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Anorexia nervosa in Kenya

Article  in  East African medical journal · May 2004

DOI: 10.4314/eamj.v81i4.9153 · Source: PubMed

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188 EAST AFRICAN MEDICAL JOURNAL April 2004

East African Medical Journal Vol. 81 No. 4 April 2004

ANOREXIA NERVOSA IN KENYA
F. G., Njenga, FRCPsych (UK), and R. N., Kangethe, MBChB, MMed. (Psych) (Nbi), P.O. Box 73749, Nairobi, Kenya

Request for reprints to: Dr. F. G. Njenga, P.O. Box 73749, Nairobi, Kenya

ANOREXIA NERVOSA IN KENYA

F. G. NJENGA and R. N. KANGETHE

ABSTRACT

Background: Anorexia nervosa is a rare disorder in Africans, inspite of posing a serious

public health hazard in the West. Whereas it is possible that African psychiatrists lack
the skills to diagnose the disorder, other possible explanations for its apparent rarity
must be sought in view of emerging evidence, which suggests a real lack of occurrence.
Objectives: To establish the knowledge of practicing Kenyan psychiatrists about the signs,
symptoms and management of anorexia nervosa and to establish the number of cases
they had seen during all their years of practice of psychiatry.
Design: Telephone survey and data collection: case-finding approach.
Setting: Kenya, June 2001
Methods: Forty seven psychiatrists registered to practice in Kenya as of June 2001
qualified for inclusion. The respondents were interviewed on the same day, to reduce
the likelihood of cross checking between colleagues. RK called each one, (all knew her)
explained the nature of the survey and obtained verbal consent to administer the brief
(10 minutes) questionnaire, developed by the authors for the purpose.
Results: Twenty seven of all those eligible were reached on the day. All but one gave consent
for the interview (55% response rate). The 20 who were not reached were similar to the
respondents with regard to experience in psychiatry, (mean duration 11.4 versus 10.9yrs)
but differed in their place of residence, the majority of those not reached resided out of
Nairobi (60% versus 26%). In a cumulative total of 320 years of practice, they had seen
16 cases of which seven were of African origin. The rest were Caucasian or of Asian origin.
The psychiatrists demonstrated adequate skill in recognising anorexia nervosa.
Conclusion: Kenyan psychiatrists can recognise cases of anorexia nervosa. The condition
is rare in Kenya. The reasons for this remain unclear and traditional explanations for
its cause as due to pressure for thinness may not be adequate for the Kenyan case.

INTRODUCTION Three hundred years after Morton's first description,

anorexia nervosa is now reported to be a major public
Traditional explanations for the occurrence of health concern in Western Europe and America. The
anorexia nervosa (AN) include social pressure for lifetime prevalence in Westernised women is 4% and
thinness, dysfunctional family dynamics and more probably rising. In the UK, the prevalence is even
recently genetic and other biological factors such as higher in private or grant-aided schools (one severe
viral infections. Anorexia nervosa was first described case of anorexia nervosa for every 100 girls aged 16
by Richard Morton(1), in a case of 'nervous consumption' to 18 years) and higher still in ballet schools (one case
clearly at the time distinguishable from tuberculosis. per 30 girls)(3). Lucas et al(4), concluded that anorexia
Since that time, it has become a well-recognised illness. nervosa is now the third most common chronic illness
Schmidt(2) states, "Anorexia nervosa and bulimia in teenage girls in Minnesota, USA.
nervosa are chronic, often debilitating, disorders with Anorexia Nervosa in Africa: Anorexia nervosa is
high levels of psychological and physical co-morbidity. probably a very rare condition in Africa. A Medline
The average duration of anorexia nervosa is six years. search (for Anorexia Nervosa, Africa) carried out by
There is evidence that the course of the illness has the authors revealed four possible cases(3,5-7).
become more severe in the past few decades. The Nwaefuma's case(5), is described in a letter to the editor
mortality of anorexia nervosa is higher than that of any that does not give sufficient detail to enable DSM IV
other functional psychiatric disorder and may be rising. diagnosis but one that nonetheless emphasises the rarity
The quality of sufferers' lives is poor and the burden of the condition 20 years ago. Buchan and Gregory(6),
on their carers is as high as that in individuals with reported one case in a black Zimbabwean woman that
psychotic disorders." satisfied Feighner's diagnostic criteria but which
April 2004 EAST AFRICAN MEDICAL JOURNAL 189

nonetheless showed unusual features in the clinical is on, but no corresponding increase in cases of
symptoms including the role of a traditional healer in anorexia nervosa has yet been seen.
her recovery. So where is the condition in Africa? Are the
In 1988, Famuyiwa(7), reported two cases of traditional explanations on aetiology adequate? What
anorexia nervosa in two Nigerian girls. He states; The is the relationship between anorexia nervosa and OCD,
relatively low prevalence of the disorder that has been both extremely rare diseases in Africa? The stability
observed might be due to the protective influence of over time in the incidence of anorexia nervosa in the
the Nigerian extended kinship system, the customary West is mirrored by the stable absence in Africa(4).
passion for plumpness as an attribute of physical It is against this seeming discrepancy in incidence
attractiveness, carbohydrate diet, "resistance" and the that the present authors decided to take a detailed look
non-inclusion of cases in hospital records because of at the situation in Africa, focusing on the Kenyan scene.
consultation with unorthodox healers". The general This paper reports firstly, a study to establish the
trend of increasing prevalence calls for more diagnostic knowledge of practising psychiatrists about the disorder
vigilance, particularly among doctors serving populations and, secondly, a case finding approach, through
with Third World background. In spite of his prediction, practicing psychiatrists, to establish the approximate
only one further case by Binite et al(8), is to be found prevalence in Kenya.
in the literature.
In 21 years of practice in Kenya, the present author MATERIALS AND METHODS
(FGN) has come across only three cases of the
condition that meet the DSM IV criteria, none of which Sample: F.G. N. is the Chairman of the Kenya Psychiatric
were in ethnic Africans. The first two cases were Association. Current members of the association and any
person registered as a psychiatrist qualified for interview.
Caucasians and the third was Indian.
Their contact data was readily available in the association's
One Caucasian girl was Kenyan born (the other records.
British) and developed the fullblown syndrome when The first part of the study concerns this group. Twenty
she went to the UK at the age of 14 years. Adverse six out of a total population of 47 were interviewed on the
domestic living arrangements, a new culture, the weather phone on the same day (June 2001). This was done to ensure
and a new school system were identified as precipitants that they did not get the chance of either checking on
to the illness. She remained anorexic following her diagnostic criteria, or that they did not discuss the questionnaire
return to Kenya six years later. She eventually presented amongst themselves. In a small closely-knit population, this
to the author at the age of 25 years for evaluation of would pose a real problem.
On the appointed day, phone contact was established
possible psychological contributions to primary
with the psychiatrists, starting with those in the same hospital,
infertility. At the time of referral, she weighed 38 kg and extending to the furthest part of the country. All were
with a height of 1.57m (BMI=15.2). Following many personally known to the interviewer (RK) and it was easy
months of supportive psychotherapy that involved her to explain the purpose of the study. They were requested to
having to write extensively about her experiences in answer a few questions on anorexia nervosa and all quickly
childhood and the trauma of being in the UK as an agreed (except one elderly psychiatrist who insisted on
adolescent, she began to put on weight, her periods checking his facts first).
recurred, and in spite of persistent fear of putting on Those not reached were either out of the country in two
weight, she had an obsessive desire to have many cases, unreachable by phone for various reasons in eleven
cases, or out of their offices on the particular day in seven
children. She now has three children, remains very thin
cases. The authors were not interviewed.
(weight 42kg) and still wants to have as many children Those who participated were given a brief description
as possible, inspite of revulsion to sex, and a desire of the study, its aims and objectives and informed that they
to remain small. Obsessional features persist, with may if they so wished decline to participate.
regard to cleanliness, order in her house and feeding The authors had developed the questionnaire so that the
of her children, which involves many stereotyped interview would last no more than 10 minutes. The
routines. questionnaire was designed to establish demographic
The usual explanation for anorexia is that it is an information on the respondents, also detail their dates and
abnormal response to immense social pressures exerted place of training as well as their knowledge of DSM IV
diagnostic criteria as well as contact with anorexia nervosa
by peers and the media to be slim. However, if this
since they started practicing psychiatry.
were the case, one would expect rates in Africa to be
rising rapidly with increasing globalisation. 21st century RESULTS
African girls in urban settings share magazines,
television, universities and future with their sisters in Response Rate: Kenya had a total of 47
the west. There is no longer room for the mistaken psychiatrists practicing in Kenya in June 2001. Twenty
perception that Africans still hold that fat women are seven were reached on the day of the interview, one
more desirable. The 21st century African is health declined and 20 could not be reached, giving an overall
conscious goes to the gym, exercises and carefully response rate of 55%. Those not reached were similar
watches his/her diet. The pressure on the girl to be slim to the respondents with regard to the number of years
190 EAST AFRICAN MEDICAL JOURNAL April 2004

in practice (mean 11.4 years versus 10.9 years) but psychiatrists either teach at the university or work in
different in that 60% were located outside Nairobi versus private practice in Nairobi.
26% of the respondents, more were exclusively locally Clinical Experience: The mean time since
trained (85% versus 50%) and had a different male/ qualification for those who hadn't seen a case of AN
female sex ration (4:1 versus 2:1). was 12.0 years compared with 10.3 years for those who
The differences observed were easily explained. It had seen a case of AN.
is easier to get psychiatrists practicing in Nairobi on the Other variables tested and found not to show
phone, secondly more psychiatrists working at the statistical significance were the age of the psychiatrist,
University of Nairobi have been exposed to both local duration since qualification, knowledge of diagnostic
and overseas training. Older more experienced criteria and number of cases seen.

Table 1

Characteristics of psychiatrists not reached (n=20)

Sex Training Location Years of practise

M F Kenya Overseas Both Nairobi Other 0-5 5-10 11-15 16-20 <20

16 4 17 1 2 8 12 0 6 10 3 1

Table 2 (i)

Characteristics of respondents (Total)

1 2 3 4 5 6 7 8
No. N o . Sex Training Age No seen last 5 AN Years of practise
of AN of years Criteria
ever Psy M F Kenya Over-Both 3 3 4 4 5 0 1 2 3 5 1 2 3 4 0-5 6-10 11-15 16-20 20+
seas 1- 6- 1- 6- 0 +
3 4 4 5 +
5 0 5 0

0 10 8 2 4 3 3 1 1 4 3 1 1 0 0 0 0 0 5 2 2 1 2 3 1 0
1 8 2 6 6 0 2 0 0 7 0 1 5 3 0 0 0 2 3 3 1 1 2 2 0 0
2 3 1 2 2 0 1 0 1 2 0 0 1 0 2 0 0 0 2 0 1 0 1 1 0 0
3 4 3 1 1 2 1 0 1 0 1 2 1 0 1 2 0 0 3 0 1 1 0 1 0 2
5+ 1 1 0 0 1 0 0 0 0 0 1 0 0 0 0 1 0 0 1 0 0 0 0 0 1

Table 2 (ii)

Nairobi based respondents

1 2 3 4 5 6 7 8
No. No. Sex Training Age No seen last 5 AN criteria Years of practise
of of years
AN Psy M F Kenya Over-Both 3 3 4 4 5 0 1 2 3 5 1 2 3 4 0-5 6-10 11-15 16-20 20+
ever seas 1- 6- 1- 6- 0 +
3 4 4 5 +
5 0 5 0

0 7 6 1 3 2 2 1 1 2 3 3 7 0 0 0 0 0 3 2 2 1 2 3 1 0
1 5 1 4 3 0 2 0 0 5 0 0 3 2 0 0 0 0 1 3 1 1 2 2 0 0
2 2 0 2 1 0 1 0 1 1 0 0 1 0 1 0 0 0 1 0 1 0 1 1 0 0
3 4 3 1 1 2 1 0 1 0 1 1 1 0 1 2 0 0 3 0 1 1 0 1 0 2
5+ 1 1 0 0 1 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0 0 0 0 0 1
April 2004 EAST AFRICAN MEDICAL JOURNAL 191

Table 2 (iii)

Rural Based Respondents

1 2 3 4 5 6 7 8
No. No. Sex Training Age No seen last 5 AN Years of practise
of of years Criteria
AN Psy M F Kenya Over Both 31- 36- 41- 46- 50+ 0 1 2 3 5+ 1 2 3 4 0-5 6-10 11-15 16-20 20+
ever seas 35 40 45 50

0 3 2 1 4 3 3 0 0 0 0 1 3 0 0 0 0 0 2 0 1 0 1 1 0 1
1 3 1 2 6 0 2 0 0 2 0 1 2 1 0 0 0 0 1 0 2 1 2 1 0 0
2 1 1 0 2 0 1 0 1 1 0 0 0 0 1 0 0 0 1 0 0 0 1 0 0 0
3 0 0 0 1 2 1 0 1 0 0 0 0 0 0 0 0 0 0 0 0 1 0 0 0 0
5+ 0 0 0 0 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

1. Number of patients with anorexia nervosa ever seen, 2. Number of pyschiatrists, 3. Sex of respondents, 4. Location of
training, 5. Age, 6. Number of patients with anorexia nervosa seen in the last five years, 7. DSMIV diagnostic features
named spontaneously by respondent, 8. Years in practise of psychiatry

Table 3

Repondents’ gender, place of training and current practice

Variable X2 P-value Significance

Sex 0.1119 0.998 NS

Male vs Female
Training
Local vs Overseas 0.318 0.999 NS
Location
Rural vs Urban 0.67 0.96 NS

Nairobi is the capital city and is the home of the DISCUSSION

Kenyan middle classes with the greatest exposure to
the Western cultural styles. It is here that one would This study suggests that AN is undoubtedly a rare
expect the majority of the cases, if Western cultural disorder in Kenyans. In a cumulative period of 320
lifestyle was a predominant causative factor. years of practice, Kenyan psychiatrists with both local
Patient characteristics: Of the 16 cases found, and overseas training have seen an average one case
12 were aged between 13-20 years, three quarters were every 16 years! It is unlikely that this group of
under weight, seven eighths had a change in perception psychiatrists are seeing but failing to make a diagnosis.
of body weight, all but one were female, 63% were All respondents were able to identify spontaneously at
students. It is also significant that only ten of the least two DSM IV criteria for the diagnosis of AN.
patients seen were of African descent. Since three Anorexia nervosa is rare outside Western Europe(9)
psychiatrists had seen the same African patient, the true and this has led authors to argue that eating disorders
number of cases comes down to seven for Africans and are a Western disease of cultural origins. Reporting on
13 in total. Asians and Caucasians who contribute no eating disorders in India, Khandelwal et al(10). Writing
more than 0.25% of the population contributing six out from a major referral hospital for India (All India
of 13 (46%). This is truly a non African condition. Institute of Medical Sciences AIMS) managed only five
Therapeutic intervention was variable. Twenty five cases which "though finally diagnosed and treated as
percent of the patients did not receive any treatment cases of eating disorder, they presented considerable
after the diagnosis. The psychiatrists did not feel they difficulty in diagnosis". They did not show over activity
could help this type of patient. Sixty three percent of or disturbances in body image!
the patients received a combination of limited counselling Further East, Lai(11) at the Chinese University of
on diet, self-control and family support, while additional Hong Kong described characteristics of 16 Chinese
interventions included variable amounts of anxiolytics, adolescents with AN. In spite of this small number,
antidepressants and phenothiazines. No consistent drug he concludes, "it appears that against the background
regime was established though the majority (63%) got of increasing westernization, the illness is taking a
antidepressants western pattern, in line with the suggestion that
192 EAST AFRICAN MEDICAL JOURNAL April 2004

significant concern about weight in anorexia nervosa find that family, especially maternal factors, play a role
is a pathoplastic effect of Westernization." The small in determining eating attitudes (Not anorexia nervosa).
numbers from Hong Kong further emphasize the rarity It may be that dieting acts as a risk factor in the
of the disorder. context of more specific genetic or biological
Theories of aetiology: What light can these vulnerability. American studies involving black versus
findings cast on the aetiology of A.N? The pressures white women have shown marked differences that are
exerted by cultural desire for thinness have long been only partly explained by the environment(13). Family
thought to be an important cause. Anorexia nervosa has factors by themselves do not explain the rarity of the
been reported in Europe since the 16th century. If the condition in Africa. Families similar to those described
social dynamic explanation was to be the most important by Minuchin as overprotective, rigid, and lacking in
causative factor, then it must be that 21st century conflict resolution are common in Africa. Depression
Africans are unaffected by a desire for thinness anywhere and major life events are thought to be important
near the pressure of 16th century Europeans. That is antecedents for anorexia nervosa(14) Depression and
unlikely to be the case given the fact of globalization major life events are extremely common in Africans
and in particular the fact that at any given time, there and yet do not seem to cause or precipitate anorexia
are at least 70,000 Kenyan students in Western Europe nervosa.
and America, exposed to the same media as the Genetic factors have been implicated. Female
Westerners. Hundreds of thousands of adolescent relatives of probands have a tenfold greater risk of
Africans have studied in the West since the 1950's, and developing an eating disorder, and twin studies(15,16)
will have been similarly exposed. In addition, Kenya have found higher levels of concordance in identical
was a British colony and continues to be influenced compared to non-identical twins.
by the British, in particular by the media. A marked More recent work would tend to support genes as
increase in weight consciousness in Kenya is reflected playing a role, however, minimal in the aetiology or
by the very large number of keep fit clubs in the cities perpetuation of the disorder. Viral, metabolic and
in the last 10 years. immunological causes have also been implicated(17).
There is also evidence that attitudes are changing Thus, rarity of anorexia nervosa among Africans
with respect to eating habits(12). In this recent paper is unexplained. Social models of aspiration for thinness
the authors report a study of a non-clinical female among western cultures as the single most important
population of adolescent girls in South Africa using a aetiological factor is not supported by the lack of rise
self-report questionnaire (EAT 26) and find an overall in anorexia in non-western societies, and the geographical
prevalence figure of abnormal eating attitudes of 21.66% distribution of the disorder requires a rethink on the
with the surprising finding of higher rates of abnormality aetiology of the disorder.
among black pupils (37.5% versus 20.67%). They Limitations:(i). The present study was a small one.
concluded that their study provides preliminary It had to so be because Africa has few psychiatrists.
epidemiological data of girls at risk of developing an It is possible that other parts of Africa e.g. Nigeria
eating disorder. However, they provided no evidence could replicate this study. (ii). Another limitation is
of finding a single case of anorexia nervosa. No link dependence on clinical populations to derive conclusions
can be made between abnormal eating habits in non- about the population at large. (iii). The low response
clinical samples and AN. rate (55%) is a possible source of error. There was
Tests of eating attitudes examine exactly what they however no difference between respondents and non-
set out to do - eating attitudes. They do not measure respondents with regard to the characteristics under
either anorexia nervosa or the risk of developing enquiry.
anorexia nervosa. Another recommended approach is to study high-
The fallacy of the jump from abnormal eating risk groups in Africa. These include female athletes and
attitudes to the conclusion of an increase in disease is adolescent girls in westernised schools in Africa.
similar to concluding that there is a high risk of a (Kenya has an abundance of both)
population developing hypertension because there is a The Future: If following a study of these groups
high level of awareness of its causation. We here argue anorexia nervosa remains truly uncommon, multicentre
that abnormal eating habits and anorexia nervosa are studies involving comparable groups in the West (UK,
independent of each other, or at the very least, that USA), and Africa, Asia and the Far East could give
people with anorexia nervosa show an aversion for food clues on the relative contribution of genes and
that is biologically/biochemically determined, while the environmental factors to this complex disorder.
rest of the population shows a similar, (not the same) Like the now discarded family theories on aetiology
type of aversion that is based on cultural factors that of schizophrenia and childhood autism, it is time to take
do not lead to the disease anorexia nervosa. a critical look at the family dynamic theories in the
Their second paper in the same issue addresses aetiology of anorexia nervosa. Genetic and environmental
factors influencing eating attitudes in South African factors could be at play in the aetiology of this disorder,
girls and uses the same self-report questionnaire. They while family factors act to perpetuate the condition.
 April 2004 EAST AFRICAN MEDICAL JOURNAL 193

Scientific publications must be wary of unsupported Brit J. Psych. 1981; 138:270-271.

statements in this regard, like "in all likelihood, societal 6. Buchan, T. and Gregory, L. D., Anorexia nervosa in a black
Zimbabwean, Brit. J. Psych. 1984; 145:326-330.
modernization intensifies vulnerability to eating disorders
7. Famuyiwa, O. O. Anorexia nervosa in two Nigerians, Acta.
in women"(18). Our study does not support this view. Psychiatr. Scand. 1988; 78:550-554.
8. Binite, A., Osaghae, and Akenzua, O. A. A case report of
CONCLUSION anorexia nervosa. Afr. J. Med. Sci. 2000; 29:175-177.
9. Davis, C., and Yager, J. Transcultural aspects of eating
This case finding approach indicates that AN is disorders: a criUcal literature review, Cult. Med. Psych.
1992; 16:377-394
indeed rare in Kenya despite an increasing degree of 10. Khandelwal, S. K. et al, Eating disorder: an Indian
westernisation in urban areas. There is no doubt that perspective, Int. J. Soc. Psych. 41. 1995.
Kenyan psychiatrists are well able to recognise the 11. Lai, K. Y. Anorexia nervosa in Chinese adolescents - does
disorder. The characteristics of the Kenyan cases culture make a difference? J. Adolesc. 2000; 23:561-568.
confirms that AN is uncommon among indigenous 12. Szabo, C. P and Hollands, C. Abnormal eating attitudes
in secondary school girls in South Africa: a preliminary
Africans. This study provides circumstantial evidence
study. South Afr. Med. J. 1997; 87:524-530.
against the wholly social hypothesis of the aetiology 13. Striegel-Moore, R. H., et al, Eating disorder symptoms
of AN, as if this were the case, one would expect to in a cohort of 11 to 16 year-old black and white girls. The
see an increase in cases in urbanised Africans. NHLBI growth and health study. Int. J. Eat. Disord. 2000;
27:49-66.
REFERENCES 14. Rastam, M. and Gillberg, G. Background factors of anorexia
nervosa. Eur. Child Adol. Psychiat., 1992; 1:54-65.
1. Morton, R. Phthisiologica: or a treatise of consumption. 15. Holland, A. J., Hall, A., Murray, R., Russell, G. F. M. and
Smith & Walford, London. 1694. Crisp, A. H. Anorexia Nervosa: a study of 34 twin pairs
2. Schmidt, T. Eating disorder services: starved of resources, and one set of triplets. Brit. J. Psychiat. 1984; 145:414-
Psychiat. Bull. 2001; 25:241-242. 419.
3. Crisp, A. H., Palmer, R. L. and Kalucy, R. S. How common 16. Treasure, J. L. and Holland, A. J. Genetic vulnerability to
is anorexia nervosa? A prevalence study. Brit. J. Psychiat., eating disorders: evidence from twin and family studies.
1976; 128:549-554. In Anorexia nervosa (ed. H. Remschmidt and M. H.
4. Lucas, A. R., Beard, C. M., O'Fallon, W. M. and Kurland, Schmidt). Hofrefe and Huber, Toronto. 1988; pp.59-68.
L. T. 50-year trends in the incidence of anorexia nervosa 17. Park, R. J., Lawrie, S. M., Freeman, C. P. Post-viral onset
in Rochester. Minn: a population based study. Amer. J. of anorexia nervosa. Brit. J. Psych. 1995; 166:386-389.
Psychiat., 1991; 148:917-922. 18. Sing Lee, Eating disorders are becoming common in
5. Nwaefuma, A., Anorexia nervosa in a developing country. the East too. Brit. Med. J. 2000; 21:321

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