A Review on Treatment of Eating Disorders in Asia 1

Individual Assignment B

Master in Clinical Psychology (MCP)

Child and Adolescent Psychopathology (MCP 5103)

Yeoh Chia Ling (Caryn)

MCP 1809-9579

Madam Lim Hooi Shan

2nd May 2018

9.00am
A Review on Treatment of Eating Disorders in Asia 2

Abstract

Eating disorders have traditionally been known to be a “Western” mental illness, however it

has recently been an increased prevalence of Eating Disorders in Asia as well. This paper

aims to review the literature on the treatment of Eating Disorders involving psychotherapy in

Asia. Medline, SAGE and EBSCO electronic databases were searched, and 10 published

articles were chosen to be reviewed. Results indicated that Cognitive Behavioural Therapy

(CBT) is still the first-line and most popularly chosen mode of treatment for Eating

Disorders. Some limitations of the studies were noted and future directions of clinical

research on Eating Disorders in Asia were discussed.

A Review on Treatment of Eating Disorders in Asia 3

1. Introduction

Eating disorders (ED) are conditions characterized by abnormal eating habit, specifically

avoidant / restrictive food intake disorder, Anorexia Nervosa, Bulimia Nervosa & binge

eating disorder. Hudson, Hiripi, Pope, & Kessler, (2007) states, in a prevalence study that it a

most common psychiatric problem that is particularly affecting young women.

Eating disorders have traditionally been known to be a “Western” mental illness, as initially,

EDs were initially found less prevalent in less developed, poorer Asian countries such as

China, Myanmar, India, Thailand, Cambodia, Indonesia, the Philippines, Laos, and Vietnam

(Lee, 2004; Tsai, 2000).

However, as the 21st century progresses, evidence has shown that the more

industrialized and globalized the country, the more EDs have followed, consequently leading

to a more widespread of dieting behaviours, weight and shape concerns, and disordered

eating habits (Tsai, 2000) Hence, although still lower than the Western countries, the

prevalence rate of Eds in non-Western countries certainly have been increasing. (Makino,

Tsuboi & Dennerstein, 2004)

Herpertz-Dahlmann, (2009) states that 15 to 19 years is the peak age of development

of Anorexia Nervosa, with nearly all people with Anorexia Nervosa presenting between 10

and 29 years old. While limited in prevalence studies, Malaysia is no exception in the rise of

EDs. The estimated figure is 1% of the population having anorexia nervosa, while 3% suffer

from bulimia nervosa. (Caren A, 2016)

However, due to the limited treatment studies on ED in Malaysia, this paper aims to

review available articles related to the issues of treatment for Eating Disorders in Asia.

Taking into account the cultural sensitivity, severity and an increasing rate of prevalence in

Asia, the non-western countries.

A Review on Treatment of Eating Disorders in Asia 4

2. Method

2.1. Selection of Studies. Using the electronic database PubMed, Sage and EBSCO a

literature search was conducted. (see Figure 1). In order to incorporate majority of the

studies on treatment of ED in Asia, the search was refined to identify studies published in

English over the last 30 years.

Keywords included in the search were, treatment or intervention or therapy, and Asia;

and the following words in the title: eating disorder, Anorexia Nervosa, Bulimia Nervosa,

binge eating disorder, restrictive/avoidant eating disorder. These keywords are selected

based on the research area of this paper and the papers collected during the review

process. The key words and title words were combined to yield 98 on PubMed, 122 on

Sage and 22 on EBSCO. Studies were then excluded for the following reason:

Prevalence, correlation or assessment studies rather than treatment studies, eating

disorders was not the target of treatment, treatment was purely pharmacological, and

articles discussing reviews of historical data rather than empirical studies. Resulting in the

final selection of studies which includes 12 studies. 6 from PubMed, 2 from Sage and 4

from EBSCO

2.2. Descriptions of studies reviewed. Table 1 summarizes all the papers and studies

included in this review. The following features are summarized: (a) study number and

reference, (b) the sample and problem for treatment (types of eating disorder), (c)

ethnicity categories, (d) gender, (e) design of studies, (f) intervention types, (g) duration

of intervention, (h) measures used, and (i) treatment outcome. The sample and problem or

treatment is used to identify the different types of eating disorder included in the study.

The sample size is important to determine the representativeness and generalizability of

results Intervention types are also important to determine the more popularly sought out

or reported to treat eating disorders. The duration is included to further understand the
A Review on Treatment of Eating Disorders in Asia 5

intervention related time and cost. Last but not least, the outcome used to measure the

severity of eating disorder is important to investigate the reliability and validity of the

treatment outcome.

3. Results

3.1. Description of Studies Included in the Review. A total of 10 studies fulfilled the above

criteria for inclusion. (Table 1) A total of 345 participants were represented in the

treatment of eating disorders, ranging from 1 (Studies 1, 5, 8, 9, 10) to 119 (Study 4). A

diversity of ethnicity and cultures from across Asia is represented with 3 from South-East

Asia (Studies 1, 3, 4), Two from Western Asia (Studies 6 & 7) and a majority of 5 from

East-Asia (Studies 2, 5, 6, 9, 10). In all of the studies included, the involved participants

all met the diagnostic criteria of Eating Disorders in the DSM at the given time. Majority

of the participants included were diagnosed with Anorexia Nervosa (n = 320) (Studies, 3,

4, 6, 7, 8, 9, 10), Bulimia Nervosa (n = 23) in Study 2, Avoidant/Restrictive Intake

Disorder (n = 1) in Study 1 and Binge Eating Disorder (n = 1) in Study 5. In terms of

gender, most of the participants in the Eating disorder studies are Female, (n = 334) with

only 11 Males in Studies 1, 3, 4 and 5.

3.2. Treatment Outcome of Eating Disorders in Asia. A review on treatment of ED in

Asia generally shows an involvement of a multidisciplinary approach. However, due to

the limited experimental studies found in Asia, studies in this review are mostly of a Case

Study design. (Studies 1, 5, 7, 8, 9, 10), with Studies 6, 3 and 4 being retrospective

studies and only Studies 2, an experimental design. Duration of treatment shown in the

studies included ranges from shorter durations of 8 weekly session (Study 5) and 20

weekly sessions of 5 months (Study 2) to 3 years (Study 1 & 8). However, this difference

in time can be attributed to the type of Eating Disorder experienced by the participant and

chronicity of the disorder. In the majority of treatment studies, BMI and patient’s or
A Review on Treatment of Eating Disorders in Asia 6

family self-report of symptoms reduction has been the main outcome measure. Only few

studies use standardized psychological assessments for measurement (Studies 2, 6, 7, 9)

Studies in this review focuses on psychological intervention, with a total of 4 types of

psychotherapy. Some studies incorporate a multidisciplinary approach of

pharmacotherapy, (Study 1), and nutritional intervention (Study 3,6,7). The types of

psychotherapy implemented are Behavioural Therapy (Study 1 & 6), Cognitive

Behavioural Therapy (Studies 1, 3, 2, 5, 7), Family Based Therapy, (Studies 4, 8, 10) and

Dialectical Behaviour Therapy (Study 9).

Cognitive Behavioural Therapy (CBT) appears to be the treatment of choice for ED in

Asia (Studies 1, 2, 3, 5, 7). This is consistent with the recommendation for CBT to be the

first line treatment in ED. (NICE, 2017) In all the studies mentioned, CBT was used to

identify, challenge and modify irrational beliefs and thoughts related to ED. Thoughts

such as “I am going to choke and die” (Ismail & Hamid, 2015) and “Skinny is Beautiful”

(Mark et al, 1993) were targets of change. Setsu et al (2018) however, incorporated CBT

with self-help manual “Getting better bite by bite” by Schmidt, Treasure and Alexander

(1993). This produced positive results whereby 10 participants (40%) achieved all-

symptom abstinence and 13 participants (52%) met the criteria for remission by DSM-IV

at the end of treatment. Meanwhile, Study 1 by Ismail & Hamid (2015) had incorporated

deep breathing techniques and well as a Person-Centred Approach to therapy to reduce

anxiety in the ED patient. It is also important to mention, while focusing on CBT, Study

7, by Mark et al (1993) also emphasized on a multidisciplinary teamwork, limiting the

patient’s manipulation of treatment. They too produced favourable results.

Family Therapy is another commonly used in the treatment of ED in Asia. According

to Katzman et al (2013), FBT is developing as the first-line therapy for paediatric patients

with AN. However, its efficacy is still reliant on the cultural backgrounds, population to
A Review on Treatment of Eating Disorders in Asia 7

which the families belong, and their eating behaviours. In Asia, a collectivist culture,

family and community are seen to be an integral part on an individual’s life. Hence, by

encouraging collaboration, involvement and empowerment of the ED patient and family,

Studies 10, 4 and 8. have also produced positive results with its healing effects not only

on the ED patient but also on her parents as well. (Ma, 2005) In studies by Ismail &

Hamid (2015) and Elizur, Wahrman & Freedman (1999), the family members were also

taught to practise the eating habits and exercises at home with the patient. In the study by

Elizur, Wahrman & Freedman (1999), the therapist, emphasizes on a culturally sensitive

program and the ED patient was put to home confinement instead of hospitalization. And

instead of a nurse or a dietician, a family member (mom) was instructed and supervised to

be in charge of the patient’s feeding and daily diet.

Behaviour Therapy (BT) is used in the study by Ismail & Hamid (2015) and Amemiya

et al (2012) by reinforcing good eating behaviour and a systematic desensitization to the

ED’s patient’s aversion towards food. They have proven favourable results whereby in

Ismail & Hamid’s (2015) study, the patient was able to progress from zero solid food

intake in the past 9 years to 3 meals a day. This is consistent with Bemis (1987) who

supports the utility of reinforcement in ‘‘operant conditioning’’ to encourage weight gain.

Lastly in the use of Dialectical Behaviour Therapy (DBT) in the study by Cheng and

Merrick (2016). Dialectical behavior therapy (DBT) was originally developed by Marsha

Linehan to treat women with self-harm or suicidal behaviours, and borderline personality

disorder (BPD) (Linehan, 1993) And similar to BPD, EDs are characterized by problem

behaviours (e.g., bingeing, purging) that are linked with emotion dysregulation. Within

this framework, an individual’s refusal to eating or binging, are seen as their

dysfunctional attempts to regulate their emotions (McCabe, LaVia, & Marcus, 2004)

Following this framework, Study (9) conducted a total of 50 DBT sessions with the ED
A Review on Treatment of Eating Disorders in Asia 8

patient, focusing on emotions and eating habits, mindfulness during eating, distress

tolerance and maintaining harmony in family relationships. This treatment was measured

using the Outcome Questionnaire-45 (OQ-45) and results showed educed symptom

distress (SD), reduced difficulties in interpersonal relation (IR) and social roles (SR). And

a full remission of the ED.

4. Discussion

This present study aimed to review all the treatment of ED performed in Asia. While

study of prevalence of ED in Asia has been steadily rising, treatment studies are still very

much limited. Research studies vary in methodology and design therefore is often

presented with conflicting findings. Consequently, leading to limitations such as, small

sample size, randomization of sample, unclear diagnosis and treatment protocol

procedures, limited outcome measures or variables, and problems with generalization of

treatment results. In most of the studies, the clinically significant change of the treatment

administered were also seldom given.

Caren A, (2016) and Rasma, Rashid, Ahmed, and Ahmed (2018) states that, ED has

been on a rise in Malaysia, however, limited treatment studies were found. Therefore, it is

clear that research on ED in Malaysia and Asia still has a long way to go.

5. Conclusion

To finish, there is an increasing awareness of the importance of research in treatment

of ED in Asia. While CBT is still a preferred treatment options, other kinds of

interventions like Family / community-based therapy are also on the rise, accommodation

to the collectivist nature of Asians.

It is estimated that 10% of people with anorexia nervosa die within 10 years of the

onset of the disorder (Sullivan, 2002) consequently resulting in 7,000 deaths a year as of
A Review on Treatment of Eating Disorders in Asia 9

2010, making them the mental illness with the highest mortality rate (Lozano et al, 2010)

Therefore, further research in treatment and application of intervention with ED patients

is crucial, especially in the Asian cultural and religion context.

A Review on Treatment of Eating Disorders in Asia 10

Appendix

Search articles via PubMed, Sage and EBSCO

Insert Keywords: treatment, Malaysia and title

words: eating disorder, anorexia nervosa, bulimia
nervosa, binge eating, avoidant/restrictive eating.

278 on PubMed, 358 on Sage and 165 on EBSCO

Combine treatment term & title words

98 on PubMed, 122 on Sage and 22 on EBSCO

Exclude studies not related to treatment yield to 10 studies.

4 from PubMed, 2 from Sage and 4 from EBSCO

Description of studies reviewed

Figure 1: Flowchart of searching articles to review

 A Review on Treatment of Eating Disorders in Asia 11

Disorder or Duration of Outcome

Study Ethnicity (n) Gender (n) Design Intervention Treatment result (+ve/-ve)
problem treatment measure
(1) Ismail & Avoidant/ Malay (n = 1) Male (n = 1) Case Study Behavioural Therapy 3 years NA Positive results, patient
Hamid Restrictive Cognitive Behavioural Therapy progress from zero solid
(2015) Intake Person centred & food intake in the past 9
Disorder psychoeducation years to 3 meals a day.
(2) Setsu et Bulimia Japanese (n = Female (n =23) Quasi Cognitive Behavioural Therapy- 16-20 BMI; EDE Positive. 10 participants
al (2018) Nervosa 23) Experiment based guided self-help (CBT- weekly 16D; EDE- (40%) achieved all-symptom
al Design GSH) sessions, 50 Q; BITE; abstinence and 13
minutes per PHQ-9; participants (52%) met the
session GAD-7 criteria for remission by
DSM-IV at the end of
treatment
(3) Lim, Anorexia Singaporean Male (n = 4) Retrospecti Cognitive Behavioural Therapy, 8 months BMI 68% positive
Sinaram, Nervosa Chinese (n = Female (n = ve study Motivational interviewing 20% no improvement 16%
Ung & Kua 81) 90) techniques, Medical Nutrition did not complete
(2007) Malay (n = 6) therapy
Indian (n = 4)
Others (n = 3)
(4) Anorexia Singaporean Females (n Retrospecti Family Based Therapy (FBT) 20 sessions BMI Positive. Patient in FBT
Wong, Goh Nervosa Chinese (n = =114) ve Study (42) over a 6– group showed higher and
& Ramacha 94) Indian (n = Male (n = 5) Or 12-month faster remission rates
ndran 13) Malay (n = Adolescent Focussed Therapy period with compared to the AFT group.
(2018) 3) (AFT) (77) 1-2 years 39% remission within year 1
Others (n = 9) follow up and 33% at year 2.
(5) Chen & Binge Eating China Male (n = 1) Case Study Cognitive Behavioural Therapy 50 minutes NA Positive. Patient reported
Tao (2010) Disorder Chinese (n = 1) sessions, ability to control emotion
once a week skilfully and use effective
over 8 methods to divert or control
weeks. his negative emotions. His
binge eating had been
eliminated; his life routine
had been become regular.
(6) Anorexia Japanese (n = Female (n = Retrospecti Inpatient therapy: The cognitive NA GCS; BMI Positive. At a follow up 3-9
Amemiya et Nervosa 67) 88) ve Study behavioural approach with years after discharge, 57.1%
 A Review on Treatment of Eating Disorders in Asia 12

al (2012) behavioural limitation of the participants were

Behaviour Therapy categorized in GCS as
Nutritional Diet Schedule excellent, 14.3% as much
improved, 14.3% as
symptomatic and 14.3% as
poor.
(7) Mark et Anorexia Israeli (n = 16) Female (n = Multiple Strict high-caloric diet NA EAT-26 Positive. Patients are
al (1993) Nervosa 16) Case Study Cognitive Behavioural Therapy healthier physically and
(Treatment Clomipramine, 150 mg per day. mentally.
Report) Family sessions
(8) Elizur, Anorexia Israeli Female (n = 1) Case Study Community and Family Based 3 years NA Positive. self-endangering
Wahrman & Nervosa Kibbutz (n = 1) Therapy starvation was controlled and
Freedman the patient learned to
(1999) regulate her food intake,
while autonomy-related
conflicts and family
transitions were negotiated
in an age-appropriate way
(9) Cheng Anorexia China Female (n = 1) Case Study Dialectical behaviour therapy 10 weekly OQ–45 Positive. Reduced symptom
and Merrick Nervosa Chinese (n = 1) (DBT) 90-min distress (SD), reduced
(2016) group DBT difficulties in interpersonal
40 weekly relation (IR) and social roles
individual (SR). The total and SD
DBT scores reported significantly
reduced distress
(10) Ma Anorexia Hong Kong Female (n = 1) Case Study Family Therapy NA (> 5 NA Positive. Full remission of
(2005) Nervosa (1) Chinese (n = 1) sessions) AN symptoms
TABLE 1: Studies on treatment of Eating Disorders in Asia
A Review on Treatment of Eating Disorders in Asia 13

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