Muslim Men and Eating Disorders

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Male Eating Disorders

I would like to start this post by Thanking Maha S Sulaiman Younis, Chair of The Department of Psychiatry at College of Medicine-Baghdad University. Thank you so much for your case study on Muslim Male Anorexia. Thank you so much for responding to my E-mail at such insane hours in the morning. I salute you for your courage and your insight into psychiatric illnesses in the Arab world. Iraq and Iraqis have gone through decades of wars, conflicts, mass murders and genocides and you did not allow anything to become an obstacle in your path of learning and helping people. Thank you and lots of prayers and peace for Iraq and rest of the world.

I know Eating Disorders don’t discriminate and affect everyone, but coming across cases of several Muslim males who are suffering from this pandemic is still a shocking revelation to me. Coming across a young Muslim Man and his obsession with losing weight and eating very healthy and very selective food was indeed staggering. People with anorexia avoid maintaining a normal body weight by severely restricting what they eat.  This can be aided by rigorous exercise and other weight loss practices.What is really distressing is how he and his family are reluctant to seek help for this ailment. Of course he is unwell and does not recognise the problem but his family knows very well that something is not right with him. What is even more disconcerting is that despite all this influx of information, his family is not willing to compromise on their stance. According to his mother this is a phrase he is going through and he will eventually pull out. He comes from an affluent family and the mere fact that their son is suffering from an ED is well seen as a breach of family’s honor- if the word gets out then entire family will feel great shame.

How do they know he is suffering from Eating Disorder, Anorexia Nervosa? It was diagnosed by their school’s practitioner.

Sadly, Eating Disorders are still a largely unrecognised problem in Muslim communities.

What I find very troubling is that how many of the features which seem to typically affect females are affecting him.  I thought males who suffer from eating disorders are those who are sports personalities, actors and etc. Underweight and thinness is something I always associated with female faction of the society.

Case scenario-  If this is not ED then what is ED?

According to his sister, last year her brother became interested in health and fitness and started using gym at home to train regularly. It was a simple quest to lose weight.  His family did not notice any changes but his school became concerned about the change in his personality. In past few months he has become more irritable and loses his temper over trivial matters. Also he spends hours grooming himself in the morning. He wants his image to be perfect but he is never satisfied. What is amazing about this boy is that how outstandingly genius he is. His grades are at the top end of the school average. He does not eat after 3 pm and spends 4 -5 hours a day exercising.

Did he reach his Ideal Weight?

He never reached his ideal body weight, because anorexia nervosa has begun. He will reach his ideal weight only after he beats this illness and approaches recovery.

What do I see here?

I learnt one thing with my Eating Disorder that when your habits cause behaviours over which you lose voluntary control then you need to accept that you have a serious problem. When an occasional eating disorder activity turns into something lethal that dominates your thoughts then you need help (for example a diet that with time turns into a behaviour that all of a sudden seems to take over your life). If a certain behaviour can be characterised as obsessive, compulsive or addictive and disrupts your daily life and affects the lives of those around you, then you need to accept that you need professional medical help.  If this is dealt in earlier stages then the chances of one recovering and leading a normal life are much greater. With time it can be almost impossible to regain control without medical intervention.

Male Eating Disorder Problems in Muslim World

No we don’t have statistics for this either. We are still desperately trying our level best to brush eating disorders under the carpet. We need to remember that nothing is won by brushing key issues under the carpet. Our history of health care is full of such mistakes where our medical faculties simple refused to accept modern pandemics that affected the health care systems. Eating Disorders are an imminent reality and have become a social dilemma in our society.  It’s really sad how we are so behind when it comes to mental health and recognising the seriousness of these issues. Eating Disorders have become a widespread problem in many Muslim countries across the world. The United Arab Emirates is at the forefront with this problem.  According to a recent study conducted by university students in the UAE, three quarters of young Emiratis have body issues, and one in five is in need of clinical intervention. It isn’t the first indication that eating disorders are on the rise here: an earlier study conducted at the end of 2012 noted the increase in negative body image among students in Dubai, blaming the influence of westernisation. In UAE there is a staggering rise in adolescent eating disorders. Dr Justin Thomas, from Zayed University, and Sabrina Tahboub-Schoult, from the American University of Sharjah, found the alarming results during a study of 361 undergraduates – 284 women and 77 men. The two most common eating disorders are anorexia and bulimia. And while one study found the ratio of female to male adolescents with eating disorders was 6 to 1, Dr Luthra warned there was increasing pressure on adolescent boys to take up bodybuilding and even steroids.

The researchers pinned much of problem on rapid social change, which has affected men and women almost equally.

My limited understanding from Media is that men are  also becoming more and more worried about their appearance and perhaps this is one factor that is leading towards the development of Eating Disorders. We all know how these images in media are simply a lie- if these people have not undergone surgeon’s knife then their imperfections have been digitally removed. Movie stars like Tom cruise and Sylvester Stallone are much shorter in real life.  It is sad how many of us are taken in by these images, and we allow our self-esteem to be diktated by such external forces.

I was reading an article by Karen Phillips on Male Eating Disorders and according to her one out of ten patients with eating disorders is a man meaning that men are 10% of all eating disorders sufferers.  

 Karen Phillips on Male Eating Disorders

Clinicians agree that diagnosing anorexia and bulimia in men is more difficult than it is in women despite identical behaviours. Men are also much more likely to be diagnosed with depression associated with appetite disturbances.
A large proportion of men suffering from eating disorders are athletes. There is a tendency among male-athletes to diet or avoid certain foods in order to achieve a target weight or body image.
Other occupations which are prone to developing eating disorders are horse racing, modelling, dancing, distance running and driving.

The lack of visibility of eating disorders in men means a number of things.

First, men don’t discuss anorexia-bulimia problems and they don’t share their information with other men.  Most of them think that the topic is a female issue.
Secondly, men associate beauty with body mass, muscle bulge and definition, not weight loss.  For many men admitting that they have an eating disorder can undermine their masculinity. This makes men keep their secret about their eating problems to themselves if they have one.
Thirdly, men think that society expects them to be tough and seeking help for emotional problems (especially something related to food) makes many males feel uncomfortable, so they don’t do it.

Nevertheless, the statistic shows that:

–          About 3% of men diet all the time or at least ten times a year.

–          About 10-14%   of young men deliberately vomit after meals in order to control weight and/or relief their stressful feelings.

–          Up to 21% of men have history of binge eating (when they binge food to moderate their emotions).

The latest studies also showed that psychologically male eating disorders are similar to female eating disorders. They both have similar emotional grounds and start for similar reasons.

What are the kind of strategies we can use for prevention and early intervention of male eating disorders?

  1.  We should recognise that eating disorders do not discriminate on the basis of gender and men can be affected the same as women.
  2.   We need to learn about the warning signs of eating disorders in men:  weight fluctuations, extreme concerns about weight and body image, general withdrawal from others, extreme fussiness regarding eating certain foods, mood swings, frequent measurements of their own body and weight, counting calories and reading food labels, overexercising and the like.
  3.    We must understand that certain activities and professions (being an athlete, actor, dancer, jockey etc.) put men at risk of developing eating disorders.
  4.  We should talk with young men about cultural attitudes to “masculinity” and how it is portrayed by media.
  5.   Should never emphasise body size or shape as an indication of a man’s worth or identity as a man.
  6.    We should confront others who try to tease men who do not meet traditional cultural expectation for masculinity.
  7.    As parents and teachers we should listen carefully what young men are saying about their feelings and emotions and take them seriously.
  8.  All fathers should understand their important role in the prevention of eating problems in their sons by not degrading them if they are not interested in sport or other so called manly events.
To conclude, male eating disorders are an important issue nowadays. Understanding, talking openly about these problems will help enormously to fight it. Encourage men to talk and share their experiences will be the first important step to overcoming it.

Case Study on Muslim Male suffering From Anorexia Nervosa

Adolescent male with anorexia nervosa: a case report from Iraq

Maha S Younis and Lava D Ali

This is the first reported case of an adolescent male with anorexia nervosa in Iraq. This disorder is believed to be rare in males across cultures and uncommon for both genders in Arab countries. The patient met the DSM-IV diagnostic criteria for anorexia nervosa. He was hospitalized and received medical and psychiatric treatment at local facilities as discussed below and responded well to treatment.

Many Arab societies do not consider being overweight a stigma, but instead a sign of good health. Thus, anorexia nervosa is scantily documented in the Arab world except for a study by Al-Awadi . Findings revealed that 10.9% of Omani males had disturbed eating attitudes. However, there are no population-based prevalence surveys of AN in the Arab world, and all available published reports agree on its rare incidence. The case reported here shows the awareness of being overweight that was sensed at the age of 14, prompted by the harsh comments of the patient’s friends. This case reflects anorectic symptoms and signs at an early age, possible due to the athletic ambition of boys in their early teens who want to build a more muscular body.

Case presentation

MR was a 14-year-old Muslim Kurdish student living in Sulimania, northeast of Iraq. His parents were of an educated middle class family who enjoyed good health and stable relationships. He was brought by his mother to the hospital on 18th July 2010 for refusing to eat, which had led to severe weight loss and generalized weakness. His condition began seven months prior when his friends teased him about his plumpness and greedy appetite. Consequently, he started restricting his food intake, avoiding high-calorie foods and indulging routinely in extensive exercise. His parents tried to convince him to eat regular meals, but he refused. He was obsessed about his body shape and measured his waist and thigh circumferences regularly. His food intake decreased rapidly until his daily meal became no more than a cup of yogurt and pieces of cucumber. A few weeks before his visit to the hospital, he experienced severe fatigue, headaches, joints aches and attacks of epigastric pain followed by vomiting. He was treated by the local doctor with multivitamins, anti-emetics and anti-spasmodics, but without improvement.

The patient seemed to be overprotected by his mother. He was the youngest of seven siblings and a clever boy. She described him as being a graceful and obedient child, but somewhat of a perfectionist. There was neither a history of physical or mental illness nor sexual abuse during childhood.

On admission to the hospital, he appeared to be severely ill. He was pale, emaciated and dehydrated. He had lost about 20 kg during the past four months, according to his mother, who reported episodes of irritability and depressed mood with the decrease in weight. His body weight was 28 kg and height 147 cm, which is below the 2nd percentile for his age according to the growth chart. His BMI was 13.0, reflecting a 37% deficit in weight for his height.

Upon examination, he showed generalized muscle wasting, and his skin was dry and covered by lanugo hair. His chest was clear, and he had a scaphoid soft abdomen. His blood pressure was 90/60 mmHg, heart rate 55 bpm and body temperature 37.8°C. Laboratory tests were as follows: blood glucose: 60 mg/dl, blood urea: 18 mg/d, serum sodium: 136 mg/dl, serum creatinine: 0.6 mg/dl, serum cholesterol: 147 mg/dl, WBC: 2200, platelet count: 150000, ESR: 1, and HB: 12 mg/dl. Blood proteins were low with slightly elevated liver enzymes. The blood culture was negative. Thyroid functions tests and steroid hormones were normal. General urine examination and culture revealed an acute bacterial infection, which accounted for his fever. Skull, spine and chest x-ray, brain scan and abdominal ultrasound were all normal. A previous gastroscopy at another hospital showed mild mucosal atrophy. An ECG revealed sinus bradycardia. The patient was smaller and shorter than his matching peers. He looked attentive but indifferent to his serious condition. His speech was rational and did not reveal delusions or hallucinations. However, he expressed strong denial of his body appearance and insisted he had a normal body shape. His mood was depressed, but he denied suicidal ideation.

The patient was admitted on 18th July 2010 to Sulimania General Hospital and was referred later for psychiatric consultation. A liaison treatment plan was designed by the attending physician, psychiatrist and dietitian focusing on scheduled feeding under the dietitian’s advice, which was to be achieved through a nasogastric tube. Caloric intake was measured to reach 2000 calories per day, and he was instructed to rest in bed under a nurse’s supervision. This ameliorated his previous hypoglycemic attacks. He was prescribed oral cephalosporin 250 mg qds to treat his urinary infection. On the second day of his admission, the psychiatrist prescribed a 20 mg daily dose of fluoxetine to treat his depressed mood and food-related obsessions. A 5 mg nightly dose of olanzapine was prescribed to resolve the distorted thoughts about his body image and promote sedation. Nasogastric refeeding was continued for the first week in the hospital until oral feeding was established. The tube was removed on the 6th day. In addition, a few sessions of cognitive psychotherapy were conducted with the patient.

At the end of the third week, he became more realistic and rational about his body weight and was more compliant with eating normal meals. His mood and irritability improved. He was discharged after 24 days in the hospital, advised to abide by the regulations of the dietitian and continue his medication for three months. He was to report to the psychiatry clinic on alternate weeks. His body weight had increased to 30 kg.

He did not keep his appointments and appeared six months later at the clinic weighing 38 kg. He was enjoying better health, although he was still having eating peculiarities. He had maintained his daily exercise but was reluctant to gain more weight. After consultation, he was advised to continue on fluoxetine for another three months. The family was advised to escort him regularly for psychotherapy sessions and watch his dietary intake.

Conclusions

The clinical presentation of anorexia nervosa among males is rare, with many subclinical cases being overlooked. Males and females tend to share similar clinical presentation and psychopathology except for amenorrhea. In addition, males are inclined towards strenuous exercise, have sexual concerns and show psychiatric comorbidity more often than females. Reports about age of onset in males vary. However, it is agreed that males tend to present at a later age than females probably because of the later onset of puberty and different social roles.

The influence of culture on the development of AN has long been appreciated and is believed to be more prevalent in industrialized and Western cultures, being far more common among young females than males and reflecting cross-cultural differences in the importance of thinness for women. Apart from a few studies showing a propensity for anorexic-like behavior, the available literature indicates that anorexia nervosa is rare among females in the Arab culture. Traditional values and cultural norms regards thinness as socially undesirable, with plumpness considered a sign of wellbeing in both genders and viewed as a symbol of fertility and womanhood in females. A positive relationship between increased body weight and higher social class has been observed in the Arab culture, contrary to Western ideal. It has been suggested in the available literature that exposure to Western values regarding body shape and weight can be blamed for the occurrence of anorexia nervosa in the Arab region.

Iraq, like many other Arab countries, is known for using English as the teaching medium, thus facilitating access to Western culture through satellite television, the Internet and periodicals. It is believed that exposure to the differences between the two cultures contributes to the etiology of eating disorders. Through recent globalization, Western cultural norms have infiltrated many Arab societies and changed local traditional values regarding ideal body shape and weight. MR was a boy from an educated middle class family residing in a suburban area north of Iraq where local values did not favor thinness. There was easy access to media, including the Internet, which might have contributed to an internal conflict regarding body image.

We believe that nutritional correction by oral and nasogastric feeding helped in weight restoration of this patient, which is a prerequisite for the effective use of psychotropic interventions. Using an oral antidepressant (flouxetine, 20 mg) improved the patient’s gloom and irritability. The oral antipsychotic (olanzaine, 5 mg) ameliorated his weight-related beliefs and probably helped him gain weight by the end of the second week with no serious side effects apart from daytime sleepiness. Medicating anorexic patients with a combination of an antidepressant and antipsychotic has previously been tried and shown to be successful.

The patient was diagnosed with anorexia nervosa, according to DSM-IV diagnostic criteria and the Eating Disorder Inventory (EDI). His history and personality profile together with the nurturing attitude of his mother were strikingly similar to many previous reports in Western and Arab societies. Despite the short period of hospitalization, lack of a special unit for eating disorders and brief psychotherapy, our patient showed significant improvement as a result of the available medical and psychiatric care he received.

The only way to change the growing rate of eating disorders is to change the way our society functions as a whole and to raise awareness of this endemic.

Eating Disorder Support for Men:

CalmZone is an excellent source of information and signposting for men who suffer from Eating Disorders – Callers can talk through any issue, and are offered information and signposting.

http://www.thecalmzone.net/

Men Get Eating Disorders Too
‘Men Get Eating Disorders Too’ is an award-winning charitable organisation seeking to raise awareness of eating disorders in men so that they are able to recognise their symptoms and access support when they need it.
The website provides essential information that is specific to the unique needs of men and an online space for them to get their voices heard. It also offers peer support via a forum.
Website: mengetedstoo.co.uk/

NHS Choices: overcoming eating disorders information
Information and advice about overcoming eating disorders for sufferers, family and friends.
Website: www.nhs.uk/eatingdisorders

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About Author

Islam and Eating Disorders founded in 2012 – run by Maha Khan, the blog creates awareness of Eating Disorders in the Muslim world, offers information and support for sufferers and their loved ones.

3 Comments

  1. Its so hard these days to break the mindset of people. Really its high time that we drop this BARBIE and KEN image and really be healthy. This image is causing many problems, not just with one’s body but in relationships, in societies.
    It would be good if the size 0 or whatever it is called, is forgotten completely, only then mind will be at peace.

    • Thank you and I agree with you completely. onventional wisdom holds that young girls develop AN as a result of excessive dieting in pursuit of thinness, which is considered beautiful in many culture.Losing weight should never be seen as a solution to body dissatisfaction, especially when weight loss disrupts normal adolescent growth and development. Sadly, we do not live in an ideal world. Many of us are not immune to the impact of the thin ideal. We need to change our thinking and we need to work towards instilling positive body image in our society

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