Eating
Disorders Revealed
Today’s Dietitian
By Kate Jackson
Vol. 6 No. 5 p. 37
Are parents, teachers, and healthcare providers
turning a blind eye toward the signs and symptoms of eating disorders?
Young people with anorexia, bulimia, or binge eating
disorder may hide these emotional afflictions and their resulting
weight loss or gain under fashionably baggy clothing until changes
are extreme. They may also become adept at disguising disordered
eating behaviors until dramatic changes in appearance draw attention
to them.
A recent report in the Los Angeles Times suggests
that in as many as one-half of all cases of eating disorders, early
warning signs are overlooked, even by doctors. American Dietetic
Association (ADA) national spokesperson Katherine Tallmadge, MA,
RD, recalls a client of hers, now in her 20s, who went on a diet
at the age of 12 and lost approximately 100 pounds. Since that time,
she’s been starving by day and bingeing by night. “Her
weight has fluctuated wildly, but it’s mostly down,”
says Tallmadge. During the client’s adolescence and young
adulthood, nobody seems to have noticed that there may be a problem.
“When this kid lost 100 pounds going on a diet on her own,
people should have been asking what she was doing.” But no
one did.
Not until she finally sought the help of a registered
dietitian more than a decade after her symptoms began did this troubled
young woman get the help she needed, which involved not only dietary
counseling, but also medical attention and psychological counseling.
But, only a small number of those afflicted with an eating disorder
will seek the services of a dietitian, says Tallmadge. “So
few people come to see us—this case represents one person
out of thousands or even millions of people who have the same problem
and aren’t getting help.” Tallmadge’s patient
was lucky to get help in time. Many more are dying to be thin.
AN ESCALATING PROBLEM
Although it’s unclear what underlies eating disorders, it
seems likely that media-driven pressure about body perfection has
played a role. Rates of these disorders have increased twofold since
the 1960s, and as many as 8 million Americans are believed to be
affected. The fear of fat and the zeal to be thin are manifesting
themselves in disorded eating behaviors and the physical consequences
in children as young as 6. According to Margo Maine, PhD, in Body
Wars: Making Peace with Women’s Bodies, 42% of girls in first
through third grade want to be thinner, 9% of 9-year-olds have vomited
to lose weight, 81% of 10-year-olds are afraid of being fat, and
the most common wish of girls aged 11 to 17 is to lose weight.
THE HIGH COST OF NEGLECT
Eating disorders can lead to multiple and severe medical complications,
including stunted growth, cardiovascular compromise, metabolic disturbances,
gastrointestinal disorders, osteoporosis, infertility, dehydration,
and multiple organ compromise. Some of the more dire consequences
are likely to require hospitalization, often long-term, which is
frequently not covered by insurance. When the disorders are not
detected and treated early, the damage caused can be—and often
is—deadly. According to Maine, who reported on the subject
at a Congressional briefing, “The mortality rate at five years
after diagnosis of clinical eating disorders is 5% and at 20 years
after the onset of symptoms is as high as 20%. The death rate for
women aged 15 to 24,” she adds, “is 12 times that which
is normally expected, and the rate of suicide is 75 times greater.”
Anorexia nervosa, or self-starvation, is a serious
psychological disorder characterized by an extreme fear of gaining
weight, a refusal to eat, and the belief, despite evidence to the
contrary, that one is greatly overweight. It frequently occurs in
individuals with other mental disorders such as clinical depression,
anxiety, personality disorder, substance abuse disorders, and obsessive-compulsive
disorders (OCDs). It can result in fluid and electrolyte imbalances,
organ atrophy, bone density loss that may lead to osteoporosis,
reduced muscle mass, lightheadedness, brain atrophy, thyroid dysfunction,
mild anemia, swollen joints, irregular heartbeat that can result
in cardiac arrest, memory impairment, mental disorientation, liver
disease, kidney disease or failure, and deterioration of the muscles,
including the heart.
Anorexia, which usually begins at puberty and, surprisingly,
is the leading cause of death in young women, carries a higher mortality
rate—as high as 20%—than that for any other psychological
disorder. According to the National Association of Anorexia Nervosa
and Associated Disorders, only one-half of all cases of anorexia
are cured, 5% to 10% of anorexics die within 10 years of the onset
of disordered eating behaviors, and 18% to 20% die within 20 years.
According to the National Institute of Mental Health (NIMH), approximately
one-half of anorexics will eventually develop bulimia as well.
Bulimia, characterized by excessive eating followed
by compensatory behaviors such as purging via compulsive exercising,
vomiting, or the use of laxatives, diuretics, or enemas, also tends
to appear first during adolescence. It is often more difficult than
other disorders to detect because bulimics may maintain a more stable
body weight than do anorexics or those suffering from binge eating
disorder. As with anorexia, individuals suffering from bulimia may
also battle addictions, depression, anxiety, and OCD. Loss of vital
minerals can lead to heart failure, and the acid in vomit can erode
the outer layer of the teeth and inflame the esophagus. Like anorexia,
bulimia is often deadly. According to the NIMH, “Individuals
with eating disorders who use drugs to stimulate vomiting, bowel
movement, or urination are in the most danger, as this practice
increases the risk of heart failure.”
Individuals with binge eating disorder, which appears
to be more common than anorexia and bulimia, have no control over
their intake of food and consume large amounts within a short period
of time, becoming full to the point of pain. Unlike bulimics, those
with binge eating disorder do not attempt to counter bingeing behavior
with purging, fasting, using laxatives or diuretics, or compulsively
exercising. Men make up as much as 40% of those with this disorder,
which affects 1% to 4% of the population. The consequences of this
out-of-control feasting may include menstrual irregularities, diabetes,
osteoarthritis, obesity, hypertension, high cholesterol, coronary
disease, depression and anxiety, suicidal ideation, and death.
RDs SPREADING THE WORD
Dietitians can help spread the word about the signs and symptoms
of clinical eating disorders as well as the behaviors of individuals
with subclinical eating disorders. Early detection and intervention
can prevent serious health consequences and decrease mortality,
but physicians and educators may not be encouraged to search for
the clues or may not recognize those clues when they appear. “I
don’t think healthcare professionals look for these problems
enough,” says Tallmadge. “I’ve worked with a lot
of 20- or 30-year-old patients who came to me because they wanted
to lose weight. It was so obvious that they had eating disorders,
but their doctors never picked it out.”
To help those who nurture or care for individuals
with hidden eating disorders get appropriate recognition and treatment,
dietitians can take all opportunities to provide education that
will let them look upon eating problems with eyes wide open. Once
an eating disorder is suspected, it may still be a challenge to
get appropriate help because those who suffer from such conditions
may be resistant to treatment and therapy. In some cases, says Tallmadge,
parents may need to see therapists themselves to learn how they
may help their children. A therapist, she says, “can guide
the parents in how to respond to bizarre behaviors of not wanting
to eat and how to respond in a way that might be more successful.”
SHATTERING THE PROFILE
The first hurdle, however, is to detect the disorder. The victims
themselves seldom address the problem or seek help because it’s
in their interest to hide it. Explains Cynthia Sass, MPH, MA, RD,
LD/N, ADA national spokesperson, “Secrecy is the ‘nature
of the beast’ with eating disorders, particularly bulimia.
Those with eating disorders become very good at hiding them; therefore,
it can take longer to identify the problem.”
Sometimes parents—the people seemingly most
likely to observe eating disordered behaviors—choose not to
identify the behavior, are unaware of the signs, or, says Sass,
think their children will grow out of it. “Sometimes, part
of the issue is that they may not want to see them,” says
Tallmadge, who adds, “so [the problem] may be obvious to everyone
but the parents.” Worse still, she explains, sometimes parents
are happy that their children are losing weight. “I have one
client,” she says, “ whose mother encouraged her to
smoke to get thin.”
One of the obstacles is that when educators and
caregivers do look for eating disorders, they look with a narrow
focus. To catch all who may be afflicted, they need to shatter stereotypes
and break down the notion that there’s a profile for individuals
with eating disorders.
Although often thought to be problems that affect
young, white women, anorexia, bulimia, and binge eating disorder
occur in the young and old, male and female, the poor and affluent,
and individuals who are of all races and ethnicities. Among all
of these groups, there may be individuals unconsciously or deliberately
concealing a serious disorder, but since they seem to be outside
the profile, they slip through the cracks. According to Gayle E.
Brooks, PhD, vice president of clinical services, The Renfrew Center,
who spoke at a congressional briefing last December, “Since
women of color and poor women do not fit the affluent, white girl
profile, doctors and therapists often fail to assess them properly
for eating disorders. Research has found that it takes longer for
nonwhite women to be correctly diagnosed with anorexia and their
symptoms are more severe at the time of diagnosis.”
Boys and men are often overlooked. Many men, for
example, may not eat all day and then binge all night long, a behavior
Tallmadge sees frequently in men, even those in their 40s and 50s.
Another stumbling block to diagnosis, says Dawn Jackson, RD, LD,
Northwestern Memorial Wellness Institute, ADA national spokesperson,
“Some of the signs and symptoms can look just like those of
a typical teen going through the typical teenage years.” Therefore,
she says, “it’s often very difficult to catch at the
beginning stages for both parents and healthcare providers.”
“I’ve seen more and more eating disorders
among older people,” says Tallmadge. “I’m shocked
at the number of women in their late 20s and 30s with eating disorders.”
One of her clients was a 40-year-old woman suffering from anorexia.
In some cases, these older patients have battled their weight for
years. “All of a sudden, they go on a diet, then the diet
never stops, and they become petrified of gaining the weight back.”
It can happen at any age, she says. “They latch onto a diet
and think that it’s working for them, and they can’t
stop because they have a horrible fear of weight gain.” By
the time they seek help, she says, what they’re manifesting
is fear—fear of weight gain, bingeing, overeating, and losing
control. “We all harbor little fears like that,” she
explains, “but their fears are beyond the norm. They’re
excessive to the point where they starve.”
The following is merely a sampling of the many telltale
signs and behaviors to which educators, caregivers, and healthcare
professionals should be alert.
ABNORMAL EATING HABITS
Although many young people are picky about foods, those with eating
disorders may be more than normally fussy about certain foods or
have eating rituals that may be tip-offs. Anorexics, for example,
says Tallmadge, may be squeamish about fattening foods. It’s
not uncommon for them, she explains, to become vegetarians or vegans.
That, she’s quick to point out, is not necessarily a negative
thing, but any dramatic change in eating habits or a change from
what the family normally eats is a sign. Adopting a vegetarian diet
is one way that eating disordered individuals can take control of
what they’re eating. “Sometimes, it’s the only
thing they can think of to get out of eating what the rest of the
family is eating,” says Tallmadge.
Parents of young people with binge eating disorder
or bulimia may notice that their children eat nonstop all afternoon.
People with anorexia may complain of feeling bloated because, says
Tallmadge, they psychologically associate bloating with certain
foods. Individuals with eating disorders have food fears, she says,
and will come up with a roster of excuses not to eat. “They’ll
have certain foods they won’t touch—for example, pasta—and
they’ll make up reasons such as ‘It’ll give me
a stomachache, it makes me sick, I’m allergic to it.’
I had an anorexic patient who told me she felt like passing out
after she drank juice because she was afraid of the high calories.”
What’s typically on a person’s plate
may provide clues to undiagnosed eating disorders. If salads, high-fiber
foods, and diet sodas are the staples, consider the possibility
of anorexia. “Anorexics get really good at understanding the
concepts of weight loss,” says Tallmadge. “We teach
people that to lose weight they should eat more fruits and vegetables,
but anorexics take it to the extreme. They stuff themselves with
fruit and vegetables, which have few calories, so that they don’t
eat anything else.”
Additionally, those with eating disorders, who typically
deny hunger, will often eat alone and will often exhibit ritualistic
eating patterns, such as pushing food around on a plate to deflect
attention from the failure to eat, eating one food at a time, not
allowing certain foods to touch on the plate, or insisting on eating
from a certain bowl or plate.
COMPULSIVE EXERCISE
Obsessiveness about exercise is a clear sign of the presence of
an eating disorder. “Most people with eating disorders exercise
excessively,” says Tallmadge. According to Sass, individuals
with eating disorders may make drastic changes in exercise habits,
going to extremes—from not exercising at all to all of a sudden
training for a marathon. In addition, she says, they may participate
in activities that typically have demanding coaches and weight and
performance goals, such as ballet or wrestling.
MOOD CHANGES
“The immediate physical consequences of starving yourself
or eating too little for a long period,” says Tallmadge, “are
depression, irritability, indifference to socializing, lack of interest
in sex, and inability to concentrate. During adolescence, some of
the signs may be difficult to distinguish from those of normal adolescence,
such as irritability, mood swings, and isolation or withdrawal from
others.”
PHYSICAL SIGNS AND SYMPTOMS
Apart from the obvious fluctuations in weight, individuals with
eating disorders may display a number of physical signs that could
point to the underlying problem.
Bad breath may be a sign of ketosis resulting from
anorexia or may result from a bulimic’s vomiting. Tooth decay,
enamel erosion, and, ultimately, tooth loss may signal bulimia.
Because anorexia causes the gastrointestinal system
to slow down and become inefficient, complaining about being bloated
or constipated may indicate an eating disorder.
When one’s metabolism is reduced—a result
of anorexia—a cold sensitivity may develop, so that the anorexic
may be colder than everyone else in the room and may be the only
one who’s wearing a sweater in the summer.
Individuals who put their fingers down their throat
to induce vomiting may display scrapes on the back of their knuckles,
caused by their teeth.
Additional physical clues include the following:
• cessation of menstruation
• paleness
• dizziness or fainting
• hair loss or dry and brittle hair
• skin yellowing
• dry skin or brittle nails
• lethargy
• weight fluctuations
• swollen glands in neck
• development of downy skin hair called lanugo
• persistent sore throat
• sores on the mouth
• bloodshot eyes
LANGUAGE
Sometimes, an individual’s language about weight or food may
provide clues to the presence of an eating disorder. Parents and
caregivers should be alert to their children’s excessive talk
about weight, complaints of feeling bloated after eating very little,
or talk that they’ve gained weight when they haven’t.
These statements may express distorted body image, feelings of guilt
associated with eating, fear of gaining weight, obsession with food,
poor self-esteem, shame, or self-criticism.
BEHAVIORS
Although individuals with eating disorders will go to great lengths
to hide their conditions, some of the following behaviors may indicate
the presence of a problem:
• smoking
• abuse of drugs, alcohol, or diet supplements
• leaving a room right after eating
• frequent use of the bathroom after eating and remaining
there for long periods
• frequent toothbrushing or excessive use of mouthwash or
breath mints to reduce bad breath associated with vomiting
• excessive use of laxatives, diuretics, diet pills, ipecac,
or enemas
• excessive spending
• promiscuous behavior or avoidance of intimacy
• hiding foods
• making frequent trips to convenience stores in a day
• wearing baggy clothing (This may be a fashion statement,
but it may also be an attempt to hide weight loss or gain. Wearing
tight, form-fitting clothing may also be an indication.)
• preoccupation with weight and consecutively trying different
diets
• making meals or baking for others but not indulging in the
foods made
Young children may be less adept at hiding the signs
or behaviors, but there may be hints. Says Sass, parents can be
alert to children hiding food in their rooms—in their closets,
drawers, and under their beds.
Educating parents, caregivers, and healthcare professionals
and alerting them to these and other clues that may suggest that
an individual is experiencing or is at risk for an eating disorder
may help prevent years of psychological damage and physical deterioration
and is likely to save lives.
— Kate Jackson is a staff writer for Today’s
Dietitian.
Resources
Academy for Eating Disorders
www.aedweb.org
Alliance for Eating Disorders Awareness
www.eatingdisorderinfo.org
American Dietetic Association
www.eatright.org
Anorexia Nervosa and Related Eating Disorders, Inc.
www.anred.com
Eating Disorders Coalition
www.eatingdisorderscoalition.org
National Association of Anorexia
Nervosa and Associated Disorders
www.anad.org
National Eating Disorders Association
www.nationaleatingdisorders.org
National Institutes of Mental Health
www.nimh.nih.gov
Overeaters Anonymous
www.overeatersanonymous.org
The Renfrew Center Foundation
www.renfrew.org
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