Weekend Special Feature: The hidden faces of eating disorders

Two recent studies in the news offer an invaluable opportunity for all of us to better understand disordered eating. The common belief, a carry over from Victorian times, is that eating disorders are mostly a nervous affliction of young women. Popular media depicts anorexia nervosa by focusing on the most extreme cases and giving us shocking images of women who’ve starved themselves close to death. These sensationalized examples may make good copy, but they’ve led most people to believe that those suffering from eating disorders are anomalies, rare and freakish. This misconception not only detrimentally labels its victims, it also means we fail to recognize, and reach out to help, the many who are suffering who don’t fit that mold.

The media paid little attention to these new studies, not recognizing their significance. But both studies highlighted a serious concern within the medical profession about how to identify and define the myriad types and severities of eating disorders which don’t fit the classic clinical definitions.

Little kids

The first study, published in the Journal of Adolescent Health, was by researchers at the Stanford University School of Medicine and Lucile Packard Children’s Hospital. They examined the records of 959 patients, ages 8 to 19, who had been seen by a child psychiatric expert and medically assessed by medical specialists at their academic medical center between 1997 to 2005 and been diagnosed with eating disorders. They found that many children don’t fit the criteria for a diagnosis of anorexia nervosa, according to the official adult guidelines from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV). These researchers reported that children sufferers don’t always have body dissatisfaction or present under 85% of their “ideal” body weight and, if they’ve not yet reached pubery, don’t really meet the criteria for amenorrhea (loss of menstrual periods).

Most astute practitioners give children and teens the diagnosis of EDNOS (“eating disorder not otherwise specified”), while others may fail to recognize a problem at all, especially among younger patients who are less likely to binge, purge or use laxatives or diuretics. Yet, in school-based studies of the general population, preoccupation with weight and eating is surprisingly common in children, with 20 to 56% dieting, up to 71% exercising trying to lose weight and up to 10% having experimented with vomiting. School children assessed using the Children’s Eating Attitudes Test, found 10.5% of 10-14 year olds and 6.9% of 7-13 year olds met the clinical threshold for disordered eating.

This study was the first to describe a large group of very young children with eating disorders. They found that, unlike teens, younger patients were more likely to be boys, to weigh considerably under their ideal weight by the time they were identified, and lose weight much faster than teens. These younger children had not only stopped growing but had even lost weight. While it’s especially imperative for parents and healthcare providers to recognize the problem quickly in younger children, it can be difficult, said lead researcher, Rebecka Peebles, M.D. Very young children don’t always express the same types of body image disturbances and call themselves “fat” or know why they don’t want to eat. “They just don’t want to be bigger.”

“Pediatricians and parents shouldn’t think of weight loss, or even lack of weight gain in a pre-teen, as a phase,” cautioned Dr. Peebles. “If a child expresses wanting to lose weight, take it seriously.”

Bulimics

The second study was published in the International Journal of Eating Disorders. Australian researchers at James Cook University in Townsville studied women with bulimia-type eating disorders. While the popular perception of bulimia nervosa is of people vomiting, the disorder also applies to those using other forms of purging such as abusing laxatives and diuretics. There are also non-purging forms of bulimia characterized by excessive exercising or dieting to counter binge eating episodes. And there are still others, according to the researchers, who fall short of meeting all of the criteria and only fit in the EDNOS category.

Nearly half of the women diagnosed with bulimia nervosa in this study didn’t see that they had an eating disorder. And those who didn’t use vomiting were six times less likely to realize they had a problem. Doctors were equally unlikely to recognize the seriousness of these eating disorders, even in the women seeking treatment. They were apt to treat them for depression or anxiety and leave the eating disorder unaddressed, said study co-author Dr. Jonathan Mond.

There’s a general perception, he said, that excessive exercising and strict calorie counting are acceptable and even “desirable.” They are not.

Those who don’t fit the stereotype

When popular images and beliefs about eating disorders focus on severely gaunt young women primarily motivated by desires to be thin, many sufferers don’t see themselves in such depictions. Hence, they may not realize they have a problem, nor are their problems recognized by friends, family and healthcare providers. Yet they have all of the same mental processes and physical behaviors, and suffer the same reduced quality of life and many of the same nutritional and health problems to varying degress, of clinically diagnosed anorexia nervosa and bulimia nervosa.

Many with disorderd eating don’t look the part — they may have “normal” body weights or even be fat. It is possible to weigh 15% below the body weight genetically natural for them and still not appear “underweight.” Because our society wrongly believes everyone eating “right” will fall within a “normal” weight range, many of these sufferers “pass” for normal. Or, they’re admired and seen as just very “thin and healthy” women and men. But they are exhibiting the same controlled eating and dietary restrictions, over-exercising and the other behaviors of their clinically-diagnosed anorexia nervosa and bulimia nervosa counterparts.

Many of these sufferers won’t ever reach the extreme state to fall under the traditional clinical diagnosis of eating disorders, even though they’re below a weight natural for their bodies, their lives are tormented by body weight concerns and their energies are devoted to staying slim. Their suffering and need for help usually go unrecognized and untreated. Sadly, they are invisible, marginalized and their problems are never taken seriously.

Thinness in our culture is seen as representing success, wealth, power, self-control and health. There are very few fat women depicted favorably in popular culture. Our society has come to see dieting and concerns over our figure as normal feminine behavior and it’s even supported and encouraged among girls, especially as they approach puberty and teen years — a time when it’s normal and healthy to gain up to 20-30% of body weight in fat as their bodies ready for menstruation and the ability to bear children. When boys start eating parents out of house and home, it’s considered a normal part of growing up. But when girls bodies hit growth spurts and they’re naturally driven to eat more, they are frowned upon. Growing girls are told their natural, normal appetites are “overeating” and they’re made to believe they have problem “issues” with food and must watch what they eat to avoid gaining weight.

Females are raised on media images of women 23% or more below what the average woman weighs, with unnaturally bony bodies lacking any fat or womanly curves. So when their own bodies begin to fill out normally, panic sets in. Research has repeatedly shown that parents become similarly concerned by the normal blossoming of their daughters.

With the “ideal” woman’s body so severely below what is normal, most women have come to hold unrealistic ideas of what women should weigh and look like. Weights of 140-150s are healthy for women of average heights, but 100 pounds has become the magic number many women live by. If they don’t weigh under 100 pounds they often don’t believe they have a problem.

Girls striving to attain unrealistic ideals are much more likely to be drawn into dieting behaviors. While dieting itself is believed by many clinicians to be a subclinical eating disorder, it is recognized as one of the primary physiological and psychological triggers for full-blown eating disorders. The causes of eating disorders are complex, with multiple psychological, sociological and physiological components, but dieting and the accompanying (normal responses to) hunger is often overlooked as a factor.

Many of the rituals characteristic of eating disorders are also indistinguishable from the “healthy” eating tips encouraged in our culture: counting and restricting caloric intakes, measuring or controlling portions, not eating certain kinds of foods, exercising religiously and watching their weight. Don’t be fooled. This is not normal eating or required for “health,” it is dieting.

Not surprisingly, many people see young girls with disordered eating as just being “health conscious” and “typical girls.” It may be inherent upon the fathers to intervene and not simply regard dieting as a “girl thing.”

Similarly, when disordered, restrained eating and/or over-exercise (a mere 30 minutes of moderate physical activity most days of the week has been shown to impart metabolic health) is present among older women and men, it is often viewed as “healthy” lifestyles. In a July 2006 Thomson Medstate Research Brief, nearly 80% of 12,000 American adults surveyed who were underweight considered their eating habits very healthy or somewhat healthy.

Increasingly recognized is disordered eating among people driven by what they believe is a pursuit of health. They may not be tormented by fears of becoming fat as much as fears over the perils in foods and ill-health. They want to eat only foods that are “good,” nutritious and pure, and continually restrict what they eat to eliminate foods they believe are unhealthy, such as meats, refined sugars, artificial ingredients or packaged foods. Surrounded by the food fears in the media and the messages of the health benefits of certain foods, much like anorectics, they seek an illusion of safety and control, said Dr. Steven Bratman, M.D., medical director of Prima Health and author of Orthorexia Nervosa: Overcoming the obsession with healthful eating (2000). After seeing increasingly more people in his practice with this, Dr. Bratman was the first to recognize it as an eating disorder and label it “orthorexia nervosa.”

“The quest for healthy food can become a disease in its own right, said Dr. Bratman. “Obsession with a healthy diet is an illness, an eating disorder.” Its sufferers develop an almost religious devotion to healthy eating, he said. When what you eat is based on its healthfulness, that isn’t healthy, he said. Many of the orthorexics he’s identified adopt unsound dietary beliefs and extreme dietary practices, such as believing they have food allergies, need to eat organic or microbiotic, and require supplements to remain healthy and youthful. While it does not yet have a specific category in the clinical definitions of eating disorders, orthorexia nervosa is increasingly being recognized among clinicians as being a similar problem and even developing into clinical anorexia nervosa.

“To be really healthy, we have to relax, live a little, flow with the movements of life, and not grasp frantically after a perfect diet,” said Dr. Bratman.

Perpetual dieting; the pursuit of “healthy” eating, “healthy” weights and “fit” bodies; and all the accompanying fears over food and fat; have become so mainstream, that eating disorders have not only soared over recent years, they are much more common than we dare admit.

©Sandy Szwarc 2006