Twenty-six year-old Alex* was clearly upset. Unable to ‘cope with life and life’s pressures’ he had approached Dr Nasser Al Hindy, consultant psychiatrist at American Center for Psychiatry and Neurology (ACPN), for help. ‘Alex exhibited symptoms of mild depression and anxiety, and said he’d been experiencing these feelings for the past several years,’ says the doctor.
A Dubai resident, Alex was obese and Dr Nasser, in the course of his examination, found that his patient was suffering from a binge-eating disorder.
‘Alex told me that he used to be bullied about his weight – some called him ‘rolling ball’ – while in school and now at work he was being made to feel ashamed about his physical size,’ says the doctor.
Alex’s family did enrol him in a gym and kick-boxing classes hoping that exercise would help him lose weight. ‘But there too he was made fun of and after just a few classes, he quit,’ says Dr Nasser.
The constant jibes and jokes left Alex with low self-esteem, guilt and associated conditions finally taking him to ACPN, which recently opened an eating disorders unit in Dubai.
As part of the treatment process, the young man was referred to a psychologist, a dietician and a physiotherapist. ‘We put together a plan for him to bring about a positive change in his life. We first worked on improving his self-esteem, how to face and tackle bullies, and how to get over his mild depression.
‘We also included his family and suggested how they too needed to be on the same page when it came to helping him,’ says Dr Nasser. That was necessary to prevent any relapse. Today, two months later, Alex is ‘a visibly a changed man. He is making great progress – he’s much more self-confident and optimistic. He was put on a diet where he lost around one kilogram per week – which is the healthy range of weight loss in his case,’ says Dr Nasser.
However, unfortunately not all such cases have a happy ending.
Eating disorders are considered the deadliest of all mental disorders, with an estimated 20 per cent of sufferers dying from their condition. But what could be a shock to many is that men make up nearly 40 per cent of patients with the condition.
Going against the stereotypical notion that women are usually the ones tackling food-related disorders, experts say that while 95 per cent of the sufferers are women in the 15 to 25 age group, the number of men suffering from eating disorders is rising. ‘There is a global increase in the number of men with eating disorders and that is reflected in the UAE as well. Men engage in eating-disordered behaviours nearly as often as women,’ says Dr Nasser.
He reveals more disturbing facts. ‘The female-to-male ratio of anorexia nervosa patients has significantly changed – from one in 10 about a decade ago to one in four in recent times,’ he says. ‘Also, one in three binge-eaters is male and there are as many men as women who want to change their weight and body shape.’
His colleague at ACPN, clinical psychologist Carine Al Khazen concurs.
‘Today, one in five people suffers from some kind of eating disorder,’ she says.
Eating disorders have a number of severe psychological and medical effects on the sufferers.
Bulimia nervosa – where bouts of extreme overeating are followed by fasting or self-induced vomiting – has serious medical repercussions, says Carine. She quotes the case of the late singer Amy Winehouse, who struggled with bulimia.
Medically unmonitored dieting is a serious cause of eating disorders. ‘A massive 35 per cent of all “normal” dieters progress to pathological dieting,’ she says.
The results of eating disorders are truly scary. ‘The condition can leave sufferers depressed, anxious and cognitively impaired; their lives are destroyed due to this pathological obsession with food and their bodies,’ says Carine. So what triggers eating disorders among men? ‘The culture of muscularity and the intense pressure to diet and exercise excessively,’ says Carine.
‘And we can see a recent escalation of these pressures.’
She points a finger at the diet and fitness industry, ‘which spends a lot of money to convince people, particularly men, to use specific diets and fitness regimens including... supplements, protein shakes and steroids’.
Those, sadly, are not the only problems.
‘For men just as women,’ says Dr Nasser, ‘being in an environment that values thinness, perfectionism and obsessional features [poses] a major risk resulting in them having eating disorders.
‘Certain sports such as athletics, wrestling and body building, and some professions such as acting and modelling too can pose a risk to men.’
Anorexia nervosa is not the only eating disorder that is worrying. ‘The obsession to be lean and [extremely muscular] can also be classified as an eating disorder when associated with other symptoms, and could be a sign of anorexia nervosa or muscle dysmorphia or bigorexia,’ says Carine.
In the case of anorexia nervosa or orthorexia nervosa – an obsession with eating food believed to be healthy – weight loss is rapid and involves obsessive behaviours impacting all areas of the person’s life.
On the other hand, binge eating disorder involves weight gain. ‘In bigorexia or muscle dysmorphia there is an obsession to bulk up,’ she says.
Dr Nasser agrees. ‘In many ways this is the opposite of anorexia nervosa. A patient with this disorder is racked by an intense fear that he is insufficiently muscular, no matter how well-built he really is.’
Such patients resort to strenuous workouts to build muscularity and reduce body fat. Body building exercises would take precedence over almost every other important area of life.
‘[Sufferers] also over-regulate protein intake and obsess about consumption of carbohydrates and fats. The use of substances such as anabolic androgenic steroids are also common among such people,’ says Dr Nasser. He cites the case of a Dubai-based 25-year-old who was obsessed with bulking up. ‘Initially he’d visit the gym a couple of days a week. The periodicity soon went up to four days and finally seven days a week.’
The spin-off was that because he was exercising more, he felt he should be eating more; then because he was eating more, he began to exercise more and soon he was trapped in a vicious diet-exercise cycle.
The effect was disastrous,’ says Dr Nasser. ‘Because he was spending so much time in the gym, his friend circle narrowed down, he broke up with his girlfriend. That left him depressed. So he began spending more time in the gym. Along the way, he also began taking steroids, which he purchased online.’
The gym sessions were also leaving him tired and his career began to suffer because he could not concentrate on his work.
‘The condition that was now spiralling out of control left him isolated and depressed. Fortunately for him, some friends realised that he needed help and encouraged him to seek treatment,’ says the doctor.
At the Centre, he was given a course of anti-depressants. A dietician then created a diet plan for him; he was also treated by a psychiatrist for anxiety. ‘Now, more than two months later, the young man is slowly limping back to normal,’ says Dr Nasser.
Dubai-based freelance fitness instructor Peter Sullivan admits that he is seeing a massive increase in the number of men ‘using the gym excessively in the UAE’.
‘Social media is a major influencing factor – a driver for this trend,’ he says. ‘Some of the more popular pictures on Instagram and Facebook are of guys in very good shape. Men who see these desire a similar physique. And they want it instantly. It’s this modern-day mentality where people seek instant gratification; if they want something, they want it now. They are willing to pay whatever it takes to have a similar body in the next six weeks, preferring to deal with the consequences later.
‘But what many men do not realise is that it would have taken several years and tremendous effort for those people to get into that shape.’ He cites the cases of some men who, after workouts, get busy uploading their pictures, publicising their physique to the world. ‘[Seeing those pictures] motivates more men to get that dream body. So it’s a self-fuelling perpetual motion of people posting images of themselves, which reaches out to more men,’ he says.
‘If your sole purpose is to have a body that is attractive then the whole mental aspect of the person’s personality is lost; you become just a beefcake – a nice body but no real brain to back it up.’
Peter however, stresses the importance of exercise to stay healthy. ‘There’s a direct strong correlation between being healthy and staying in a motivated state.
‘When you go to the gym you feel happy, positive and motivated in other areas of your life.’ Fitness First manager Nicky Holland agrees that while not exercising can affect health adversely, ‘so can exercising too much’.
‘The body can be pushed but you must give yourself rest days. Getting up early in the morning, training twice a day, going to the gym seven days a week, can be good but it is not sustainable. Excessive gym usage can lead to burnout and can have an impact on you physically and mentally.’
Exercising needs to become part of your lifestyle as a habit rather than a chore. Nicky also touches upon the other bugbear of the fitness world – protein shakes.
‘Protein shakes are very popular in the fitness industry with more and more people taking them,’ says Nicky. She insists that protein shakes ‘need to be used as a supplement and not a replacement, unless prescribed by a doctor. Getting your protein from food and natural sources is best.’
Peter agrees. He suggests having a healthy approach to the protein shakes often relied upon to beef up the body. ‘They can be healthy – provided they are taken the right way. The danger is when people move away from natural foods and consume only protein shakes.’
Dubai-based nutritionist Rashi Chowdhary (a member of Friday’s Ask The Experts panel) concurs with the fitness instructor. ‘Protein shakes should be seen as supplements, not as something that replaces your main meal,’ she says.
‘If you are a non-vegetarian, you don’t really need to consume a protein shake unless you are working out heavily in the gym. For vegetarians, including a protein shake in your diet could be helpful, but only on the advice of your doctor or nutritionist. You should not rely on protein shakes for all your nutritional needs.’
Dr Nasser too sounds a warning note on the unregulated use of protein powders and shakes. No supplement is more widely consumed than protein powders, he says, adding that people may be encouraged to consume high-protein foods without considering the health consequences.
The only times one needs more protein in the diet is in the teenage years, when starting a fitness programme, when increasing workouts, when recovering from an injury or if you’re going vegan, he says.
‘The body needs between 10 and 14 additional grams per day to build a pound of muscle. However, some of the protein powders available in the market have around 80g of protein per serving. The maximum amount of protein that most adults can use per day is 0.9g per pound of body weight.’
Including too much of protein without fat can deplete calcium in the body, leading to bone weakness and related complications. It can also damage the liver and kidney.
Dr Nasser also warns those who exercise often to be extremely careful with anabolic-androgenic steroids. ‘They can lead to several complications including high blood pressure, heart attacks, strokes, and liver and kidney conditions,’ he says.
The warning signs
According to Dr Nasser, an obsession for working out is the first step to slipping down an eating disorder slide.
Carine lists more: ‘An obsession to lose weight, count calories and eat healthy; extremely rigid and unbreakable food rules; an intense fear of being fat; food phobias; obsessions with going to the gym and to have a perfect body, which never appears to satisfy the person, no matter how thin or muscular he is; obsessions about body image and checking and comparing behaviours; periods of uncontrollable binges followed by guilt and remorse; and an urge to burn off or get rid of the calories ingested – sometimes through unhealthy and dangerous methods – can suggest an eating disorder,’ she says.
Although there are several noticeable signs of eating disorders, the detection and treatment of the condition in men is relatively more difficult because they often do not seek help in time.
‘Men who binge-eat or compulsively overeat may go undiagnosed more than women simply because of society’s willingness to accept an overeating or an overweight man more than an overeating or overweight woman,’ says Dr Nasser. ‘In fact around 50 per cent of obese people have a binge-eating disorder.’
Another important factor for the delay in detecting and treating eating disorders in men is because they consider the condition shameful and embarrassing, so do not approach a doctor. ‘An eating disorder is perceived as being a women’s disorder so men are reluctant to seek psychological help,’ says Carine.
‘Compared to men, women cope better with eating disorders. For one, they seek help earlier than men. This can lead to a better prognosis and early treatment options,’ she adds.
The fact that disorders in men are detected late leads to poorer prognosis.
Detecting and addressing diet-related concerns early on can go a long way in correcting the dangerous trend, says Dr Carine.
*Name has been changed to protect identity
Eating disorders among children
Eating disorders can affect children, too, says clinical psychologist Carine Al Khazen, and the repercussions can be dangerous…
Which disorders affect children?
[Adult and child disorders are] the same, and have the same psychological and medical repercussions. But the medical implications on children are more dramatic, as they involve stunted growth and impaired neurological development. Avoidant Restrictive Food Intake Disorder, a children’s eating disorder that is less frequent in adults, is an anxiety disorder about food where children have intense fear of foods because they have had a negative experience around it. With time their fears expand and they reach a state of malnourishment, and starvation in extreme cases. It’s picky eating to the extreme.
What are the warning signs?
Extreme weight fluctuations. Even if the weight loss is called for, it should not have happened in a very short period of time and shouldn’t have required obsessive behaviours (like extreme dieting and exercise regimens). If so, it could definitely be the early sign of anorexia nervosa. Food missing from the house and/or hidden candy and chocolate wrappers discovered in odd places could mean binge-eating. Body-checking behaviours like spending undue amounts of time in front of the mirror scrutinising their bodies, frequent and negative comments about their bodies, and a need for constant reassurance regarding their body weight and shape could be other pointers.
What can parents do?
Seek help as soon as you spot the signs. Even if you are wrong, one consultation cannot give your child something they don’t have – better to be safe than sorry. Please remember, it’s a life-threatening disorder that has much better outcomes when treated early. Once the diagnosis is confirmed, present the multi-disciplinary treatment as non-negotiable.