Eating disorders are complex, chronic illnesses largely
misunderstood and misdiagnosed. The most common eating
disorders - anorexia nervosa, bulimia nervosa, and binge
eating disorder - are on the rise in the United States
and worldwide. No one knows exactly what causes eating
disorders. However, all socioeconomic, ethnic and
cultural groups are at risk.
More than ninety percent of those with eating disorders
are women. Further, the number of American women
affected by these illnesses has doubled to at least five
million in the past three decades.
Eating disorders are one of the key health issues facing
young women. Studies in the last decade show that eating
disorders and disordered eating behaviors are related to
other health risk behaviors, including tobacco use,
alcohol use, marijuana use, delinquency, unprotected
sexual activity, and suicide attempts. Currently, 1-4%
of all young women in the United States are affected by
eating disorders.1 Anorexia nervosa, for example, ranks
as the third most common chronic illness among
adolescent females in the United States.2
Eating disorders have numerous physical, psychological
and social ramifications, from significant weight
preoccupation, inappropriate eating behavior, and body
image distortion. Many people with eating disorders
experience depression, anxiety, substance abuse, and
childhood sexual abuse, and may be at risk for
osteoporosis and heart problems. Moreover, death rates
are among the highest for any mental illness.
TYPES OF EATING DISORDERS
Anorexia Nervosa
Anorexia nervosa is a dangerous condition in which
people can literally starve themselves to death. People
with this disorder eat very little even though they are
already thin. They have an intense and overpowering fear
of body fat and weight gain, repeated dieting attempts,
and excessive weight loss. This particular eating
disorder affects from 0.5% to 1% of the female
adolescent population with an average age of onset
between 14 and 18 years.3 Anorexia is identified in part
by refusal to eat, an intense desire to be thin,
repeated dieting attempts, and excessive weight loss. To
maintain an abnormally low weight, people with anorexia
may diet, fast, or over exercise. They often engage in
behaviors such as self-induced vomiting or the misuse of
laxatives, diuretics, or enemas. People with anorexia
believe that they are overweight even when they are
extremely thin. Often, the beginning of illness will
occur after a stressful life event such as initiation of
puberty or moving out of the parents' home.
Those with anorexia are often characterized as
perfectionists and overachievers who appear to be in
control. In reality, they suffer from low self-esteem
and confidence and overly criticize themselves. They are
also very concerned about pleasing others.
Complications - The most severe and noticeable
consequences of anorexia nervosa resemble those of
starvation. The body reacts to the lack of food by
becoming extremely thin, developing brittle hair and
nails, dry skin, lowered pulse rate, cold intolerance,
and constipation as well as occasional diarrhea. In
addition, mild anemia, reduced muscle mass, loss of
menstrual cycle and swelling of joints often accompany
anorexia.
Beyond experiencing the immediate effects of anorexia
nervosa, individuals suffer long-term consequences
throughout the life cycle, regardless of treatment. In
addition to the risks of recurrence, malnutrition may
cause irregular heart rhythms and heart failure. Lack of
calcium places anorexics at increased risk for
osteoporosis both during their illness and in later
life. A majority of anorexics also have clinical
depression while others suffer from anxiety, personality
disorders or substance abuse, and many are at risk for
suicide. Approximately 1 in 10 women afflicted with
anorexia will die of starvation, cardiac arrest, or
other medical complication, making its death rate among
the highest for a psychiatric disease.4
Bulimia Nervosa
Individuals suffering from Bulimia Nervosa follow a
routine of secretive, uncontrolled or binge eating
(ingesting an abnormally large amount of food within a
set period of time) followed by behaviors to rid the
body of food consumed. This includes self - induced
vomiting and/or the misuse of laxatives, diet pills,
diuretics (water pills), excessive exercise or fasting.
Bulimia afflicts approximately 1% - 3% of adolescents in
the US with the illness usually beginning in late
adolescence or early adult life.3 As with anorexia
nervosa, those with bulimia are overly concerned with
food, body weight, and shape. Because many individuals
with bulimia 'binge and purge' in secret and maintain
normal or above normal body weight, they can often hide
the disorder from others for years. Binges can range
from once or twice a week to several times a day and can
be triggered by a variety of emotions such as
depression, boredom, or anger. The illness may be
constant or occasional, with periods of remission
alternating with recurrences of binge eating.
Individuals with bulimia are often characterized as
having a hard time dealing with and controlling
impulses, stress, and anxieties. Bulimia nervosa can and
often does occur independently of anorexia nervosa,
although half of all anorexics develop bulimia.
Complications - Most medical complications attributed to
bulimia nervosa result from electrolyte imbalance and
repeated purging behaviors. Loss of potassium due to
vomiting, for example, damages heart muscle, increasing
the risk for cardiac arrest. Repeated vomiting also
causes inflammation of the esophagus and possible
erosion of tooth enamel as well as damage to the
salivary glands. Some individuals with bulimia struggle
with addictions such as drugs and alcohol, and
compulsive stealing. Like those with anorexia, many
people with bulimia suffer from clinical depression,
anxiety, obsessive-compulsive disorder and other
psychiatric illnesses.
Binge Eating Disorder (BED)
Binge eating disorder (BED) is the newest clinically
recognized eating disorder. BED is primarily identified
by repeated episodes of uncontrolled eating. The
overeating or bingeing does not typically stop until the
person is uncomfortably full. Unlike anorexia nervosa
and bulimia nervosa, however, BED is not associated with
inappropriate behaviors such as vomiting or excessive
exercise to rid the body of extra food. The illness
usually begins in late adolescence or in the early 20s,
often coming soon after significant weight loss from
dieting. Some researchers believe that BED is the most
common eating disorder, affecting 15% - 50% of
participants in weight control programs. In these
programs, women are more likely to have BED than males.
Current findings suggest that BED affects 0.7% - 4% of
the general population.3
To the lay person, BED can be difficult to distinguish
from other causes of obesity. However, the overeating in
individuals with BED is often accompanied by feeling out
of control and followed by feelings of depression,
guilt, or disgust.
Complications - People with BED are often overweight
because they maintain a high calorie diet without
expending a similar amount of energy. Medical problems
for this disorder are similar to those found with
obesity such as increased cholesterol levels, high blood
pressure, and diabetes, as well as increased risk for
gallbladder disease, heart disease, and some types of
cancer. Researchers have shown that individuals with BED
also have high rates of depression.
Eating Disorder not Otherwise Specified (ENDOS)
The Eating Disorder Not Otherwise Specified (EDNOS)
category is for disorders of eating that do not meet the
criteria for any specific eating disorder. In EDNOS,
individuals engage in some form of abnormal eating but
do not exhibit all the specific symptoms required to
diagnose an eating disorder. For instance, an individual
with EDNOS may meet all the criteria of anorexia nervosa
but manage to maintain normal weight while someone else
may engage in purging behavior with less frequency or
intensity than a diagnosed bulimic.
Disordered Eating
Far more common and widespread than defined eating
disorders are atypical eating disorders, or disordered
eating. Disordered eating refers to troublesome eating
behaviors, such as restrictive dieting, bingeing, or
purging, which occur less frequently or are less severe
than those required to meet the full criteria for the
diagnosis of an eating disorder. Disordered eating can
be changes in eating patterns that occur in relation to
a stressful event, an illness, personal appearance, or
in preparation for athletic competition. The 1997 Youth
Risk Behavior Surveillance Study found that over 4% of
students nationwide had taken laxatives, diet pills or
had vomited either to lose weight or to keep from
gaining weight.5
While disordered eating can lead to weight loss or
weight gain and to certain nutritional problems, it
rarely requires in depth professional attention. On the
other hand, disordered eating may develop into an eating
disorder. If disordered eating becomes sustained,
distressing, or begins to interfere with everyday
activities, then it may require professional evaluation.
DIAGNOSIS
Because of the secretive habits of many individuals with
eating disorders, their conditions often go undiagnosed
for long periods of time. In the cases of anorexia
nervosa, signs such as extreme weight loss are more
visible. Bulimics who maintain normal body weight, on
the other hand, may be able to hide their condition to
the casual observer. Family members and friends might
notice some of the following warning signs of an eating
disorder:
A Person with Anorexia may…
Eat only 'safe' foods, usually those low in calories and
fat
Have odd rituals, such as cutting food into small pieces
Spend more time playing with food than eating it
Cook meals for others without eating · Engage in
compulsive exercising
Dress in layers to hide weight loss
Spend less time with family and friends, become more
isolated, withdrawn, and secretive
A person with Bulimia may…
Become very secretive about food, spend a lot of time
thinking about and planning the next binge
Take repeated trips to the bathroom, particularly after
eating
Steal food or hoard it in strange places
Engage in compulsive exercising If an individual is
displaying any of these characteristics, they should be
taken to a physician, nutritionist, or other
professional with expertise in diagnosing eating
disorders.
TREATMENT AND RECOVERY
Eating disorders are most successfully treated when
diagnosed early. The longer abnormal eating behaviors
persist, the more difficult it is to overcome the
disorder and its effects on the body. In some cases,
long term treatment and hospitalization is required.
Families and friends offering support and encouragement
can play an important role in the success of the
treatment program.
Treatment
Presently, there is no universally accepted standard
treatment for anorexia nervosa, bulimia nervosa, or
binge eating disorder. Ideally, an integrated approach
to treatment would include the skills of nutritionists,
mental health professionals, endocrinologists and other
physicians. Various types of psychotherapy may be
employed, including cognitive-behavioral therapy,
interpersonal therapy, and family and group therapy.
Self-esteem enhancement and assertiveness training may
also be helpful. Antidepressants and other drugs have
been part of some therapeutic regimes.
The status of eating disorders as curable diseases has
been controversial, since relapse rates for disturbed
eating patterns can be very high.
ETIOLOGY
No exact cause of eating disorders has yet been found.
However, some characteristics have been shown to have
influence in the development of the illnesses.
Personality Factors
Most people with eating disorders share certain
personality traits: low self-esteem, feelings of
helplessness, and a fear of becoming fat. In anorexia,
bulimia, and binge eating disorder, eating behaviors
seem to develop as a way of handling stress.
Genetic and Environmental Factors Eating disorders
appear to run in families, with female relatives most
often affected. However, there is growing evidence that
a girl's immediate social environment, including her
family and friends, can emphasize the importance of
thinness and weight control. For example, regular
discussion of weight and dieting may normalize societal
pressure to be thin. Weight related teasing by peers and
family is related to low body esteem and eating
disturbances in young girls. The National Institute of
Mental Health (NIMH) reports that girls who live in
families that tend to be strict and place strong
emphasis on physical attractiveness and weight control
are at an increased risk for inappropriate eating
behaviors.4
Additionally, people pursuing professions or activities
that emphasize thinness - like modeling, dancing,
gymnastics, wresting, and long distance running - are
more susceptible to the problem.
Body Image
The idealization of thinness has resulted in distorted
body image and unrealistic measures of beauty and
success. Cultural and media influences such as TV,
magazines, and movies reinforce the belief that women
should be more concerned with their appearance than with
their own ideas or achievements. Body dissatisfaction,
feelings of fatness, and drive for thinness has led many
women to become overly concerned about their appearance.
Research has shown that many normal weight and even
underweight girls are dissatisfied with their body and
are choosing inappropriate behaviors to control their
appetite and food intake. The American Association of
University Women found that adolescent girls believe
physical appearance is a major part of their self-esteem
and that their body image is a major part of their sense
of self.6
Biochemistry
Recent studies have revealed a connection between
biological factors associated with clinical depression
and the development of anorexia nervosa and bulimia
nervosa. Stress hormones such as cortisol are elevated
in those with eating disorders, while neurotransmitters
such as serotonin may not function correctly. Research
continues to better understand this relationship.
POPULATION DIFFERENCES
Gender Differences
Eating disorders are much more prevalent in females than
in males. However, recent studies have shown that
incidence and prevalence rates are increasing among
males. Currently, there is approximately one male case
to ten female cases. Further, up to one in four children
referred to an eating disorders professional for
anorexia is a boy. Many boys with eating disorders share
the same characteristics as their female counterparts,
including low self-esteem, the need to be accepted, an
inability to cope with emotional pressures, and family
and relationship. Males with eating disorders are most
commonly seen in specific subgroups. For instance, males
who wrestle show a disproportionate increase in eating
disorders, rates seven to ten times the normal.
Additionally, homosexual males have an increased rate of
eating disorders.7
Cultural Variation
Eating disorders are often perceived to be an affliction
of Caucasian girls and young women in middle and upper
socio-economic classes. Nevertheless, increasing numbers
of cases are being seen in men and women of all
different ethnic and cultural groups.3
Girls and women from all ethnic and racial groups may
suffer from eating disorders and disordered eating. The
specific nature of the most common eating problems, as
well as risk and protective factors, may vary from group
to group, but no population is exempt. Research findings
regarding prevalence rates and specific types of
problems among particular groups are limited, but it is
evident that disturbed eating behaviors and attitudes
occur across all cultures.
Age
While eating disorders tends to peak between adolescence
and early adulthood, the incidence and prevalence has
shown an increase in all age groups. For instance,
eating disorders are increasing rapidly among
pre-pubertal girls. Disordered eating habits and weight
concerns are beginning at earlier ages and concerns of
body weight and image emerge in girls as young as 9
years of age. A recent study found that 70% of sixth
grade girls surveyed report that they first became
concerned about their weight between the ages of 9 and
11.8
Eating disorders are also becoming more common among
elderly women. This is in part due to patients
maintaining their illness into old age. Also, elderly
women have been shown to initiate weight control
practices, such as bingeing and purging.9
PREVENTION
Increasing interest and concern about eating disorders
has been demonstrated in both the public and private
sectors but research into prevention has been limited.
Although many risk factors for developing eating
disorders have been identified, efforts at prevention
have so far been disappointing. A few studies have
attempted to intervene in high-risk groups with mixed
results.
Attitudes that lay the groundwork for developing eating
disorders occur as early as fourth or fifth grade or
younger, making prevention a major challenge. Better
success has been accomplished in early detection and
treatment of individuals with eating disorders.
ACTIONS BY THE DEPARTMENT OF HEALTH AND HUMAN SERVICES
Consistent with its mission to protect and advance the
Nation's health, the Department of Health and Human
Services (DHHS) undertakes various activities to advance
the understanding and education of eating disorders.
Office on Women's Health
The Office on Women's Health is sponsoring "BodyWise",
an educational campaign on eating disorders. The goal of
the program is to increase knowledge of eating
disorders, including their signs and symptoms, steps to
take when concerned about students, and ways to promote
healthy eating and reduce preoccupation with body weight
and size. An information packet has been developed that
includes materials emphasizing the links among healthy
eating, positive body image, and favorable learning
outcomes.
OWH also sponsors the National Women's Health
Information Center, a one-stop gateway to Federal and
private sector information resources on a variety of
women's health topics including eating disorders,
nutrition, and body image. OWH also a supports the Girl
Power! campaign which provides positive messages,
accurate health information, and support for girls ages
9 to 14 years.
BodyWise information packets can be accessed on the
National Women's Health Information Center (www.womenshealth.gov)
as well as the Girl Power! website (http://www.health.org/gpower/).
National Institutes of Mental Health
The National Institute of Mental Health (NIMH) conducts
and supports research on mental illness and mental
health, seeking to improve basic, clinical and service
delivery knowledge concerning any aspect of behavioral
and mental disorders. The NIMH is also concerned with
the speedy dissemination and implementation of this
knowledge in practice and service delivery systems. As
part of this effort, scientists funded by NIMH are
actively studying ways to better treat and understand
eating disorders.
Food and Drug Administration
The Food and Drug Administration (FDA) provides
information for women and adolescents on diet and
nutrition. Information can be downloaded from: http://www.fda.gov/womens/informat.html
FDA Consumer magazine also periodically runs articles
with important health information for teenagers, ranging
from eating disorders and nutrition to sun safety and
attention deficit disorder. These "Teen Scene" articles
are available electronically at http://www.fda.gov/oc/opacom/kids/html/7teens.htm
and some are available as reprints. To order single
copies, call toll-free 1-888-INFO-FDA (1-888-463-6332).
National Institute of Diabetes and Diseases of the
Kidney Weight - Control Information Network
The National Institute of Diabetes and Diseases of the
Kidney (NIDDK) provides consumers and health
professionals with information on nutrition and obesity.
Fact sheets can be found at: http://www.niddk.nih.gov/health/health.htm
NIDDK also sponsors the Weight-control Information
Network (WIN). WIN was established in 1994 to provide
health professionals and consumers with science-based
information on obesity, weight control, and nutrition.
WIN has also developed the Sisters Together: Move More,
Eat Less program that encourages black women to achieve
a healthy weight by making changes in their lifestyle.
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1. Yager J, Andersen A, Devin M, Mitchell J, Powers P,
Yates A. American Psychiatric Association practice
guidelines for eating disorders. Am J Psychiatry
1993;150:207-28 2. Fisher M, Golden NH, Katzman DK, et
al. Eating disorders in adolescents: A background paper.
J Adolesc Health 1995;16:420-437. 3. American
Psychiatric Association: Diagnostic and Statistical
Manual of Mental Disorders, Fourth Edition. Washington,
DC, American Psychiatric Association, 1994. 4. National
Institute Of Mental Health, National Institutes of
Health. "Eating Disorders, " 1994. 5. Kann L, Kinchen
SA, Williams BI, et al. Youth Risk Behavior Surveillance
-- United States, 1997. Centers for Disease Control and
Prevention. August 14, 1998 / 47(SS-3);1-89 6. American
Association of University Women Education Foundation
(1991): Shortchanging Girls, Shortchanging America.
Washington, DC, American Association of University Women
Educational Foundation Press, 1991. 7. Andersen AE.
Eating disorders in males. In Brownell KD, Fairburn CG
(eds.): Eating Disorders and Obesity; A Comprehensive
Handbook. Guilford Press, New York, 1995. 8. Shisslak
CM, Crago M, McKnight KM, Estes LS, Gray N, Parnaby OG.
Potential risk factors associated with weight control
behaviors in elementary and middle school girls. J
Psychosomatic Research 1998;44:301-313. 9. Hsu LK,
Zimmer B. Eating disorders in old age. Intl J of Eating
Disorders 1988;7:1:133-138.
RESOURCES
FEDERAL GOVERNMENT
Office on Women's Health 200 Independence Ave SW, Room
712E Washington, DC 20201
Ph: (202) 690-7650 http://www.womenshealth.gov.
Food and Drug Administration 200 C St., SW Washington,
DC 20204 Ph: 1-888-INFO-FDA http://www.fda.gov.
National Institute of Mental Health Public Inquiries
Section 5600 Fishers Lane, Room 7C-02 Rockville, MD
20857 Ph: (301) 443-4513 http://www.nimh.nih.gov.
Weight-control Information Network (WIN) (Sponsored by
the National Institute of Diabetes and Diseases of the
Kidney) 1 WIN WAY Bethesda, MD 20892-3665 Ph: (800)
WIN-8098 http://www.niddk.nih.gov/health/nutrit/win.htm.
OTHER GROUPS
National Eating Disorders Association. Phone: (800)
931-2237 Internet Address: http://www.nationaleatingdisorders.org
Harvard Eating Disorders Center Massachusetts General
Hospital ACC-725 15 Parkman Street Boston, MA 02114
http://www.hedc.org.
National Association of Anorexia Nervosa and Associated
Disorders Box 7 Highland Park, IL 60035 Ph: (847)
831-3438 http://www.anad.org.
Pennsylvania Educational Network on Eating Disorders
3277 Cedar Run Road Allison Park, PA 15101 Ph: (412)
366-9966 |
