Saher’s* quest for the perfect figure began in her early teens. The Atkins regime was followed by a vegetarian diet, eventually leading to a keto diet. She was happy with the results of keto until the guilt of consuming a high-fat diet ate at her. Saher then started secretly throwing up after every meal in order to keep herself looking ‘fit’.

Her family noticed disagreeable changes in her physical appearance and urged her to seek medical assistance. The doctors quickly referred her to a dietician and also a psychologist. Saher was diagnosed with a moderate case of bulimia nervosa.

Maha*, 23, is also battling bulimia. “I was 13 when I first started eating less because I was constantly called ‘fat’ by my classmates,” she says. “Family members complimented my cousins and mocked me for being a ‘chubby, ugly duckling’. Girls around me were prettier and slimmer. Someone I liked rejected me because I was ‘plump.’ So I began skipping meals and purchased lots of makeup products to look beautiful. Throughout my teens, I lost a lot of weight. By the time I turned 21, I became obsessed with being a size zero. My friends and family said I looked fine, however, the mirror showed me the opposite.

“A few months back, I read about vomiting food [to avoid gaining weight]. I tried it for a few weeks. I began losing more weight, albeit I felt weak and dizzy most of the time. That didn’t matter because I was getting closer to my size -zero goal. I would vomit and rinse, till my mother found out.”

From both these cases, one can see that bulimia has a strong association with self-perception formed via distasteful social interactions.

A society that shuns unrealistic body image standards can help women overcome severe eating disorders

Bulimia nervosa is a life-threatening eating disorder typically characterised by compulsive eating. It is followed by episodes of compensatory actions (such as vomiting or excessive use of laxatives) in order to lose weight. Patients usually indulge in binge-eating and then deliberately throw up to get rid of the food they have consumed. They induce vomiting immediately after meals so their bodies can expel food instead of digesting and absorbing nutrients from it. As a consequence, patients lose weight. However, they get so caught up in the vicious binge-and-purging cycle that they ignore all undesirable physical and mental side-effects of purging as long as their primary purpose of losing weight is fulfilled.

Bulimics also resort to non-purging methods like exercising obsessively or continuously fasting to lose weight.

The malady is more common among young females as it is associated with one’s body image, confidence and self-worth.

Dr Sana Azfar, a nutritionist at Aga Khan University Hospital, terms bulimia and other eating disorders as psychological problems rather than physical conditions. Dr Azfar explains that most eating disorders often have a strong and intimate association with the patients’ past. Once the causes are identified, she believes, a sustainable course of treatment (often psychological) can be prescribed.

“Short-term treatment for bulimia includes inserting a nasogastric (NG)tube — in severe cases — to feed patients with vital nutrients and prevent further physical deterioration,” says Azfar. “However, for complete rehabilitation, we recommend patients undergo cognitive behavioural therapy (CBT) sessions.”

Maha visits a therapist every week. She has been advised to attend at least seven therapy sessions. “In the beginning, my therapist asked if something was depressing me and caused me to vomit food but nothing did,” Maha says. “I was only trying to look slim. It is important for me to feel beautiful,” she says. Maha’s emotions are valid because, being a bulimic, she struggles with body image issues.

Azfar explains that during sessions, the therapist usually discovers there wasn’t enough emotional support and guidance available to help bulimics transform into confident adults. “Their misinterpretations of being ‘unattractive’ or ‘fat’ often began in their early teens and this is when they turn to unprescribed diet plans,” she says. “Therefore, therapists let them pour their hearts out to try and destroy their perceptions.”

So far, Maha has had four sessions with her therapist. She was shown pictures and interviews of different ‘fat’ people who were comfortable in their own skin. “I was amazed to see their confidence and happiness. Even [plus-sized] people can find love. This made me think if what I was doing was right,” Maha says.

Anorexia nervosa is another eating disorder that has become relatively common amongst girls. It is characterised by extremely low body weight — a condition in which patients are fearful of gaining weight, so they avoid eating. They keep shedding weight despite being severely under-weight. Anorexics don’t vomit but, like bulimics, their obsession stems from unresolved emotional issues in the past which leads them to take extreme measures to become thin.

Aliya* hails from Hyderabad and has been diagnosed with anorexia recently. In her early teens, she was a food lover but soon she noticed that people would avoid her because of her weight and dark complexion. She stopped eating. “I began eating less and eventually skipped meals to lose weight. I went to extremes, yet I felt I still looked ugly,” Aliya says.

Anorexics often feel alone and depressed because they hate the way they look, and find solace in abstaining from eating. The origin of anorexia lies in the perception girls have about beauty and perfection, which needs to be broken in order to cure them.

Elaborating on this condition, Dr Ayesha Afzal, a psychologist based in the UAE, says, “Anorexics perceive themselves unpleasant-looking and our role is to assist them in severing the strings of self-doubt and become confident.”

Recovery from anorexia depends three stages of family-based treatment (FBT).

In the first phase, doctors focus on weight restoration by educating patients about healthy eating, nutritional value of food and harmful effects of starvation. “Our aim is to [help the patient] regain one kilogramme in weight every week in phase one,” says Dr Afzal. “In the second phase, we give back patients some control over their eating habits and allow them to resume their daily routines only after a reasonable amount of weight has been regained. We address their weight issues through therapy in this phase.”

A therapist counsels anorexics that they are not fat; that their bodies, skin colour, facial features and likes on social media don’t measure their worth. “In the third phase, strategies to prevent relapse are discussed with patients at length,” Afzal explains.

The media has set unrealistic standards of feminine beauty which greatly impact young girls and even compel them to take desperate measures to meet the expectations of what society considers beautiful. Combined with social pressure and lack of parental guidance, the problem exacerbates — in certain cases, even driving a young woman to commit suicide.

On the other end of the spectrum of eating disorders is binge-eating. These days restaurants and dhabas have sprouted in every nook and cranny of the cosmopolitan centres, prompting people to ‘eat out’ very often. Therefore, binge-eating has become prevalent these days. This disorder begins in late adolescence or early adulthood and is characterised by eating even when one is full. It is a method of camouflaging negative emotions such as stress, depression, nervousness, loneliness or anxiety, as one tries to cope with their problems by devouring food.

“Binge-eaters feel guilty and embarrassed at their weight and appe­arance, yet they can’t control their cravings,” says Dr Azfar. “In some cases, I refer them to an endocrinologist to undergo hormonal treatment. However, in most cases, binge-eating depends on the patients’ will power to control their cravings.”

The most important thing for patients with any eating disorder is to acknowledge their problem and confide in someone. “The realisation needs to come from within themselves that following diets, purging and starving themselves is wrong and can prove life-threatening,” says Dr Azfar. Others around them need to be supportive, patient and understanding. Often these disorders take a lot of counselling and time to improve.

Girls need to accept and love their bodies; they need to recognise that they are beautiful as persons, and that the beauty standards advertised by media are all forged and temporary. “In real life, girls need to eat to be healthy. They are not required to have size-zero bodies. Instead, they need to acquire education and confidence to carry themselves gracefully,” adds Dr Azfar.

Aliya is now in the second phase of recovery. “I often feel I’ve over-eaten, but my family, friends and therapist always encourage me to eat more,” she says. “I can feel that I have gained some weight. However, everyone says I look better now. I keep reminding myself that it is important to eat and live, rather than dying in quest of a perfect body.”

Aliya has come a long way, but she is yet to fully accept her body the way it is.

• Names have been changes to protect the identity of individuals

Published in Dawn, EOS, March 10th, 2019