Prof. B. M. Hegde,
Vice Chancellor,
MAHE Deemed University,
Manipal-576 119.

We are all aware of the fact that illiteracy and ignorance are the two leading risk factors for the common man’s unhealthy life style. Lately we claim that better education of the masses in healthy life styles has improved the outlook at least in the industrialized west! It is also reported that the west has been better off in this respect. In addition, there is big business out there in selling healthy foods and vitamins in addition to what is called health education for the masses. Education has reduced smoking among adults, cut down the intake of junk food in the middle aged in the west, and has also made people (especially hypochondriacs) to see their doctors frequently to get checked up. Unfortunately, all these have their downside as well. Smoking is going up among women and children in most countries, unbalanced diet and the anxiety of eating right has wrecked havoc with many and the regular check up of the apparently healthy has resulted in the epidemic rise of the Ulysses syndrome, the new syndrome resulting from unnecessary tests and interventions.1

Dysrexia nervosa is a neo-logism. Dys is an inseparable combining form from Greek that conveys a bad sense to any word it is hooked onto.2 It conveys the meaning of defective, difficult, ill, or painful. It should not be confused with dis from Latin, which is used as a prefix meaning apart, asunder, or deprived of. There are many medical words starting with dys. Greek word orexis denotes appetite and means just that. It could also mean, at times, other types of yearning, and perhaps that is the reason why one form of the male hormone, testosterone is, occasionally, called Oreton. Dysrexia nervosa is a new epidemic these days among the “educated masses.” It is the painful process of eating.

When these patients sit on the dining table they do not seem to enjoy food, which is what they have to do in the first place to be healthy. On the contrary, they start eyeing each item with their half-baked knowledge of western nutrition and look for traces of cholesterol, sucrose, sodium chloride and many other poisons. Every food item, including the mineral water they drink, is thus labeled. In addition, they also have to assess the amount of various vitamins and minerals in their diet to keep themselves healthy, not to speak of the complicated way in which they have to keep an account of the total calories that they are consuming. This makes life miserable and takes away the most important part of human life-the pleasures of the dining table! Those who suffer from this malady, through its protean manifestations, are to be labeled dysrexia nervosa from now on.

This is a new syndrome and has to be learnt in great detail by all practising doctors and the future ones in the medical schools, lest they should miss out on the most important and largest group of the educated ignorant patients, whose numbers would go up exponentially in the coming decades! A new disease is thus born, like a new star in the firmament. (Haubrich WS: Medical Meanings, 1984. American College of Physicians, Philadelphia)

Dysrexia nervosa should not be mistaken for the sub-nutrition (less than normal amount of calories) and malnutrition (wrong type of food calories) resulting from poverty and the inability to get food. The greatest risk factor for all diseases is the sorrow of not knowing where your next meal is coming from. Poverty is the womb of all diseases, except the two described by me, viz.: unrest syndrome 3, and dysrexia nervosa syndrome. These two are exceptionally the diseases of the well to do and the rich! Malnutrition has no psychological element to it. It is the inability to get enough amount of the right foods that results in the patient suffering from lack of calories and the vital elements in the diet, whereas dyrexia nervosa is the painful psychological illness of not enjoying the food with the misconception that it is not the wholesome food that it ought to be, although it could rarely be associated with malnutrition.

Poverty is not an isolated phenomenon of the poor developing countries. It is equally prevalent in the developed world; may be the total numbers are less because of the paucity of population in many of those rich countries. A recent survey in the Republic of Ireland, published in The Irish Times (10th June 2001 issue) by the author of the report, Kelvin Balanda, described the findings as shocking. Poverty and inequality killed more than 6000 people prematurely in one year (relatively very small population). The findings of the study were:

• Cancers were 100% higher among the poor.
• For circulatory diseases, it was 120% higher.
• For respiratory diseases it was 200% higher.
• Injuries and poisonings were 150% higher.
• The mortality rate was 54% higher for males.
• Rates were slightly more (5-10%) in the Republic in comparison to Northern Ireland.

“Poorer you are, the worse your health,” concluded the report.

Such statistics are not available in our country for obvious reasons. The disparity, conceivably, could be much higher, though! The stimulus for me to uncover this syndrome, dysrexia nervosa, came from an excellent book that I was reading lately (can not remember the author’s name) which was talking about orthorexia, that is straightening the wrong diet perceptions!

I would like to dispel the myth that the present nutritional advice in our lay journals and even in the medical journals is based on sound foundation. This kind of advice is the main reason for the epidemic of dysrexia nervosa. Unlike patients suffering from anorexia nervosa or bulimia, patients with dysrexia want to eat normally if not in excess, but they suffer because of their wrong knowledge. Years ago the Roman philosopher, Cicero, had rightly commented that: “ half of what man knows today would be proved wrong in the next five years, but the problem with mankind would be that they would not know which half it is.” How true! Our “scientific” nutritional advice derives its sustenance from the Nazi secrets of the Second World War. There has been hardly any groundbreaking research in this field since then, although we have been nibbling at bits and pieces from time to time. I would like to call this as incrementalism, which, by far, has not added any valuable wisdom to this field. Smaller studies show some remarkable findings, which are invariably refuted by larger studies, as would be shown later in the article. Indian ancient wisdom of thousands of years of observational research has given us more data than all that one could find in the western literature. Ayurveda, in particular, has extensive wisdom in the field of dietetics.

The number of people suffering from dysrexia would far outnumber that with anorexia nervosa or bulimia. There is a marked difference in the aetio-pathogenesis of the two conditions, though. Whereas anorexia is basically a reactive depressive trait, dysrexia, on the other hand, is basically a phobic disorder with an added element of obsession thrown in good measure.

Symptoms of the disease:

Patients suffering from this malady live in constant unhappiness. Their main preoccupation seems to be eating right. Their spare time is spent in worrying about eating the wrong food. They are the ones who do not miss any health magazine, most of which give out half-truths and doctored facts to suit the convenience of the manufacturers. Many of these journals live on the money doled out by such companies. Food industry is the most powerful and durable business. One need not necessarily buy a motor car but one will have to eat to live.

The patients’ spouses live in constant anxiety as they bring home almost daily newer ideas about eating the right way! The dining table is the most miserable place for the patient. Before and after eating he keeps worrying about the quality of food, the nutritional content and the micro-nutrients that he has consumed. In a manner of speaking these patients die everyday on the dining table. Some of them look famished and too thin, their skin having wrinkled very fast and their face without the natural glow. Their social interaction centers round food and health related matters.

Many of them do not enjoy life at all, all the time worrying and fretting about food and its consequences.

Management:

Here the management is predominantly, if not solely, preventive and correctional behavioural therapy, although well established disease could be helped by group therapy using bio-feed back and modern psychotherapeutic techniques. Prevention takes the cake. It is not only less expensive it is more effective.

Prevention could be universally effective if the right type of messages about food and eating habits could reach the target population, but that is a Himalayan task, both because of its size as also because of the power of the food industry to be able to give the doctored version with their money power 4. It is, therefore, mandatory that the therapist must be equipped with the correct dietary information. The following simple rules should help everyone.

• Moderation in anything that one eats is the best policy.
• Indulging in the wrong type of food once in a way is not harmful.
• Vegetarian meals are preferable, although meat is not poison: fish being good for health is also a fishy affair5..
• Small, frequent meals are better than large infrequent ones.
• Fresh food, without much change from its natural state, would be ideal.
• Most of the nutritional data put out in lay press does not have any solid scientific basis 6.
• Reductionist science has to, perforce, change its teachings frequently. The truth of today could be the folly of tomorrow.
• 30 ml. of water per kilogram body weight is adequate as a daily ration.
• Caffeinated beverages could be kept to the minimum.
• Alcohol could be conveniently avoided, although there is so much propaganda on every adult consuming a small quantity of alcohol to keep diseases at bay. The latter is a fraud on the public 7.
• The risk factor hypothesis plays on a very sticky wicket.(Strandberg SE, Salornaa VV, and Naukkarinen VA, et.al Long-term mortality after five-year multifactorial primary prevention of cardiovascular diseases in middle-aged men 8.
• The fat hypothesis began with the misconception that since the second world war deaths due to vascular diseases have been going up directly proportionate to the per capita consumption of fat! With prosperity in Europe after the war people were eating more and more. It is not only fat, but refined carbohydrates and many other items have gone up. Since medical muddling is always a profitable business, the fat hypothesis stuck on as there was a billion-dollar industry around it. In addition to all these the disease awareness and labeling accounted for the apparent increase in all diseases 9.
• In the 50s another theory of sugar (sucrose) being the be all and end all of vascular diseases came into being.
• If one understands the simple mathematical rules, when two things concurrently go up in society their relationship should be linear; but that does not mean that they have a cause-effect relationship 10.
• In fact, the first diet-heart study done in Framingham, USA, did not show any relationship between diet and heart disease! This study had used $ 110 million of the tax payers money but the final negative result, at the end of five years, did not get published. The result was suppressed as there was a multimillion dollar industry manufacturing low fat food items already in existence by then! 11
• It is not what you eat that kills you; it is what eats you (negative thoughts) that kills you. ( Hippsley-Cox J, Fielding K, and Pringle M. Depression as a risk factor for IHD in men) 12. There are a host of scientific studies, both prospective and retrospective, that have shown a very close cause-effect relationship between negative thoughts like anger, pride, hostility, and depression and vascular diseases and, even, cancer! 13
• Junk food, preserved to enhance its shelf-life, is the enemy of good health. The main reason is that all the preserved food will have to be high in salt, the latter being the best preservative in view of its powerful anti-microbial function.
• High salt diet harms in many ways. Basically, it pushes the blood pressure up in some of us, encourages heart failure in those with diseases of the heart, increases the risk of stroke, and worsens old age bone mineral loss by throwing out calcium in the kidney.
• No salt diet (difficult to get) is also harmful as it could stimulate rennin secretion with all the attendant dangers.
• Some of the harmless looking breakfast cereals have as much salt as contained in seawater!
• Fat rich diet harms the body in the long run.
• Very low fat diet is unhealthy in that it could result in fatty acid deficiency syndromes. It could also encourage gallstones by reducing the gall bladder contractions.
• Rich food helps obesity-a major health risk these days.
• Regular physical exercise, not heavy exercise, keeps the body healthy, both by suppressing appetite after a while and burning extra calories if needed.

The risk factor hypothesis, the basis of all food based fears of the educated masses culminating in dysrexia, would not stand the test of strict scientific scrutiny. While a few million at a given time could be ill, the vast majority of the billions of people in this world are well at any given time, despite the fact that the environment remains the same for all of us. Whereas there are the less fortunate ones who do not get two square meals a day and suffer from starvation, the minority who overeat suffer because of eating in excess rather than eating the wrong type of food.

Worrying about eating the right food is perhaps a greater risk for disease than the food eaten. The food fads that the lay press puts forward from time to time are based more on the doctored literature of the food industry rather than the unequivocal hard data from the scientific community.

Repeated indoctrination on the lines suggested above might allay the anxiety that is at the root of the dysrexic syndrome. Group therapy using these data and other proven effective methods of therapy would certainly prevent dysrexia. It might also be effective in treating the established syndrome, assisted, in addition, by relaxation techniques.

Indian wisdom of Ayurveda has many more useful tips in dietetics. Ayurveda talks of three basic types of food: rajas, thamasa and satvik. Suitable good food varies from season to season and from person to person. There is nothing that could be universally equally good or bad. The saying that "one man's poison could be another's food" is true to a certain extent. Half of what a rich man eats keeps him going and the other half keeps his doctor going. We should wake up before dysrexia becomes an epidemic in our country as it has already done in the industrialized west.

BIBLIOGRAPHY.

01. Korn D: Conflicts of interest in biomedical research. JAMA 2000; 284: 2234-2238
02. Gilman MW. Enjoy your fruits and vegetables. BMJ1996; 313: 765-766. Hegde BM. The Fishy Meal
03. Kmietowicz Z Cholesterol screening is not worthwhile. BMJ 1998; 316: 725
04. Edwards G, Anderson P, Babor T, et. al Alcohol policy and the public good. Oxford. Oxford University Press, 1994.
05. JAMA 1991; 266: 1225-1229
06. Lancet 1993;341:993-994
07. Editorial: Do epidemiologists cause epidemics? Lancet 1993; 341:993-994
08. Hegde BM Cholesterol Myth. Cardiologist 2001; :
09. BMJ 1998; 316:1714-1718
10. Angerer P. Social support, hostility, and other psychosocial conditions in coronary artery disease. Cardi. Research and Review 2001; June: 331-333.