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

By Loren A. Olson, MD

(Photo source: iStock)

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:

  • 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

Different manifestations of unhealthy relationships with food

There are different manifestations of disordered eating, including:

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

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

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

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

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.)

Orthorexia:

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:

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:

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.

Related content by the same author: Body Dysmorphic Disorder: Obsession with a Flaw Interferes with Life

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.

Risks for developing eating disorders

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

  • Internalizing a thin-ideal
  • Body dissatisfaction

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.

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

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.

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]

Cognitive Behavioral Therapy (CBT)

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.

Family-Based Treatment (FBT)

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.

Interpersonal therapy (IPT)

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.

Cognitive remediation therapy (CRT)

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

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

  • 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. National Eating Disorders Association. What Are Eating Disorders? https://www.nationaleatingdisorders.org/learn/by-eating-disorder/anorexia Accessed 12/10/20
  2. 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
  3. National Institute of Mental Health. Easting Disorders. https://www.nimh.nih.gov/health/statistics/eating-disorders.shtml Accessed 12.10/20
  4. 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
  5. 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
  6. 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
  7. 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
  8. 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
  9. 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
  10. 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

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