South East Scotland Deanery, Edinburgh
Department of Psychological Medicine and Symptoms Research, University of Edinburgh
Cullen Centre, Royal Edinburgh Hospital
Robert Fergusson Unit and Department of Clinical Neurosciences, Royal Edinburgh Hospital, Edinburgh, UK
Correspondence: Dr Dinah Bennett, Specialist Registrar in Psychiatry, Department of Psychiatry, St Johns Hospital, Howden Road West, Livingston, Edinburgh EH54 6PP, UK. E-mail: Dinah.Bennett{at}lpct.scot.nhs.uk
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ABSTRACT |
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Aims To determine whether there were any cases of anorexia nervosa in female students attending two secondary schools in the north-east region of Ghana.
Method The body mass index (BMI) of consenting students was
calculated after measuring their height and weight. Those with a BMI 19
kg/m2 underwent a structured clinical assessment including mental
state, physical examination and completion of the Eating Attitudes Test and
the Bulimic Investigatory Test, Edinburgh. Participants nominated a best
friend to serve as a comparison group, and these young women under went the
same assessments.
Results Of the 668 students who were screened for BMI, 10 with a BMI <17.5 kg/m2 appeared to have self-starvation as the only cause of their low weight. All 10 viewed their food restriction positively and in religious terms. The beliefs of these individuals included ideas of self-control and denial of hunger, without the typical anorexic concerns about weight or shape.
Conclusions Morbid self-starvation may be the core feature of anorexia nervosa, with the attribution for the self-starvation behaviour varying between cultures.
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INTRODUCTION |
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There are reasons to question this view. First, there are historical descriptions of cases of self-starvation without weight concern in cultures in which there was no emphasis on slimness (Bemporad, 1996). Second, cross-cultural comparison has suggested that anorexia nervosa does not necessarily follow the accepted Western form (Lee et al, 1993; Lee, 1996). Despite these reports, we are not aware of any systematic examination of anorexia nervosa in a sub-Saharan African population. We therefore aimed to determine whether there were any cases of anorexia nervosa among female students at two secondary schools in north-east Ghana. We predicted that anorexia might take a different form in a non-Western culture, and therefore our aims were to identify any young women who were underweight to a clinically significant extent as a result of self-starvation, and to record the attitudes and beliefs associated with this self-starvation.
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METHOD |
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All female students who gave informed consent were measured for height and
weight and their body mass index (BMI) was calculated. Any student with a BMI
19 kg/m2 underwent further assessment for anorexia nervosa. The
acceptable range for a healthy BMI is generally considered to be 2024.9
kg/m2 (Trusswell,
1999). The ICD10 diagnostic criteria for anorexia nervosa
specify a BMI of less than 17.5 kg/m2 or 15% less than expected. In
order to maximise sensitivity of screening, a BMI of 19 or less was chosen as
the threshold to trigger further assessment. All participants in this category
were asked to nominate a friend of normal weight (BMI >19 kg/m2)
and these young women served as a comparison group, undergoing the same
assessments for anorexia, bulimia and depression (because several students
nominated the same friend or a low-weight friend who was already in the sample
group, this group was smaller than the low-BMI group). A similar technique has
been used previously in a study of the families of patients with anorexia
nervosa and cystic fibrosis (Blair et
al, 1995).
The assessment consisted of a clinical examination of both mental and
physical state, supplemented by three structured assessment scales (see
below). The mental state examination included a detailed assessment of
cognitions, beliefs and behaviours surrounding eating. Physical assessment
included background medical information. A symptom checklist was used to
screen for physical illness. A full physical examination was made of all
participants with a BMI 19 kg/m2. Referral to the local
hospital was advised in a number of cases (e.g. for suspected
schisto-somiasis). Although they had to pay for investigation and treatment,
participants benefited because they did not have to pay for an initial medical
consultation. Individuals with gastrointestinal symptoms were offered
treatment for worms and giar-diasis (as per local medical practice). All
participants reporting symptoms were followed up to ensure their symptoms had
resolved.
All participants also completed two standard measures of eating attitudes and behaviour: the 40-item version of the Eating Attitudes Test (EAT; Garner & Garfinkel, 1979) and the Bulimic Investigatory Test, Edinburgh (BITE; Henderson & Freeman, 1987). The Eating Attitudes Test has been validated in a West African population (Oyewumi & Kazarian, 1992b). The study was conducted in English, the official language of instruction in Ghana but not the first language of most of the students. The schools covered a wide geographical area with several different languages. To ensure understanding, the scales were administered as structured interviews, despite being designed as self-report questionnaires (e.g. most of the students were unfamiliar with terms such as binge and diet). Depressive disorders were screened for using the mood module from the PRIMEMD (Spitzer et al, 1994).
All assessments were conducted by D.B., who has training in both mental state examination and tropical paediatrics. The study was granted ethical approval by the Northeast Ghana District Medical Officer and was approved by the head teachers of the participating schools.
Analysis
We first described the participants with very low weight (BMI <17.5
kg/m2, the ICD10 cut-off point for anorexia nervosa). We
then compared scores on the eating attitudes and behaviour scales across the
groups with very low weight (BMI <17.5 kg/m2), low weight (BMI
17.519 kg/m2) and normal weight (BMI >19
kg/m2). As the data were not normally distributed, non-parametric
statistical techniques were used.
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RESULTS |
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Religious fasting was reported commonly by the participants at interview, and in moderation this seemed to be a benign and culturally accepted activity. The schools discouraged such fasting. Participants who reported fasting identified their religion as either Christianity or Islam. The Christian churches included Catholic, Pentecostal and a number of Evangelical churches. Seventy-two of the 184 (39%) participants interviewed identified themselves as Christian and reported occasional fasting (mostly during Lent and a period in October). In addition, 13 of the 184 (7%) identified themselves as Christian and reported fasting once a week (usually just for a few hours), and 23 of the 184 (12%) reported fasting at least twice a week. Three participants reported fasting for a week at a time every 34 weeks (generally eating a small meal once a day). Twenty of the 184 (11%) participants identified themselves as Muslim and reported fasting during Ramadan only. In addition, 6 (3%) described themselves as Muslim and reported fasting at least twice a week.
Eating Attitudes Test
The EAT was used as a measure of anorexia-like behaviour. A score above 30
is considered suggestive of disordered eating. The results showed no
statistical difference between the three groups (BMI <17.5
kg/m2, BMI 17.519.0 kg/m2 and BMI >19
kg/m2; P=0.3) when the median total scores for the EAT
were compared (Table 2).
However, participants with a BMI <17.5 kg/m2 scored
significantly higher on the oral control sub-scale
(P<0.005). There was no difference between the three groups on the
other sub-scales, anorexic attitude, bulimia and food
preoccupation and dieting; this was in keeping with the
findings on clinical examination.
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Bulimic Investigatory Test, Edinburgh
The BITE was used as a measure of bulimic symptoms. No participant scored
above the cut-off point of 25 for the total score on the bulimia scale. Three
young women of normal weight reported being distressed by episodes of
overeating without any associated purging behaviour. None of the three
participants met the criteria for bulimia nervosa.
Case descriptions
Case 1
One student described only ever eating a small quantity of food and fasting
for the whole day, three or four times a week. She believed that by fasting
she would atone for her sins and God would help her in her studies. She was 16
years old and had a BMI of 17.45 kg/m2, an EAT score of 19 and BITE
scores of 8 and 6 (bulimia symptoms and severity, respectively).
Case 2
This young woman reported that she frequently felt pressured to eat by
other people and that other people felt that she was too thin. She scored
highly on the items relating to self-control. She would restrict her food
intake for 12 h daily, one week every month. She reported that she liked to
punish her body and that restricting her food intake concentrated her mind on
prayer. She had no symptoms of depression but reported feeling under pressure
from her father to perform well at school. She was 19 years old and had a BMI
of 17.21 kg/m2, an EAT score of 28 and BITE scores of 1 and 2
(bulimia symptoms and severity, respectively).
Medical assessment
When the 29 participants whose BMI was below 17.5 kg/m2 were
examined in more detail, physical illness (particularly malaria) might have
contributed to the low weight in 19 cases. Five of the 10 young women we
considered to have a primary eating disorder had recently been treated for
malaria. However, physical illness did not account for the distinct ideas and
beliefs motivating their self-starvation. Malaria is endemic during the wet
season, and everyone participating in the study (n=668) had received
treatment for it at some point.
Among the 10 low-weight young women who reported food restriction, one (BMI 17.41 kg/m2, EAT score 28) required treatment for worms. However, she reported restricting her food intake once or twice a week. Another (BMI 16.56 kg/m2, EAT score 15) reported recent pneumonia, malaria and had worms. Physical illness did not account for her attitude towards restricting her food intake. She reported frequent food restriction and that she enjoyed the sense of feeling hungry.
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DISCUSSION |
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Our findings suggest that beliefs associated with anorexia nervosa may differ between cultures. Although none of the individuals in these potential cases exhibited weight concern, they all showed other features of anorexia nervosa. Additionally, all 10 individuals viewed their resulting low weight positively. Their beliefs were also different from those of their peers, many of whom also reported religious fasting to varying degrees.
We wish to emphasise that our findings do not suggest that religious fasting equates to anorexia nervosa, but rather that it may be a risk factor similar to dieting, which has been established as a risk factor for anorexia nervosa (Patton et al, 1990). Dieting is common and in most cases does not lead to anorexic behaviour. Similarly, most of the religious fasting appeared to be a benign activity and did not appear to be linked to anorexia-like attitudes and behaviours.
Neither the EAT nor the BITE assessments were predictive of the 10 students who reported self-imposed dietary restriction.
In none of the 10 potential cases of anorexia nervosa was the condition severe. However, these young women reported deliberately restricting their food intake and viewing the resulting state positively. Anorexia-like conditions clearly exist in a spectrum of severity. None of the participants reported amenorrhoea. A large Canadian community study reported that amenorrhoea in anorexia nervosa suggests hypothalamic dysfunction but has low sensitivity in case definition (Garfinkel et al, 1996).
Physical illness might have been a partial explanation of the low weight in many of our cases. One shortcoming of the study is that none of the participants was screened for HIV infection or tuberculosis; although this could potentially explain the low weight, one would expect to have observed other stigmata of disease on detailed physical examination. It is estimated that 1% of pregnant women tested positive for HIV in the Bolgatanga area in the year 2000 (National AIDS/SDI Control Programme, Disease Control Unit, 2001). Neither condition would explain the distinct obsessional ideas of self-control and restricted dietary intake. Previous research has shown that eating disorders are likely to be an aetiological factor in contracting tuberculosis, rather than vice versa (Szabo, 1998).
Physical illness in the young woman with the BMI of 16.56 kg/m2 did not account for her attitude towards restricting her food intake, particularly her enjoyment of the sense of feeling hungry. It is difficult to determine in a cross-sectional assessment, but this individuals low weight might have predisposed her to contracting physical illness. Furthermore, the relationship between anorexia nervosa and physical illness remains poorly understood. It has been suggested that viral, bacterial or parasitic illness might trigger the onset of severe restrictive anorexia nervosa in biologically vulnerable people, possibly maintained by abnormal behavioural or neuroendocrine responses. The proposed mechanisms are speculative and clearly this is an area requiring further investigation (Park et al, 1995).
Asceticism and anorexia nervosa have long been linked, particularly in the historical context of the extreme fasting of saints such as Catherine of Siena (Rampling, 1985). There are a small number of case reports examining the relationship between religion and eating disorders. Morgan et al (2000) described a contemporary series of case reports in which the religious beliefs and the eating disorder pathology were linked. Bhadrinath (1990) reported the cases of three Asian adolescents with anorexia nervosa whose symptoms became more severe during the Muslim fasting month of Ramadan. There are other case reports of women with anorexia nervosa who have used religious motifs of asceticism relating to food and the body to express the personal meaning of their self-starvation. Banks (1997) described the case of Jane who viewed her self-starvation as fasting, which often coincided with the Christian Church calendar. She frequently fasted for 24 h on Saturday before taking communion on Sundays. The temporal relationship of the fasting behaviour with the Christian calendar was similar to that reported by the Ghanaian students.
The findings of this study need to be viewed within the context of growing cross-cultural research into eating disorders. There does appear to be some evidence that the cultural context can influence the development of disordered eating, for example the study by Becker et al (2002), which reported an increase in disordered eating and behaviours among ethnic Fijian girls following the introduction of television. However, other studies particularly those from Asian cultures have reported that weight concern is frequently absent (Khandelwal & Saxena, 1990; Lee et al, 1993; Lee, 1996). Weight concern in anorexia nervosa becomes more common as the degree of Westernisation increases (Lee et al, 1993).
We believe that our study is unique, as it is the only one to our knowledge involving detailed individual assessment of all the participants drawn from an African population. Previous African studies (Oyewumi & Kazarian, 1992a,b; Szabo & Hollands, 1997; Le Grange et al, 1998; Wassenaar et al, 2000) have failed to assess individually those who scored highly on measures of disordered eating with the application of diagnostic criteria. Our study suggests that the high rates of disordered eating previously reported may be unrelated to anorexia nervosa and may relate to obesity.
Limitations of the study
Approximately a third of the female population attend secondary school in
northern Ghana. This creates a bias towards higher social classes being
included in this study. However, the aim was to determine whether cases of
anorexia existed in a rural Ghanaian setting, not to conduct a prevalence
study.
The anorexia and bulimia scales were administered as interviews to ensure comprehension, although they have not been validated in this way. This is unlikely to have biased the results, as in all potential cases of anorexia the participants were interviewed clinically in addition to the structured assessment. Another potential limitation is that the study was conducted in English, the official language of instruction in Ghana but not the first language of most of the students. The assessments were conducted on one occasion only, and it is possible that the students who reported self-starvation might not have been entirely open about their beliefs or reasons for fasting. However, the questionnaires asked about body image in many different ways, so it is likely that this would have identified weight concern. The BMI cut-off value used is one chosen for Western adult populations and may not be appropriate for northern Ghana or younger girls. There is controversy about the best measure of anthropometric indices in adolescence; BMI for age or height for age might be more appropriate (Onis & Habicht, 1996). The nomination of a best friend of normal weight might have introduced some bias to the comparison group. Finally, the interviews were conducted by a single interviewer who was not masked to the participants weight status (D.B.)
Implications of our findings
The findings of our study suggest that anorexia nervosa may take different
forms in different cultures. We wish to make the case that the 10 young women
in our study who had self-starvation as the only detectable cause of their low
weight had a form of anorexia nervosa without weight concern. Studies
examining eating disorders in developing countries have assumed that the
psychopathology of anorexia nervosa follows the recognised
Western form. We wish to suggest that a unifying theme of the
diverse cultural presentations of this disorder is morbid self-starvation,
which may be driven in many ways. Morbid self-starvation may be the core
feature of anorexia nervosa, with the attribution for the self-starvation
behaviour varying between cultures.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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Received for publication September 17, 2003. Revision received May 24, 2004. Accepted for publication May 31, 2004.
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