Eating disorders amongst young persons in Malta : a nationally representative study of the prevalence and effect of eating disorders among young persons in Malta

Abstract

At any point in time several million people across the globe are affected by eating disorders. Eating disorders such as Anorexia Nervosa, Bulimia Nervosa and Binge Eating Disorder affect women more than men, with young female adolescents being the most at-risk group. However, there is growing awareness that this is not solely a young women’s issue, as men and older women are increasingly being diagnosed with eating disorders. These disorders devastate lives and have a high mortality rate. Their sociological and public health impacts make them major public health concerns. The duration and course of an eating disorder can be anywhere from a few years to around 15 years, with the detrimental effects on a sufferers’ life resulting in very real costs to person in terms of education, employment productivity and future security. The American Psychological Association (APA) defines eating disorders (EDs) as abnormal eating habits that can threaten health or even life. Eating disorders cause disruptions to normal perceptions and attitudes to food whereby, depending on the disorder, the sufferer exerts intense control, typical with anorexia nervosa, or loses control over their food intake, such as with binge eating disorder or bulimia. The 5th edition of the Diagnostic and Statistical Manual of Mental Disorders, (DSM-5, 2013), lists six main specific eating disorders and two other categories - OSFED (other specified feeding and eating disorders) and UFED (unspecified feeding and eating disorders), which are also clinical diagnoses. The most commonly recognised and prevalent of these disorders are Anorexia Nervosa (AN), Bulimia Nervosa (BN) and Binge Eating Disorder (BED). Another eating disorder, that is becoming increasingly prevalent and disturbing, in that it affects even the very young, is Avoidant/Restrictive Food Intake Disorder (ARFID) - previously referred to as Selective Eating Disorder (SED). Anorexia Nervosa (AN), or simply, Anorexia, is characterised by an extreme fear of gaining weight, an abnormally low body weight and a distorted perception of weight. Persons suffering from anorexia have a strong wish to control their weight and shape and use extreme efforts, including starvation, to achieve this objective. The pursuit of the anorexic ideal has a significant effect on the life of sufferers, yet leaves them dissatisfied. No matter how much weight is lost, sufferers remain fearful of weight gain and experience a constant desire to lose more weight. This is because anorexia is not about weight or food. It is a dangerous and unhealth psychological way to exert control over emotional or psychological problems. Anorexia, Despite being the rarest of the eating disorders, anorexia is perhaps the most renowned and has the highest mortality risk of all the Eds, and the lowest recovery outcomes. Bulimia Nervosa (BN), or Bulimia as it is usually referred to, is characterised by frequent and uncontrollable episodes of overeating or binges, habitually consisting of the consumption of thousands of calories in a single sitting, accompanied by extreme efforts to avoid gaining weight. These behaviours set up a vicious cycle that wreaks havoc on body and mind, and tend to be accompanied by extreme secrecy and feelings of shame. Binge Eating Disorder (BED), is compulsive eating without purging behaviours. It is characterized by recurring episodes of excessive food consumption over a short period of time, often to the point of discomfort. As a result, sufferers are highly likely to be overweight or obese. This loss of control over food intake is accompanied by feelings of shame and guilt. Typically binge eaters are dissatisfied with their body shape, but this is not accompanied by body image distortion as with AN or BN. Avoidant/Restrictive Food Intake Disorder (ARFID), is a type of extreme picky eating or food phobia that is characterised by a restriction or avoidance of certain foods that sufferers find themselves unable to eat - to the extent that sufferers cannot meet their nutritional needs through food intake alone. Often whole food groups will be excluded, such as meat or green vegetables, which, besides causing clinical nutritional deficiencies to persons suffering from this condition, also interferes significantly with the sufferers’ life. Eating disorders arise for complex reasons and usually centre around a desire to control food intake, whereby, what starts as an attempt to lose weight or eat healthily, can spiral out of control. There is not usually one, single, cause for an eating disorder, and much less expert agreement as to what causes EDs. Rather there may be various causes at the root of a disorder. Aside from attempts to diet, family dynamics and genetic factors are shown to have significant influence on the predisposition to eating disorders. A family history of eating or mental health disorders, as well as exceedingly high family expectations, particularly in the case of female suffers, are indicated as possible causes. Psychological and emotional factors such as anxiety, depression, stress and low self-esteem, as well as abuse and childhood trauma, can also trigger an eating disorder. Other factors thought to be significant risk stimuli for eating disorders are self-esteem and body dissatisfaction issues linked to impossible ideals of female beauty - and nowadays even male ideals - on traditional and social media. The epidemiology of eating disorders provides information about trends in frequency and occurrence of eating disorders over time. Despite challenges in data collection, the epidemiological study of EDs remains extremely important in providing a general picture of how these disorders develop and progress. Epidemiological studies show that the most studied cohort is 15-19-year old females, and that eating disorders are on the increase in non- Western countries, as well as being on the rise among men and older women. Prevalence data shows that lifetime prevalence for a full threshold ED is 2.9% for females and 0.1% for males. For sub threshold EDs, lifetime prevalence figures are 2.2% for females and 0.7% for males (Nagl et al., 2016). Persons afflicted with eating disorders suffer a number of adverse medical and psychological problems. Eating disorders put the body under great strain and the medical impact of an eating disorder touches every organ system in the body (Jahraus, 2018). Eating disorders have various physical effects, such as fatigue, they disrupt natural growth, have detrimental effects on the circulation and nervous system, can cause cardiac and renal difficulties and chronic pain. Although some of these effects can be reversed once detrimental feeding behaviours are stopped, some health consequences can be lasting. The negative outcomes are even more severe for children and adolescents. As well as impacting health, eating disorders also cause significant disturbance to an individual’s social and psychological wellbeing. Eating disorders, particularly Anorexia and Bulimia, have the highest mortality rate of all the psychological illnesses. Suicide attempts are common among patients with EDs, particularly sufferers of Anorexia. Given the several adverse consequences of EDs on every area of a patients’ life, and the diminished quality of life that sufferers lead, identifying and treating EDs is crucial. The earlier the patient is diagnosed and treatment started, the better the outcome. Awareness of EDs by primary care professionals and specialists is extremely important. The consensus nowadays is that best treatment practice is a multidisciplinary and tailored approach that will treat the physical and medical aspects of the disorder, as well as psychological factors and other attributes.