Eating disorders, now renamed as Feeding and Eating disorders by the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), are a common group of diseases in young ladies who develop abnormal eating patterns based on their excessive concern with body image and/or weight. These diseases can impair women’s physical health or psychosocial functioning and can lead to high morbidity and mortality.
Epidemiology. Although eating disorders can affect people of all ages and both genders, they are often reported in adolescents and young women. One in eight youngsters may have at least one eating disorder by twenty years of age. Approximately 5 million Americans are affected by eating disorders every year. However, eating disorders are common worldwide in all communities. These occur selectively (over 90 percent) in young ladies in their teens and are not restricted to white women as was stated earlier. The commonest disorder is the non-specific eating disorder, followed by anorexia nervosa and bulimia nervosa.
Causes. Why should young ladies take to abnormal eating habits? Most authorities believe that these disorders have their roots in the perception of body dissatisfaction in a social context and these girls believe that their body image is awkward, they are overweight, and they value thinness, self-efficacy, and body control. Underlying factors in this perception may be psycho-developmental, socio-cultural, or genetic. Patients with eating disorders have many associated psychiatric diseases.
Broad Abnormal Eating Patterns. To reach their goal these girls use one or more of the three abnormal eating habits as a means to soothe their emotions. One is to restrict food (restrictive pattern), the second is a craving to eat large quantities of low caloric value foods over a short period of time (binge eating) and the third is to waste/consume the food taken at binge or otherwise through self-induced vomiting, by use of laxatives or diuretics or by intake of stimulants to consume food (purging).
Categories. Based on the combination of eating patterns, eating disorders can be categorized into several syndromes, which include Anorexia nervosa, Bulimia nervosa, Binge eating disorder, Avoidant or restrictive food intake disorder, Pica, Rumination, and other specified feeding and eating disorders like Purging disorder, Night eating syndrome, atypical anorexia nervosa, Subthreshold bulimia nervosa and binge eating disorder and Orthorexia and unspecified feeding and eating disorders.
Anorexia Nervosa. Anorexia nervosa is the most classical type of eating disorder. In this, the subject predominantly uses a restrictive pattern of eating (eats very little to nothing for days together). The goal is to lose weight and weight loss in these girls is always to a level of severe malnutrition (body mass index less than 17 kg/m2). Although weight loss is substantial these girls stay very active and never get tired and even attend the gym to further lose weight. Because of malnutrition many hormonal changes occur in the body and amenorrhea (loss of monthly menstrual bleeding) is an important associated development. Nearly one-third to half of these girls may have associated binge habits with purging.
The index case of Anorexia Nervosa [Case record of Dr. Khuroo’s Medical Clinic]. A worried mother approached me with her 17-year-old daughter who has been losing weight over the last year (body mass index was 13 kg/m2 against a normal 23 kg/m2) and she was reduced to skin and bones. In addition, she had stopped her menstrual cycles for six months. The girl had taken to the habit of voluntary severe restricted food intake and would eat nearly nothing for days together. At times (one or two times per week) she had craved to eat large amounts of food and subsequent to this would self-induce vomiting to throw whatever she had eaten. The mother further stated that her daughter was fixed on the idea of excess weight and abnormal body features and would watch a mirror in her house for hours together and make concerned comments about her body image and weight. She continued to be active and never got fatigued on physical exertion and has been attending the gym to lose further weight and stay/look fit. I knew this girl suffered from the most classical eating disorder named “anorexia nervosa”.
Bulimia Nervosa. World media caught the attention of this disorder when it was known that Late Princess Diana suffered from a severe form of bulimia, and this led to a famous movement to control this disease called the “Diana Effect”. Bulimia is characterized by recurrent binge eating associated with purging. During binge eating which occurs one to two times per week, these women have a craze to consume large quantities of low-caloric value foods over short periods of time. At the end of eating, they develop abdominal pain and feel uncomfortable due to abdominal distension and bloating. To compensate for overeating they self-induce vomiting to bring out and throw what has been eaten. Other methods are to use laxatives to induce diarrhea or use enemas to force excreta out of the body. Others use diuretics to lose body water. Some take stimulants like caffeine, ephedra, methylphenidate, or cocaine to consume calories and thus become substance abusers. Patients with bulimia usually do not lose weight and may even be overweight.
Binge Eating Disorder. Binge eating disorder is the most common eating disorder, begins in adolescence and one-third of such patients are males. Such patients eat enormous amounts of food in a short period, accompanied by loss of control during binge-eating behavior, as seen in Bulimia Nervosa. However, there is no associated purging to compensate for overeating as seen in Bulimia. Binge eating disorder poses a risk of obesity and complications associated with obesity like diabetes, heart disease, or stroke.
Avoidant or Restrictive Food Intake Disorder (ARFID). This disorder is common in infancy, toddlers, and children. Such patients have a loss of interest in eating, and an intense dislike for specific food items because of taste, smell, or color. ARFID impairs social function and inhibits the individual from eating with others. Also, it causes underweight and micronutrient deficiency.
PICA. Here an individual craves for non-food items like soil, chalk, soap, paper, or hair. It is common in children and pregnant women and usually is benign and self-resolving. However, it can be chronic and devastating in intellectually disabled persons. Pica poses a risk for parasitic infections, micronutrient deficiency, intestinal obstruction, and heavy metal poisoning.
Rumination Disorder. Here individuals regurgitate the previously swallowed food, chew it again, and then swallow or spit. Rumination is a voluntary action that usually happens within 30 minutes of having the food. Rumination developed in infancy usually resolves by 12 months. Rumination disorder in children and adults can lead to weight loss or malnutrition.
Prognosis. Eating disorders particularly in classical or severe forms are serious illnesses that shorten life span and cause excessive mortality. In fact, these patients are five times more prone to die than the normal population. After effective evaluation and treatment more than half of patients can make full recovery and remaining the most severe types continue to have to suffer for long periods of time. These disorders lead to a score of complications in the heart and related organs, skin, stomach, intestines, and liver and endocrine and metabolic functions.
Management Issues. There is a wide variation in how eating disorders are managed. Treatments are frequently multi-faceted and include psychotherapy, pharmacotherapy, nutritional counselling, and aftercare and monitoring. Psychotherapy is the first line of therapy for all eating disorders and includes several methods including Enhanced Cognitive Behaviour Therapy (CBT-E), Family-based treatment (FBT), Maudsley Anorexia Nervosa Therapy for Adults (MANTRA), and Focal Psychodynamic Therapy (FPT). Neuromodulation modalities like repetitive transcranial magnetic stimulation and deep brain stimulation are under study as adjunct treatments for eating disorders. Fluoxetine is the only FDA-approved drug used for the treatment of Bulimia nervosa and Binge eating disorders. The role of olanzapine in anorexia nervosa has been studied, which shows mixed results. Medications like antidepressants, antipsychotics, or mood stabilizers may help treat coexisting psychiatric illnesses such as anxiety or depression. Nutritional support is essential for all eating disorders and may include increased caloric supplementation, correction of nutritional deficiencies like electrolytes, calcium, Zinc, Vit D, Vit B12, etc, use of nasogastric feeding, or total parenteral nutrition (extreme cases of Anorexia Nervosa) and managing obesity in Binge Eating Disorder. Aftercare is important as the patients recover from eating disorders and see their weight gain, they might experience a resurgence of anxiety and depressive symptoms and drop out of treatment programs.
(Prof Mohammad Sultan Khuroo is a renowned gastroenterologist. He can be mailed at khuroo@yahoo.com. mohammad.khuroo@gmail.com)
DISCLAIMER: The views and opinions expressed in this article are the personal opinions of the author.
The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.