Kiev State Linguistic University
The Ukraine
Fall, 1999
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
Group 202
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).
Conclusions
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
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.
Getting
Help
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.
DISORDER'S DEFINITIONS
According to the American
Psychiatric Association, a person diagnosed as bulimic or anorectic must
have all of that disorder's specific symptom's:
Bulimia
Nervosa
·
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.
Anorexia
Nervosa
·
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 NERVOSA
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."
Bulimia Nervosa
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.
Possible
Complications
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.
Bibliography:
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.