Eating Disorder

What is an Eating Disorder?

Eating disorders are mental illnesses that cause serious disturbances in a person’s everyday diet. It can manifest as eating extremely small amounts of food or severely overeating. The condition may begin as just eating too little or too much but obsession with eating and food over takes over the life of a person leading to severe changes.

In addition to abnormal eating patterns are distress and concern about body weight or shape. These disorders frequently coexist with other mental illnesses such as depression, substance abuse, or anxiety disorders.

Eating disorders when manifested at a young age can cause severe impairment in growth, development, fertility and overall mental and social wellbeing. In addition, they also raise the risk of an early death. People with anorexia nervosa are 18 times more likely to die early compared with people of similar age in the general population.

Who gets eating disorders?

Eating disorders can affect both men and women and are slightly more common among women. Often these disorders begin during adolescence or young adulthood but may also develop during childhood or later in life.

Types of eating disorders

  • Anorexia nervosa – This is characterized by an intense fear of being obese and a continued pursuit of becoming thin.
  • Bulimia nervosa
  • Binge-eating disorder
  • Eating disorders not otherwise specified (EDNOS) – this includes eating disorders that do not meet the criteria for anorexia or bulimia nervosa. Binge eating could be a type of EDNOS. EDNOS is the most common diagnosis among people who seek treatment

Symptoms of eating disorders

  • Anorexia nervosa

There is a loss of at least 15 percent of body weight resulting from refusal to eat adequately despite feeling hungry. There is an unnatural fear of becoming fat. There is a distortion of self-perception. Thin anorexics may feel they are fat. There may be a tendency to exercise obsessively. Anorexic women may go months without getting their periods, suffer weight loss and may suffer from infertility. A significant proportion of people with anorexia will also develop bulimia.

  • Bulimia nervosa

These patients first eat too much (binging) and then purge or vomit it all out. Eating binges involve consumption of large amounts of calorie-rich foods. The person feels totally out of control and self-disgust during these periods. After such binges they attempt to purse out the food to compensate for binges and to avoid weight gain. This could be by self-induced vomiting or misuse of laxatives. A person with bulimia is usually close to their normal body weight and are less recognisable than a person with anorexia.

  • Binge eating disorder

This is characterized by frequent episodes of binge eating. Individuals feel loss of control during these binge episodes. The binge eating can lead to serious health consequences such as obesity, diabetes, hypertension (high blood pressure) and heart disease.

Treatment for eating disorders

Eating disorders can be effectively treated. The earlier they are detected, the easier it is to treat them. Recovery can take months or years, but the majority of people recover. Once diagnosed, treatment is a multidisciplinary approach.

The health care providers involved include psychiatrists, psychologists, physicians, dieticians or nutritional advisers, social workers, occupational therapists and nurses.

Treatment includes diet education and advice, psychological interventions and treatment of concurrent mental ailments like depression and anxiety disorders.

Eating Disorder Signs

The most common symptom or sign of an eating disorder is the distorted body image also known as body dysmorphia. Body dysmorphia occurs in both anorexia and bulimia.

Warning signs of eating disorders include:

  • Several food and eating related behaviors may be altered. The person may skips meals, take tiny portions, refuse to eat with others, eats in ritualistic ways, chews food only to spit it out, and mixes strange food combinations.
  • Another characteristic sign is shopping for groceries and cooking meals for the family while not partaking in them. Early signs include disgust with former favorite foods, stopping and eliminating fat from all foods taken, gorging on foods in secret and secret attempts at purging.
  • Behaviors related to appearance and body image – The individual often shows early signs of fears of weight gain and obesity. They tend to start wearing baggy clothes and layers of clothes to hide fat or emaciation. There may be excessive obsession about clothing size, image in the mirror, hatred for all or specific parts of the body, especially breasts, belly, thighs, and buttocks and complaints about being fat even when they are not.
  • Behaviors related to exercise - The person exercises excessively and compulsively. Athletic performance suffers over time due to lack of nutrition but the individual keeps up.
  • Signs in thoughts and beliefs – There may be early behavioral changes that involve denial of anything being wrong. The individual often argues with those who wish to help and may then sulk or withdraw or throw a tantrum. He or she may have trouble talking about feelings, especially anger. They may become excessively irritable, cross, snappish, moody and touchy.
  • Changes in social behaviors – Individuals may try to please everyone and withdraws when this is not possible. May present self as needy and dependent or as independent rejecting of all attempts to help. While anorexics are averse to sex, bulimics may engage in casual or even promiscuous sex. There may be drugs or alcohol abuse.
  • Those with binge eating disorder may have any compensatory behavior e.g. they do not purge, use laxatives or engage in compulsive exercise. The episode is triggered by an emotional upset and not by hunger. The individual may shop or procure large qualities of food that disappears soon after. These patients are usually overweight or obese, even though persons of normal or average weight can be affected. They tend to eat rapidly, large amounts of food, feel the lack of control to stop eating, never feel satisfied or satiated, eat without hunger, are embarrassed. These individuals are often depressed. Women with Polycystic Ovary Syndrome (PCOS) may develop binge eating and bulimic behavior.
  • Rumination Syndrome – the individual practices painless regurgitation of food following a meal which is then either re-chewed, re-swallowed or discarded.
  • Food Maintenance Syndrome – This is seen in children in foster care and shows a pattern of aberrant eating behaviors.
  • Female Athlete Triad – This is a combination of three features. There is an eating disorder along with loss of menstrual periods for long periods of time and decreased bone mineral density commonly in female athletes.

Eating Disorders Diagnosis

Diagnosis of eating disorders is a process that begins with acceptance of its presence. Often the patient needs to be convinced of its presence as there is severe denial and resistance to the problem.

There are too many patients that diagnose themselves as being allergic to gluten or carbohydrates and resort to restrictive diets. In addition, when diagnosed in children, parents often perceive it as a parental failure and there are multiple factors that influence the detection of eating disorders.

Diagnosis involves:

Interview based tests

Medical interviews with a supportive companion (preferred) are the initial steps in diagnosis. The physician tries to find out additional information on the patient's eating history. The interviews use various questionnaires to assess the patients.

The Eating Disorders Examination (EDE), which is an interview of the patient by the doctor, and the self-reported Eating Disorders Examination-Questionnaire (EDE-Q) are both considered valid tests.

Another test is called the SCOFF questionnaire, which can help identify both very young and adult patients who meet the full criteria for anorexia or bulimia nervosa.

Eating Disorder Specific Psychometric Tests
Eating Attitudes Test SCOFF questionnaire
Body Attitudes Test Body Attitudes Questionnaire
Eating Disorder Inventory Eating Disorder Examination Interview

Screening questionnaire

A screening questionnaire is first applied:

  • How many diets have you been on in the past year?
  • Do you think you should be dieting?
  • Are you dissatisfied with your body size?
  • Does your weight affect the way you think about yourself?

A positive response to any of these questions warrants further evaluation

SCOFF questionnaire

Broadly the SCOFF Questionnaire includes questions like:

  • Do you make yourself sick because you feel uncomfortably full?
  • Do you worry you have lost control over how much you eat?
  • Have you recently lost more than one stone's worth of weight (14 pounds or 6.4kg) in a 3-month period?
  • Do you believe yourself to be Fat when others say you are too thin?
  • Would you say that food dominates your life?

One point for every yes answer; a score 2 indicates a likely case of anorexia nervosa or bulimia nervosa

Bulimia diagnosis

For bulimia diagnosis there has to be at least two bulimic episodes per week for 3 months. Since there may be dental and gum related problems in bulimic patients dentists and oral pathologists may also help in diagnosis.

Anorexia nervosa diagnosis

For diagnosis of anorexia nervosa the criteria are patients refusal to maintain a body weight normal for age and height and an intense and irrational fear of becoming fat even though underweight. Patients typically have a distorted self-image that results in diminished self-confidence and do not accept that fact that they may be seriously emaciated and ill.

There is in addition loss of menstrual function for at least 3 months. Once detected, anorexia may be categorized further. Some have restrictive anorexia nervosa who practice severe dieting only while other may have Anorexia bulimia who have binge-purge behaviour.

Medical tests for complications

Medical tests are advised to detect and rule out complications of eating disorders. Tests should include:

Medical Tests used in the Diagnosis and Assessment of Eating Disorders
Complete Blood Count (CBC) a test of the white blood cells. red blood cells and platelets used to assess the presence of various disorders such as leukocytosis, leukopenia, thrombocytosis and anemia which may result from malnutrition.
urinalysis a variety of tests performed on the urine used in the diagnosis of medical disorders, to test for substance abuse , and as an indicator of overall health
ELISA Various subtypes of ELISA used to test for antibodies to various viruses and bacteria such as Borrelia burgdoferi (Lyme Disease)
Western Blot Analysis Used to confirm the preliminary results of the ELISA
Chem-20 Chem-20 also known as SMA-20 a group of twenty separate chemical tests performed on blood serum. Tests include cholesterol, protein and electrolytes such as potassium, chlorine and sodium and tests specific to liver and kidney function.
glucose tolerance test Oral glucose tolerance test (OGTT) used to assess the bodies' ability to metabolize glucose. Can be useful in detecting various disorders such as diabetes, an insulinoma, Cushing's Syndrome, hypoglycemia and polycystic ovary syndrome
Secritin-CCK Test Used to assess function of pancreas and gall bladder
Serum cholinesterase test a test of liver enzymes (acetylcholinesterase and pseudocholinesterase) useful as a test of liver function and to assess the effects of malnutrition
Liver Function Test A series of tests used to assess liver function some of the tests are also used in the assessment of malnutrition, protein deficiency, kidney function, bleeding disorders, Crohn's Disease
Lh response to GnRH Luteinizing hormone (Lh) response to gonadotropin-releasing hormone (GnRH). Tests the pituitary glands' response to GnRh a hormone produced in the hypothalumus. Central hypogonadism is often seen in anorexia nervosa cases.
Creatine Kinase Test (CK-Test) measures the circulating blood levels of creatine kinase an enzyme found in the heart (CK-MB), brain (CK-BB) and skeletal muscle (CK-MM).
Blood urea nitrogen (BUN) test urea nitrogen is the byproduct of protein metabolism first formed in the liver then removed from the body by the kidneys. The BUN test is used primarily to test kidney function. A low BUN level may indicate the effects of malnutrition.
BUN-to-creatinine ratio A BUN to creatinine ratio is used to predict various conditions. High BUN/creatinine ratio can occur in severe hydration, acute kidney failure, congestive heart failure, intestinal bleeding. A low BUN/creatinine can indicate a low protein diet, celiac disease rhabdomyolysis, cirrhosis of the liver.
echocardiogram utilizes ultrasound to create a moving picture of the heart to assess function
electrocardiogram (EKG or ECG measures electrical activity of heart can be used to detect various disorders such as hyperkalemia
electroencephalogram (EEG) measures the electrical activity of the brain. Can be used to detect abnormalities such as those associated with pituitary tumors
Upper GI Series test used to assess gastrointestinal problems of the middle and upper intestinal tract
Thyroid Screen TSH, t4, t3 test used to assess thyroid functioning by checking levels of thyroid-stimulating hormone (TSH), thyroxine (T4), and triiodothyronine (T3)
Parathyroid hormone (PTH) test tests the functioning of the parathyroid by measuring the amount of(PTH) in the blood. Test is used to diagnose parahypothyroidism. PTH also controls the levels of calcium and phosphorus in the blood (homeostasis).
barium enema an x-ray examination of the lower gastrointestinal tract

Differential Diagnosis

Other disorders that mimic eating disorders include:

  • Hyperthyroidism – overactive thyroid
  • Cancers
  • Inflammatory bowel disease like Crohn’s disease and ulcerative colitis
  • Immunodeficiency and AIDS like states
  • Chronic infections
  • Malabsorption syndromes
  • Addison's disease
  • Diabetes

Co-existing diseases

Some diseases commonly co-exist among patients with eating disorders. These include:

  • Depression - Major depression is the most common comorbid condition among patients with anorexia
  • Anxiety disorders - Anxiety disorders, especially social phobia, also are common
  • Obsessive-compulsive disorder – This has a prevalence of 30 percent among patients with eating disorders
  • Substance abuse – This has prevalence is estimated at 12 to 18 percent in patients with anorexia and 30 to 70 percent in patients with bulimia
  • Schizophrenia