Eating Disorders: A Comprehensive Overview

Jennifer Hanes MS, RDN, LD

February 22-28, 2021 is NEDAs Eating Disorder Awareness Week.   I feel like there’s a lot of confusion around eating disorders, particularly those of us whose last education on the subject was health class in middle school.

The stereotypical eating disorder is the blonde, white, female cheerleader.  She is vain, way too preoccupied with her appearance, and is “otherwise healthy.”

But in reality, eating disorders affect every age, gender, race, ethnicity, and any other category you can think of. And they typically are manifestations of other factors, such as genetic or biological factors, trauma, or other mental health disorders.

Additionally, placing every eating disorder into a neat box of anorexia or bulimia is not adequate. Not only does this leave out a wide range of other eating disorders, but also oversimplifies what someone is going through.

Read on to learn more.

Risk Factors for Eating Disorders

There are many risk factors for eating disorders that are often missed or ignored.  If you are concerned about a loved one, consider the following.

  • Relative with an eating disorder.  An individual whose mother or siblings have an eating disorder are more likely to develop an eating disorder themselves.
  • Relative with a mental health condition, particularly anxiety, depression, or addiction.
  • History of dieting. Western “diet culture” is well-documented to trigger disordered eating patterns. In particular, binge eating disorder can be a response to chronic dieting.
  • Type 1 Diabetes. Approximately 25% of women with type 1 diabetes go on to develop an eating disorder, potentially a result of constant monitoring of their food intake.
  • Perfectionism. This is a constant struggle with my patients with an eating disorder. They have a drive for perfection that simply doesn’t exist. And typically, if they reach their “perfect” weight or “perfect” food intake, it’s still not enough.
  • Body Image Dissatisfaction. An intense focus on body image as an outward expression of their perceived worth. 
  • Personal history of Anxiety. Two-thirds of patients with anorexia have been diagnosed with an anxiety disorder prior to the development of an eating disorder.
  • Behavioral Inflexibility.  This is almost universal among my patients with an eating disorder.   They are very rigid in their beliefs regarding the right and wrong way to do anything. There is a prevalence of “black and white” thinking with no room, or even acknowledgment, of the “grey zone.”
  • Teasing or bullying. Particularly in regards to their weight.
  • Limited social networks. Many people with eating disorders report a very small support system with limited participation in social activities.  Whether this is a cause or result of eating or anxiety, disorders are unclear.
  • Trauma of any type. Personal, racial, historical, and intergenerational trauma can all contribute to the development of an eating disorder.

Types of Eating Disorders

As I briefly discussed above, there are different types (and sub-types) of eating disorders.  These include, but are not limited to:

  • Anorexia Nervosa – with restrictive, binge/purge, and atypical subtypes
  • Bulimia Nervosa – with purging and non-purging subtypes
  • Binge Eating Disorder
  • Avoidant Restrictive Food Intake Disorder
  • Other Specified Feeding or Eating Disorder – for example, orthorexia, body dysmorphic disorder, diabulimia, compulsive exercise, or eating disorders that don’t quite meet the diagnostic criteria of the above disorders.

Anorexia Nervosa (AN)

If eating disorders had a public face, anorexia would be it. It’s what we hear about most often in pop culture, and what gets, unfortunately, joked about the most often.

To be diagnosed with AN a person must have the following symptoms:

  1. Restriction of energy intake relative to requirements, leading to significantly low body weight in the context of age, sex, developmental trajectory, and physical health.  A teenager that has always been on the low end of the growth curve and is “skinny” on presentation won’t necessarily qualify.
  2. Intense fear of gaining weight or becoming fat, even though they are underweight.
  3. Disturbance in the way one’s body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the currently low body weight.

 

Signs of anorexia include dramatic weight loss, preoccupation with food, calories, fat, and carbs, restriction whole categories of food, cold intolerance, cooks for others without eating, numerous excuses to avoid eating, loss of menstrual cycle, inflexible thinking, fainting, dry skin, thinning or brittle hair, frequent illnesses, and more.

 

The Restricting sub-type of AN is what most people think of when they think of anorexia. Extreme food restriction may or may not be accompanied by excessive exercise.

The Binge/Purge subtype of AN is more confusing for some people to think about. These individuals’ primary eating disorder behavior is severe food restriction. However, they will occasionally engage in binge eating followed by a purge of some type.

Atypical anorexia meets every requirement of AN, but the individual is not technically underweight. These individuals are often missed, or even praised, for their weight loss.  However, there are no differences in the physical or mental impact of AN between typical and atypical anorexia nervosa.

 

Bulimia Nervosa (BN)

To be diagnosed with BN, a person must have the following symptoms:

  • Recurrent episodes of binge eating:
    • Eating, in a specific period of time an amount of food that is definitely larger than most people would eat during a similar period of time and under similar circumstances.
    • A sense of lack of control over eating during the episode (a feeling that one cannot stop eating or control what or how much one is eating).
  • Recurrent inappropriate compensatory behavior in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, or other medications, fasting, or excessive exercise.
  • The binge eating and inappropriate compensatory behaviors both occur, on average, at least once a week for three months.
  • Self-evaluation is unduly influenced by body shape and weight.
  • The disturbance does not occur exclusively during episodes of anorexia nervosa.

Some signs of bulimia nervosa include evidence of binge eating (disappearance of food or lots of empty wrappers), frequent trips to the bathroom after meals, appears uncomfortable eating around others, excessive food rituals, hoarding food, excessive use of mints, gum, or mouthwash, callouses on the back of the hand, extreme mood swings, noticeable weight fluctuations, non-specific GI complaints (i.e. “stomach hurts”), dizziness/fainting, dental problems, menstrual irregularities, poor wound healing, frequent illnesses,  increasing impulsivity.

 

Individuals with BN are typically NOT underweight, according to the outdated BMI model.

 

Subtypes of BN are really 2 sides of the same coin.

Purging type includes individuals with self-induced vomiting or misusing diet pills, laxatives, or diuretic medications.

Non purging type includes individuals that use fasting or excessive exercise to compensate for a binge. 

Binge Eating Disorder (BED)

To be diagnosed with BED, a person must have the following symptoms:

  • Recurrent episodes of binge eating, as defined above.
  • The binge-eating episodes are associated with three (or more) of the following: 
    • Eating much more rapidly than normal.
    • Eating until feeling uncomfortably full.
    • Eating large amounts of food when not feeling physically hungry.
    • Eating alone because of feeling embarrassed by how much one is eating.
    • Feeling disgusted with oneself, depressed, or very guilty afterward.
  • Marked distress regarding binge eating is present.
  • Binge eating occurs, on average, at least once a week for 3 months.
  • Binge eating is not associated with the recurrent use of inappropriate compensatory behaviors (e.g., purging) as in bulimia nervosa and does not occur exclusively during the course of bulimia nervosa or anorexia nervosa.

 

Signs of BED include hoarding food, the disappearance of large amounts of food, weight fluctuations, low self-esteem, stomach cramps, and difficulty concentrating.

Avoidant Restrictive Food Intake Disorder (ARFID)

ARFID is unique among eating disorders in that it typically is NOT accompanied by a body image disruption. Instead, there are unhealthy eating behaviors that have some other underlying factors.

To be diagnosed with BED, a person must have the following symptoms:

  • An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs associated with one (or more) of the following:
    • Significant weight loss (or failure to achieve expected weight gain or faltering growth in children).
    • Significant nutritional deficiency.
    • Dependence on enteral feeding or oral nutritional supplements.
    • Marked interference with psychosocial functioning.
  • The disturbance is not better explained by a lack of available food or by an associated culturally sanctioned practice.
  • The eating disturbance does not occur exclusively during the course of anorexia nervosa or bulimia nervosa, and there is no evidence of a disturbance in the way in which one’s body weight or shape is experienced.
  • The eating disturbance is not attributable to a concurrent medical condition or not better explained by another mental disorder. When the eating disturbance occurs in the context of another condition or disorder, the severity of the eating disturbance exceeds that routinely associated with the condition or disorder and warrants additional clinical attention.

Many people consider this a severe form of “picky eating.”  

While picky children are more likely to later develop ARFID, they are not the same thing.  Risk factors for ARFID include individuals with autism spectrum conditions, ADHD, or intellectual disabilities, as well as children with anxiety disorders.  Patients with ARFID are more likely than the general population to later develop other psychiatric disorders.

 

Signs of ARFID include dramatic weight loss, constipation, abdominal pain, fatigue, will only eat certain types or textures of food, fear of choking or vomiting, poor appetite or low interest in food, narrowing the range of acceptable foods, dizziness/fainting, poor wound healing, frequent illnesses, thinning of hair, dry skin, anemia, slow heart rate.

Other Specified Feeding or Eating Disorder (OSFED)

OSFED is basically used as a term or diagnosis for those individuals with eating disorder behavior that doesn’t quite meet the diagnostic criteria listed above.

This can range from someone who binges but not often enough to be diagnosed with BED to disordered eating patterns that don’t necessarily have a true diagnosis.

Examples include diabulimia (skipping or reducing insulin used to induce weight loss), orthorexia (obsession with “clean” or healthy eating), pica (compulsive craving to eat non-food items), bigorexia (or muscle dysmorphia or reverse anorexia instead of obsessively losing weight, these individuals will obsessively gain muscle), purging disorder (purging that is not associated with binge eating), and more.

Health Consequences of an Eating Disorder

The health outcomes of an eating disorder vary depending on a multitude of factors, such as severity and longevity of the disorder, whether or not the individual seeks and commits to treatment and recovery, and the particular eating disorder behavior.

It is important to understand that eating disorders, particularly Anorexia Nervosa, are considered to be the deadliest of all mental health disorders. One study found that individuals with AN were 6 times more likely to die compared to the general population. Causes of death included starvation, substance abuse, and suicide.

    • Cardiovascular
      • inadequate food intake can cause the body to break down muscle, including the heart. This leads to a weak and slow heart rate
      • Purging can alter the electrolyte balance in the body which can lead to heart irregularities and even failure.
      • Binge eating disorder can lead to elevated cholesterol and triglycerides as well as high blood pressure.
      • Conversely, severe AN can lead to very cholesterol and triglycerides as well.  
    • Gastrointestinal
      • Inadequate food intake can lead to constipation and stomach pain.
      • The GI tract may slow down causing nausea, vomiting, bloating, and infections.
      • Laxative abuse can cause dependency, making it near impossible for the individual to have a bowel movement without them.
      • Binge eating can lead to stomach rupture.
      • Pica can lead to bowel obstructions, intestinal perforations, chemical burns, or various infections depending on what is eaten.
    • Neurological
      • Malnutrition leads to mood swings, difficulty concentrating, and obsessing about food.
      • Chronic, inadequate fat intake can damage the nervous system, leading to tingling and even pain in the extremities.
      • Fainting and dizziness, particularly on standing.
      • Individuals with binge eating disorder are at increased risk of sleep apnea due to the increased risk of obesity.
    • Endocrine
      • Loss of menstrual cycle.
      • Reduction in sex hormones can lead to reduced libido as well as increase bone loss, potentially leading to fractures.
      • BED can lead to insulin resistance, with the potential to progress to type 2 diabetes.

Treatment for Eating Disorders

Eating disorder treatment requires a treatment team.  This should include a medical doctor, a therapist, and a dietitian. A psychiatrist should be involved to manage any concurrent mental health conditions, such as depression and anxiety, that may require medical management.

And every one of those health practitioners should be familiar and experienced in the treatment of eating disorders.

Ultimately, treatment depends on the severity of the eating disorder.  Sometimes outpatient treatment is adequate, and sometime a higher level of care may be necessary. 

Your treatment team should be able to guide you on these needs.

Common myths regarding eating disorders

There are so many misconceptions about eating disorders. That is why this week is so important. The two biggest, and I think most dangerous, are that eating disorders aren’t that big of a deal, and that boys don’t get eating disorders.

Myth: Eating Disorders are a choice

Just like no one chooses to have schizophrenia, or depression, or any other mental health condition, no one chooses to have an eating disorder.

As listed above, there are many risk factors and causative events that can lead to an eating disorder. And not a single one is “just for the heck of it.”

Myth: You can tell if someone has an eating disorder by looking at them

Absolutely not.

Boys and individuals with obesity are often overlooked because they don’t “look like they have an eating disorder.”

These individuals may be praised for their progress (such as muscle gains or weight loss), further encouraging their eating disorder.

Notice that none of the diagnostic criteria listed above indicate a particular BMI or “look” to be considered an eating disorder. This is for a reason.

Myth; Eating Disorders aren’t serious

Actually, eating disorders can have a very high mortality rate.  It is a very serious condition. Attempting to recover on your own can be dangerous all by itself. 

Eating disorders and eating disorder recovery should be treated seriously and like the mental and physical health crisis that it is.

Myth: Eating Disorders only affect girls and women

Again gender (or race, age, culture) are not considered in the diagnosis of an eating disorder.

Boys and men have different social pressures for appearance than girls and women do. But they are just as susceptible to eating disorders.

Because the belief that boys don’t develop eating disorders is so prevalent, many are misdiagnosed or just flat missed.  This can, in turn, lead to delayed (or no) treatment and worse outcomes in boys.

Eating disorders simply look different in boys compared to girls, especially to an untrained observer.

They may actually develop earlier than they do in girls, and the tendency is towards “bigorexia” rather than a drive to thinness. As a result, boys tend to overexercise and abuse supplements (testosterone, steroids, other muscle growth “aids”) more than girls do.

Going back to our second myth, boys with an eating disorder may actually look “healthier” than their peers and may be considered more “in shape” than their peers.

Myth: Eating Disorders start during the teenage years

Kids as young as 6 have reported body image problems that lay the foundation for a future eating disorder.  I’ve had clients that report they don’t remember NOT worrying about their weight or calorie intake and have clients as young as 8 or 9 that religiously track their food intake.

On the other side, it is entirely possible for an eating disorder to appear later in life, such as in pregnancy or in middle-aged individuals.

Myth: You can never recover from an eating disorder

Eating disorder recovery takes work, dedication, and perseverance.

 

But it can occur.

What can you do to increase awareness?

Educate yourself.  There are several resources (see below) that can help you be an ambassador for individuals with an eating disorder.   

Careful what you post on social media, and who you follow.  There are tons of great body-positive social media accounts that you can follow. Find them and share their content. Normalize conversations around different body types.

Careful how you compliment someone! For real though, the best time to comment on someone’s weight is absolutely never.   Eating disorder brain can misconstrue even the most innocent of compliments.  “You look healthy” becomes “I’ve gained weight, so now I need to restrict again.”     

“Have you been working out?” becomes “Restricting my food intake is working!”

Just try not to compliment people on appearance. There are so many other great things about them!    Examples:

  • You did a great job on that presentation.
  • I can tell that was hard for you, and you did a great job.
  • Your smile/laugh is contagious.
  • You make me feel safe/content/happy/calm
  • I am proud of you.
  • You are such a strong person
  • You always teach me something.
  • You are so kind.
  • I always enjoy spending time with you.

 

Look into Operation Beautiful.  Love this idea!

 

Share your story, if you’re comfortable doing so.

 

Additional Resources

Seeds of Hope

National Eating Disorder Association

Eating Recovery Center

National Eating Disorders Collaboration

How to talk to yourself 

How to talk to your kids

 

 

How to talk to yourself about health

We’ve talked about discussing health, diet, and weight with children.  But how do you talk to yourself?

I know that many of my clients and patients say things to and about themselves that they would never say to anyone else. Why do you expect perfection in yourself and allow for mistakes and mishaps in others?

Positive self talk

There’s this idea of a self-fulfilling prophecy.  If you expect a bad outcome, you’ll get it, and vice versa.

Practice positive thinking throughout your day.  Instead of “XYZ is so hard,” think, “I’m smart enough to figure out XYZ.”

Instead of “I don’t know how to do that,” think, “I get to learn how to do that.”

I know it sounds cheesy, and if you’re used to thinking negative thoughts, it will take some practice.  But it’s amazing how much it can change your outlook and experiences in life.

Research on positive thinking shows us that a positive outlook, or optimism, leads to fewer symptoms of depression and anxiety, better stress and illness management, and even better physical health.

Body gratitude list

If you’re accustomed to thinking negatively about your body, this almost seems laughable. But we’re working on ourselves here, right?

Create a list of things about your body you are grateful for.

  • Did it grow and then nourish your child?
  • Can you use it to rough house with that child now that they’re older?
  • Does it feel good when you take the time to move it?
  • Do you love the color of your eyes or the freckles across your nose?
  • Do people tell you they love your smile?
  • Does it cook and then eat awesome-tasting food?

There’s so much more to your body than how it looks or how much space it takes up. Write down what about your body you are grateful for.  Keep it in a file on your phone, and refer to it when the negative thoughts get overwhelming.

Mindful eating – enjoy your food

Mindful eating has many facets to it – enough that I plan to do an entire post just on this topic.

However, for the purpose of this post, we’ll focus on the part where we get to enjoy our food.

You honor your body and yourself when you respond to hunger cues.  And fullness cues.  Nobody feels good when they’re overly hungry or when they are overfull. 

When you feel hungry, respond. Eat a filling meal (or snack).

Eat it slowly; shoveling food in your mouth as fast as you can get it there isn’t enjoying your food. Stop eating when you’re comfortable but fuller than neutral.

Similar concepts apply when you’re going for a splurge. Eat to satiety, enjoy the hell out of it, then stop eating it when it’s no longer satisfying.

As you practice mindful eating, you may come to the realization that certain foods are more filling and more satisfying than others. That you feel better after eating certain foods and terrible when other foods are eaten. Eventually, you probably won’t even want to eat those foods that make you feel bad.

Assess your posture

Your posture affects your mood!

Think about it. You slouch in your chair when you’re tired or stressed. Then your back hurts.  So now you’re pissy and in pain.  

Try to work on your posture. Again, this will take time and practice.  Start by setting an alarm every hour to check your posture. Or go one step further and get up, take a 2-3 minute movement break, get some water, then sit back down with good posture.

Slouching causes long-term muscle weakness and pain in your lower back.   It can lead to fatigue, poor motivation, increased stress, and lower mood.

So this is important!

Consider your food fuel

You should absolutely take the time to enjoy your food.

However, start to think about food as a fuel for your body instead of just a means to quickly tame the hunger beast. Think about how food can work for you. The carb provides energy, the protein can build your muscles, the fruits and vegetables fill you up and help reduce inflammation, and the fat can make your hair shiny and keep you full longer.

Consider ALL foods as different types of fuel that your body needs. Food should not be a punishment, and you should not punish yourself for eating it. 

Ate a cupcake at your co-worker’s birthday celebration.  So what?  You don’t owe yourself an extra hour on the treadmill. You owed yourself the time to celebrate your friend.

Likewise, that salad for dinner isn’t a punishment for skipping the gym.  It provides the fiber and other fuel that your body needs at that time.

Expect imperfection

No one is perfect, and you’ve probably accepted that about every single person around you.

So why haven’t you accepted this about yourself?

You went grocery shopping, but then you were too tired or ran out of time to cook. So you had to stop on the way home to feed everyone before they were hangry.  So what? Everyone’s done it.

You have mandatory overtime at work for the next couple of weeks, and now you don’t have time or energy to go on a walk every day. Take the break, give yourself time to relax, then get back to it as soon as you can.

You are not “bad” or “cheating” when these things happen.

While we know that eating healthy and moving our bodies is important and should be a focus and priority, we also know that sometimes the extra stress this can cause is more harmful than a one-off fast food meal or skipping a run.

Most importantly, if you wouldn’t say it to a stranger or a close friend, don’t say it to yourself!

For real, you’re a nice person. You would never tell your friend she’s too fat to order dessert or that she needs to starve herself with dry lettuce every meal for 2 weeks.

You would never bully them into a workout when they’re almost ready to pass out from fatigue.

So why the hell do you say this stuff to yourself?

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