Eating disorders are psychiatric illnesses that result in abnormal eating patterns that have negative effects on health.
Approximately 30 million people in the United States will suffer from an eating disorder at some point in their lives, and every 62 seconds a person dies as the result of one of these disorders. In general, more women have eating disorders than men, although precise figures on male incidence are often difficult to ascertain due to gender bias in the relevant studies and the stigma associated with males admitting to an eating disorder. Among the common disorders, women are more likely to suffer from anorexia nervosa and bulimia nervosa, whereas anorexia athletica, muscle dysmorphic disorder, and orthorexia nervosa tend to be more common in men. Almost as many men as women develop binge-eating disorder. Rumination and pica affect men and women equally. Eating disorders affect all racial, ethnic, and socioeconomic groups.
According to the National Institute of Mental Health, binge-eating disorder is the most common eating disorder in the United States; 2.8% of Americans will suffer from a binge-eating disorder in their lifetimes. Approximately 60% of binge eaters are female.
Bulimia is another common eating disorder in the United States. The lifetime prevalence of bulimia among US citizens is 1.5% for women and 0.5% for men. In men, the disorder is more often diagnosed in homosexuals than in heterosexuals. Bulimia usually develops during the adolescent and young adult years, but can occur in older adults and even in very young children.
Anorexia can occur in people as young as age seven, but the disorder most often begins during adolescence. Slightly more than 1% of Americans over the age of 15 will suffer from anorexia in their lifetime, with women being about three times more likely than men to exhibit the disorder (0.9% versus 0.3%).
Eating disorders are mental disorders. They develop when a person has an unrealistic attitude toward or abnormal perception of his or her body. This causes behaviors that lead to destructive eating patterns that have negative physical and emotional consequences. Individuals with eating disorders often hide their symptoms and resist seeking treatment. Depression, anxiety disorders, and other mental illnesses often are present in people who have eating disorders, although it is not clear whether these cause the eating disorder or are a result of it.
The best-known eating disorders—anorexia nervosa, binge-eating disorder, and bulimia nervosa—have formal diagnostic criteria and are recognized as psychiatric disorders in the Diagnostic and Statistical Manual for Mental Disorders, published by the American Psychiatric Association (APA).
People who have anorexia nervosa are obsessed with body weight. They constantly monitor their food intake and starve themselves to become thin. No matter how much weight they lose, they continue to restrict their calorie intake in an effort to become ever thinner. Some persons with anorexia exercise to the extreme or abuse drugs or herbal remedies that they believe will help them burn calories faster. A few purge their body of the few calories they do eat by abusing laxatives, enemas, and diuretics. In time, they reach a point where their health is seriously, and potentially fatally, impaired.
Competitive athletes of all races have an increased risk of developing anorexia nervosa, especially in sports where weight is tied to performance. Jockeys, wrestlers, figure skaters, cross-country runners, and gymnasts (especially female gymnasts) have higher than average rates of anorexia. People such as actors, models, cheerleaders, and dancers (especially ballet dancers), who are judged mainly on their appearance, are also at high risk of developing the disorder. The constant pressure to be a certain weight, and the criticism that often is aimed at athletes who do not have the correct body shape and weight, can quickly lead to an obsession with weight loss. This same group of people is at higher risk for developing bulimia nervosa as well.
People with bulimia often consume unreasonably large amounts of food in a short time. Afterward, they purge their body of the calories. This is done most often by self-induced vomiting, often accompanied by laxative abuse. Some people with bulimia do not vomit after eating but will instead fast and exercise obsessively to burn calories. Both behaviors result in impaired health.
People with bulimia feel out of control when they are binge eating. Unlike people with anorexia, they recognize that their behavior is abnormal. Often they are ashamed and feel guilty about their behavior and go to great lengths to hide their binge/purge cycles from family and friends. People with bulimia are often of normal weight. Although their behavior results in negative health consequences, because they are less likely to be extremely thin, these consequences are less likely to be life threatening.
Binge eating rises to the level of a disorder only when bingeing occurs at least once a week for three months or more. People with binge-eating disorder may eat thousands of calories in an hour or two. While they are eating, they feel out of control and may continue to eat long after they feel full. Unlike bulimia, people with binge-eating disorder do not purge or exercise to get rid of the calories they have eaten. As a result, many, but not all, people with binge-eating disorder are obese, although not all obese people have binge-eating disorder.
People with binge-eating disorder are usually ashamed of their behavior and try to hide it by eating in secret and hoarding food for future binges. After a binge, they usually feel disgusted with themselves and guilty about their eating behavior. They often promise themselves that they will never binge again but are unable to keep this promise. Binge-eating disorder often takes the form of an endless cycle—rigorous dieting followed by an eating binge followed by guilt and rigorous dieting, followed by another eating binge. The main health consequences of binge eating are the development of obesity-related diseases, such as type 2 diabetes, sleep apnea, stroke, and heart attack.
There are a number of other lesser-known eating disorders. Many have only recently come to the attention of researchers and have been the subject of only a few small studies. Some have been known to the medical community for years but are rare.
Purge disorder is thought by some experts to be a separate disorder from bulimia. It is distinguished from bulimia by the fact that the individual maintains a normal or near normal weight despite purging by vomiting or through laxative, enema, or diuretic abuse.
Anorexia athletica is a disorder of compulsive exercising. The individual places exercise above work, school, or relationships and defines his or her self-worth in terms of athletic performance. People with anorexia athletica also tend to be obsessed less with body weight than with maintaining an abnormally low percentage of body fat. This disorder is common among elite athletes.
Muscle dysmorphic disorder is the opposite of anorexia nervosa. Whereas people with anorexia think that they are too fat, persons with muscle dys-morphic disorder believe that they are too small. This belief is maintained even when the person is clearly well muscled. Abnormal eating patterns are less of a problem in people with muscle dysmorphic disorder than damage from compulsive exercising (even when injured) and the abuse of muscle-building drugs, such as anabolic steroids.
Orthorexia nervosa is a term coined by Steven Bratman, a Colorado physician, to describe “a pathological fixation on eating ‘proper,’ ‘pure,’ or ‘superior’ foods.” People with orthorexia allow their fixation with eating the correct amount of properly prepared healthy foods at the correct time of day to take over their lives. This obsession interferes with relationships and daily activities. For example, sufferers may be unwilling to eat at restaurants or friends' homes because the food is “impure” or improperly prepared. The limitations they put on what they eat can cause serious vitamin and mineral imbalances. These individuals are judgmental about what other people eat to the point where it interferes with personal relationships. They justify their fixation by claiming that their way of eating is healthy. Some experts believe orthorexia may be a variation of obsessive-compulsive disorder.
Rumination syndrome occurs when an individual, either voluntarily or involuntarily, regurgitates food almost immediately after swallowing it, chews it, and then either swallows it again or spits it out. Regurgitation syndrome is the human equivalent of a cow chewing its cud. The behavior often lasts up to two hours after eating. It must continue for at least one month to be considered a disorder. Occasionally the behavior simply stops on its own, but it can last for years.
Pica is the eating of nonfood substances by people developmentally past the stage where this is normal (usually around age two). Earth and clay are the most common nonfoods eaten, but people with pica have been known to eat hair, feces, lead, laundry starch, chalk, burnt matches, cigarette butts, light bulbs, and other equally bizarre items. This disorder has been known to the medical community for years and, in some cultures, is considered normal. Pica is most common among people with mental retardation and developmental delays. It only rises to the level of a disorder when health complications require medical treatment.
Eating disorders have multiple causes. A genetic predisposition toward developing an eating disorder appears to exist in some people. Biochemistry also seems to play a role. Neurotransmitters in the brain, such as serotonin, play a role in regulating appetite. Serotonin also helps regulate mood, and low serotonin levels are thought to play a role in causing depression. Abnormalities in the amount of some neurotransmitters are thought to play a role in anorexia, bulimia, and binge-eating disorder. Other disorders have not been studied enough to draw any conclusions.
Personality type can put an individual at risk for developing an eating disorder. Low self-worth is common among people with eating disorders. People with binge-eating disorder or with bulimia tend to have problems with impulse control and anger management. A tendency toward obsessive-compulsive behavior and black-or-white, all-or-nothing thinking puts people at higher risk.
Pressure, competition, and intense training in sports often lead to eating disorders in athletes. Participating in sports in which weight and slim body shape are emphasized, such as ballet and gymnastics, is more likely to lead to anorexia. Sports such as wrestling and bodybuilding, in which bulk and muscle mass are emphasized, are more likely to lead to muscle dysmorphic disorder. Athletes are judged based on their bodies and may be denied participation in a competition because they are deemed “too fat” by coaches, judges, or others in the sport. This tends to be more pronounced in individual-based sports versus team sports such as soccer, basketball, or football.
Athletes who participate in all sports are at an increased risk of anorexia athletica, and elite athletes are at a particularly high risk for having eating disorders that go unnoticed and untreated. Heightened interest in body shape, weight, and musculature is required for elite athletes in every sport. It often can be difficult to identify when this increased interest crosses the line into the obsession that characterizes an eating disorder.
Anorexia athletica can be particularly difficult to identify in elite athletes, because they are required to train many hours a day most days of the week. This training is necessarily a primary focus in their lives. When it becomes an obsession that precludes other normal activities and relationships, however, it requires treatment by a trained medical professional. Athletes competing at high levels also tend to be perfectionists with strong mental focus. Although this is a valuable skill for training and excelling in a sport, it can also make the individual more likely to persist with an eating disorder.
Eating disorders have physical and psychological consequences. These include:
Symptoms of binge eating may be difficult to detect. Binge eating is different from continuous snacking. People who binge eat are often secretive about food, and their bingeing is often done in private. Obesity and obesity-related diseases, such as hypertension (high blood pressure), type 2 diabetes, and joint pain, are signs that binge-eating disorder could be present, but not all obese people binge eat. Behaviors such as secretive eating, constant dieting without losing weight, obsessive concern about weight, depression, anxiety, and substance abuse are all clues, but none of these signs is definitive. The individual may complain about symptoms related to obesity, such as fatigue and shortness of breath, or mention unsuccessful dieting, but again, these signs are not definitive.
A physical examination begins with weight and blood pressure, physical appearance, and patient symptoms. Based on the physical exam, the physician may order laboratory tests. In general, these tests include a complete blood count (CBC), urinalysis, blood chemistries (to determine electrolyte levels), and liver function tests. The physician may also order an electrocardiogram to look for heart abnormalities. Other conditions, including metabolic disorders, brain tumors (especially hypothalamus and pituitary gland lesions), diseases of the digestive tract, and a condition called superior mesenteric artery syndrome, can cause weight loss or vomiting after eating. The physician may perform tests needed to rule out the presence of these disorders and assess the patient's nutritional status.
The individual may be referred to a psychiatrist for a mental status evaluation. The psychiatrist evaluates things such as appearance, observable state of emotion (affect), attitude toward food and weight, delusional thinking, thoughts of self-harm or suicide, and orientation in time and space. This evaluation helps to distinguish between an eating disorder and other psychiatric disorders, including depression, schizophrenia, social phobia, obsessive-compulsive disorder, and body dysmorphic disorder. Two diagnostic tests that medical professionals often use are the Eating Attitudes Test (EAT) and the Eating Disorder Inventory (EDI).
Treatment depends on the degree to which the individual's health is impaired.
Hospitalization is recommended for persons with anorexia or bulimia and any of the following characteristics:
Hospital impatient care is first geared toward correcting problems that present as immediate medical crises, such as severe malnutrition, severe electrolyte imbalance, irregular heartbeat, pulse below 45 beats per minute, or low body temperature. Patients are hospitalized if they are a high suicide risk, have severe clinical depression, or exhibit signs of an altered mental state. They may also need to be hospitalized to interrupt weight loss; stop the cycle of vomiting, exercising, and/or laxative abuse; treat substance disorders; or for additional medical evaluation.
The mainstay of treatment is psychotherapy. An appropriate therapy is selected based on the type of eating disorder and the individual's psychological profile. Some of the common therapies used in treating eating disorders include:
A nutrition consultant or dietitian is an essential part of the team needed to successfully treat eating disorders. The first treatment concern is medically to stabilize the individual by increasing calorie intake and balancing electrolytes. After that, nutritional therapy is needed to support the long process of recovery and stable weight gain. This is an intensive process involving nutrition education, meal planning, nutrition monitoring, and helping the client develop a healthy relationship with food. Nutritional counseling alone, however, will not resolve an eating disorder.
Recovery from an eating disorder can be a long, difficult process interrupted by relapses. With treatment, around 60% of those with an eating disorder will recover. Without treatment, approximately 20% of those with a serious eating disorder will die. All eating disorders have serious social, emotional, and health consequences. The sooner a person with an eating disorder gets professional help, the better the chance of recovery.
Prevention involves both preventing and relieving stresses and enlisting professional help as soon as abnormal eating patterns develop. Certain steps can be taken to help prevent an eating disorder from developing.
See also Obesity ; Weight loss .
Jones, Keith. Eating Disorders Sourcebook. 4th ed. Detroit: Omnigraphics, 2016.
Lask, Bryan, and Ian Frampton, eds. Eating Disorders and the Brain. Chichester, West Sussex, UK: Wiley, 2011.
Setnick, Jessica. Academy of Nutrition and Dietetics Pocket Guide to Eating Disorders. 2nd ed. Chicago: American Dietetic Association, 2017.
Stein, Daniel, and Yael Latzer, eds. Treatment and Recovery of Eating Disorders. Hauppauge, NY: Nova Science, 2013.
Gisladôttir, M., and E. K. Svavarsdôttir. “Educational and Support Intervention to Help Families Assist in the Recovery of Relatives with Eating Disorders.” Journal of Psychiatric and Mental Health Nursing 18, no. 2 (March 2011): 122–30.
Kornstein, Susan G. “Epidemiology and Recognition of Binge-Eating Disorder in Psychiatry and Primary Care.” Journal of Clinical Psychiatry 78, suppl. 1 (2017): 3–8.
Mairs, Rebecca, and Dasha Nicholls. “Assessment and Treatment of Eating Disorders in Children and Adolescents.” Archives of Disease in Childhood 101, no. 12 (December 2016): 1168–75.
American Family Physician. “Eating Disorders: What You Should Know.” American Academy of Family Physicians. http://www.aafp.org/afp/2015/0101/p46s1.html (accessed February 22, 2016).
Mayo Clinic Staff. “Eating Disorders.” Mayo Clinic.org . http://www.mayoclinic.org/diseases-conditions/eatingdisorders/home/ovc-20182765 (accessed February 22, 2016).
National Institute of Mental Health. “Eating Disorders.” US Department of Health and Human Services. https://www.nimh.nih.gov/health/topics/eating-disorders/index.shtml (accessed February 22, 2016).
Academy of Nutrition and Dietetics, 120 South Riverside Plaza, Ste. 2000, Chicago, IL, 60606, (800) 877-1600, http://www.eatright.org .
American Psychiatric Association, 1000 Wilson Blvd., Ste. 1825, Arlington, VA, 22209, (703) 907-7300, (888) 35-PSYCH (357-7924), http://www.psychiatry.org .
American Psychological Association, 750 First St. NE, Washington, DC, 20002, (202) 336-5500, (800) 374-2721, http://www.apa.org .
National Association of Anorexia Nervosa and Associated Disorders, 750 E. Diehl Rd., Ste. 127, Naperville, IL, 60563, (630) 577-1330, firstname.lastname@example.org, http://www.anad.org .
National Eating Disorders Association, 165 W. 46th St., Ste. 402, New York, NY, 10036, (206) 382-3587, Fax: (212) 575-6200, (800) 931-2237, info@National EatingDisorders.org, http://www.nationaleating disorders.org.
Tish Davidson, AM