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Eating disorders - General information

 

Eating disorders are important psychological illnesses among adolescent girls and young women. (They are the third most important chronic illness in adolescent females behind asthma and obesity.)

 

In Australia, about 25% of girls aged 13 to 17 eat to control weight and about 47% exercise to control weight. However, only about 1% of adolescent girls suffer from bulimia nervosa and 0.3% suffer from anoxia nervosa. (These rates are hard to assess and the figures mentu=ioned may underestimate the problem.)

 

Males are occasionally affected, mostly in association with substance abuse. While dieting is a major risk factor for the disease, especially severe dieting, the vast majority of adolescent girls who diet do not develop an eating disorder.

 

Having a personal or family predisposition to being overweight is a risk factor for developing an eating disorder, with the effect being both genetically and culturally based. Other risk factors include childhood trauma (including sexual abuse), an early menarche in girls and the conditions are often associted with other mental illnesses such as low self-esteme and anxiety and depression.

 

Anorexia

 

Characteristics associated with anorexia include low body weight, food avoidance, excessive concern about being fat / putting on any weight, distorted body-size image, the use of purging, and excessive exercise. Weight goals are continually lowered as the disease progresses. Anorexia patients do not binge-eat in a true sense as they rarely consume excessive amounts of food. However, they feel that they binge as even consuming a normal sized meal seems like a binge to them.

 

The condition has both genetic and cultural influences and often follows a major life-change / life stress. It is more common in women who are involved in activities that value thinness, such as ballet, high-level athletics and modelling. It is about 10 times more common in women than men.

 

Their medical problems stem from a lack of energy and nutrients in their diet and from the use of laxatives, diet pills etc. Common problems occuring with the condition include weakness, chronic fatigue, osteoporosis (weak bones), growth retardation, diarrhoea or constipation, low blood pressure, anaemia and hormonal problems, such as menstrual periods becoming less frequent or ceasing, impaired fertility and the appearance of fine body hair. They also often have co-existing mental illness, especially rapid mood swings, depression / anxiety, self harm, obsessive compulsive disorder and social phobia. (They are often solitary people.)

 

They ususally have low self-esteem that is linked to assessments of their weight and the longer this association persists, the harder treatment becomes.

 

They are often deny their symptoms and thus are relatively unconcerned about them; indeed, they often see them as a solution to their underlying psychological problems. Thus, they are often difficult to engage in treatment. As weight loss has become part of their life coping strategy, treatment needs to include building alternate coping strategies and this takes time.

 

Death from the complications of anorexia also occur very occasionally and anorexia is also a risk factor for suicide.

 

The three criteria for diagnosis are as follows:

Bulimia nervosa

 

In bulimia, the person is usually normal weight or overweight but has tried or is trying to lose weight by food restriction. A period of food restriction is followed by binge eating. These eating binges occur is characterised by:

Binging usually occurs several times a week but can occur up to a couple of time a day in more serious cases.

 

Other efforts to lose weight can include the use of diuretics, stimulants and excessive exercising.

 

They have often experienced large fluctuations in weight and are often not underweight. This cycle continues with the person having haphazard eating patterns. The guilt associated with the behaviours causes low self-esteem and the anxiety related to food and weight leads to relationship problems, depression and self-harm. Other associated problems include weakness, teeth problems, and alcohol and other substance abuse, obsessive complusive disorders, multiple gastrointestinal symptoms and electrolyte imbalance. Genetic predisposition is a prominant risk factor and having poor self esteem. A past history of being over weight is also a risk factor but most people with bulimia have a normal weight.

 

Bulimia is most commonly diagnosed in adolescents; between 13 and 20 years. About 50% fully recover and about 20% partially recover.

 

Binge eating disorder

 

Binge eating disorder is associated with frequently binge eating, similar to the patterns found in bulimia nervosa, but is not associated with purging (self-induced vomiting after eating). It can be condsidered a mild form of bulimia; with bingeing occurring less often. It occurs in about 2% of the population, is more common in women and is the most common eating disorder in adults. It is common in young women and adults seeking weight loss treatment. Like bulimia it is often associated with other mental illness.

 

 

 

Self-esteemin annorexia and bulimia

In both disorders, self esteem is unduly influenced by weight and addressing this issue is one of the main aims of therapy. Sufferers are often irritable, depressed, socially withdrawn, exhibit reduced concentration and are obsessive, especially with regard to food and eating patterns. Many patients do not feel they have a problem and this makes treatment difficult.

 

Other specified feeding or eating disorders

As well as the three commonly recognised disorders mentioned above, new variants of these disorders are being recognised. They occur in about 3% of the population and include:

Relative energy deficiency in sport.

This is another condition that is in some individuals linked to eating disorders. It mainly occurs in women who play sport seriously and thus do a lot of exercise. It is easy for them to end up consuming inadequate energy from their food to supply enough energy for their exercise and maintaining normal body function. In some individuals this is inadvertant while in others it is intentional and it is these individuals who have an eating disorder. Their body tries to adapt to this energy deficiency by altering its normal functioning to reduce energy expenditure. This topic is dealt with in detail separately. See section 'Relative energy deficiency in sport.'

 

As can be seen from the above, eating dosorders are a complex mix of different conditions . Anyone suspected of having an eating disorder or who has a relative they suspect of having an eating disorder should see their GP.

 

Risk factors for eating disorders

 

There are four major risk factors for eating disorders.

 

Dieting: Dieting is the major risk factor and the risk is proportional to the extent of the dieting. The problem is that most diets are unsustainable because they are too strict and restrictive to be adhered too for very long and often provide insufficient energy to allow the body to function adequately in the long term. Thus, diets are only kept too in the short term , resulting in failure to achieve desired weight loss and accompanying guilt and reduced self-esteme. Repeated failures often lead to alternate, more inappropriate behaviours being undertaken, such as the use of laxatives and diuretics and purging, and the person starts to develop obsessive thoughts and behaviours relating to eating and exercise.

Some overweight people do need to change their eating patterns. The important thing is that this is done in a healthy manner by sensible, sustainable and realistic changes that are adopted for the long term. Short term fixes are never a good solution to weight problems. This topic is comprehensively covered in the section on obesity.

 

Body image: It is common for women to have distorted images of their body, with over half of those in the healthy weight range thinking that they are too fat. Self-destructive behavious such as dieting and associated rebound binge eating commonly result from distorted body image that causes reduced self esteme.

 

Low self esteme: Self esteme is a measure of how a person feels about themselves generally and is determined by many factors. (Body image percetion is one.) Thus, low self esteme in a person usually has multiple causes. Self esteme is very important as it determines the way a person chooses to live their life. It influences the relationships, lifestyles, career paths and activities they choose to incorporate into their lives.

 

Some tips for improving self esteem

  • Choose to spend time with people who are supportive / encouraging by nature and spend less time with people who tend to be overly critical / undermine others.
  • Try to recognise and overcome poor thinking that is unhelpful / detrimental to getting through the daily challenges that everyone faces. Such thoughts are often called automatic negative thoughts and most people have them to some extent. They are very commun. Overcoming them is discussed in detail in the section on Cognitive behavioural therapyin the topic Achieving Lifestyle Changes; a section every person should read. (An excellent book on the topic is 'Change your thinking' by Sarah Edlman. Published by ABC Books.)
  • Look after yourself. Eat well, do adequate exercise / keep physically fit and ensure time is provided during each week for doing things that you enjoy. (This is not being selfish, it is being fair. Everyone is important and time needs to be divided fairly between one's commitments and one's self.)
  • Try to do things that are worth doing; that will be helpful to you or to others.
  • Try to be kind / supportive to others and yourself. Doing deliberate acts of kindness are very beneficial to self esteme. Write down a list of possible acts of kindness that will be a help to friends, family and general members of the community and plan them for the week ahead. Include strangers. (Random acts of kindness.) If ideas are hard to think of, google the topic. There will be no shortage of helpful sites.
  • Celebrate achievements.

 

Perfectionism: Perfectionism is a common personality characteristic in people who develop eating disorders. These people wish to attain a perfect body image which is in most cases not achievable. This leads to disappointment ans lower self esteme. People who have this character trait (or the parents of adolescents with this trait) need to be aware of its association with eating disorders and seek help early should early signs of eating dosorders start to develop. (See below.)

Advice for parents regarding preventing eating disorders in their children

 

General advice regading attitudes to body image

Advice regading family eating habits / attitudes to food. (This topic is covered more fully in the section on avoiding Childood Obesity.)

 

Diagnosis of eating disorders

 

It is imortant to recognise eating disorders early for two reasons;

Early warning signs that an eating disorder is developing include:

The SCOFF Screening Test

A positive response to two or more of the following five questions indicates an eating disorder is likely to be present.

1.      Do you make yourself sick because you feel uncomfortably full?

2.      Do you worry that you have lost control over what you eat?

3.      Have you recently lost over six kilograms in weight in a three-month period?

4.      Do you believe yourself to be fat when others say you are too thin?

5.      Would you say that food dominates your life?

 

It is important to note that this is a screening test to help identify people with eating disorders. Parents / other carers do not need to wait for these symptoms to appear to seek help if they are worried that their child or a relative or friend has a problem with eating.

Some Screening Questions

Assessing weight in adolescents

Several facts make assessing the significance of weight change in adolescents difficult.

Below are suggested Body Mass Index (BMI) criteria for anorexia are as follows. Again, parents should seek help well before these levels are reached as early treatment is likely to increase treatment effectiveness and reduce illness duration.

Treatment of eating disorders

 

A very important part of treatment is a coordinated approach throughout and thus a decision regarding who is going to treat the patient needs to be made at the outset. Where ever possible, this should include a specialist psychiatrist / psychologist, a dietician and a GP.

 

It is very important to realise that treatment success is greatly enhanced by early initiation of treatment. In the past many families have not sought and / or received help until adolescent eating patterns and the family responses to these patterns are too entrenched to be changed significantly.

 

Annorexia

There are many therapies for treating anorexia but the one for which there is most evidence of benefit is family-based therapy. (The Maudsley Approach) It is very helpful in overcoming / preventing the shame / guilt relationship that commonly develops between the patient and their family and has best results when treatment is commenced early on in the illnesss, before behaviours become too entreanched. (Within three years of symptom onset is best.) It usually done through a hospital outpatients clinic attached to a specialist eating disorder unit or Local Area Mental Health Services. Therapy involves the parents and the adolescent consulting nutritional, medical and mental health experts. It typically involves 6 to 12 months of therapy with full weight restoration in 50% to 75% and most patients who are going to recover have done so at 12 months. Full recovery at 5 years occurs in about 60% to 70% of cases, with the best results occurring in patients when treatment is started earlier on in the illness. Patents and the patient can be seen together or serparately or both.

 

The detrimental habits associated with Anorexia, such as purging and the use of laxitives, are often denied by patients. Such behaviours are part of their life coping system and it is difficult for patients to leave them behind until they have constructed alternate coping mechanisms. Thus, they often need to be tolerated during the initial stages of psychological therapy.

 

Recovery from Anorexia can take many years and is often punctuated by relapse. Long term prognosis really depends on the patient willingly engaging in therapy. Forcing eating on the patient, while helping with weight gain in the short term, is often conterproductive in the long term.

 

Eating disorders associated with being overweight (and normal weight bulimia)

 

Bulimia and binge eating disorder are best treated by the adolescent receiving cognitive behavioural therapy by a suitably qualified health professional. As well as improving eating behaviour, these therpaies often also result in weight loss; something the patient usually desires.

 

Medically supervised behavioural weight-loss programs such as the LEARN program have been found to be beneficial in achieveing weight loss.

 

CBT programs have four core stages:

While numerous medications have been tried, there are no specific medications recommended for the treatment of eating disorders associated with overweight.

 

 

 

 

Resources

 

Further Reading

James Lock and Daniel Le Grange. Helping Your Child Beat an Eating Disorder. The Guildford Press, 2015

June Alexander and Professor Daniel Le Grange. My Kid Is Back. Melbourne University Press, 2009

 

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