Karen Sadler, MD, of the MassGeneral Hospital for Children Department of Medicine and Division of Adolescent and Young Adult Medicine, sheds some light on eating disorders, their symptoms and treatment options.
Q: What are eating disorders?
A: The main eating disorder categories include anorexia nervosa, bulimia nervosa, binge eating disorder, avoidant/restrictive food intake disorder, and other specified feeding or eating disorder.
The hallmark feature of anorexia nervosa is significantly low body weight, followed by an intense fear of gaining weight, and difficulty appreciating the health consequences of being underweight. Some individuals with anorexia nervosa engage in binge eating (i.e., eating large amounts of food while feeling out of control) and/or purging (i.e., trying to compensate for calories consumed through self-induced vomiting or inappropriate use of laxatives, diuretics, or other medications). Others do not binge or purge, but consume a very limited diet that does not adequately support their nutritional needs.
In contrast, individuals with bulimia nervosa are not underweight. Instead, bulimia nervosa is characterized by binge eating followed by inappropriate compensatory behaviors. Compensatory behaviors may include self-induced vomiting, laxative or diuretic abuse, fasting, or excessive exercise. A key feature of bulimia nervosa is that those who struggle base most of their self-worth on their current shape or weight, meaning that even minor fluctuations on the scale can produce dramatic shifts in self-esteem.
People with binge eating disorder frequently go on eating binges, but do not use inappropriate compensatory behaviors. This distinguishes binge eating disorder from bulimia nervosa. Experts agree that binge eating is not just having an extra helping of dessert on a holiday or other special occasion. Rather, binge eating involves eating an unusually large amount of food (someone else observing would agree that the amount was large) in a discrete period of time, and feeling as though it is hard to control the eating behavior (i.e., it's hard to stop even though you really want to). People with binge eating disorder typically feel very distressed about their pattern of eating.
Avoidant/restrictive food intake disorder is a newly recognized eating disorder in which limited dietary intake leads to weight loss, inadequate growth, or nutritional deficiency. Rather than experiencing an intense fear of weight gain (as in anorexia nervosa), individuals with avoidant/restrictive food intake disorder show little interest in feeding, avoid specific foods due to a feeding-related traumatic event (e.g., gagging or choking), or avoid foods with specific sensory qualities (e.g., texture, taste, temperature).
Other specified feeding or eating disorder is a term for eating disorders of clinical severity that cause impairment but cannot be captured by any of the official eating disorder categories. Individuals with other specified feeding or eating disorder are just as deserving of treatment as those with the official recognized diagnoses described above. Examples include atypical anorexia nervosa (anorexic features without low body weight), subthreshold bulimia nervosa (bingeing and purging less than once per week or for less than three months), subthreshold binge eating disorder (binge eating less than once per week or for less than three months), purging disorder (vomiting, laxative misuse, or diuretic misuse in the absence of binge eating), and night eating syndrome (a pattern of nocturnal eating that causes distress).
Q: What are other types of eating and feeding difficulties?
A: People with rumination disorder struggle with recurrent food regurgitation for at least one month. This is different from self-induced vomiting, because the regurgitation of food comes back up into the mouth effortlessly, but still could be voluntary.. After regurgitating, individuals with rumination disorder typically re-chew, re-swallow, or spit out the previously ingested food. Rumination disorder is also different from esophageal reflux and other gastrointestinal conditions, which can be verified by physical examination or other testing.
Individuals with pica eat non-nutritive, non-food substances, such as paper, cloth, or dirt. Food that isn’t typically eaten on its own or are eaten differently, such as cornstarch, ice, or uncooked pasta, aren’t considered for a diagnosis of pica, but this behavior could still could be impairing and require support to stop. Eating non-food substances for cultural or religious reasons would not qualify for a diagnosis of pica, nor would developmentally normal mouthing behaviors in young children (i.e., under the age of two).
Q: How common are eating disorders?
A: Eating disorders affect millions of people at any given point in time. Rates of eating disorders are particularly high among females between the ages of 12 and 35. Estimates indicate that approximately 0.5 to 3.7% of females have anorexia in their lifetime, while 1.1 to 4.2% of females experience bulimia and 2-5% of men and women have binge eating disorder in their lifetime. Importantly, individuals might struggle with a certain eating or feeding disorder (different types described above) at one point in time, but then develop symptoms of another eating or feeding disorder later. Reports show that migration between symptoms and behaviors over time can be common in eating disorders.
Our culture is keenly aware of body weight and shape, and concerns begin early in life, as reflected by reports that 40-60% of high school girls diet, and 13% of high school girls purge. Eating disorders most often develop during adolescence or early adulthood, but there are some reports of onset in early childhood and older adulthood. Eating disorders have long been thought of as problems affecting affluent white females. Although the prevalence of eating disorders in other socio-demographic groups is lower, we are seeing an increase in eating disorders among males and individuals from a variety of socio-economic and cultural backgrounds. The specific nature of the eating disturbance, as well as protective and risk factors, may vary, but the distress and impact on functioning occurs across gender and culture. It is estimated that approximately 5-15% of people with anorexia or bulimia and 35% of people with binge eating disorder are male.
Q: What causes an eating disorder?
A: This is an excellent question, and one that does not have an easy answer. Therefore, if you or your child struggles with an eating disorder, please do not blame yourself! Over the years, our understanding of the underlying cause of eating disorders has changed significantly. Eating disorders were once thought to be found only in high-achieving, affluent, Caucasian teenagers with demanding families. Adolescent girls were thought to starve themselves to prevent the body changes and social expectations associated with becoming a woman. Now, we believe that eating disorders are related to a combination of biologic, psychologic and social factors. They affect men and women of every age, socioeconomic, ethnic and cultural group.
Eating disorders are associated with other psychiatric illnesses such as substance use disorder, depression, anxiety, and obsessive-compulsive disorder. Like other psychiatric illnesses, they tend to run in families, which suggests an underlying genetic component. Eating disorders typically arise during life transitions (puberty, starting college, getting married, childbearing, changing jobs), or other stressful events (moving, death in family, divorce, loss of significant relationship, trauma or abuse). Sometimes, there are clear family problems that contribute to the development of an eating disorder. At other times, they arise in people with very loving, supportive families. Finally, cultural and societal expectations of beauty, which are perpetuated by the media, can lead to negative body image, which can in turn lead to disordered eating and exercise. For most people struggling with an eating disorder, several of the above factors converge to cause eating disorder symptoms. Effective treatment often involves teasing apart the underlying factors, and targeting each with an appropriate intervention.
Q: I'm worried that my child might have an eating disorder. How can I talk to him or her about this?
A: It is important to approach your child in a calm, empathic and non-judgmental manner. Tell him or her that you've noticed a change in his or her weight, exercise patterns or attitudes toward food, and that you're concerned that there may be problem. It is important for your child to hear that you are interested in understanding what is going on rather than trying to blame him or her. Encourage your child to respond to your concerns. Ask what he or she would like you to do. If your child doesn't know how you can be helpful, offer to speak to her pediatrician, or to set up an evaluation with a mental health professional. If she is resisting help, or says that there is nothing to worry about, tell her that you are still worried, and would like a professional's advice. While adolescents can resist limits, they need them, and despite their protests they typically feel reassured that their parents are involved and concerned. If you ever become concerned about your child's safety, due to low weight, threats of self-harm or threats of harm to others, seek emergency care immediately.
Q: I think I have an eating disorder, but I feel embarrassed to tell my doctor about my symptoms. What should I do?
A: You are not alone. Many people struggling with an eating disorder feel too ashamed or embarrassed about it to tell anyone, including their doctors. Yet there are some important reasons not to let your embarrassment stop you from telling your physician or counselor.
First, because eating disorder symptoms can lead to many potentially serious and even life-threatening medical risks, it is necessary to obtain a careful medical examination. Second, letting a doctor or counselor know about an eating disorder is a crucial step in the recovery process. Research has shown that telling a doctor or counselor about an eating disorder is linked with a greater likelihood of getting treatment for it.
We offer the following suggestions to help you summon your courage to talk with your doctor or mental health professional. Keep in mind that doctors, nurses, and therapists have heard the eating disorder story many times before and are comfortable hearing detailed descriptions of the symptoms. If you do not feel you can trust your doctor, ask friends (maybe even someone who has been in your situation) or family members that you do trust for the names of providers they have found helpful. You might even consider bringing a friend or family member along to your appointment for support.
Q: One of my close friends has an eating disorder but won't get help. What can I do?
A: First of all, your friend is fortunate to have your friendship. It is impossible to force someone into treatment unless they are ready to get help. That being said, you can sit down with your friend and let her know that you have noticed that her eating patterns have changed, and that you are worried that she might have a problem with eating or exercise. It is important to approach the discussion in an empathic, non-shaming manner. Your friend may become angry or may accuse you of being jealous or wanting to make her fat. This may be very difficult to hear, but try not to take it personally.
Due to the underlying eating disorder, people who are struggling with poor self-esteem and distorted body image sometimes lash out at the people who care about them. If your friend responds in this manner, calmly tell her that you regret that she feels that way, but that you are concerned and want to find a way to help her. Remain available to her in case she changes her mind. If your friend agrees to get help, she should contact her primary care physician for referrals to a dietician and mental health clinician. If your friend is a child or teenager, you really need to let her parents know why you are concerned, so that they can help her. You should also find a family member, teacher or counselor to talk to so that you don't feel so alone with this problem.
Q: Do eating disorders cause medical problems?
A: Eating disorders are the psychiatric illnesses with the highest rates of medical complications, including death. Because eating disorders can be associated with severe physical problems, patients should be closely followed by a primary care physician or, if indicated, a medical specialist. Some of the complications are minor and bothersome, while others can be life threatening. The following paragraphs outline some common medical complications of eating disorders:
Symptoms Associated with Low Body Weight. Eating disorders can commonly be associated with weakness, inability to tolerate cold temperatures, and hair loss due to malnutrition and low body weight. Sometimes, because the body is trying to conserve energy, starvation can cause problems with thinking, poor concentration, poor energy, problems with sleeping, and loss of interest in previously enjoyable activities. These symptoms closely resemble depression, so it is important to have a mental health clinician evaluate the situation. The above symptoms will usually improve as nutritional status improves and weight is restored to a healthy range. Neuroendocrine complications such as bone loss and hormonal changes are common in eating disorders. About 90% of young women with anorexia nervosa suffer from bone loss, putting them at increased risk for fractures. "Osteopenia" is thinning of the bones and "osteoporosis" is severe thinning of the bones. Furthermore, when body weight is very low, patients will sometimes grow downy hair, called lanugo, on their body. This happens because there is not enough body fat present to insulate the body; it typically goes away as weight normalizes.
In addition, many women with eating disorders experience changes in their menstrual periods. Their periods may become irregular, or may disappear completely. Some women have difficulty getting pregnant when they are struggling with eating problems. However, it is important to remember that one can still get pregnant, even when periods are irregular or absent, so it is important to continue to protect yourself against pregnancy if you do not wish to be pregnant. As nutritional status improves, periods will often become more regular, and fertility can be restored. Sometimes, a gynecologist or endocrinologist will be involved in treating these issues.
Dental and Gastrointestinal Complications. Stomach acid, which comes in contact with teeth during vomiting, can erode the enamel and can cause severe dental cavities. Patients who induce vomiting or experience effortless regurgitation should seek help from a dentist to prevent ongoing dental problems. Patients with eating disorders commonly report stomachaches or constipation, which can be related to dehydration, and lack of bulk in the diet. Again, these symptoms often resolve as the body gets used to refeeding and can also be treated by increasing fluid and fiber intake to a healthier range.
Metabolic and Cardiac Complications. Binge-eating can lead to obesity, which can subsequently lead to high blood pressure, heart disease, diabetes, and increased risk for cancer. Monitored, moderate weight loss and regular exercise can decrease the risk of each of these health problems. More severe medical side effects include life-threatening irregularities in heartbeat, which can cause cardiac arrest and sudden death. These are most commonly caused by abnormalities in electrolytes, such as potassium, which are necessary for the heart to beat properly. Vomiting and diarrhea, which often results from laxative or enema abuse, can lead to very low levels of potassium. Water pills can also cause electrolytes to become abnormal. However, it is important not to take potassium supplements unless directed to do so by your doctor, as high levels of potassium can also cause heart problems.
Q: What are the most effective treatments for eating disorders?
A: Evidence-based outpatient treatments for eating disorders include cognitive-behavioral therapy, family-based treatment, and guided self-help. In some cases, a more intensive approach, such as inpatient hospitalization, is necessary. Learn more about levels of care for eating disorders.
Learn more about our eating disorder treatment options at Mass General.
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