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eating disorders

On this page you’ll find:

  • Eating Disorders: An Overview

  • Disordered Eating vs. Eating Disorders

  • How many people have eating disorders?

  • How Eating Disorders Affect an Individual: Short-Term and Long-Term

  • Categories of Eating Disorders

  • Costs of Eating Disorders

  • Socioeconomic Status, Ethnicity, and Eating Disorders


Eating Disorders: An Overview 

Eating disorders are serious psychological and medical conditions. The popular media have publicized eating disorders lately, especially since many actors and models have come out with their struggles with eating disorders. However, the focus of these stories is on weight and weight loss, leaving the impression that eating disorders are simply about weight. This minimizes the seriousness and complexity of these conditions and gives the impression that people choose to have eating disorders, which places blame on the individual with the disorder.Eating disorders are some of the most troubling disorders in our society today, and they reflect one of the more extreme (and yet sadly, fairly common) reactions to our toxic media environment. However, some people believe that eating disorders are conditions that people choose to have, as if they would adopt some sort of diet or lifestyle. By presenting these facts, we aim to dispel myths such as this one and raise awareness of how all the issues are interconnected.

Some general facts:

  1. Eating disorders rank among the 10 leading causes of disability among young women [Mathers et al., 2000]
  2. Evidence is emerging that eating disorders among Hispanic and minority groups remain undetected because of barriers to treatment (language, access, finances). [Cachelin and Striegel-Moore, 2006]

American Psychologist, the journal of the American Psychological Association, devoted its April 2007 issue to eating disorders. Many internationally recognized leaders in the field contributed to this issue, resulting in comprehensive, state-of-the-art articles on eating disorders. These articles greatly informed the following sections.

Disordered Eating vs. Eating Disorders

  • Some people do not meet the clinical criteria to be diagnosed with an eating disorder. However, repeated dieting; losing and then regaining weight; self-blame and guilt related to eating; excessive exercising; poor body image; fear of getting fat; or periodic binge eating can certainly be problematic. When food and eating create psychological pain and suffering, even though a full-blown eating disorder is not present, the problem is called disordered eating. [Academy of Eating Disorders, 2007]
  • Many adolescents do not meet all of the criteria required for a psychological diagnosis of anorexia nervosa or bulimia nervosa, but do suffer from partial eating disorders and/or a problematic relationship with food. [Chamay-Weber et al., 2005]
  • Disordered eating occurs across ethnicities, genders, and ages. It is associated with acculturation to Western societies. [Cachelin and Regan, 2006]

How Many People Have Eating Disorders?

  • Most experts agree that the incidence of eating disorders has increased over the last 30 to 40 years. Approximately 0.5% to 1% of late adolescent or adult women meet criteria for the diagnosis of anorexia nervosa. Approximately 1% to 2% of late adolescent and adult women meet criteria for the diagnosis of bulimia nervosa. [Academy of Eating Disorders, 2007]
  • However, at any given time, 10% or more of late adolescent and adult women report symptoms of eating disorders. Although these symptoms may not satisfy full diagnostic criteria, they do often cause distress and impairment. Interventions with these individuals may be helpful and may prevent the development of more serious disorders. [Academy of Eating Disorders, 2007]

What Causes Eating Disorders?    

There are many avenues to developing an eating disorder. There is no one single cause but rather a complex interaction between biological issues such as genetics and metabolism; psychological issues such as control, coping skills, personality factors, and family issues; and social issues such as a culture that promotes thinness and media that transmits this message. [National Association for Anorexia Nervosa and Bulimia Nervosa, 2007]

  • Dieting
    Why do some people diet but don’t develop an eating disorder? And why do others develop eating disorders?
    • In a study of adolescents, those that were considered “severe dieters” had an 18 times greater chance of developing an eating disorder than a control group who did not diet; with moderate dieting they were 5 times more likely to develop an eating disorder. The non-dieters had a 1 in 500 chance of developing an eating disorder. [National Association for Anorexia Nervosa and Bulimia Nervosa, 2007]
  • Genetics
    Genes load the gun, and environment pulls the trigger.
    • We are far from knowing which specific genes cause eating disorders. There are a number of genes that work with environmental triggers and possible dieting. Loss of weight may influence the development of anorexia by turning on a gene that may influence an eating disorder. [National Association for Anorexia Nervosa and Bulimia Nervosa, 2007]
    • There are many transgenerational and twin studies that show that eating disorders run in families. There is probably a 5 or 6 times greater chance of developing an eating disorder if an immediate relative has an eating disorder. [National Association for Anorexia Nervosa and Bulimia Nervosa, 2007]
  • Depression and Anxiety

    Depression and anxiety disorders are commonly found to coexist in the eating-disorder patient and her or his family. [National Association for Anorexia Nervosa and Bulimia Nervosa, 2007]

  • Excessive Exercise

    Referred to as exercise-induced anorexia, excessive exercise involves a compulsion—a psychological need which results in over-exercising. [National Association for Anorexia Nervosa and Bulimia Nervosa, 2007]

  • Psychological Factors

    • No single factor causes an eating disorder. The list below is incomplete. Everyone is unique, but sometimes there are patterns. [National Association for Anorexia Nervosa and Bulimia Nervosa, 2007]
    • For anorexia:

      • fear of growing up
      • inability to separate from family
      • need to please or be liked
      • perfectionism
      • need to control
      • need for attention
      • lack of self-esteem
      • high family expectations
      • parental dieting
      • family discord
      • temperament (the person is often described as the “perfect child”)
      • teasing about weight and body shape
    • For bulimia:

      • difficulty regulating mood

      • impulsivity

      • sexual abuse

      • family dysfunction

  • Social-cultural causes

    • the sexual revolution

    • emphasis on thinness as the ideal for beauty

    • availability of and indulgence in food

    • role of the media

    • obesity and reaction to larger body sizes

    [National Association for Anorexia Nervosa and Bulimia Nervosa, 2007]

How Eating Disorders Affect an Individual: Short-Term and Long-Term

Eating disorders can have a profoundly negative impact on an individual’s quality of life. Interpersonal relationships, financial status, and job performance are often diminished or destroyed. It’s unclear whether these problems are an inherent part of eating disorders or are secondary to them. The range of negative effects does, however, highlight the critical importance of treatment. [Academy of Eating Disorders, 2007]

  • Eating disorders are associated with high rates of other coexisting psychiatric disorders, particularly mood disorders and anxiety disorders. [Keel and Herzog, 2004]
  • Bulimia nervosa may be particularly associated with alcohol and/or drug abuse problems. [Keel and Herzog, 2004]
  • In interviews that explored parents’ experiences of having a child or adult child with an eating disorder, the following themes emerged: family unification or disintegration, parent’s inability to cope with the eating disorder, inconsiderate comments from significant others, social isolation, and financial impacts of paying for treatment. [Hillege et al., 2006]
  • Caring for someone with anorexia nervosa is distressing. When 20 mothers and 20 fathers were asked about their caregiving experiences, these themes emerged [Whitney et al., 2005]:
    • Parents perceived anorexia nervosa to be chronic and disabling.
    • Parents blamed themselves as contributing to the illness and perceived themselves as helpless in promoting recovery.
    • Mothers illustrated an intense emotional response, whereas fathers produced a more analytical and detached account.
    • Part of the distress in living with anorexia nervosa may be explained by unhelpful assumptions and unhealthy responses to the illness.
    • Training parents in skills to manage the illness may improve the patient’s outcome by reducing interpersonal maintaining factors (family dynamics/factors that fuel and sustain the eating disorder).

Categories of Eating Disorders

  • Anorexia Nervosa The media has vividly portrayed female actors suspected of having anorexia nervosa. Close-up shots have emphasized their bodies, along with a string of allegations, leaving the reader to speculate whether they have the disorder. This often characterizes anorexia nervosa as a glamorous game, or even a lighthearted joke, in which the victim gets blamed. However, anorexia nervosa is a serious condition.

    • Anorexia nervosa is defined by the successful pursuit of thinness through dietary restriction and other measures, resulting in body weight below the normal range–usually less than 85% of expected weight or body mass index (BMI) of less than 18.[American Psychiatric Association, 2000]

    • BMI is a ratio between weight and height. It is a mathematical formula that correlates with body fat, used to evaluate a person’s weight (given a certain height). [Wilson et al., 2007]

    • Patients’ views of their symptoms are complex. For instance, they often feel “too fat,” yet take pride in their achievement of thinness and restraint. [Wilson et al., 2007]

    • Patients are intensely fearful of losing control and becoming overweight; over time, nearly half succumb to binge eating. [Wilson et al., 2007]

    • Anorexia nervosa typically begins during adolescence and principally affects girls and women; its prevalence rate among females is 0.3%. [Hoek and van Hoeken, 2003]

    • Collected results from long-term follow-up studies indicate that nearly 50% of patients eventually make a full recovery, 20% to 30% show residual symptoms, 10% to 20% remain severely ill, and 5% to 10% die of related causes. [Steinhausen, 2002]

    • The most salient fact about psychotherapy research on anorexia nervosa is that there is remarkably little evidence to review. Over the past 20 years, only 15 experimental studies have been completed and published. [Wilson et al., 2007]

    • The ongoing lack of controlled treatment research in anorexia nervosa is attributable to distinctive features of the disorder: its rarity, its medical complications that sometimes require hospitalization, and the extended period of treatment necessary for full symptom remission (the time it takes for symptoms to go away) in established cases. [Wilson et al., 2007]

    • Family therapy is the most extensively researched treatment for anorexia nervosa, with the Maudsley Method being the best-studied approach. As applied to adolescent patients, the intervention involves 10 to 20 family therapy sessions spaced over 6 months. [Lock and le Grange, 2005]

    • Anorexia nervosa has one of the highest mortality rates of any psychological illness. Estimates range from 5% to 20%. [Birmingham et al., 2005]

    • Medications do not seem to be helpful in treatment for anorexia nervosa. [Preston et al., 2006]

  • Bulimia Nervosa Bulimia nervosa is the other eating disorder often glamorized in the media. In several black comedies (the film Heathers, for example), we have seen characters exhibiting purging behaviors while their friends watch, which minimizes the seriousness of the disorder. The disorder primarily occurs in young females, and prevalence is roughly 1% to 2% in community samples. [Hoek and van Hoeken, 2003]

    • Bulimia nervosa is characterized by: Bulimia nervosa sufferers’ body weights are typically normal or low normal, although bulimia nervosa does occur in some overweight individuals. Associated general psychopathology (e.g. depression and personality disorders) and psychosocial impairment are common. [Wilson et al., 2007]

      • recurrent binge eating (uncontrolled consumption of a large amount of food);
      • regular compensatory behavior designed to influence body weight and shape (e.g. self-induced vomiting, laxative misuse, or excessive exercise);
      • negative self-evaluation that is unduly determined by body shape and weight. [American Psychiatric Association, 1994]
    • Standard cognitive behavioral therapy is the most researched, evidence-based treatment for bulimia nervosa. Interpersonal psychotherapy has also received empirical support. Cognitive behavioral therapy typically eliminates binge eating and purging in roughly 30% to 50% of all cases. Controlled outcome research on alternative forms of psychotherapy for bulimia nervosa is lacking as of this writing. [Wilson et al., 2007]
    • Some medications have been found to be helpful in the treatment of bulimia nervosa. [Zhu and Walsh, 2002]

    • Surprisingly, there are no published controlled treatment studies of adolescents with bulimia nervosa as of this writing. [Commission on Adolescent Eating Disorders, 2005]

  • Binge Eating Disorder: General Information from the Academy of Eating Disorders

    • The term, “binge eating disorder” was officially introduced in 1992 to describe individuals who binge eat but do not regularly use inappropriate compensatory weight control behaviors such as fasting or purging to lose weight.

    • The binge eating may involve rapid consumption of food with a sense of loss of control, uncomfortable fullness after eating, and eating large amounts of food when not hungry. Feelings of shame and embarrassment are prominent.

    • Binge eating disorder is often associated with obesity.

    • In the past, individuals suffering from binge eating disorder were often referred to as compulsive overeaters, emotional overeaters, or food addicts.

    • Available research suggests that approximately one fifth of the people who seek professional treatment for obesity meet the criteria for binge eating disorder.

    • In the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM- IV-TR), binge eating disorder is not an officially recognized eating disorder, but is included in the category titled Eating Disorder Not Otherwise Specified (EDNOS) [see the next section for more information]. [Academy of Eating Disorders, 2007]

    • According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), binge eating disorder is defined by recurrent binge eating without the regular use of the inappropriate compensatory weight-control methods (self-induced vomiting, laxative misuse, or excessive exercise) that are a defining feature of bulimia nervosa. [American Psychiatric Association, 1994]

    • The prevalence of binge eating disorder is estimated to be roughly 3% of adults, but it is higher in obese persons. [Grilo, 2002]

    • The distribution of binge eating disorder is broader and more diverse than that of bulimia nervosa and anorexia nervosa; it is evenly distributed throughout adulthood and is not uncommon in men or persons of color. [Grilo, 2002]

    • In studies of treatment-seeking and non-treatment-seeking overweight children, weight problems often precede dieting and binge eating behaviors. [Reas and Grilo, 2007]

    • Individuals with binge eating disorder who seek treatment are typically older than patients with either bulimia nervosa or anorexia nervosa. Emerging research, however, suggests that the onset of binge eating disorder frequently dates back to adolescence. [Grilo and Masheb, 2000]

    • Binge eating disorder may be a contributor to the development of obesity in some persons. [Yanovski, 2003]

    • Binge eating disorder is associated with obesity, and obese individuals with binge eating disorder are at increased risk for many illnesses and death. [Flegal et al., 2005]

    • Individuals with binge eating disorder often suffer from other psychiatric problems that occur at the same time, psychological distress, and medical disorders. [White and Grilo, 2006]

  • Eating Disorder Not Otherwise Specified (EDNOS)

    • Eating Disorders Not Otherwise Specified (EDNOS) covers all eating disorders that do not fall into either of the two main diagnostic groups: anorexia nervosa and bulimia nervosa. Although these less well known conditions are common and can be very severe, they are often neglected. [Norring and Palmer, 2005]

    • EDNOS, as listed in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), is a heterogeneous and poorly specified diagnostic category. Studies from different countries are consistent in showing that the disorders encompassed by EDNOS are the most common eating disorders health-care professionals encounter in routine clinical practice. [Fairburn and Bohn, 2005]

  • Excessive Exercise
    • The findings suggest that exercise is excessive when its delay comes with intense guilt and/or when it is used solely or primarily to influence weight or shape. The combination of both responses appears to indicate clinically defined eating disorder symptoms. [Mond et al., 2006]

    • The female athlete triad
      • The “female athlete triad” is a set of symptoms (disordered eating, amenorrhea [stopping of the menstrual period], and osteoporosis) present in female athletes who engage in various behaviors to control weight as part of their training regimens. [Drinkwater et al., 2005; Otis et al., 1997]

      • Disordered (e.g. restrictive) eating and low body weight are implied as the primary factors in the development of the “female athlete triad.” [Drinkwater et al., 2005; Otis et al., 1997]

Costs of Eating Disorders

  • Physical Costs of Eating Disorders The following are physical complications of eating disorders:

    • Semi-starvation in anorexia nervosa can negatively affect most organ systems.

    • Physical signs and symptoms can include constipation, cold intolerance, abnormally low heart rate, abdominal distress, skin dryness, hypotension, and fine body hair (lanugo). The lack of menstrual periods (amenorrhea) in women is also hallmark of anorexia nervosa.

    • Anorexia nervosa causes anemia, kidney dysfunction, cardiovascular problems, changes in brain structure, and osteoporosis (i.e. thinning of bones due to inadequate calcium).

    • Self-induced vomiting, seen in both anorexia nervosa and bulimia nervosa, can lead to swelling of salivary glands, electrolyte and mineral disturbances, and erosion of tooth enamel.

    • Use of ipecac (a medicine used to induce vomiting) can lead to extreme muscle weakness, including heart-muscle weakness.

    • Laxative abuse can lead to long-lasting disruptions of normal bowel functioning.

    • Rarer complications are tearing of the esophagus, stomach ruptures, and life-threatening irregularities of the heart rhythm [Academy of Eating Disorders, 2007]

  • Financial Costs of Eating Disorders Eating disorders place a tremendous financial burden on all involved—families of loved ones, hospitals, and schools. Families often have to take out a second mortgage on their homes in order to accommodate eating-disorder treatment costs.

    • The economic burden and health-service use of eating-disorder treatment have received little attention, and not much data exists on these costs. This data is necessary to provide an estimation of costs and resource allocation for treatment and thus to advocate for increased resources and necessary changes in clinical practice for patient care and other health care and school settings. [Frisch et al., 2006]

    • The average length of stay in residential eating-disorder treatment programs is 83 days, with an average cost per day of US$956. That average stay and cost per day works out to about US$80,000. [Frisch et al., 2006]

    • This systematic review reports the current international evidence on the resource use and cost of eating disorders.

    • In the United Kingdom, the health-care cost of anorexia nervosa was estimated to be £4.2 million (about US$8.2 million) in 1990.

    • In Germany, the health-care cost was 65 million DM (about US$100 million) for anorexia nervosa and 10 million DM (about US$15.3 million) for bulimia nervosa during 1998.
    • An Australian study reported the health-care costs of eating disorders to be Aus$22 million for the years 1993 to 1994.

    • There is a lack of research on non-health-care (financial, emotional etc.) costs.

    • Comprehensive data on resource use by patients with eating disorders are urgently needed for better estimations, and to be able to determine cost-effective treatment options.[Simon et al., 2005]

    • Here’s a detailed look at the costs of eating disorders in Germany. This example is to illustrate not only the direct costs of eating disorders but also the indirect costs.This cost-of-illness analysis for eating disorders in Germany considers hospitalization, rehabilitation services, and indirect costs due to inability to work and premature death. The cost estimates are based on projections derived from benefit data as listed by health-insurance schemes and pension-insurance schemes and from epidemiological studies on the prevalence of eating disorders and mortality rates.

      • For anorexia, the cost of illness amounts to approximately 195 million (about US$299 million). For bulimia, it comes to around 124 million.

      • The annual cost per anorexia and bulimia patient is approximately 5,300 (about $8,125) and 1,300 (about US$2,000), respectively. This cost-of-illness analysis underlines the significance of indirect costs due to premature death, but also highlights the extremely cost-intensive treatment.

      • The hospitalization cost of 12,800 per anorexia patient is markedly higher than the average hospitalization cost of 3,600.[Krauth et al., 2002]

Socioeconomic Status, Ethnicity, and Eating Disorders

The popular idea that eating disorders are mainly a problem among the wealthy has now been disproven by several studies. In recent years, researchers have found that eating disorders are now also occurring among women in groups of lower socioeconomic status (SES) [Pate et al., 1992; Rosen et al., 1995; Root, 1990; Story et al., 1995] It seems that eating disorders are no longer confined to white upper-class women; ethnic groups other than whites are now also experiencing the pressure to be thin.

  • In 1994, an article in Essence magazine (a publication aimed at an African-American audience) written by an African-American woman made it painfully clear that “largeness … once accepted-even revered-among black folks … now carries the same unmistakable stigma as it does among whites.” [Gregory, 1994]

  • A study in Essence magazine on eating disorders examined a sample of 600 female respondents. Of these respondents, 66% reported dieting behavior, 39% claimed that food controls their lives, and 54% were at risk for an eating disorder.[Pumariega et al., 1994]

  • In a separate study, black adolescent girls demonstrated a significantly higher drive for thinness than white adolescent girls. The study also found that black girls’ drive for thinness was significantly correlated with having been criticized for being too fat. [Striegel-Moore et al., 1986]

  • In a study of 2,379 black and white 9- and 10-year-olds, 40% of the girls reported wanting to lose weight, with no significant difference between black and white girls on this measure. [Schreiber et al., 1996]Increased social, vocational, and economic opportunities are available to women of color who can conform to the dominant, white culture’s norms. Women of color thus may become vulnerable and will conform to pressure to be “perfect” in the context of upward social mobility. This perfection may be pursued by shaping one’s body to fit the mainstream culture’s female body ideal. [Root, 1990]

    • One hypothesis is that the more acculturated (assimilated into the mainstream popular culture, which is mainly white) a woman is, the more she will experience body-image dissatisfaction. The more a person is pressured to emulate the mainstream image, the more the desire to be thin is adopted, and with it comes an increased risk for the development of body image dissatisfaction and eating disorders.

  • A study examined disordered-eating behavior and attitudes among high school Hispanics, Native Americans, and whites in the United States. Rates of self-induced vomiting and binge eating were significantly higher for the two minority groups, even when controlling for weight. The study concluded that the rate of disturbed eating behavior is at least as prevalent among Native Americans and Hispanics as it is among white adolescents. [Smith and Krejci, 1991]

  • In Japan, the desire to be thinner has increased within the last 20 years, accompanied by an increase in body-size dissatisfaction among the Japanese. [Matsuura et al., 1992]

  • One study asked 1,044 Hong Kong-born bilingual university students to complete the English version of the EAT (Eating Attitudes Test). The results indicated that young Chinese women were much in agreement with their Western counterparts where desire to be slim was concerned. Of these young Chinese women, 36% reported a preoccupation with the desire to be thin. [Lee, 1993]

  • In a study of 9,971 female self-reported dieters, unhealthy eating attitudes for women who diet (such as binging and purging) were similar across ethnic groups, again suggesting that eating disordered behavior is not simply a white woman’s problem anymore. For all racial groups, self-esteem was rated highest for times when the subjects’ weight was lowest. [Le Grange et al., 1998]

  • Studies are showing that ethnic minority groups are reaching parity with Caucasians in body image and eating disturbances, suggesting that ethnicity does not appear to protect against the broader sociocultural factors that foster body dissatisfaction among adolescent females. [Shaw et al., 2004; French et al., 1997]

Also see the Facts on Health & Weight section for information on “obesity prevention” ad campaign that was protested by the Academy for Eating Disorders.