Eating disorders are devastating behavioral maladies brought on by a complex interplay of factors, which may include emotional and personality disorders, family pressures, a possible genetic or biologic susceptibility, and a culture in which there is an overabundance of food and an obsession with thinness. There are four general categories of eating disorders:
- Bulimia nervosa.
- Anorexia nervosa.
- Binge eating.
- Eating disorders not otherwise specified.
These are not new disorders. Although anorexia nervosa was first defined as a medical problem in the late 1800s, descriptions of self-starvation have been found even in medieval writings.
Bulimia nervosa
It is characterized by cycles of bingeing and purging, and typically takes the following pattern: Bulimia is often triggered when young women attempt restrictive diets, fail, and react by binge eating. (Binge eating involves consuming amounts of food that are larger than average portions within a two-hour period.) In response to the binges, patients compensate, usually by purging, by vomiting, by using enemas, or by taking laxatives, diet pills, or drugs to reduce fluids.
Patients then revert to severe dieting, excessive exercise, or both. (Some patients with bulimia follow bingeing only with fasting and exercise. They are then considered to have non-purging bulimia.)
The cycle then swings back to bingeing and then to purging again. Some studies have reported that patients with bulimia average about 14 episodes of binge-purging per week. To be diagnosed with bulimia, however, a patient must binge and purge at least twice a week for three months. (Some experts believe that going through the cycle only once a week is sufficient for a diagnosis.)
In some cases, the condition progresses to anorexia. Most people with bulimia, however, have a normal to high-normal body weight, although it may fluctuate by more than 10 pounds because of the binge-purge cycle.
Anorexia Nervosa
At least 15% to as much as 60% of normal body weight is lost.
The patient with anorexia nervosa has an intense fear of gaining weight, even when he or she is severely underweight. Individuals with anorexia nervosa have a distorted image of their own weight or shape and deny the serious health consequences of their low weight. Women with anorexia nervosa miss at best three consecutive periods. (It should be noted that some experts believe women can be anorexic without this occurrence.) Patients with the condition are often characterized as anorexia restrictors or anorexic bulimic patients. Each type is about equally prevalent.
It should be noted that the term "anorexia" literally means absence of appetite. For example, severe anorexia is common in the elderly, who may experience weight loss because of social isolation, impaired gastrointestinal function, or loss of certain chemicals related to the feeding drive. Such anorexia, however, is not synonymous with anorexia nervosa, which is a psychologic disorder.
Binge-Eating (Binge-Eating Disorder)
Known as compulsively overeating (binge eating) without other bulimic
behaviors, such as vomiting or laxative abuse, used to eliminate calories.
Binge-eating usually leads to becoming overweight.
To be diagnosed as a binge eater, a person typically has the following
characteristics: Bingeing at least twice a week for six months. Consuming
5,000 to 15,000 calories in one sitting. Eating three meals a day plus
frequent snacks. Overeating continually throughout the day, rather than
consuming large amounts of food during binges. Since binge-eating disorder
is generally associated with weight gain, it will not be further discussed
in this report.
Eating Disorders Not Otherwise Specified
Infrequent binge-purge episodes (occurring less than twice a week or
having such behavior for less than three months). Repeated chewing and
spitting without swallowing large amounts of food. Normal weight and
anorexic behavior.
WHO DEVELOPS EATING DISORDERS?
The approach to food in Western Countries is extremely problematic.
Enough food is produced in the US to supply 3,800 calories every day
to each man, woman, and child, far more than any single person needs
to sustain life. Obesity is a global epidemic, and few people living
in this over-fed and sedentary culture eat a meal guiltlessly. One can
nearly make the sweeping generalization that everyone who lives in a
developed nation is at risk for either obesity or some eating disorder. Age
In general, eating disorders occur in adolescents and young adults,
although one study reported that 5% of cases occurred in children under
12 years old.
Age of Onset for Bulimia
A 1997 survey by the Centers for Disease Control of high school students
reported that 4.5% induced vomiting after meals or used laxatives to
lose weight. Estimates of the prevalence of bulimia nervosa among young
women range from about 3% in adolescents to 10% in college women. Some
experts claim that even these percentages grossly underestimate the
problem because many people with bulimia are able to conceal their purging
and do not become noticeably underweight. For example, a European study
detected bulimic behavior in 14.4% of adolescents 14 to 16 years old,
with full-blown bulimia observed in 1.8% of girls and 0.3% of boys.
Age of Onset for Anorexia
Anorexia nervosa is the third most common chronic illness in adolescent
women, and is estimated to occur in 0.5% to 3% of all teenagers. Anorexia
usually first occurs in adolescence with peaks at 13 to 14 years of
age and at 17 to 18 years of age. Over the past 40 years, however, the
incidence has been steady in teenagers, but it has increased threefold
in young adult women. Gender
Studies typically report that 90% of eating disorder cases are in females.
However, the rate in males appears to be increasing. For example, a
2000 study of teenagers in Minnesota reported that 13% of girls and
7% of boys reported disordered eating behavior.
When eating disorders occurs in young adults, men are more apt to conceal
them, so the incidence among males may be underreported. One study of
Navy men, for example, reported a prevalence of 2.5% for anorexia, 6.8%
of bulimia, and 40% for binge eating. A 2001 study reported that the
psychiatric and social profiles of men and women with eating disorders
were very similar to each other, although profiles between men with
eating disorders and men without were quite different. Sexual preference
may affect the risk of specific eating disorders in men. One study reported
that 42% of male civilians with bulimia reported that they were homosexual
or bisexual while 58% of the men with anorexia were asexual. Ethnic Factors
Most studies of individuals with eating disorders have been conducted
using Caucasian middle-class females. Studies are now reporting, however,
that minority populations, including Hispanic- and African-American,
are significantly affected. There is some indication that African-American
girls and young women may be at particular risk for eating disorders
because of poor body images caused by cultural attitudes that denigrate
the physical characteristics of minorities. In one study, bulimia was
equally common among both Caucasian and African American women, although
the latter were more likely to binge recurrently, to fast, and to use
laxatives and diuretics to control weight. Binge eating may be an even
more severe a problem in Hispanic Americans. A 2000 study on Asian women
also reported rates of dieting and body dissatisfaction that were similar
to those in other cultures, but Asian women had much lower percentages
of actual eating disorders. Socioconomic Factors
Living in any economically developed nation on any continent appears
to pose more of a risk for eating disorders than belonging to a particular
population group. Symptoms remain strikingly similar across high-risk
countries.
Income Levels
Oddly enough, within developed countries there appears to be no difference
in risk between the rich and the poor. Some studies suggest that those
in lower economic groups may be at higher risk for bulimia.
Urban Life
City living is a risk factor for bulimia but it has no effect on risk
for anorexia.
Intelligence
In one sample, people with eating disorders scored significantly higher
than average on IQ tests. People with bulimia, but not anorexia, had
higher nonverbal than verbal scores.
Excessively Physically Active People
Highly competitive athletes are often perfectionists, a trait common
among people with eating disorders.
Women Athletes and Dancers
Women in "appearance" sports, including gymnastics and figure skating,
and in endurance sports, such as track and cross-country, are at particular
risk for anorexia. Success in ballet also depends on the development
of a wiry and extremely slim body. Estimates for episodes of eating
disorders among such athletes and performers range from 15% to over
60%.
Male Athletes
Male wrestlers and light-weight rowers are also at risk for excessive
dieting. One-third of high school wrestlers use a method called weight-cutting
for rapid weight loss. This process involves food restriction and fluid
depletion using steam rooms, saunas, laxatives, and diuretics. Although
male athletes are more apt to resume normal eating patterns once competition
ends, studies are showing that the body fat levels of many wrestlers
are still well below their peers during off-season and are often as
low as 3% during wrestling season. Of concern is a recently recognized
body-image disorder, referred to as muscle dysmorphia, that occurs mostly
in men who are preoccupied with weight lifting and perceive themselves
as puny.
Men and Women in the Military
Studies are also showing a higher-than-average risk for eating disorders
in men and women in the military. A study of eating behavior on one
Army base reported that 8% of the women had an eating disorder, compared
to 1% to 3% in the civilian female population.
Vegetarians
Studies report that vegetarianism in adolescence is a risk factor for
eating disorder in both males and females. In one study, while these
teens appear to eat more fruits and vegetables, they are also twice
as likely to diet frequently, four times as likely to intensively diet,
and eight times as likely to use laxatives as their non-vegetarian peers.
This study does not mean that being a vegetarian equals having an eating
disorder. It does suggest, however, that parents with children who suddenly
become vegetarian, should be sure their children are eating a balanced
meal with sufficient calories. Anorexic behavior in vegetarians should
be suspected under certain conditions:
If the person has stopped eating meat only to avoid
fat rather than from other motives, such as love of animals. If vegetarian
diet coincides with rapid weight loss.
If the person is avoiding certain foods, such as tofu, nuts, and dairy
products, that contain oils or fats.
Young People with Diabetes or Other
Chronic Diseases
According to one survey, 10.3% of teenage girls and 6.9% of boys with
chronic illness, such as diabetes or asthma, had an eating disorder.
Diabetes. Eating disorders are particularly serious problems
in people with either type 1 or type 2 diabetes. Binge eating (without
purging) is most common in type 2 diabetes and, in fact, the obesity
it causes may even trigger this diabetes in some people.
Both bulimia and anorexia are common in type 1 diabetes. Some experts
report that one-third of insulin-dependent patients have an eating disorder,
most often because diabetic women omit or underuse insulin in order
to control weight. If such patients develop anorexia, their extremely
low weight may appear to control the diabetes for a while. Eventually,
however, if they fail to take insulin and continue to lose weight, these
patients develop life-threatening complications.
Early Puberty
There is a greater risk for eating disorders and other emotional problems
in girls who undergo early puberty, when the pressures experienced by
all adolescents are intensified by experiencing, possibly alone, these
early physical changes, including normal increased body fat. One interesting
study reported the following:
This study was reporting on girls without eating disorders, but it certainly suggests patterns that can lead to eating problems, particularly in girls who go through puberty early.
WHAT CAUSES EATING DISORDERS?
There is no single cause for eating disorders. Although concerns about
weight and body shape underlie all eating disorders, the actual cause
of these disorders appear to result from a convergence of many factors,
including cultural and family pressures and emotional and personality
disorders. Genetics and biologic factors may also play a role.
Personality Disorders
A 2000 study reported that people with eating disorders tended to share
similar personality traits, including low self-esteem, dependency, and
problems with self-direction. Researchers have been attempting to determine
specific personality disorders or behavioral characteristics that might
put people at higher risk for one or both of the eating disorders. Some
studies have reported the following personality disorders linked to
particular eating disorders:
Avoidant Personalities
Some studies indicate that as many as a third of anorexia restrictors
have avoidant personalities. This personality disorder is characterized
by the following: Being a perfectionist.
Being emotionally and sexually inhibited.
Having less of a fantasy life than people with bulimia or without an
eating disorder.
Not being rebellious, or usually perceived as always being "good." Being
terrified of being ridiculed or criticized or of feeling humiliated.
People with anorexia are extremely sensitive to failure, and any criticism,
no matter how slight, reinforces their own belief that they are "no
good." The person with both anorexia and avoidant personality disorder
may hypothetically develop a behavioral and eating pattern as follows:
For such individuals, achieving perfection, with all that that involves, is the only way to obtain love.
Part of the drive for perfection and love is being trouble-free and attaining some ideal image of thinness. The individual is driven to demand nothing, including food.
Failure is inevitable, since being loved by another person rarely has anything to do with being perfect. (In fact, people who are always seeking perfection can alienate others around them.)
Failure to achieve love is followed by a sense of being even more imperfect (which is equivalent to being fat) and a renewed sense of striving for perfection (ie, becoming even thinner).
Although people with eating disorders are not typically
suicidal, one expert described her anorexic patients as having a total lack of self, well beyond having low self-esteem. The process of
not-eating, then, becomes an act of passive revenge on those whose love
is always out of reach: "See? I am slowly disappearing, and you will
be very sad when I am gone."
Borderline Personalities
Studies indicate that almost 40% of people who are diagnosed with bulimic
anorexia (who lose weight by bingeing and purging) may have borderline
personalities. Such people tend to have the following characteristics:
Narcissism
Studies have also found that people with bulimia or anorexia are often highly narcissistic and manifest the following personality traits:
Having an inability to soothe oneself.
Having an inability to empathize with others.
Having a need for admiration. Being hypersensitive to criticism or defeat.Accompanying Emotional Disorders Between 40% and 96% of all eating-disordered
patients experience depression and anxiety disorders. Depression, anxiety,
or both is also common in families of patients with eating disorders.
It is not clear if emotional disorders, particularly obsessive-compulsive
disorder (OCD), are actual causes of the eating disorders, increase
susceptibility to them, or share common biologic cause.
Obsessive-Compulsive Disorder (OCD)
Obsessive-compulsive disorder is an anxiety disorder that occurs in
up to 69% of patients with anorexia and up to 33% of patients with bulimia.
In fact, some experts believe that eating disorders are just variants
of OCD. Obsessions are recurrent or persistent mental images, thoughts,
or ideas, which may result in compulsive behavior, repetitive, rigid,
and self-prescribed routines that are intended to prevent the manifestation
of the obsession. Women with anorexia and OCD may become obsessed with
exercise, dieting, and food. They often develop compulsive rituals,
eg, weighing every bit of food, cutting it into tiny pieces, or putting
it into tiny containers. The presence of OCD with either anorexia or
bulimia does not, however, appear to have any effect on whether a patient
improves or not.
Other Anxiety Disorders
A number of other anxiety disorders have been associated with both bulimia
and anorexia. Phobias. Phobias often precede the onset of the eating
disorder. Social phobias, in which a person is fearful about being humiliated
in public, are common in both eating disorders.
Panic Disorder. Panic disorder often follows the onset of an eating
disorder. It is characterized by periodic attacks of anxiety or terror
( panic attacks ). Post-Traumatic Stress Disorder. One study
of 294 women with serious eating disorders reported that 74% of them
recalled a traumatic event and more than half exhibited symptoms of
post-traumatic stress disorder (PTSD), which is an anxiety disorder
that occurs in response to violent circumstances. Depression
Depression is common in people with eating disorders, particularly anorexia.
Depression and eating disorders are also linked to a similar seasonal
pattern, as indicated by the following observations:
Major depression is unlikely to be a cause of eating disorders,
however, because treating and relieving depression rarely cures an eating
disorder. The severity of the eating disorder is also not correlated
with the severity of any existing depression. In addition, depression
often improves after anorexic patients begin to gain weight.Dysmorphic Disorder
Body dysmorphic disorder involves a distorted view of one's body that
is caused by social, psychologic, or possibly biologic factors. It is
often associated with anorexia or bulimia, but it can also occur without
any eating disorder. People with this disorder also commonly suffer
from emotional disorders, including obsessive-compulsive disorder and
depression.
Muscle Dysmorphia
Experts are also increasingly reporting a disorder in which people have
distorted body images involving their muscles. It tends to occur in
men who perceive themselves as being "puny" and results in excessive
body building, preoccupation with diet, and social problems.
Negative Family Influence
Negative influences within the family play a major role in triggering
and perpetuating eating disorders. Some studies have produced the following
observations and theories regarding family influence.
Insecure Infancy
Some experts theorize that parents who fail to provide a safe and
secure foundation in infancy may foster eating disorders. In such
cases, children experience so-called insecure attachments .
They are more likely to have greater weight concerns and lower self-esteem
than are those with secure attachments.
Parental Personalities
One study found that 40% of nine to 10 year-old girls try to lose
weight generally with the urging of their mothers. Some studies have
found that mothers of anorexics tend to be over-involved in their
child's life, while mothers of people with bulimia are critical and
detached. Some research strongly implicates overly critical fathers,
brothers, or both in the development of anorexia in both girls and
boys.
Family History of Addictions
or Emotional Disorders
Studies report that people with either eating disorder are more likely
to have parents with alcoholism or substance abuse than are those
in the general population. Parents of people with bulimia appear to
be more likely to have psychiatric disorders than parents of patients
with anorexia.
History of Abuse
Women with eating disorders, particularly bulimia, appear to have
a higher incidence of sexual abuse; studies have reported sexual abuse
rates as high as 35% in women with bulimia.
Family History of Obesity
People with bulimia are more likely than average to have an obese
parent or to have been overweight themselves during childhood.
In some studies people with anorexia have reported a higher than average incidence of problems during the mother's pregnancy or after birth. These problems include the following:
- Infection.
- Physical trauma.
- Seizures.
- Low birth weight.
- Older maternal age.
Some experts believe, then, that such patients experienced some injury to the brain while in the womb that predisposed them to eating problems in infancy and subsequent eating disorders later in life. Studies have suggested that people with anorexia often had stomach and intestinal problems in infancy.
Genetic Factors
Anorexia is eight times more common in people who have relatives with
the disorder, and some experts estimate that genetic factors may influence
more than half of the variances in eating disorders. For example, a
2000 study reported that twins had a tendency to share specific eating
disorders (anorexia nervosa, bulimia nervosa, and obesity). Some evidence
has reported an association with genetic factors responsible for serotonin,
the brain chemical involved with both well-being and appetite. Some
inherited traits that might make someone susceptible to eating disorders
include the following:
Inherited personality traits also play some causal role.
Cultural Pressures
One interesting anthropologic study reported the following observations:
During periods or in cultures where female independence has been possible, the standard of female attractiveness tends toward thinness.
One study reported that teenage boys and girls who made strong efforts to look like celebrities of the same sex were more likely to be constant dieters. On the other hand, food is overproduced, and the media floods the public, and particularly women and children, with attractive ads for consuming foods, both at home and out of the home. And, the emphasis is on junk foods. In a country where obesity is epidemic, young women who achieve thinness believe they have accomplished a major cultural and personal victory; they have overcome the temptations of junk food and, at the same time, created body images idealized by the media. Weight loss brings a feeling of triumph over helplessness. This sense of accomplishment is often reinforced by the envy of heavier companions who perceive the anorexic friend as being emotionally stronger and more sexually attractive than they are. Excessive Athleticism and the Female Athlete Triad. The cultural attitude toward physical activity is a fitting companion to the general disordered attitude regarding eating. Americans are encouraged to admire physical activity only as an intense competitive effort that few can attain, leaving most people in their armchairs as spectators.
In the small community of athletes, excessive exercise plays a major role in many cases of anorexia (and, to a lesser degree, bulimia). In young female athletes, anorexia postpones puberty, allowing them to retain a muscular boyish shape without the normal accumulation of fatty tissues in breasts and hips that may blunt their competitive edge. Many coaches and teachers compound the problem by overstressing calorie counting and loss of body fat. Some over-control the athletes' lives and are even abusive to an athlete that goes over the weight limit. (Male athletes are also vulnerable to their coaches' influence and anorexia is also a problem among this group.)
In response, people who are vulnerable to such criticism may lose excessive weight, which has been known to be deadly even for famous athletes. The term "female athlete triad" in fact, is now a common and serious disorder facing young female athletes and dancers and describes the combined presence of the following problems:
The primary setting of many of these abnormalities originate in a small area of the brain called the limbic system. A specific system called hypothalamic-pituitary-adrenal axis (HPA) may be particularly important in eating disorders. It originates in the following regions in the brain:
Hypothalamus. The hypothalamus is a small structure
that plays a role in controlling our behavior, such as eating, sexual
behavior and sleeping, and regulates body temperature, emotions, secretion
of hormones, and movement.
The Pituitary Gland. The pituitary gland develops from an extension
of the hypothalamus downwards. It is involved in controlling thyroid
functions, the adrenal glands, growth and sexual maturation.
Amygdala. This small almond-like structure lies deep
in the brain and is associated with regulation and control of major
emotional activities, including anxiety, depression, aggression, and
affection. Stress Hormones. The HPA systems trigger the production
and release of stress hormones called glucocorticoids, including the
primary stress hormone cortisol. Chronically elevated levels
of stress chemicals have been observed in patients with anorexia and
bulimia. Cortisol is very important in marshaling systems throughout
the body (including the heart, lungs, circulation, metabolism, immune
systems, and skin) to deal quickly with any threat. Among the specific
effects is inhibition of neuropeptide Y (NPY), a powerful
appetite stimulant that also has anti-anxiety properties. This process
may serve as a biologic link between extreme stressful conditions
in a young person's life and the later development of anorexia, although
some imaging studies indicate that stress-hormone related changes
occur after anorexia has developed. More work is needed to
determine if changes in stress hormones are a cause or result of eating
disorders.
Release of Neurotransmitters. The HPA system also releases certain
neurotransmitters (chemical messengers) that regulate stress, mood,
and appetite and are being heavily investigated for a possible role
in eating disorders. Abnormalities in the activities of three of them,
serotonin, norepinephrine, and dopamine, are of particular interest.
Serotonin is involved with both well-being and appetite (among other
traits), and norepinephrine is a stress hormone. Abnormalities in
both have been observed in patients who binge and in those with anorexia
or bulimia. Dopamine is involved in reward-seeking behavior, so deficiencies
might create a more intense need for rewards, such as carbohydrates.
Studies on dopamine abnormalities have been mixed, however.
Low-Leptin Levels. Leptin is a hormone that appears to trigger the
hypothalamus to stimulate appetite, and low levels have been observed
in people with anorexia and bulimia.
Low Reproductive HormonesThe hypothalamic-pituitary system is also responsible for the production of important reproductive hormones that are severely depleted in anorexics. Although most experts believe that these reproductive abnormalities are a result of anorexia, others have reported that in 30% to 50% of people with anorexia, menstrual disturbances occurred before severe malnutrition set in and remained a problem long after weight gain, indicating that hypothalamic-pituitary abnormalities precede the eating disorder itself.
Compensating for Mood Swings during Binge-Purging CyclesSerotonin Imbalances. Low levels of serotonin have been observed not only in eating disorders but also in depression. One theory for the persistence of the binge-purge cycle in bulimia involves restoring serotonin imbalances and so improving mood. It involves the following:
The binge-purge cycle then might be stimulated by chemical changes and perpetuated by feelings of guilt and depression after bingeing and release from guilt and euphoria during and after purging. Infections In some cases, infection has been associated with anorexia. Immune factors released to fight these infections may cause inflammation and injury in the areas of the brain that affect appetite and behavior. Streptococcal Infection. Research has found a link between anorexia and group A beta-hemolytic streptococcal (GABHS) bacteria, the cause of strep throat. GABHS has already been identified as a trigger of a rare form of obsessive-compulsive disorder (OCD) in children, which often accompanies eating disorders. Epstein Barr. Epstein Barr, the virus that causes mononucleosis has also been associated with the development of anorexia.
HOW SERIOUS IS BULIMIA NERVOSA WITHOUT SERIOUS WEIGHT LOSS (ANOREXIA)?
Chances for Recovery
Some studies have suggested that between 60% and 80% of patients are in remission within three months of treatment. However, relapse is common and up to half of women with bulimia continue to battle disordered eating habits for years, with bulimia itself persisting in 10% to 25% of patients. Medical
Consequences
In general, there are few major health problems for bulimic people who maintain normal weight and do not go on to become anorexic. For example, one study comparing adolescents with anorexia and bulimia reported abnormal heart rhythms in patients with anorexia but not in those with bulimia. It should be noted, however, that in one study of bulimic patients undergoing therapy, after six years the mortality rate was 1%. Those who have both bulimia and anorexia, however, are in great danger.
And, the disorder, even without anorexia, is not without health problems and serious risks. The following are medical problems associated with bulimia:
Self-Destructive Behavior
A number of self-destructive behaviors occur with bulimia:
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HOW SERIOUS IS ANOREXIA NERVOSA?
Chances for Recovery
At this time no treatment program for anorexia nervosa is completely
effective, and about 50% of patients never achieve a normal weight.
Many still display traits characteristic of the disorder, including
perfectionism and a drive for thinness, that could keep them at risk
for recurrence of the eating disorder. Even in those who recover, one
study indicated that recovery took between four and nearly seven years.
Risk
Factors for Early Mortality
Studies of anorexic patients have reported death rates ranging from
4% to 25%. According to different studies, the risk for early death
is higher in the people with the following conditions or characteristics:
Suicide
Suicide has been estimated in some studies to account for as many as half the deaths in anorexia. In one study, suicide rates occurred in 1.4% of women with anorexia. The study, however, only looked at female death records. Such records may not have always recorded anorexia as an accompanying condition, so the incidence of suicide in anorexia may be much higher.
Heart Disease
Heart disease is the most common medical cause of death in people with severe anorexia. The effects of anorexia on the heart are as follows:
A primary danger to the heart is from abnormalities in the balance of minerals, such as potassium, calcium, magnesium, and phosphate, which are normally dissolved in the body's fluid. The dehydration and starvation that occurs with anorexia can reduce fluid and mineral levels and produce a condition known as electrolyte imbalance . Electrolytes of calcium and potassium are critical for maintaining the electric currents necessary for a normal heart beat. An imbalance in these electrolytes, then, can be very serious and even life-threatening unless fluids and minerals are replaced. Heart problems are a particular risk when anorexia is compounded by bulimia and the use of ipecac, a drug that causes vomiting.
Medical Consequences of Hormonal ChangesAnorexia has a number of hormonal effects that can have severe health consequences:
- Reproductive hormones are lower.
- Thyroid hormones are lower.
- Stress hormones are higher.
Growth hormones are lower. Children and adolescents with anorexia may experience retarded growth.
Long-Term Outlook on Fertility
After treatment and weight increase, estrogen levels are usually restored and periods resume. In severe anorexia, however, even after treatment, normal menstruation never returns in 25% of such patients. If a woman with anorexia becomes pregnant before regaining normal weight, she faces a higher risk for miscarriage, cesarean section, and for having an infant with low birth weight or birth defects. She is also at higher risk for post partum depression. Women with anorexia who seek fertility treatments have lower chances for success.
Long-Term Effect on Bones
Loss of bone minerals (osteopenia) and loss of bone density (osteoporosis) is a common result of low estrogen levels in women with anorexia. Bone loss in such women may also be worsened by low calcium levels and by higher levels of stress hormones (which impair bone growth). Up to two-thirds of children and adolescent girls with anorexia fail to develop strong bones during their critical growing period. The less the patient weighs, the more severe the bone loss. Women with anorexia who also binge-purge face an even higher risk for bone loss.
Weight gain, unfortunately, does not restore bone. Only achieving regular menstruation as soon as possible can protect against permanent bone loss. The longer the eating disorder persists the more likely the bone loss will be permanent. Neurological Problems People with severe anorexia may suffer nerve damage that affects the brain and other parts of the body. The following nerve-related conditions have been reported:
Gastrointestinal Problems
Bloating and constipation are both very common problems in people with anorexia.
Multiorgan Failure
In very late anorexia, the organs simply fail. The main signal for this is elevated levels of liver enzymes, which require immediate administration of calories.
Diabetic Adolescents
Eating disorders are very serious in young people with type 1 diabetes. The complications of anorexia that affect all patients are even more dangerous in this group of patients. Hypoglycemia, or low blood sugar, for example, is a danger in anyone with anorexia, but it is a particularly dangerous risk in those with diabetes. One study found that 85% of young women with diabetes and eating disorders had retinopathy, damage to the retina in the eye, which can lead to blindness.
Drug and Alcohol Abuse
Some studies estimate that between 12% and 18% of people who are anorexic also abuse alcohol or drugs.
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WHAT ARE THE SYMPTOMS OF EATING DISORDERs
Distorted Body Image
Possibly the most bewildering symptom of both eating disorders is the distorted body image ( body dysmorphia ). Although people typically associate distorted body image with severe anorexia, one study indicated that distortion may be more prevalent in people with bulimia. People with bulimia were more likely than those with anorexia to overestimate their size. There was also a greater disparity between what they wanted to look like and what they believed they looked like. In another study, people with anorexia tended to have an accurate perception of their upper body, but overestimated the size of their abdominal and pelvic area. Symptoms
Specific to Bulimia without Anorexia
People with bulimia nearly always practice it in secret, and, although they may be underweight, they are not always anorexic. Symptoms or signs of bulimia, then, may be very subtle and go unnoticed. They may include the following:
Dry mouth
Teeth develop cavities, diseased gums, and irreversible enamel erosion
from excessive acid. (Gargling with baking soda after purging rather
than using toothpaste may help neutralize the acid.)
Rashes and pimples.
Small cuts and calluses across the tops of finger joints. (These cuts can occur from repeated self-induced vomiting, in which a person thrusts the hand down the throat past the front teeth.)Symptoms Specific to Anorexia
Weight Loss
The primary symptom of anorexia is major weight loss from excessive and continuous dieting, which may either be restrictive dieting or binge-eating and purging. Note. Young women who have both diabetes and eating disorders may have normal weight or even be overweight from the effects of insulin. However, they still are at high risk from the medical consequences of anorexia.
Other Symptoms
Other symptoms may include the following:
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WHAT WILL CONFIRM A DIAGNOSIS OF EATING DISORDERS?
Admitting the Problem
The first step toward a diagnosis is to admit the existence of an eating disorder. Often, the patient needs to be compelled by a parent or others to see a doctor because the patient may deny and resist the problem. Some patients may even self-diagnose their condition as an allergy to carbohydrates, because after being on a restricted diet, eating carbohydrates can produce gastrointestinal problems, dizziness, weakness, and palpitations. This may lead such people to restrict carbohydrates even more severely.
It is often extremely difficult for parents as well as the patient to admit that a problem is present. For example, because food is such an intrinsic part of the mother/child relationship, a child's eating disorder might seem like a terrible parental failure. Parents themselves may have their own emotional issues with weight gain and loss and perceive no problem in having a "thin" child.
Interview Tests
It is recommended that a supportive companion be present during part of the initial medical interview to offer additional information on the patient's eating history and to help offset any resistance or denial the patient may express.
Various questionnaires are available for assessing patients. For example, a brief British test called the SCOFF questionnaire is proving to be very reliable in accurately identifying people who are at high risk for either eating disorder.
SCOFF Questionnaire
S Do you feel Sick because you feel full?
C Do you lose Control over how much you eat?
O Have you lost more than One stone (about 13 pounds) recently?
F Do you believe yourself to be Fat when others say you are thin?
F Does Food dominate your life?
Answering yes to two of these questions is a strong indicator of an eating disorder.
Diagnosing Bulimia Nervosa
In spite of the prevalence of bulimia, in one study only 30% of Midwest family physicians had ever diagnosed bulimia in a patient. Younger and female physicians are more likely to detect bulimia. A physician should make a diagnosis of bulimia if there are at least two bulimic episodes per week for three months. Because people with bulimia tend to have complications with their teeth and gums, dentists could play a crucial role in identifying and diagnosing bulimia.
Diagnosing Anorexia Nervosa
Generally, an observation of physical symptoms and a personal history will quickly confirm the diagnosis of anorexia. The standard criteria for diagnosing anorexia nervosa are:
Tests for electrolyte imbalances. Low potassium levels indicate that the disorder is more likely to be accompanied by the binge-purge syndrome. Test for protein levels. An electrocardiogram and a chest x-ray. Tests for liver, kidney, and thyroid problems.
A bone density test.
Statistics
In the United States, conservative estimates indicate that after puberty, 5-10 million girls and women and 1 million boys and men are struggling with eating disorders including anorexia, bulimia, binge eating disorder, or borderline conditions.
The Prevalence of Eating Disorders
Because of the secretiveness and shame associated with eating disorders, many cases are probably not reported. In addition, many individuals struggle with body dissatisfaction and sub-clinical disordered eating attitudes and behaviors. For example, 80% of American women are dissatisfied with their appearance (Smolak, 1996). The Drive for Thinness
42% of 1st-3rd grade girls want to be thinner (Collins, 1991). 81% of 10 year olds are afraid of being fat (Mellin et al., 1991). The average American woman is 5’4" tall and weighs 140 pounds. The average American model is 5’11" tall and weighs 117 pounds. Most fashion models are thinner than 98% of American women (Smolak, 1996).
Dieting
25% of American men and 45% of American women are on a diet on any given day (Smolak, 1996).
Americans spend over $40 billion on dieting and diet-related products each year (Smolak, 1996).
Symtoms of Anorexia
- Distorted Body Image
- Intense fear of gaining weight
- Feelings of guilt after eating
- Is already thin and weight is still dropping
- Cessation of a period for three consecutive cycles
- Counts every calorie and fat gram that is eaten
- Paleness, dizziness, or fainting spells
- Intense, dramatic mood swings
- Excessively and compulsively exercises
- Complaints of being cold
- Hair loss
- A high need for control
- Wearing loose clothing
- Exhaustion and Fatigue
- Hiding food in napkins, under beds, in drawers, etc.
- Abuse of laxatives, diet pills, or diuretics Very poor self-esteem
- Never eats around others
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Some Telling Signs that Anorexia
May Be in Progress
- The individual is constantly complaining about being "fat," "obese" or "huge."
- The individual is very preoccupied with weight, counting calories and fat grams, and dieting.
- The individual is drained and has little energy.
- The individual has begun wearing extremely loose fitting clothing.
- The individual comes up with new found excuses not to eat such as, "I already ate and I have an upset stomach."
- The individual is extremely defensive about his/her weight.
- The individual is often cold.
- The individual often cooks or bakes food for other people, but refuses to eat the food themselves.
- The individual has started growing fine facial and body hair-a type of fur (lanugo).
- The individual is extremely irritable and has dramatic mood swings.
- The individual tends to isolate in social situations or avoid social gathering.
- The individual consumes a lot of non-caloric foods such as diet soda, gum, etc.
- The individual's hair is falling out and/or becoming extremely dry and brittle.
- The individual often withdraws from touching others
- The individual avoids restaurants and eating in front of others.
- The individual's complexion has become pale and his/her skin is extremely dry.
- When the individual looks in the mirror, his/her reflection is like a "funhouse" mirror. (Distorted)
- Meal times have become extremely ritualistic- e.g. the individual will insist on eating in the same bowl, he/she will cut their food into tiny pieces, he/she will not let the articles of food on the plate touch one another, he/she will keep on moving food around the plate to make it appear as if something has been eaten, etc.
- The individual uses excessive laxatives,
diuretics, or diet pills to control weight.
- Bingeing and Purging
- Secretive Eating- Missing Food
- Severe self-criticism
- Feelings of guilt after eating
- Visits to the bathroom after meals
- Weight fluctuations (10-20 lbs.)
- Tooth decay
- Avoids eating in public, in front of others
- Swollen glands in neck & puffiness in cheeks
- Excessive and compulsive exercise regimes
- Constant sore throat
- Increased promiscuous attitude
- Feels like he/she has no control over food
- Wearing tight clothing
- Broken blood vessels in eyes
- Poor impulse control- i.e. drugs, alcohol, spending,mood, etc.
- Abuse of laxatives, diet pills, ipecac, and/or diuretics
- Very poor self-esteem
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Some Telling Signs that Bulimia May Be in Progress
- The individual often goes to the restroom right after meals and remains for an extended period of time.
- The individual feels like he/she does not have control over food.
- The individual hides food in secret locations for use during binges.
- The individual eats a great deal but does not seem to gain or lose a lot of weight.
- The individual takes laxatives and gives himself/herself enemas more than once a week. The individual constantly complains about being "fat," "obese," or "huge."
- The individual has blood shot eyes.
- The individual eats nothing or very little in front of others, and then binges in private. Quantities of food seem to mysteriously disappear from their refrigerator and/or pantry.
- The individual tends to have swollen glands in his/her neck and/or face.
- The individual has scrape wounds on the back of her/his knuckles (due to the contact between knuckles and teeth to induce vomiting).
- The individual abuses Ipecac Syrup, laxatives, diuretics, and/or diet pills.
- The individual has started to excessively drink, smoke, abuse drugs, or spend money.
- The individual is extremely defensive when questioned about his/her weight.
- The individual's tooth enamel is eroding and has increased cavities.
- The individual has begun to wear extremely tight fitting, figure revealing clothes.
- The individual will go through times of dramatic weight fluctuations of ten pounds or more within a short period of time.
- The individual tends to be sexually overactive, even quite promiscuous.
- The individual takes numerous trips to grocery stores, convenience stores, etc. in a single day.
- The individual has an enormous preoccupation with body weight and food.
- The individual is constantly complaining of a sore throat.
- The individual alternates between eating massive quantities of food and periods of self-starvation.