Background: We set out to determine whether anorexia nervosa exists in a culture where the pressure to be thin is less pervasive.

Aims: To determine whether there were any cases of anorexia nervosa in female students attending two secondary schools in the north-east region of Ghana.
Method: The body mass index (BMI) of consenting students was calculated after measuring their height and weight. Those with a BMI 19 kg/m2 underwent a structured clinical assessment including mental state, physical examination and completion of the Eating Attitudes Test and the Bulimic Investigatory Test, Edinburgh. Participants nominated a best friend to serve as a comparison group, and these young women under went the same assessments.
Results Of the 668 students who were screened for BMI, 10 with a BMI <17.5 kg/m2 appeared to have self-starvation as the only cause of their low weight. All 10 viewed their food restriction positively and in religious terms. The beliefs of these individuals included ideas of self-control and denial of hunger, without the typical anorexic concerns about weight or shape.
Conclusions Morbid self-starvation may be the core feature of anorexia nervosa, with the attribution for the self-starvation behaviour varying between cultures.
Study was done by
Dinah Bennett, MBBS, MPhil, MRCPsych
South East Scotland Deanery, Edinburgh

Michael Sharpe, MA, MRCP, MD, MRCPsych
Department of Psychological Medicine and Symptoms Research, University of Edinburgh

Chris Freeman, FRCPsych, FRCP(Ed)
Cullen Centre, Royal Edinburgh Hospital

Alan Carson, MBChB, MPhil, MD, MRCPsych
Robert Fergusson Unit and Department of Clinical Neurosciences, Royal Edinburgh Hospital, Edinburgh, UK

Correspondence: Dr Dinah Bennett, Specialist Registrar in Psychiatry, Department of Psychiatry, St John?s Hospital, Howden Road West, Livingston, Edinburgh EH54 6PP, UK. E-mail: Dinah.Bennett@lpct.scot.nhs.uk