Eating disorders include extreme emotions, attitudes, and behaviors surrounding weight and food issues. Eating disorders are serious emotional and physical problems that can have life-threatening consequences for females and males. Eating Disorders Treatment in Wisconsin is available at CAPC, HorsesTreat

Causes

Eating disorders are complex conditions that arise from a combination of long-standing behavioral, biological, emotional, psychological, interpersonal, and social factors. Scientists and researchers are still learning about the underlying causes of these emotionally and physically damaging conditions. While there may be a difference of opinion among experts and within the literature regarding the causes of eating disorders, there are some generally accepted factors that contribute to their development.

Eating disorders may begin with preoccupations with food and weight, but they are most often about much more than food. People with eating disorders often use food and the control of food in an attempt to compensate for feelings and emotions that may otherwise seem over-whelming. For some, dieting, bingeing, and purging may begin as a way to cope with painful emotions and to feel in control of one’s life, but ultimately, these behaviors will damage a person’s physical and emotional health, self-esteem, and sense of competence and control.

Psychological Factors that can Contribute to Eating Disorders:

  • Low self-esteem
  • Feelings of inadequacy or lack of control in life
  • Depression, anxiety, anger, or loneliness

Interpersonal Factors that can Contribute to Eating Disorders:

  • Troubled personal relationships
  • Difficulty expressing emotions and feelings
  • History of being teased or ridiculed based on size or weight
  • History of physical or sexual abuse

Social Factors that can Contribute to Eating Disorders:

  • Cultural pressures that glorify “thinness” and place value on obtaining the “perfect body”
  • Narrow definitions of beauty that include only women and men of specific body weights and shapes
  • Cultural norms that value people on the basis of physical appearance and not inner qualities and strengths

Biological Factors that can Contribute to Eating Disorders:

  • Scientists are still researching possible biochemical or biological causes of eating disorders. In some individuals with eating disorders, certain chemicals in the brain that control hunger, appetite, and digestion have been found to be unbalanced. The exact meaning and implications of these imbalances remains under investigation.
  • Eating disorders often run in families. Current research is indicates that there are significant genetic contributions to eating disorders.

Eating disorders can originate from a complex interplay of multiple factors.   Once an eating disorder is set in motion, they can create a self-perpetuating cycle of physical and emotional destruction. All eating disorders require professional help.

Prevalence

In the United States, as many as 10 million females and 1 million males are fighting a life and death battle with an eating disorder such as anorexia or bulimia.

Millions more are struggling with binge eating disorder

Many more individuals struggle with body dissatisfaction and sub-clinical disordered eating attitudes and behaviors.

Data from the NIMH-funded National Comorbidity Survey Replication (NCS-R) was published in  February 1, 2007, issue of

Biological Psychiatry:

  • Nearly 1 percent of women and 0.3 percent of men reported having anorexia at some time in their lives
  • 1.5 percent of women and 0.5 percent of men reported having bulimia.
  • 3.5 percent of women and 2 percent of men reported having binge-eating disorder at some point in their lives.
  • People with eating disorders, regardless of the type, often have coexisting mood, anxiety, impulse-control, or substance use disorders.

Because of the secretiveness and shame associated with eating disorders, many cases are probably not reported.

80% of American women are dissatisfied with their appearance (Smolak, 1996).

Mortality

For females between 15-24 years old who suffer from anorexia nervosa, the mortality rate associated with the illness is twelve times higher than the death rate of ALL other causes of death (Sullivan, 1995).

Without treatment—and most patients are not being treated– one-fifth of patients will die prematurely.

Even with treatment, after 8 to 25 years, the premature mortality rates are 4% for AN patients, 3.9% for bulimia nervosa (BN) patients and 5.2% for those with eating disorders not otherwise specified, or EDNOS.

Anorexia nervosa has the highest premature fatality rate of any mental illness (Sullivan, 1995).

In a review of the literature, Hoek and van Hoeken (2003):

  • 40% of newly identified cases of anorexia are in girls 15-19 years old.
  • Significant increase in incidence of anorexia from 1935 to 1989 especially among young women 15-24.
  • A rise in incidence of anorexia in young women 15-19 in each decade since 1930.
  • The incidence of bulimia in 10-39 year old women TRIPLED between 1988 and 1993.
  • Only one-third of people with anorexia in the community receive mental health care.
  • Only 6% of people with bulimia receive mental health care.
  • The majority of people with severe eating disorders do not receive adequate care.

Hoek, H.W., & van Hoeken, D. (2003). Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders, 383-396.

Sullivan, P. (1995). American Journal of Psychiatry, 152 (7), 1073-1074.

Smolak, L. (1996). National Eating Disorders Association/Next Door Neighbors Puppet Guide Book.

Hudson JI, Hiripi E, Pope HG, Kessler RC. The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication.

Biological Psychiatry

2007; 61:348-358.

Onset and Duration

The onset of an eating disorder most commonly occurs in adolescence but may occur as young as 7 or as old as 70.

Evidence shows that there are two peak periods for the onset of an eating disorder, occurring at puberty and late adolescence.

Regardless of the age of a person at the time their eating disorder begins, there can often be a considerable period of time between onset and the time of first treatment. This delay is likely to negatively influence the duration of the eating disorder and the outcomes of treatment.

Physical Signs and Symptoms

Individuals with Eating Disorders may present in a variety of ways.

An Eating disorder May occur without obvious physical signs or symptoms

In addition to the cognitive and behavioral signs that characterize Eating Disorders, the following are possible physical signs and symptoms that can occur in patients with an Eating Disorder as a consequence of nutritional deficiencies, binge-eating, and inappropriate compensatory behaviors, such as purging.

Gastrointestinal

• Epigastric discomfort
• Early satiety, delayed gastric emptying

• Gastroesophageal reflux
• Hematemesis
• Hemorrhoids and rectal prolapse • Constipation

Endocrine

  • Amenorrhea or irregular menses
  • Loss of libido
  • Low bone mineral density and increased risk for bone fractures and osteoporosis
  • Infertility

Neuropsychiatric

  • Seizures
  • Memory loss/Poor concentration
  • Insomnia
  • Depression/Anxiety/Obsessive
  • Behavior
  • Self-harm
  • Suicidal ideation/suicide attempt

Dermatologic

  • Lanugo hair
  • Hair loss
  • Yellowish discoloration of skin
  • Callus or scars on the dorsum of the hand (Russell’s sign)
  • Poor healing

Primary Care Tools

(Click here for PDF)

This mnemonic written by Margo Maine, PhD may help providers think about screening for eating disorders, and considering the ways their office, and their interactions might trigger persons at risk for eating disorders.

Used Courtesy of National Eating Disorders Association

Outcomes

Without treatment—and most patients are not being treated–one-fifth of patients will die prematurely.

Even with treatment, after 8 to 25 years, the premature mortality rates are 4% for AN patients, 3.9% for bulimia nervosa (BN) patients and 5.2% for those with eating disorders not otherwise specified, or EDNOS.

Anorexia nervosa has the highest premature fatality rate of any mental illness (Sullivan, 1995).

Common Misconceptions

Eating disorders are frequently misunderstood and underestimated in contemporary society.

Eating disorders are serious mental illnesses that can have devastating impacts upon both the person experiencing the eating disorder and their family or circle of support.

Some common misconceptions about eating disorders include:

  • Eating disorders are about vanity
  • Eating disorders are a choice, not an illness
  • Eating disorders are just a diet gone wrong
  • Eating disorders are a cry for attention or a person ‘going through a phase’
  • Eating disorders only affect adolescent girls
  • Families, particularly mothers, are to blame for eating disorders
  • Eating disorders only affect white, middle class females

These misconceptions occur amongst all age groups. Amongst 12–17 year olds:

  • 51.3% of 12-17 year olds strongly agreed or agreed that a person with an eating disorder should “snap out of it, there are more important things in life to worry about”

These types of misconceptions are not limited to the general public. A person with an eating disorder may receive similar reactions and responses when presenting for help from a general practitioner or other health professional. This may lead to failure to detect and treat the eating disorder, as well as causing distress and shame to the person who is seeking help.

Research shows that adolescents are confused about eating disorders. Young people recognize that eating disorders are potentially harmful; however they also accept body ‘obsession’ and dieting as normal parts of growing up.

Research indicates that there is a generally low level of mental health literacy in the community.

These general beliefs about mental health affect community responses to eating disorders.

In order to develop an appropriate level of understanding of eating disorders extensive community education is required.

This would involve educating the public about eating disorders, the identification of symptoms, supporting prevention and early help-seeking.

Treatment

Patients with EDs may not recognize that they are ill and/or they may be ambivalent about accepting treatment.

This is a symptom of their illness. In addition, patients may minimize, rationalize, or hide ED symptoms and/or behaviors. Their persuasive rationality and competence in other areas of life can disguise the severity of their illness. Outside support and assistance with decision-making will likely be necessary regardless of age.

EATING DISORDERS TREATMENT PRINCIPLES:

Adequate nutrition, reducing excessive exercise, and stopping purging behaviors are the foundations of initial treatment.

Recovery of normal weight and nutritional status can assist in the distorted perceptions and thinking.

Specific forms of psychotherapy and medication are effective for many eating disorders.

For more chronic cases, specific treatments have not yet been identified. Treatment plans often are tailored to individual needs and may include one or more of the following:

  • Individual, group, and/or family psychotherapy
  • Medical care and monitoring
  • Nutritional counseling
  • Medications.

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

  • Early intervention can help minimize the potentially life long complications of this disorder, and can reduce the severity of this life long battle
  • Without treatment—and most patients are not being treated– one-fifth of patients will die prematurely.
  • Even with treatment, after 8 to 25 years, the premature mortality rates are 4% for AN patients, 3.9% for bulimia nervosa (BN) patients and 5.2% for those with eating disorders not otherwise specified, or EDNOS.
  • Anorexia nervosa has the highest premature fatality rate of any mental illness (Sullivan, 1995).

Parents/guardians are vital to the recognition and treatment of children and adolescents with EDs.

Trust their concerns. Even a single consultation about a child’s eating behavior or weight/shape concerns is a strong predictor of the presence or potential development of an ED.

Current evidence suggests that treatment of EDs is most successful when the family is involved in treatment.

Families should understand that they did not cause the illness

Families also need to understand that their child/family member did not choose to have it an eating disorder, and they cannot just choose to STOP having an eating disorder

This recognition facilitates acceptance of the diagnosis, treatment, referral, interventions, and minimizes undue stigma associated with having the illness.

Monitor physical health including vital signs and laboratory tests.

Low weight patients or those patients who have significant weight loss may present with bradycardia (heart rate < 50 beats per minute). This should not be automatically attributed to an athlete’s heart, even if the patient is an athlete.

Always assess for psychiatric risk, including suicidal and self-harm thoughts, plans and/or intent.

Up to 1/3 of deaths related to EDs are due to suicide.

  • Early intervention can help minimize the potentially life long complications of this disorder, and can reduce the severity of this life long battle

  • Without treatment—and most patients are not being treated– one-fifth of patients will die prematurely.
  • Even with treatment, after 8 to 25 years, the premature mortality rates are 4% for AN patients, 3.9% for bulimia nervosa (BN) patients and 5.2% for those with eating disorders not otherwise specified, or EDNOS.
  • Anorexia nervosa has the highest premature fatality rate of any mental illness (Sullivan, 1995).

Treatment Goals

Key Points

Evidence-based treatment delivered by health professionals with expertise in the care of patients with ED is mandatory.

Optimal care includes a multidisciplinary team approach by ED specialists including medical, psychological, nutritional, and psychopharmacologic services.

Families & spouses should be included whenever possible.

Treatment Goals

Nutritional rehabilitation, weight restoration & stabilization, complete physiologic restoration, management of refeeding complications, and interruption of purging/compensatory behaviors should be the immediate goals of treatment for all patients with EDs.

Achievement of an individual’s appropriate healthy weight will improve the physical, psychological, social, and emotional functioning of that patient.

Failure to fully restore weight correlates with worse outcomes, and maintenance of the weight restored strongly correlates with a good outcome.

If psychological and other therapeutic goals are sometimes addressed from the beginning of treatment, in parallel with early nutritional and physiologic goals. If this was not possible, they should be addressed shortly after early nutritional and therapeutic goals are reached.

A person with an ED is NOT recovered once physical health and weight are restored. Distorted body image and/or ED thoughts may persist despite weight restoration and will likely require longer-term therapy.

Mindful Eating

When Are We Really Hungry for Food?

The first step in mindful eating (also called intuitive eating) is to wait to feel physically hungry before eating.

While it sounds simple to eat when a person feels physically hungry, this can often be a difficult thing to learn to do.

Many of us have engaged in dieting behaviors or chaotic eating patterns such that we have learned to ignore physical hunger cues, or we eat when we are not physically hungry at all.

When we have ignored our physical hunger cues we can become confused about when we are truly hungry for food.

Following this one principle of mindful eating, can very likely improve the way most people eat.

Mastering Mindful Eating – Intuitive Eating

The most logical place to start getting back in touch with physical hunger cues is to establish some structure for the timing and balance of meals:

  • Ideally, start by eating within the first few hours of waking, then every 3 to 5 hours from that point on.
  • Ensure that most meals/snacks contain grains/starchy vegetables, protein foods and fruits/vegetables.

Next, experiment with separating “mouth hunger” (emotional and spiritual hungers) from “stomach hunger” (physical hunger).

  • If you think you may be hungry but aren’t sure, wait a while. It will become clear.
  • Physical hunger becomes more intense with time.
  • Emotional or spiritual desires that you experience as hunger generally do not intensify over time.

Working with a hunger and satiety scale can help increase your awareness of physical hunger and satisfaction. Rating your level of hunger or satisfaction with a number helps you to stop and consider what is actually going on in your body.

Here’s one example of a hunger scale used in mindful eating or intuitive eating: (Though if you click here, you can have a visual image of the hunger satiety scale)

  1. ravenous, may have a headache or feel nauseous
  2. overly hungry, may be preoccupied with hunger and pangs may be VERY uncomfortable
  3. urge to eat is strong, stomach growls, can sense pangs/gnawing sensation; may even notice a slight pressure in the back of the throat
  4. a little hungry, feeling empty or hollow in the stomach, perhaps noticing your thoughts drifting to food
  5. neutral, no longer experiencing pangs, but not feeling full or satisfied; at this stage you would not sense food in the stomach
  6. able to feel the weight of food in the stomach, and notice the feeling of the stomach stretching slightly as a result of eating
  7. hunger is gone; rate of eating slows; experiencing a sense of well being from having had enough to eat
  8. not uncomfortable, but definitely full; taste, texture, appearance of the food may not stand out very much at this point. You may notice yourself eating without paying attention to the food
  9. uncomfortable, noticing a significant stretch to the stomach, perhaps noticing difficulty breathing due to physical stretch, would be uncomfortable with light activity (walking) after eating
  10. painfully full, “couldn’t take another bite,” activity is out of the question.

Mindfulness and eating, over eating, binge eating

If you consistently eat without listening for hunger and satisfaction cues, you may very well end up overeating, given the many opportunities to eat most of us face daily.

Take a moment to reflect on your typical hunger & satiety range, without judging.

  • What number are you at when you sit down for most meals and snacks?
  • How do you rate at the end of most meals and snacks?
  • Ideally, we begin to eat when at a 3 or a 4, when it’s clear our bodies are requesting food.
  • Most of us feel most comfortable when we stop around 7 or 8.

Consider when your range of hunger and satisfaction is“off.”

  • Do you often get overly hungry (1’s and 2’s)? When? Why?
  • Do you eat until stuffed and uncomfortable at times? When? Why?
  • Do you eat when not yet hungry? What triggers this?
  • Practice eating within a range that feels right to you. What changes when we do?

Internal cues for starting and stopping eating are something we’re born with but often lose touch with. By tuning into our bodies’ physical hunger and satisfaction cues, we can begin to return to ‘normal’ eating, which is really what mindful eating is all about. Our internal cues intuitively support healthy weight management.

Advocacy

Despite the prevalence of eating disorders they continue to receive inadequate research funding.

In 2005, the National Institutes of Health estimates funding the following disorders accordingly:

Despite the prevalence of eating disorders they continue to receive inadequate research funding.

In 2005, the National Institutes of Health estimates funding the following disorders accordingly:

  • Eating disorders: 10 million affected ($7,000,000* spent on research by NIMH)
  • Alzheimer’s disease: 4.5 million affected ($412,000,000 spent on research by NIMH)
  • Schizophrenia: 2 million affected ($249,000,000 spent on research by NIMH)

* The reported research funds are for anorexia nervosa only. No estimated funding is reported for bulimia nervosa or eating disorders not otherwise specified.

NIMH Research dollars spent on anorexia averaged $.70 per affected individual, compared to over $159.00 per affected individual for schizophrenia.

American Public Opinion on Eating Disorders

In March 2005, NEDA contracted with Global Market Insite, Inc. (GMI), a leader in global market research, to conduct a 1,500 nationwide sample of adults in the U.S. Their findings concluded from those surveyed that:

  • Three out of four Americans believe eating disorders should be covered by insurance companies just like any other illness.
  • Americans believe that government should require insurance companies to cover the treatment of eating disorders.
  • Four out of ten Americans either suffered or have known someone who has suffered from an eating disorder.