Eating Disorders are serious physical and mental illnesses that involve abnormal or disturbed eating habits. Eating disorders are an illness, not a choice. Evidence has been found, via literature, art, and artifacts, of people having eating disorders for thousands of years. They are not a new phenomenon.
Eating disorders affect all genders, race, religions, ethnicities, sexual orientations, body shapes, and body weights. Over 20 million women and 10 million men will have disordered eating in their lifetime. Eating disorders do not discriminate who they affect.
Eating disorders are the third most common chronic condition in children behind asthma and obesity. The average age of people experiencing eating disorders is 12.5 years of age with the range from young children through adulthood. There has been a 119% increase in eating disorders in children under 12 in the past decade. Eating disorders can occur at any age but most frequently begin during adolescence.
Young people are particularly at risk due to rapidly changing bodies, the desire to fit in, and societal expectations. Over ½ of teen girls and 1/3 of teen boys have tried dangerous diets and over ¼ of teen dieters will develop disordered eating and behaviors.
What causes an eating disorder? The cause is multifactorial and believed to be a combination of biological, psychological, and sociocultural factors.
A person may be more likely having an eating disorder if they have a parent or sibling with an eating disorder or a close relative with anxiety, depression. A personal history of addiction, dieting, or Type 1 Diabetes as increase the risk of an eating disorder.
A person who has perfectionist tendencies or anxiety may be more likely to have an eating disorder. Behavioral inflexibility or rigidity increase the risk of an eating disorder.
The risk of developing an eating disorder is also higher for people with body image dissatisfaction. Although social media has not shown to be directly linked to eating disorders, it can increase body dissatisfaction, a known risk factor of eating disorders. Body dissatisfaction can result from appearance comparison as well as self-objectification.
Appearance comparison occurs when a person compares their appearance to that of another person. A person may look at images for fitness or diet advice or motivation to achieve their desired body type. Some people may even visit “pro-eating disorder” sites or seek out this type of content for motivation and tips. Frequent exposure to this type of content, increases appearance comparisons and has been shown to increase symptoms of an eating disorder.
Self-objectification occurs when a person is considering how other’s view their body. A person posting a lot of “selfies” and who is preoccupied with feedback or a person who spends a lot of time creating the “perfect” selfie through filters, posing, or photo manipulation is more likely to suffer body dissatisfaction.
Sociocultural factors that increase risk of an eating disorder include being teased or bullied about weight, acculturation (assimilating to a dominant culture), cultural weight stigma, and believing socially defined body ideals. A person without a strong social network is also at risk.
There are risk factors that increases a person’s risk of developing an eating disorder in addition to the above biological, psychological, and sociocultural factors.
Families that talk about weight and dieting increases the risk of a child developing an eating disorder. Talking about weight, expressing body dissatisfaction, or frequent talk about dieting can be directed at yourself or directed at your child. Risk also increases when families tease children about weight.
The risk of an eating disorder can also increase after a person experiences a stressful life event or life transition.
Athletes, particularly national or Division 1 ranked athletes, have an increased risk of eating disorders with over 21% of national team athletes having disordered eating versus 3% of the general population. Unfortunately, only 4% of these athletes are diagnosed. This is because weight loss or disordered eating is normalized in sports. Often, coaches and staff are not well trained about eating disorders. Additionally, the pressure to improve performance is a contributing factor.
Eating disorders are stereotypically thought to be a “white women” illness, but Black people are more likely to have eating disorders than white people. A Black person’s increased risk is believed to be related to the trauma of racism and oppression, body images issues due to beauty standards that stress Eurocentric beauty, and higher levels of food insecurity. Unfortunately, the medical system fails BIPOC individuals who are half as likely to be diagnosed or receive treatment for their eating disorder.
People in the LGBTQIA+ community, especially those older than age 12, are at higher risk of an eating disorder, in particular a binge eating disorder. They are more likely to engage in purging behaviors than cis-gendered and heterosexual peers. This may be due to internalized negative messages, discrimination, bullying, fear of rejection, discordance between biological sex and gender identity, inability to meet body ideals in a cultural context, or post-traumatic stress disorder. In particular, men make up a smaller percentile of people with an eating disorder but of those men, 42% identify as gay.
People with disabilities are at an increased risk of an eating disorder. More research is needed but it is believed to be due to vulnerability around body dissatisfaction, appearance, and body function. They experience negative feelings about their body that they may perceive as a burden to others or obstructive. A person may also be encouraged by medical professionals to lose weight or keep their weight low to improve mobility. People with Autism are at increased risk of eating disorder due to rule setting and inflexibility around food.
Both type 1 and type 2 diabetes are risk factors for eating disorders. A child with a type 2 diabetes diagnosis is 242 times more likely to develop and eating disorder.
There are protective things you can do to reduce the risk of your child developing an eating disorder. They include how to talk about bodies as well as how to treat food and eating.
- Teach your child that weight alone is not a measure of health
- Teach your child that weight does not determine their value as a human being
- AVOID WEIGHT TALK (YOUR WEIGHT OR THEIR WEIGHT)
- AVOID TEASING CHILDREN ABOUT THEIR WEIGHT (UNDER OR OVERWEIGHT)
- NEVER COMMENT ON ANOTHER PERSON’S BODY
- Foster a healthy body image
- Make activity a part of daily life, not a punishment for eating
- Teach your child that food can provide
- Serve a variety of foods
- Eat meals as a family
- Model eating nourishing and satisfying meals
- Do not diet or talk about dieting in front of your child
- Keep food neutral—do NOT label foods good or bad
- Do not cut out food groups
- Do not do any elimination diets not prescribed by a medical professional
- Scheduled eating can help a child honor their hunger cues and tune into their body’s needs as well as provide a framework for meals and snacks
- Let a child stop eating when they are done--no clean plate club!
A recent study showed the three most protective factors that can prevent eating disorders AND obesity are avoiding dieting, avoiding weight talk, and avoiding teasing about weight.
TYPES OF EATING DISORDERS
There are five main types of eating disorders: anorexia nervosa, bulimia, binge eating, orthorexia, and avoidant-restrictive food intake disorder. A person does NOT need to be under weight to be diagnosed with an eating disorder. A person also does NOT need to lose their menstrual cycle to be diagnosed with an eating disorder.
Anorexia nervosa is characterized by an obsessive desire to lose weight. A person will obsess about their weight, what they eat, and may have a fear of being overweight. The term atypical anorexia nervosa applies to patients who have symptoms of anorexia nervosa but have “normal” weights. This term is outdated and dangerous. By focusing on body weight instead of behaviors patients who are overweight are often underdiagnosed.
Anorexia nervosa affects 0.3-0.4 percent of young women and 0.1% of young men. Despite affecting a smaller percentage of men, they are at much higher risk of dying due to a later diagnosis. Athletes are also considered high risk with over 30% of NCAA Division 1 athletes at risk. The risk is high for sports that have weight classes, such as wrestling, rowing, or horse racing, or are “aesthetic” sports, such as gymnastics, swimming, diving, figure skating, and body building. Of these high-risk athletes, anorexia nervosa affects up to 62% of females and 33% of males.
Over the past 50 years, the rate of anorexia nervosa has increased in 15- to 24-year-old young adults but stayed stable for older age groups.
Binge eating disorder is an eating disorder characterized by recurrent episodes of eating large quantities of food, often quickly, and ignoring discomfort. A person may feel they are not in control during a binge. They may feel shame, guilt, or distress after a binge. After a binge, a person with binge eating disorder does not use unhealthy measures to offset the binge eating. To be diagnosed, binges must occur at least weekly for 3 months.
Binge eating is the most common eating disorder diagnosis with 3.5% of women and 2% of men exhibiting binge eating behaviors in their lifetime. This is 3 times more individuals than are seen with anorexia nervosa. Binge eating disorder can happen at any age but is usually seen in late teens and early 20s. We also see more men with binge eating disorder than other eating disorders with men making up almost 40% of this population.
Bulimia is characterized by an individual experiencing cycles of binge eating followed by compensatory behaviors to offset the effects of binge eating. A person may compensate for binging by vomiting, using laxatives, using diuretics, using other weight loss medications, fasting, or excessively exercising.
Bulimia is seen in 1% of women and 0.1% of men. Black teens are 50% more likely to exhibit bulimic behaviors than white teens. Younger children and pre-teens are also more likely to have bulimia versus anorexia nervosa or binge eating disorder
Orthorexia is an unhealthy obsession with healthy eating. Obsessions can be around ingredients, nutrition content and labels, individual foods, or food groups (such as sugar, all dairy, all carbohydrates). A person may only consume food they deem “good” such as organic, whole or farm fresh foods. They will be rigid in what foods they eat. They may also worry about sickness or disease if they don’t eat healthy or feel like “bad” foods may poison them. Orthorexia can result in weight loss or malnutrition but doesn’t always.
A person with these obsessions will be unable to eat anything not deemed healthy and will become distressed if these foods are not available. They will also take unusual interest in what others are eating. They may also obsessively follow healthy lifestyle blogs or social media influencers. They may or may not have body image issues.
As orthorexia is a new term or diagnosis used, and not yet in the Diagnostic & Statistical Manual of Mental Disorders, 5th edition, the manual of psychiatric diagnosis, there are no current statistics on the rate of orthorexia in the general population. It is believed to be around 7%. Athletes, nutritionists or dieticians, and performance artists are noted to have higher rates upwards of 40-50% based on self-report.
Avoidant-Restrictive Food Intake Disorder (ARFID)
ARFID is an eating disorder characterized by limited food intake due to sensory issues, lack of interest, fear of vomiting, fear of pain, or fear of choking. There are NOT weight-based fears associated with this disorder.
SYMPTOMS OF EATING DISORDERS
Symptoms of eating disorders fall into 3 categories: physical, emotional, and behavioral.
Physical symptoms include:
- A child who isn’t gaining weight or falls off their growth curve
- Rapid weight loss (this can be quick and marked in younger children)
- Weight increases and decreases
- Cold intolerance
- Abdominal pain
- Excessive energy
- Does not feel hunger
- Stops menstruating or has menstrual irregularities
- Shaking or trembling
- Sleep problems
- Cuts on the top of fingers or calluses on back of hands
- Mouth ulcers
- Dental issues
- Discolored teeth
- Swelling of cheeks or jaw
- Dry skin
- Dry or brittle fingernails
- Hair loss
- Developing fine downy hair on body
- Acid reflux
- Muscle weakness
- Muscle soreness
- Yellow skin
- Cold hands and feet
- Mottled looking hands and feet
- Swollen feet
- Numbness or tingling of hands and feet
- Night sweats
- Poor wound healing
- Impaired immune system function
Emotional symptoms include:
- Distorted body image
- Says things such as they feel fat, they are disgusting, they are “huge”
- Expresses need to burn off calories
- Intense fear of weight gain
- Intrusive thoughts
- Low self-esteem
- Loss of identity
- Mental exhaustion
- Lack of focus
- Difficulty learning
- Lack of motivation
- Flat mood
- Mood swings
- Memory problems
- Emotional numbness
Behavioral symptoms include:
- Restricting food
- Binge eating
- Leaving evidence of binge eating (wrappers etc) or hiding evidence
- Purging---vomiting, excessive exercise, abusing medications
- Disappears after eating
- Hiding vomit
- Hiding wrappers or packages of laxatives, diuretics, or diet pills
- Dresses in layers
- Pre-occupied with food, dieting, or calories
- Tries food fads or diets
- Refuses certain foods or food groups
- Denies hunger
- Cooks for others but doesn’t eat the food
- Rigid exercise routine
- Withdraws from friends and family
- Inflexible thinking
- Food rituals
- Avoids social activities
- Looking for weight loss information on websites/online
- Hiding food, hoarding food, or stealing food
- Eating alone
- Frequent bathroom trips
- Obsessing over what others are eating
- Smelling foods but not eating foods
- Avoiding others
- Constantly comparing self
- Hides body with baggy clothes
- Uses mouthwash, mints or gum excessively
PHYSICAL CONSEQUENCES OF EATING DISORDERS
If your body doesn’t get enough nutrients due to restriction, it stops normal body processes to conserve energy. To get the energy it needs but isn’t receiving from food, the body may breakdown body tissues for energy, this includes the heart. When this happens, we can see heart rates and blood pressure decrease. The heart pumps less blood and has less fuel to pump blood. This can result in heart failure.
If the brain does not get enough energy, this makes the brain start obsessing over food. It also makes a person unable to concentrate on anything else. If the nervous system doesn’t receive enough energy, it can lose the layer of fat around the neurons. This can result in numbness and tingling of hands and feet. Lack of nutrition also results in decreased blood cells including red and white blood cells. This causes anemia and increases the risk of infections.
Restricting food as well as purging food can result in electrolyte imbalances as the body is depleted of chemicals. Depleting the body of potassium can cause an irregular heartbeat, heart failure and even death. Electrolyte imbalances can cause muscle cramps and seizures. Not getting enough fluids can cause dehydration and kidney failure.
Purging by vomiting can result in erosion to the esophagus, swollen parotid glands. Restricting, binging, and purging can result in the pancreas becoming inflamed as well as intestinal obstructions and holes in the intestines. Binge eating can result in insulin resistance which increases the risk of diabetes.
If the body doesn’t get enough fat, it can’t make hormones. Hormones are needed for a healthy reproductive system, to keep body temperature regulated, and also for bone building. Without fat, sex hormones decrease which affects menstruation, bones can become brittle and break or fracture, and you can develop hypothermia. Your body will not be able to produce enough thyroid hormone which can result in hair loss, feeling cold, and constipation. Restricting food can actually increase your cholesterol.
A very real risk of eating disorders is increased risk of death. Eating disorders carry the 2nd highest mortality rate of any mental disorder behind opioid addiction. This is due to the actual eating disorder as well as the high rate of suicide in people who have an eating disorder.
A person with an eating disorder is six times more likely to die than the general population but young adults aged 15-24 are 10 times more likely to die. Causes of death include starvation, substance abuse and suicide. Over 20% of people with anorexia and 25-35% of people with bulimia will attempt suicide in their lifetime. Men are at increased risk of death due to late diagnosis.
In addition to death due to their eating disorder, this population is also at increased risk of death due to other causes including “natural causes” and cancer.
COMORBIDITIES WITH EATING DISORDERS
The most common comorbidity of eating disorders are other mental health disorders with over 94% of all individuals admitted with an eating disorder having co-existing mood disorders:
- 50-75 had depression
- 56% had anxiety
- 20% had obsessive compulsive disorder
- 22% had substance or alcohol abuse disorder
- 36% had engaged in self-harming behaviors
- 20% had ADHD
If a person has anorexia nervosa:
- Over 2/3 showed anxiety symptoms years before their diagnosis
- Are more likely to have perfectionist tendencies
- 20% had obsessive compulsive disorder
- 10% had borderline personality disorder
If a person has bulimia
- 11% had obsessive compulsive disorder
- 28% had borderline personality disorder
If a person has binge eating disorder
- 12% had obsessive compulsive disorder
- 25% had borderline personality disorder
If you suspect your child has an eating disorder, please have them evaluated as soon as possible. If you notice any of the physical, emotional, or behavioral signs, do not ignore this or assume your child will correct themselves. Have a conversation with your child. Ask questions, offer support. If you notice a worrisome behavior, talking about it WILL NOT MAKE IT WORSE! Early diagnosis and treatment improve outcomes.
Diagnosis involves interviewing and examining an individual. The individual must meet DSM-V (the Diagnostic & Statistical Manual of Mental Disorders, 5th edition) criteria. A patient will undergo a physical examination including evaluation of weight and height, blood pressure, and heart rate. The growth chart needs to be examined for weight changes and expected development. A physical exam will access the heart, skin, hair, and gastrointestinal system. A thorough history will be done including menstrual history.
Labs may be ordered to evaluate the individual’s health, checking blood cells, electrolytes, and thyroid function. Labs may also be done to rule out other causes of weight loss or weight gain. An EKG may also be ordered to check heart function.
Treatment is a combination of psychological and nutritional counseling, medical and psychiatric monitoring. The treatment team generally involves the primary care provider, a therapist, a dietician, a psychiatrist, and ancillary therapists such as yoga or art therapist. Some patients will require a case manager to help coordinate treatment.
Treatment must address the eating disorder, any coexisting condition, and any medical consequences of the eating disorder. Treatment generally occurs in this order:
- Correct any life threatening medical or psychiatric symptoms
- Interrupt the eating disorder behaviors
- Nutritional rehabilitation (establishing normalized eating)
- Challenging unhelpful or unhealthy eating disorder thoughts/behaviors
- Addressing medical or mental health issues
- Plan to prevent relapse
There are multiple levels of treatment:
Intensive outpatient or outpatient treatment is for patients who are medically and psychiatrically stable. They don’t need medical monitoring. Their symptoms are in control enough to function socially including the ability to attend school or work.
Partial hospitalization is for patients who are medically stable, but their psychological or mental status requires daily assessment. Their eating disorder impairs their ability to function, and they can’t attend work or school. They continue to engage in binging, purging, fasting, limiting food intake, or engaging in weight control behaviors.
Residential treatment is for patients who are medically stable but psychiatrically impaired. They may have not responded to partial hospitalization or outpatient treatment. They need full time monitoring.
Inpatient treatment is for patients who are medically unstable. Their vital signs may be unstable or depressed. Their lab findings may present immediate health risks. They may also have complications from coexisting medical conditions. They are also psychiatrically unstable and have worsening symptoms. They may have suicidal thoughts. These patients need 24-hour a day medical and psychiatric monitoring.
Many current nutritional plans, for patients who are outpatient or in partial hospitalization treatment plans, are focused on family-based treatment feeding. The goal of this plan is to establish weight restoration at home in the least restrictive environment.
In this plan, the parent takes over ALL meal planning and feeding. They decide on the meal and plate with meal with NO input from the child. A nutritionist or dietician helps guide the parents with meal planning.
Often with this plan, there is NO calorie counting. Instead, the child is given 3 meals a day and 2 snacks a day with assigned food groups (protein, grain/starch, and fat). A 10-inch plate is used and is divided into sections. The plate will be filled up with food groups depending on their individual need and requirements (this will be determined by a nutritionist).
The benefit of this type of approach is
- it can be used for all types of eating disorders and all ages
- It can be adjusted to each person’s individual needs
- it can be made to fit all types of foods and all cultures
- It helps teach normalcy around foods
- It increases volume as well as variety
- It increases flexibility and decreases the rigidity that can be found in exchange systems or calorie counting systems.
This meal plan has 3 phases. The first phase is restoring health. When restoring weight, a person needs more nutrition. It can be 2 to 3 times the amount of food they may need at baseline. The volume WILL be larger than their peers.
The second phase is supporting normalcy. During this phase, the person in treatment stops fighting the meal plan. They become more flexible and independent.
The third phase is where a person is out of medical danger. Their food intake has stabilized, and they are learning how to feed themselves and hunger signals.
Recovering can be a long road but full recovery is possible. Recovery is often not linear. Recovery has different phases including different levels of care. The recovery process may include relapse. It is not unusual for a person to return to old behaviors during the recovery process. Relapse can occur at any time or in reaction to a life stressor. Knowing triggers (exams, holidays, relationship changes), can help a person prepare ahead of time, watch out for warning signs, and get extra help during these times. Early detection, early treatment, a supportive family and friend group, and continued communication can help a person work through a relapse.
Holidays can be challenging during treatment due to the emphasis on food. During this time, the goal should be
- Keep holiday food neutral
- Keep holidays simple
- Stick to your regular meal and snack schedule
- Make sure to check in with your child
- Check in with their team regularly
- Increase therapy if needed.
SUPPORTING YOUR CHILD WITH AN EATING DISORDER
Having a child with an eating disorder can be challenging to the whole family.
- Be Patient with your child
- Remember---you are fighting the eating disorder NOT your child
- Be supportive
- Be empathetic
- Keep communication open
- Let your child know you care for them
- Let your child know you believe in them
- Provide comfort to your child
- Make time to spend with your child where you do not talk about the eating disorder. Do something FUN!
- Do not blame yourself
- Accept the eating disorder is no one’s fault
- Take time to keep learning about eating disorders
- Be willing to be part of the healing process
- Be prepared for the non-linear recovery process
- Advocate for your child
- Take care of yourself
- Don’t be afraid to get professional help for yourself and other family members
A recent study found that young people with eating disorders want their family and friends to know that
- Their eating disorder is not their choice
- The eating disorder fights them as well as you
- They cannot reason their way out of the disordered behaviors
- It is not easy to “just eat”
- They are scared of change
- They need help feeling safe without their food rules
- They sometimes need distractions and do not want to talk about food or their disorder
ED Matters (Spotify and Apple Podcasts)
Eating Disorder Recovery Podcast (Apple Podcasts)
The Recovery Warrior Show (Spotify and Apple Podcasts)
Brain over Binge (Spotify and Apple Podcasts)
Breaking Up with Binge Eating (Spotify and Apple Podcasts)
The Butterfly Podcast (Spotify and Apple Podcasts)
Eating Disorders: Navigating Recover
The Eating Disorder Therapist
National Eating Disorders Association
If you are concerned your child may have an eating disorder, please do not hesitate to reach out to their primary care provider. Early diagnosis and treatment improve outcome. Any warning signs should be taken seriously.
Children’s Health Care of Newburyport, Massachusetts and Haverhill, Massachusetts is a pediatric healthcare practice providing care for families across the North Shore, Merrimack Valley, southern New Hampshire, and the Seacoast regions. The Children’s Health Care team includes pediatricians and pediatric nurse practitioners who provide comprehensive pediatric health care for children, including newborns, toddlers, school aged children, adolescents, and young adults. Our child-centered and family-focused approach covers preventative and urgent care, immunizations, and specialist referrals. Our services include an on-site pediatric nutritionist, special needs care coordinator, and social workers. We also have walk-in appointments available at all of our locations for acute sick visits. Please visit chcmass.com where you will find information about our pediatric doctors, nurse practitioners, as well as our hours and services.
Disclaimer: this health information is for educational purposes only. You, the reader, assume full responsibility for how you choose to use it.