Eating Disorders: Risk Factors, Diagnosis, Treatment, and Outcomes

By Loren A. Olson, MD

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Eating disorders are among the most dangerous and difficult to treat of all mental health disorders. Eating disorders do not discriminate. They can be found in both genders, all age groups, and across a wide variety of races and ethnic backgrounds. Eating disorders adversely impact the health and well-being of those affected. And, sometimes, eating disorders can become quite severe and, without aggressive medical treatment, can lead to death.[1]

This article will explore the key features of these often misunderstood disorders.

Our unhealthy relationship with food

Were you ever told you must clean up your plate? Or eat your Brussel sprouts before you could have dessert? If so, you aren’t alone. Many of us grew up being harangued with some variation of these types of “eat your food or else” threats. However, they are just one of many contributing factors to American’s unhealthy relationship with food. Among others are:

  • Our belief that anything enjoyable is inherently wrong
  • Thinking that things that are good for us are not enjoyable
  • Eating and dieting are national obsessions
  • Obsession with thin beauty is reinforced by the media
  • Dietary recommendations are conflicting, contradictory, and constantly changing
  • Physicians and other health professionals may not recognize there is a problem until it is quite advanced

The dichotomy between good food and bad food generates fear, anxiety, and guilt. We feel guilty about eating enjoyable foods, yet we use them to lift our moods, reward behavior, and celebrate milestones.

This mentality leads to problems with eating disorders.

Different manifestations of unhealthy relationships with food

There are different manifestations of disordered eating, including:

  • Some individuals gorge themselves into obesity
  • Others eschew food altogether.
  • Yet others gorge on food and then purge.
  • And some rigidly obsess about what they eat.

Many of us may do these things to a lesser degree or intermittently. But in some individuals, these patterns take control of their lives. At this point, we say that they have developed a serious eating disorder.

Types of eating disorders

The three types of eating disorders most discussed and researched are Anorexia Nervosa, Bulimia Nervosa, and Binge Eating. [A detailed discussion of specific diagnostic criteria can be found here.[2]

Anorexia nervosa is characterized by weight loss (or lack of appropriate weight gain in growing children), difficulties maintaining the right body weight, and a distorted body image.

Bulimia nervosa is characterized by a cycle of bingeing, self-induced vomiting, and/or laxative abuse designed to undo the effects of binge eating.

Binge eating disorder is the most common eating disorder. It is characterized by recurrent episodes of feeling out-of-control while quickly consuming large quantities of food. Binges are accompanied by feelings of guilt and shame. Purging and laxative abuse do not occur with this disorder.

Other subtypes of eating disorders

These disorders are not formally recognized in the Diagnostic and Statistical Manual of Mental Disorders ( DSM-5.)

The pursuit of a healthy diet is considered laudable. But when fixation on eating a correct diet becomes the most critical part of one’s life, it is regarded as a disorder.

Muscle Dysphoric Disorder is sometimes referred to as “Bigorexia,” “Megarexia,” or “Reverse Anorexia.” It is not listed in DSM-5 as a separate diagnosis but rather as a subset of Body Dysmorphic Disorder.{3] While it shares several characteristics with anorexia, it is a desire to be bigger rather than smaller.

Diabulimia is not recognized as a formal diagnosis by the medical or psychiatric communities. However, it has been referred to as the world’s most dangerous eating disorder. It refers to an eating disorder in a person with diabetes, typically Type I Diabetes, wherein the person purposefully restricts insulin to lose weight.

How common are eating disorders?

The National Institute of Mental Health (NIMH) reports that binge eating disorder occurs in 1.2% of adults. The rate twice as high among females. Bulimia nervosa affects 0.3% of adults and is five times higher among females than males. The lifetime prevalence of anorexia nervosa in adults is 0.6%, and it occurs three times more among females than males.

Many more individuals may experience the symptoms of an eating disorder but do not yet have a formal diagnosis. Also, many individuals struggle with body dissatisfaction and subthreshold disordered eating attitudes and behaviors.

What causes eating disorders?

A considerable amount of research has been done on the biological, psychological, developmental, and sociocultural risks associated with eating disorders. While the number of risk factors identified as contributing to the development of eating disorders has increased, evidence for the cause of eating disorders [5] has not been conclusive.

Risk factors are first present in early adolescence, but eating disorders tend to emerge in late adolescence and early adulthood. Eating disorders do not present in the same way from one person to the next. However, research has found similarities in significant risks for developing eating disorders.

Risks for developing eating disorders

There are three variables that are commonly associated with eating disorders:

  • Perceived pressure to be thin
  • Internalizing a thin-ideal
  • Body dissatisfaction

In the last few years, research has shifted toward the genetics and neurobiology of eating disorders. Most researchers no longer believe that the cause is a matter of “will” or self-control.

Poor food choices

People routinely make poor choices, despite knowledge of negative consequences. Still, individuals with anorexia nervosa make bad food choices to the point of starvation.

One study found that individuals with anorexia engage a different part of their brain when making food choices compared to healthy subjects. The part of the brain identified is associated with habitual behaviors.[6]

Genetics

Another report suggests a genetic model that considers environmental, nutritional, and genetic factors in eating disorders.[7] Evidence for a genetic link is supported by the fact that eating disorders occur more frequently when a close relative has an eating disorder or a mental health condition.

Other risk factors:

  • Perfectionism
  • Body image dissatisfaction
  • Personal history of an anxiety disorder
  • Always following the rules
  • Weight stigma
  • History of dieting
  • Type 1 (insulin-dependent) diabetes
  • Teasing or bullying
  • Racial and ethnic minority groups
  • Loneliness and isolation
  • Psychological trauma
  • Bullying
  • Weight stigma

Perfectionism is one of the most common risk factors for eating disorders. Eating disorder risks are higher in racial and ethnic communities, particularly for those undergoing rapid Westernization. Bullying leads to low self-esteem, isolation, and poor body image.

Over 70% of people with eating disorders reported mental health issues.[8] The most common are anxiety disorders, followed by mood disorders, self-harm, and substance abuse. Perfectionism and negative emotions (anger, sadness, guilt, anxiety, and disappointment) are frequently associated with eating disorders.

Eating disorders in athletics

Both female and male athletes are at higher risk of developing an eating disorder compared to non-athletes [9] This is especially true for athletes participating in sports where leanness confers a competitive advantage.

Eating disorders are more prevalent in appearance-oriented athletic activities called “aesthetic sports “[10] (swimming, gymnastics, dance, and bodybuilding) than in ball sports.

Early specialization in a sport appears to be a factor. Athletes tend to under-report their disordered eating. In combat sports like martial arts sports, athletes compete within weight classes. Disordered eating and pre-competition of rapid cutting of weight are everyday occurrences and predispose to eating disorders.

Diagnosis and treatment

Treatment begins with a good medical evaluation by a health care provider. Severe cases may require stabilization in a hospital experienced in the safe refeeding of severely malnourished individuals.[1]

Much of the psychiatric treatment of eating disorders focuses on psychotherapy with one of the following:

CBT is the leading evidence-based treatment for all eating disorder diagnoses in adults. It can also be adapted for adolescents. CBT is designed to produce changes in thinking. In eating disorders, it focuses on what is keeping the eating problem going. CBT includes homework exercises to complete between therapy sessions. Issues addressed include shape and weight, dietary rules, moods related to eating, perfectionism, and low self-esteem.

FBT is the leading evidence-based treatment for eating disorders in adolescents and children. In FBT, parents play an active and positive role to help their child.

IPT is a time-limited, focused therapy developed for the treatment of depression that has been adapted for eating disorders. It recognizes the importance of current interpersonal relationships in the recovery process.

CRT was developed initially for patients with brain injuries. patients with eating disorders have deficits in their thinking. In particular, they have inflexible thinking.

The Eating Disorder Assessment for DSM-5 (EDA-5) is a semi-structured interview meant to assist in assessing a feeding or eating disorder according to DSM-5 criteria. It is intended for use by clinicians who have some familiarity with the feeding and eating disorders. It is available electronically and in Spanish as well as other languages. The EDA-5 is available at no cost for use in clinical settings.

In those individuals with co-morbid mental conditions like anxiety and depression, anti-depressant medications are indicated.

Treatment outcomes

The best predictor of outcomes in treating eating disorders[11] is the degree of symptom reduction early in treatment. Other predictors of treatment success relate to

  • Body Mass Index (BMI)
  • fewer binge/purge episodes
  • higher motivation
  • lower depression
  • lower concerns about shape and weight
  • fewer comorbidities
  • better interpersonal functioning
  • fewer family problems

The bottom line

Eating disorders are serious and, at times, life-threatening mental illnesses that require knowledge about the risk factors, causes, treatment options, and outcomes.

References:

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  1. Mehler P. Medical Management of Severe Eating Disorders. The Doctor Weighs In, 2020 Dec 1. https://thedoctorweighsin.com/medical-management-severe-eating-disorders/ Accessed 12/10/20.
  2. National Eating Disorders Association. What Are Eating Disorders? https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia Accessed 12/10/20
  3. Veale D. Body Dysmorphic Disorder. BMJ 2015; 350 doi: Cite this as: BMJ 2015;350:h2278) Accessed 12/10/20. Ed. note: this reference is behind a paywall. https://doi.org/10.1136/bmj.h2278 Published
  4. National Institute of Mental Health. Easting Disorders. https://www.nimh.nih.gov/health/statistics/eating-disorders.shtml Accessed 12.10/20
  5. Rikani AA, Choudhry Z, Choudhry A et al. A critique of the literature on etiology of eating disorders. Ann Neurosci. 2013 Oct; 20(4): 157–161. doi: 10.5214/ans.0972.7531.200409
  6. Foerde K, Steinglass J, Shohamy D, et al. Neural mechanisms supporting maladaptive food choices in anorexia nervosa. Nature Neuroscience (Advancce online publication), 2015 Oct 12. doi:10.1038/nn.4136. https://shohamylab.zuckermaninstitute.columbia.edu/sites/default/files/2017-02/karinsNNanorexia.pdf
  7. Himmerich H, Bentley J, Carol Kan et al. Genetic risk factors for eating disorders: an update and insights into pathophysiology. Therapeutic Advances in Psychopharmacology 2019 Feb 12. https://doi.org/10.1177/2045125318814734 https://journals.sagepub.com/doi/full/10.1177/2045125318814734
  8. Keski-Rahkonen A, Mustelin L. Epidemiology of eating disorders in Europe: prevalence, incidence, comorbidity, course, consequences, and risk factors, Current Opinion in Psychiatry: doi: 10.1097/YCO.0000000000000278 https://journals.lww.com/co-psychiatry/Abstract/2016/11000/Epidemiology_of_eating_disorders_in_Europe_.5.aspx
  9. Joy E, Kussman A, Nattiv A. 2016 update on eating disorders in athletes: A comprehensive narrative review with a focus on clinical assessment and management, British J Sports Medicine, 2015, http://dx.doi.org/10.1136/bjsports-2015-095735 https://bjsm.bmj.com/content/50/3/154.short
  10. Thiemann P, Legenbauer T, Vocks S. et al. Eating Disorders and Their Putative Risk Factors Among Female German Professional Athletes https://doi.org/10.1002/erv.2360 https://onlinelibrary.wiley.com/doi/abs/10.1002/erv.2360
  11. Vall E, Wade T. Predictors of treatment outcome in individuals with eating disorders: A systematic review and meta‐analysis, International J of Eating Disorders, 2015 July 14, https://doi.org/10.1002/eat.22411. (behind a paywall). https://onlinelibrary.wiley.com/doi/abs/10.1002/eat.22411

Resources:

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Dr. Loren A. Olson completed his undergraduate degree at the University of Nebraska at Lincoln NE and then continued his education in medical school at the University of Nebraska Medical Center in Omaha. He spent an internship year at Bryan Memorial Medical Center in Omaha. After medical school, he spent four years in the Navy as a Flight Surgeon during the Viet Nam era. After his discharge, he entered his psychiatry residency at Maine Medical Center in Portland Maine. During his final year he served as Chief Resident in Psychiatry. He has been board certified by the American Board of Psychiatry and Neurology since 1975.

Dr. Olson is a Distinguished Life Fellow American Psychiatric Association for exceptional service to the profession of psychiatry. He has received awards from the American Psychiatric Association for his writing and editing from the APA. Dr. Olson received the Exemplary Psychiatrist Award from the National Alliance on Mental Illness.

Dr. Olson has presented at the World Congress of Psychiatry in Prague, the Gay and Lesbian Medical Association, and the Association of Gay and Lesbian Psychiatrists. He is also a member of the American Medical Association. Dr. Olson “retired” from Innovative Psychiatric Services in June 2018. His love for the practice of psychiatry, pulled him out of retirement to work as an independent contractor for United Community HealthCare in Des Moines. His most recent position has been practicing adult outpatient psychiatry for Mercy One Psychiatry in Waterloo, Iowa.

Dr. Olson came out as gay at the age of forty and began to wonder if his experience coming out in midlife was like others who came out later in life. His research let to the publication Finally Out, first published in 2011 with a second edition published in 2017. The second edition won the Ben Franklin Gold Award for the best LGBT non-fiction book from the Independent Book Publishers Association in 2018.

After publication of Finally Out, Dr. Olson began speaking to groups throughout the United States and Canada. Not only did he speak about his story but also through personal interviews and correspondence, expanded his exposure to the lives of hundreds of mature gay men from many different cultures and socio-economic groups around the world.

Dr. Olson has always enjoyed the challenges of writing, initially focusing on subjects related to psychiatry. After coming out, his primary interests have been writing about LGBT experiences and the challenges and opportunities that come with growing older.

Dr. Olson’s essays in Psychology Today have been accessed over one million times. He has also written for The Advocate, Huffington Post, Medium, and many other local and national newspapers

He has been interviewed many times for the print, radio and TV media, including an appearance on ‘Good Morning America.”

Loren A Olson MD is a gay father, psychiatrist, popular speaker, and author of Finally Out. Dr. Olson helps people find ways to keep emotional pain from becoming needless suffering.

Dr. Olson’s former wife, Lynn, and his now husband, Doug, have been known to cook Thanksgiving dinner together for their children and grandchildren. Their children and grandchildren just shrug their shoulders and smile when asked why they have two grandmothers and three grandfathers.

Originally published at https://thedoctorweighsin.com on December 14, 2020.

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