Question: My child is eating less food than usual. I am not sure if it's a phase or an eating disorder. The term "eating disorder" confuses me. Can you explain the different types of eating disorders?
I find few areas in medicine as controversial as nutrition. It seems to me that there are many opinions which are contradictory and strongly held by a vast spectrum of experts.
At the present time the American Psychiatric Association's DSM criteria offers the best approach to categorizing the three main eating disorders:
- Anorexia nervosa
- Bulimia nervosa
- Eating disorder not otherwise specified (EDNOS)
According to DSM criteria, anorexic patients refuse to maintain their body weight at or above a minimally normal weight for age and height; they have an intense fear of gaining weight or becoming fat, even though underweight; they deny the seriousness of the current low body weight; and, if female, they experience amenorrhea (a failure to menstruate for at least three consecutive menstrual cycles).
Bulimia is characterized by frequent binge eating and subsequent compensatory behavior to get rid of the food or weight gain. These patients resort to binge eating to satisfy their overwhelming hunger and cannot depend on the usual satiety cues to stop eating. The binge eating and compensatory behaviors both occur, on average, at least twice a week for three months. According to DSM criteria there are two types:
- Purging Bulimia: patients use vomiting, laxatives, diuretics, diet pills or enemas to counter binge eating.
- Non-purging Bulimia: patients fast or use exercise excessively to lose or maintain weight.
The last category of eating disorder, Eating Disorders Not Otherwise Specified (EDNOS), is an important condition to learn to recognize as it is often the precursor to one of the more severe eating disorders. Unfortunately, it often goes undiagnosed because it is not as severe as the other two conditions. The earlier EDNOS is detected, the greater the chance that the condition will not progress to anorexia.
The exact causes of these eating disorders remain elusive. However, there are at least five areas that we can study to determine causation:
- Genetics
- Hormonal imbalances (i.e. in serotonin and leptin)
- Family dynamics
- Socio-cultural factors
- Psycho developmental considerations
It is interesting to note that the risk for developing anorexia increases four-fold when there is a first degree relative with an eating disorder. Other factors which may play a role are:
- Perfectionism
- Low self-esteem
- Families described as over-involved and overprotective
- A history of various forms of abuse including sexual, verbal, physical or emotional
The prevalence of anorexia nervosa is estimated to be between 0.3% and 3% and over the past 20-years the incidence of this disorder has doubled. The majority of patients are white adolescent females, but the incidence among teenage males and non-white populations has increased. Males represent about 5-10% of patients with eating disorders.
Anorexia is more common among those who participate in activities such as, gymnastics, ice-skating, ballet and modeling, because these activities often require a thin body shape and size for success. Sadly, two-thirds of patients with anorexia are of normal weight at the onset of their disorder.
Patients with bulimia nervosa are usually older than their anorexic counterparts but a third of them have a history of anorexia. They tend to have an increased incidence of borderline personalities and they have challenges with impulse control and high-risk behaviors.
The treatment for anorexia is very complex and requires a team of patient and knowledgeable experts. Hospitalization is usually required when there is a history of:
- Severe malnutrition
- Dehydration
- Electrolyte imbalance
- Abnormal heart rate
- Low blood pressure
- Acute refusal of any food
- Seizures
- Suicidal ideation
- Severe depression or obsessive compulsive behaviors
It comes as no surprise that poor nutrition impacts growth of just about all parts of the body; but, the skeletal structure, reproductive organs, heart, brain and kidneys are particularly vulnerable to the ravages of eating disorders.
According to recent data from the American Academy of Pediatrics, about 50% of patients with anorexia achieve full recovery, 30% experience partial recovery, and 20% have no substantial improvement. Death rates vary, but the Academy's figures indicate a mortality rate of about 5%.
Even when anorexic patients recover, they may still have to deal with poor self-esteem, school troubles, relationship challenges, and, eventually, job performance issues. Anorexia and all of its consequences do not go away overnight; but, I believe that with a lot of determination, love, and belief it can be faced and overcome.
For more information on eating disorders see a fine article published in the New England Journal of Medicine (Becker, A.E. et al, “Eating Disorders”, NEJM 1999; 340: 1092-1098).
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