Introduction

Across America, some 30 million people are suffering from an eating disorder (ED) at any time1.

Contrary to common portrayals in the media, eating disorders affect all ethnicities, economic groups, and genders2. EDs are not merely a “skin-deep” illness, either: statistically, they are the deadliest mental illness in America. To Illustrate the seriousness of this issue, someone dies about once an hour from complications from one or more eating disorders3.   

Anorexia nervosa and bulimia are probably the most well-known eating disorders, but others include binge-eating disorder, avoidant-restrictive food intake disorder, and a host of other disorders classified under the umbrella term “Otherwise Specified Feeding or Eating Disorder (OSFE)4.”

Again, popular portrayals of EDs usually show sickly thin individuals, but the truth is that it’s impossible to tell whether someone has an eating disorder just from outward appearance. This may be part of the reason why eating disorders are at a risk for being misdiagnosed or missed altogether by medical professionals.  

Because eating disorders can show up in any age group or gender, anywhere in the country, primary care or general practitioners are the most likely clinicians to encounter patients who may have an eating disorder.

How can doctors and other clinicians get better at spotting and diagnosing these disorders before they turn deadly? Simple, affordable steps like improved screening could make a huge difference. For busy primary care clinics, technology offers a valuable inroad to getting patients quickly and effectively screened for a variety of problems.

Programs like GreenLight have been developed by experts to help patients rate various symptoms from depression and anxiety to addiction and EDs. Another important factor in the efficacy of these programs is that emerging research has found that patients who are not comfortable directly self-identifying face-to-face with a care practitioner feel more comfortable divulging this information via a digital screening device—especially in the case of younger generations who grew up texting5.

In the case of GreenLight, an application is loaded onto a tablet computer that can be given to patients waiting to be seen. Through a series of simple screening tests, the program can be used to:

  • Identify potentially dangerous symptoms of psychiatric disorders.
  • Help practitioners evaluate major symptoms of all clinically-recognized eating disorders, as well as other risky behaviors, including tendency toward abusing drugs and/or alcohol.
  • Summarize findings with easy-to-read point-based “scores”, including flags for follow-up questions, so that practitioners can make informed treatment decisions.
  • Allow doctors to track changes in patient scores over time.
  • Protect health information and remain compliant with HIPPA.

Along with a national crisis of addiction and mental health problems, eating disorders affect a statistically-significant portion of the population. Clinics who extend their ability and capacity to confront these problems can be part of the solution.

Eating Disorders: Overview

Researchers think that an unhealthy relationship with food is caused by a combination of genetics, environment, and social conditions6. Like other mood disorders, eating disorders may involve genes that are passed down in families.

Eating disorders can also spring up as a form of “control” for patients who feel otherwise powerless due to factors like growing up in abusive or addict-run households; exposure to trauma, especially sexual trauma; or as a coping skill for co-occurring mood disorders like depression and anxiety7.

Unhealthy relationships with food also have social causes like unrealistic body expectations for both men and women, although this is only one of many factors that leads to full-blown eating disorders. Although eating disorders may cause a significant increase or decrease in BMI, this is not always the case.    

People die from eating disorders in a variety of ways. Anorexia may be the deadliest disease, killing up to 20% of diagnosed sufferers8. Anorexia kills because eventually malnutrition affects the heart and other organs. As organs shut down after persistent starvation, anorexics may suffer a heart attack9.

Although it is less deadly, bulimia can also kill. Besides an increased risk of heart attack from electrolyte imbalance from purging, frequent exposure to the extremely corrosive stomach acid in vomit can actually cause the esophagus or stomach to burst10. Other eating disorders can kill, too.

For example, diabetics who abuse their insulin can accidentally put themselves in a coma and die. Other disorders (or less-extreme versions of anorexia or bulimia) may not kill but can still cause irreversible damage to the kidneys, heart, and other vital systems11.    

Types of Eating Disorders:

  • Anorexia Nervosa. Anorexia is formulated around long-term calorie restriction. Among lower-BMI sufferers, physical symptoms include thinning hair, a layer of peach fuzz-like hair called “inguna” covering the back and limbs, and in extreme cases an emaciated appearance12. Signs of anorexia may include obsessively counting calories, visiting “pro ana” websites, or obsessively exercising, although exercise-induced calorie purging may be getting its own eating disorder category in the future. The “nervosa” stands for the fact that sufferers of anorexia also tend to suffer from symptoms of anxiety, social phobia, and high levels of neuroticism13.   
  • Bulimia. Bulimia is characterized by vomiting or “purging” food, often after binging. Most sufferers of bulimia are a normal- to above-average weight. Signs and symptoms include binging on food or evidence of binging like high grocery bills, secretive behavior, swollen cheeks, yellowed teeth and bad breath14.
  • Binge-eating Disorder. Binge-eating disorder is characterized by out-of-control binges, or food binges that start negatively affecting other areas of life. Most sufferers of binge-eating disorder are overweight to obese, but there are also normal-weight sufferers of the disorder15.
  • Avoidant-restrictive food intake disorder (ARFID) is essentially extreme picky eating. If the picky eater is suffering from symptoms of malnutrition due to being unable or unwilling to eat a well-rounded diet, they may be diagnosed with ARFID16. This behavior can be diagnosed in both children and adults; it often responds well to cognitive-behavioral therapy.
  • Otherwise Specified Feeding or Eating Disorder (OSFED): several of the more commonly occuring other disorders include “diabulima,” where diabetic patients misuse insulin for weight-loss purposes; orthrexia, where patients become so obsessed with “healthy” or “clean” eating that they become malnourished, and pica, or the eating of non-food objects16. Like the other disorders, OSFED is basically an unhealthy coping skill for psychological issues like a need for control, anxiety, stress, depression, and being severely affected by American social beauty standards that unduly emphasize being thin and/or muscular.  

 

Both men and women are at risk of developing all of these eating disorders, with an increase in male sufferers being noted recently by researchers.

Whether this is due to increased pressure on men to look muscular, or simply being more comfortable reporting these problems is still being determined17. Women suffer anorexia and orthorexia at higher rates, and men are equally likely to be diagnosed with bulimia and slightly more likely to be diagnosed with OSFED18.  

Risk Factors For Eating Disorders

If unrealistic social expectations alone accounted for the cause of eating disorders, many more people would presumably fall into the diagnostic guidelines, since all Americans are exposed to idealized human bodies in film, tv, and advertisements from a very young age.

So why do only some people go on to develop full-blown disorders? There are several critical factors that separate those who develop EDs from the rest of the population.

Depression, anxiety, and other mood disorders. Although not everyone with a mood disorder has an eating disorder, most people with an ED could also be diagnosed with one or more concurrent mood disorders like depression or anxiety19.

Eating disorders often function as a coping skill or “safety valve” to deal with the symptoms of mood disorders. Conversely, treating the underlying mood disorders with therapy and/or medication often helps improve symptoms of EDs. Addiction can also play a role in EDs: the disorder itself can be addictive, as in the case of bulimia (certain endorphins are released by the brain after vomiting)20, but people using substances to feel better may also be at a higher risk of using EDs for the same purpose.     

A traumatic background. There are several ways trauma can cause eating disorders: in the first place, EDs may develop by the traumatized patient as a way to “control” their world in the face of memories that invoke powerlessness like growing up in an abusive or alcoholic household.21

Trauma, especially in the case of sexual trauma, may also cause patients to want to alter their bodies22. By making themselves either “too big” to be attractive, or starving to reduce feminine curves that invoke sexuality in the case of women, the body can become a literal battleground for EDs, trauma, and PTSD symptoms.    

Genetics. There is some evidence that like mood disorders, eating disorders may have a genetic or hereditary component23. A hereditary tendency towards the psychological symptoms that lead to the development of eating disorders has been seen in some twin studies.

There may also be a contribution of “learned” hereditary behavior, or children who watch (and normalize) disordered eating or an unhealthy relationship with food in a parent.    

Do other cultures get eating disorders? We know that some illnesses are universal, so what about eating disorders? If artificial food shortages caused by famine, war, or extreme poverty are discounted, some form of unhealthy relationship with food occurs in most cultures, so the answer is probably “yes.”24

However, these eating disorders may be more likely to present themselves in different ways, like obsessive religious or ritual fasting. Even in the pre-modern Western world, there are records of what we might now call anorexia in obsessively-pious nuns in the medieval period25.

It does go without saying that rates of eating disorders today are much more common in “first world” places like Europe and North America because these locations are much less affected by shortages of food like in the conditions outlined above.

 

Prevention

How can eating disorders be prevented? Because there are myriad causes, a combination of preventative approaches is most likely to effectively reduce rates of these deadly disorders. Education and raising awareness, increased medical and behavioral health care, and support for medical research are all areas with something to contribute.

Education and awareness are especially important, beginning in elementary-aged children.

A growing movement called “media literacy” trains kids to understand how traditional media and social media alike may be distorting reality. Understanding how photoshop, filters, and other “tricks” can make bodies look perfect is key to helping boys and girls become less likely to fall victim to unrealistic body image.

Helping parents, teachers, coaches, and other members of the community understand symptoms of eating disorders is one way to help reduce the development of EDs in the first place.

Due to the fact that eating disorders also involve other behavioral or mood disorders, increasing access to mental health as well as medical care for all Americans can also help ED sufferers get the assistance and support that they need26. Because symptoms of EDs can be invisible, investing in more advanced screening tools is one way that doctors can help their patients.

Additionally, medical research should continue into why some at-risk patients develop eating disorders and others don’t. Like mood disorders, EDs may be great candidates for new types of medication as well as novel therapeutic techniques.   

Eating Disorders in America: Conclusion

Although they may seem shallow at first glance, eating disorders are a devastating and deadly serious condition. Like other mental illnesses, EDs cut across every section of American society to cause damage and tragedy when left untreated.

This includes affecting both genders; reducing stigma and providing support for men is one component of successful treatment and prevention alike. Just like the mental health epidemic, untreated eating disorders are partially a symptom of a healthcare system that needs serious attention.

EDs require medical knowledge to treat, and it is likely that doctors are missing many diagnoses either because patients don’t have access to healthcare or because the practitioners themselves are missing symptoms. Telemedicine and increased screening technology with programs like GreenLight are both important ways to extend the reach of primary care and other front-line practices.

Encouraging medical research and development of new kinds of therapy will also be important tools in the battle against EDs.

Although it will require increased political and cultural will to reduce rates of eating disorders, the fate of millions of current and future sufferers hangs in the balance.

Improving education and access to healthcare will pay dividends not only to this struggling segment of society, but to the greater problem of mental health sufferers as well. The ensuing reduced rates of morbidity and mortality for the 1/3 of Americans who suffer from eating disorders and/or mental illness could have a huge effect on the economy, making it a win-win situation for everyone.

Notes

  1. Le Grange, D., Swanson, S. A., Crow, S. J., & Merikangas, K. R. (2012). Eating disorder not otherwise specified presentation in the US population. International Journal of Eating Disorders, 45(5), 711-718.
  2. Marques, L., Alegria, M., Becker, A. E., Chen, C.-n., Fang, A., Chosak, A., & Diniz, J. B. (2011). Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: implications for reducing ethnic disparities in health care access for eating disorders. International Journal of Eating Disorders, 44(5), 412-4120.
  3. Eating Disorders Coalition. (2016). Facts About Eating Disorders: What The Research Shows.http://eatingdisorderscoalition.org.s208556.gridserver.com/couch/uploads/file/fact-sheet_2016.pdf
  4. National Association of Anorexia Nervosa and Associated Disorders. (2015) Eating Disorder Statistics. http://www.anad.org/get-information/about-eating-disorders/eating-disorders-statistics/
  5. Joinson, Adam M. (2011). Self-Disclosure in Computer-Mediated Communication: the Role of Self-Awareness and Visual Anonymity. European Journal of Social Psychology, 31(2), 177-192. DOI: doi.org/10.1002/ejsp.36  
  6. Culbert, K. M., Racine, S. E., & Klump, K. L. (2015). Research Review: What we have learned about the causes of eating disorders – a synthesis of sociocultural, psychological, and biological research. Journal of Child Psychology and Psychiatry, 56(11), 1141-1164. DOI: dx.doi.org/10.1111/jcpp.12441
  7. Ulfvebrand, S., Birgegard, A., Norring, C., Hogdahl, L., & von Hausswolff-Juhlin, Y. (2015). Psychiatric comorbidity in women and men with eating disorders results from a large clinical database. Psychiatry Research, 230(2), 294-299.
  8. National Association of Anorexia Nervosa and Associated Disorders. (2015)Eating Disorder Statistics. http://www.anad.org/get-information/about-eating-disorders/eating-disorders-statistics/
  9. Carl Laird Birmingham, Scott A. Lear, Jennifer Kenyon, Sammy Yat Man, Chan G.B., John Mancini, Jiri Frohlich (2003). Coronary atherosclerosis in anorexia nervosa. International Journal of Eating Disorders, 34(2), 375-377 DOI: doi.org/10.1002/eat.10190
  10. Eating Disorder Catalogue (2013). Medical Dangers of Bulimia. https://www.edcatalogue.com/medical-dangers-bulimia/
  11. Culbert, K. M., Racine, S. E., & Klump, K. L. (2015). Research Review: What we have learned about the causes of eating disorders – a synthesis of sociocultural, psychological, and biological research. Journal of Child Psychology and Psychiatry, 56(11), 1141-1164. DOI: dx.doi.org/10.1111/jcpp.12441
  12. (1963) Primary and Secondary Anorexia Nervosa Syndromes. The British Journal of Psychiatry, 109 (461), 470-479. DOI: https://doi.org/10.1192/bjp.109.461.470
  13. IBID
  14. Eating Disorder Catalogue (2013). Medical Dangers of Bulimia. https://www.edcatalogue.com/medical-dangers-bulimia/
  15. Pull, Charles B. (2004) Binge eating disorder. Current Opinion in Psychiatry, 17(1), 43-48.
  16. National Association of Anorexia Nervosa and Associated Disorders. (2015) Eating Disorder Statistics. http://www.anad.org/get-information/about-eating-disorders/eating-disorders-statistics/
  17. National Eating Disorders Association (2018)Eating Disorders in Men & Boys. https://www.nationaleatingdisorders.org/learn/general-information/research-on-males
  18. Culbert, K. M., Racine, S. E., & Klump, K. L. (2015). Research Review: What we have learned about the causes of eating disorders – a synthesis of sociocultural, psychological, and biological research. Journal of Child Psychology and Psychiatry, 56(11), 1141-1164. DOI: dx.doi.org/10.1111/jcpp.12441
  19. Ulfvebrand, S., Birgegard, A., Norring, C., Hogdahl, L., & von Hausswolff-Juhlin, Y. (2015). Psychiatric comorbidity in women and men with eating disorders results from a large clinical database. Psychiatry Research, 230(2), 294-299.
  20. IBID
  21. Culbert, K. M., Racine, S. E., & Klump, K. L. (2015). Research Review: What we have learned about the causes of eating disorders – a synthesis of sociocultural, psychological, and biological research. Journal of Child Psychology and Psychiatry, 56(11), 1141-1164. DOI: dx.doi.org/10.1111/jcpp.1244
  22. Stephen A. Wonderlich,Steven Rosenfeldt,Ross D. Crosby,James E. Mitchell, Scott G. Engel,Joshua Smyth,Raymond Miltenberger (2007). The effects of childhood trauma on daily mood lability and comorbid psychopathology in bulimia nervosa. Journal of Traumatic Stress, 31(1). DOI:doi.org/10.1002/jts.20184
  23. National Association of Anorexia Nervosa and Associated Disorders. (2015) Eating Disorder Statistics. http://www.anad.org/get-information/about-eating-disorders/eating-disorders-statistics/
  24. Maria Makino et al., Prevalence of Eating Disorders: A Comparison of Western and Non-Western Countries. Medscape General Medicine. 2004; 6(3): 49.
  25. Mario Reda (2001). ANOREXIA AND THE HOLINESS OF SAINT CATHERINE OF SIENA, Journal of Criminal Justice and Popular Culture, 8(1), 37-47.
  26. Ulfvebrand, S., Birgegard, A., Norring, C., Hogdahl, L., & von Hausswolff-Juhlin, Y. (2015). Psychiatric comorbidity in women and men with eating disorders results from a large clinical database. Psychiatry Research, 230(2), 294-299.
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