Eating disorders are serious disturbances in eating behavior, such as extreme and unhealthy reduction of food intake or severe overeating. They are accompanied by feelings of distress or excessive concern about body shape or weight. The main types of eating disorders are Anorexia , Bulimia Nervosa , and Binge Eating Disorder.
What Is Eating Disorders
Risk Factors For Eating Disorders
A risk factor is something that increases your likelihood of getting a disease or condition. It is possible to develop eating disorders with or without the risk factors listed below. However, the more risk factors you have, the greater your likelihood of developing eating disorders. If you have a number of risk factors, ask your doctor what you can do to reduce your risk.
A number of factors can play a role in your risk of developing an eating disorder. Emotional stress, generated by significant life events, often precedes the onset of an eating disorder in susceptible individuals.
The following factors have been found to increase the risk of developing an eating disorder:
Females are much more likely than males to develop an eating disorder. An estimated 5%-15% of people with Anorexia or Bulimia Nervosa are male, and an estimated 35% of those with binge eating disorder are male.
People living in economically developed nations appear to have a higher risk for developing eating disorders. Studies suggest that, within economically developed countries, the risk for Bulimia Nervosa may be higher among lower socioeconomic groups.
Eating disorders are most prevalent in people (usually girls and young women) between the ages of 12-25. Although, eating disorders can occur in children and older adults.
Genetics and Biochemical Factors
Studies suggest that abnormalities in brain pathways involving the neurotransmitter serotonin persist after recovery from certain eating disorders. These findings lead to speculation that serotonin and other similar chemical substances within the brain may have a causative role in anorexia. Further studies are needed. Some genes have also been found to be associated with eating disorders in certain people. Further research may bring new insights into the causes and treatments of these disorders.
Athletics and Certain Professions
Athletes, such as dancers, jockeys, gymnasts, runners, wrestlers, and cheerleaders, tend to be at a higher risk for eating disorders. Many coaches and teachers encourage thinness to achieve a competitive edge. They may advocate calorie counting and inappropriate loss of body fat. There is also a higher risk of eating disorders in models, actresses, entertainers, sorority members, and socialites, all of whom may experience social pressures to be thin.
Girls who experience early puberty are more at risk for developing an eating disorder. Since they mature physically faster than their peers and have an increase in normal body fat, they may feel isolated and under greater pressure to restrict their food intake.
Certain personality factors seem to increase a person’s risk of developing an eating disorder. People with eating disorders tend to be perfectionists who have high expectations of themselves and others. In spite of being high achievers, they may have low self-esteem and identity problems. They are prone to dichotomous thinking (ie, seeing everything as good or bad, a success or a failure). This thinking carries over to issues about weight, where thin is good and thinnest is best.
Fear of change and difficulty coping with stress are common in people who have eating disorders. They may also fear criticism, avoid sexuality, or act out impulsively. Among people with eating disorders, there are high rates of personality disorders (eg, Borderline Personality Disorder, avoidant personality disorder, Obsessive-Compulsive Personality Disorder, and narcissism.
People with mood disorders (eg, major depressive disorder, Obsessive-Compulsive Disorder, Anxiety are at greater risk for developing an eating disorder. In fact, between 40%-96% of all people with eating disorders also have mood disorders.
Negative influences within a family can play a role in eating disorders. Some studies suggest that eating disorders are more prevalent in people where one or both parents are overprotective, detached, critical, rigid, or ineffective at resolving conflict.
A person may be more at risk for developing an eating disorder if she has parents who have psychiatric disorders or who abuse Alcohol Abuse and Alcoholism or other addictive substances. Research suggests that daughters of mothers who have a history of eating disorders may be at higher risk for an eating disorder. Eating disorders are also more common in families where there is pressure to be thin.
Social and Cultural Pressures
Beauty standards in Western culture focus on youth and thinness. Images of thin, beautiful, successful people are constantly portrayed in the media. These and other pressures, such as pressures from appearance-obsessed peers and romantic partners, lead to higher rates of eating disorders in people in Western culture.
History of Abuse
Researchers are investigating the link between childhood abuse and the development of eating disorders. Some studies have found an association between women who have been sexually abused and bulima.
Diagnosing Eating Disorders
The first step in diagnosis is admitting that you have symptoms of an eating disorder. You may need support and encouragement from others before seeking help.
- Initial evaluation-During the initial evaluation, your doctor will ask about your symptoms and medical history, the amount of food you eat, and how you try to control your weight.
- Physical exam and tests-Your doctor will give you a physical exam and check your height and weight. If you have symptoms of Bulimia Nervosa , she may look at your teeth to check for erosion (a sign of frequent vomiting). You will also have routine blood, urine, and other tests to check your overall health status.
- Psychiatric evaluation-A mental health professional may perform a series of tests and evaluate you for other psychiatric conditions, such as Depression and Anxiety , which are common in people with eating disorders. Diagnosis of a particular type of eating disorder is based on an evaluation of your symptoms using the criteria of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Screening tests such as the Eating Attitudes Test (EAT-26) can be used to screen for symptoms of eating disorders.
Diagnosis of Anorexia Nervosa
According to the DSM-IV, Anorexia is characterized by:
- An intense fear of gaining weight
- A refusal to maintain adequate nutrition, often associated with an erroneous image of the self as fat
- Loss of original body weight to 85% or less of what is expected for normal height and weight
- Disturbance of body image and negative self-evaluation
- Absence of at least three consecutive menstrual periods in females who have started menstruating
Diagnosis of Bulimia Nervosa
According to the DSM-IV, bulimia nervosa is characterized by:
- Frequent occurrence of binge eating episodes accompanied by a sense of loss of control
- Recurrent inappropriate behavior (ie, vomiting, use of laxatives, fasting, or excessive exercise) intended to prevent weight gain
- Both of the above behaviors occur at least twice a week, on average, for three months
- Negative self-evaluation influenced by body shape and weight
Diagnosis of Binge Eating Disorder
Binge eating disorder is characterized by:
- Binge eating episodes accompanied by a sense of loss of control
- No inappropriate behavior to prevent weight gain
- The behavior occurs at least twice a week, on average, for three months
Symptoms of Eating Disorders
If you have this disorder, you see yourself as overweight even though you are dangerously thin. The process of eating becomes an obsession. You develop unusual eating habits, such as avoiding food and meals, picking out a few foods and eating these in small quantities, or carefully weighing and portioning food. You may repeatedly check your body weight and engage in other techniques to control your weight, such as intense and compulsive exercise or purging. Purging can be done by vomiting or by abusing laxatives, enemas, and diuretics. Girls with Anorexia often experience a delayed onset of their first menstrual period.
Symptoms of anorexia nervosa may include:
- Excessive weight loss
- Obsession with food calories and fat content
- Dieting even when thin
- Intense fear of gaining weight, even when underweight
- Distorted self-image of excess weight despite evidence to the contrary
- Undue influence of body weight or shape on self-evaluation
- Loss of menstrual periods (secondary amenorrhea ) or delay in onset of period (menarche)
- Excessive exercising
- Feeling cold, especially in the hands and feet
- Being secretive about food
- Hair loss and/or growth of fine hair on the body
- Fainting or severe lightheadedness
- Depression and/or Anxiety
- Heart palpitations
The course and outcome of anorexia nervosa varies among people. Some recover fully after a single episode, some have a fluctuating pattern of weight gain and relapse, and others experience a chronically deteriorating course of illness over many years.
In Bulimia Nervosa , binge eating episodes are followed by purging or exercise. Therefore, you may weigh within the normal range for your age and height. However, like individuals with anorexia, you may fear gaining weight, desire to lose weight, and feel intensely dissatisfied with your body. You may binge and purge in secrecy, feeling disgusted and ashamed when you binge, yet relieved once you purge.
Behavioral symptoms include:
- Eating huge amounts of food at one time and, as a result, often spending a great deal of money on food
- Feeling like your eating is out of control
- Making yourself throw up
- Taking laxatives, enemas, water pills, or diet pills
- Excessive exercising
- Spending a lot of time alone
- Mood swings
- Trouble controlling impulses
- Alcohol Abuse and Alcoholism or Drug Abuse and Drug Addiction
Physical symptoms include:
- Abdominal pain
- Menstrual problems
- Swelling of cheeks and jaw
- Sore throat
- Swollen salivary glands
- Stained or chipped teeth due to contact with stomach acid
- Cuts or scars on back of hands from scraping skin on teeth during forced vomiting
Bulimia can lead to other problems including:
- Dental and throat problems from stomach acid that rises during vomiting
- Changes in body chemistry and fluids due to vomiting and abuse of laxatives or water pills
Symptoms of these complications include:
- Feeling faint
- Extreme thirst
- Muscle cramps
- Irregular heartbeat
- Heart problems
Binge Eating Disorder
If you have Binge Eating Disorder , you experience frequent episodes of out-of-control eating, with the same binge eating symptoms as those with bulimia. The main difference is that you do not purge. Therefore, you may be overweight for your age and height. Feelings of self-disgust and shame associated with this illness can lead to recurrent binging.
- Recurrent episodes of binge eating, characterized by eating an excessive amount of food within a discrete period of time and by a sense of lack of control over eating during the episode
- The binge-eating episodes are associated with at least three of the following:
- Eating much more rapidly than normal
- Eating until feeling uncomfortably full
- Eating large amounts of food when not feeling physically hungry
- Eating alone because of embarrassment about how much you are eating
- Feeling disgusted with yourself, depressed, or very guilty after overeating
- Marked distress about the binge eating behavior
- The binge eating occurs, on average, at least two days a week for six months
- The binge eating is not associated with the regular use of inappropriate compensatory behaviors (ie, purging, fasting, or excessive exercise)
Living With Eating Disorders
Joanne is a dietitian living in Illinois. She began restricting her food intake and vomiting while in high school, but she believes the roots of her eating disorder date back much further. In college, she tried to stop on her own. Once she recognized that she needed help, she sought treatment for anorexia and bulimia. Today, at age 25, she has fully recovered.
What was your first sign that something was wrong? What symptoms did you experience?
I first showed signs of anorexia in 1991, when I was a sophomore in high school. I began limiting food. I was a synchronized swimmer and wanted to lose weight to look better in a bathing suit. Rather than eating lunch, I’d study or talk to friends. I stayed late at school and skipped dinner. I exercised compulsively, sometimes working out all night. I didn’t want to sleep, because I wouldn’t be burning any calories. Keeping up the self-starvation became more difficult when I started going to Sweet 16 parties. I’d eat a salad or soup, a binge for me at that time. To compensate, I began purging and taking pills-laxatives, diet pills, water pills-25 or 30 a day.
I lost weight. I always felt cold and often lightheaded. I fainted. I was very moody and temperamental. Toward the end, I developed fine baby hair on my tummy (a symptom of anorexia). The enamel on my teeth eroded from the stomach acid coming back up when I vomited. I needed many fillings. I still suffer from gastroesophageal reflux disease. All the throwing up I did caused my lower esophageal sphincter to loosen.
When I went to college, at a school far from home, I thought of it as starting fresh. No one knew about my eating disorder. I behaved like a normal freshman and gained 15 pounds. I didn’t like the added weight. My clothes didn’t fit. I thought I was ugly and fat. By winter break, I knew I had to do something to shed the pounds, so I began writing down everything I ate, taking pills, and removing myself from social activities.
What was the whole diagnosis experience like?
Going to my pediatrician was not an option. She had started me dieting in third grade and sent me to Weight Watchers in fifth, planting the seed that I was fat.
My turning point came at the end of my freshman year. I called home and told my mom that I wanted to see someone about my eating disorder. She made an appointment for me with a psychiatrist. He wanted me to enter a day-treatment program, but they didn’t allow participants to be vegetarian (which I was). I knew it wasn’t for me. I found another psychiatrist who was easy to talk with.
What was your initial and then longer-term reaction to the diagnosis?
I knew I had an eating disorder. My recovery was quicker and more permanent than others because I made the decision that I didn’t want to do it anymore. I didn’t want to live the life of an anorexic or bulimic. Thinking about your body 98% of the time and feeling horrible is a waste of time. I knew I needed to do something to feel good about myself. I’d never resort back to restricting or purging. It’s not worth it.
How was your disease treated?
The psychiatrist started me on a high dose of an SSRI antidepressant, then weaned me down. We decided on a Weight Watchers food plan, which includes eating a healthy amount of calories and weighing in weekly. My mother went with me. I learned to eat healthy and lost 15 pounds, without going to extremes. I returned to college and followed up with a psychiatrist.
Did you have to make any lifestyle or dietary changes in response to your illness?
I eat balanced meals with things from all food groups, even meat. I had stopped exercising, because I was obsessed with it and I was scared to start again. Now I walk on a treadmill, swim, and work out in moderation.
Did you seek any type of emotional support?
Just seeing the psychiatrist. My friends were wonderful throughout my recovery.
Did/does your condition have any impact on your family?
My family was very supportive, but we didn’t sit and talk about it. My parents and I have a great relationship.
What advice would you give to anyone living with this disease?
There are so many better things on the other side of the rainbow. It may be hard to get there, but once you’re there, you’ll never want to go back. Call the ANAD hotline at 847-831-3438 for information about eating disorders and professionally run support groups, and referrals to treatment centers and therapists around the world.
The purpose of screening is early diagnosis and treatment. Screening tests are usually administered to people without current symptoms, but who may be at high risk for certain diseases or conditions.
Currently, there are no national screening guidelines for eating disorders. However, the annual National Eating Disorders Screening Program is sponsored by a number of prestigious organizations, including the American Psychiatric Association, American Psychological Association, American Academy of Pediatrics, and National Collegiate Athletic Association. The program incorporates educational materials, a short screening questionnaire, and post-questionnaire follow up by a knowledgeable eating disorders counselor.
Examples of questions from the screening questionnaire include:
- Are you terrified about being overweight?
- Have you gone on eating binges where you feel you may not be able to stop?
- Do you feel extremely guilty after eating?
- Do you vomit or have the impulse to vomit after meals?
- Do you feel that food controls your life?
Having healthy attitudes toward food and your body can help prevent you from developing an eating disorder.
The following steps can help you develop such healthy attitudes:
- Maintain a healthy weight and body image.
- Maintain a rational approach to dieting, food, and exercise.
- Know and avoid triggers.
- Receive treatment, as necessary.
- Work on building a meaningful, fulfilling, and satisfying life.
- Develop effective coping skills.
Maintain a Healthy Weight and Body Image
Work on developing and maintaining a healthy and realistic body image and weight. During the times when you feel fat, ask yourself if your life would really be much different if you were underweight. Would you automatically be more successful, popular, and loved? Realize that the things you want to achieve in life have little to do with being underweight and more to do with setting and achieving realistic goals. Remember that being thin does not equal being happy.
Maintain a Rational Approach to Dieting, Food, and Exercise
Do not diet, even if you need to lose some weight. Rather, you need a meal plan that gives you adequate nutrition for health and normal growth. You can work toward a healthy weight by limiting your intake of high fat foods, sugar, and refined carbohydrates, and eating whole grains , fruits, vegetables, and adequate protein. If you need help planning your diet, a registered dietitian or nutritionist is the best source for advice.
Also, make sure you get regular, but not excessive, exercise. This can help you maintain a healthy weight. Thirty to 60 minutes of exercise 3-5 days a week is sufficient.
Know and Avoid Triggers
Certain situations can trigger disordered eating behavior. Do not let yourself get too hungry and don’t deprive yourself of good-tasting food. Feelings of deprivation can lead to cravings and food binges. If you crave a certain high-fat, high-calorie food, it’s okay to have it occasionally.
There are probably certain foods and situations that tempt you to overeat. Keep these foods out of the house and stay away from tempting situations as much as possible. If you tend to overeat at buffets, for example, stay away from them.
Emotions, such as fear, anger, sadness, and even happiness, can be powerful triggers for food binges. Pay attention to your feelings and how you may turn to food to deal with them. Find alternative ways of dealing with strong emotions, such as talking with a friend or therapist or writing in a journal.
Receive Treatment, as Necessary
Talk to your doctor if:
- Your eating feels out of control
- You think your quest for thinness may be getting out of control
- You think you may be developing an eating disorder
Work on Building a Meaningful, Fulfilling, and Satisfying Life
Rather than focusing on food and weight for fulfillment, spend time building a meaningful, satisfying life. This involves developing feelings of competence and self-esteem by discovering and using your talents. Work on appreciating and enjoying your abilities without having to do everything perfectly. Develop some hobbies and do things that are fun and pleasurable. Join some clubs and groups with people who share common interests and work on developing healthy relationships.
Develop Effective Coping Skills
Stressful life events can trigger eating disorders in susceptible people or trigger a relapse in those who have recovered. You can control self-induced stress by developing a more realistic self-image and expectations. This can be achieved through counseling and learning how to take charge of the things you can control, such as your attitude and ability to make healthy choices.
Various relaxation techniques, such as meditation , deep breathing, progressive relaxation, yoga , and biofeedback , can also help you cope with stress. These techniques increase your awareness of tension in your body and help release it through exercises that quiet your mind and relax your muscles. Regular pleasurable activities can help you relieve stress, as well.
Medication And Treatment
People with eating disorders often do not recognize or admit that they are ill. As a result, they may strongly resist starting and staying in treatment. Family members or other trusted people can help to ensure that the person with an eating disorder receives needed care and rehabilitation. For some people, treatment may be long term.
Eating disorders can be successfully treated and a healthy weight restored. The sooner your disorder is diagnosed and treated, the better the outcomes are likely to be. Because of their complexity, eating disorders require a comprehensive treatment plan. Treatment involves medical care and monitoring, psychosocial interventions, nutrition counseling, and, when appropriate, medication management.
Treatment of Anorexia calls for a specific program that involves three main phases:
- Restoring you to a healthy weight and keeping you there
- Treating psychological disturbances, such as distortion of body image, low self-esteem, and interpersonal conflicts
- Achieving long-term remission and rehabilitation or full recovery
Early diagnosis and treatment increase your chances of a positive outcome. Your doctor may consider prescribing medicine for you. But, it may be started only after you have gained an appropriate amount of weight. A healthy weight is above 85%, but not necessarily as high as 100%, of your ideal weight. To achieve this weight, your intake of calories will be gradually increased.
If your weight loss is severe, care will likely be provided in an inpatient hospital setting in order to treat very serious or life-threatening physical conditions. In a hospital, doctors will develop feeding plans to address your medical and nutrition needs. In some cases, a feeding tube may be recommended. Once malnutrition has been corrected and weight gain has begun, you may receive psychotherapy (often cognitive behavioral or interpersonal psychotherapy) to help you overcome low self-esteem and address distorted thought and behavior patterns. Families are often included in the therapeutic process.
General Treatment Guidelines for Bulimia Nervosa and Binge Eating Disorder
The primary goals of treatment for Bulimia Nervosa are to:
- Stop binging
- Stop purging (in the case of bulimia)
- Provide education about healthy eating habits and nutrition
- Focus self-esteem away from body image and shape
Bulimia and binge eating disorder are treated with nutrition rehabilitation, psychosocial intervention, and medication management strategies. Treatment is generally done on an out-patient basis. Treatment includes establishing a pattern of regular, non-binge meals, improving your attitude related to the eating disorder, and encouraging regular but not excessive exercise. Any co-occurring conditions, such as mood or Anxiety , should be treated as well. You may also benefit from family or marital therapy.
Treatment of eating disorders involves the following:
Currently, there are no surgical options for the treatment of eating disorders.
Questions For A Doctor
You have a unique medical history. Therefore, it is essential to talk with your doctor about your personal risk factors and/or experience with eating disorders. By talking openly and regularly with your doctor, you can take an active role in your care.
General Tips for Gathering Information
Here are some tips that will make it easier for you to talk to your doctor:
- Bring someone else with you. It helps to have another person hear what is said and think of questions to ask.
- Write out your questions ahead of time, so you don’t forget them.
- Write down the answers you get and make sure you understand what you are hearing. Ask for clarification, if necessary.
- Don’t be afraid to ask your questions or ask where you can find more information about what you are discussing. You have a right to know.
Specific Questions to Ask Your Doctor
About Eating Disorders
- How serious are my symptoms?
- How much weight do you think I should gain?
- Have I damaged my body in any way?
- Can I have a physical exam? Should I have any tests to assess potential physical problems related to my eating disorder?
- Where can I get more information about eating disorders?
About Your Risk of Developing Complications
- What health complications do I need to be concerned about?
- Can I reverse any damage that has been done as the result of my eating disorder?
- Will my periods return?
About Treatment Options
- What treatments are available for eating disorders?
- Are there medicines that can help me? If so:
- How long will they take to work?
- What benefits can I expect?
- What side effects should I be aware of?
- Have you helped other people with eating disorders? If not, can you refer me to another doctor who has?
- Can you refer me to a counselor who treats people with eating disorders?
- Where can I find a support group or an eating disorders treatment program?
- Can you refer me to a dietitian who specializes in eating disorders and who can help me develop a healthful eating plan?
If you decide to try counseling, interview counselors who treat people with eating disorders. Be sure that you feel comfortable with the counselor. Ask the following questions:
- How much training and experience do you have treating eating disorders?
- What is your basic approach to treatment?
- How long do I need treatment?
- How long and how frequent are the treatment sessions?
- What type of health insurance is accepted?
- Do you have special fee schedules and sliding scale fees to accommodate various financial circumstances?
About Lifestyle Changes
- What lifestyle changes can help me manage my eating disorder? What can I do about:
- Diet and eating habits
- How else can I change my patterns so that I don’t go back to disordered eating behaviors?
- What are my chances of recovery?
- What can I do to prevent a relapse?
- Will I be able to become pregnant?