Are Eating Disorders Really About Eating?

By Lena Snyder, M.D.

Eating disorders are characterized by a marked disturbance in eating behaviors and body image. The disordered attitudes and behaviors related to eating result in a loss of self-control, alienation from self and others, feelings of anxiety and guilt and can also lead to physiologic imbalances that may be life threatening.

The two major categories are anorexia nervosa (AN) and bulimia nervosa (BN). A third is called eating disorders NOS (not otherwise specified). The latter includes those who meet some but not all of the strict criteria for AN or BN (see charts) or have other disturbed eating patterns such as repeatedly chewing and spitting out but not swallowing large amounts of food.

DIAGNOSTIC CRITERIA FOR ANOREXIA NERVOSA

• Refusal to maintain minimal normal body weight for age and height
• Weight loss leading to body weight 15 percent below expected weight or failure to have expected weight gain during growth, leading to weight 15 percent below expected
• Disturbance of body image, feels fat despite emaciation
• Intense fear of becoming obese, even with progressive weight loss
• Absence of at least three consecutive menstrual cycles or failure of menses to occur by age 16
• No known physical illness to account for weight loss

• Recurrent episodes of binge eating involving rapid consumption of a large amount of food over a short period of time
• Feels lack of control over eating during binge episode
• Regularly engaging in inappropriate compensatory behaviors: self-induced vomiting, use of laxatives or diuretics, strict dieting, fasting or vigorous exercise to prevent weight gain
• The binging and inappropriate compensatory behaviors occur at least 2x/week for three months
• Persistent over concern with body shape and weight

These disorders often start in adolescence, with the tendency of AN to start earlier and BN to start later in adolescence or in young adults. The typical patient is a white female of middle or upper class. However, an increasing number of cases are occurring in all social and economic classes. Young men account for only about five to 10 percent of cases. The prevalence of AN is estimated at 0.5 to 1 percent of adolescents and BN between one and three percent. When you include those who fall into the NOS category, the prevalence of eating disorders may be as high as five to 10 percent of adolescent or young adult women.

Anorexia usually begins when a young teenager sees herself as being overweight and begins dieting. However, they continue to diet well past the normal end point and, unlike the normal dieter, will often try to disguise their weight loss with bulky or layered clothing even in warm weather. Even with extreme weight loss, they still believe they are "fat."

The typical bulimic patient is usually a normal to slightly overweight female who learns she can control her weight with the use of cathartics or self-induced vomiting. They soon lose control with frequent binge-purge cycles, leading to weight fluctuations of several pounds, but with no extreme weight loss as seen in AN.

The cause of eating disorders is complex. Family dynamics play a large and complex role, and society also contributes with its emphasis on thinness and dieting. There is often a high rate of depression, alcohol dependence or eating disorders in family members.

Certain athletes are at higher risk for development of eating disorders because of the emphasis on a lean appearance (gymnastics, cheerleading, dance, figure skating) or body leanness for optimal performance (long-distance running, swimming, cross-country skiing). Other sports that utilize weight classes are also at risk (wrestling, rowing, weight lifting). Certain professions, such as acting and modeling, also have a higher risk.

DIAGNOSIS

In general, people with eating disorders rarely seek help on their own. Primary care physicians should ask routine screening questions about disordered eating or distorted body images at yearly well exams beginning in early adolescence. Clinicians and parents should not wait for all of the "official" criteria of AN or BN to appear before deciding to intervene; generally speaking, the earlier the signs are recognized and treatment initiated, the better the prognosis.

Warning signs are:

• Compulsive exercising above and beyond the requirements for the sport
• An increasingly restrictive diet
• A preoccupation with food, calories and body weight
• Fear of becoming fat even when of average or below average weight
• Frequent trips to the bathroom after meals (for purpose of purging)
• Eating secretly or avoiding eating with others
• Binge eating and fasting.

Diagnosis is based on historical findings in combination with a careful physical exam. Because bulimia patients maintain a normal weight and show less-frequent physical findings, unless asked specific questions and answered honestly, the condition is usually chronic at the time of diagnosis. In any case, a few lab studies may be supportive, but not diagnostic. Electrolyte imbalances (i.e. changes in potassium, chloride, sodium, etc.) may range from mild to life threatening in severe cases.

COMMON PHYSICAL FINDINGS:

Anorexia nervosa:

• Loss of subcutaneous fat
• Loss of scalp or pubic hair
• Presence of lanugo hair (fine hair growth on face or body)
• Cold, mottled hands and feet
• Bradycardia (low heart rate)
• Hypotension (low blood pressure)
• Hypothermia

Bulimia Nervosa:

• Dental carries
• Erosion of tooth enamel
• Calluses on knuckles (from induced vomiting)
• Parotid gland swelling
• Swelling of hands or feet  

TREATMENT

Treatment of eating disorders involves a multi-disciplinary approach that includes a primary care physician, nutritionist and a psychiatrist or psychologist trained in managing eating disorders. Individual therapy is important, but treatment may frequently require family psychotherapy. Family dynamics play a large role in its development, but denial of this fact can be very strong. Antidepressants can also be an important adjunct to therapy.

Hospitalization occurs much less frequently in BN than AN and usually involves significant electrolyte disturbances. Some indications for acute hospitalization in AN include severe weight loss (<75 percent ideal body weight), dehydration, electrolyte disturbances, acute food refusal or physiologic instability (e.g. severe decrease in heart rate, low blood pressure or hypothermia). Anorexic patients often benefit more from longer psychiatric hospitalization with supervised diets.

If you suspect a family member shows signs of an eating disorder, it is important to seek help from their primary care physician who can aid in diagnosis and appropriate referrals to a therapist and nutritionist.

Lena Snyder, M.D., is a general pediatrician and graduate of University of Louisville 's School of Medicine . She is currently doing acute care work in the Louisville area.

LOCAL RESOURCES :

Judith Peoples, Ph.D.
120 Meridan Avenue
502-893-5896

Mohammad Shafii, M.D. (Adolescent psychiatrist)
601 S. Floyd Street Suite 12
502-629-5258

Barbara Ann Fitzgerald, M.D.
Norton Psychiatric Clinic
502-629-8850

The Kentuckiana Foundation for Eating Disorders Recovery
1562 Bardstown Road
502-458-5277

Family Care Center
1425 Story Avenue
502-584-1369

Kathy Rapp, R.D.
Martha Gregory & Associates
3010 Taylor Springs Dr .
502-458-4558

HOSPITALS:

Norton Psychiatric Center
200 E. Chestnut St .
502-629-8850

Ten Broeck Healthcare
1405 Browns Lane
502-896-0495

Baptist Hospital East Center for Behavorial Health
4000 Kresge Way
502-896-7105

Wellstone Regional Hospital
2700 Vissing Park St .
Jeffersonville , IN 47130
812-284-8000