the influence of culture on the development of eating disorders such as anorexia nervosa ( an ) and bulimia nervosa ( bn ) has been long appreciated .
these syndromes are more prevalent in industrialized , and often western cultures and are far more common among females than males , mirroring cross - cultural differences in the importance of thinness for women .
these patterns indict current cultural beauty ideals in the etiology and maintenance of eating disorders .
a secular trend of increased prevalence of bn is observed in the west during the current century , and the recent point prevalence of bn is around 1% of young western women . with another 3 - 5% suffering from similar eating disorders , known as eating disorder
not otherwise specified ( ednos ) in the diagnostic and statistical manual - iv ( dsm - iv ) .
only few classical cases has been reported so far from the asian countries , particularly having more western influence , such as japan , hongkong .
atypical case of bn has recently been reported from india . to our best knowledge ,
a 22-year - old , unmarried female medical undergraduate , belonging to an urban hindu extended nuclear family of the upper socio - economic status from a metropolitan city , with predominantly narcissistic and a histrionic traits and family history of recurrent depressive disorder in paternal grandmother , presented with the poor eating habits of insidious onset for 9 years . during her 8 class
, she developed liking for a boy in her class who rejected her calling fat .
though , she managed to move on ; however , developed dissatisfaction for her body image , and would consider herself fat on the mirror and started looking for means to reduce weight .
with gradually increasing concern over growing fat , she started skipping two meals and would take only one meal and salads in class 10 . over next 6 - 7 month period , she lost up to 12 kg and looked thin , although she would consider it inadequate and would find herself flabby , in front of the mirror , although at other times , she could appreciate that her clothes had become loose . however , she never had symptoms of micronutrient deficiency or menstrual irregularity .
at the same time , she also developed intense liking for the high calorie foods .
she would binge on them 5 - 6 times a month and would regret afterwards .
she started exercising for 1 - 1 h in order to compensate weight gain out of binging .
this pattern continued for next 1 - 1 when she gave up working out unwillingly , to focus more on studies , and she gained about 4 - 5 kg .
she restarted dieting ; however , within few months she again started having increased craving for the high calorie foods and binging , which would be more when she would deny food in parties .
though she knew that her body mass index ( bmi ) was well within normal range , she started taking one tablet of orlistat daily secretly along with skipping meals and rejoining gymnasium in order to reduce her weight to below 50 kg , which was below normal for her height .
she could undergo a single session after which it came to the knowledge of a family member , who refrained her . during last 5 year
, she would compare herself with every female she met or read about in novels , would feel better on seeing obese females , and feel let down if they were slim .
, she would avoid parties , going out with friends , standing for photos , and would spend hours in the gymnasium . at the time of consultation in the psychiatry out - patient department , her bmi was 23 , which is within normal range .
her laboratory investigations including , complete hemogram , liver , and renal function tests , serum electrolytes , plasma blood glucose levels were normal .
she is under regular opd follow - up with sustained improvement since last 18 weeks .
this case is a typical case of bn with obvious presence of a morbid dread of fatness , body image dissatisfaction and setting a sharply defined weight threshold and binging associated with compensatory behavior .
rapid and sustained improvement with the low - dose fluoxetine and cognitive behavioral therapy as observed in this case is usually not seen . despite ongoing adoption of western values world - wide , body dissatisfaction is remarkably lower in non - western countries .
study on indian medical students by the srinivasan et al . found 15% of the 210 students had a form of distress and disorder in attitude towards eating habits and body weight , which are milder or subtle than an or bn . the author termed this as eating distress syndrome .
pary - jones , referring to the historical evolution of eating disorder have mentioned about its  archaic 
form , a less sever and benign form of an or bn . the authors stated that the current severe form of eating disorder such as an , bn might have emerged form of this archaic form .
this historical evolution of major eating disorder from older form had been observed in studies carried out across different culture and region over different periods of time .
hence , it is possible that major eating disorder might be in evolution phase in countries like india , and largely present here in its archaic form .
however , this case may be taken as an indicator of emergence of bn in the context of rapidly increasing western influence in india .
 a classic case of the bulimia nervosa in a young indian female is reported . 
 this is in the context of the impression that due to increasing western influence , and change in cultural concepts of beauty and thinness among women , illnesses previously considered rare in indian subcontinent might be becoming more prevalent . many of the established pre - disposing factors such as female gender , metropolitan domicile , family history of depressive disorder have conglomerated in this case . 
 rapid and sustained improvement with the low - dose fluoxetine and the cognitive behavioral therapy is also worth paid attention . 