November 2010 Issue
‘Under-the-Radar’ Eating Disorders — Know the Signs to Improve Care
By Dale Ames Kline, MS, RD, LD, CNSC
Today’s Dietitian
Vol. 12 No. 11 P. 68
Suggested CDR Learning Codes: 4130, 4180, 5080, 5200; Level 2
In February, the American Psychiatric Association released the long-awaited preliminary draft of the Diagnostic and Statistical Manual, Fifth Edition (DSM-V) for comment. Of significance to dietitians was the inclusion of binge eating disorder as a recognized diagnosis. Previously, the more familiar anorexia nervosa and bulimia nervosa, with various subcategories, were the only “legitimate” eating disorders. Patients with obviously disordered eating patterns who do not meet the rigid diagnostic criteria have been lumped into the category eating disorder not otherwise specified (EDNOS), a practice that many believe is shortsighted and denies care to patients.
It has been a case of making the patient fit the template rather than addressing the actual symptoms in a rational and scientific way. A 2010 Stanford University study found that many EDNOS-diagnosed patients are undertreated because they don’t have “real” eating disorders.1 The diagnostic criteria for eating disorders were developed by expert consensus, as the DSM-V process illustrates, without the benefit of studies to track patients’ health. Thus, behaviors that are obviously abnormal are not tracked and rarely are the likely health consequences addressed.
As our understanding of food behaviors matures, experts have identified several other disordered eating patterns. The purpose of this article is to define and discuss them in an effort to help dietitians work more effectively with clients and patients.
It is important to stress that although the American Psychiatric Association is not considering other disordered eating patterns such as orthorexia, diabulimia, and pregorexia for defined diagnostic criteria in DSM-V, these eating patterns are real issues for people and may have serious health and personal consequences. Dietitians must be aware of these behaviors in their clients.
Orthorexia Nervosa
Orthorexia, an obsession with correct eating, was first defined by Steven Bratman, MD, who noticed disordered eating patterns among some clients. He derived orthorexia nervosa from “ortho” (straight, true, or correct); “orexia” (eating, appetite); and “nervosa” (obsession, fixation).2,3
There is little actual scientific evidence on orthorexia; the medical and research community does not appear to be taking this disorder very seriously, although there have been a few references in the journals over the past decade. But the fact remains that many patients fit this description to some degree and in the extreme, the disorder may become clinically significant. The following discussion summarizes and draws conclusions from the available references.
Essentially, an individual with orthorexia takes healthful eating to an unhealthful extreme. Most want to optimize health, prevent or treat disease, correct bad eating habits, increase a sense of well-being, or lose weight. Individuals employ a wide variety of eating protocols, which generally fall into the following four categories:
• religious, such a strict kosher diet;
• pseudoscientific, such as macrobiotics;
• philosophical, such as fruitarianism; and
• medical, such as cleansing or allergy-prevention diets.
Obviously, there is a blending of these factors: A committed macrobiotic will have scientific, philosophical, and medical rationales and a near-religious view of food and diet, and an Orthodox Jew will believe that kosher food is not only spiritually superior but also more healthful. There is nothing wrong with these rationales, per se; but taking them to extremes can prompt health and psychosocial consequences. The extremes are as follows:
• The individual makes ever-narrowing dietary choices.
• Planning, preparing, and eating “special” foods is a central concern.
• Resisting temptation (to stray from the regimen) dominates thoughts and acts.
• Emotional status depends on following the regimen.
• The person feels superior for following the regimen or condemns himself or herself for lapses.
Individuals with orthorexia often attempt to convert others to their lifestyle, actively seek out kindred dieters, and shun skeptics and nonbelievers. In this, the person with orthorexia differs greatly from those with other eating disorders. The person with bulimia typically tries to conceal his or her disorder and may feel shame and guilt because of it; the individual with anorexia, denying that he or she has deficient eating patterns, has little interest in what others eat or weigh. Individuals with orthorexia believe they are following a perfected diet and are proud of it; they believe others simply are not making the grade and should be proselytized. Status is gained through recruiting others.
Orthorexics’ attempts to convert others can be especially harmful if the targeted individual happens to be a child in their care. Severe dietary restrictions prevent normal growth and development and may set the stage for obsessive food behaviors in the child.
Status and self-esteem depend on escalating the quest for purity, which can isolate the person socially. Straying from the dietary rules is often followed by guilt, self-punishment, and adopting even stricter rules (fasting and colonics are common). Fear of being unable to obtain the desired foods is debilitating. Seeking balance and purity, orthorexics create imbalance.
Dietitians should be alert to individuals who report certain behaviors: raw food diets, “cleansing” diets, macrobiotic diets, diets to prevent unsubstantiated food allergies or hypoglycemia, eating plans based on blood type, diets that manipulate micronutrient composition (eg, electrolytes, acid-base balance), Candida diets, and eating plans that promote large quantities of supplements or “magical foods.” Many of these diets improve health in moderation but all have the potential to be taken to unhealthful extremes.
When and how do professionals intervene? Bratman proposed asking the following two direct questions:
1. “Do you care more about the virtue of what you eat than the pleasure you receive from eating it?”
2. “Does your diet socially isolate you?”
Weight loss is always a good indicator of eating issues. Dietitians who suspect unhealthful obsession in a client might subtly explore these questions with the person. If the individual’s eating habits are creating malnutrition or an unhealthful weight, it is important that dietitians intervene. Referrals to eating disorder specialists are advised.
In my experience, individuals with eating disorders are obsessed with the nutritional content of foods and have an extensive knowledge of the fat and calorie content of foods, which often sends me to books or an online database to verify or answer questions. Lack of knowledge about food is not the issue. In fact, it may contribute to the problem, as the individual uses that knowledge as a rationale to avoid eating certain foods and to defend any attempt to question the restrictive dietary regimen. A recent article on NaturalNews.com (www.naturalnews.com/029098_orthorexia_mental_disorder.html) illustrates a common defensive reaction to treatment initiatives.
A team approach is critical. Dietitians can provide nutritional facts and analyses, but a psychologist and a physician must be involved in treatment.
Pregorexia
Pregorexia, a word conjured up by the media, describes pregnant women who exercise to excess and reduce calories in an effort to control pregnancy weight gain.4 The term indicates an unhealthful restriction on food intake and an obsession with minimizing weight gain during pregnancy.
How widespread this practice is and how much of a problem it is are unanswered questions. Gaining too little weight during pregnancy is not a concern for very many women; gaining too much is the more common issue. Reducing calories and overexercising to an unhealthful degree during pregnancy has been little noted in professional literature.
Dietitians working with pregnant women need to be aware of the potential for pregorexia in their clients. The consensus among those describing this phenomenon is that women most at risk are those with subclinical eating disorders or those in recovery from diagnosed eating disorders. The emotions surrounding pregnancy and rapid physical changes can trigger a relapse, according to Brenda Woods, MD, of the Remuda Ranch clinic, as quoted in Pregnancy Today.
On the Momlogic website, Maggie Baumann, MA, a counselor at a residential eating disorders treatment facility, recalled being buffeted by emotions during her pregnancy. She recalled experiencing the following:
• a sense of lost control;
• a dissociation from her changing body;
• a fear of rapid weight gain; and
• a preoccupation with perfection.
She sought to alleviate these feelings through a rigid and unremitting exercise regimen, even after her obstetrician attributed uterine bleeding to too much stress and exertion. Dietitians should recognize these emotions as those commonly reported by individuals with anorexia. Baumann had never been diagnosed with anorexia, but after struggling through her pregnancy, she sought treatment. Going public with her story to help others, she was shocked at the intensity of the negative and shaming responses. Realizing that other pregnant women must be hiding similar problems, she has become an advocate and therapist.
Along with the emotional damage, extreme caloric restriction during pregnancy can result in complications for the mother, including hypertension, vaginal bleeding, Cesarean delivery, anemia, postpartum depression, and breast-feeding difficulties. Consequences for the baby can also be extreme and include fetal mortality, premature birth, low birth weight, developmental disorders (eg, attention-deficit/hyperactivity disorder), and failure to thrive.
As with all eating disorders, professionals must look to popular culture for causes. Celebrity moms who proudly display their prepartum and postpartum lean bodies are unrealistic but powerful role models for mothers-to-be. Since youthful preoccupation with body image is pervasive and peer pressure for thinness so strong, extremely young mothers are most at risk.
A current obsession with evaluating weight in absolute numerical terms sends the message that there are very strict limits to acceptable weight gain in pregnancy. Indeed, concern about overweight and obesity levels prompted the Institute of Medicine (IOM) to revise its 1990 guidelines for weight gain during pregnancy.5
Realizing the danger of a woman already above a desirable weight gaining up to 60 lbs by “eating for two,” thus putting her baby at risk and saddling herself with a postpartum weight problem, the IOM tightened guideline recommendations slightly for women who are obese. Women buffeted by the changes of pregnancy, and perhaps having a long subclinical disordered eating pattern, may believe they are gaining too much weight and develop an unhealthful obsession with thinness and meeting “correct” weight standards.
Dietitians must stress that the “guidelines and reporting recommendations are intended to be used in concert with good clinical judgment”5 and be alert for excessive worry and concern in expectant mothers. Any signs that these women may be restricting food intake, forming unrealistic body image consciousness, or increasing their exercise regimen beyond a common-sense norm should prompt immediate attention and referral.
Roger Harms, MD, answering a question about pregorexia on the Mayo Clinic website, describes the following warning signs in pregnant women:
• talking about the pregnancy as if it weren’t real;
• heavily focusing on calorie counts;
• eating alone or skipping meals; and
• exercising excessively.
Table 1 below summarizes the recommendations for weight gain during pregnancy, but the full report is worth reading.
Diabulimia
Diabulimia is another media term that trivializes a very hazardous practice. Although it is not a “real” eating disorder diagnosis, diabulimia—the practice of people with type 1 diabetes deliberately decreasing or withholding their insulin injection in order to lose weight—is of great concern.6
While this practice may be new to the popular media, it is well known among diabetes educators and dietitians working in the field. It is most common in young women with type 1 diabetes who are aware of the relationship between weight and insulin, which they learn from losing large amounts of weight prediagnosis and then experiencing significant regain once they start using insulin. The severity of the complications related to experimenting with weight and insulin intake depends on frequency and the extent to which this habit occurs.
Ann Goebel-Fabbri, PhD, a psychologist at the Joslin Diabetes Center and instructor of psychiatry at the Harvard Medical School, who has focused her research on the relationship between diabetes and eating disorders, notes, “It is shocking that women would take such extreme measures and risks for the purpose of weight loss. What is not shocking is that the results can be catastrophic.”7
Goebel-Fabbri found that women with type 1 diabetes who reported taking less insulin than prescribed had a threefold increase in risk of death and higher rates of disease complications than those who did not skip their insulin.7 The 11-year follow-up study found a higher rate of reported eating disorder symptoms and more frequent insulin restriction in those who had died compared with those still living.7 These practices can be lethal.
The increased rate of complications seen in those with diabulimia is due mostly to increased blood sugar levels. Without insulin, blood sugar cannot move into the tissues. Constantly elevated blood sugar levels in the short term can lead to dehydration, fatigue, and a breakdown in muscle tissue. Longer term, professionals know that elevated blood sugars lead to kidney disease, peripheral vascular neuropathy, and eye disease.
Because of the great risk it poses, diabulimia requires a multidisciplinary team that includes a physician, a dietitian, a diabetes educator, and a mental health professional. Those with diabetes, particularly younger women, must understand the consequences of what may seem like a quick and harmless way to stay stylishly thin.
Nocturnal Sleep-Related Eating Disorder
Remember the comic strip character Dagwood sleepwalking to the kitchen to prepare and eat a giant sandwich? People with a sleep-related eating disorder go on eating binges at night only to awaken the next morning with little or no memory of the event. Besides gaining weight, some endanger themselves by chopping ingredients or turning on the stove. Others eat raw ingredients or gorge on peanut butter straight from the jar, which can cause choking.
The disorder is poorly understood but, like sleepwalking, it occurs during non-REM sleep. Dietitians may be the first to learn of an individual’s nocturnal noshing in the course of a food history or food diary counseling session. Patients may have sudden flashes of memory, and family members may remark on the mess left in the kitchen.
The sudden realization of sleepwalking and nocturnal eating can be distressing. Dietitians should refer the patient for a psychological consult and medical treatment. Drugs that increase dopamine, a neurotransmitter associated with reward and pleasure, can help stop unconscious nighttime snacking.
Drunkorexia
While not a medical term, drunkorexia is defined as restricting food intake to increase alcohol intake without gaining weight. This type of disorder combines both an eating disorder and an addiction to alcohol and is most common on college campuses.
As with all other eating disorders and addictions, there are health consequences. Drinking on an empty stomach increases the speed of alcohol intoxication, as there is no food to slow down the absorption of alcohol, and can lead to blackouts and alcohol poisoning. The risk of many diseases increases with rising alcohol intake and includes cancer, heart disease, arthritis, kidney disease, liver disease, and obesity. It has also been associated with psychological problems such as anxiety, depression, and insomnia. Individuals with drunkorexia need counseling for their alcohol problem and may need dietary counseling if disordered eating persists in sobriety.
Eating Disorder Not Otherwise Specified
Added to the fourth edition of the DSM in 1994, EDNOS is a classification that addresses eating disorders that do not meet the criteria for anorexia nervosa and bulimia nervosa. The most common EDNOS is binge eating disorder, which is now being considered for inclusion in DSM-V as its own category. The present diagnostic criteria for EDNOS are as follows:
• All of the criteria for anorexia nervosa are met except the individual has regular menses.
• All of the criteria for anorexia nervosa are met except that, despite substantial weight loss, the individual’s current weight is in the normal range.
• All of the criteria for bulimia nervosa are met except binges occur at a frequency of less than twice per week or for a duration of less than three months.
• An individual of normal body weight regularly engages in inappropriate compensatory behavior after eating small amounts of food (eg, self-induced vomiting after consuming two cookies).
• An individual repeatedly chews but does not swallow large amounts of food.
• Binge eating disorder: recurrent episodes of binge eating in the absence of the regular use of inappropriate compensatory behaviors characteristic of bulimia nervosa.8
The main purpose of defining EDNOS criteria is to ensure that individuals with serious disordered eating and thinking patterns that do not fit the anorexia nervosa or bulimia nervosa criteria do not go undiagnosed and untreated. In fact, more than 50% of patients with eating disorders who present for outpatient treatment are diagnosed with EDNOS.9
Too often an EDNOS diagnosis is not taken as seriously as an anorexia nervosa or a bulimia nervosa diagnosis and, unfortunately, often goes untreated. A mixture of anorexia and bulimia symptoms are often found in adolescents presenting with subsyndromal (one or more diagnostic criteria absent) eating disorders with equally serious mental and physical consequences and a need for comprehensive treatment. And, of course, EDNOS includes a large number of individuals with binge eating disorder.
Since individuals with many types of disordered eating are lumped into one diagnosis, an EDNOS diagnosis makes treatment difficult. For instance, individuals with an EDNOS diagnosis may have some characteristics of anorexia and some of bulimia or they may have a combination of symptoms that do not fit into any category. Although data are limited, it has been suggested that up to 40% of patients diagnosed with EDNOS are diagnosed with anorexia or bulimia within one year, while others have a spontaneous remission.9
The medical complications of EDNOS are often severe in children and adolescents, as they go untreated until they become sicker than those with a recognized eating disorder.1 For this reason, the suggestion has been made to broaden the diagnostic criteria of anorexia and bulimia so that children who meet most of the diagnostic criteria can get the medical help they need.1
The causes and triggers of EDNOS are very similar to anorexia and bulimia and have already been presented, except those of binge eating disorder, which will be addressed in the next section. Signs of EDNOS are the same ones a professional would look for in anorexia and bulimia. Constant concern about food and weight as well as behaviors designed to restrict eating and compensate for eating, including purging and exercise, are also key signs. Psychological signs such as moodiness, sadness, anxiety, social withdrawal, and substance abuse are common. The particular eating behaviors have already been discussed, and the medical complications are a result of those behaviors.
We are now learning that the differences between EDNOS and anorexia and bulimia may not be very significant. In fact, one study found that the main differences between the diagnoses were amenorrhea (in those with anorexia) and less-frequent binges (in individuals with bulimia).9 One conclusion drawn from the study is that “EDNOS represents a set of disorders associated with substantial psychological and physiological morbidity.” The authors recommend that the diagnostic criteria in the DSM-IV be expanded to include what they term “subtypes” of anorexia and bulimia.
In a four-year study, Agra et al concluded that the majority of individuals with EDNOS were either on the way to remission from a diagnosed eating disorder or on their way to a relapse of a previously diagnosed eating disorder.10 The authors believed that individuals with a previous eating disorder diagnosis should not then be classified as EDNOS, as it was misleading. Only 18% of the EDNOS group had not had an eating disorder diagnosis in the past.
Binge Eating Disorder
In the revised DSM-V—with an estimated publication date of May 2013—binge eating disorder will probably be a separate diagnosis. The characteristics of binge eating disorder include the following:
• eating much more quickly than usual during a binge;
• eating until uncomfortably full;
• eating large amounts of food, even if not hungry;
• eating alone and secretively due to embarrassment over the amount of food consumed; and
• feeling disgusted, guilty, embarrassed, or depressed after overeating.
Approximately 4 million Americans (2% of the U.S. population) have binge eating disorder, and more than one third are men. Binge eating disorder is more common in people who are obese and morbidly obese but also occurs in individuals who are overweight and normal weight.
No one knows what causes binge eating, but more than one half of those with this disorder are depressed or have been depressed in the past. These individuals have more trouble handling emotions and are more impulsive. The question remains as to whether depression and lack of impulse control come before or after the eating disorder. Other causes may be biological, genetic, psychological (low self-worth and impulse control), and environmental (culture of thinness).
Medical complications from binge eating disorder include obesity, type 2 diabetes, high cholesterol and blood pressure, heart and gallbladder diseases, certain types of cancer, osteoarthritis, and joint pain. Psychologically, binge eaters experience depression, low self-esteem, and suicidal ideation.
Treatment for binge eating is available and falls into four categories: psychotherapy, medications, behavioral weight-loss programs, and self-help.
It has been suggested that dieting and food restriction may increase binges, so supervised weight-loss programs and self-help strategies, such as Overeaters Anonymous, may be good starting points. Regardless of the treatment, having support and incorporating good eating habits and exercise are key to long-term success.
Be Proactive
The media is on a diagnostic binge of sorts, finding “orexia” an irresistible suffix and those with “orexias” behind every shopping cart or menu. While we may smile at some of the more outrageous neologisms, dietitians must be cognizant, observant, and empathetic and cannot allow “the book” to cloud our judgment that something is amiss with our clients. Proactivity in the pursuit of healing and health is a skill RDs must cultivate.
— Dale Ames Kline, MS, RD, LD, CNSC, president of Nutrition Dimension, Inc, has created continuing education programs since 1984 for international, national, state, and local groups of medical, fitness, and nutrition professionals.
Learning Objectives
After completing this continuing education exercise, the student should be able to:
1. Name four newly identified disordered eating syndromes and discuss the characteristics of each.
2. Explain the main behavior that differentiates orthorexia from other kinds of eating disorders.
3. List the complications to the mother and baby of severe caloric restriction in pregnancy.
4. Explain why using insulin dosage to control weight is hazardous.
5. Summarize the debate about classifying eating disorders.
Examination
1. Anorexia nervosa and bulimia nervosa are the only two recognized eating disorders.
a. True
b. False
2. Which of the following are symptoms of orthorexia?
a. Resisting temptation dominates thoughts and actions.
b. Emotional status depends on following the regimen.
c. Food choices steadily decrease.
d. The person feels superior for following the regimen and condemns himself or herself for lapses.
e. All of the above
3. Orthorexia may lead to which of the following health problems?
a. Weight gain and diabetes
b. Weight loss and malnutrition
c. Electrolyte imbalance
d. Fungal infection
4. Pregorexia is best defined as:
a. eating uncontrollably during pregnancy and gaining excessive weight.
b. an aversion to food because of heartburn, bloating, and altered taste.
c. restricting food intake to minimize weight gain during pregnancy.
d. obsessive concern with purity of food during pregnancy.
5. A pregnant woman with pregorexia will exhibit all of the following warning signs except:
a. eating alone or skipping meals.
b. exercising excessively.
c. vomiting after eating.
d. talking about pregnancy as if it were not real.
e. heavily focusing on calorie counts.
6. Which of the following causes a higher rate of disease complications and death in people with diabulimia?
a. Hypoglycemia leading to coma and death
b. Hyperglycemia for extended periods of time that impairs organ functions
c. Malnutrition from an extremely restrictive diet
d. Excessive exercising and restrictive eating leading to erratic blood sugar levels
7. Which of the following best describes an eating disorder not otherwise specified (EDNOS)?
a. Individuals with serious disordered eating who have most but not all criteria for anorexia nervosa or bulimia nervosa
b. Individuals who have a less serious eating disorder
c. Individuals who did not respond to accepted treatment for diagnosed anorexia nervosa or bulimia nervosa
d. Obese individuals with a binge eating disorder
e. Individuals who are underweight and are at risk for developing an eating disorder
8. A patient is referred for counseling due to extreme weight loss. Which of the following characteristics/behaviors lead(s) you to a diagnosis of EDNOS?
a. Excessive exercise
b. Extensive and obsessive knowledge of calorie and fat content of foods
c. Restrictive eating
d. Menstruation still occurs
e. All of the above
9. Binge eating disorder can be diagnosed only if the individual is overweight or obese.
a. True
b. False
10. Successful treatment for a binge eating disorder includes which of the following?
a. Dieting and food restrictions to avoid foods that trigger binges
b. Emotional support, good eating habits, and exercise
c. Dieting, emotional support, and the use of medication
d. Psychotherapy, exercise, and inpatient treatment
e. Bariatric surgery
References
1. Peebles R, Hardy KK, Wilson JL, Lock JD. Are diagnostic criteria for eating disorders markers of medical severity? Pediatrics. 2010;125(5):e1193-1201.
2. Bratman S. Health food junkie. Yoga Journal. October 1997.
3. Bratman S, Knight D. Health Food Junkies: Orthorexia Nervosa: Overcoming the Obsession With Healthful Eating. New York: Broadway Books; 2001.
4. Mathieu J. What is pregorexia? J Am Diet Assoc. 2009;109(6):976-979.
5. Committee to Reexamine IOM Pregnancy Weight Guidelines, Institute of Medicine, National Research Council. Weight Gain During Pregnancy: Reexamining the Guidelines. Washington, D.C.: National Academies Press; 2009.
6. Mathieu J. What is diabulimia? J Am Diet Assoc. 2008;108(5):769-770.
7. Goebel-Fabbri AE, Fikkan J, Franko DL, et al. Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care. 2008;31(3):415-419.
8. National Alliance on Mental Illness. Eating disorders not otherwise specified (EDNOS). Available at: http://www.nami.org/Template.cfm?Section=By_Illness&template=/Content
Management/ContentDisplay.cfm&ContentID=65849. Accessed September 24, 2010.
9. Thomas JJ, Vartanian LR, Brownell KD. The relationship between eating disorder not otherwise specified (EDNOS) and officially recognized eating disorders: Meta-analysis and implications for DSM. Psychol Bull. 2009;135(3):407-433.
10. Agras WS, Crow S, Mitchell JE, Halmi KA, Bryson S. A 4-year prospective study of eating disorder NOS compared with full eating disorder syndromes. Int J Eating Disord. 2009;42(6):565-570.
Table 1: New Recommendations for Total Weight Gain During Pregnancy
Prepregnancy BMI |
Total Weight Gain (Range in kg) |
Total Weight Gain (Range in lbs) |
Low or underweight |
12.5 to 18 |
28 to 40 |
Normal weight |
11.5 to 16 |
25 to 35 |
High or overweight |
7 to 11.5 |
15 to 25 |
Obese |
5 to 9 |
11 to 20 |
