Eating disorders

Summary
-
Eating disorders are abnormal eating behaviours. The most common eating disorders are anorexia nervosa and bulimia nervosa.
- The factors that lead to eating disorders are complex and not clearly understood. It is widely acknowledged that psychological, social, biological, cultural and familial factors all play a role.
- Anorexia is characterised by refusal to maintain a normal body weight, intense fear of gaining weight, body image distortion and amenorrhea (the absence or stopping of the menstrual periods).
- Bulimia is characterised by repeated episodes of binge eating followed by inappropriate compensatory methods such as self-induced vomiting, the use of laxatives, diuretics, enemas or other medications, or excessive exercise.
- Treatment of eating disorders is most effective when it consists of a multidisciplinary approach including psychotherapy, nutritional advice and medical monitoring.
- Call a doctor if someone you know loses a substantial amount of weight, refuses to eat regularly, diets excessively, constantly feels fat when he/she is actually thin, exercises excessively to lose weight, uses laxatives, diuretics or diet pills, or vomits after eating.

Alternative names
Anorexia nervosa; anorexia
Bulimia nervosa; bulimia

What are eating disorders?
Eating disorders are abnormal eating behaviours. The most common eating disorders are anorexia nervosa and bulimia nervosa.

Anorexia nervosa:
Anorexia is characterised by refusal to maintain a normal body weight, intense fear of gaining weight, body image distortion and amenorrhea (the absence or stopping of the menstrual periods). It is subcategorised into restrictive (starvation) and purging (including bingeing and purging or excessive exercise).

Anorexia usually begins with a desire to diet and lose weight. It may be triggered by an event such as the end of a relationship or the death of someone significant. It may include the need to exert control over feelings, by instead controlling food intake.

The condition is more likely to start when a young person is going through a difficult life stage. The very high risk age for developing anorexia nervosa is 16-24 years, the earlier group going through many physical and social changes associated with increased anxiety levels.

Bulimia nervosa:
Bulimia, on the other hand, is characterised by repeated episodes of binge eating followed by inappropriate compensatory methods such as self-induced vomiting, the use of laxatives, diuretics, enemas or other medications, or excessive exercise.

There are two types of bulimia: the purging type (in which the person regularly self-induces vomiting or misuses laxatives, diuretics or enemas) and the non-purging type (in which the person uses other forms of inappropriate behaviour to compensate for overeating, such as fasting or excessive exercise).

Other eating disorders:
Both binge eating disorder and orthorexia nervosa have recently been described and proposed as eating disorders.

However, the focus of this article is on anorexia nervosa and bulimia nervosa, both of which are common, well-recognised illnesses.

What causes it?
Anorexia nervosa:
The factors that lead to anorexia are complex and not clearly understood. It is widely acknowledged that psychological, social, biological, cultural and familial factors all play a role in the development of the disorder.

Certain family patterns place an individual at risk for anorexia. Anorexic people often come from families that over-value high achievement. They are therefore often over-achievers who are perfectionists, hard-working, ambitious and compulsive about many aspects of their lives.

Bulimia nervosa:
The true cause of bulimia is not known, but there is some evidence to suggest that serotonergic, noradrenergic and endorphin dysfunction may be involved in development of the condition. This could possibly have some hereditary component.

Although many factors may contribute towards the development of bulimia, there is evidence that suggests the family environment plays an important role.

Eating disorders in general also have a known association with the Western obsession with slimness as a mark of beauty and success.

What are the symptoms?
Anorexia nervosa:
The following symptoms are present in confirmed cases of anorexia:
- Refusal to maintain body weight at or above 85 percent of normal for a person of that age and height.
- An intense fear of gaining weight or becoming fat, even though underweight.
- A distorted body image, with a perception of being overweight, even when thin.
- Being thin or emaciated and underweight.
- Absence of at least three consecutive menstrual cycles (unless on a contraceptive pill).

Other features which may be present include:
- Vomiting and abuse of laxatives in an attempt to control weight.
- Use of appetite suppressants.
- Strict rules about eating.
- Obsessive compulsive rituals.
- Excessive exercise.
- An abnormal preoccupation with food.
- Lack of sexual desire.
- Denial of the problem.
- Decline in day-to-day functioning.
- Efforts to hide or disguise the condition, such as wearing bulky and concealing clothing, vomiting in private and hiding food.
- Cognitive fall-off. Substance abuse is quite often evident. Sometimes alcohol can be the exclusive caloric intake.

Anorexia can have a serious impact on all areas of an individual's life. Starvation can lead to effects similar to depression. The individual is likely to be very tired, suffer from decreased attention and concentration and may lose interest in previously enjoyed activities. They may withdraw socially and interpersonal and close intimate relationships may suffer.

Associated medical complications related to starvation may include:
- Abnormally low heart rate
- Dry, sallow skin
- Fine downy hair on face and arms
- Excessive energy
- Cold intolerance, especially sensitivity in the hands and feet
- Low blood pressure or light-headedness
- Gastrointestinal problems such as constipation and abdominal pain
- Hormonal disturbances
- Swelling of joints
- Brittleness of hair and nails

In severe cases of semi-starvation, complications may include:
- Irregular heart rate
- Impaired kidney functioning
- Anaemia
- Severely low blood pressure
- Erosion of dental enamel because of repeated vomiting
- Brittleness of bones (osteoporosis)

The complications of anorexia can be fatal.

Bulimia nervosa:
The symptoms and signs of bulimia include:
- Recurrent episodes of binge eating. This is generally defined as eating more in a short period of time (less than two hours) than most people would eat under the same circumstances.
- A sense of lack of control over eating.
- Vomiting, misuse of laxatives, diuretics, enemas or other medications; fasting or excessive exercise are then used to try to compensate for any weight gain as a result of the binge.
- A distorted idea of body shape and size.

Warning signs of bulimia include:
- Visiting the toilet soon after meals (often you will hear the sound of running water to hide the sound of vomiting).
- Depressive moods.
- Strict dieting followed by increased criticism of body size or shape.
- Difficulty swallowing and retaining food.
- Puffiness around the face (below cheeks).
- Sudden appearance of acne.
- Damage to the throat.
- Headache.
- Dizziness.
- Increased impulsive behaviour and/or argumentativeness.
- Possible increase in drug use.

How is it diagnosed?
As with most psychiatric problems, a list of criteria which are found in a manual called the DSM4-R are used to reach a diagnosis. These criteria are essentially the same as the symptoms and signs listed above. A person who shows most or all of these symptoms and signs will be diagnosed as having an eating disorder.

How are eating disorders treated?
Anorexia nervosa:
The primary aim of treatment is to address the underlying psychological and interpersonal factors and to restore weight loss in a caring, humane manner. It is critical that weight restoration be the primary objective. Exploring underlying causes too early can exacerbate the anorexic behaviour.

Treatment is most effective when it consists of a multidisciplinary approach including psychotherapy, nutritional advice and medical monitoring.

Individual psychotherapy should be the first choice of treatment. A dietician is extremely important in offering adjunct treatment.

If the person is still living at home, family therapy will probably be suggested. Group therapy with a supportive network of people experiencing similar problems is best as an adjunct therapy, but a good option where finances are very limited.

Nutritional advice and medical attention will support these forms of psychotherapy. A target diet will be established in conjunction with the patient, who will be slowly coached to eat the required amount of calories for a healthy diet. Antidepressant and anti-anxiety drugs have been found to be useful in some cases.

In severe cases, patients may be hospitalised.

Bulimia nervosa:
As with anorexia, there are three main interventions:

Nutritional rehabilitation and counselling focus on correcting unhealthy eating patterns and behaviours are related to the eating disorder, and may be used together with other treatment methods. The idea is to minimise food restriction, increase the variety of foods eaten and encourage healthy, but not excessive, exercise.

Each patient needs to be carefully evaluated as to their psychological and intellectual development, any other psychological or psychiatric problems and their family situation. Wherever possible, family therapy should be considered, particularly for teenagers still living with parents or older patients who have problems with their family relationships.

Many people with bulimia benefit from antidepressants. This is particularly true at the start of treatment.

Prognosis
Anorexia nervosa:
Anorexia is considered a chronic disorder. Its course varies: there may be spontaneous recovery without treatment, recovery after any of a variety of treatments, a fluctuating course of weight gains followed by relapses, or a gradually deteriorating course resulting in death.

The prognosis for recovery is better if the disorder is detected and treated early. People with milder cases who do not require hospitalisation are also more likely to recover. Approximately 70 to 80 percent of people with eating disorders experience some success with treatment.

However, anorexia is often quite resistant to treatment and relapses are common. About 50 percent of anorexic people get back to their normal weight, but almost half of them continue to suffer from other symptoms such as depression, anxiety or difficulty with close interpersonal and familial relationships. Some sufferers will enter remission, but relapse into a bulimic condition or develop a drug (narcotic) dependency.

Bulimia nervosa:
Very little is known of the long-term prognosis of patients with untreated bulimia.

The overall short-term success rate for patients receiving psychotherapy treatment or medication has been reported to be 50-70 percent. Relapse rates of between 30 and 50 percent after six months to six years of follow-up have been reported for patients who were able to successfully complete a treatment programme. There is some evidence to suggest that these relapsed patients will, however, continue to slowly improve over 10 to 15 years if they are followed up on.

Patients who have good social functioning and relatively mild symptoms at the start of treatment generally do better than those whose symptoms are severe.

When to call your doctor
Call your doctor if someone you know:
- Loses a substantial amount of weight or shows rapid weight loss.
- Refuses to eat regularly.
- Diets excessively.
- Constantly feels fat when she or he is actually thin.
- Exercises excessively to lose weight.
- Is preoccupied with food and obsessive about kilojoule intake.
- Uses laxatives, diuretics or diet pills, or vomits after eating.
- Is dizzy, faints or is very listless.
- Has an irregular heartbeat.
- Has trouble sleeping and is hyperactive.
- Denies that there is a problem.
- Psychiatric complications such as depression or anxiety are present.

How can eating disorders be prevented?
Anorexia nervosa:
There is no known method for the prevention of anorexia, but the risk of a person developing the disorder may be reduced in the following ways:
- Parents and caregivers can help children focus on their strengths and reinforce a positive self-image in their child.
- Parents can take care that a child's sense of self worth does not become too closely related to feelings about body image and weight.
- Parents should not criticise children for being overweight or place undue emphasis on weight.
- Parents should discourage their children from dieting and rather focus on healthy eating patterns.
- People should try to spot suspicious behaviour or rigorous dieting as quickly as possible.
- Ideally, there should be less media emphasis on false ideals.

Bulimia nervosa:
The risk of a person developing bulimia may be reduced in the following ways:
- Parents should set good examples for appropriate eating and exercise patterns. If a mother feels good about herself, she will convey a positive body image to her daughter.
- Children must be taught to respond to hunger rather than environmental or emotional cues for eating.
- Parents should avoid placing moral values on food - classify them as "sometimes" and "always" foods rather than "good" and "bad" foods.
- Educators should provide information about the normal physical changes that occur during puberty and discourage fad diets and meal skipping. They should also encourage a healthy approach to weight loss, healthy exercise and moderate eating.
- The family should try to eat meals together. Meals should be regular (three meals and two to three snacks a day).

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