Eating Disorders:

The Eating Disorder Continuum and General Definitions

• Defining "Normal" Eating: Identifying an eating disorder requires a baseline definition of normal eating. Attitudes toward food, weight, and body image exist on a continuum rather than as binary states.

• The Eating Disorders Continuum:

  • Healthy End: Healthy weight, good body image, healthy eating/exercise habits.

  • Mid-Continuum (Disordered Behaviours): Weight/shape preoccupation, fasting, overeating, yo-yo dieting, excessive exercising, steroid use.

  • Clinical End: Anorexia, compulsive eating/exercise, distorted body image, bulimia, laxative abuse, binge eating disorder, muscle dysmorphia.

• Eating Disorder vs. Disordered Eating:

  • Eating Disorder: A specific psychiatric condition characterized by extreme body dissatisfaction and long-term eating patterns that cause physical harm to the body.

  • Other Specified Feeding or Eating Disorder (OSFED) and Unspecified Feeding or Eating Disorder (UFED): These terms encompass a variety of atypical or abnormal eating behaviours specifically used to reduce weight.

Causes and Contributing Factors of Eating Disorders

• Genetic and Biological Factors:

  • The probability of developing an eating disorder is several times higher if a biological relative is also diagnosed with one.

  • While this suggests a genetic component, it is difficult to isolate genetics from environmental influences.

  • Specific personality traits often coincide with these disorders.

• Environmental Factors:

  • A genetic predisposition may remain dormant until an environmental trigger activates the behaviour.

  • Environmental experiences are estimated to play a role in the development of the disease in $20\text{-}40\%$ of diagnosed individuals.

• Family Environment:

  • Family structures influence eating patterns.

  • Families with a member suffering from anorexia nervosa often exhibit a more rigid family structure.

  • Families with a member suffering from bulimia nervosa often show less stable family organization.

• Media Images and Sociocultural Values:

  • Exposure to computer-enhanced images of "perfect" bodies is constant.

  • Adolescents often struggle to distinguish reality from media fantasy, leading to a negative body image through comparison.

  • Western culture equates slenderness with beauty, self-discipline, health, and wealth. These values directly influence body image and susceptibility to disorders.

Anorexia Nervosa: Clinical Profile and Risks

• Definition: A medical disorder involving unhealthful behaviours to maintain a body weight less than $85\%$ of the expected weight for one's age, height, and sex.

• Demographics and Mortality:

  • $90\text{-}95\%$ of cases are young girls and women.

  • Approximately $0.5\text{-}4\%$ of Canadian females will develop anorexia.

  • The mortality rate is high; $5\text{-}20\%$ of females with anorexia will die from complications.

• DSM-5 Diagnostic Criteria:

  • Restriction of food intake leading to significantly low body weight.

  • Intense fear of gaining weight or becoming fat.

  • Distorted view of themselves and their condition (denial of seriousness).

  • Subcategories:

    1. Restricting type.

    2. Binge-eating/purging type.

• Behavioural, Emotional, and Mental Signs:

  • Behavioural: Difficulty eating with others, lying about food, frequent weighing, measuring portions, food rituals (chewing excessively, rearranging food), avoidance of mealtimes, and rigid exercise regimens.

  • Emotional/Mental: Depression, social isolation, intense need for control, low self-worth tied to weight, perfectionism, irritability, insomnia, and difficulty concentrating due to malnutrition.

• Physical Signs and Health Risks:

  • Skin/Hair: Thinning hair, loss of hair, lanugo (fine, downy body hair), dry skin, yellowish skin, brittle nails, and easy bruising.

  • Cardiovascular: Low blood pressure, slow heart rate, irregular heartbeat (arrhythmia), fluttering (palpitations), and heart failure.

  • Metabolic/Fluid: Electrolyte imbalances (low potassium, magnesium, and sodium), lowered body temperature, and tingling in extremities due to poor circulation.

  • Organ/Systemic: Muscle and organ wasting, kidney stones, kidney failure, constipation, bloating, bone density loss (osteoporosis), and fractures.

  • Reproductive: Loss of menstrual periods (amenorrhea), infertility, and high-risk pregnancy (miscarriage, low birthweight).

Bulimia Nervosa: Clinical Profile and Risks

• Definition: An eating disorder characterized by episodes of binge eating followed by purging.

  • Binge Eating: Consuming a large amount of food in a short, discrete period.

  • Purging: Attempts to rid the body of food via vomiting, laxatives, diuretics, fasting, or excessive exercise.

• Demographics and Prevalence:

  • Affects $1\text{-}4\%$ of women.

  • Male-to-female ratio is between $1:6$ and $1:10$.

  • $1\%$ of patients die from complications within 10 years of diagnosis.

  • Rates in men are higher in sports requiring low body weight.

• DSM-5 Diagnostic Criteria:

  • Recurrent binge eating episodes with a felt lack of control.

  • Recurrent inappropriate compensatory behaviours.

  • Binge and compensation occur at least $1$ time per week for a duration of $3$ months.

  • Self-evaluation is unduly influenced by body shape and weight.

• Physical Signs and Health Risks:

  • Electrolyte Imbalance: Caused by dehydration and loss of sodium and potassium from vomiting; can lead to heart failure.

  • Gastrointestinal: General GI problems.

  • Oral/Physical: Dental decay (from stomach acid), swelling of the cheeks or jaw area, and calluses on the knuckles or backs of hands (Russell's sign).

Binge Eating Disorder (BED) and Pica

• Pica: The persistent eating of non-nutritive, non-food substances for at least one month.

• Binge Eating Disorder (BED): Classified as a formal eating disorder in the DSM-5.

  • Criteria: Recurrent episodes of eating significantly larger amounts of food than normal in a discrete period (e.g., $2$ hours) accompanied by a sense of lack of control.

  • Distinction: Unlike Bulimia, BED involves no regular use of inappropriate compensatory behaviours.

  • Frequency: Occurs on average at least $1$ day per week for $3$ months.

  • Symptoms: Marked distress regarding the binging, including unpleasant feelings and concerns about long-term health and weight.

• BED Causes and Onset:

  • Onset usually occurs in late teens or early twenties.

  • Often follows significant weight loss from dieting.

  • Stress is a major precipitating factor; there may be a genetic link.

Other Specified Feeding or Eating Disorders (OSFED) and RED-S

• OSFED Categories:

  • Atypical Anorexia Nervosa (weight is within or above normal range).

  • Binge Eating Disorder of low frequency or limited duration.

  • Bulimia Nervosa of low frequency or limited duration.

  • Purging Disorder.

  • Night Eating Syndrome.

• OSFED Health Risks: Decreased basal metabolic rate ($BMR$), psychological stress, poor nutrient intake, and increased risk of progression to full Anorexia or Bulimia.

• RED-S (Relative Energy Deficiency Syndrome):

  • A state where energy intake is insufficient to meet the demands of exercise expenditure.

  • Formula: $\text{Energy Expenditure} > \text{Energy Intake} = \text{Decreased Energy Availability}$.

  • Affected Systems: Cardiovascular, psychological, gastrointestinal, immunological, menstrual function, bone health, metabolic, hematological, endocrine, and growth/development.

Treatment and Prevention Strategies

• The Team Approach: Successful treatment requires a multidisciplinary team including the patient, physician, nutritional counselors (RD), and psychiatric counselors.

• Treatment Modalities:

  1. Nutritional Rehabilitation: Restoring healthy weight and habits.

  2. Psychosocial Interventions: Correcting dysfunctional feelings and thought patterns.

  3. Medications:

     • Anorexia/Bulimia: Antidepressants.

     • BED: Antidepressants, appetite suppressants, and anticonvulsants (e.g., NRP104, $70\,mg$).

• Specific Treatment Goals:

  • Anorexia: Restore weight, treat physical complications, enlist family support, and correct dysfunctional feelings.

  • Bulimia: Identify and modify binging triggers, monitor and alter thought patterns related to body image, and enlist support systems.

  • BED: Cognitive Behaviour Therapy (CBT) is the most accepted treatment. It involves psycho-education, stimulus control, relapse prevention, and cognitive restructuring.

• Prevention:

  • Reducing weight-related criticism of youth.

  • Developing media literacy to identify unrealistic images.

  • Encouraging healthy physical activity.

  • Modeling of healthy dieting and body image by parents.

Questions & Discussion

• Question: True or False: Dieting and paying a great deal of attention to how you eat can contribute to the development of an eating disorder.

• Answer: True. As shown in the continuum, preoccupation with weight and shape and habits like yo-yo dieting are precursors to clinical eating disorders.