EATING DISORDERS: THE INDIAN CONTEXT

Written by: Aditi Singh (3rd year) Department Of Applied Psychology

The Indian Culture, one of the most ancient in the world, is known for its diversity at every step. From fashion to architecture, religions to traditions, literature, music, and cinema, one can see the beauty of these differences at every block. The biggest demonstrator of this diversity is Indian food and the meaning it carries.

Food (Sanskrit— bhojana,“that which is to be enjoyed,” Hindi— khana, Tamil— shapad) presents a way to understand everyday Indian culture as well as the complexities of identity and interaction with other parts of the world that are both veiled and visible. Intricately woven within our culture is the sense of community, belonging, and identity that our food carries. How one eats, what one eats, with whom, when, and why, is key to understanding the Indian social landscape as well as the relationships, emotions, statuses, and transactions of people within it. While we put so much emphasis on the importance of the Indian diet and the pleasure it brings, nowadays the same culture is facing an upsurge in disordered eating which is often the result of the same cultural, social and psychosocial factors that are supposed to promote the values of healthy living. To understand this upsurge, we must first understand what eating disorders are and how their prevalence needs to be recognized as an alarming issue in the country.

Eating disorders in essence can be described as behavioral conditions characterized by severe and persistent disturbance in eating behaviors and associated distressing thoughts and emotions. They are a group of psychological issues that result in the formation of unhealthy eating patterns. They may begin with an obsession with food, weight, or physical appearance. Eating disorders can occur in people of any age, sex, race and of all body weights, shapes and sizes. The physical, mental and emotional symptoms vary from person to person and by type of eating disorder. Eating disorders can be categorized into various types, although a person can have more than one type. Some of the most commonly known eating disorders include:

• Anorexia nervosa: People with anorexia nervosa greatly restrict food and calories sometimes to the point of self-starvation. You can have anorexia at any body size. It is characterized by an obsessive desire to lose weight and a refusal to eat healthy amounts of food for your body type and activity level.

• Bulimia nervosa: People diagnosed with bulimia nervosa binge or eat, or perceive they ate, large amounts of food over a short time. Afterward, they may force themselves to purge the calories in some way such as vomiting, using laxatives or exercising excessively to rid their body of the food and calories.

• Binge eating disorder (BED): People who have a binge eating disorder experience compulsory eating behaviors. They eat, or perceive that they have eaten, large amounts of food in a short period of time. However, after binging they don’t purge food or burn off calories with exercise. Instead, they feel uncomfortably full and may struggle with shame, regret, guilt or depression.

• Avoidant/restrictive food intake disorder (ARFID): it is a condition that causes you to limit the amount and type of food you eat. It isn’t the result of a distorted self-image or an attempt to lose body weight, which is common among other eating disorders. ARFID can cause one to: lose interest in eating, feel anxious about the consequences of eating, like choking on food or vomiting and avoid foods that have an unwanted color, taste, texture or smell.

GLOBAL SCENARIO

Currently, eating disorders affect at least 9% of the global population. Among chronic debilitations, eating disorders rank as the third most common place for teenage women in America. After evaluating a group of 496 adolescent girls for eight years until they reached the age of 20, medical researchers found that 5.2% of them met the standards for a diagnosis of binge eating, bulimia, and anorexia. They also listed symptoms that don't target specific disorders, though 13.2% had an eating disorder under that criteria. In the US, African Americans, Indigenous groups, and other people of colour are three times less likely to have an eating disorder or experience symptoms that are synonymous with eating disorders. The prevalence of eating disorders among young women is 3% globally, with men accounting for 1.5%. These stats were taken by researchers between 2001 and 2004.

According to a recent review done by Silén, Y., & Keski-Rahkonen, A. (2022), In Western settings, a substantial proportion of young people have reported an eating disorder. Overall, 5.5--17.9% of young women and 0.6-2.4% of young men have experienced a DSM-5 eating disorder by early adulthood. Lifetime DSM-5 anorexia nervosa was reported by 0.8-6.3% of women and 0.1-0.3% of men, bulimia nervosa by 0.8-2.6% of women and 0.1-0.2% of men, binge eating disorder by 0.6-6.1% of women and 0.3-0.7% of men, other specified feeding or eating disorders by 0.6-11.5% of women and 0.2-0.3% of men, and unspecified feeding or eating disorders 0.2-4.7% of women and 0-1.6% of men. Gender and sexual minorities were at particularly high risk. Emerging studies from Eastern Europe, Asia, and Latin America show similar high prevalences. During the COVID-19 pandemic, the incidence of eating disorders has still increased.

What we see is an ongoing, rising trend in eating disorders all over the globe and an urgent need for global health concerns among young people—improved detection, management, and prevention methods. While we do see and acknowledge the soaring need for these, there needs to be a higher understanding of the implications that these disorders have on the individual suffering from them and how at a broader level it is a societal concern.

IMPACT

Eating disorders have a detrimental effect on one’s psychological and physical well-being, the number of issues caused by eating disorders can be fleeting but for the majority of the time they are long-lasting, some even causing life-long complications. Addressing the gravity of eating disorders thus requires understanding and being aware of these effects for a better perspective and prevention approaches.

The array of physical implications of eating disorders is not limited and can affect every organ system in the body and for some people these illnesses are fatal

Some common implications include: dry skin from Low caloric and fat consumption, and hair becoming brittle and falling out. The body grows fine and has downy hair called lanugo, to conserve warmth during periods of starvation. kidney failure due to severe, prolonged dehydration. The development of anaemia when there are too few red blood cells or too little iron in the diet. Symptoms include fatigue, weakness, and shortness of breath. Malnutrition can also decrease infection-fighting white blood cells. Tooth enamel loss and cavities can be associated with purging by vomiting.

Some life long and even fatal implications include the following:

• Cardiovascular- Consuming fewer calories than you need means that the body breaks down its own tissue to use for fuel. Muscles are some of the first organs broken down, and the most important muscle in the body is the heart. Pulse and blood pressure begin to drop as the heart has less fuel to pump blood and fewer cells to pump with. The risk for heart failure rises as the heart rate and blood pressure levels sink lower and lower. Purging by vomiting or laxatives depletes your body of important chemicals called electrolytes. Electrolyte imbalances can lead to irregular heartbeats and possibly heart failure and death.

• Gastrointestinal- Slowed digestion is known as gastroparesis. Food restriction and/or purging by vomiting interferes with normal stomach emptying and the digestion of nutrients, which can lead to stomach pain and bloating, nausea and vomiting, blood sugar fluctuations, blocked intestines from solid masses of undigested food, bacterial infections, feeling full after eating only small amounts of food.

• Binge eating can cause the stomach to rupture, creating a life-threatening emergency and Vomiting can wear down the oesophagus and cause it to rupture, also creating a life-threatening emergency.

• Frequent vomiting can also cause sore throats, a hoarse voice or ulcers. Both, malnutrition and purging can cause pancreatitis, an inflammation of the pancreas. Symptoms include pain, nausea, and vomiting.

• Neurological- Extreme hunger or fullness at bedtime can create difficulties falling or staying asleep. The body’s neurons require an insulating, protective layer of lipids to be able to conduct electricity. Inadequate fat intake can damage this protective layer, causing numbness and tingling in hands, feet, and other extremities Neurons use electrolytes (potassium, sodium, chloride, and calcium) to send electrical and chemical signals in the brain and body. Severe dehydration and electrolyte imbalances can lead to seizures and muscle cramps. If the brain and blood vessels can’t push enough blood to the brain, it can cause fainting or dizziness, especially upon standing.

• Endocrine- The body makes many of its needed hormones with the fat and cholesterol we eat. Without enough fat and calories in the diet, levels of hormones can fall, including sex hormones estrogen and testosterone and thyroid hormones.

• Lowered sex hormones can cause menstruation to fail to begin, to become irregular, or to stop completely. They can also significantly increase bone loss (known as osteopenia and osteoporosis) and the risk of broken bones and fractures. diminished sex drive and sexual functioning can also result from lowered sex hormones.

• Over time, repeated binge eating episodes can potentially increase the chances that a person’s body will become resistant to insulin, a hormone that lets the body get energy from carbohydrates. This can lead to Type 2 Diabetes. Without enough energy to fuel its metabolic fire, core body temperature will drop and hypothermia may develop. Starvation can also cause high cholesterol levels, due to disruptions in lipid metabolism.

In addition to their physical effects, eating disorders are often characterized by psychological troubles, such as distorted thoughts, obsessive behaviours, low self-esteem, self-harm, anxiety, depression, social isolation, and a risk for suicide.

Guilt, shame, feelings of isolation, alienation and anxiety are extremely common results when one suffers from an eating disorder. A more interior symptom, cyclical thought patterns tend to plague those with eating disorders. These thinking patterns are similar to obsessive-compulsive disorder thought patterns and tend to feel uncontrollable. A 2020 research review found that globally, 15% of people who have an eating disorder have OCD at the same time, and 18% of people with an eating disorder experience OCD at some point in their lives (even if the two conditions do not happen at the same time).

Many people do not recognize eating disorders as mental health conditions and therefore do not always recognize the psychological impact that eating disorders can have. Eating disorders often occur together with other psychiatric illnesses, such as clinical depression, anxiety and personality disorders, and substance abuse. The biggest issue arises as we observe how eating disorders can form a gateway to substance abuse and often go hand in hand with them.

The National Center on Addiction and Substance Abuse cites that individuals with an eating disorder are up to five times more likely to abuse drugs and alcohol than the general population. There are multiple reasons for this:

1. Certain drugs support weight loss by suppressing appetite – Alcohol, cocaine, and amphetamines can suppress a person’s appetite, making it easier for them to abstain from eating and to maintain weight loss. These drugs may trick a user into feeling satiated.

2. Self-medication for psychological distress or depression – When a person is suffering an eating disorder, he or she may also be battling co-occurring disorders like depression, anxiety, or post-traumatic stress disorder. In efforts to calm their psychological distress, the person may turn to drugs to self-medicate and “feel better,” even if only temporarily. This starts the addiction cycle.

As mental health issues, both types of disorders stem from the same areas of the brain – our reward centres. You see, the brain’s reward centres are stimulated by certain pleasure-producing behaviors, such as being praised or complimented, eating delicious food, exercising, or falling in love

The problem is, the parts of the brain dedicated to pleasure can also be stimulated by artificial means, such as drugs and alcohol, and through disordered eating behaviours – both of which produce “feel-good” neurotransmitters in certain individuals. The behaviors, while temporary, become habit-forming. To feel happy or to find relief, a person will continue those negative behaviors to feel the same pleasurable effects (e.g. getting high, feeling thin, binge eating).

A study published in 2022 has also shown that death rates are significantly increased when people with eating disorders also use substances. This is alarming because substance use disorders have the highest premature mortality rates of any mental illness, with anorexia nervosa having the second highest. For patients with anorexia who use drugs, the risk of premature death increases up to 22-fold compared with matched control subjects. A paper by Papadopoulos studied more than 6000 individuals with AN over 30 years using Swedish registries and also suggested that overall people with anorexia nervosa had a six-fold increase in mortality compared to the general population.

Social implications also exist when a person or someone in a person’s close circles suffers from an eating disorder. Eating disorders bring pain and suffering not only to the people who have them but also their families, friends and romantic partners. Co-workers and even casual acquaintances can be affected too. These problems include:

• Disruption of family. Blame fights over food, weight, treatment etc.

• Family members may struggle with guilt, worry, anxiety, and frustration when nothing they do seems to make things better.

• Friendships and romantic relationships may be damaged or destroyed. A person with an eating disorder is or becomes emotionally cool and withdrawn, irritable, minimally or not at all interested in sex, secretive and controlling - often in a passive/aggressive manner.

• If the person is a student or athlete, the teachers, coaches and trainers may experience the same worry and frustration that plague the family members, it can affect their career and future while also having social implications, i.e., the loss of an important person in that field.

STIGMATISATION OF EATING DISORDERS

Stigmatization of eating disorders is often the result of being uninformed and having inaccurate knowledge. Often people, without any research make assumptions from knowledge gained through unreliable sources. This leads to several myths that further contribute to delayed detection and further stigmatization of eating disorders. In this section, we look at some myths that contribute to this and the truth that precedes them.

Myth 1: Eating disorders are just about food.

Truth: While eating disorders generally involve an obsession with calories, weight or shape, these illnesses are rooted in biological, psychological and sociocultural aspects. Restriction, bingeing, purging or over-exercise behaviours usually signify an attempt to control something of substance in the individual’s life. So, eating less, more or healthier doesn’t help or cure a person as many people believe.

Myth 2: Eating disorders are a women’s illness.

Truth: While research shows that eating disorders affect significantly more women than men, these illnesses occur in men and boys as well. While males used to represent about 10 percent of individuals with eating disorders, a recent Harvard study found that closer to 25 percent of individuals presenting for eating disorder treatment are male. The widespread belief that eating disorders only affect women and girls can prevent accurate diagnosis of an eating disorder in a man or boy, even among healthcare experts.

Myth 3: Only very thin people have an eating disorder.

Truth: While anorexia is characterized by extremely low weight, many individuals struggling with bulimia, binge eating disorder and EDNOS are normal-weighted. The misconception that an eating disorder can only occur if someone is very thin contributes to misdiagnosis or delayed diagnosis in many cases, even among those patients seeking support from medical and mental healthcare professionals. Unfortunately, many healthcare experts lack eating disorder exposure and training, which highlights the important role of eating disorder specialists in ensuring effective diagnosis and early intervention.

Myth 4: Eating disorders aren’t serious illnesses.

Truth: Anorexia nervosa, bulimia nervosa, binge eating disorder and eating disorder not otherwise specified (EDNOS) are very real and very serious mental illnesses. Each disorder has clear diagnostic criteria in the Diagnostic and Statistical Manual, the go-to diagnostic reference for mental healthcare professionals. Another reason to take eating disorders seriously is that they have a high mortality rate. Anorexia nervosa has the highest mortality rate of any psychiatric disorder. Women ages 15 to 24 years of age who suffer from anorexia nervosa are 12 times more likely to die from the illness than any other cause of death.

Myth 5: You can tell if someone has an eating disorder by looking at them.

Truth: People who suffer from eating disorders come in all shapes and sizes. The media and other public discussions about eating disorders often focus on a specific diagnosis: anorexia, wherein sufferers often display the symptoms of being severely underweight. Individuals who suffer from eating disorders can be of any weight, and they can fluctuate in weight which is extremely common.

Myth 6: recovery from eating disorders is rare.

Truth: Recovery can take months or years due to the complexity of eating disorders but, with the right treatment combinations and interventions, recovery is possible.

INDIAN SOCIETY AND EATING DISORDERS

Despite growing evidence of their prevalence, research on feeding and eating disorders (FEDs) in India has been sporadic and has historically received less attention than in Western countries. For any illness, with genetic and biological factors, the cultural context strongly and equally impacts the emergence and progression of the illness. Without delving into these cultural aspects, we cannot navigate the larger issue at hand. The same goes for the prevalence of eating disorders in our society. On one hand, cultural practices in India emphasize the sanctity of food and avoiding wastage. Gratitude and moderation are ingrained in eating habits, often commencing meals with prayers. Figurines from the Mauryan era depict women with attributes signifying fertility, such as full breasts and wide hips. South Indian literature describes beautiful women as possessing skin with a lustrous glow, substantial hips, and voluminous hair. This perspective plays a protective factor.

Despite these cultural beliefs and practices being engrained in our Indian society, the current scenario paints an entirely distinguished picture. At large we might be able to say that this culpability falls on Western ideals and norms influencing the Indian culture due to globalization and the surge of Western media but they can not entirely take the blame.

Body shaming is deeply embedded in our culture. Body shaming involves humiliating someone by making inappropriate or negative comments about their body size or shape. As well as “fat shaming,” you may also hear negative comments if you’re underweight or about a specific body part. In our culture, body shaming often begins at home. Name-calling based on one’s appearance is often seen as a joke but this joke often comes at the expense of someone’s mental health. Negative commenting on someone’s appearance, especially body shape and size often leads them to internalize that negativity and in attempting to “fix” these newfound insecurities a person may begin indulging in disordered behaviours. Casual body shaming further, is trickier to spot. It can come as a compliment, often thinly veiled so you know that they don’t think your body is good enough. It is often also disguised as concern for one’s health but is blatantly used to shame or make them feel insecure and it isn’t limited to an age or gender, almost no one is spared from this extremely toxic habit.

Another contributor is mass media. The obsession with Western media is nothing new, but in recent years the comparison between people has intensified to such an extent that any form of deviation from those standards of beauty and habits is seen as abnormal and shamed by the people of our very own culture. Body dissatisfaction arises when one does not fit into an ideal form of beauty and the Western standard is being conveyed to people all over the world due to the globalization of media. Unrealistic standards of beauty, thinness and even lifestyle play a huge role in body perception, image and satisfaction. We see young women and men alike nowadays, resorting to fad diets and supplements to achieve these glorified ideals which are often unrealistic and can only be achieved through unhealthy means. Music videos largely objectify women, and it has been observed that the longer participants were indulging in watching the videos, the more likely they were to use dietary supplements (Nigar and Naqvi, 2019)

Diet culture views food as fuel. Based on their macronutrient content, foods are simply rated ‘good’ or ‘bad’. However, food is more than a source of energy. It has been an integral part of celebrations and culture since ancient times. Still, ‘Detoxifying’ and ‘cleansing’ after a celebration or holiday season remain classic examples of foods being perceived only as calories and often promote the idea that highcaloric food is inherently unhealthy and even toxic. The casual comments on food habits and one’s body are also prevalent in Indian society to a large extent. This frequently leads to people avoiding certain foods, even whole food groups, and social gatherings and resorting to habits that cause disordered and distorted views of eating and body image. Indian society, in addition, is no stranger to social comparison in any aspect. The narrative of beauty in India is being constructed upon the basis of Western standards of beauty and is deviating from the native standards. Indian women are being exposed to Western as well as Indian media that depict unattainable thin ideals that increase body dissatisfaction (Nagar & Virk, 2017). Reports say that attitudes toward fatphobia and body dissatisfaction are comparable to the numbers in the West. 33% of Indian native women reported experiencing body dissatisfaction and about 10% of the sample population showed indication of developing clinical ED. This is a growing concern as this comparison is now being done socially as well. Internal conflicts are almost being fed by these ideals being pushed onto people who are completely different from the set ideal. From genetic and biological makeup to societal factors, western and Asian people differ significantly and to expect an almost homogenous appearance in a largely heterogeneous population can significantly impact those deviating from the set standards to which they do not conform.

Although the Eurocentric standard itself has shifted over time, from a voluptuous figure to slenderness, it has never been the average-sized people. In that sense, an average person is not represented by the media, and hence is left out of the picture which may give rise to body dissatisfaction. The spread of homogeneous ideals paints an unrealistic picture that amplifies body dissatisfaction and low self-esteem (Sepúlveda & Calado, 2012). The dissatisfaction gives rise to unhealthy eating habits, and this increases the risk of developing eating disorders.

Another very significant aspect is the denial of mental illnesses in Indian society, often those suffering from mental illness are regarded as just physically unwell or “dramatic”. Still in this day and age, there is little awareness of mental illnesses especially eating disorders. Often, people are termed as just “being weird about food”, “just dieting” or simply regarded as being a nuisance in case they present an aversion to certain foods. There is a dire need education among the Indian people about eating disorders and the habits in our culture that promote such behviours. Treatment is generally extremely hard to seek when there is no support or understanding about what you are going through and this lack of awareness in our culture may further contribute to feelings of isolation while someone suffers significantly with a disorder than can potentially be fatal. Addressing these issues and acknowledging the presence and existence of mental illness consequently proves to be of grave importance for our society.

PREVENTION

Preventing disordered behaviour that can lead to eating disorders is thus crucial with the rise in eating disorders. Being mindful and looking out for signs of eating disorder behaviour can lead to early intervention and prevention. Here, we list some signs to look out for:

• Dramatic weight loss

• Wearing loose, bulky clothes to hide one’s body

• Preoccupation with food, dieting, counting calories, etc.

• Refusal to eat certain foods, such as carbs or fats

• Avoiding mealtimes or eating in front of others

• Preparing elaborate meals for others but refusing to eat them

• Exercising excessively

• Making comments about being “fat”

• Stopping menstruating

• Complaining about constipation or stomach pain

• Evidence of binge eating, including the disappearance of large amounts of food in a short time, or finding lots of empty food wrappers or containers

• Hoarding food, or hiding large quantities of food in strange places

• Evidence of purging, including trips to the bathroom after meals, sounds or smells of vomiting, or packages of laxatives or diuretics

• Using gum, mouthwash, or mints excessively

• Scarred knuckles from repeatedly inducing vomiting

• Constantly dieting

TREATMENT AND RECOVERY

While there are a variety of different treatment options available for those struggling with eating disorders, it is important to find the treatment, or combination of treatments, that works best for the individual.

Effective treatment should address more than just one’s symptoms and destructive eating habits. It should also address the root causes of the problem—the emotional triggers that lead to disordered eating and your difficulty coping with stress, anxiety, fear, sadness, or other uncomfortable emotions.

Treatment often requires medical intervention through a psychologist, it requires constant support of close ones and the motivation to get better. Recovery from any mental illness is not an easy, straight path and the same applies to eating disorders. Relapses and set backs are a part of one’s recovery and with the right treatment and support, it is possible to recover and lead a healthy life.

BEAUTY IN RECOVERING

Allowing this process and journey to take precedence in your life opens more doors and opportunities in the future because you will be able to see and discover your values, desires, passions, and wants, which all have been clouded. You will find yourself genuinely enjoying living and time spent with yourself and loved ones, going out with friends, eating at restaurants, doing enjoyable activities, all without the obsession with food, exercise, and numbers. The sooner you work and challenge the eating disorder, the quicker you will find peace in your mind, body, and soul. Your mind will not be overwhelmingly consumed with anxious thoughts concerning food, measuring, calories, body image, exercise, the scale, etc. Instead, it will fill with curiosity, joy, peace, and rest.

A life outside of worries, anxieties, and fear waits after recovery. For the beautiful connections and moments of joy and peace, hope for healing and recovery can never come too late. It takes immense time, effort, and capacity, but is well worth it.

CONCLUSION

Indian society as a whole, has a long way to widespread acceptance and awareness of eating disorders. With globalization and the augmented influence of Western media and many inherent issues that need to be addressed, there is a critical need for us to come together to improve, learn and support each other to be able to prevent and effectively address the upsurge of eating disorders in our society.

There is so much more that awaits once we can overcome the issues contributing to the prevalence of eating disorders, prevent more people from falling into the same patterns and lead those suffering to a better, more peaceful path.

REFERENCES

1. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

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3. Garfinkel, P. E., Kennedy, S. H., & Kaplan, A. S. (1995). Views on classification and diagnosis of eating disorders. The Canadian Journal of Psychiatry, 40(8), 445-456.

4. Mellentin, A. I., Mejldal, A., Guala, M. M., Støving, R. K., Eriksen, L. S., Stenager, E., & Skøt, L. (2022). The Impact of Alcohol and Other Substance Use Disorders on Mortality in Patients With Eating Disorders: A Nationwide Register-Based Retrospective Cohort Study. The American Journal of Psychiatry, 179(1), 46–57. https://doi.org/10.1176/appi.ajp.2021.21030274

5. Sharma, P., Batres, K., & Lindroth, M. (2021). The Effects of the Homogenization of the Western Beauty Standard [Documents] https://jstor.org/stable/community.36366723

6. Vaidyanathan, S., Kuppili, P. P., & Menon, V. (2019). Eating Disorders: An Overview of Indian Research. Indian Journal of Psychological Medicine, 41(4), 311–317. https://doi.org/10.4103/IJPSYM.IJPSYM_461_18

Written by: Aditi Singh

Reviewed by:

Shreeyanshi (Senior Content team Coordinator| Editor-in-chief)

Ananya Chauhan (Deputy Senior Content team Coordinator)