Anorexia nervosa was rare before the 1960s. Bulimia and binge eating disorders didn’t even exist, at least not as diagnosable entities anyway. By the 1970s, however, many developed nations began experiencing a sharp rise in the incidence of these eating disorders. Within approximately the same timeframe, there was also a sharp rise in the rate of obesity. A coincidence? Of course not.
Genetics plays a role. However, the rapidity with which these problems arose points, overwhelmingly, to changes in environment and behaviour (in other words, lifestyle) as the key causal factors. One obvious and oft-cited environmental factor is the rise of consumer culture, fuelled as it is by relentless and aggressive advertising. For example, the frequent use of unrealistically thin models to promote products, including chocolate bars, sends mixed messages. The explicit message is: “consume”, while the conflicting implicit message is: “starve”. It is easy to see how such contradictory communication can be mapped to anorexia (starve), obesity (consume) and bulimia (consume and starve).
Given the epidemiological similarities and shared psycho-social factors associated with eating disorders and obesity, one might expect greater conceptual integration. However, to date, these overlapping eating and weight-related behavioural problems are still viewed and treated very separately. Typically, those interested in the body (physicians) tackle obesity, while those fascinated by the mind (psychiatrists/psychologist) focus on eating disorders. This, of course, is an oversimplification, but not an excessive one.
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This separation of mind and body is even more absurd when we consider the degree to which obesity and eating disorders overlap and co-occur. For example, binge eating disorder (BED) is known to go undiagnosed in about 30 per cent of obese people attending weight loss clinics. Similarly, obese and overweight individuals are at a much higher risk of engaging in bulimic-style weight control strategies, such as self-induced vomiting, laxative abuse and other compulsive compensatory forms of behaviour.
This failure to integrate obesity and eating disorders means that we miss valuable opportunities for health promotion, and we may indeed also be creating future problems for ourselves. For example, a study undertaken in Al Ain, published in the Bahrain Medical Bulletin, reported a 48 per cent obesity rate for Emirati women between the age of 30 and 39. The article goes on, and rightly so, to make recommendations about increasing obesity prevention activities. However, the same study also reports a rate of 28 per cent underweight among the same population. In relative international terms, this is an extremely high rate. However, the article makes nothing of it. It is almost as if we have forgotten that being underweight is a health problem, too. Apart from being one of the diagnostic criteria for anorexia nervosa, emaciation is associated with a whole host of physical health complications, including endocrinological complaints (infertility), haematological problems (anaemia, leukopenia) and skeletomuscular conditions (osteoporosis).
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Another problem arising from our failure to view obesity and eating disorders as an integrated spectrum of food and weight loss problems is the conflicting messages people receive as part of disjointed preventative initiatives. For example, the overly zealous anti-obesity campaign might unintentionally promote excessive weight and shape concern, also providing the individual with a rationale for unhealthy weight loss practices, for example, pseudo-veganism. Who could insist on their child finishing a meal when the child (secretly an aspirant cat-walk model) is claiming diabetes-prevention as the rationale for her ever-decreasing portion sizes and her born-again veganism? An integrated approach to food and weight-loss problems would be better able to address these issues, preventing the iatrogenic effects associated with having separate programmes of prevention.
Earlier this month, Dubai hosted the first USA Healthcare Symposium and Showcase on Nutrition, Obesity and Diabetes, an event designed to strengthen connections between US and UAE experts focused on new approaches to nutrition, obesity and diabetes. International cooperation and interdisciplinary dialogue are always commendable. However, I hope the second symposium will integrate eating disorders and place equal emphasis on the implications of over and undernutrition.