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CASE REPORT
Year : 2022  |  Volume : 1  |  Issue : 1  |  Page : 28-30

Unmasking anorexia nervosa in a Nigerian female undergraduate: A case report


Department of Mental Health, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria

Date of Submission29-Jul-2021
Date of Acceptance22-Jan-2022
Date of Web Publication30-Aug-2022

Correspondence Address:
Rafiat O Lawal
Department of Mental Health, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jnam.jnam_6_21

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  Abstract 

We report a rare case of anorexia nervosa in a 20-year-old woman undergraduate of the Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, Nigeria. The patient met the ICD-10 diagnostic criteria for anorexia nervosa. The major reason for presentation was amenorrhea. A significant etiological factor in the patient was her belief that gaining weight was linked to the fact that weight while in a romantic relationship was linked to being sexually active. She received psychotherapy, and her diet was modified on an outpatient basis and she made an significant improvement.

Keywords: Anorexia nervosa, female, Nigeria


How to cite this article:
Lawal RO, Ugalahi TO, Mosaku S K, Oginni OA. Unmasking anorexia nervosa in a Nigerian female undergraduate: A case report. J Niger Acad Med 2022;1:28-30

How to cite this URL:
Lawal RO, Ugalahi TO, Mosaku S K, Oginni OA. Unmasking anorexia nervosa in a Nigerian female undergraduate: A case report. J Niger Acad Med [serial online] 2022 [cited 2022 Nov 27];1:28-30. Available from: http://www.jnam.com/text.asp?2022/1/1/28/354770




  Background Top


Anorexia nervosa (AN) is an eating disorder initially believed to be uncommon until the late 18th century, and it is characterized by very low body weight (15% below standard weight or body mass index [BMI] less than 17.5 kg/m2), concerns about body shape and weight, a strong desire to be thin, and amenorrhea.[1] Most of the cases were reported in young women (female to male ratio of 9:1), and it generally begins as an ordinary effort at dieting, which then becomes uncontrollable. Individuals may try to lose weight by reducing caloric intake, inducing vomiting, exercising excessively, or misusing laxatives. Other associated symptoms may include depression, anxiety and obsessive symptoms, social withdrawal, and the lack of sexual interest.

The lifetime prevalence of AN in young women ranges between 1% and 4.2%,[2] but much lower in males, about 0.3%.[1] The incidence is lower in non-Western countries.[3] In Nigeria, to the best of our knowledge, there are three reported cases of AN in Nigeria.[3] Famuyiwa suggested that this may be due to the cultural value placed on plumpness as a sign of beauty and well-being.[3] A study in Kenya found that AN is still very rare despite the trend toward globalization.[4]


  Case Presentation Top


Miss A.S. is a 20-year-old undergraduate student of the Obafemi Awolowo University, Ile-Ife, where she resides on-campus, is single, and is a Christian. She was referred from the gynecological unit of the hospital to the Mental Health Department on September 26, 2014 with a 3-year history of progressive weight loss and a year history of cessation of menstrual flow. The weight loss was induced, following recurrent comments by her friends that she was gaining weight, which they attributed to engaging in sexual activity. The patient was distressed by this as she was not sexually active due to her religious beliefs.

She began reducing her food intake by skipping meals in order to lose weight and stop her friends’ comments, taking an average of one meal in 48 h. She also avoided foods that she believed contained high levels of cholesterol, based on information from the Internet and sometimes induced vomiting whenever she ate such foods. She exercised more frequently but as the weight loss progressed, she found it difficult to continue.

At presentation to the Mental Health Unit, she was unable to tolerate more than six teaspoonfuls of food per meal. Miss A.S. found her low weight satisfying, despite complaints from her family, friends, and classmates about her severe weight loss. As the illness progressed, she terminated the relationship with her boyfriend because she lost interest in every social engagement.

She observed a reduction in the frequency of her menstrual cycle about a year prior to presentation, which subsequently ceased. This led to presentation at the school clinic from where she was referred to the gynecology clinic where a hormonal assay was carried out and she was commenced on oral contraceptive pills. This was followed by withdrawal bleeding but was not sustained. She was counseled to increase her food intake to gain weight; however her weight continued to decrease. She was further reviewed by the medical team who excluded other causes of weight loss such as pulmonary (and extra-pulmonary) tuberculosis, HIV infection, and occult malignancies after which she was referred to our unit. She did not have any chronic medical conditions nor was she taking medications such as diuretics or purgatives. There was no history of sustained mood abnormalities, psychotic symptoms, or any history suggestive of an obsessive compulsive disorder.

She attained menarche at 14 years and normal flow lasts 3 days in a regular 28-day cycle. Her father is an accountant with one of the State agencies and her mother a primary school teacher. She is the first of three siblings in a monogamous family setting. Miss A.S. does not view her parents as strict and is closer to her mother.

On mental state examination, overvalued ideas about body shape were the only abnormality detected. Physical examination revealed a grossly underweight young woman, with a weight of 36 kg and BMI of 14 kg/m2 (height = 1.6 m). There were bony prominences at the shoulders and pelvis, her skin was dry, and lanugo hair was present. Her vital signs were within normal limits with a blood pressure of 100/70 mmHg and pulse rate of 80 beats per minute. Results of investigations revealed the following: serum calcium: 2.29 mmol/L, serum creatinine: 85 µmol/L, serum bicarbonate: 22 mmol/L, serum potassium: 3.2 mmol/L, serum sodium: 131 mmol/L, serum total protein: 76 g/L, serum albumin: 36 g/L, serum globulin: 40 g/L, and fasting blood glucose: 5.2 mmol/L and 2 h postprandial glucose: 5.3 mmol/L. Packed cell volume: 40%, white blood cell count: 5.9 × 109/L, all of which were within normal limits.

She was managed as an outpatient. A meal plan was drawn up to include all the classes of food and progressively increase the frequency and quantity of meals taken daily and this was monitored with a diary. She also had psychotherapy, which was eclectic with cognitive behavioral and supportive approaches, focused on educating her about the negative effects of being underweight. She was supported by her mother and roommates who helped monitor adherence to the diet plan; however, her father declined participation because of prior conflicts about the patient’s weight.

She was seen weekly, and at each visit, her BMI was calculated, the meal plan was revised, and psychotherapeutic sessions continued. She gained an average of 0.5 kg weekly; however, after about a month, she developed symptoms of constipation, which reduced the quantity of dietary intake. This reflected in her weight gain for November and December [Figure 1] and [Table 1].
Figure 1: The chart showing the weight and BMI changes of A.S. during treatment

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Table 1: Excerpts from the patient’s meal diary

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Her menstruation commenced 5 months after treatment at a weight of 44 kg and BMI of 17.9 kg/m2. Her dietary intake has been steady, and the slight reduction in weight and BMI in the 29th week was due to the stress of ongoing examinations. The beliefs about her body image have resolved, and she is in a relationship with a new partner.


  Discussion Top


Etiological factors reported in AN were psychological such as struggle for a sense of control, identity conflicts, and abnormal patterns of family interactions, which may further interact with genetic susceptibility.[1] It was reported that in 50% of Nigerian female students, religious fasts were associated with excessive reduction in diet.[5] In this patient, however, the belief that sexual activity was associated with weight gain was a significant precipitating and sustaining factor. Her father’s refusal to participate was also suggestive of poor conflict resolution in the family.

This summary also highlights the importance of patient participation in the dietary modification. Meals were locally sourced and were easy to prepare between classes and progressively included more carbohydrates and proteins. We also emphasize the importance of psychotherapy in the management of AN in this environment as well as the need for a social support system.


  Conclusions Top


While AN is not common in this environment, etiological factors may differ from those described in high-income countries. Other cultural factors such as the beliefs attached to weight gain in adolescence should be further investigated as etiological factors in AN in this environment. Psychotherapy and psychosocial support were also highlighted as significant aspects of treatment.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Cowen P, Harrisson P, Burns T Shorter Oxford Textbook of Psychiatry. 2012.  Back to cited text no. 1
    
2.
A summary of Issues, Statistics and Resources. The Renfrew Center Foundation for Eating Disorders, Eating Disorders 101 Guide. 2003.  Back to cited text no. 2
    
3.
Famuyiwa OO Anorexia nervosa in two Nigerians. Acta Psychiatr Scand 1988;78:550-4.  Back to cited text no. 3
    
4.
Njenga FG, Kangethe RN Anorexia nervosa in Kenya. East Afr Med J 2004;81:188-93.  Back to cited text no. 4
    
5.
Dike IP Anorexia and Bulimia nervosa: The scenario among Nigerian female students. J Psychol Couns 2009;1:26-9.  Back to cited text no. 5
    


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    Tables

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