Eating disorders are illnesses in which the people experience severe disturbances in their eating behaviors and related thoughts and emotions. People with eating disorders typically become pre-occupied with food and their body weight.
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There is no one sign of an eating disorder, however there are red flags. These can include excessive “fat, weight or calorie talk,” a pattern of eating a limited choice of low-calorie food or a pattern of occasional binge eating of calorie-dense foods. People with anorexia nervosa may excessively exercise or excessively stand, pace or fidget. Affected individuals may severely limit the amount of calories they consume or may avoid weight gain following meals by inducing vomiting or abusing laxative, diuretic and diet pills. Feeling self-conscious about one’s eating behavior is common. Affected individuals often avoid social eating settings and eat alone.
There is no single cause of an eating disorder. We know that genetics play a large role, but genetic vulnerability is only part of the story. Environment plays a role too, especially in triggering onset, which often occurs in adolescence. Pressure to diet or weight loss related to a medical condition can be the gateway to anorexia nervosa or bulimia. For those who are genetically vulnerable to anorexia nervosa, once they lose the first five to 10 lbs, dieting becomes increasingly compelling and rewarding. Looked at another way, if eating disorders were the result solely of social pressure for thinness we would expect eating disorder rates to have increased as obesity has in the past few decades, yet anorexia nervosa and bulimia remain relatively rare and often cluster in families.
Treatment for an eating disorder is challenging. It involves interrupting behaviors that have become driven and compelling. Recovery takes a team, which includes family, friends and other social supports, as well as medical and mental health professionals. Be empathic, but clear. List signs or behaviors you have noticed and are concerned about. Help locate a treatment provider and offer to go with your friend or relative to an evaluation. Be prepared that the affected individual may be uncertain about seeking treatment. Treatment is effective, many are able to achieve full recovery and the vast majority will improve with expert care. Treatment assists affected individuals to change what they do. It helps them normalize their eating and reframe the irrational thoughts that sustain eating disordered behaviors. Food is central to many social activities and the practice of eating meals with supportive friends and family is an important step in recovery.
Eating disorders do not discriminate and can affect anyone. Although they are most common in young women, it is not unusual for older women to have an eating disorder. Some have had one all their life, others were only mildly affected until some life event triggers clinical worsening – a stressor, physical illness or a co-occurring psychiatric illness, such as depression or anxiety. Recent evidence strongly suggests that anxiety disorders, especially social anxiety disorder, and obsessive compulsive personality traits increase individual vulnerability to an eating disorder. Eating disorders occur in men too. An estimated 10 percent of people with anorexia nervosa and bulimia and a third or more of people with binge eating disorder are male.
Overeating on occasion or at festive occasions such as Thanksgiving is normal. By contrast, binge eating is the consumption of a large amount of food associated with a sense of loss of control over eating. Bingeing is usually a secretive behavior associated with feeling embarrassed, depressed and guilty. It often includes eating rapidly, untill uncomfortably full, or when not hungry and feeling disgusted by this behavior. Food addiction is a controversial term used by some researchers to describe parallels between the difficulties some people experience in limiting eating and substance addiction. Unlike in addiction however, where an individual is addicted to one particular class of drug, it is difficult to identify one food that underlies “food addiction.” Similarly the withdrawal syndrome caused by dependence on a drug of abuse is hard to demonstrate in overeaters. Despite the similarities between eating disorders and substance abuse, the neurobiology of binge eating and of drug addiction are not the same.
Research on eating disorders has progressed rapidly in the past decade. We now know that eating disorders are biologically based illnesses and not lifestyle choices. Recent research has focused on identifying who is most at risk for eating disorders genetically. New studies are focusing on epigenetic gene-environment interactions that may help our understanding of the causes and sustaining factors. This is exciting work that holds promise for developing novel treatments in the coming years.
The most effective current treatments are behavioral interventions. In anorexia nervosa, family-based therapy is the treatment of choice in adolescents. For severely ill patients at very low weight who are unable to gain weight in outpatient treatment, admission to a specialized residential or hospital-based treatment program can be lifesaving. The most consistent indicator of relapse after intensive treatment is incomplete weight restoration, so reaching a healthy weight is necessary for recovery. Evidence now suggests that weight gain rates of three to four lbs a week are safe for patients with close medical monitoring and 24-hour nursing care. Some programs utilize feeding tubes. However, behavioral specialty programs are able to achieve weight gain of four pounds a week with oral feeding alone in most cases. Close outpatient follow up care following hospitalization is important as relapse risk is elevated for six months following inpatient treatment.
For bulimia, cognitive behavioral therapy is the most successful outpatient treatment approach. Binge eating also responds to cognitive behavioral interventions. Interpersonal therapy is effective in both bulimia and in binge eating disorder. Some medications may be useful along with these therapies.
With the advent of two federal laws (the Mental Health Parity and Addiction Equity Act (MHPAEA) and the Affordable Care Act (ACA)) more individuals are now eligible for coverage of treatment for eating disorders. The ACA prohibits insurance from denying coverage for a pre-existing condition and provides for coverage for young adults up to age 26 under their parents’ insurance. This is important as many individuals develop an eating disorder in their teens or early adulthood.
The problem, however, is that inpatient or residential treatment for severe anorexia nervosa may require weeks or even months of treatment for patients to reach a healthy weight. The criteria set by insurance companies to assess medical necessity for ongoing hospitalization or residential care remain very stringent. As a result, even when patients qualify for admission, adequate treatment remains difficult to obtain for many, as insurance will often only cover partial weight restoration. The evidence suggests that only full weight restoration in anorexia is associated with improved prognosis. For more information on insurance-related questions see the National Eating Disorders Association (NEDA) and the Eating Disorders Coalition.
Here are some questions that may be relevant to an admission for treatment of anorexia nervosa include:
- What are your average rates of weekly weight gain? What percentage of your patients reach full weight restoration?
- Do you employ oral refeeding only and if not, what percentage of patients have a feeding tube placed?
- What is the target weight you use and how do you establish it?
- What types of therapy do you offer?
- How are families involved in treatment?
- What are the credentials and training of your staff?
- What medical services do you provide and how do you manage medical complications or co-occurring psychiatric conditions?
Lists of outpatient and inpatient providers are available from the Academy of Eating Disorders and the National Eating Disorders Association.