eating disorders may be eroding as adolescents acculturate to mainstream American culture (Pumariega, 1986).
The notion that eating disorders are associated with upper socioeconomic status (SES) also has been challenged. Association between anorexia nervosa and upper SES has been poorly demonstrated, and bulimia nervosa may actually have an opposite relationship with SES. In fact, several recent studies have shown that bulimia nervosa was more common in lower SES groups. Thus, any association between wealth and eating disorders requires further study (Gard and Freeman, 1996).
Eating Disorders in Other Countries
Outside the United States, eating disorders have been considered to be much rarer. Across cultures, variations occur in the ideals of beauty. In many non-Western societies, plumpness is considered attractive and desirable, and may be associated with prosperity, fertility, success and economic security (Nassar, 1988). In such cultures, eating disorders are found much less commonly than in Western nations. However, in recent years, cases have been identified in nonindustrialized or premodern populations (Ritenbaugh et al., 1992).
Cultures in which female social roles are restricted appear to have lower rates of eating disorders, reminiscent of the lower rates observed during historical eras in which women lacked choices. For example, some modern affluent Muslim societies limit the social behavior of women according to male dictates; in such societies, eating disorders are virtually unknown. This supports the notion that freedom for women, as well as affluence, are sociocultural factors that may predispose to the development of eating disorders (Bemporad, 1997).
Cross-cultural comparisons of eating disorder cases that have been identified have yielded some important findings. In Hong Kong and India, one of the fundamental characteristics of anorexia nervosa is lacking. In these countries, anorexia is not accompanied by a "fear of fatness" or a desire to be thin; instead, anorexic individuals in these countries have been reported to be motivated by the desire to fast for religious purposes or by eccentric nutritional ideas (Castillo, 1997).
Such religious ideation behind anorexic behavior also was found in the descriptions of saints from the Middle Ages in Western culture, when spiritual purity, rather than thinness, was the ideal (Bemporad, 1996). Thus, the fear of fatness that is required for the diagnosis of anorexia nervosa in the Diagnostic and Statistical Manual, Fourth Edition (American Psychiatric Association) may be a culturally dependent feature (Hsu and Lee, 1993).
Anorexia nervosa has been described as a possible "culture-bound syndrome," with roots in Western cultural values and conflicts (Prince, 1983). Eating disorders may, in fact, be more prevalent within various cultural groups than previously recognized, as such Western values are becoming more widely accepted. Historical and cross-cultural experiences suggest that cultural change, itself, may be associated with increased vulnerability to eating disorders, especially when values about physical aesthetics are involved. Such change may occur across time within a given society, or on an individual level, as when an immigrant moves into a new culture. In addition, cultural factors such as affluence and freedom of choice for women may play a role in the development of these disorders (Bemporad, 1997). Further research of the cultural factors influencing the development of eating disorders is needed.
Dr. Miller is an associate professor at James H. Quillen College of Medicine, East Tennessee State University, and is director of the university psychiatry clinic.
Dr. Pumariega is professor and chair of the department of psychiatry at the James H. Quillen College of Medicine, East Tennessee State University.
On the Teen Scene:
Eating Disorders Require Medical Attention
by Dixie Farley
For reasons that are unclear, some people -- mainly young women -- develop potentially life-threatening eating disorders called bulimia nervosa and anorexia nervosa. People with bulimia, known as bulimics, indulge in bingeing (episodes of eating large amounts of food) and purging (getting rid of the food by vomiting or using laxatives). People with anorexia, whom doctors sometimes call anorectics, severely limit their food intake. About half of them also have bulimia symptoms.
The National Center for Health Statistics (NCHS) estimates that 10,000 bulimia cases and 11,000 anorexia cases were diagnosed in 1989, the latest year for which statistics are available. Studies indicate that by their first year of college, 4.5 to 18 percent of women and 0.4 percent of men have a history of bulimia and that as many as 1 in 100 females between the ages of 12 and 18 have anorexia.
Males account for only 5 to 10 percent of bulimia and anorexia cases. While people of all races develop the disorders, the vast majority of those diagnosed are white. Most people find it difficult to stop their bulimic or anorectic behavior without professional help. If untreated, the disorders may become chronic and lead to severe health problems, even death. NCHS reports 67 deaths from anorexia in 1988, the latest year for which it has figures, but does not have similar information on bulimia.
As to the causes of bulimia and anorexia, there are many theories. One is that some young women feel abnormally pressured to be thin as the "ideal" portrayed by magazines, movies and television. Another is that defects in key chemical messengers in the brain may contribute to the disorder's development or persistence.
The Bulimia Secret
Once people begin bingeing and purging, usually in conjunction with a diet, the cycle easily gets out of control. While cases tend to develop during the teens or early 20s, many bulimics successfully hide their symptoms, thereby delaying help until they reach their 30s or 40s. Several years ago, actress Jane Fonda revealed she had been a secret bulimic from age 12 until her recovery at 35. She told of bingeing and purging up to 20 times a day.
Many people with bulimia maintain a nearly normal weight. Though they appear healthy and successful -- "perfectionists" at whatever they do -- in reality, they have low self-esteem and are often depressed. They may exhibit other compulsive behaviors. For example, one physician reports that a third of his bulimia patients regularly engage in shoplifting and that a quarter of the patients have suffered from alcohol abuse or addiction at some point in their lives.
While normal food intake for a teenager is 2,000 to 3,000 calories in a day, bulimic binges average about 3,400 calories in a 1 1/4 hours, according to one study. Some bulimics consume up to 20,000 calories in binges lasting as long as eight hours. Some spend $50 or more a day on food and may resort to stealing food or money to support their obsession.
To lose the weight gained during a binge, bulimics begin by purging by vomiting (by self-induced gagging or with an emetic, a substance that causes vomiting) or by using laxatives (50 to 100 tablets at a time), diuretics (drugs that increase urination), or enemas. Between binges, they may fast or exercise excessively.
Extreme purging rapidly upsets the body's balance of sodium, potassium, and other chemicals. This can cause fatigue, seizures, irregular heartbeat, and thinner bones. Repeated vomiting can damage the stomach and esophagus (the tube that carries food to the stomach), make the gums recede, and erode tooth enamel. (Some patients need all their teeth pulled prematurely.) Other effects include various skin rashes, broken blood vessels in the face, and irregular menstrual cycles.
Complexities of Anorexia
While anorexia most commonly begins in the teens, it can start at any age and has been reported from age 5 to 60. Incidence among 8- to 11- year-olds is said to be increasing.
Anorexia may be a single, limited episode with large weight loss within a few months followed by recovery. Or it may develop gradually and persist for years. The illness may go back and forth between getting better and getting worse. Or it may steadily get more severe.
Anorectics may exercise excessively. Their preoccupation with food usually prompts habits such as moving food about on the plate and cutting it into tiny pieces to prolong eating, and not eating with the family.
Obsessed with weight loss and fear of becoming fat, anorectics see normal folds of flesh as "fat" that must be eliminated. When the normal fat padding is lost, sitting or lying down brings discomfort not rest, making sleep difficult. As the disorder continues, victims may become isolated and withdraw from friends and family.
The body responds to starvation by slowing or stopping certain bodily processes. Blood pressure falls, breathing rate slows, menstruation ceases (or, in girls in their early teens, never begins), and activity of the thyroid gland (which regulates growth) diminishes. Skin becomes dry, and hair and nails become brittle. Lightheadedness, cold intolerance, constipation, and joint swelling are other symptoms. Reduced fat causes the body temperature to fall. Soft hair called lanugo forms on the skin for warmth. Body chemicals may get so imbalanced that heart failure occurs.
Anorectics who additionally binge and purge impair their health even further. The late recording artist Karen Carpenter, an anorectic who used syrup of ipecac to induce vomiting, died after buildup of the drug irreversibly damaged her heart.
Early treatment is vital. As either disorder becomes more entrenched, its damage becomes less reversible.
Usually, the family is asked to help in the treatment, which may include a psychotherapy, nutrition counseling, behavior modification, and self-help groups. Therapy often lasts a year or more -- on an outpatient basis unless life-threatening physical symptoms or severe psychological problems require hospitalization. If there is deterioration or no response to therapy, the patient (or parent or other advocate) may want to talk to the health professional about the plan of treatment. There are no drugs approved specifically for bulimia or anorexia, but several, including some antidepressants, are being investigated for this use.
If you think a friend or family member has bulimia or anorexia, point out in a caring, nonjudgemental way the behavior you have observed and encourage the person to get medical help. If you think you have bulimia or anorexia, remember that you are not alone and that this is a health problem that requires professional help. As a first step, talk to your parents, family doctor, religious counselor, or school counselor or nurse.
According to the American Psychiatric Association, a person diagnosed as bulimic or anorectic must have all of that disorder's specific symptom's:
· Recurrent episodes of binge eating (minimum average of two binge-eating episodes a week for at least three months).
· A feeling of lack of control over eating during the binges.
· Regular use of one or more of the following to prevent weight gain: self-induced vomiting, use of laxatives or diuretics, strict dieting or fasting, or vigorous exercise.
· Persistant over-concern with body shape and weight.
· Refusal to maintain weight that's over the lowest weight considered normal for age and height.
· Intense fear of gaining weight or becoming fat, even though underweight.
· Distorted body image.
· In women, three consecutive missed menstrual periods without pregnancy.
Food is the only source of vitally important nutrients: proteins, fats, carbohydrates, mineral substances, microelements and vitamins, which are necessary for growth and formation and its activity and stability for unfavorable influence of the external environment. Out of products of the nutrient dissolution through the complex chemical transformations there goes in organism the constant synthesis of proteins and protein substances, carbohydrates, mineral and other complex combinations which are necessary for providing stability and renewing morphological structures and the formation of functionally active combinations - hormones, ferments etc.
The constant influx of energy is necessary for the synthesis processes to go on. Energy exchange is one of the main display of life activity, owing to which growth and development are accomplished and the high regulation of exchanging processes and functional organization of biologic systems are provided. Organism obtains a demandable amount of energy, releasing after the dissolution of fats and carbohydrates, entering with foods and proteins in the less degree, which are used in a growing organism for plastic purposes.
The basis of life lies in assimilation and dissimulation processes. The correlation of these processes characterizes metabolism, the level of which varies every next age period. The assimilation and synthesis processes are predominant in a growing organism.
Metabolism is accomplished with the help of the ferments - biological catalysts, which define the mutual coordination and strict consequence of chemical reactions and which have the ability to accelerate this reactions much. Different breaches in the regulation of exchanging processes inevitably lead to the breach of the organism cooperation with the external environment and the development of purposeless adaptive reactions, organism weaking and diseases.
Anorexia nervosa is a condition where there is an intense fear of becoming fat. This fear leads the sufferer to pursue a programme which will ensure that they lose weight. Apart from not eating, this may include the taking of laxatives, self-induced vomiting and excessive exercise. The loss of weight can be considerable. The fear is so intense that there is a distortion of body image so that patients believe they are fat even when this is not the case. As a result of the loss of weight and starvation, the sufferer will become physically and psychologically ill, leading to loss of periods, anxiety, tiredness, loss of hair and poor skin. Bulimia nervosa tends to occur at a later age than anorexia. It too is characterized by a compulsion to being thin and a concern over body image. Weight loss is not such a feature. The sufferer has repeated episodes of binge eating (bulimia) during which she feels out of control. This is followed by feelings of guilt and worthlessness which lead to episodes of self-induced vomiting, diarrhoea brought on by laxatives or extreme dieting. The sufferer may also be depressed and feel ashamed and guilty.
The cause of these eating disturbances is not known. A number of factors are considered to be important. In anorexia but not in bulimia, there is a suggestion that there may be an inherited tendency. Both the personality of the sufferer as well as family relationships may be important. Some consider that cultural issues are relevant: Western fashion tends to pressurize women to be thin.
The above factors may have been present for many years. These illnesses may be triggered off by a virus infection, an episode of depression or embarking on a slimming diet. They are considerably more common in women.
In anorexia, weight loss can be very severe and it may be necessary for the sufferer to be admitted to hospital: sometimes it is possible to manage the problem without this. The object of treatment is to restore the sufferer to their normal weight. A high calorie diet is therefore encouraged. It is important to help the sufferer to accept that this is necessary. The main treatment consists of psychotherapy (or talking treatment) and behavioural therapy (which attempts to change behaviour patterns). Drugs are not often used unless there is an underlying depression.
Family therapy is sometimes used for the younger patient. Psychotherapy is also known as "talking therapy". This is undertaken either with the individual, in groups or with the other members of the family (family therapy). It seeks to give the sufferer an opportunity to discuss and explore some of her feelings. By so doing, it allows an insight into the sufferer's personality and perhaps an understanding of the reasons behind her illness.
Behaviour therapy is a form of psychological treatment that involves a planned programme which aims to change the individual's behaviour. Attempts are made to deal with any underlying anxiety or depression. A weight target may be set and a programme of regular meals may be planned, to bring about a gradual weight gain.
Treatment is principally supportive and is therefore without any serious side effect. During treatment, it is not unusual for the sufferer to "cheat" by self-induced vomiting or diarrhoea. Alternatively, she may lie and pretend to have eaten a meal. It will be necessary to attend a clinic regularly, not only for psychotherapy, but also to have weight checked to ensure that it is increasing. If attempts to manage the problem at home fail, then hospital admission may be required.
It is important for both these conditions to be treated. Untreated, they will lead to serious ill health, causing problems such as pneumonia, mineral and vitamin deficiencies, kidney and heart disorders. It is important to realize that these are both serious conditions which carry a risk of death. However, treatment can be successful and is more likely to be so if started early on in the condition.
These are both distressing conditions. The behaviour of the patient can be difficult to understand and the loss of weight can be very worrying. It is not unusual for the patient to lie and manipulate their family and friends. It is important, however, that family and friends work together with the doctor to provide the patient with sympathetic support, encouragement and understanding. Especially in the younger sufferer, the family become more actively involved in treatment by taking part in family therapy.
Bulimia is a pattern of binge eating (excessive eating) and purging (vomiting) that happens over and over again. When a victim eats an excessive amount of food that are very rich and high in sugars and fats, it is almost always in secret. The victim knows that the behaviour is not normal, and the victim feels guilty. The bulimic is afraid of not being able to stop. Purging includes vomiting, using overdoses of laxatives and diuretics (drugs that remove water from the body), or fasting (going without food for several days, or very little for several weeks.) Because of these actions, the bulimic's weight may often change dramatically. (Wolhart, pg. 6)
Bulimics commonly set high goals for themselves, just like anorectics. They feel they are failures if they are anything less than perfect. Families and friends are often confused when a loved one developes an eating disorder. Usually the bulimic is a very good student who seems to have few problems. Yet, these seemingly "perfect" young people often have a very low self-esteem, and want to please others. They also depend on other people to make them feel good about themselves. (Wolhart, pg. 9)
The symptoms of bulimia nervosa are different from anorexia nervosa. The patient binges and then purges. When a bulimic binges, it is usually on huge quantities of high-caloric food. These binges may alternate with severe diets, resulting in dramatic fluctuations in weight. The bulimic then purges her body of these calories by self-induced vomiting and often by using laxatives. Teenagers may also try to hide the signs of throwing up by running water while spending an extended period of time in the bathroom. The purging of bulimia presents a serious threat to the patient's physical health, including dehydration, hormonal imbalance, the depletion of important minerals, and damage to vital organs.
Bulimia is not as obvious as anorexia because of the secrecy the patient usually uses, but is actually more common. It effects at least 3 percent to 10 prcent of adolescent and college-age women in the United States. Approximately 10 percent of identified bulimic patients are men. Bulimics are also susceptible to other compulsions, affective disorders, of addictions. In the long run, bulimics have slightly better chance at recovering from the disorder than anorectics. However, many bulimics continue to retain slightly abnormal eating and dieting habits even after the recovery period.
ANAD (National Association for Anorexia Nerosa and
Associated Disorders) in Highland Park, Illinois, has given the following
advice for individuals who think that they might be either anorectic or bulimic:
"Learn as much as you can about anorexia nervosa, with emphasis on articles, etc., on bulimia. If you are keeping the problem a secret, try to understand that you can best overcome it by seeking help. Locate and go to a therapist (psychologist, medical doctor, social worker, etc.) who understands and treats anorexia and bulimia.
"Join a self-help group if there is one in your area. If none exists, form one if you feel capable of leading a group. Become a resource person responding to others by mail or telephone, or assist ANAD in bringing attention to this problem and participating in programs to educate the public and health professionals.
"Many anorectics have a low sense of self-esteem. This may be improved by learning to be more assertive. Assertiveness training courses are offered in various places. If courses are not available, read the books listed below. Many other titles on the subject are also available."
What is Bulimia Nervosa?
Bulimia Nervosa is characterized by recurrent episodes of binge eating (consumption of large amounts of food in a short period of time) in which the person experiences a feeling of loss of control over eating (bingeing) and regularly engages in either self-induced vomiting, abuse of laxatives, and/or diuretics, or rigorous dieting/fasting to purge the effects of bingeing. A typical binge involves rapid intakes of food (especially of high calorie value) greater than 15,000 calories in a few hours. Binges are usually episodic, often triggered by psychosocial stresses, and may occur as often as several times a day. Often times, binges are carried out in secret.
Someone who is bulimic is often anxious about becoming overweight, but unlike anorexics they usually do not become extremely thin. In many cases, a bulimic's weight tends to fluctuate 10-15% below or above their healthy body weight.
What Causes Bulimia Nervosa?
The cause of Bulimia Nervosa is unknown, but it is thought to be emotionally related. Social factors appear to play an important role. Emphasis on the desirability to be thin prevails in our society, and obesity is associated with a wide range of undesirable traits. Recent studies indicate that 80 to 90% of pre-teen children are aware of these pressures from our society and over 50% of these girls attempt diets and other ways to control their weight. Other significant factors include family and emotional conflicts, ineffective coping skills, peer pressure to be thin, a history of being slightly overweight, a desire for perfection, a tendency toward being compulsive or over- achieving, and psychological stress. Poor or few interpersonal relationships can contribute as well.
Risk Factors for Bulimia Nervosa
Signs and Symptoms of Bulimia Nervosa
Diagnosis of Bulimia Nervosa
Diagnosis begins with observation of symptoms. Diagnosis is suspected in a person who is abnormally concerned or obsessed about weight gain and has fluctuations in weight. A diagnostic sign is the act of self-induced vomiting, abuse of laxatives or diuretics, strict obsessive dieting, fasting, or vigorous exercise to prevent weight gain. However, the diagnosis does depend on the person's description of binge or binge-purge behavior.
Treatment for Bulimia Nervosa
General therapy should consist of assessing nutritional status, establishing target goals, identifying triggers, improving relationships, improving overall well-being, and learning techniques to avoid stress.
Although treatment in a hospital is only used in severe cases, treatment in an eating disorder clinic or facility may be recommended.
Counseling or psychotherapy including hypnosis or biofeedback training may be used.
Antidepressants may be helpful. This decision is made case by case.
Typically, there is no activity restriction on a recovering bulimic.
Typically, regulation of eating habits, maintenance of a food diary, and reintroduction of feared foods is used.
In cases of hospitalization, intravenous fluids may be used. Vitamin and mineral supplements may be needed to reverse the sign of deficiencies. Lastly, normal eating patterns are established.
Recovery of Bulimia Nervosa
Patients can learn to control the behavior with counseling, psychotherapy, biofeedback training and individual or group psychotherapy, but outcomes are variable.
There are possible fluid and electrolyte imbalances from vomiting. The vomiting can also contribute to dental disease and in extremely rare cases stomach rupture. Other complications would include cardiac complications, low pulse rate, and low blood pressure. There is also a chance of relapses.
Note: Bulimia Nervosa can and often co-exists with Anorexia Nervosa. See Anorexia Nervosa.
Alberti, Robert E., and Micahel L. Emmons. Your Perfect Right. San Luis Obispo, Calif.: Impact, 1970-74.
Butler, Pamela E. Self-Assertion for Women. New York: Harper & Row, 1981.
Stanlee, Phelps, and Nancy Austin. The Assertive Woman. San Luis Obispo, Calif.: Impact, 1975.
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