Healing Center

What Are Eating Disorders?
Key Symptoms
What Causes Eating Disorders?
Conventional Treatments
Medications
Tests and Procedures
Treatment and Prevention
How Supplements Can Help
Self-Care Remedies
Alternative Therapies
When to Call a Doctor
References
Evidence Based Rating Scale

What Are Eating Disorders?                                

The collective group of conditions known as eating disorders is actually not about food. People with eating disorders focus on food restriction, food elimination, compulsive exercise, and weight control as physical coping mechanisms for deep painful psychological problems. Eating disorders are often associated with psychiatric disorders such as anxiety disorders, obsessive-compulsive disorder, personality disorders, and substance abuse. Most individuals with eating disorders are in denial and rarely seek medical or family intervention. Adolescent females have the highest occurrence of eating disorders but increasingly more males have sought treatment for eating disorders since 1980.

There are two specific categories of eating disorders defined by the Diagnostic and Statistical Manual (DSM-IV) for Mental Disorders of the American Psychiatric Association: Anorexia Nervosa (AN) and Bulimia Nervosa (BN). An individual who cannot be classified as anorexic or bulimic is diagnosed as Eating Disorder Not Otherwise Specified (EDNOS).

Anorexia nervosa, or anorexia, has been defined by the Columbia Center for Eating Disorders of Columbia University Medical Center as a "serious mental illness" categorized by specific criteria.(1) There are two subtypes of anorexia—restrictive eating, and binge eating/purging. Individuals who practice restrictive eating lose weight mainly by limiting the amount of food they eat while those in the binge/purge subtype may use vomiting, laxatives, or diuretics to rid themselves of the food they've ingested. While this latter behavior is typical of bulimia, patients will still be labeled anorexic if the other criteria are met. In addition to food control, both types of anorexics may use compulsive exercise to reduce their weight. 

Anorexia is most prevalent in teenage girls, affecting up to 0.7% of this age group. Most people with anorexia recover partially or completely; however, about 20% of anorexics go on to develop a chronic eating disorder and approximately 5% die of the disorder: indeed, anorexia has the highest mortality rate of any psychiatric condition. 

Bulimia nervosa, or bulimia, is characterized by frequent fluctuations in weight caused by periods of uncontrollable binge eating followed by purging with laxatives, diet pills, diuretics, or vomiting. In bulimia, individuals usually eat beyond the point of fullness before purging.

A third category, binge eating disorder, is sometimes identified as a subcategory of EDNOS but is increasingly being recognized as a separate disorder with different characteristics from anorexia and bulimia.  This disorder is often triggered by chronic dieting and involves periods of secretly overeating for comfort. With binge eating disorder, individuals experience periods of uncontrolled, impulsive or continuous eating in a short period of time or do sporadic fasts or repetitive diets. 

Eating Disorder Not Otherwise Specified (EDNOS) has become a broad category for any condition that does not clearly fall under the anorexia or bulimia category. For instance, if an individual exhibits all but one criterion for anorexia or bulimia, they are automatically diagnosed as EDNOS. This has resulted in EDNOS being the most-used category but the least understood due to a scarcity of research in this category.

Eating disorders that fall under EDNOS include nocturnal eating disorders such as sleep-related eating disorder (SRED) and night-eating syndrome (NES).  In SRED, the individual awakens in the middle of the night to consume large amounts of food; they may be conscious or have no memory of the episode in the morning. Night-eating syndrome is a circadian delay that causes an abnormally increased evening appetite (hyperphagia), nocturnal eating, and morning anorexia. There is also non-fat-phobia anorexia (NFP-AN) which is anorexia where a person loses weight because of an intense fear of gaining weight.

People with eating disorders experience a psychological reinforcement when they engage in the behavior. This means that there is a mental "payoff" for them to continue these harmful habits. For anorexia, the reinforcement occurs as persons develop a sense of security from realizing they can skillfully and effectively control dieting, exercising, and losing weight. They may feel they have no control over any other aspects of their lives except weight.  In bulimia, the psychological reinforcement comes from realizing that binging and purging can alleviate anxiety in the same manner as drugs or alcohol; they can become addicted to the "good feelings" they get after ridding their bodies of food. (1-8)

Key Symptoms

The DSM-IV lists four specific criteria for a diagnosis of anorexia nervosa:

• Refusal to maintain weight within normal range for height and age (more than 15% below ideal body weight)
  
  
• Fear of weight gain
  
  
• Severe body image disturbance in which body image is the predominant measure of self-worth with denial of the seriousness of the illness
  
  
• In females, absence of the menstrual cycle after it has started at puberty, or amenorrhea (greater than three cycles)

For bulimia, the criteria are:

• Episodes of binge eating with a sense of loss of control
  
  
• Binge eating is followed by compensatory behavior of the purging type (self-induced vomiting, laxative abuse, diuretic abuse) or nonpurging type (excessive exercise, fasting, or strict diets)
  
  
• Binges and the resulting compensatory behavior must occur a minimum of two times per week for three months
  
  
• Dissatisfaction with body shape and weight (3)

DSM-IV currently diagnoses all other eating disorders as Eating Disorder Not Otherwise Specified (EDNOS).

In addition to the above symptoms, there are numerous physical complications that arise from persistent purging and starving such as:

Osteopenia and osteoporosis. Bone loss is one of the most severe complications of anorexia, affecting approximately half of anorexic patients. Osteopenia is the precursor to osteoporosis where bone mineral density (BMD) is low enough to significantly increase the risk of fracture. The conditions are most often seen in women after menopause. But women accrue 40-60% of their bone mass in adolescence. Bone loss or failure to make bone during adolescence may be severe enough to increase fracture risk at the time, but can also mean an increased risk of fractures later in life. Effects are long-lasting since bone loss is difficult to reverse. Bone loss is also linked to growth delay, or short stature, more often seen in adolescent boys than girls. The time of onset of anorexia and the duration of anorexia most likely determine stature. Low bone density is less likely with normal weight bulimia unless there is a history of low weight or amenorrhea. (9-12)

Amenorrhea is the absence of a menstrual cycle, either because it is interrupted or the cycle does not start. Studies show amenorrhea inhibits the ability to attain peak bone mass. In anorexia, amenorrhea and bone loss are caused by multiple factors including nutritional deficiencies, low levels of estrogen, and low levels of the hormones leptin and ghrelin—hormones that affect energy balance and meal initiation. (10, 13-15)

Female infertility. Leptin plays a role in initiating puberty. Recent animal studies show a link between leptin and reproductive dysfunction and suggest that, in some conditions, reproductive function can be restored with leptin-replacement therapy. (16) Eating disorders may continue to be a problem or recur during pregnancy when the expanding abdominal girth again raises issues with body image. For women with a history of an eating disorder, it is particularly important to pay attention to nutrition to support normal fetal growth.

Endocrinologic changes. The endocrine system involves the hypothalamus and pituitary gland in the brain, the thyroid and adrenal glands, the gonads, and the bones, all of which interact in numerous complex feedback loops that are affected by changes in food intake. Thus, multiple systems are affected by eating disorders. The thyroid gland may have decreased hormone levels in a condition known as "sick euthyroid syndrome" due to anorexia although the thyroid itself is not the problem. There may be an increase in growth hormone (secreted by the gonads), and cortisol levels (secreted by the adrenal glands) are generally higher in anorexic patients. (69) Elevated cortisol levels are responsible for the "fight or flight" response: over time they can cause muscle breakdown and suppressed immune function leading to increased susceptibility to illness or injury. One theory suggests that stress leading to elevated cortisol levels plays a role in binge eating disorder by promoting increased food intake. (9, 17-18) Dehydroepiandrosterone, or DHEA, is the most abundant steroid in humans and is secreted by the adrenal glands. Low levels of serum DHEA are found in eating disorder patients and may also be linked to bone loss. (19-20) Nocturnal melatonin levels have been found to be low in the subset of anorexia patients who have concurrent major depression. (69) And melatonin may also be related to the perception of pain, or, in this case, decreased pain perception allowing normal hunger signals to go unnoticed. (70)

Cardiovascular impairment. Most of the mortality associated with eating disorders stems from cardiovascular complications such as hypotension (abnormally low blood pressure) and arrhythmia (irregular heartbeat). In one case report, a 56-year-old woman with a 25-year history of anorexia experienced increasing shortness of breath upon exertion, ankle swelling, and orthopnea—a condition where a person can only breathe comfortably while sitting up straight or standing erect. She was diagnosed with heart failure caused by severe prolonged protein-calorie malnutrition. In addition to general malnutrition, specific deficiencies of thiamine, phosphorus, magnesium, and selenium have been reported to cause heart failure in patients with anorexia. Toxicity from ipecac used to induce vomiting has also been reported. Additional cardiovascular risk accompanies the incremental caloric feeding necessary for treating malnutrition. Heart failure, arrhythmia, or sudden cardiac death can occur with "refeeding syndrome" unless carefully monitored.  (21-22)

Electrolyte impairments. Anorexia is often associated with low electrolyte levels in the blood such as potassium (hypokalemia), phosphorus (hypophosphatemia), and sodium (hyponatremia). With decreased electrolyte levels in the blood, swelling occurs as too much fluid accumulates in body tissues (edema) and also increases the self-perception of being fat in a vicious cycle. Hypokalemia and chronic dehydration may lead to the development of kidney failure as well as conduction abnormalities and arrhythmia in the heart. (23) Chronic pancreatitis has also been reported. (73)

Dental impairments associated with bulimia include erosion of dental enamel, enlarged salivary glands, and xerostomia, or dry mouth, due to the recurring presence of acidic gastric juices in the mouth. (24)

What Causes Eating Disorders?

It is believed that a combination of factors is involved in the development of an eating disorder. Psychological factors such as low self-esteem, feelings of lack of control or inadequacy, loneliness, and anger may cause an individual to use dieting and weight control to avoid dealing with these problems.

Any type of family stress can contribute to eating disorders. Adolescents may develop eating disorders in response to high expectations from their parents to succeed academically and/or athletically. In addition, studies show pressure from society to conform to standards of beauty associated with extreme thinness seen in magazines and media have been associated with binge eating disorders.

Studies of genetic factors have found that young women with a first degree relative with an eating disorder, affective disorder, or alcoholism have an increased risk for developing eating disorders. There may also be a genetic predisposition for susceptibility for anorexia and bulimia.

The central nervous system (CNS) may play a role in the development of eating disorders. Studies have shown the neurotransmitters dopamine, serotonin, and norepinephrine are all dysfunctional in patients with eating disorders. Reduced levels of norepinephrine may account for the hypotension (low blood pressure) that is seen with starvation. Increased serotonin levels may account for loss of appetite. Animal studies show stimulation of serotonin receptors in mice reduced their eating drive and suggest a possible reason for the addictive aspect of anorexia. Magnet Resonance Imaging (MRI) studies have shown brain changes in anorexia patients but the significance of these findings is unclear.

Athletic activities such as running, ballet, and gymnastics where leanness is required for success are associated with a higher incidence of eating disorders. Young women with restrictive eating disorders, amenorrhea, and osteoporosis have been referred to as having the "female triad." (25-37)

Risk factors for eating disorders include but are not limited to:

• Dietary restraint
• Incidents of self-harm
• Feelings of shame and shame-based responses
• High body mass index (BMI)
• Increased dissatisfaction with body weight and shape
• Childhood anxiety disorders
• Being a type I diabetic—type I diabetics have higher rates of disturbed eating behaviors than their non-diabetic peers (38-42)

Conventional Treatments

The most effective treatment for eating disorders is a multidisciplinary approach involving a thorough medical assessment, nutritional guidance, and individual, group, and family psychotherapy. Although most people with eating disorders deny they have a problem or attempt to hide it, the sooner they seek help, the sooner they can benefit from treatment.

Treatment strategy is determined by the nature and severity of the eating disorder diagnosis. Guidelines have been established for hospitalization, day programs, intensive outpatient therapy and group therapy incorporating a multidisciplinary team of primary care physicians, psychiatrists, psychologists, social workers, and nutritionists.

For anorexia, the key strategy is medical management, behavioral therapy, and family therapy. Family therapy has been shown to be the most effective treatment for adolescents with anorexia. With bulimia, key strategies include cognitive behavioral therapy (the first choice therapy for bulimia), problem-solving, cost benefit analyses, and pharmacotherapy involving selective serotonin reuptake inhibitors (SSRI's) antidepressants such as fluoxetine (Prozac).

Binge eating disorder is still classified under the category EDNOS. It is different from bulimia in that binge eaters don't purge, exercise, or engage in dieting. The key strategies for the treatment of binge eating disorder are cognitive behavioral therapy and antidepressants. (4, 31, 43)

Medications 

Conventional medications for eating disorders include SSRI antidepressants such as fluoxetine (Prozac) primarily for bulimia and binge eating disorder. There is growing evidence that antiepileptic drugs such as topiramate (Topamax), zonisamide (Zonegran), and phenytoin (Dilantin) may be effective in treating binge eating disorder and bulimia, but topiramate and zonisamide have adverse effects limiting their use. Carbamazepine (Tegretol) and valproate (Depacon) may be effective in treating bulimia or anorexia in patients with a psychiatric or neurological disorder; otherwise, both are associated with weight gain. Other drugs include mood stabilizers (lithium), anxiolytics (Xanax), and antipsychotic (Haldol) drugs. (42-44)

Test Procedures

The first part of the testing procedure is a visit to a physician for a physical examination. The physician will begin with vital sign measurements including heart rate, blood pressure, and body temperature. They will examine the skin for dryness, bruising, and fine hair growth on the arms and legs. Other physical tests include a cardiac examination, an EKG for arrhythmia, and abdominal and neurological examinations to determine if other conditions are causing weight loss and vomiting. In addition, the physician will check the teeth for signs of enamel erosion and look for lesions on the fingertips indicating they're used to induce vomiting.

Next, blood and urine samples are taken and a complete blood count (CBC) is done including a pregnancy test for females with amenorrhea. The blood work will also help the physician to determine if hospitalization is needed due to extreme dehydration and starvation.

The physician may ask a series of questions designed to determine the emotional state. Questions such as those on the SCOFF questionnaire help the physician determine if there is an eating disorder and may include:

S: "Do you feel sick because you feel full?"

C: "Do you lose control over how much you eat?"

O: "Have you lost more than 13 pounds recently?"

F: "Do you believe that you are fat when others say that you are thin?"

F: "Does food and thoughts of food dominate your life?"

Beginning in 1980, the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-IV) for Mental Disorders officially recognized two specific categories for the diagnosis of eating disorders: Anorexia Nervosa (AN) and Bulimia Nervosa (BN). The term Eating Disorder Not Otherwise Specified (EDNOS) was adopted and added in the 1994 DSM-IV to diagnose eating disorders that did not meet the criteria for anorexia or bulimia. For a diagnosis of anorexia or bulimia, the patient must meet all the criteria; if they miss just one, they are automatically diagnosed with EDNOS. Not surprisingly, EDNOS is now the most commonly diagnosed category—accounting for 50% to 70% of all eating disorder diagnoses—but the least understood category. Few studies include EDNOS patients; therefore, it is difficult to determine the expected course, outcome, and treatment of this category. As a result, the American Psychiatric Association is reviewing Broad Categories for the Diagnosis of Eating Disorders (BCD-ED) as a replacement for EDNOS.

Treatment and Prevention

Effective treatment of eating disorders is dependent upon the determination of anorexia, bulimia, or EDNOS. All categories require a multidisciplinary approach and begin by first addressing any physical conditions that may require immediate attention such as dehydration, arrhythmia, and vomiting. Members of the team are cognizant of their roles and how they relate to the other disciplines on the team.

Restoring weight is essential for the treatment of eating disorders. Patients are assigned a registered dietitian (RD) to provide nutritional counseling, medical monitoring, and determine signs of eating disorders. RD's determine the best approach and timeline for effectively reintroducing food to the patient. In addition, nutritional rehabilitation may include behavioral interventions with a combination of reinforcements where exercise, bed rest, and privileges are linked to attaining target weight and desired behaviors.

Cognitive therapy for anorexia makes two core assumptions. The first is that food avoidance is considered a food phobia and the second is that anorexia has a positive function in that it provides an escape from painful psychological problems distressing life events. With cognitive restructuring, the patient identifies negative thoughts, lists the evidence for and against these thoughts, and then forms a reasonable conclusion that is used to guide their behavior instead of medicating with the eating disorder. Another aspect of cognitive behavior is problem-solving, where the patient identifies a problem and forms various reasonable solutions to the problem that can be implemented. Patients are also required to write down the details of their eating such as times, food eaten, moods, and the environment.

For bulimia, behavioral therapy involves restricting exposure to purge cues and developing alternative behaviors with response prevention techniques to stop the use of vomiting. Nutritional rehabilitation involves establishing patterns of regular meals and increasing caloric intake to correct any nutritional deficiencies. Treatment for binge eating disorder is similar to that for bulimia. (15, 25)

How Supplements Can Help

Suboptimal vitamin status is common in eating disorder patients and has broad ramifications for multiple organ systems. (86)  Additionally, anti-oxidant levels are low, likely due to excessive depletion from the combination of emotional and physical stressors associated with eating disorders as well as from malnutrition. (87) And Essential Fatty Acids (EFAs) are likely to have been avoided in the limited food regimens of those with eating disorders. (88) Animal studies using protein supplements alone to treat eating disorders have been found to be ineffective. (46) Nutritional supplements can greatly accelerate return to normal body function as well as being helpful for specific complications of eating disorders.

For Osteoporosis, most of the evidence for supplementation comes from studies on post-menopausal osteoporosis. Calcium and magnesium are essential for preserving bone mass and strength. Calcium works best when combined with vitamin D, which is necessary for calcium absorption. This combination also helps prevent osteoporosis and decreases the risk of fractures. (47-58) Boron helps with calcium and magnesium absorption and controls the urinary loss of these minerals. (59) Vitamin C may be beneficial in maintaining greater bone density and it seems to enhance the production of the protein collagen, which is where the calcium is stored. (60) Zinc and manganese help with mineral absorption and encourage bone health. These supplements have been effective in treating bone loss in post-menopausal women and may be of benefit in treating bone loss from eating disorders. (Note: if zinc is used for more than a month it should be taken in combination with copper.) (61) Adequate levels of vitamin K are necessary for proper bone formation. A daily dose of 45mg vitamin K has been shown to reduce bone mineral density loss and the risk of fractures. (62-64) Numerous clinical trials have shown that the soy extract ipriflavone enhances the body's ability to absorb calcium, thereby preventing loss of bone mineral density in post-menopausal women with osteoporosis. Some evidence indicates ipriflavone taken with calcium may even increase bone mineral density. (65-68)

The etiology of bone loss in eating disorders may be related to elevated levels of stress hormones in addition to the estrogen deficiency associated with amenorrhea. Small studies using supplementation with 50-200mg daily of Dehydroepiandrosterone (DHEA) have demonstrated improved bone density, decreases in markers of bone turnover and improvements in mood, as well. (89)