Understanding Eating Disorders: A helpful guide for health professionals

When someone mentions eating disorders, do you immediately envision someone of a particular gender, weight, race, or age? The reality is that eating disorders are common, affecting 28.8 million Americans facing an eating disorder in their lifetime, and the global prevalence of eating disorders is on the rise.

An eating disorder occurs when an individual has a severe preoccupation with their food intake and discontentment with their body and is often paired with negative emotions and irregular eating patterns. Because there are frequent misconceptions about eating disorders and their subtle signs, they often remain undiagnosed. It's crucial for health professionals, patients, and their loved ones to be aware of the signs and symptoms to help ensure patients get the help and support that they need.

Food is our body's fuel, and when we don't meet our body's needs, the effects are detrimental and even fatal. Having a clearer understanding of the different types of eating disorders, how to recognize the signs, and the steps to recovery can truly be lifesaving.

Common Types of Eating Disorders

Before we jump into breaking down each of the three main types of eating disorders, Anorexia Nervosa, Bulimia Nervosa, and Binge Eating Disorder let's take a look at a few of the commonalities among them:

• More common in women than men
• Eating disorders have the second highest risk of death when compared to all other mental health conditions
• Typically, start between ages 12 and 25
• Can affect anyone, regardless of race or gender

Anorexia Nervosa

First, let's take a look at what exactly Anorexia Nervosa is and its health impact on patients. Anorexia Nervosa is a condition in which patients have an intense worry about gaining weight, a distorted perception of their bodies, and limited food intake. These preoccupations can manifest in two ways: restrictive and binge-purge. Restriction is when patients eat significantly limited amounts and lose weight through dieting, fasting, or excessive exercise. Binge-purge manifests through eating excessive amounts of food and purging it through forced vomiting, laxative use, diuretic use, and/or intense exercise.

Regardless of the type, an important characteristic of Anorexia Nervosa is having an extremely low body weight. Patients with a body mass index (BMI) of less than 18.5 places them in the underweight category, with a low BMI as the distinguishing presentation between Anorexia Nervosa and Bulimia Nervosa.

Other symptoms of Anorexia Nervosa include:

• Denial of low body weight and its severity
• Constant pursuit of being thin and refusal to maintain a normal or healthy weight
• Extreme fear of gaining weight
• Distorted perception of self-image and body, significantly affected by personal views on body weight and shape

Severely limiting food intake and maintaining a very low body weight has a profoundly negative impact on overall health. For example, Anorexia Nervosa negatively impacts hormones, organs, and bodily functions in the following ways:

• Decreased body temperature, leading to constantly feeling cold
• Anemia
• Thinning of bones, leading to a decreased density and increased risk for fractures
• Can lead to conditions such as osteoporosis or osteopenia
• Fragile hair and nails
• Muscle weakness
• Low blood pressure
• Slowed heartbeat
• Abnormally slow breathing rate
• Abnormal or irregular heartbeat (cardiac arrhythmias)
• Constipation
• Fertility challenges
• Electrolyte imbalances, which may lead to arrhythmias or brain swelling
• Dry skin
• Growth of thin hair all over the body
• Persistent fatigue
• Organ failure

Compared with other disorders, it's important to note that Anorexia Nervosa has a very high death rate, not only due to medical complications but also due to patients taking their own lives. Knowing the signs and symptoms of Anorexia Nervosa and encouraging patients to get help is the first and most crucial step in saving their lives.

Bulimia Nervosa

Bulimia Nervosa is a condition involving patients who engage in frequent episodes of eating very large amounts of food and then find ways to compensate for the increase in calories through vomiting, laxative use, diuretic use, or excessive exercise. The goal of these compensatory behaviors is to eliminate extra calories and prevent the chance of gaining weight.

To be diagnosed with Bulimia Nervosa, binge eating and compensatory behaviors must occur at least once a week for three months. Take note that patients with Bulimia Nervosa tend to have a normal body weight or are overweight. The purging portion of Bulimia Nervosa takes a toll on patients' bodies with symptoms that include:

• Dehydration due to loss of bodily fluids
• Constant sore throat
• Enlarged salivary glands
• Deteriorated tooth enamel and tooth decay due to repetitive vomiting
• Electrolyte imbalances
• Gastrointestinal discomfort due to excessive laxative use
• Calluses on the back of hands due to vomiting
• Abnormal or irregular heartbeat (cardiac arrhythmias)

In addition to these complications, Bulimia Nervosa is also associated with other mental health conditions, such as anxiety disorders, mood disorders, and borderline personality disorder, as well as an elevated risk of suicide.

Binge Eating Disorder

With Binge Eating Disorder, patients have episodes of eating very large amounts of food. These binge episodes must occur at least once weekly for three months to be diagnosed. This disorder differs from Anorexia Nervosa and Bulimia Nervosa in that patients aren't trying to control their weight and do not engage in compensatory behaviors after binging. Most patients are overweight or obese. Rather than trying to control weight, these patients tend to feel out of control while binging food, as well as feelings of distress or guilt.

Additional symptoms of Binge Eating Disorder include eating exceptionally large amounts of food, called binge episodes, within a two-hour period, in addition to:

• Eating very rapidly
• Eating until uncomfortably full
• Eating when they're not hungry
• Eating alone to avoid feeling embarrassed
• Experiencing feelings of depression, guilt, or disgust after a binge episode

Patients with Binge Eating Disorder suffer medical issues related to obesity, such as diabetes, heart disease, and metabolic syndrome.

Causes and Risks

There are a variety of factors that put people at risk for developing an eating disorder, including biological, psychological, and sociocultural factors.

Biological factors include:

• Family history of eating disorders
• Family history of mental health conditions such as depression, addiction, and anxiety
• History of using weight control methods
• Type 1 Diabetes (commonly due to skipping insulin injections to lose weight)

Psychological factors include:

• Perfectionism
• Difficulty regulating emotions
• Dissatisfaction with body image
• Impulsivity
• Avoidance of difficult thoughts and feelings
• History of a mental health condition
• History of substance use disorder

Sociocultural factors include:

• Discrimination due to a person's weight and weight stigma
• Being bullied about weight
• Societal pressure to be thin
• Social isolation and loneliness
• Trauma (physical, social, and/or emotional)

Diagnosis and Early Recognition

Eating disorders cause a wide range of medical complications, may coexist with other mental health conditions, and are potentially life-threatening. Identifying warning signs of these disorders, along with timely identification and intervention, can significantly impact the severity of symptoms, quality of life, and survival rates of patients.

General warning signs to look out for are the development of food rituals, preferring to eat alone, wearing baggy clothing, severe fluctuations in weight, rigidity around food, sleep issues, extreme concern with weight, and hoarding food.

Aside from these warning signs, there are also screening tools that can aid in the early detection of eating disorders. Two helpful ones include the EDA 5 and the SCOFF questionnaire, a 5-question screening tool that can be used in almost any health setting.  

To use the SCOFF questionnaire, assign one point for every "yes" answer from your patient. A score of 2 or more indicates an eating disorder is likely.

Treatment Approaches

When treating eating disorders, it's essential to develop a patient-centered treatment plan involving a multidisciplinary team that may include a psychiatrist, primary care physician, dietician, psychologist, and others to ensure each patient gets much-needed treatment and support.

Nutritional counseling is an integral part of an eating disorder treatment plan. With nutritional counseling, the goals are to help the patient return to a healthy nutritional state, develop balanced eating patterns, get to an appropriate body weight, and shed behaviors that stem from their eating disorder. A dietician will curate a personalized nutrition plan to support the patient's needs and provide nutritional rehabilitation.

Psychotherapy is another critical part of the treatment process. Depending on their needs, patients may engage in cognitive behavioral therapy, family therapy, interpersonal psychotherapy, and/or group therapy.

Medications such as antidepressants, antipsychotics, or mood stabilizers may also be used for the treatment of eating disorders.

Support from family and friends is also very important in the treatment process for an eating disorder. There are also support groups available, but they're not a replacement for medical and mental health care for someone living with an eating disorder.

Research is ongoing and leading to innovations in Eating Disorder Therapy. Studies have found a reduction in negative emotions and dissatisfaction with body image when patients try Virtual Reality Therapy for eating disorders and are exposed to virtual food. Though this type of therapy hasn't been widely adopted, it could be included in treatment plans for eating disorder recovery in the future.

Lack of access is a known barrier to care. To address it, more digital health apps for recovery are being developed, including those for eating disorders. These apps allow for remote delivery and an expansion of access to care, including monitoring what patients eat without focusing on calories, taking note of their feelings, receiving motivation, and offering helpful coping strategies.

Prevention Strategies

Education and awareness are both essential for preventing eating disorders. Knowing the warning signs of disordered eating and the tools for recovery is empowering. Whether you use the knowledge for yourself, a patient, or a loved one, it will make a difference.

Remember, society may promote one specific beauty standard, but, as individuals, we can promote a positive body image by being conscious of how we discuss our bodies, eating healthy food, and encouraging those around us to do so.

Challenges in Treatment

There are a variety of misconceptions to dispel about eating disorders. The first is that people choose not to eat enough when it's not actually a choice but a result of a mental illness. Another hurdle is that eating disorders are often considered a "female disorder," which is not accurate, and leads to fewer men seeking treatment along with experiencing disparities in care.

There's also an inaccurate belief that once someone receives treatment, they're cured. Unfortunately, this isn't always the case. Some patients make full recoveries, while others relapse, which is why it's crucial to have a long-term treatment plan in place.

Strategies to prevent relapse include:

• Having a strong support system
• Understanding triggers
• Adopting healthy coping mechanisms
• Knowing when to ask for help if worried about relapsing.

The Role of Health Professionals

Eating disorders often go undiagnosed. Which means it's doubly important for health professionals to stay up to date on the symptoms of these disorders, their treatment options, and new innovations in the field of study.

As a health professional, if you encounter a patient who's dealing with an eating disorder, a collaborative approach is necessary to work within a multidisciplinary treatment team, keep the patient's support system involved, and deliver the best care for the patient.

Stigma can create a sense of shame or increase an individual's reluctance to seek help, making it a significant barrier to care. Educating patients and yourself about common misconceptions about eating disorders is helpful, allowing patients to feel more comfortable seeking treatment.

Resources and Support

Eating disorders are a group of mental health conditions that need to be better understood by the public and health professionals. They are complex and life-threatening, but recognizing warning signs, using screening tools, having honest conversations, and creating a well-rounded treatment plan make a significant impact.

Check out these helplines, support groups, and additional educational resources to learn more about eating disorders.

References

• https://www.nationaleatingdisorders.org/statistics/
• https://medicine.yale.edu/news-article/study-people-with-eating-disorders-infrequently-seek-help-for-symptoms/
• https://www.hopkinsmedicine.org/psychiatry/specialty-areas/eating-disorders/faq#:~:text=The%20most%20common%20age%20of,diagnosis%20was%20defined%20relatively%20recently
• Ganti, Latha; Kaufman, Matthew S.; and Blitzstein, Sean M. First Aid for the Psychiatry Clerkship, Fifth Edition. New York: McGraw-Hill Education, 2018
• https://www.nationaleatingdisorders.org/risk-factors/
• https://www.hsph.harvard.edu/wp-content/uploads/sites/1267/2012/08/STRIPED-Fact-Sheet-on-Eating-Disorders-Early-Detection.pdf
• https://www.nationaleatingdisorders.org/bulimia-nervosa/
• https://www.psychiatrictimes.com/view/a-life-and-death-measure-eating-disorder-treatment
• https://nedc.com.au/eating-disorders/treatment-and-recovery/the-care
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4096990/
• https://www.nationaleatingdisorders.org/what-to-expect-from-treatment/
• https://www.allianceforeatingdisorders.com/groups/
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5948410/
• https://www.verywellmind.com/apps-and-eating-disorders-the-good-and-the-bad-3878432
• https://medicine.yale.edu/news-article/study-people-with-eating-disorders-infrequently-seek-help-for-symptoms/
• https://www.urmc.rochester.edu/childrens-hospital/adolescent/eating-disorders/myths.aspx
• https://www.eatingdisorderhope.com/blog/5-relapse-prevention-ed-recovery