Eating Disorders

Eating disorders affect both the mind and the body. Although deviant eating patterns have been reported throughout history, eating disorders were first identified as medical conditions by the British physician William Gull in 1873. The incidence of eating disorders increased substantially throughout the twentieth century, and in 1980 the American Psychiatric Association formally classified these conditions as mental illnesses.

Diagnosis

Individuals with eating disorders are obsessed with food, body image, and weight loss. They may have severely limited food choices, employ bizarre eating rituals , excessively drink fluids and chew gum, and avoid eating with others. Depending on the severity and duration of their illness, they may display physical symptoms such as weight loss; amenorrhea ; loss of interest in sex; low blood pressure ; depressed body temperature; chronic , unexplained vomiting; and the growth of soft, fine hair on the body and face.

There are various types of eating disorders, each with its own physical, psychological , and behavioral manifestations. They are classified into four distinct diagnostic categories by the American Psychiatric Association: anorexia nervosa , bulimia nervosa, binge eating disorder , and eating disorder not otherwise specified.

Anorexia nervosa.

Clinically, anorexia nervosa is diagnosed as intentional weight loss of 15 percent or more of normal body weight. The anorexic displays an inordinate fear of weight gain or becoming fat, even though he or she may be extremely thin. Food intake is strictly limited, often to the point of life-threatening starvation. Sufferers may be unaware of or in denial of their weight loss, and may therefore resist treatment.

Peak ages of onset are between 12 and 13 and at age 17. Among women of menstruating age, menstruation ceases due to weight-related declines in female hormones .

This illness has two subtypes: the restricting type, in which weight loss is achieved solely via reduction in food intake, and the binge eating/purging type, in which anorexic behavior is accompanied by recurrent episodes of binge eating or purging.

Bulimia nervosa.

Bulimia nervosa is characterized by repeated episodes of bingeing followed by compensatory behaviors to prevent weight gain. Compensatory behaviors include vomiting, diuretic and laxative abuse, fasting, or excessive exercise. Like the anorexic, the typical bulimic has an unusual concern about body weight and weight loss. Unlike the anorexic, he or she is acutely aware of this condition and has a greater sense of guilt and loss of self control.

Bulimia typically develops during the late teens and early twenties. In contrast to the typically emaciated anorexic, most bulimics are of normal body weight, although weight may fluctuate frequently. Physically, the bulimic may have symptoms such as erosion of tooth enamel, swollen salivary glands, potassium depletion, bruised knuckles, and irritation of the esophagus.

To qualify for a clinical diagnosis of bulimia nervosa, binge eating and related compensatory behaviors must take place at least two times a week for a minimum of three months. Sufferers are classified into one of two subtypes: the purging type, which employs laxatives, diuretics , or self-induced vomiting to compensate for bingeing, or the nonpurging type, which relies on behaviors such as excessive exercising or fasting to offset binges.

Binge eating disorder.

Binge eating disorder is characterized by eating binges that are not followed by compensatory methods. This condition, which frequently appears in late adolescence or the early twenties, affects between 15 and 50 percent of individuals participating in diet programs and often develops after substantial diet-related weight loss. Of those affected, 50 percent are male.

Binge eating disorder is diagnosed when an individual recurrently (at least twice a week for a six month period) indulges in bingeing behavior. A clinical diagnosis also requires three or more of the following behaviors: (1) eating at an unusually rapid pace, (2) eating until uncomfortably full, (3) eating large quantities of food in the absence of physical hunger, (4) eating alone out of shame, and (5) feelings of self-disgust, guilt, or depression subsequent to bingeing episodes.

Eating disorder not otherwise specified.

The category eating disorder not otherwise specified (EDNOS) is used to diagnose individuals whose eating disorders are equally as serious as anorexia nervosa, bulimia nervosa, or binge eating disorder, but do not meet all of the diagnostic criteria for these illnesses. An example of EDNOS might be a female who fulfills all of the criteria for anorexia but is still having regular menstrual periods, or an individual with all of the signs of bulimia who binges and purges less than twice a week.

Prevalence

Originally considered to be a disease targeting affluent white women and adolescents, eating disorders are now prevalent among both males and females, affecting people of all ages and from many ethnic and cultural groups. As many as 70 million people worldwide are estimated to suffer from these conditions, with one in five women displaying pathological eating patterns.

Most eating-disorder research focuses on females, who represent 90 percent of all cases. The additional 10 percent are males, a group that is often underdiagnosed due a widespread misperception that this disease only affects females. This belief also makes males less likely to seek treatment, frequently resulting in poor recovery. Among males, body image is a driving factor in the development of eating problems. Gender identity may also play a role in the evolution of eating disorders, with homosexual males more prone to this disorder than the overall male population.

Risk Factors

Environmental, social, biological , and psychological factors all contribute to eating-disorder risk. Early childhood environment and parenting may have a substantial impact. Many sufferers report dysfunctional family histories, with parents who were either emotionally absent or overly involved in their upbringing. As a result, these children may not tolerate stress well, they may have low self-esteem, and they may have difficulty in interpersonal relationships. Children who have been abused either physically, sexually, or psychologically are also highly vulnerable to eating disorders, particularly bulimia. Those raised by eating-disordered parents may be at heightened risk due to repeated exposure to maladaptive food-related behaviors.

Professions, activities, and dietary regimens that emphasize food or thinness may also encourage eating disorders. For example, athletes, ballet dancers, models, actors, diabetics, vegetarians, and food industry and nutrition professionals may have higher rates of disordered eating than the general population. In addition to environmental and social influences, biological and psychological factors may also increase risk for eating disorders in some people. Low levels of serotonin , a neurotransmitter involved in appetite regulation and satiety, may be indicative of a predisposition to pathological eating behaviors. Similarly, as many as 50 to 75 percent of those who are diagnosed with eating disorders suffer from depression, a mental illness also associated with abnormalities in serotonin balance. Other psychiatric disturbances, such as bipolar depression, obsessive-compulsive disorder, seasonal affective disorder, post-traumatic stress disorder, attention-deficit–hyperactivity disorder, and addictive behaviors, are also common in people with eating disorders.

Causes

Societal influences also contribute to this illness. Increasingly, Westernized culture portrays thinness as a coveted physical ideal associated with happiness, vitality, and well-being, while obesity is perceived as unhealthy and unattractive. This has encouraged a growing sentiment of body dissatisfaction, particularly among young women. Endless images of unrealistically thin models and actors in all forms of media further promote body dissatisfaction—one of the strongest risk factors for the development of disordered eating.

Abnormal eating patterns are most likely to develop during the mid- to late teens, a period of considerable physical, psychological, and social change. While the exact events that lead to the evolution of these disorders are unknown, there are two common milestones that can trigger disordered eating, especially in those with a biological predisposition. The first is the occurrence of a traumatic event, such as the death of a loved one or a divorce. The other is the adoption of a strict diet, which may be even more pivotal than a personal trauma. In fact, rigorous dieting has been identified again and again as the most common initiating factor in the establishment of an uncontrollable pattern of disordered eating.

Treatment Modalities

Treatment is based on a combination of psychotherapy, medication, and nutritional counseling. Goals include restoration of healthy body weight, correction of medical complications, adoption of healthful eating habits and treatment of maladaptive food-related thought processes, treatment of coexisting psychiatric conditions, and prevention of relapse. Depending on the severity of the illness, therapy may be conducted on an outpatient, day treatment, or inpatient basis.

Outpatient therapy.

Outpatient therapy provided by practitioners specializing in eating disorders is appropriate for highly motivated patients within 20 percent of their normal body weight and whose illness is mild or just developing. Treatment consists of cognitive-behavioral therapy, intensive nutritional counseling, support-group referrals, and medical monitoring. At the outset of treatment, a contract is established, outlining an anticipated rate of weight gain (usually between 0.5 and 2 pounds per week), target goal weight, and consequences if weight gain is not achieved. Vitamin and mineral supplementation and the use of liquid supplements to facilitate weight gain may also be indicated.

Day treatment programs.

Day treatment programs are being used with increasing frequency in place of inpatient hospitalization. This form of therapy provides an intermediate level of care for patients who require frequent monitoring but do not require treatment twenty-four hours a day. It may be used for patients who are not responding to outpatient therapy or who are stepping down from inpatient hospitalization. Treatment, which may take place four or five days per week from morning until evening, is similar in structure to outpatient therapy, but is provided on a more intensive level.

Inpatient hospitalization.

Inpatient hospitalization is indicated for patients whose eating disorder has reached life-threatening status. Criteria for admission to such programs are weight loss of 25 percent or more of ideal body weight or the presence of an eating disorder in a child or adolescent. It may also be necessary for individuals who are medically unstable. Usually, participants in inpatient programs are anorexic, although hospitalization for bulimia may be necessary if there is serious deterioration of vital signs, uncontrollable vomiting, or concurrent psychiatric illness.

The immediate goals of inpatient treatment are weight gain and stabilization of vital signs. In many cases, the patient is so fragile that complete bed rest is required. Eating is gently encouraged. In extreme medical situations refusal may be met with tube feeding or, in rare instances, intravenously.

Medication.

Medication is increasingly becoming a routine part of treatment for eating disorders. Antidepressants, particularly the selective serotonin reuptake inhibitors (SSRIs), are the most effective and most commonly used medication in treating this spectrum of illnesses. They are found to be of greatest benefit when used in combination with therapy, and are of little value if offered on their own. In the case of anorexia, these medications are most effective if employed after successful weight restoration is achieved, at which time they can be useful for relapse prevention and the treatment of coexisting psychiatric conditions. SSRIs are also used in preventing binge relapses among bulimics, although their effectiveness ceases once the medication is discontinued. Although antidepressants have also been employed in the treatment of binge eating disorder, outcomes have not been sufficiently positive to warrant recommendations for their use.

Outcomes

Individuals are usually considered to be ready to terminate therapy once they have achieved a healthy body weight and can eat all foods free of guilt or anxiety . For a complete recovery, extensive treatment may be required from six months to two years, and for as long as three to five years in cases where other psychiatric conditions are present. For some, eating disorders will be a lifelong struggle, with stressful or traumatic events triggering relapses that may require occasional check-in therapy to restore healthful eating patterns.

Eating Disorders throughout History

Although eating disorders first came to widespread attention in the 1970s, self-starvation and other pathological eating practices are found throughout recorded history. Bulimia was widely known in both Greek and Roman societies and was recorded in France as early as the eighteenth century. Self-starvation for religious reasons became widespread in Europe during the Renaissance, as hundreds of women starved themselves, often to death, in hopes of attaining communion with Christ. During the nineteenth century, as corpulence stopped being viewed as a symbol of prosperity, self-starvation became common again. The incidence of eating disorders varies widely among cultures and time periods, suggesting that they can be encouraged or inhibited by social and economic factors. Eating disorders have most often been seen in affluent societies and are rarely reported during periods of famine, plague, and warfare.

—Paula Kepos

Of individuals with anorexia nervosa, 50 percent will have favorable outcomes, 30 percent will have intermediate results, and 20 percent will have poor outcomes. The prognosis for bulimics is slightly less favorable, with 45 percent achieving favorable outcomes, 18 percent having intermediate results, and 21 percent with poor results. Among both anorexics and bulimics, 5.6 percent will die of complications related to their illness. Those who receive treatment early in the course of their disease have a greater chance of full recovery on both a physical and an emotional level. A favorable prognosis is also likely with an early age at diagnosis, healthy parent-child relationships, and close supportive relationships with friends or therapists. With early identification and treatment, eating disorders can be prevented from becoming chronic and potentially lethal.

see also Addiction, Food; Anorexia Nervosa; Bulimia Nervosa; Eating Disturbances.

Karen Ansel

Bibliography

American Academy of Pediatrics (2003). "Policy Statement: Identifying and Treating Eating Disorders." Pediatrics 111(1):204–211.

American Psychiatric Association (2000). Diagnostic and Statistical Manual of Mental Disorders, 4th edition. Washington, DC: Author.

Berkow, Robert M., ed. (1997). The Merck Manual of Medical Information Home Edition. Whitehouse Station, NJ: Merck Research Laboratories.

Cassell, Dana, and Gleaves, David (2000). The Encyclopedia of Eating Disorders, 2nd edition. New York: Facts on File.

Costin, Carolyn (1996). The Eating Disorder Sourcebook. Los Angeles: Lowell House.

Pritts, Sarah D., and Susman, Jeffrey (2003). "Diagnosis of Eating Disorders in Primary Care." American Family Physician January 15.

Rome, Ellen S., et al. (2003). "Children and Adolescents with Eating Disorders: The State of the Art." Pediatrics 111:e98–e108.

Stice, Eric; Maxfield, Jennifer; and Wells, Tony (2003). "Adverse Effects of Social Pressure to Be Thin on Young Women: An Experimental Investigation of the Effects of 'Fat Talk.'" International Journal of Eating Disorders 34:108–117.

Woolsey, Monika M. (2002). Eating Disorders: A Clinical Guide to Counseling and Treatment. Chicago: American Dietetic Association.

Internet Resources

American Psychiatric Association (2001). "Men Less Likely to Seek Help for Eating Disorders." Available from <http://www.nlm.nih.gov/medlineplus>

American Psychiatric Association. "Practice Guideline for the Treatment of Patients with Eating Disorders." Available from <http://www.psych.org>

Anorexia Nervosa and Related Eating Disorders, Inc. (2002). "Males with Eating Disorders." Available from <http://www.anred.com/males.html>

Devlin, Michael J., and Walsh, Timothy B. (2000) "Psychopharmacology of Anorexia Nervosa, Bulimia Nervosa, and Binge Eating." American College of Neuropsychopharmacology. Available from <http://www.acnp.org/g>

National Eating Disorders Association (2002). "Males and Eating Disorders." Available from <http://www.nationaleatingdisorders.org>

National Eating Disorders Association (2002). "What Causes Eating Disorders?" Available from <http://www.nationaleatingdisorders.org>

Renfrew Center Foundation (2002). "Eating Disorders: A Summary of Issues, Statistics and Resources." Available from <http://www.renfrew.org>

Eating disorders

Eating disorders are psychological conditions that involve either overeating, voluntary starvation, or both. The best-known eating disorders are probably anorexia nervosa, anorexic bulimia, and obesity. Researchers are not sure what causes eating disorders, although many believe that family relationships, biochemical (physical) abnormalities, and society's preoccupation with thinness all may contribute to their onset.

Eating disorders are virtually unknown in parts of the world where food is scarce. They also are rarely seen in less prosperous groups in developed countries. Although these disorders have been documented throughout history, they have gained attention in recent years. This attention has come, at least in part, because some famous people have died as a result of their eating disorders.

Young people are more likely than older people to develop an eating disorder. The condition usually begins before the age of 20. Although both men and women can develop the problem, it is more common in women. Only about 5 percent of people with eating disorders are male. In either males or females, eating disorders are considered serious and potentially deadly health problems. Many large hospitals and psychiatric clinics have programs designed especially to treat these conditions.

Anorexia nervosa

The word anorexia comes from the Greek adjective anorektos, which means "without appetite." But the problem for people with anorexia is not that they aren't hungry. They starve themselves out of fear of gaining weight, even when they are severely underweight. The anorectic's self-image is so distorted that he or she sees himself or herself as "fat" even when that person looks almost like a skeleton. Some anorectics refuse to eat at all; others nibble only small portions of fruit and vegetables or live on diet drinks. In addition to fasting, anorectics may exercise strenuously to keep their weight abnormally low. No matter how much weight they lose, they always worry about getting fat.

This self-imposed starvation takes a heavy toll on the body. Skin becomes dry and flaky. Muscles begin to waste away. Bones stop growing and may become brittle. The heart weakens. With no body fat for insulation, the anorectic has difficulty staying warm. Downy hair starts to grow on the face, back, and arms in response to lower body temperature. In women, menstruation stops and permanent infertility may result. Muscle cramps, dizziness, fatigue, even brain damage and kidney and heart failure are possible. An estimated 10 to 20 percent of people with anorexia die, either as a direct result of starvation or by suicide.

Researchers believe that anorexia is caused by a combination of biological, psychological, and social factors. They are still trying to pinpoint the biological factors, but they have discovered some psychological and social triggers of the disorder. Many people with anorexia come from families in which parents are overprotective and have unrealistically high expectations of their children. Also, the condition seems to run in families, which leads researchers to believe it may have a genetic basis. Anorexia often seems to develop after a young person goes through some stressful experience, such as moving to a new town, changing schools, or going through puberty. Low self-esteem, fear of losing control, and fear of growing up are common characteristics of anorectics. The need for approval, combined with American culture's idealization of extreme thinness, also are believed to contribute to the disorder.

The obvious cure for anorexia is eating. But that is typically the last thing a person with anorexia wants to do. It is unusual for the person himself or herself to seek treatment. More commonly, a friend, family member, or teacher initiates the process. Hospitalization, combined with psychotherapy and family counseling, is often needed to control the condition. Force-feeding may be necessary if the person's life is in danger. About 70 percent of anorexia patients who are treated for about six months

return to normal body weight. About 15 to 20 percent can be expected to relapse, however.

Anorexic bulimia

Anorexic bulimia gets its name from the Greek term boulimos, meaning "great hunger," or, literally, "the hunger of an ox." The condition is commonly known simply as bulimia. People with bulimia go on eating binges, often gorging on junk food and then forcing their bodies to get rid of the food, either by making themselves vomit or by taking large amounts of laxatives.

Like anorexia, bulimia results in starvation. But there are behavioral, physical, and psychological differences between the two conditions. Bulimia is much more difficult to detect because people who have the disorder tend to be of normal weight or may even be overweight. They tend to hide their habit of binge eating followed by purging by vomiting or using laxatives. In fact, bulimia was not widely recognized, even among medical and mental health professionals, until the 1980s.

Words to Know

Binge-eating: Unrestrained eating.

Euphoria: A feeling of elation.

Laxative: A chemical that is designed to relieve constipation, often used by bulimics to rid the body of digested food.

Morbid: Having the tendency to produce disorder or disease.

Pinch test: A method of estimating the percent of fat in a person's body by grabbing a small area of skin between the fingers.

Risk factor: Any habit or condition that makes a person more susceptible to a disease.

Serotonin: A naturally occurring chemical that affects nerve transmissions in the brain and influences a person's moods, among other emotions.

Unlike anorectics, bulimics are aware that their eating patterns are abnormal, and they often feel remorse after a binge. For them, overeating offers an irresistible escape from stress. Many suffer from depression, repressed anger, anxiety, and low self-esteem, combined with a tendency toward perfectionism. About 20 percent of bulimics also have problems with alcohol or drug addiction, and they are more likely than nonbulimics to commit suicide.

Many people overeat from time to time but are not considered bulimic. According to the American Psychiatric Association's definition, a bulimic binges on enormous amounts of food at least twice a week for three months or more.

Bulimics plan their binges carefully, setting aside specific times and places to carry out their secret habit. They may go from restaurant to restaurant, to avoid being seen eating too often in any one place. Or they may pretend to be shopping for a large dinner party, when actually they intend to eat all the food themselves. Because of the expense of consuming so much food, some resort to shoplifting.

During an eating binge, bulimics favor high-carbohydrate foods, such as donuts, candy, ice cream, soft drinks, cookies, cereal, cake, popcorn, and bread, consuming many times the amount of calories they normally would consume in one day. No matter what their normal eating habits, they tend to eat quickly and messily during a binge, stuffing the food in their mouths and gulping it down, sometimes without even tasting it. Some bulimics say they get a feeling of euphoria during binges, similar to the "runner's high" that some people get from exercise.

The self-induced vomiting that often follows eating binges can cause all sorts of physical problems, such as damage to the stomach and esophagus, chronic heartburn, burst blood vessels in the eyes, throat irritation, and erosion of tooth enamel from the acid in vomit. Excessive use of laxatives can be hazardous, too. Muscle cramps, stomach pains, digestive problems, dehydration, and even poisoning may result. Over time, bulimia causes vitamin deficiencies and imbalances of critical body fluids, which in turn can lead to seizures and kidney failure.

Some researchers believe that bulimia, as well as other types of compulsive behavior, is related to an imbalance in the brain chemical serotonin. The production of serotonin, which influences mood, is affected by both antidepressant drugs and certain foods. But most research on bulimia focuses on its psychological roots.

Bulimia is not as likely as anorexia to reach life-threatening stages, so hospitalization usually is not necessary. Treatment generally involves psychotherapy and sometimes the use of antidepressant drugs. Unlike anorectics, bulimics usually admit they have a problem and want help overcoming it. Estimates of the rates of recovery from bulimia vary widely, with some studies showing low rates of improvement and others suggesting that treatment usually is effective. Even after apparently successful treatment, however, some bulimics relapse.

Obesity

A third type of eating disorder is obesity. Obesity is caused by excessive overeating. Being slightly overweight is not a serious health risk. But being severely over one's recommended body weight can lead to many health problems.

Doctors do not entirely agree about the definition of obesity. Some experts classify a person as obese whose weight is 20 percent or more over the recommended weight for his or her height. But other doctors say standard height and weight charts are misleading. They maintain that the proportion of fat to muscle, measured by the skinfold pinch test, is a better measure of obesity.

The causes of obesity are complex and not fully understood. While compulsive overeating certainly can lead to obesity, it is not clear that all obesity results from overindulging. Recent research increasingly points to biological, as well as psychological and environmental, factors that influence obesity.

In the United States, people with low incomes are more likely to be obese than are the wealthy. Women are almost twice as likely as men to have the problem, but both men and women tend to gain weight as they age.

In those people whose obesity stems from compulsive eating, psychological factors seem to play a large role. Some studies suggest that obese people are much more likely than others to eat in response to stress, loneliness, or depression. As they are growing up, some people learn to associate food with love, acceptance, and a feeling of belonging. If they feel rejected and unhappy later in life, they may use food to comfort themselves.

Just as emotional pain can lead to obesity, obesity can lead to psychological scars. From childhood on, many obese people are taunted and shunned. They may even face discrimination in school and on the job. The low self-esteem and sense of isolation that typically result may contribute to the person's eating disorder, setting up an endless cycle of overeating, gaining more weight, feeling even more worthless and isolated, then gorging again to console oneself.

People whose obesity endangers their health are said to be morbidly obese. Obesity is a risk factor in diabetes, high blood pressure, arteriosclerosis (hardened arteries), angina pectoris (chest pains due to inadequate blood flow to the heart), varicose veins, cirrhosis of the liver, and kidney disease. Obesity can cause complications during pregnancy and in surgical procedures. Obese people are about one-and-one-half times more likely to have heart attacks than are other people. Overall, the death rate among people ages 20 to 64 is 50 percent higher for the obese than for people of normal weight.

Since compulsive eating patterns often have their beginnings in childhood, they are difficult to break. Some obese people get caught up in a cycle of binging and dieting—sometimes called yo-yo dieting—that never results in permanent weight loss. Research has shown that strict dieting itself may contribute to compulsive eating. Going without favorite foods for long periods makes people feel deprived. They are more likely, then, to reward themselves by binging when they go off the diet. Other research shows that dieting slows the dieter's metabolism. When the person goes off the diet, he or she gains weight more easily.

The most successful programs for dealing with overeating teach people to eat more sensibly and to increase their physical activity (exercise) to lose weight gradually without going on extreme diets. Support groups and therapy can help people deal with the psychological aspects of obesity.

EATING DISORDERS

The term "eating disorders" encompasses a group of problems that fall into two broad categories—overeating (binging), and undereating (anorexia)—sometimes referred to as "starving or stuffing." Eating disorders are most commonly found in young females during early adolescence. However, eating disorders affect both males and females at many stages in the life cycle. Although the conditions create physical problems, the causes are usually psychological.

Eating disorders have been recognized by health experts for many years. Bulimia symptoms were described by the Egyptians, Hebrews, and Greeks; and anorexia nervosa was first described in the 1600s. However, it was not until 1980 that these conditions were categorized as psychiatric disturbances.

Eating disorders are marked by extreme dissatisfaction and preoccupation with body size and shape. People with these disorders may see themselves as overweight when their weight is actually lower than normal, or they may measure their self-worth by their weight. Emotional disturbance accompanies disordered eating, including self-loathing over amounts eaten or panic about possible weight gain. In addition to overeating or undereating, individuals with eating disorders engage in "compensatory behaviors," such as purging (self-induced vomiting or inappropriate use of laxatives, enemas, or diuretics), fasting, excessive exercise, and restricting (overly strict limiting of calories or food types).

Eating disorders can be distinguished from dieting by the psychological distress that accompanies the concern about weight; by the interference with everyday responsibilities and pleasures; and by the danger of causing medical problems, possibly even death.

Shame and secrecy often accompany eating disorders, and the problem may go undetected for years. Recognition of these disorders is necessary to begin the long process of treatment. Unlike other addictive or habit problems, food cannot be avoided, and recovery requires developing a healthier relationship to food and to one's own body, as well as improved coping skills.

TYPES OF EATING DISORDERS

Mental health professionals recognize three main types of eating disorders, anorexia nervosa, bulimia nervosa, and binge eating.

Anorexia. Although the word "anorexia" literally means "without appetite," the condition is better described as "restricted eating" or "self-starvation." The person with anorexia has an appetite, and food tastes good; however, food is seen as "the enemy." One authority terms anorexia "food phobia." The disorder is characterized by a refusal to maintain a minimal normal body weight, an intense fear of gaining weight, a disturbance in the self-perception of body size and shape, and (in women) an absence of menstrual periods for three or more consecutive months. Anorexia may be further classified as a restricting type or binge-eating/purging type.

Bulimia. Bulimia (Greek for "ox hunger") is characterized by recurrent episodes of binge eating. Binging (eating an extreme amount of food) is accompanied by a sense of lack of control over amounts eaten, and a feeling of being unable to stop. The disorder is further classified as either purging or nonpurging bulimia depending on whether the individual uses fasting or exercise instead of purging to "compensate" for binging.

Binge Eating. Binge eating is sometimes termed "stress eating" or "emotional overeating." It is characterized by compulsive overeating, usually in secret and without purging, followed by guilt or remorse for the episode. It has been estimated that up to 40 percent of people with obesity may be binge eaters. The term "binge eating disorder" was officially introduced in 1992. Unlike nonpurging bulimia, there is no attempt to "compensate" for the binge by fasting or overexercising.

CAUSATION

Eating disorders can be considered biologically based alterations filtered through cultural pressures and individual psychology. The psychological aspects of anorexia are frequently thought to include conflicts between mothers and adolescent daughters over perfection. Bulimia is often thought to involve conflicts over dependence and loneliness. Binging may share causal factors with obsessive-compulsive behavior.

PREVALENCE AND RISK FACTORS

Since people commonly deny or try to hide their disordered eating behaviors, it is difficult to accurately estimate the number of people affected by these problems. Nonetheless, experts report approximately 1.2 million women in the United States are affected by anorexia or bulimia.

Anorexia is more present in developed societies, especially in societies where being attractive is linked to being thin. The prevalence of anorexia has been estimated to be 0.5 to 1 percent of the population, and rates appear to be increasing. The condition usually begins in early adolescence (13–18 years) and 90 percent of the cases are female. Occasionally, but rarely, the disorder may begin in someone over age forty. Stressful life events (e.g., leaving home for college) occasionally trigger the onset of the problem. Long-term death rates from anorexia approach 10 percent, with death usually resulting from starvation, suicide, or electrolyte imbalance.

The chances of developing an eating disorder are higher among females (female cases outnumber male cases 10 to 1), among those pressured by society or family to be thin, and among athletes. Athletes for whom weight control and/or thinness provides an advantage (e.g., gymnastics, wrestling) are particularly susceptible to eating disorders. Psychological factors that put a person at risk for disordered eating include low self-esteem, poor coping ability, perfectionism, and body image distortion. Genetics may also play a role. Risk increases among those with a close relative (a parent or sibling) with an eating disorder, especially with binging/purging.

IMPACT

Eating disorders cause an array of medical problems ranging from fatigue to illness, and occasionally death. Even when eating disorders do not reach this level of severity they can be significant sources of suffering for the patient and family members. Mild complications include lack of energy, cavities, cold intolerance, irregular periods, constipation and diarrhea, and difficulty with concentration. Serious complications include electrolyte instability, irregular heartbeat, suicidal tendencies, and death. Between 5 to 18 percent of those with anorexia or bulimia will die from complications of the disorder.

Malnourishment and self-starvation affect the heart, thyroid, and the digestive and reproductive systems, as well as seriously decreasing bone density. Specific problems seen in athletes with eating disorders include impaired athletic performance and an increased risk of injuries and stress fractures. Female athletes with an eating disorder may be considered to have the "female athlete triad" if they manifest symptoms of: (1) disordered eating (which leads to decreased body fat causing a lower estrogen level); (2) amenorrhea (not having a period for three consecutive cycles because of low estrogen); and (3) osteoporosis (fragile bones because of low estrogen).

Although eating disorders are not contagious, the culture in which the person lives can contribute to the spread of an eating disorder, particularly in cultures that glorify thinness. Although obesity may be a consequence of binge eating, it does not typically result from the major eating disorders. Prevention efforts may help, and early detection efforts are essential as patients do not typically request treatment for themselves. Psychological consequences of semistarvation include depressed mood, social withdrawal, insomnia, irritability, and loss of libido, as well as obsessive thoughts about food.

TREATMENT

The most important factor in treating people with eating disorders is the recognition of the disorder. Disordered eating is usually not self-diagnosed because of associated denial and embarrassment. Anorexics usually do not even realize there is a problem with their behavior, and bulimics usually realize the problem but try to hide their behavior. Family, friends, or health care professionals are often the people who recognize the problem. A team treatment approach is frequently employed, consisting of a physician, a nutritionist, and a psychologist. Medically, antidepressants may be needed, and complications may require treatment or hospitalization if the situation is severe enough. Nutritionally, people with disordered eating need to learn how to eat in a healthful way. Psychologically, modification of inappropriate food-related behavior and development of improved coping mechanisms are necessary. In addition, changes in body image and ideal body image may be necessary.

Treatment, especially for anorexia, can be a long drawn-out affair, and it can take a big toll on family resources and on the social productivity of the person. Recovery from these disorders is difficult, and estimates of 50 percent relapse rates for anorexia and 33 percent for bulimia are common. A difficulty in the control of disordered eating behaviors is the need to continue to eat. This it is in contrast to other disorders of habit or addiction in which treatment involves total avoidance of the abused substance.

RESOURCES

The Academy of Eating Disorders (http://www.acadeatdis.org) is a multidisciplinary professional group devoted to the improved detection and treatment of these conditions. Efforts to expand screening are promoted through eating disorders awareness week on U.S. college campuses, and this has now been expanded to high school and the general public (http://www.nmisp.org/eat.htm).

Other valuable resources include the following:

• American Anorexia/Bulimia Association, 165 West 46th Street #1108, New York, New York 10036; (212) 575–6200, http://www.aabainc.org/
• National Eating Disorders Organization (formerly the National Anorexic Aid Society), 6655 South Yale Avenue, Tulsa, Oklahoma 74136; (918) 481–4044, http://www.kidsource.com/nedo/
• Overeaters Anonymous Headquarters, World Service Office, 6075 Zenith Court NE, Rio Rancho, New Mexico 87124;(505) 891–2664, http://www.overeatersanonymous.org/

Leonard J. Haas

Trisha Palmer

(see also: Anorexia; Menstrual Cycle; Mental Health; Nutrition; Social Determinants )

Bibliography

American Psychiatric Association (1994). Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Washington, DC: Author.

American Psychiatric Association (2000). "Practice Guideline for the Treatment of Patients with Eating Disorders (Revision)." American Journal of Psychiatry 157 (January Supp.):1.

Browell, K. D., and Fairburn, C. G., eds. (1995). Eating Disorders and Obesity. New York: Guilford Press.

Christensen, L. (1996). Diet-Behavior Relationships: Focus on Depression. Washington, DC: American Psychological Association Books.

Danowski, D., and Lazora, P. (2000). Why Can't I Stop Eating? Recognizing, Understanding, and Overcoming Food Addiction. Center City, MN: Hazelden Information Education Services.

Fairburn, C. G. (1995). Overcoming Binge Eating. New York: Guilford Press.

Natenshon, A. H. (1999). When Your Child has an Eating Disorder: A Step-by-step Workbook for Parents and Other Caregivers. San Francisco: Jossey Bass Publishers.

Siegel, M.; Brisman, J.; and Weinshel, M. (1997). Surviving an Eating Disorder: New Perspectives and Strategies for Family and Friends. New York: Harper Collins.

Stunkard, A. J., and Wadden, T. (ed.) 1993. Obesity: Theory and Therapy. Lancaster, CA: Raven Press.

Thompson, A. K., ed. (1996). Body Image, Eating Disorders and Obesity: An Integrated Guide to Assessment and Treatment. Washington, DC: American Psychological Association Books.

Eating Disorders

Eating disorders have become a major health problem in Western society, and there is evidence of their emergence in most parts of the world. The most common eating disorders are anorexia nervosa and bulimia nervosa, with a number of variations on these, including binge eating disorder. What they have in common, besides an excess preoccupation with weight and shape, is poor self-esteem. Indeed, they might equally be called disorders of self-esteem because self-esteem in this population is based on weight and shape.

In anorexia nervosa, people refuse to maintain a minimally normal body weight, engage in a relentless pursuit of thinness, have a distorted body image, and suffer physical side effects such as amenorrhoea (loss of menstrual cycle), poor blood circulation, low blood pressure, muscle wasting, and osteoporosis.

People with bulimia nervosa tend to maintain a normal weight, but engage in overeating (bingeing) and purging (use of laxatives, self-induced vomiting, and diuretics). Bulimia also results in serious medical complications such as cardiac abnormalities, gastro- and intestinal problems, tooth erosion, and damage to the ovaries.

Binge eating disorder is characterized by consuming an excessive amount of food, accompanied by a lack of control and marked distress, but no purging or distortion of body image.

In each of these conditions, eating gives rise to shame, disgust, fear, and self-loathing. Purging leads to a sense of relief.

In childhood and early adolescence, other eating disorders may occur in addition to anorexia nervosa and bulimia nervosa. These include food avoidance emotional disorder (FAED) in which there is determined food avoidance but without the intense preoccupation with weight and shape seen in anorexia and bulimia; selective eating, in which there is a very limited number of foods consumed, although the total calorie intake is sufficient to maintain a normal weight; and functional dysphagia, in which the child is frightened of swallowing for fear of vomiting or choking.

Who Develops Eating Disorders

The majority of eating disorders are far more likely to occur in females than males, the ratio being around 10:1. Conservative estimates suggest that between 1 and 4 percent of older adolescent females and young women in Western society suffer from anorexia nervosa or bulimia nervosa (Brownell and Fairburn 2001). Food avoidance emotional disorder, selective eating, and functional dysphagia affect boys and girls equally (Lask and Bryant-Waugh 2000).

Previously, eating disorders were most likely to occur in white middle-class young women. However, incidence patterns are now changing and eating disorders may be found in any race, ethnicity, social class, culture, age, or sex, although prevalence data are not available.

Specific risk factors for the development of eating disorders include:

1. Poor self-esteem;
2. Family history of eating disorders;
3. Participation in sports or other pursuits that emphasize low body weight, for example, modeling, ballet, gymnastics, cheerleading, athletics;
4. Past history of sexual abuse; and
5. Perfectionist and conscientious personality types, who have a need to please others and have difficulty in expressing negative feelings.

How Culture Contributes

Although eating disorders are clearly multifactorial in their origin—in other words, there are many different components to their development including genetic predisposition, biological vulnerability, entry into puberty, and stress (Lask and Bryant-Waugh 2000)—cultural influences do seem to be particularly important (Wolf 1991). The barrage of social and cultural messages about maintaining a low weight, and equating thinness with beauty, exerts enormous pressure on young women (Fallon, Katzman, and Wooley 1993). For those who have particularly low self-esteem, one means of feeling better about themselves is to conform to what society maintains as "looking good." This is exemplified by the fact that in the 1970s the average fashion model weighed 8 percent less than the average U.S. woman. In the 1990s the difference rose to 23 percent. In the twenty-first century, images of models are computer modified to the point where the idealized body shape and size is virtually impossible to achieve. Nonetheless, the vulnerable strive to do so.

The Family's Role

The role of the family in eating disorders is complex and unclear. There is increasing evidence that genetic factors play a major part (Brownell and Fairburn 2001). The emphasis within a family upon the value of thinness exerts strong temptations upon young females to maintain a low body weight. The tendency to overemphasize the importance of appearance at the cost of other features such as kindness, intelligence, and creativity enhances the risk. Furthermore, what family members do is as important as what they say. Thus, mothers who diet or who have eating disorders are more likely to have children who ultimately develop eating disorders.

Families can also set the stage for how children relate to food, regardless of issues related to weight. For example, parents may use food to reward, punish, placate, or distract. Children then learn that food is more than a substance of nourishment. It can also be a source of comfort or a source of distress. Some parents ignore their children's cues and feed them according to parental needs, schedules, or beliefs about how much the child should eat. This does not allow the individual to develop an awareness of appetite, hunger, or fullness, thus setting the tone for the development of eating disorders.

Pre-teenage girls often have a very close relationship with their fathers. As they progress into puberty, fathers may have difficulty in coping with their daughters' emerging sexuality, and consequently reduce their closeness. Alternatively, they may try to maintain the same level of contact as previously. Either of these can be a source of distress for the teenage girl, who may subconsciously start trying to return to an earlier stage of development by dieting (Maine 1991).

Regardless of whether or not a family may have contributed in some inadvertent way to the development of an eating disorder, the way in which they manage the problem can be extremely influential. A positive approach can quickly resolve the problem whilst confused, inconsistent, or negative approaches can exacerbate it. Arguments between parents about how best to proceed when their child or teenage daughter develops an eating disorder can exacerbate the problem. The teenager becomes caught up in parental conflict, feels worse, and delves deeper into the eating disorder. Sometimes the individual with the eating disorder can serve as a peacemaker, best friend, or confidante to one or both parents. Although the eating disorder symptoms may emerge for a number of different reasons, it may ultimately serve the purpose of helping family stability. As the individual becomes increasingly ill, parents often pay attention to the individual in a way that is reassuring and comforting. A couple in conflict may work together to try to help their child, especially when they see how serious are the side effects of the illness. This can exacerbate the illness by giving the subconscious message that illness equates with parental harmony.

Treatment

Because the eating disorders are complex, serious and varied, there can be no one simple approach to treatment (Lask and Bryant-Waugh 2000; Brownell and Fairburn 2001). For children and adolescents who live at home, working with the parents as well as the child is essential. Focusing on the factors that appear to maintain the problem is an essential part of the treatment program. Whether this is achieved through parental counseling and individual therapy for the child, or family therapy, or a combination of these, matters less than the family's involvement. For young adults, individual therapy/counseling is of undoubted help, so long as it focuses on the "here and now" problems that the individual is experiencing. There is no evidence that therapy focused on "subconscious" material or the distant past is of particular value. A problem-solving approach that looks at why it is necessary to maintain an eating disorder and that helps to enhance self-esteem is far more likely to work.

Many of these comments also apply to the treatment of bulimia nervosa, although in addition, medication can be valuable. Fluoxetine or related drugs do seem to reduce the urge to binge and can improve mood. Antidepressants can also be useful when there is marked mood lowering.

For the other eating disorders that occur in childhood, a combination of working through the parents and various individual approaches is usually helpful (Lask and Bryant-Waugh 2000). Medication that is chosen judiciously and monitored carefully may also have value.

Whichever condition is being treated, the involvement of family members and open exploration of issues and problems that contribute to and maintain the eating disorder will help people with eating disorders to feel less guilty, less abnormal, and will enhance their self-worth and self-confidence. Thus, although families may be part of the problem, they are equally part of the solution. A number of self-help and parent guides are available (Bryant-Waugh and Lask 1999; Schmidt and Treasure 1993; Siegel, Brisman, and Weinshel 1988).

Conclusion

Eating disorders are potentially life threatening, resulting in death for as many as 10 percent of those who develop them. They can also cause considerable psychological distress and major physical complications. Important relationships are eroded as the eating disorder takes up time and energy, brings about self-absorption, and impairs self-esteem. Treatment should be initiated as quickly as possible, focus upon the immediate distress experienced by the individual, and aim to help the patient and family become powerful enough to overcome the eating disorder.

See also:Childhood, Stages of: Adolescence; Depression: Children and Adolescents; Food; Health and Families; Self-Esteem; Sexuality in Adolescence; Therapy: Family Relationships; Therapy: Parent-Child Relationships

Bibliography

brownell, k., and fairburn, c. (2001). eating disorders and obesity: a comprehensive handbook, 2nd edition. new york: guilford press.

bryant-waugh, r., and lask, b. (1999). eating disorders:a parent's guide. london: penguin.

fallon, p.; katzman, m.; and wooley, s. (1993). feministperspective on eating disorders. new york: guilford press.

lask, b., and bryant-waugh, r. (2000). anorexia nervosa and related eating disorders in childhood and adolescence. hove, uk: psychology press.

maine, m. (1991). father hunger: fathers, daughters andfood. carlsbad, ca: gurze books.

pate, j. e.; pumariega, a. j.; hester, c.; and garner, d. m.(1992). "cross-cultural patterns in eating disorders: a review." journal of the american academy of child and adolescent psychiatry 31:802–808.

schmidt, u., and treasure, j. (1993). getting better bit(e) by bit(e): a survival guide for sufferers of bulimia nervosa and binge eating disorders. hove, uk: psychology press.

siegel, m.; brisman, j.; and weinshel, m. (1988). surviving an eating disorder: strategies for families and friends. new york: harper and row.

wolf, n. (1991). the beauty myth: how images of beauty are used against women. new york: william morrow.

bryan lask

EATING DISORDERS

The "Disease of Abundance."

When Karen Carpenter, a member of the popular singing duo The Carpenters, read a review that called her "chubby," she began an eight-year obsession with her weight. By 1983, when she died from heart failure from emetine poisoning brought on by taking ipecac to induce vomiting, anorexia and bulimia had become household words. American society was obsessed with dieting, and these puzzling and frustrating disorders were extreme examples of the national obsession with weight and appearance.

Anorexia Nervosa

Anorexia was a form of extreme self-starvation and distortion of body image. Patients refused food until they reached a point of severe emaciation or even death. Even though looking in a mirror should tell them that they were too thin, they persisted in seeing themselves as too fat and were proud of their control over food. The term anorexia which means "lack of appetite," was first used in England by physician Sir William Gull in 1873. Although anorexia was better defined as an obsession with food, Gull was also the first to note its prevalence in young upper-middle-class girls. In the 1980s it occurred most commonly among adolescent women. As it became more common during the decade, estimates of its incidence among young women in the United States were as high as one in one hundred teenage girls and young women. Unlike other psychological disorders that are more randomly distributed, anorexics had many social traits in common. Anorexia was fifteen times more likely to be found in females than males, typically began in adolescence, and, as Gull noted, was most common in wealthier families.

Bulimia

Little known even by physicians before the 1980s, bulimia was first thought to be an aspect of anorexia nervosa. It was characterized by secretive episodes of uncontrollable eating binges followed by self-induced vomiting to prevent weight gain. Bulimics differed from anorexics in terms of their loss of control over their eating. The anorexic prided herself on her control over food. Bulimics knew they had an eating disorder and were repulsed and frightened by their behavior, while the anorexic denied it. Most bulimics were either normal weight or overweight compared with the emaciated anorexics. Left untreated, the disease caused vitamin deficiency and serious physical ailments such as liver, kidney, and heart disease. Hair loss occurred. Repeated vomiting could rupture the stomach, and the acid in the vomit eroded tooth enamel. About 40 percent of women with bulimia developed irregular menstruation, and, like anorexics, about 20 percent entirely stopped having their periods.

Causes

Theories about these disorders included psychological, biological, and social explanations. Psychological explanations for anorexia focused on the fear of maturing and the fear of loss of control. Bulimia was regarded as a fear of food that created a compulsion, which led to stress and fear around episodes of binge eating and purging. Scientists also thought the disorders might be associated with a disorder of the hypothalamus, which produces hormones and regulates hunger, thirst, and temperature. Since some bulimics improved after treatment with antidepressant drugs, other biological theories linked it to decreased serotonin activity in the brain. Social scientists blamed social pressures. Women were constantly bombarded with advertisements and un-realistic role models suggesting that women's only worth was in their youth and their slim appearances. A Glamour magazine survey in 1984 revealed that even 45 percent of underweight respondents thought they were too fat and needed to lose weight. Although the response was not reflective of the population as a whole, the survey revealed a striking number of women who considered themselves overweight even though they were normal or underweight.

BROCCOLI-FLAVORED ICE CREAM,
ANYONE?

Calcium products and supplements became hot tickets in supermarkets, health food stores, and drug stores in 1984, after a well-publicized National Institutes of Health conference on the bone disease osteoporosis. High-powered marketing campaigns by the dairy industry and calcium supplement makers fueled the public's interest as other tentative research suggested that more calcium in the diet might protect against high blood pressure and colon cancer in some people. Sales of calcium supplements—powders, tablets, liquids, gels, gums, mints—increased sevenfold between 1980 and 1985. But the craze had its dark side, as excessive amounts of calcium upset the body's absorption of iron, zinc, and manganese, causing constipation and kidney stones. Some supplements contained lead and other toxic metals. Very often a change to a diet that supplied calcium from foodstuffs such as dairy products, tofu, sardines with bones, broccoli, and collard greens was all that was needed to avoid osteoporosis.

Source:

Health & Medical Horizons 1986 (New York: Macmillan,1986), pp. 306-307.

Treatment

Hospitalization and lifesaving measures were the first course of treatment for anorexia, with psychotherapy following as soon as the patient was stabilized. Residential treatment facilities for anorexics were developed during the 1980s that included family therapy, behavior modification, and counseling. Between 15 percent and 25 percent of anorexics relapsed occasionally; and another 15 percent to 20 percent continued to be anorexic. Ten to 20 percent died from self-starvation. Bulimics could be successfully treated outside the hospital since their disorder was not so life threatening. Treatment usually consisted of therapy and antidepressant drugs, but a high rate of treatment failure was reported. As celebrities such as Jane Fonda and Cherry Boone O'Neill, the daughter of singer Pat Boone, publicly admitted their struggles with these eating disorders, other Americans continued their obsession with food and dieting. Almost any diet cookbook could appear rapidly on the best-seller list, but the diseases anorexia and bulimia were still poorly understood, and the treatments for them were far from universally successful.

SCHOOL KIDS, NUTRITION, AND THE
CONDIMENT WARS

In 1981 the news media had a field day when the Department of Agriculture proposed new rules for the nutritional content of federally subsidized school lunches—rules that reflected the Reagan administration's efforts to cut government support for social services. The new rules cut back from 1 1/2 ounces of meat or meat substitute per day per child to one ounce, and elementary-school kids found their milk ration dropping from eight ounces to six. Government regulations for the school lunch program also required that children be given two vegetables or fruits a day. Under the new regulations ketchup and pickle relish were redefined as vegetables. Sen. Henry J. Heinz (R-Penn.), of the family-owned condiment company H. J. Heinz Co., stated, "Ketchup is a condiment. This is one of the most ridiculous regulations I ever heart of. I suppose I need not add that I do know something about ketchup and relish!" In the face of all the publicity and criticism, the administration quickly shelved the proposals. French fries with ketchup were not defined as an adequate number of veggies in a school lunch.

Source:

"Who Deserves a Break Today?," Newsweek (24 September 1981): 43.

Source:

John R. Matthews, Eating Disorders (New York: Facts On File, 1991).

EATING DISORDERS

EATING DISORDERS are a group of psychological ailments characterized by intense fear of becoming obese, distorted body image, and prolonged food refusal (anorexia nervosa) and/or binge eating followed by purging through induced vomiting, heavy exercise, or use of laxatives (bulimia). The first American description of eating disorders appeared in 1859, when the asylum physician William Stout Chipley published a paper on "sitomania," a type of insanity consisting of an intense dread or loathing of food. Clinical research in Great Britain and France during the 1860s and 1870s replaced sitomania with the term "anorexia nervosa" and distinguished the disorder from other mental illnesses in which appetite loss was a secondary symptom and from physical "wasting" diseases, such as tuberculosis, diabetes, and cancer.

Eating disorders were extremely rare until the late twentieth century. Publication of Hilde Bruch's The Golden Cage (1978) led to increased awareness of anorexia nervosa, bulimia, and other eating disorders. At the same time, a large market for products related to dieting and exercise emerged, and popular culture and the mass media celebrated youthful, thin, muscular bodies as signs of status and popularity. These developments corresponded with an alarming increase in the incidence of eating disorders. Historically, most patients diagnosed with eating disorders have been white, adolescent females from middle-and upper-class backgrounds. This phenomenon suggests that eating disorders are closely linked with cultural expectations about young women in early twenty-first century American society.

BIBLIOGRAPHY

Brumberg, Joan Jacobs. Fasting Girls: The Emergence of Anorexia Nervosa as a Modern Disease. Cambridge, Mass: Harvard University Press, 1988.

Vandereycken, Walter, and Ron van Deth. From Fasting Saints to Anorexic Girls: The History of Self-Starvation. Washington Square: New York University Press, 1994.

Heather MunroPrescott/c. w.

See alsoDiets and Dieting ; Mental Illness ; Women's Health .

eating disorders in psychology, disorders in eating patterns that comprise four categories: anorexia nervosa, bulimia, rumination disorder, and pica. Anorexia nervosa is characterized by self-starvation to avoid obesity. People with this disorder believe they are overweight, even when their bodies become grotesquely distorted by malnourishment. Bulimia is characterized by massive food binges followed by self-induced vomiting or use of diuretics and laxatives to avoid weight gain. Some anorexic patients combine bulimic purges with their starvation routine. These disorders generally afflict women—particularly in adolescence and young adulthood—and are much less common among men. Some researchers believe that anorexia and bulimia are caused by chemical imbalances in the brain; one study has linked bulimia to deprivation of tryptophan, an amino acid used by the body to make the neurotransmitter serotonin. Others contend that these disorders are rooted in societal ideals that value slenderness. Rumination disorder generally occurs during infancy, and involves repeated regurgitation accompanied by low body weight. Infants suffering from rumination disorder may re-ingest the regurgitated food. Pica, also found primarily among infants, is characterized by eating various non-nutritive substances like plaster, paint, or leaves. Obesity is not generally considered an eating disorder, since its causes tend to be physiological.

Eating disorders

Eating disorders are characterized by an obsessive preoccupation with food and/or body weight.

Eating disorders are rooted in complex emotional issues that center on self-esteem and pervasive societal messages that equate thinness with happiness. Eating disorders usually surface in adolescence , and more than 90% of sufferers are female, although the incidence among males appears to be growing. Because eating disorders are neither purely physical nor purely psychological, effective treatment must include both medical management and psychotherapy . The earlier a diagnosis is made and treatment is started, the better the chances of a successful outcome.

The two most common types of eating disorders are anorexia nervosa and bulimia , which are covered separately in this book.

Gail B. Slap, M.D.

Further Reading

Maloney, Michael and Rachel Kranz. Straight Talk About Eating Disorders. New York: Facts on File, 1991.

Further Information

National Association of Anorexia Nervosa and Associated Disorders (ANAD). P.O. Box 7, Highland Park, IL 60035,(847) 831–3438.

National Eating Disorders Organization. 6655 Yale Avenue, Tulsa, OK 74136, (918) 481–4044.

Eating Disorders

What Are Eating Disorders?

Who Develops Eating Disorders?

What Causes Eating Disorders?

What Medical Complications Are Caused By Eating Disorders?

How Do Doctors Diagnose Eating Disorders?

How Are Eating Disorders Treated?

Resources

Eating disorders are habits or patterns of eating that are out of balance and may involve major health and emotional problems.

Keywords

for searching the Internet and other reference sources

Anorexia nervosa

Binge eating disorder

Binge and purge Bulimia nervosa

Compulsive overeating

Food and nutrition

Weight loss

What Are Eating Disorders?

Eating disorders are not merely unhealthy eating habits; they involve patterns of eating too little or too much, and they may cause a variety of physical and emotional problems. Eating disorders usually develop during adolescence and usually affect girls, although boys can also be affected. Eating disorders include anorexia (an-o-REK-see-a), bulimia (bull-EE-me-a), binge eating disorder, and obesity (o-BEE-si-tee).

Anorexia

Anorexia is an eating disorder that involves fear of becoming or being fat, intensive dieting or exercise, and a distorted body image. People with anorexia see themselves as fat even though they may be dangerously underweight. They severely restrict their food intake and/or exercise to extremes in order to lose weight. Someone may be diagnosed with anorexia if she refuses to eat enough food to maintain a healthy weight, and has lost more than 15 to 20 percent of her healthy weight. For example, a girl with anorexia whose healthy weight is 125 pounds might weigh 105 pounds. She might eat as little as 500 calories a day (most healthy teenagers eat 2,000 or more calories a day).

Bulimia

Sometimes referred to as the “binge-purge” disorder, bulimia involves repeated episodes of binge eating (consuming large quantities of food while feeling little control over the behavior) followed by purging (trying to rid the body of the food by vomiting or by using laxatives or enemas). Some people with bulimia also exercise excessively. In bulimia, self-image is overly tied to body shape and weight, and people with this disorder are dissatisfied with these aspects of their body. However, unlike those with anorexia, people with bulimia usually stay at a fairly healthy weight.

Binge eating disorder

Binge eating disorder involves out-of-control overeating but lacks the purging that is seen with bulimia. Binge eaters often are obese or constantly dieting and they often feels guilty after a binge. Painful emotions or stress may trigger binges.

Obesity

Obesity is an excess of body fat. People are considered overweight if extra body fat causes them to weigh 20 percent more than the healthy weight for their height and obese if they if they weigh more than 30 percent above what is healthy for their height.

Who Develops Eating Disorders?

Most teenagers are concerned about how they look. After all, their appearance is changing very quickly. Girls are developing breasts and their hips are becoming rounded and curvy. Boys’ voices are deepening and body hair is increasing. Most teenagers have an ideal image in their minds about what they should look like, and images on television and in the movies reinforce the goal of thinness as perfection.

Many young people, particularly girls, go on diets to control their body weight. Dieting has been reported to start as early as elementary school. Dieting without guidance by a medical doctor can cause problems with growth and development for children and teens. Sometimes an earnest but misguided effort to control weight can evolve into an eating disorder.

Consider Diane, a 13-year-old seventh grader. Her diet began innocently enough. She thought she was 10 to 15 pounds overweight and switched her lunch from a sandwich and cookies to a salad. She lost a few pounds. She liked feeling thinner, got a lot of compliments, and pretty soon she reduced the salad at lunch to a carrot and a piece of cheese. Diane trimmed her dinner as well, telling her parents that she had eaten a big lunch and was not hungry. Before long, Diane had lost 20 pounds. But Diane was surprised that she did not feel happy; instead, she was obsessed with food and her weight (she still felt fat) and was embarrassed whenever anyone commented on her body. Diane continued dieting and also began to exercise two times a day to try to lose more weight.

Diane is not alone; experts say that more than five million American women and girls and one million men and boys suffer from eating disorders. About 1 in 100 girls between 12 and 18 years old has an eating disorder. As many as 1 in 10 college females has anorexia or bulimia. More than 1,000 young women die each year from the serious medical problems that develop because of eating disorders!

Young people who participate in sports that prize thinness are at particularly high risk of developing eating disorders. Female dancers, ice skaters, and gymnasts have a three times greater risk for developing an eating disorder than do girls not involved in such activities. Boys who participate in similar sports or in wrestling are also at higher risk. Girls who enter puberty early and girls who are overweight may also be more likely to develop eating disorders.

What Causes Eating Disorders?

There is no clear-cut, single cause for any of the eating disorders. Many factors seem to contribute, including influences from society and culture (such as the glorification of thinness by the mass media), emotional issues (such as a teenager’s striving for perfection, exposure to intensely stressful situations, and fears of maturity, puberty, or sexuality), family factors (such as overly controlling parents, serious emotional conflicts, or problems expressing feelings), or poor childhood feeding and eating patterns. People who have an eating disorder usually do not set out to deliberately have this problem. Generally, eating disorders develop slowly, as do the signs and symptoms.

What Medical Complications Are Caused By Eating Disorders?

Eating disorders are serious problems and can cause a variety of medical complications. In anorexia, rapid weight loss can lead to blood chemical imbalances, failure to menstruate*, slow pulse, low blood pressure, and heart problems. In some cases, damage to vital organs is so serious that it can result in death. The frequent vomiting associated with bulimia can cause throat tears or sores, damaged tooth enamel, broken blood vessels in the eyes, and puffy cheeks from swollen salivary glands. With both anorexia and bulimia, bowel and intestinal problems can occur and serious vitamin and mineral deficiencies can cause serious and long-lasting problems. Binge eating often results in obesity, which in turn can lead to other health problems. People who are obese are at greater risk of developing diabetes*, heart disease*, high blood pressure*, osteoarthritis*, and other health problems.

* menstruate

(MEN-stroo-ate) means to discharge the blood-enriched lining of the uterus. Menstruation occurs normally in females who are physically mature enough to bear children. Because it usually occurs at four-week intervals, it is often called the “monthly period.” Most girls have their first period between the age of 9 and 16.

* diabetes

(dy-a-BEE-teez) is a disorder that reduces the body’s ability to control blood sugar.

* heart disease

is a broad term that covers many conditions that prevent the heart from working properly to pump blood throughout the body.

* high blood pressure

,or hypertension (hy-per-TEN-shun), is a condition in which the pressure of the blood in the arteries is above normal. Arteries are the blood vessels that carry blood from the heart through the en-tire body.

* osteoarthritis

(os-tee-o-ar-THRYtis) is a common disease that involves inflammation and pain in the joints (places where bones meet), especially those in the knees, hips, and lower back of older people.

How Do Doctors Diagnose Eating Disorders?

Teenagers with anorexia, bulimia, and binge eating disorder often try to hide the problem, so formal diagnosis can be delayed or difficult. Even when caring friends or family members ask about the weight loss or other symptoms, most teenagers with eating disorders are ashamed or embarrassed, especially by the purging that accompanies bulimia. Because of distorted body image, those with anorexia may not be able to recognize the seriousness of their extreme weight loss. Unbearable fear of being fat may cause people with anorexia to resist attempts to help them gain weight. A concerned health professional might ask questions about eating, body image, and exercise. Blood or other laboratory tests can help determine if a person’s nutrition is adequate and if general body chemistry is balanced. A careful interview and health history may reveal concerns about body image or distorted opinions about body appearance.

A doctor can generally determine if adults are obese by measuring their body weight and height. Obesity in children can be similarly determined but these measurements should be considered more carefully because the child is still growing. Over the last decade, there has been a significant rise in obesity in children in the United States. This is likely in part a result of people eating more frequently in fast food restaurants, watching a lot of television, working or playing games on computers, and engaging in other activities that promote over-eating and a sedentary (sitting too much with little exercise) lifestyle.

Eating disorders have multiple causes, which may include social and cultural pressures, emotional issues, and family stressors. Chemical imbalances in the brain, shown here in crosssection, may also cause eating disorders. These imbalances affect the hypothalamus, which is believed to control appetite.

How Are Eating Disorders Treated?

Overcoming eating disorders may take a long time and lots of commitment and hard work. Most teenagers with eating disorders need the assistance of mental health and other health care professionals to manage the problem. Anorexia, bulimia, and binge eating disorder are treated most successfully with a combination of therapies. Behavior change programs, monitoring of diet and eating patterns, individual or group psychotherapy*, support groups, nutritional counseling, family counseling, and sometimes medication may all be part of treatment.

* psychotherapy

(sy-ko-THER-apea) is the treatment of mental and behavioral disorders by support and insight to encourage healthy behavior patterns and personality growth.

People with obesity can be helped by doctor-recommended weight-loss programs that teach healthy habits. To lose weight, people must take in fewer calories* than they use, and the best way to control weight is through exercising and eating a balanced diet. In some cases, doctors may also treat severe obesity by prescribing very low-calorie diets or medications. In rare cases, doctors may advise a surgical procedure that either limits the amount of food the stomach can hold or causes food to bypass the stomach or part of the intestines.

* calorie

(KAL-or-ee) is a unit of energy used to describe both the amount of energy in food and the amount of energy the body uses.

See also

Anorexia

Anxiety and Anxiety Disorders

Body Dysmorphic Disorder

Body Image

Bulimia

Depression

Emotions

Obesity

Peer Pressure

Stress

Resources

Books

Bennett, Cherie. Life in the Fat Lane. New York: Random House, 1999. A novel about the high school experiences of an overweight girl.

Berg, Frances M. Afraid to Eat: Children and Teens in Weight Crisis. Hettinger, ND: Healthy Weight Journal, 1997.

Folkers, Gladys, and Jeanne Engelmann. Taking Charge of My Mind and Body: A Girl’s Guide to Outsmarting Alcohol, Drugs, Smoking, and Eating Problems. Minneapolis: Free Spirit Publishing, Inc., 1997. For ages 11-18.

Siegel, Michele, Judith Brisman, and Margot Weinshel. Surviving an Eating Disorder: Strategies for Family and Friends. New York: Harper-Collins, 1997.

Organizations

U.S. Food and Drug Administration (FDA) posts the fact sheet On the Teen Scene: Eating Disorders Require Medical Attention at its website. http://www.fda.gov/opacom/catalog/eatdis.html

The American Psychological Association posts the fact sheet How Therapy Helps Eating Disorders at its website. http://helping.apa.org/therapy/eating.html

Eating Disorders Awareness and Prevention, Inc. (EDAP), 603 Stewart Street, Suite 803, Seattle, WA 98101. Telephone 800-931-2237 for toll-free information and referral hotline http://www.edap.org

www.KidsHealth.org, a website sponsored by the Nemours Foundation and the Alfred I. duPont Hospital for Children, Wilmington, DE, posts articles for kids, teens, and parents about eating disorders, obesity, nutrition, and related topics.

National Association of Anorexia Nervosa and Associated Disorders (ANAD), P.O. Box 7, Highland Park, IL 60035. Telephone 807-831-3438 http://anad.org

eating disorders Range of disorders involving eating habits and appetites. The most common are anorexia nervosa and bulimia nervosa.