Eating Disorders and The Search For Solutions

Facts About Eating Disorders and the Search for Solutions

Eating is controlled by many factors, including appetite, food
availability, family, peer, and cultural practices, and attempts at
voluntary control. Dieting to a body weight leaner than needed for
health is highly promoted by current fashion trends, sales campaigns for
special foods, and in some activities and professions. Eating disorders
involve serious disturbances in eating behavior, such as extreme and
unhealthy reduction of food intake or severe overeating, as well as
feelings of distress or extreme concern about body shape or weight.
Researchers are investigating how and why initially voluntary behaviors,
such as eating smaller or larger amounts of food than usual, at some
point move beyond control in some people and develop into an eating
disorder. Studies on the basic biology of appetite control and its
alteration by prolonged overeating or starvation have uncovered enormous
complexity, but in the long run have the potential to lead to new
pharmacologic treatments for eating disorders.

Eating disorders are not due to a failure of will or behavior; rather,
they are real, treatable medical illnesses in which certain maladaptive
patterns of eating take on a life of their own. The main types of eating
disorders are anorexia nervosa and bulimia nervosa.1 A third type,
binge-eating disorder, has been suggested but has not yet been approved
as a formal psychiatric diagnosis.2 Eating disorders frequently develop
during adolescence or early adulthood, but some reports indicate their
onset can occur during childhood or later in adulthood.3

Eating disorders frequently co-occur with other psychiatric disorders
such as depression, substance abuse, and anxiety disorders.1 In
addition, people who suffer from eating disorders can experience a wide
range of physical health complications, including serious heart
conditions and kidney failure which may lead to death. Recognition of
eating disorders as real and treatable diseases, therefore, is
critically important.

Females are much more likely than males to develop an eating disorder.
Only an estimated 5 to 15 percent of people with anorexia or bulimia4
and an estimated 35 percent of those with binge-eating disorder5 are
male.

Anorexia Nervosa

An estimated 0.5 to 3.7 percent of females suffer from anorexia nervosa
in their lifetime.1 Symptoms of anorexia nervosa include:

- Resistance to maintaining body weight at or above a minimally normal
weight for age and height

- Intense fear of gaining weight or becoming fat, even though
underweight

- Disturbance in the way in which 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 current low body weight

- Infrequent or absent menstrual periods (in females who have reached
puberty)

People with this disorder see themselves as overweight even though they
are dangerously thin. The process of eating becomes an obsession.
Unusual eating habits develop, such as avoiding food and meals, picking
out a few foods and eating these in small quantities, or carefully
weighing and portioning food. People with anorexia may repeatedly check
their body weight, and many engage in other techniques to control their
weight, such as intense and compulsive exercise, or purging by means of
vomiting and abuse of laxatives, enemas, and diuretics. Girls with
anorexia often experience a delayed onset of their first menstrual
period.

The course and outcome of anorexia nervosa vary across individuals: some
fully recover after a single episode; some have a fluctuating pattern of
weight gain and relapse; and others experience a chronically
deteriorating course of illness over many years. The mortality rate
among people with anorexia has been estimated at 0.56 percent per year,
or approximately 5.6 percent per decade, which is about 12 times higher
than the annual death rate due to all causes of death among females ages
15-24 in the general population.6 The most common causes of death are
complications of the disorder, such as cardiac arrest or electrolyte
imbalance, and suicide.

Bulimia Nervosa

An estimated 1.1 percent to 4.2 percent of females have bulimia nervosa
in their lifetime.1 Symptoms of bulimia nervosa include:

- Recurrent episodes of binge eating, characterized by eating an
excessive amount of food within a discrete period of time and by
a sense of lack of control over eating during the episode

- Recurrent inappropriate compensatory behavior in order to prevent
weight gain, such as self-induced vomiting or misuse of laxatives,
diuretics, enemas, or other medications (purging); fasting; or
excessive exercise

- The binge eating and inappropriate compensatory behaviors both occur,
on average, at least twice a week for 3 months

- Self-evaluation is unduly influenced by body shape and weight

Because purging or other compensatory behavior follows the binge-eating
episodes, people with bulimia usually weigh within the normal range for
their age and height. However, like individuals with anorexia, they may
fear gaining weight, desire to lose weight, and feel intensely
dissatisfied with their bodies. People with bulimia often perform the
behaviors in secrecy, feeling disgusted and ashamed when they binge, yet
relieved once they purge.

Binge-Eating Disorder

Community surveys have estimated that between 2 percent and 5 percent of
Americans experience binge-eating disorder in a 6-month period.5,7
Symptoms of binge-eating disorder include:

- Recurrent episodes of binge eating, characterized by eating an
excessive
amount of food within a discrete period of time and by a sense of lack
of control over eating during the episode

- The binge-eating episodes are associated with at least 3 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 being embarrassed by how much
one is eating; feeling disgusted with oneself, depressed, or very guilty
after overeating

- Marked distress about the binge-eating behavior

- The binge eating occurs, on average, at least 2 days a week for 6
months

- The binge eating is not associated with the regular use of
inappropriate compensatory behaviors (e.g., purging, fasting,
excessive exercise)

People with binge-eating disorder experience frequent episodes of
out-of-control eating, with the same binge-eating symptoms as those with
bulimia. The main difference is that individuals with binge-eating
disorder do not purge their bodies of excess calories. Therefore, many
with the disorder are overweight for their age and height. Feelings of
self-disgust and shame associated with this illness can lead to bingeing
again, creating a cycle of binge eating.

Treatment Strategies1

Eating disorders can be treated and a healthy weight restored. The
sooner these disorders are diagnosed and treated, the better the
outcomes are likely to be. Because of their complexity, eating disorders
require a comprehensive treatment plan involving medical care and
monitoring, psychosocial interventions, nutritional counseling and, when
appropriate, medication management. At the time of diagnosis, the
clinician must determine whether the person is in immediate danger and
requires hospitalization.

Treatment of anorexia calls for a specific program that involves three
main phases: (1) restoring weight lost to severe dieting and purging;
(2) treating psychological disturbances such as distortion of body
image, low self-esteem, and interpersonal conflicts; and (3) achieving
long-term remission and rehabilitation, or full recovery. Early
diagnosis and treatment increases the treatment success rate. Use of
psychotropic medication in people with anorexia should be considered
only after weight gain has been established. Certain selective serotonin
reuptake inhibitors (SSRIs) have been shown to be helpful for weight
maintenance and for resolving mood and anxiety symptoms associated with
anorexia.

The acute management of severe weight loss is usually provided in an
inpatient hospital setting, where feeding plans address the person's
medical and nutritional needs. In some cases, intravenous feeding is
recommended. Once malnutrition has been corrected and weight gain has
begun, psychotherapy (often cognitive-behavioral or interpersonal
psychotherapy) can help people with anorexia overcome low self-esteem
and address distorted thought and behavior patterns. Families are
sometimes included in the therapeutic process.

The primary goal of treatment for bulimia is to reduce or eliminate
binge eating and purging behavior. To this end, nutritional
rehabilitation, psychosocial intervention, and medication management
strategies are often employed. Establishment of a pattern of regular,
non-binge meals, improvement of attitudes related to the eating
disorder, encouragement of healthy but not excessive exercise, and
resolution of co-occurring conditions such as mood or anxiety disorders
are among the specific aims of these strategies. Individual
psychotherapy (especially cognitive-behavioral or interpersonal
psychotherapy), group psychotherapy that uses a cognitive-behavioral
approach, and family or marital therapy have been reported to be
effective. Psychotropic medications, primarily antidepressants such as
the selective serotonin reuptake inhibitors (SSRIs), have been found
helpful for people with bulimia, particularly those with significant
symptoms of depression or anxiety, or those who have not responded
adequately to psychosocial treatment alone. These medications also may
help prevent relapse. The treatment goals and strategies for
binge-eating disorder are similar to those for bulimia, and studies are
currently evaluating the effectiveness of various interventions.

People with eating disorders often do not recognize or admit that they
are ill. As a result, they may strongly resist getting and staying in
treatment. Family members or other trusted individuals can be helpful in
ensuring that the person with an eating disorder receives needed care
and rehabilitation. For some people, treatment may be long term.

Research Findings and Directions

Research is contributing to advances in the understanding and treatment
of eating disorders.

- NIMH-funded scientists and others continue to investigate the
effectiveness of psychosocial interventions, medications, and the
combination of these treatments with the goal of improving outcomes for
people with eating disorders. 8,9

- Research on interrupting the binge-eating cycle has shown that once a
structured pattern of eating is established, the person experiences less
hunger, less deprivation, and a reduction in negative feelings about
food and eating. The two factors that increase the likelihood of
bingeing-hunger and negative feelings-are reduced, which decreases the
frequency of binges.

- 10Several family and twin studies are suggestive of a high
heritability
of anorexia and bulimia,11,12 and researchers are searching for genes
that confer susceptibility to these disorders. 13Scientists suspect
that multiple genes may interact with environmental and other factors
to increase the risk of developing these illnesses. Identification of
susceptibility genes will permit the development of improved treatments
for eating disorders.

- Other studies are investigating the neurobiology of emotional and
social behavior relevant to eating disorders and the neuroscience of
feeding behavior.

- Scientists have learned that both appetite and energy expenditure are
regulated by a highly complex network of nerve cells and molecular
messengers called neuropeptides. 14,15 These and future discoveries will
provide potential targets for the development of new pharmacologic
treatments for eating disorders.

- Further insight is likely to come from studying the role of gonadal
steroids. 16,17 Their relevance to eating disorders is suggested by the
clear gender effect in the risk for these disorders, their emergence at
puberty or soon after, and the increased risk for eating disorders among
girls with early onset of menstruation.