What are eating disorders

Eating disorders are serious and complex mental illnesses with associated behavior problems that can affect people of every age, sex, gender, race, ethnicity, and socioeconomic group. Eating disorders can include severe overeating or not consuming enough food to stay healthy. Eating disorders can be recognized by a persistent pattern of unhealthy eating or dieting behavior that can cause health problems and/or emotional and social distress.

• Eating disorders are real, treatable medical illnesses.

Eating disorders can affect a person’s physical and emotional health and involve intense emotions and behaviors around food and about body shape or body weight. Eating disorders are very dangerous illnesses and can lead to permanent serious consequences and can be fatal if left untreated.

• Women are 2½ times more likely than men to have eating disorders. They usually start in the teenage years and often occur along with depression, anxiety disorders, and substance abuse.

Although there are formal guidelines that health care professionals use to diagnose eating disorders, unhealthy eating behaviors exist on a continuum. Even if a person does not meet the formal criteria for an eating disorder, he or she may be experiencing unhealthy eating behaviors that cause substantial distress and may be damaging to both physical and psychological health.

Types of eating disorders

• Anorexia nervosa, in which you become too thin, but you don’t eat enough because you think you are fat. Anorexia nervosa involves food restriction (limiting or not having certain foods or food groups). People with anorexia drastically limit their food intake and have an intense fear of gaining weight, even though they are underweight.
• Bulimia nervosa, which involves periods of overeating followed by purging, sometimes through self-induced vomiting or using laxatives. Bulimia nervosa involves cycles of binge eating followed by a purging behavior. People with bulimia will eat an unusually large amount of food in a short period of time and then exercise excessively or purge by vomiting, using laxatives, enemas, diuretics as a way to avoid gaining weight.
• Binge eating disorder, which is out-of-control eating. Binge eating disorder involves eating an unusually large amount of food in a short period of time and feeling a loss of control during this episode. Binge eaters do not purge afterwards, but often feel a lot of shame or guilt about their binge eating.
• Avoidant Restrictive Food Intake Disorder (ARFID). Although many children go through phases of picky or selective eating, a person with Avoidant Restrictive Food Intake Disorder (ARFID) does not consume enough calories to grow and develop properly and in adults, to maintain basic body function. In children, this results in stalled weight gain and vertical growth; in adults, this results in weight loss. Avoidant Restrictive Food Intake Disorder (ARFID) can also result in problems at school or work, due to difficulties eating with others and extended times needed to eat.
• Other specified feeding or eating disorders (OSFED). Other specified feeding or eating disorder involves some combination of symptoms of the other eating disorders such as an intense fear of weight gain and a preoccupation with food (thinking about food or having food related thoughts most of the day). People with Other specified feeding or eating disorders have some of the symptoms of anorexia, bulimia, or binge eating disorder, but don’t meet all of the criteria for diagnosis. Treatment for people with other specified feeding or eating disorder (OSFED), involves using the treatments for the eating disorder it most closely resembles.

No one knows exactly what causes eating disorders, but a growing consensus suggests that a range of biological, psychological, and sociocultural factors come together to spark an eating disorder. Eating disorders occur all over the world, especially in industrialized regions or countries.

Once the eating disorder has taken hold, it can become a self-sustaining process that usually requires professional help and support to recover. Eating disorders can lead to heart and kidney problems and even death. Getting help early is important. Treatment involves monitoring, talk therapy, nutritional counseling, and sometimes medicines.

How devastating are eating disorders ?

• For women aged 15-24, eating disorders are among the top four leading causes of burden of disease in terms of years of life lost through death or disability.
• Anorexia nervosa has one of the highest overall mortality rates and the highest suicide rate of any psychiatric disorder. The risk of death is three times higher than in depression, schizophrenia or alcoholism and 12 times higher than in the general population.
• Up to 10% of women with anorexia nervosa may die due to anorexia-related causes. Early recognition of symptoms and proper treatment can reduce the risk of death. Deaths in anorexia nervosa mainly result from complications of starvation or from suicide.
• Health consequences such as osteoporosis (brittle bones), gastrointestinal complications, and dental problems are significant health and financial burdens throughout life.
• Quality of life is severely impaired in all eating disorders.

Who is at increased risk for eating disorders ?

• Eating disorders are more common in women, but they do occur in men. Rates of binge-eating disorder are similar in females and males.
• Athletes in certain sports are at particularly high risk for eating disorders. Female gymnasts, ice skaters, dancers, and swimmers, to name a few, have been found to have higher rates of eating disorders. In a study of Division 1 NCAA athletes, over one-third of female athletes reported attitudes and symptoms placing them at risk for anorexia nervosa.
• Male athletes are also at increased risk—especially those in sports such as wrestling, bodybuilding, crew, running, cycling, climbing, and football.
• Although white females may be more likely to suffer from anorexia nervosa, African-American girls may be especially vulnerable to developing eating disorders that involve binge-eating. Body dissatisfaction in young girls has been shown in White, African-American, Hispanic, and Asian girls.

How common are eating disorders ?

• Anorexia nervosa: Between 0.3 and 1% of young women have anorexia nervosa (which makes anorexia as common as autism).
• Bulimia nervosa: Around 1 to 3% of young women have bulimia nervosa.
• Binge Eating Disorder: Around 3% of the population has binge-eating disorder.

Between 4% and 20% of young women practice unhealthy patterns of dieting, purging, and binge-eating.
Currently, about one in 20 young women in the community has an eating disorder.

Has the prevalence of eating disorders increased over the years ?

• Anorexia nervosa: Cases of anorexia nervosa have been described throughout history in many different cultural contexts, with the first medical descriptions dating back to the 19th century. The number of new cases presenting increased up to the 1970s and since then has been stable.
• Bulimia nervosa: Bulimia nervosa is a newer disorder and between the 1980s and 1990s there was a dramatic rise in the number of cases presenting with this disorder. The largest proportion of people presenting for treatment being adolescents and young adults.

Eating Disorder Truths

1. Truth #1: Many people with eating disorders look healthy, yet may be extremely ill.
2. Truth #2: Families are not to blame, and can be the patients’ and providers’ best allies in treatment.
3. Truth #3: An eating disorder diagnosis is a health crisis that disrupts personal and family functioning.
4. Truth #4: Eating disorders are not choices, but serious biologically influenced illnesses.
5. Truth #5: Eating disorders affect people of all genders, ages, races, ethnicities, body shapes and weights, sexual orientations, and socioeconomic statuses.
6. Truth #6: Eating disorders carry an increased risk for both suicide and medical complications.
7. Truth #7: Genes and environment play important roles in the development of eating disorders.
8. Truth #8: Genes alone do not predict who will develop eating disorders.
9. Truth #9: Full recovery from an eating disorder is possible. Early detection and intervention are important.

Eating disorders in children and teens

Eating disorders are so common in America that 1 or 2 out of every 100 students will struggle with one. Each year, thousands of teens develop eating disorders, or problems with weight, eating, or body image.

The most common eating disorders are anorexia nervosa and bulimia nervosa (usually called simply “anorexia” and “bulimia”). But other food-related disorders, like avoidant restrictive food intake disorder, binge eating disorder, body image disorders, and food phobias, are becoming more and more commonly identified.

Binge eating disorder

Binge eating disorder is a severe, life-threatening and treatable eating disorder characterized by recurrent episodes of eating large quantities of food (often very quickly and to the point of discomfort); a feeling of a loss of control during the binge; experiencing shame, distress or guilt afterwards; and not regularly using unhealthy compensatory measures (e.g., purging) to counter the binge eating. It is the most common eating disorder in the United States.

Binge eating disorder is one of the newest eating disorders formally recognized in the Diagnostic and Statistical Manual of Mental Disorders (DSM–5). Before the most recent revision in 2013, binge eating disorder was listed as a subtype of Eating Disorder- Not Otherwise Specified (EDNOS) [now referred to as Other Specified Feeding and Eating Disorders (OSFED)]. The change is important because some insurance companies will not cover eating disorder treatment without a DSM diagnosis.

The formal diagnostic criteria are:

• Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following:
  • Eating, in a discrete period of time (e.g., within any 2-hour period), an amount of food that is definitely larger than what most people would eat in a similar period of time under similar circumstances.
  • A sense of lack of control over eating during the episode (e.g., a feeling that one cannot stop eating or control what or how much one is eating).
• The binge eating episodes are associated with three (or more) 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 feeling embarrassed by how much one is eating.
  • Feeling disgusted with oneself, depressed, or very guilty afterward.
• Marked distress regarding binge eating is present.
• The binge eating occurs, on average, at least once a week for 3 months.
• The binge eating is not associated with the recurrent use of inappropriate compensatory behaviors (e.g., purging) as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

Statistics

National Eating Disorders Association (NEDA) has gathered data on the prevalence of eating disorders from the US, UK, and Europe to get a better idea of exactly how common eating disorders are. Although binge eating disorder is not a new disorder, its new formal recognition in the research community has left far more gaps in the data on the incidence and prevalence of binge eating disorder than for anorexia and bulimia.

• A 2007 study asked 9,282 English-speaking Americans about a variety of mental health conditions, including eating disorders. The results, published in Biological Psychiatry, found that 3.5% of women and 2.0% of men had binge eating disorder during their life
  • This makes binge eating disorder more than three times more common than anorexia and bulimia combined.
  • Binge eating disorderis also more common than breast cancer, HIV, and schizophrenia.
• When researchers followed a group of 496 adolescent girls for 8 years until they were 20, they found:
  • 5.2% of the girls met criteria for DSM5 anorexia, bulimia, or binge eating disorder.
  • When the researchers included nonspecific eating disorder symptoms, a total of 13.2% of the girls had suffered from a DSM-5 eating disorder by age 20.
• Combining information from several sources, Eric Stice and Cara Bohon ¹ found that:
  • Between 0.2% and 3.5% of females and 0.9% and 2.0% of males will develop binge eating disorder
  • Subthreshold binge eating disorder occurs in 1.6% of adolescent females
• Research estimates that:
  • 28.4% of people with current binge eating disorder are receiving treatment for their disorder
  • 43.6% of people with binge eating disorder at some point in their lives will receive treatment
• Binge eating disorder often begins in the late teens or early 20s, although it has been reported in both young children and older adults.
• Approximately 40% of those with binge eating disorder are male.
• Three out of ten individuals looking for weight loss treatments show signs of binge eating disorder.

Anorexia nervosa

People with anorexia have a real fear of weight gain and a distorted view of their body size and shape. As a result, they eat very little and can become dangerously underweight. Many teens with anorexia restrict their food intake by dieting, fasting, or excessive exercise. They hardly eat at all — and the small amount of food they do eat becomes an obsession in terms of calorie counting or trying to eat as little as possible.

Others with anorexia may start binge eating and purging — eating a lot of food and then trying to get rid of the calories by making themselves throw up, using some type of medication or laxatives, or exercising excessively, or some combination of these.

Bulimia Nervosa

Bulimia is similar to anorexia. With bulimia, people might binge eat (eat to excess) and then try to compensate in extreme ways, such as making themselves throw up or exercising all the time, to prevent weight gain. Over time, these steps can be dangerous — both physically and emotionally. They can also lead to compulsive behaviors (ones that are hard to stop).

To have bulimia, a person must be binging and purging regularly, at least once a week for a couple of months. Binge eating is different from going to a party and “pigging out” on pizza, then deciding to go to the gym the next day and eat more healthfully

People with bulimia eat a large amount of food (often junk food) at once, usually in secret. Sometimes they eat food that is not cooked or might be still frozen, or retrieve food from the trash. They typically feel powerless to stop the eating and can only stop once they’re too full to eat any more, or they may have to go to extreme measures (like pouring salt all over a dessert to make it inedible) in order to get themselves to stop eating. Most people with bulimia then purge by vomiting, but also may use laxatives or excessive exercise.

Although anorexia and bulimia are very similar, people with anorexia are usually very thin and underweight, but those with bulimia may be an average weight or can be overweight.

Avoidant Restrictive Food Intake Disorder (ARFID)

Avoidant Restrictive Food Intake Disorder (ARFID) is a new term that some people think just means “picky eating,” but a number of other eating issues can also cause it. People with Avoidant Restrictive Food Intake Disorder (ARFID) don’t have anorexia or bulimia, but they still struggle with eating and as a result don’t eat enough to keep a healthy body weight.

Diagnostic criteria for Avoidant Restrictive Food Intake Disorder (ARFID) ² include food restriction or avoidance without shape or weight concerns or intentional efforts to lose weight that results in significant weight loss and nutritional deficiencies and are associated with disturbances in psychological development and functioning. Some patients present with highly selective eating, neophobia (the fear of new things) related to food types, or hypersensitivity to food texture, appearance, and taste ³. For some patients, fear of swallowing or choking contributes to food avoidance; a specific event can sometimes be identified as triggering that fear. Avoidant Restrictive Food Intake Disorder also applies to individuals who have a lack of interest in eating or who have low appetite.

According to the DSM-5, ARFID is diagnosed when:

• 1. An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
  • Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
  • Significant nutritional deficiency.
  • Dependence on enteral feeding or oral nutritional supplements.
  • Marked interference with psychosocial functioning.
• 2. The disturbance is not better explained by lack of available food or by an associated culturally sanctioned practice.
• 3. The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
• 4. The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.

Types of eating problems that might be considered Avoidant Restrictive Food Intake Disorder include:

• difficulty digesting certain foods
• avoiding certain colors or textures of food
• eating only very small portions
• having no appetite
• being afraid to eat after a frightening episode of choking or emetophobia (fear of vomiting)
• Nearly half of children with ARFID report fear of vomiting or choking, and one-fifth say they avoid certain foods because of sensory issues.
• The same study found that one-third of children with ARFID have a mood disorder, three-quarters have an anxiety disorder, and nearly 20 percent have an autism spectrum condition

Because they don’t get enough nutrition in their diet, people with Avoidant Restrictive Food Intake Disorder lose weight, or, if they’re younger kids, they may not gain weight or grow as expected. Many people with Avoidant Restrictive Food Intake Disorder need supplements each day to get the right amount of nutrition and calories.

People with Avoidant Restrictive Food Intake Disorder also might have issues in their day-to-day lives, at school, or with their friends because of their eating problems. For example, they might avoid going out to eat or eating lunch at school, or it might take so long to eat that they’re late for school or don’t have time to do their homework.

Some people with Avoidant Restrictive Food Intake Disorder may go on to develop another eating disorder, such as anorexia or bulimia.

Other Specified Feeding and Eating Disorders (OSFED)

Other Specified Feeding and Eating Disorders (OSFED) was previously known as Eating Disorder- Not Otherwise Specified (EDNOS) in previous editions of the Diagnostic and Statistical Manual. Despite being considered a ‘catch-all’ classification that was sometimes denied insurance coverage for treatment as it was seen as less serious, OSFED/EDNOS is a serious, life-threatening, and treatable eating disorder. The category was developed to encompass those individuals who did not meet strict criteria for anorexia or bulimia but still had a significant eating disorder. In community clinics, the majority of individuals were historically diagnosed with Eating Disorder- Not Otherwise Specified (EDNOS).

Research into the severity of EDNOS/OSFED shows that the disorder is just as severe as anorexia and bulimia based on the following:

• Children hospitalized for EDNOS had just as many medical complications as children hospitalized for anorexia nervosa
• Adults with ‘atypical’ or ‘subclinical’ anorexia and/or bulimia scored just as high on measures of eating disorder thoughts and behaviors as those with DSM-diagnosed anorexia and bulimia
• People with EDNOS were just as likely to die as a result of their eating disorder as people with anorexia or bulimia

Symptoms of Other Specified Feeding and Eating Disorders (OSFED)

Because Other Specified Feeding and Eating Disorders (OSFED) encompasses a wide variety of eating disordered behaviors, any or all of the following symptoms may be present in people with Other Specified Feeding and Eating Disorders (OSFED).

• Frequent episodes of consuming very large amount of food followed by behaviors to prevent weight gain, such as self-induced vomiting.
• A feeling of being out of control during the binge-eating episodes.
• Self-esteem overly related to body image.
• Dieting behavior (reducing the amount or types of foods consumed).
• Expresses a need to “burn off” calories taken in.
• Use of compensatory behaviors (self-induced vomiting, laxative abuse) even after eating normal amounts of food.

Changes to the latest edition of the DSM were meant to clarify definitions of anorexia, bulimia, and binge eating disorder to more accurately diagnose eating disorders. Although this reduced the number of OSFED diagnoses, it remains a common diagnosis. In the DSM-5, a person must present with a feeding or eating behaviors that cause clinically significant distress and impairment in areas of functioning, but do not meet the full criteria for any of the other feeding and eating disorders.

A diagnosis might then be allocated that specifies a specific reason why the presentation does not meet the specifics of another disorder (e.g., bulimia nervosa – low frequency).

The following are further examples for Other Specified Feeding and Eating Disorders (OSFED):

• Atypical Anorexia Nervosa: All criteria are met, except despite significant weight loss, the individual’s weight is within or above the normal range.
• Binge Eating Disorder (of low frequency and/or limited duration): All of the criteria for BED are met, except at a lower frequency and/or for less than three months.
• Bulimia Nervosa (of low frequency and/or limited duration): All of the criteria for bulimia nervosa are met, except that the binge eating and inappropriate compensatory behavior occurs at a lower frequency and/or for less than three months.
• Purging Disorder: Recurrent purging behavior to influence weight or shape in the absence of binge eating.
• Night Eating Syndrome: Recurrent episodes of night eating. Eating after awakening from sleep, or by excessive food consumption after the evening meal. The behavior is not better explained by environmental influences or social norms. The behavior causes significant distress/impairment. The behavior is not better explained by another mental health disorder (e.g. BED).

Statistics of Other Specified Feeding and Eating Disorders (OSFED)

National Eating Disorders Association (NEDA) has gathered data on the prevalence of eating disorders from the US, UK, and Europe to get a better idea of exactly how common eating disorders are. Older data from other countries that use more strict definitions of anorexia and bulimia give lower prevalence estimates. Several more recent studies in the US have used broader definitions of eating disorders that more accurately reflect the range of disorders that occur, resulting in a higher prevalence of eating disorders:

• In a study of 31,406 Swedish twins born from 1935-1958, 1.2% of the women had strictly defined anorexia nervosa during their lifetime, which increased to 2.4% when a looser definition of anorexia was used.
• A 2007 study asked 9,282 English-speaking Americans about a variety of mental health conditions, including eating disorders. The results, published in Biological Psychiatry, found that:
  • 0.9% of women and 0.3% of men had anorexia during their life
  • 1.5% of women and 0.5% of men had bulimia during their life
  • 3.5% of women and 2.0% of men had binge eating disorder during their life (Hudson et al., 2007).
• When researchers followed a group of 496 adolescent girls for 8 years, until they were 20, they found:
  • 5.2% of the girls met criteria for DSM5 anorexia, bulimia, or binge eating disorder.
  • When the researchers included nonspecific eating disorder symptoms, a total of 13.2% of the girls had suffered from a DSM-5 eating disorder by age 20.

Have these numbers changed over time ? The answer isn’t clear. It does appear that, at least for the last two decades, the rates of new diagnoses of anorexia and bulimia have remained relatively stable, while the rates of EDNOS/OSFED have increased.

• An analysis of many studies from Europe and North America revealed that rates of anorexia increased sharply until the 1970s, when they stabilized.
• Rates of bulimia increased during the 1980s and early 1990s, and they have since remained the same or decreased slightly.
• A British study also found stability in new anorexia and bulimia diagnoses in both males and females, although rates of EDNOS diagnoses increased in both groups.
• Eating disorder symptoms are beginning earlier in both males and females, which agrees with both formal research and clinical reports.

Signs and symptoms of Anorexia and Bulimia

Sometimes a person with anorexia or bulimia starts out just trying to lose some weight or hoping to get in shape. But the urge to eat less or to purge or over-exercise gets “addictive” and becomes too hard to stop.

Teens with anorexia or bulimia often feel intense fear of being fat or think that they’re fat when they are not. Those with anorexia may weigh food before eating it or compulsively count the calories of everything. People to whom this seems “normal” or “cool” or who wish that others would leave them alone so they can just diet and be thin might have a serious problem.

How do you know for sure that someone is struggling with anorexia or bulimia? You can’t tell just by looking — a person who loses a lot of weight might have another health condition or could be losing weight through healthy eating and exercise.

But there are some signs to watch for that might indicate a person has anorexia or bulimia.

Someone with anorexia might:

• become very thin, frail, or emaciated
• be obsessed with eating, food, and weight control
• weigh herself or himself repeatedly
• deliberately “water load” when going to see a health professional to get weighed
• count or portion food carefully
• only eat certain foods, avoiding foods like dairy, meat, wheat, etc. (of course, lots of people who are allergic to a particular food or are vegetarians avoid certain foods)
• exercise excessively
• feel fat
• withdraw from social activities, especially meals and celebrations involving food
• be depressed, lethargic (lacking in energy), and feel cold a lot

Someone with bulimia might:

• fear weight gain
• be intensely unhappy with body size, shape, and weight
• make excuses to go to the bathroom immediately after meals
• only eat diet or low-fat foods (except during binges)
• regularly buy laxatives, diuretics, or enemas
• spend most of his or her time working out or trying to work off calories
• withdraw from social activities, especially meals and celebrations involving food.

Eating Disorders: Warning Signs and Symptoms

You can’t tell whether a person is struggling with an eating disordered just by looking at them, but there are often warning signs. Warning signs or “red flags” might suggest that a teen may develop or already has an eating disorder. Below is a list of signs that are linked to certain types of eating disorders. A person who has an eating disorder may have one or more of these signs. These signs may also mean that a person has another kind of health condition, so it’s best to talk with a trusted adult about your concerns before jumping to any conclusions.

Red flags for Anorexia Nervosa:

• Skips meals
• Makes excuses not to eat
• Over-exercises (makes exercise a top priority)(exercises too often, too strenuously or for too long)
• Eats only “safe” foods (low calorie, low-fat)
• Doesn’t eat certain food groups (ex. carbs, fats)
• Has unusual behaviors around food (measuring food, cutting food into small pieces, always finding something wrong with food, pushing food around the plate)
• Cooks or bakes food for others but doesn’t eat it
• Watches food shows or visits food websites often
• Obsessively reads nutrition information or counts calories
• Constantly weighs themselves, or “body checks” (looks at their body in the mirror or feels their body with their hands)
• Chews a lot of gum or drinks large amounts of water, coffee, diet soda, or calorie-free beverages
• Denies that there is a problem despite weight loss

Red flags for Bulimia Nervosa:

• Uses the bathroom after eating or in the middle of meals
• Consumes unusually large amounts of food at one time
• Loses control around food
• Hides food or empty wrappers
• Diets often
• Food may be missing from cabinets at home or disappears rapidly

Red flags for Binge Eating Disorder:

• Frequently eats very large amounts of food in one sitting
• Loses control around food
• Eats when not hungry
• Eats alone
• Eats as a way to control emotions
• Hides food or empty wrappers
• Others notice food disappearing rapidly
• May hoard food

What causes eating disorders

No one is really sure what causes eating disorders, although there are many theories about it. Researchers are finding that eating disorders are caused by a complex interaction of genetic, biological, psychological, and social factors. But many questions still need answers. Researchers are studying questions about behavior, genetics, and brain function to better understand risk factors, identify biological markers, and develop specific psychotherapies and medications that can target areas in the brain that control eating behavior. Brain imaging and genetic studies may provide clues for how each person may respond to specific treatments for these medical illnesses. Ongoing efforts also are aimed at developing and refining strategies for preventing and treating eating disorders among adolescents and adults.

Many people who develop an eating disorder are between 13 and 17 years old. This is a time of emotional and physical changes, academic pressures, and a greater degree of peer pressure.

Although there is a sense of greater independence during the teen years, teens might feel that they are not in control of their personal freedom and, sometimes, of their bodies. This can be especially true during puberty.

For girls, even though it’s completely normal (and necessary) to gain some additional body fat during puberty, some respond to this change by becoming very fearful of their new weight. They might mistakenly feel compelled to get rid of it any way they can.

When you combine the pressure to be like celebrity role models with the fact that bodies grow and change during puberty, it’s not hard to see why some teens develop a negative view of themselves. Celebrity teens and athletes conform to the “Hollywood ideal” — girls are petite and skinny, and guys are athletic and muscular, and these body types are popular not only in Hollywood but also in high school.

Many people with eating disorders also can be depressed or anxious, or have other mental health problems such as obsessive-compulsive disorder (OCD). There is also evidence that eating disorders may run in families. Although part of this may be genetics, it’s also because we learn our values and behaviors from our families.

Sports and Eating Disorders

Athletes and dancers are particularly vulnerable to developing eating disorders around the time of puberty, as they may want to stop or suppress growth (both height and weight).

Coaches, family members, and others may encourage teens in certain sports — such as gymnastics, ice skating, and ballet — to be as thin as possible. Some athletes and runners are also encouraged to weigh less or shed body fat at a time when they are biologically destined to gain it.

Risk Factors for Eating Disorders

Biological

• A family history of anorexia, bulimia and/or binge eating disorder may make certain people more at risk to have an eating disorder because of their genes or family upbringing
• Chemicals in the brain that control hunger, digestion, and appetite

Psychological

• Obsessive compulsive disorder (OCD)
• Past or current trauma such as physical, emotional or sexual abuse
• Anxiety
• Depression
• Desire to have control over some aspect of life
• Inability to control behaviors
• Personality traits such as perfectionism (wanting to be perfect), extreme desire to succeed, and/or impulsivity (doing things without planning or considering the consequences)
• Family values about body size, appearance and food
• Low self-esteem or self-worth
• Sense of loss

Environmental

• Society’s intense focus on thinness and dieting
• Participation in sports that focus on body shape and size such as dancing, rowing, gymnastics, track, wrestling, etc.
• Abusive or troubled relationships that cause emotional stress and feelings of loss of control
• Stress at school, sports, with peer groups, etc.
• Specific cultural attitudes about how a person should look and behave

Body Image and Self-Esteem

Body Image and Self-Esteem: Teens are constantly exposed to unrealistic standards in the media such as airbrushed images and very fit-looking models and may feel pressure to lose weight or look a certain way. Because of these pressures, many teenagers develop bad body image and self-esteem. Although it’s normal for teenagers to not feel completely content with their bodies because they’re constantly changing, it’s important for teens to find ways to feel comfortable with the natural shape and size of their bodies.

Body distortion: Body distortion is when someone sees her or his body shape, size and appearance differently from what everyone else sees. Body distortion causes a person to over-focus on flaws or imperfections that they are insecure about. Most people who struggle with an eating disorder have body distortion issues that are very hard to get rid of, because they often worry about how they look and what people think of them.

Effects of Eating Disorders

Eating disorders are serious medical illnesses. They often go along with other problems such as stress, anxiety, depression, and substance use. Eating disorders can lead to the development of serious physical health problems, such as heart conditions or kidney failure.

Someone whose body weight is at least 15% less than the average weight for that person’s height may not have enough body fat to keep organs and other body parts healthy. In severe cases, eating disorders can lead to severe malnutrition and even death.

With anorexia, the body goes into starvation mode, and the lack of nutrition can affect the body in many ways:

• a drop in blood pressure, pulse, and breathing rate
• hair loss and fingernail breakage
• loss of periods
• lanugo hair — a soft hair that can grow all over the skin
• lightheadedness and inability to concentrate
• anemia
• swollen joints
• brittle bones

With bulimia, constant vomiting and lack of nutrients can cause these problems:

• constant stomach pain
• damage to the stomach and kidneys
• tooth decay (from exposure to stomach acids)
• “chipmunk cheeks,” when the salivary glands permanently expand from throwing up so often
• loss of periods
• loss of the mineral potassium (this can contribute to heart problems and even death)

A person with binge eating disorder who gains a lot of weight is at risk of developing diabetes, heart disease, and some of the other diseases associated with being overweight.

The emotional pain of an eating disorder can take its toll, too. When someone becomes obsessed with weight, it’s hard to concentrate on much else. It can be exhausting and overwhelming to monitor food intake and exercise, and be in a constant state of stress about food and how your body looks. It’s easy to see why when you develop an eating disorder you could become withdrawn and less social. It gets too hard to join in on snacks and meals with friends or families, or too hard to stop the addictive exercising or working out to have fun.

Having an eating disorder also can use up a lot of mental energy planning what to eat, how to avoid food, planning a binge, getting money to buy food or laxatives or other medications, making up reasons to use the bathroom after meals, or figuring out how to tell people around you that you want to be alone after a meal.

Treatment for Eating Disorders

Fortunately, eating disorders can be treated. People with eating disorders can get well and gradually learn to eat well and more like their family and friends again. Eating disorders involve both the mind and body. So medical doctors, mental health professionals, and dietitians will often be involved in a person’s treatment and recovery.

• Eating disorders are treatable and the sooner someone gets the treatment he or she needs, the better the chance of a good recovery.

Typical treatment goals include restoring adequate nutrition, bringing weight to a healthy level, reducing excessive exercise, and stopping binging and purging behaviors. Specific forms of psychotherapy, or talk therapy—including a family-based therapy called the Maudsley approach and cognitive behavioral approaches—have been shown to be useful for treating specific eating disorders. Evidence also suggests that antidepressant medications approved by the U.S. Food and Drug Administration may help for bulimia nervosa and also may be effective for treating co-occurring anxiety or depression for other eating disorders.

Treatment plans often are tailored to individual needs and may include one or more of the following:

• Individual, group, or family psychotherapy
• Medical care and monitoring
• Nutritional counseling
• Medications (for example, antidepressants).

Some patients also may need to be hospitalized to treat problems caused by malnutrition or to ensure they eat enough if they are very underweight. Complete recovery is possible.

Therapy or counseling is a very important part of getting better — in many cases, family therapy is one of the keys to eating healthily again. Parents and other family members are important in supporting people who have to regain weight that they are afraid of, or to learn to accept the body shape that their culture, genes, and lifestyle allows for.

If you want to talk to someone about eating disorders but are unable or not ready to talk to a parent or close family member, try reaching out to a friend, teacher, school nurse or counselor, coach, neighbor, your doctor, or another trusted adult.

Remember that eating disorders are very common among teens. Treatment options depend on each person and their families, but many treatments incorporate journaling, talking to therapists, and working with dietitians and other professionals.

Learning to be comfortable at your healthy weight is a process. It takes time to unlearn some behaviors and relearn others. Be patient, you can learn to like your body, understand your eating behaviors, and figure out the relationship between feelings and eating — all the tools you need to feel in control and to like and accept yourself for who you are.

Anorexia nervosa: The critical first step in treatment of anorexia nervosa is re-nutrition (carefully monitored feeding, often with the assistance of a medical team) and weight restoration back to the healthy weight range. There is no consensus on the best approaches to treating anorexia nervosa, but family therapy appears to be helpful for younger patients who have recently developed an eating disorder. Cognitive Behavior Therapy (CBT) may be helpful after weight restoration.

Bulimia nervosa: A review of research studies concluded that bulimia nervosa can be treated effectively with cognitive behavioral therapy (CBT). CBT is a type of psychotherapy that addresses an individual’s thoughts and feelings to make changes in her behavior. Improvement in symptoms over a short period of time are also seen with the only FDA approved medication for bulimia nervosa fluoxetine (i.e., Prozac).

Binge-Eating Disorder: Binge-eating disorder also responds to cognitive-behavioral therapy, behavioral weight loss therapy and a variety of medications (e.g., selective serotonin reuptake inhibitors, tricyclic antidepressants) have also been shown to lead to improvement.

Can one recover from an eating disorder ?

• In general, early detection and treatment are associated with a better chance of recovery. One reason for this may be that brain development is not complete until about age 20 and the effects of starvation on the developing brain are particularly noxious.
• Anorexia nervosa: Over a 10-year period, about half of those with anorexia nervosa recover fully, a small percentage continues to suffer from anorexia nervosa, and the rest develop other eating disorders. Even among those individuals who recover from an eating disorder, it is common for them to continue to maintain a low body weight and experience depression.
• Bulimia nervosa: More than half of those treated for bulimia nervosa have recovered at follow-up.

National Eating Disorders Association

National Eating Disorders Association (NEDA) supports individuals and families affected by eating disorders, and serves as a catalyst for prevention, cures and access to quality care ⁴.

Whether you have been personally affected by an eating disorder or care about someone who has, National Eating Disorders Association’s programs and services are designed to help you find the help and support you need. Recovery is possible!

Find out more about NEDA’s programs and services:

• Get Screened Online for an Eating Disorder
• Contact the Helpline
• Find Treatment
• Support Groups & Research Studies
• NEDA Navigators
• Parent, Family & Friends Network
• Loss Support Network
• NEDA Walks
• NEDAwareness Week
• Legislative Advocacy
• The Body Project
• Feeding Hope Fund for Clinical Training
• Events

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3. Kreipe, R. and Palomaki, A. Beyond picky eating: avoidant/restrictive food intake disorder. Curr Psychiatry Rep. 2012; 14: 421–431[↩]
4. National Eating Disorders Association. https://www.nationaleatingdisorders.org/[↩]