Understanding Adult and Pediatric Eating Disorders

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Presented by: Debra L. Safer, MD
Co-Director, Stanford Eating and Weight Disorder Program
November 1, 2012

Eating disorders are abnormal behavior patterns that compromise physical health and mental well-being. These behaviors include anorexia nervosa (self-starvation), bulimia nervosa (binge eating and purging), binge eating disorder, and other non-specified conditions.

Anorexia affects 10 times more females than males while rates of binge eating are 1.5 times more common in females than males. The National Institute of Mental Health estimates that 5 to 10 percent of the U.S. population has an eating disorder of one type or another.

Though eating disorders affect relatively few people, the impact on those suffering from them is severe. Anorexia has the highest mortality rate of any psychological disorder.

“Eating disorders are not about vanity, or choice, or needing attention,” said Debra L. Safer, MD, co-director of Stanford’s Eating and Weight Disorders Program, who spoke at a presentation sponsored by the Stanford Hospital Health Library. “Nor are they a phase. They are serious mental illnesses with dire consequences, so they need to be taken seriously.”

Growing Numbers
Eating disorders affect primarily females and are most common among teens and young adults. About 86 percent of eating disorders patients say they developed the condition before age 20, and there appears to be a higher risk of anorexia nervosa among Caucasians, people from higher socio-economic levels, and from subcultures that put a strong emphasis on appearance, such as models and athletes.

“The numbers appear to be growing in all populations,” Safer said, “but it’s difficult to assess anorexia because there are often inadequate numbers of patients who will participate in studies. Only about .5 to 1 percent of the population has anorexia and the dropout rate from studies by adult anorexics is often about 50 percent.”

Anorexia nervosa causes people to obsess about their weight and the food they eat. They will attempt to maintain a weight that’s far below normal, and to prevent weight gain or to continue losing weight, they may starve themselves or exercise excessively.

People with bulimia may secretly purge, trying to get rid of calories by forced vomiting or excessive exercise. While most people overindulge now and then, there are strict criteria for defining a binge, Safer said, that include consuming an excessive amount of food in less than two hours. Bulimics are preoccupied with weight and body shape and may also misuse laxatives, diuretics, or enemas.

Binge eating involves rapid and uncontrolled consumption of excess food, usually in solitude, followed by feelings of guilt or self-disgust. Unlike bulimia or anorexia, binge eaters do not purge their food, exercise excessively, or eat only small amounts of only certain foods. Because of this, binge eaters are often overweight or obese.

Anorexia usually manifests around age 1214, bulimia around age 1416, and binge eating at age 1822, but many patients report having some symptoms much younger, she added. Almost 40 percent of American 9-year-olds report that they been on diets and/or already started on risky behaviors.

Multiple Complications
“Anorexia is associated with lots of medical complications. They tend to be multisystem, affecting all the organs,” Dr. Safer said. “There are many long-term effects because it interrupts the adolescent growth spurt. In severe cases, the body goes through a ‘hibernation response,’ which is a physical shut-down with low blood pressure, lowered body temperature, and abnormal heart rhythms that can be fatal.”

Other consequences include bone loss, which increases the risk of early-onset osteoporosis; hormone imbalances that cause the absence of periods in girls and decreased testosterone in boys; and gastrointestinal problems, such as constipation and bloating, which make it even harder for patients to want to eat. Purging depletes the body of nutrients, leading to low potassium levels that can cause heart arrhythmias.

There are also neurological consequences. With reduced blood to the brain, eating disorder patients really do think and respond more slowly than their peers and tend to suffer short-term memory loss.

“The cognitive changes associated with malnutrition affect their sense of self and distort their self-assessment,” Dr. Safer said. “The disease causes an actual change in brain chemistry that can perpetuate the cycle. Happily, the effects of malnutrition in the brain can be reversed.”

In bulimia, stomach acids can erode both the esophageal lining and tooth enamel. Binge eaters tend to suffer from high blood pressure, high cholesterol, heart disease, and gall bladder problems.

It’s a misconception that eating disorders in adolescents are the fault of controlling parents or the result of a culture that emphasizes lean bodies and unrealistic beauty standards, Dr. Safer said. In fact, the cause may stem from multiple factors, including genetics, environment, and personal psychology.

Researchers are exploring the tie between eating disorders and larger issues of cognition and thinking patterns. They hypothesize that, for some, reduced self-esteem can lead to distorted concerns about appearance and a destructive cycle of behavior (a cognitive behavior model). For others, an emotional trigger may set off a way of seeing control of food as an escape from emotional pain that makes them dependent on their behavior (an emotion regulation model).

“No one chooses to have an eating disorder,” she added. “Many are in denial about the seriousness of their illness or have distorted perceptions about how they really look.”

Early Intervention
Treatment for eating disorders includes family-based, individual, and group therapy, with a majority of patients being treated as outpatients. Fifty percent of eating disorders patients make a full recovery; about 20 percent maintain a chronic condition; and 30 percent keep some symptoms or experience recurrence.

While there are no FDA-approved medications to treat anorexia nervosa, family-based therapy—in which the parents participate as active caregivers—works for many adolescents. Another approach is called cognitive behavioral therapy: It focuses on changing flawed thoughts and beliefs to improve the patient’s emotional state. And interpersonal behavioral therapy seeks to improve underlying interpersonal relationships.

“The goal is first to make our patients medically stable and restore their weight,” said Dr. Safer. “Then we start to address other aspects and look at contributing issues. Early intervention can treat or cure the disease. Over time the habit becomes part of the person’s identity so it’s harder for them to change.”

About the Speaker
Debra Safer, MD, is an assistant professor of psychiatry and behavioral sciences and co-director of Stanford’s Eating and Weight Disorder Program. The program involves staff from the Lucile Packard Children’s Hospital’s Center for Adolescent Health and the Stanford University School of Medicine divisions of Adolescent Medicine and Child Psychiatry. A specialist in adult and pediatric eating disorders, Dr. Safer studies the nature and treatment of these disorders, the development and treatment of obesity, and the relationship between binge eating and the metabolic syndrome. She received her MD from UCSF Medical Center, and completed her internship, residency, and fellowship at Stanford. Dr. Safer is board certified in psychiatry by the American Board of Psychiatry and Neurology.

For More Information:

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About Dr. Safer

Stanford Hospital Psychiatry

Pediatric Eating Disorders Clinic

Eating Disorders Research Program

Stanford Hospital Health Library

National Eating Disorders Association