|Year : 2013 | Volume
| Issue : 3 | Page : 313-317
Eating disorders among Omani adolescents attendees at a tertiary care center
Hassan Mirza, Hamed Al Sinawi, Naila Al Ruqaishi
Department of Behavioural Medicine, Sultan Qaboos University Hospital, Oman
|Date of Submission||23-Oct-2012|
|Date of Acceptance||19-Dec-2012|
|Date of Web Publication||10-Jul-2013|
P.O. Box 1340, Ruwi, PC 112
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Eating disorders are serious illnesses with significant impact on both physical and socio-emotional health of young people; they also have a negative impact on families and cause significant mortality and morbidity. This case series discusses seven Omani adolescents who have been diagnosed with an eating disorder at the Department of Behavioural Medicine at Sultan Qaboos University Hospital, Oman. The aim of this case series was to increase the level of awareness of eating disorders among Oman's health-care professionals and most importantly, to highlight the complexity and difficulties faced in managing these adolescents.
Keywords: Adolescents, anorexia, eating disorder, Oman
|How to cite this article:|
Mirza H, Al Sinawi H, Al Ruqaishi N. Eating disorders among Omani adolescents attendees at a tertiary care center. Int J Nutr Pharmacol Neurol Dis 2013;3:313-7
|How to cite this URL:|
Mirza H, Al Sinawi H, Al Ruqaishi N. Eating disorders among Omani adolescents attendees at a tertiary care center. Int J Nutr Pharmacol Neurol Dis [serial online] 2013 [cited 2018 Jul 23];3:313-7. Available from: http://www.ijnpnd.com/text.asp?2013/3/3/313/114833
| Introduction|| |
Eating disorders are a group of conditions characterized by abnormal attitude toward food, being it insufficient oral intake or overeating, that have a detrimental effect on both physical and mental health. Although eating disorders are classified into many subtypes; the most common are anorexia nervosa, bulimia nervosa, and compulsive overeating. Individuals suffering from eating disorders carry a significantly higher mortality rate, with anorexia nervosa having the highest mortality rate of 18% in some studies. ,
Despite emergence of eating disorders in the Arab world, studies from other non-Western communities around suggest that eating disorders do not manifest as clinical phenotype as those described in International Classification of Diseases, 10th Edition (ICD-10). In Oman, various studies have indicated that youth are prone to succumb to eating disorders. , Some of the previous studies have raised doubt on the applicability of the present diagnosis criterion for the Omani population. , However, these studies were based on a community survey, and the present aim is to oversee whether some of the correlates of an individual with abnormal attitude toward food, echoes the socio-demographic situation and clinical variable as reported elsewhere among the clinical population attending mental health unit at a tertiary care hospital.
Eating disorders, in general, and anorexia nervosa in particular, have long been regarded as disorders of the Western societies. Nevertheless, since the late 1970s, cases of eating disorders have been reported in non-Western societies as well.  Eating disorders were long considered as "Western culture-bound syndromes," while non-Western societies were known to possess some degree of immunity against such disorders, as plumpness has been regarded as a symbol of beauty, prosperity, and fertility. , However, recent studies have demonstrated an increase in the prevalence of eating disorders in the non-Western societies, which were deemed immune in the past. 
Although numerous studies conducted in the Arab World have elicited disturbed eating habits among Arabs. ,,, no population-based prevalence survey has been performed. However, the prevalence of eating disorders in non-Western countries is lower than that of the Western countries, but appears to be increasing. 
Multiple theories have been suggested for the etiology of eating disorders. One of the most popular ones is the major role of media in encouraging calorie watching and slimness;  other theories include fear of maturation, separation from a maternal figure, and the development of secondary sexual characteristics. What patients themselves nearly always say is that the central feature for them is that they fear loss of control and that this is countered by the increase sense of self-control from strict dieting and from being able to determine one's size and shape.
| Case Reports|| |
A 14-year-old Omani boy was brought by his parents to the psychiatric clinic in Sultan Qaboos University Hospital (SQUH) with a 1-year history of poor appetite and significant weight loss. He had gradually reduced his oral intake and had started spending most of his time studying. He was an above-average student who wished to excel in all subjects so that he could become a pilot. He did not have a distorted body image nor did he possess a persistent dread of fatness. He was described by his parents as a very stubborn and perfectionist child who liked controlling things and both parents had expressed their frustration and failure to control their child. One day prior to the presentation at SQUH, he was found unconscious at home and was rushed to the Accident and Emergency Department, where upon assessment and thorough investigations, his blood sugar was found to be 2.8 mmol/L, and his potassium level was 2.5 mEq/L. On examination, he was emaciated with a body mass index (BMI) of 16.5, lethargic, hypothermic, bradycardic, and hypotensive. He was admitted in the psychiatric ward where he remained negativistic, resisted any form of oral intake, and refused nasogastric tube insertion. He was started on IV fluids, dextrose normal saline, with addition of potassium chloride to correct the hypokalemia. However, repeated attempts to increase his weight had failed, and psychotherapeutic sessions were ineffective due to the patient's resistance. It was suggested to the parents that the child be taken abroad for treatment as we lacked specialized service for treating eating disorders in Oman. The clinical presentation of this patient did not meet the ICD10 diagnostic criteria of anorexia nervosa, but can be classified as eating disorders not otherwise specified (EDNOS).
An 18-year-old Omani girl was referred to the psychiatric clinic at SQUH after extensive medical investigations could not find the cause of her weight loss. She came accompanied by her mother who started the conversation by saying "my daughter has been vomiting after every meal she eats for the last 4 years, and she lost significant weight." She denied inducing vomiting or having any intention of losing weight or distorted body image, nor had she any depressive symptoms. She also experienced syncopal attacks and felt lethargic most of the time. On examination, she was severely underweight with a BMI of 9.8, pale, bradycardic, and hypotensive. Her blood investigations showed very low level of hemoglobin, i.e., 5 mg/dL, and she was hypokalemic with potassium level of 2.7 mEq/L. Her anemia was managed with blood transfusion, and her hypokalemia with KCL infusion. During her stay in the hospital, she gained minimal weight, as her vomiting was controlled by antiemetics. However, her condition ran a chronic course with multiple admissions without notable improvement. The case was diagnosed as EDNOS.
An Omani male teacher, aged 21, was referred from a regional hospital with a long history of poor appetite associated with significant weight loss for which no organic etiology could be identified. His condition started at the age of 13 when he started dieting as he believed he was overweight; his weight back then was 64 kg with a BMI of 28. Over the following 6 months, he lost 25 kg and his BMI dropped to 17, which eventually affected his scholastic performance and overall function. During that time, he was taken by his family to a local healer, following which he was reported to have gained reasonable amount of weight and returned to his premorbid self. He remained in complete remission for the next 5 years; however, he relapsed at the age of 18. The second episode was characterized by poor appetite and preoccupation with food, and postprandial feelings of guilt, anxiety, and depression. However, he did not seek any medical help for 3 years, and when assessed eventually, he weighed 36.2 kg with a BMI of 12.8.
No identified trigger was reported. He refused admission and he was started on paroxetine 10 mg and multivitamins supplement. He did not present again and lost his subsequent follow-up appointment, the social worker could not contact him either. The case met the ICD-10 criteria of anorexia nervosa.
An Omani girl, aged 17, was referred to psychiatry clinic for assessment of repetitive vomiting and weight loss after being thoroughly investigated to no avail. She first developed the symptoms at age of 13. The episodes of vomiting were not self-induced, and were psychogenic in nature. On examination, her BMI was 12.5. She was admitted and treated as an in-patient for almost a year. Her management initially constituted of nasogastric feeding and psychotherapy, however, the improvement remained minimal. Subsequently, she developed low mood, social withdrawal, poor sleep, and ideas of self-harm. Due to her associated mood symptoms, she was started on fluoxetine 20 mg OD. Although her affective symptoms subsided with fluoxetine, her eating behavior remained the same. Throughout the years, she did not meet the criteria of a specific eating disorder.
An 18-year-old Omani girl who had been suffering from anorexia nervosa since the age of 13 presented to the Accident and Emergency Department with drug overdose with an unknown quantity of promethazine tablets. She gave history of low mood, poor sleep, refusal to eat and fear of gaining weight. On examination, her BMI was 15.4. She was started on fluoxetine 20 mg once daily, which eventually was increased to 60 mg once daily, along with psychotherapy. Throughout the course of her illness, she had multiple admissions but her weight remained constant, however, she did show improvement in her depressive symptoms, but there was no change in her eating habits. Her condition meets the diagnostic criteria of anorexia nervosa, as throughout the course of her illness her weight has been 15% below the expected weight, the weight loss is self-induced due to a distorted body image. Her family is very supportive of her and no dysfunction was observed in the family dynamics.
A 16-year-old Omani girl was referred by a physician after being admitted in the intensive care unit for two days. She was brought to the Accident and Emergency Department by her parents, feeling tired and weak with history of fainting episodes. On physical examination, she was emaciated with low body weight of 35 kg and BMI of 13.3. She was dehydrated, hypotensive, and had bradycardia with pulse rate of 45 beats per minute. Investigations showed hypoglycemia, pancytopenia, hypocalcemia, and severe hypokalemia that caused occasional arrhythmias. After hydration and electrolyte imbalance correction, she was referred to psychiatry for evaluation as she was refusing to eat and had intense fear of becoming fat despite her extremely low weight. Her eating habits changed at the age of 14 when she started dieting with a group of friends at school, at that time her weight was in the normal range for her age and height, and her BMI was 20.3. During the course of her illness, she used to eat only one apple throughout the day, which eventually became half an apple. She exhibited a morbid fear of fatness, a relentless pursuit of thinness, and a distorted body image. There was associated low mood, loss of interest, social isolation, and gradual decline in her school performance. The dynamics of her family revealed that her father had a dominant personality and liked to establish his authority at home, she described him as a very strict man who always won any argument he got into. She was admitted and treated as an in-patient. The initial goal of the treatment was maintaining a gradual weight gain of 1-2 kg/week, which was successfully achieved, in combination with psychotherapy, to which she showed good response She was discharged with a adequate BMI. This case was among the very few cases of anorexia nervosa with very good response to treatment.
An Omani boy, aged 16 was referred by a physician for a psychiatric assessment regarding his morbid obesity due to overeating. On further history, the parents said that their son had been eating large amounts of food throughout the day and had been gaining significant weight. The symptoms were first noticed when he was 12 years old. On assessment, his weight was 125 kg with a BMI of 48.8. His younger brother suffered from the same condition and died at the age of 13 while asleep. He also suffered from dyslipidemia, and he was hypertensive. He was admitted in the medical ward and was started on a diet program, he did lose weight while on diet but he remained morbidly obese. After discharge, he returned to his old eating habits and put on excessive weight again. He expressed feelings of sadness and blamed his father as the main reason for his condition. He said that his father was trying to control his life and asked too much from him. The father said that all he was doing was disciplining his son who was disobedient, not performing prayers, and masturbating while watching pornography on his mobile phone. Fluoxetine was advised but the patient refused, and psychotherapeutic sessions did not show much improvement either. Although the adolescent continued to be in distress, the father showed very little support for his son, and blamed his obesity and overall poor health to being a disobedient and rebellious teenager.
| Discussion|| |
The etiology of eating disorders remains poorly understood.  In this case series, we discuss the different plausible etiological risk factors available in literature, and try their applicability to the cases studied.
High socio-economic status (SES) has long been regarded as a risk factor for eating disorders, and those that belong to high SES are more likely to watch calories, diet, and have a lower body weight.  And it has been hypothesized that non-Western societies, as they become more affluent, develop a higher risk of eating disorder. For example, a study by Lee and Lee supports this association,  the study compared eating pathology with three socio-economic zones in China, and it found that body dissatisfaction and eating disturbance was greater among schoolgirls of the more affluent zone. Similarly, there were no reports of anorexia nervosa in the ethnic minority groups in USA back when they were not among the affluent groups of the society.  However, in recent times, African-American women from high SES have reported similar levels of body dissatisfaction when compared to North-European American women.  In the cases discussed in this study, none of the patients were of affluent background two were part of a middle-working-class family, whereas five were from lower-middle class working families [Table 1]. Therefore, it is argued that increased wealth is not proportional with increased prevalence of eating disorders, and eating pathology is no longer restricted to high SES. ,
Family dynamics and function have long been linked with anorexia nervosa.  However, a review of the literature has yielded inconsistent findings.  And if the function of a family is considered pathological, then that depends on support of members of that family for such a pattern of function.  For example, it is a cultural norm in Asian and Middle-Eastern families for the head of the family to exercise authority, and therefore, what is considered overprotection and rigidity in some societies may not be perceived similarly in another.  And although paternal rigidity may be a norm in some cultures, cases six and seven of this series have expressed disapproval of such authoritarian pattern.
Moreover, psychological control has been hypothesized to play a major role in the development of eating disorders.  For example, the desire to control one's own life and the power to control within a family setting may develop and maintain anorexia nervosa,  and because control over eating provides objective, direct, and tangible evidence at self-control,  such hypothesis is evident in case one.
Furthermore, in this case series, the age of onset vis-a-vis age of presentation to the medical services has been long, the average duration in years is 3.8 [Figure 1]. Such late presentation can be one of the reasons that explain the poor response to treatment and poor psychotherapeutic alliance. There can be few explanations for such late presentation, firstly, lack of awareness and understanding of eating disorders among the families of the patients. Secondly, the explanatory model, and attitude toward mental illness that the family possesses, as it is not uncommon for Middle-Eastern families to seek help of folk healers for mental disorders, which can lead to delay in seeking professional help.
|Figure 1:Age at onset vs. age at presentation in Omani adolescents with eating disorders|
Click here to view
|Table 1: Socio-demographic background of Omani adolescents with eating disorder|
Click here to view
Finally, eating disorder symptoms present in five out of seven cases in this series do not meet the criteria of a specific eating disorder such as anorexia nervosa [Table 2]. This area needs further research to determine the cluster of eating disorder symptoms in Arab youth to facilitate early detection and treatment.
| Conclusion|| |
This case series concurs with emerging evidence that eating disorders are no longer exclusive to the affluent society though their etiological factor remain unestablished. Also, the presentation of eating disorder among youth in Oman can be different and may not meet the criteria for a specific eating disorder. It therefore appears that most people with something akin to eating disorder are likely to receive EDNOS in clinical settings in Oman.
Despite an increase in the incidence of eating disorders in non-Western societies, early detection remains poor and response to treatment remains minimal. Therefore, media can play a crucial role in improving public awareness about eating disorders, and validated screening tools can be used for early detection of subtle cases, as well as setting up specialized units for optimal management of the cases.
| References|| |
|1.||Hoek HW. Incidence, prevalence and mortality of anorexia nervosa and other eating disorders. Curr Opin Psychiatry 2006;19:389-94. |
|2.||Arcelus J, Mitchell AJ, Wales J, Nielsen S. Mortality rates in patients with anorexia nervosa and other eating disorders. A meta-analysis of 36 studies. Arch Gen Psychiatry 2011;68:724-31. |
|3.||Al-Adawi S, Dorvlo AS, Burke DT, Al-Bahlani S, Martin RG, Al-Ismaily S. Presence and severity of anorexia and bulimia among male and female Omani and non-Omani adolescents. J Am Acad Child Adolesc Psychiatry 2002;41:1124-30. |
|4.||Al-Adawi S, Dorvlo AS, Burke DT, Moosa S, Al-Bahlani S. A survey of anorexia nervosa using the Arabic version of the EAT-26 and "gold standard" interviews among Omani adolescents. Eat Weight Disord 2002;7:304-11. |
|5.||Vandereycken W, Deth RV. From fasting saints to anorexic girls: The history of self-starvation, 1994. Available from: http://www.cabdirect.org/abstracts/19941407456.html; jsessionid=8A263CF44ED2E5B06BAEDC75E76E2C47. [Last cited 2012 Jul 30]. |
|6.||Nasser M. Culture and weight consciousness. J Psychosom Res 1988;32:573-7. |
|7.||Rucker CE, Cash TF. Body images, body-size perceptions, and eating behaviors among African-American and white college women. Int J Eat Disord 1992;12:291-9. |
|8.||le Grange D, Stone AA, Brownell KD. Eating disturbances in white and minority female dieters. Int J Eat Disord 1998;24:395-403. |
|9.||Eapen V, Mabrouk AA, Bin-Othman S. Disordered eating attitudes and symptomatology among adolescent girls in the United Arab Emirates. Eat Behav 2006;7:53-60. |
|10.||Nasser M. Screening for abnormal eating attitudes in a population of Egyptian secondary school girls. Soc Psychiatry Psychiatr Epidemiol 1994;29:25-30. |
|11.||Makino M, Tsuboi K, Dennerstein L. Prevalence of eating disorders: A comparison of Western and non-Western countries. Med Gen Med 2004;6:2004;6:49. |
|12.||Hepworth J. The social construction of anorexia nervosa. London Sage Publications; 1999. |
|13.||Soh NL, Touyz SW, Surgenor LJ. Eating and body image disturbances across cultures: A review. Eur Eat Disord Rev 2006;14:54-65. |
|14.||Rogers L, Resnick MD, Mitchell JE, Blum RW. The relationship between socioeconomic status and eating-disordered behaviors in a community sample of adolescent girls. Int J Eat Disord 1997;22:15-23. |
|15.||Lee S, Lee AM. Disordered eating in three communities of China: A comparative study of female high school students in Hong Kong, Shenzhen, and rural human. Int J Eat Disord 2000;27:317-27. |
|16.||Bruch H. Eating disorders: Obesity, anorexia nervosa, and the Person within. London: Basic Books; 1973. |
|17.||Polivy J, Herman CP. Causes of eating disorders. Annu Rev Psychol 2002;53:187-213. |
|18.||Nasser M. Culture and weight consciousness. New York: Routledge; 1997. |
|19.||Fear JL, Bulik CM, Sullivan PF. The prevalence of disordered eating behaviours and attitudes in adolescent girls. NZ J Psychol 1996;25:7-12. |
|20.||Weiss MG. Eating disorders and disordered eating in different cultures. Psychiatr Clin North Am 1995;18:537-53. |
|21.||Bulik CM, Sullivan PF, Fear JL, Pickering A. Outcome of anorexia nervosa: Eating attitudes, personality, and parental bonding. Int J Eat Disord 2000;28:139-47. |
|22.||Olson DH. Circumplex model of marital and family sytems. J Fam Ther 2000;22:144-67. |
|23.||Tsai G. Eating disorders in the far east. Eat Weight Disord 2000;5:183-97. |
|24.||Surgenor LJ, Horn J, Plumridge EW, Hudson SM. Anorexia nervosa and psychological control: A reexamination of selected theoretical accounts. Eur Eat Disord Rev 2002;10:85-101. |
|25.||Fairburn CG, Shafran R, Cooper Z. A cognitive behavioural theory of anorexia nervosa. Behav Res Ther 1999;37:1-13. |
[Table 1], [Table 2]