By completing this course the healthcare professional will be able to:
1. Identify the causes of eating disorders
2. Describe co-occurring psychological disorders of eating disorders
3. Identify the physical changes associated with eating disorders
4. Describe the types of treatment available
5. Identify signs and symptoms of eating disorders
6. Describe intervention techniques used with eating disorder patient
Eating is controlled by many factors, including appetite, food availability, family, peer, and cultural practices, and attempts at voluntary control. Dieting to a body weight leaner than needed for health is highly promoted by current fashion trends, sales campaigns for special foods, and in some activities and professions. Eating disorders involve serious disturbances in eating behavior, such as extreme and unhealthy reduction of food intake or severe overeating, as well as feelings of distress or extreme concern about body shape or weight. Researchers are investigating how and why initially voluntary behaviors, such as eating smaller or larger amounts of food than usual, at some point move beyond control in some people and develop into an eating disorder. Studies on the basic biology of appetite control and its alteration by prolonged overeating or starvation have uncovered enormous complexity, but in the long run have the potential to lead to new pharmacologic treatments for eating disorders.
Eating disorders are not due to a failure of will or behavior; rather, they are real, treatable medical illnesses in which certain maladaptive patterns of eating take on a life of their own. The main types of eating disorders are anorexia nervosa and bulimia nervosa. A third type, binge-eating disorder, has been suggested but has not yet been approved as a formal psychiatric diagnosis. Eating disorders frequently develop during adolescence or early adulthood, but some reports indicate their onset can occur during childhood or later in adulthood.
Eating disorders frequently co-occur with other psychiatric disorders such as depression, substance abuse, and anxiety disorders. In addition, people who suffer from eating disorders can experience a wide range of physical health complications, including serious heart conditions and kidney failure which may lead to death. Recognition of eating disorders as real and treatable diseases, therefore, is critically important.
Females are much more likely than males to develop an eating disorder. Only an estimated 5 to 15 percent of people with anorexia or bulimia and an estimated 35 percent of those with binge-eating disorder are male.
Causes of Eating Disorders
While eating disorders may begin with preoccupations with food and weight, they are most often about much more than food.
Eating disorders are complex conditions that arise from a combination of long-standing behavioral, emotional, psychological, interpersonal, and social factors. Scientists and researchers are still learning about the underlying causes of these emotionally and physically damaging conditions. We do know, however, about some of the general issues that can contribute to the development of eating disorders.
People with eating disorders often use food and the control of food in an attempt to compensate for feelings and emotions that may otherwise seem over-whelming. For some, dieting, bingeing, and purging may begin as a way to cope with painful emotions and to feel in control of one’s life, but ultimately, these behaviors will damage a person’s physical and emotional health, self-esteem, and sense of competence and control.
Psychological Factors that can Contribute to Eating Disorders:
- Feelings of inadequacy or lack of control in life
- Depression, anxiety, anger, or loneliness
Interpersonal Factors that Can Contribute to Eating Disorders:
- Troubled family and personal relationships
- Difficulty expressing emotions and feelings
- History of being teased or ridiculed based on size or weight
- History of physical or sexual abus
Social Factors that Can Contribute to Eating Disorders:
- Cultural pressures that glorify "thinness" and place value on obtaining the "perfect body"
- Narrow definitions of beauty that include only women and men of specific body weights and shapes
- Cultural norms that value people on the basis of physical appearance and not inner qualities and strengths
Other Factors that can Contribute to Eating Disorders:
- Scientists are still researching possible biochemical or biological causes of eating disorders. In some individuals with eating disorders, certain chemicals in the brain that control hunger, appetite, and digestion have been found to be imbalanced. The exact meaning and implications of these imbalances remains under investigation.
- An estimated 0.5 to 3.7 percent of females suffer from anorexia nervosa in their lifetime. Symptoms of anorexia nervosa include:
- Resistance to maintaining body weight at or above a minimally normal weight for age and height
- Intense fear of gaining weight or becoming fat, even though underweight
- Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight
- Infrequent or absent menstrual periods (in females who have reached puberty)
People with this disorder see themselves as overweight even though they are dangerously thin. The process of eating becomes an obsession. Unusual eating habits develop, such as avoiding food and meals, picking out a few foods and eating these in small quantities, or carefully weighing and portioning food. People with anorexia may repeatedly check their body weight, and many engage in other techniques to control their weight, such as intense and compulsive exercise, or purging by means of vomiting and abuse of laxatives, enemas, and diuretics. Girls with anorexia often experience a delayed onset of their first menstrual period.
The course and outcome of anorexia nervosa vary across individuals: some fully recover after a single episode; some have a fluctuating pattern of weight gain and relapse; and others experience a chronically deteriorating course of illness over many years. The mortality rate among people with anorexia has been estimated at 0.56 percent per year, or approximately 5.6 percent per decade, which is about 12 times higher than the annual death rate due to all causes of death among females ages 15-24 in the general population. The most common causes of death are complications of the disorder, such as cardiac arrest or electrolyte imbalance, and suicide.
Skeletal Effects of Anorexia
Approximately one percent of adolescent girls develop anorexia nervosa, an eating disorder characterized by an irrational fear of weight gain. The condition usually begins around the time of puberty and is associated with restricted eating and extreme weight loss. Anorexia is a mental disorder with significant physical consequences. Affected individuals typically experience an absence of menstrual periods and other health problems which negatively impact bone density.
Anorexia and Bone Loss
Both nutritional and endocrine factors set the stage for bone loss in anorectics. One of the most significant factors is estrogen deprivation. Low body weight causes the body to stop producing estrogen. This disruption in the menstrual cycle, known as amenorrhea, is associated with estrogen levels similar to those found in postmenopausal women. Significant losses in bone density typically occur.
Elevated glucocorticoid levels also contribute to low bone density in anorectics. Sufferers tend to have excessive amounts of the glucocorticoid "cortisol," which is known to trigger bone loss. Other factors, such as a decrease in the production of growth hormone and growth factors, low body weight (apart from estrogen loss), calcium deficiency, and malnutrition have also been proposed as possible causes of bone loss in girls and women with the disorder.
The Scope of the Problem
Bone loss is a well established consequence of anorexia. Recent studies suggest that not only is osteopenia very common, but that it occurs early in the course of the disease. Key studies have found significant decreases in bone density in anorectic adolescents. For example, affected teens have been shown to have spinal density 25% below that of healthy controls. Up to two thirds of teens with the disorder have bone density values more than two standard deviations below the norm.
Studies suggest that half of peak bone density is achieved in adolescence. Anorexia typically develops between mid to late adolescence, a critical period for bone accretion. Affected teens experience decreases in bone density at a time when bone formation should be occurring. Studies have shown that anorectic girls are less likely to reach their peak bone density and are at increased risk for osteoporosis and fracture throughout life.
Anorexia in Men
According to the American Anorexia Bulimia Association, approximately ten percent of eating disorder sufferers are male. While men are much less commonly affected by anorexia than women, research suggests that male victims also experience significant bone loss. A recent study at the University of Iowa found substantial decreases in spinal bone mineral density in anorectic college men. Researchers speculated that weight loss, restricted dietary input and testosterone deficiency may be responsible for the low bone density found in men with the disorder.
Health Consequences of Anorexia Nervosa:
In anorexia nervosa’s cycle of self-starvation, the body is denied the essential nutrients it needs to function normally. Thus, the body is forced to slow down all of its processes to conserve energy, resulting in serious medical consequences.
- Abnormally slow heart rate and low blood pressure, which mean that the heart muscle is changing. The risk for heart failure rises as the heart rate and blood pressure levels sink lower and lower.
- Reduction of bone density (osteoporosis), which results in dry, brittle bones.
- Muscle loss and weakness.
- Severe dehydration, which can result in kidney failure.
- Fainting, fatigue, and overall weakness.
- Dry hair and skin; hair loss is common.
- Growth of a downy layer of hair called lanugo all over the body, including the face, in an effort to keep the body warm.
Health Consequences of Bulimia Nervosa:
The recurrent binge-and-purge cycles of bulimia can affect the entire digestive system and can lead to electrolyte and chemical imbalances in the body that affect the heart and other major organ functions.
- Electrolyte imbalances that can lead to irregular heartbeats and possibly heart failure and death.
- Electrolyte imbalance is caused by dehydration and loss of potassium, sodium and chloride from the body as a result of purging behaviors.
- Potential for gastric rupture during periods of bingeing.
- Inflammation and possible rupture of the esophagus from frequent vomiting.
- Tooth decay and staining from stomach acids released during frequent vomiting.
- Chronic irregular bowel movements and constipation as a result of laxative abuse.
- Peptic ulcers and pancreatitis.
Health Consequences of Binge Eating Disorder:
Binge eating disorder often results in many of the same health risks associated with clinical obesity.
- High blood pressure.
- High cholesterol levels.
- Heart disease as a result of elevated triglyceride levels.
- Type II diabetes mellitus.
- Gallbladder disease.
Dental Complications of Eating Disorders:
The frequent vomiting and nutritional deficiencies that often accompany eating disorders can have severe consequences on one’s oral health. Studies have found that up to 89% of bulimic patients show signs of tooth erosion.
Did You Know?
It is often the pain and discomfort related to dental complications that first causes patients to consult with a health professional. Dental hygienists and dentists are often the first health professionals to observe signs and symptoms of disordered eating habits.
However, recent studies cite two deterrents to dental practitioners addressing eating concerns with their patients:
- Lack of knowledge of the scope and severity of eating disorders, and
- Lack of comfort in discussing their concerns or suspicions.
In spite of these deterrents, the role of dental practitioners in early detection, identification, and intervention is crucial. This information is being provided to enable dental practitioners to recognize the effects of eating disorders and talk with their patients about these concerns.
Signs and Symptoms
- Loss of tissue and erosive lesions on the surface of teeth due to the effects of acid. These lesions can appear as early as 6 months from the start of the problem.
- Changes in the color, shape, and length of teeth. Teeth can become brittle, translucent, and weak.
- Increased sensitivity to temperature. In extreme cases the pulp can be exposed and cause infection, discoloration, or even pulp death.
- Enlargement of the salivary glands, dry mouth, and reddened, dry, cracked lips.
- Tooth decay, which can actually be aggravated by extensive tooth brushing or rinsing following vomiting.
- Unprovoked, spontaneous pain within a particular tooth.
Changes in the mouth are often the first physical signs of an eating disorder. If you notice any of these symptoms, please talk with your patient about ways to care for their teeth and mouth.
Managing Bone Loss
The aim of medical therapy for anorectic females is weight gain and the return of regular menstrual periods. Research from Children's National Medical Center in Washington D.C. suggests that menses usually resumes when girls have achieved 90% of the standard body weight for their age and height. While calcium intake has not necessarily demonstrated a therapeutic value, a nutritionally sound diet, including adequate calcium and vitamin D, is recommended.
Is Recovery of Bone Loss Possible?
The effect of exercise on bone recovery is not clear. Some studies have identified a skeletal benefit from weight bearing activity in anorectics. However, the potential benefits of exercise need to be weighed against the risk of fracture, delayed weight gain, and exercise induced amenorrhea. The impact of estrogen preparations on bone density in affected girls and young women is also unclear. Estrogen may offer a limited benefit in some patients, but it should not be a substitute for nutritional support.
The longer the duration of anorexia nervosa, the less likely it is that bone mineral density will return to normal. While the possibility for complete recovery of normal bone mineral density is low, weight gain and the resumption of menses increase the likelihood that some gains in bone density will occur. Unfortunately a significant number of girls and young women will suffer a permanent reduction in bone density which places them at risk for osteoporosis and fracture throughout their lifetime.
- An estimated 1.1 percent to 4.2 percent of females have bulimia nervosa in their lifetime. Symptoms of bulimia nervosa include:
- Recurrent episodes of binge eating, characterized by eating an excessive amount of food within a discrete period of time and by a sense of lack of control over eating during the episode
- Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting or misuse of laxatives, diuretics, enemas, or other medications (purging); fasting; or excessive exercise
- The binge eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for 3 months
- Self-evaluation is unduly influenced by body shape and weight.
- Because purging or other compensatory behavior follows the binge-eating episodes, people with bulimia usually weigh within the normal range for their age and height. However, like individuals with anorexia, they may fear gaining weight, desire to lose weight, and feel intensely dissatisfied with their bodies. People with bulimia often perform the behaviors in secrecy, feeling disgusted and ashamed when they binge, yet relieved once they purge.
Binge Eating Disorders:
Community surveys have estimated that between 2 percent and 5 percent of Americans experience binge-eating disorders in a 6-month period.
Symptoms of binge-eating disorder include:
Recurrent episodes of binge eating, characterized by eating an excessive amount of food within a discrete period of time and by a sense of lack of control over eating during the episode.
The binge-eating episodes are associated with at least 3 of the following: eating much more rapidly than normal; eating until feeling uncomfortably full; eating large amounts of food when not feeling physically hungry; eating alone because of being embarrassed by how much one is eating; feeling disgusted with oneself, depressed, or very guilty after overeating.
- Marked distress about the binge-eating behavior.
- The binge eating occurs, on average, at least 2 days a week for 6 months.
- The binge eating is not associated with the regular use of inappropriate compensatory behaviors (e.g., purging, fasting, excessive exercise).
Binge Eating Disorder: People with binge-eating disorder experience frequent episodes of out-of-control eating, with the same binge-eating symptoms as those with bulimia. The main difference is that individuals with binge-eating disorder do not purge their bodies of excess calories. Therefore, many with the disorder are overweight for their age and height. Feelings of self-disgust and shame associated with this illness can lead to bingeing again, creating a cycle of binge eating.
Should People With Binge Eating Disorder Try To Diet?
People who are not overweight should avoid dieting because it sometimes makes their binge eating worse. Dieting here means skipping meals, not eating enough food each day, or avoiding certain kinds of food (such as carbohydrates). These are unhealthy ways to try to change your body shape and weight. Many people with binge eating disorder are obese and have health problems because of their weight. These people should try to lose weight and keep it off. People with binge eating disorder who are obese may find it harder to stay in a weight-loss program. They also may lose less weight than other people, and may regain weight more quickly. (This can be worse when they also have problems like depression, trouble controlling their behavior, and problems dealing with other people.) These people may need treatment for binge eating disorder before they try to lose weight.
How Can People With Binge Eating Disorder Be Helped?
People with binge eating disorder, whether or not they want to lose weight, should get help from a health professional such as a psychiatrist, psychologist, or clinical social worker for their eating behavior. Even those who are not overweight are usually upset by their binge eating, and treatment can help them. There are several different ways to treat binge eating disorder. Cognitive-behavioral therapy teaches people how to keep track of their eating and change their unhealthy eating habits. It also teaches them how to change the way they act in tough situations. Interpersonal psychotherapy helps people look at their relationships with friends and family and make changes in problem areas. Drug therapy, such as antidepressants, may be helpful for some people.
Researchers are still trying to find the treatment that is the most helpful in controlling binge eating disorder. The methods mentioned here seem to be equally helpful. For people who are overweight, a weight-loss program that also offers treatment for eating disorders might be the best choice.
If you think you might have binge eating disorder, it's important to know that you are not alone. Most people who have the disorder have tried but failed to control it on their own. You may want to get professional help. Talk to your health care provider about the type of help that may be best. The good news is that most people do well in treatment and can overcome binge eating.
Eating disorders can be treated and a healthy weight restored. The sooner these disorders are diagnosed and treated, the better the outcomes are likely to be. Because of their complexity, eating disorders require a comprehensive treatment plan involving medical care and monitoring, psychosocial interventions, nutritional counseling and, when appropriate, medication management. At the time of diagnosis, the clinician must determine whether the person is in immediate danger and requires hospitalization.
Treatment of anorexia calls for a specific program that involves three main phases: (1) restoring weight lost to severe dieting and purging; (2) treating psychological disturbances such as distortion of body image, low self-esteem, and interpersonal conflicts; and (3) achieving long-term remission and rehabilitation, or full recovery. Early diagnosis and treatment increases the treatment success rate. Use of psychotropic medication in people with anorexia should be considered only after weight gain has been established. Certain selective serotonin reuptake inhibitors (SSRIs) have been shown to be helpful for weight maintenance and for resolving mood and anxiety symptoms associated with anorexia.
The acute management of severe weight loss is usually provided in an inpatient hospital setting, where feeding plans address the person's medical and nutritional needs. In some cases, intravenous feeding is recommended. Once malnutrition has been corrected and weight gain has begun, psychotherapy (often cognitive-behavioral or interpersonal psychotherapy) can help people with anorexia overcome low self-esteem and address distorted thought and behavior patterns. Families are sometimes included in the therapeutic process.
The primary goal of treatment for bulimia is to reduce or eliminate binge eating and purging behavior. To this end, nutritional rehabilitation, psychosocial intervention, and medication management strategies are often employed. Establishment of a pattern of regular, non-binge meals, improvement of attitudes related to the eating disorder, encouragement of healthy but not excessive exercise, and resolution of co-occurring conditions such as mood or anxiety disorders are among the specific aims of these strategies. Individual psychotherapy (especially cognitive-behavioral or interpersonal psychotherapy), group psychotherapy that uses a cognitive-behavioral approach, and family or marital therapy have been reported to be effective. Psychotropic medications, primarily antidepressants such as the selective serotonin reuptake inhibitors (SSRIs), have been found helpful for people with bulimia, particularly those with significant symptoms of depression or anxiety, or those who have not responded adequately to psychosocial treatment alone. These medications also may help prevent relapse. The treatment goals and strategies for binge-eating disorder are similar to those for bulimia, and studies are currently evaluating the effectiveness of various interventions.
People with eating disorders often do not recognize or admit that they are ill. As a result, they may strongly resist getting and staying in treatment. Family members or other trusted individuals can be helpful in ensuring that the person with an eating disorder receives needed care and rehabilitation. For some people, treatment may be long term.
Research Findings and Directions
Research is contributing to advances in the understanding and treatment of eating disorders. Scientists and others continue to investigate the effectiveness of psychosocial interventions, medications, and the combination of these treatments with the goal of improving outcomes for people with eating disorders.
Research on interrupting the binge-eating cycle has shown that once a structured pattern of eating is established, the person experiences less hunger, less deprivation, and a reduction in negative feelings about food and eating. The two factors that increase the likelihood of bingeing—hunger and negative feelings—are reduced, which decreases the frequency of binges.
Several family and twin studies are suggestive of a high heritability of anorexia and bulimia, and researchers are searching for genes that confer susceptibility to these disorders. Scientists suspect that multiple genes may interact with environmental and other factors to increase the risk of developing these illnesses. Identification of susceptibility genes will permit the development of improved treatments for eating disorders.
Other studies are investigating the neurobiology of emotional and social behavior relevant to eating disorders and the neuroscience of feeding behavior. Scientists have learned that both appetite and energy expenditure are regulated by a highly complex network of nerve cells and molecular messengers called neuropeptides. These and future discoveries will provide potential targets for the development of new pharmacologic treatments for eating disorders.
Further insight is likely to come from studying the role of gonadal steroids. Their relevance to eating disorders is suggested by the clear gender effect in the risk for these disorders, their emergence at puberty or soon after, and the increased risk for eating disorders among girls with early onset of menstruation.
What are the symptoms of eating disorders?
- Anorexia nervosa - People who have anorexia develop unusual eating habits such as avoiding food and meals, picking out a few foods and eating them in small amounts, weighing their food, and counting the calories of everything they eat. Also, they may exercise excessively.
- Bulimia nervosa - People who have bulimia eat an excessive amount of food in a single episode and almost immediately make themselves vomit or use laxatives or diuretics (water pills) to get rid of the food in their bodies. This behavior often is referred to as the "binge/purge" cycle. Like people with anorexia, people with bulimia have an intense fear of gaining weight.
- Binge-eating disorder - People with this recently recognized disorder have frequent episodes of compulsive overeating, but unlike those with bulimia, they do not purge their bodies of food. During these food binges, they often eat alone and very quickly, regardless of whether they feel hungry or full. They often feel shame or guilt over their actions. Unlike anorexia and bulimia, binge-eating disorder occurs almost as often in men as in women.
What medical problems can arise as a result of eating disorders?
- Anorexia nervosa - Anorexia can slow the heart rate and lower blood pressure, increasing the chance of heart failure. Those who use drugs to stimulate vomiting, bowel movements, or urination are also at high risk for heart failure. Starvation can also lead to heart failure, as well as damage the brain. Anorexia may also cause hair and nails to grow brittle. Skin may dry out, become yellow, and develop a covering of soft hair called lanugo. Mild anemia, swollen joints, reduced muscle mass, and light-headedness also commonly occur as a consequence of this eating disorder. Severe cases of anorexia can lead to brittle bones that break easily as a result of calcium loss.
- Bulimia nervosa - The acid in vomit can wear down the outer layer of the teeth, inflame and damage the esophagus (a tube in the throat through which food passes to the stomach), and enlarge the glands near the cheeks (giving the appearance of swollen cheeks). Damage to the stomach can also occur from frequent vomiting. Irregular heartbeats, heart failure, and death can occur from chemical imbalances and the loss of important minerals such as potassium. Peptic ulcers, pancreatitis (inflammation of the pancreas, which is a large gland that aids digestion), and long-term constipation are also consequences of bulimia.
- Binge-eating disorder - Binge-eating disorder can cause high blood pressure and high cholesterol levels. Other effects of binge-eating disorder include fatigue, joint pain, Type II diabetes, gallbladder disease, and heart disease.
What is required for a formal diagnosis of an eating disorder?
- Anorexia nervosa - Weighs at least 15 percent below what is considered normal for others of the same height and age; misses at least three consecutive menstrual cycles (if a female of childbearing age); has an intense fear of gaining weight; refuses to maintain the minimal normal body weight; and believes he or she is overweight though in reality is dangerously thin.
- Bulimia nervosa - At least two binge/purge cycles a week, on average, for at least 3 months; lacks control over his or her eating behavior; and seems obsessed with his or her body shape and weight.
- Binge-eating disorder - At least two binge-eating episodes a week, on average, for 6 months; and lacks control over his or her eating behavior.
How are eating disorders treated?
- Anorexia nervosa - The first goal for the treatment of anorexia is to ensure the person's physical health, which involves restoring a healthy weight. Reaching this goal may require hospitalization. Once a person's physical condition is stable, treatment usually involves individual psychotherapy and family therapy during which parents help their child learn to eat again and maintain healthy eating habits on his or her own. Behavioral therapy also has been effective for helping a person return to healthy eating habits. Supportive group therapy may follow, and self-help groups within communities may provide ongoing support.
- Bulimia nervosa - Unless malnutrition is severe, any substance abuse problems that may be present at the time the eating disorder is diagnosed are usually treated first. The next goal of treatment is to reduce or eliminate the person's binge eating and purging behavior. Behavioral therapy has proven effective in achieving this goal. Psychotherapy has proven effective in helping to prevent the eating disorder from recurring and in addressing issues that led to the disorder. Studies have also found that Prozac, an antidepressant, may help people who do not respond to psychotherapy. As with anorexia, family therapy is also recommended.
- Binge-eating disorder - The goals and strategies for treating binge-eating disorder are similar to those for bulimia. Binge-eating disorder was recognized only recently as an eating disorder, and research is under way to study the effectiveness of different interventions
What is Eating Disorders Prevention?
Prevention is any systematic attempt to change the circumstances that promote, initiate, sustain, or intensify problems like eating disorders.
- Primary prevention refers to programs or efforts that are designed to prevent the occurrence of eating disorders before they begin. Primary prevention is intended to help promote healthy development.
- Secondary prevention (sometimes called "targeted prevention") refers to programs or efforts that are designed to promote the early identification of an eating disorder---to recognize and treat an eating disorder before it spirals out of control. The earlier an eating disorder is discovered and addressed, the better the chance for recovery.
Basic Principles for the Prevention of Eating Disorders
1. Eating disorders are serious and complex problems. We need to be careful to avoid thinking of them in simplistic terms, like "anorexia is just a plea for attention," or "bulimia is just an addiction to food." Eating disorders arise from a variety of physical, emotional, social, and familial issues, all of which need to be addressed for effective prevention and treatment.
2. Eating disorders are not just a "female problem" or "something for the girls." Males who are preoccupied with shape and weight can also develop eating disorders as well as dangerous shape control practices like steroid use. In addition, males play an important role in prevention. The objectification and other forms of mistreatment of women by others contribute directly to two underlying features of an eating disorder: obsession with appearance and shame about ones body.
3. Prevention efforts will fail, or worse, inadvertently encourage disordered eating, if they concentrate solely on warning the public about the signs, symptoms, and dangers of eating disorders. Effective prevention programs must also address: