Eating Disorders

Eating disorders are likely more common than we suspect because they are often hidden from family and health care providers. You may encounter eating disorders on the ward or in the outpatient setting, depending on severity and secondary health effects. Although previously characterized as affecting non-Hispanic white, affluent adolescent girls, eating disorder behaviors are increasingly identified in all racial and ethnic groups, lower socioeconomic classes, preadolescent children, males, and children and adolescents perceived as having an average or increased body size. In all these populations, diagnosis may be delayed or overlooked.

An eating disorder stems from disordered thoughts and behaviors surrounding eating that may alter the intake or absorption of food and can have negative effects on health and psychosocial factors (and social engagement).

Individuals with eating disorders may experience shame and guilt about their eating habits. In addition, sensitivity to the stigma of eating disorders can make someone reluctant to discuss their behaviors. Talking to patients about an eating disorder requires patience, empathy, and the creation of a safe environment to encourage disclosure of the behavior.

Types of Feeding and Eating Disorders

In the section on Feeding and Eating Disorders, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), recognizes the following six unique eating disorders plus two additional diagnoses (other specified feeding or eating disorder and unspecified feeding or eating disorder).

• Pica: Recurrent and consistent eating of nonnutritive, nonfood substances that is neither developmentally appropriate nor culturally guided for at least one-month duration. Individuals with the condition may routinely ingest substances such as ice, clay, cornstarch, paper, and soap and usually do not have an underlying aversion to food.

• Rumination disorder: Regurgitation of food followed by its rechewing, re-swallowing, or spitting out for at least a period of one month.

• Avoidant/restrictive food intake disorder (ARFID): Avoidance of food or restriction of intake due to lack of interest or distaste that results in an inability to meet nutritional needs and leads to significant weight loss, nutritional deficiency, dependence on nutritional supplements or artificial nutrition, or impairment in psychosocial functioning.

  • ARFID differs from anorexia nervosa in that affected individuals do not experience the emotional distress components of fear of weight gain or distorted body image associated with anorexia.

• Anorexia nervosa: Behavior driven by the pursuit of thinness, a fear of obesity, or a distorted body image that leads to restriction of food intake out of balance with requirement and often results in significantly low body weight (less than minimally normal for adults or less than minimally expected for children or adolescents) and negative effects on health. The two subtypes of anorexia nervosa are characterized by the presence or absence of binge-eating or purging behavior:

  • the restricting type (without binging or purging behavior)

  • binge-eating/purging type

• Bulimia nervosa: Recurrent, frequent episodes of overeating followed by compensating behavior such as purging (e.g., self-induced vomiting, laxative use, enemas, or excessive exercise) to avoid weight gain.

  • Unlike anorexia nervosa, individuals may be any weight — even normal or overweight. However, body image distortions are like those experienced by patients with anorexia nervosa.

• Binge-eating disorder: Recurring episodes of overeating or consumption of large amounts of food due to the feeling of a lack of control leading to:

  • eating faster than normal or more than normal although not hungry

  • eating alone to avoid embarrassment

  • eating until uncomfortably full

  • feelings of disgust, depression, or guilt afterward

  • differs from bulimia nervosa in that individuals do not exhibit compensatory behaviors to avoid weight gain (e.g., purging) or to prevent weight gain

Screening

The SCOFF questionnaire is a British assessment tool developed in 1999 that offers a set of questions to use to begin a conversation about weight loss and eating behaviors. The questions can be used during a routine clinic visit or school physical exam.

The Eating Attitudes Test is a standardized self-report measure of symptoms and concerns characteristic of eating disorders.

Diagnosis

History: A thorough history remains the foundation for diagnosis of an eating disorder. Gathering information from the patient as well as family members, friends, and teachers may reveal signs of disordered eating, including:

• family members or teachers notice or report withdrawal from social engagements, especially any that involve food

• a history of rapid weight loss that is excessive or worrying to the person, their family, or other health professionals

• a disproportionate value placed on thinness, a fear of being fat, history of food restriction, excessive exercise, or binge-and-purge episodes — either occurring together or separately

• patient report of feeling easily fatigued or dizzy

• a history of gastrointestinal or endocrine problems (e.g., delayed onset of menses in pediatric patients or secondary amenorrhea in adults)

• patient or family report excessive diet pill or laxative use

• signs of pallor or evidence of purge behaviors (e.g., enlarged salivary glands, eroded dentition, or scars on the back of the hands)

• unexplained electrolyte or micronutrient imbalances or hypoglycemia

• coexisting mental health problems: depression and anxiety disorders are among the most common psychiatric comorbidities occurring in patients with eating disorders; premorbid psychopathology is more common in preteens than older adolescents

• disordered eating attitudes in males may focus on leanness, weight control, and muscularity; purging, use of muscle-building supplements, substance abuse, and comorbid depression are common

• chronic health conditions in adolescents requiring dietary control (e.g., diabetes, cystic fibrosis, inflammatory bowel disease, and celiac disease) may also increase risk of disordered eating

Laboratory Testing

Purging and laxative use are characteristic of anorexia nervosa and bulimia nervosa. These behaviors can cause electrolyte abnormalities in routine labs. The following table provides some recommended laboratory studies for the assessment of patients with anorexia nervosa.

Patients with the binge-eating or purging subtype of anorexia nervosa can have similar electrolyte abnormalities as patients with bulimia. The following table provides serum and urine electrolyte changes usually associated with purging.

(Source: Bulimia Nervosa. N Engl J Med 2003.)

Treatment

It is important to assess what patients and their family members or caregivers know about eating disorders and address any concerns or misconceptions. Advising and educating patients and caregivers about the condition, available treatment options, and support services (for both the patient and their support network) form the basis of treatment. Some treatment approaches include:

• Nutritional therapy: Nutritional therapy focuses on guidance for healthy food and energy intake. Weight gain is a surrogate marker for improving health. In female patients, being persistently underweight can cause secondary amenorrhea. In recovery, the return of menses can be another sign of improvement. Encourage a steady weight gain of 0.5-1.0 pound per week to avoid refeeding syndrome (shifts in fluid and electrolytes associated with the initiation of nutrition following a period of malnutrition or starvation).

• Psychotherapy: Eating-disorder-focused cognitive behavior therapy and interpersonal psychotherapy focusing on relationships, loss, and changing roles (e.g., associated with marriage or employment).

• Pharmacotherapy: Some antidepressant classes, such as the selective serotonin-reuptake inhibitors (e.g., fluoxetine), have been shown to reduce depressive symptoms as well as the frequency of binge-and-purge behaviors in bulimia nervosa. Although data are lacking to support the use of any particular pharmacologic intervention for treatment of anorexia nervosa, treatment of comorbid depression or anxiety may be beneficial.

• Family-based therapy: Family therapy may be useful in patients with both bulimia nervosa and anorexia nervosa, particularly in adolescents. Maudsley Anorexia Nervosa Treatment for Adults (MANTRA) is a method of personal or family-based therapy used in the treatment of anorexia nervosa.

• Inpatient treatment: When deciding whether to admit a patient, consider the patient’s motivation to pursue therapy, the availability of treatment resources in the community, and whether psychosocial or family supports are present to help the patient during outpatient care. Once admitted to the hospital and immediate issues are stabilized, patients may require further inpatient care and support and are recommended to continue care at a facility specializing in eating-disorder therapy. Inpatient treatment is usually individualized to address symptom severity and comorbid psychiatric conditions. The following table lists criteria to use to determine when a patient presenting with severe symptoms secondary to eating-disordered behavior may require admission for inpatient hospital care.

(Source: Anorexia Nervosa. N Engl J Med 2005.)