Anorexia, Bulimia Can Compromise Health and Life

In the fall of 2006, the organizers of Fashion Week in Spain issued an edict: Models whose height-to-weight ratio falls below standards the World Health Organization considered normal would not be allowed to strut the new designer clothes. That generally was interpreted as models weighing less than 125 pounds. Organizers of the event said they wanted to project "an image of beauty and health." The edict spawned a debate throughout the European and American fashion industry about whether frail, skeletal women were still desirable on runways.

For George R. Jacobson, PhD, Medical College of Wisconsin Associate Professor of Psychiatry and Behavioral Medicine, the discussion is a healthy one. As a specialist who treats people with eating disorders, he has seen his share of patients who deliberately starve themselves, putting their health and their lives at risk. He blames not only the fashion industry but also manufacturers of food products, promoters of diets, and cultural patterns prevalent among western nations for encouraging women to diet excessively to attain a certain appearance.

"Women, especially, are more unfairly judged on their appearance in these countries," he says. "It erodes their self-esteem, and many of them respond by refusing to eat properly." Women account for an overwhelming percentage of those with eating disorders, he adds, whereas men with similar emotional problems are more likely to abuse alcohol or drugs.

Anorexia and Bulimia
The eating disorders Dr. Jacobson treats are anorexia nervosa, in which patients skip meals or severely limit the foods and quantities they do eat; and bulimia nervosa, a cycle of gorging then vomiting, also called bingeing and purging. Some also use laxatives excessively.

Originally, he says, eating disorders were considered a condition of infancy and childhood. (Some children do have eating disorders, such as pica, which involves eating nonnutritive substances like chalk, ashes, mud, clay, or paint chips.) Today, however, anorexia and bulimia typically begin in adolescence. Although these disorders can also begin among adults, they rarely occur before the onset of puberty, he notes.

True eating disorders differ from other common conditions such as obesity - "That's typically a medical disorder, not a psychiatric disorder," Dr. Jacobson says - or "yo-yo" dieting, in which an overweight person tries one fad diet after another, without lasting success. "Another type of problem not characterized as a psychiatric eating disorder," he says, "is called body dysmorphic disorder, where a person is psychologically dissatisfied with the appearance of his or her body. They might be obsessively concerned with the size and shape of their buttock or thighs, for instance."

What constitutes a true eating disorder?

Control is Often an Issue
If someone has anorexia, he or she might follow certain dietary patterns, marked by a high degree of constriction - a lack of variability - in what they eat, Dr. Jacobson says. "Some people have a high degree of consistency: They might only eat certain foods in certain amounts. I had a patient who ate only four foods and no others. Some patients play with their food, or practice rituals so it appears they are consuming more. If they allow themselves to eat grapes, for example, they might cut each grape into tiny pieces or portions, then eat them slowly and deliberately."

With bulimic patients, who compulsively overeat before purging, "they can have a tendency to choose high-calorie, high-fat foods that can be eaten quickly or secretly. And they often don't like to be observed eating."

Eating disorders tend to run in families, Dr. Jacobson says, although they are not classified as genetic. Dietary habits are often influenced by how and what one's family eats, or doesn't eat.

"Another common issue that's crucial in diagnosing eating disorders is control," he says. "Although it's not a diagnostic criterion, I've observed it in 95% of the patients I've treated. People who feel overwhelmed by life focus on eating because it's one area they can control. That's something children learn at an early age. If they turn mealtime into a battleground, they can control the parent. It's one area where they can assert independence."

Another factor Dr. Jacobson has observed in his practice is that more than 70% of women with eating disorders also had been sexually abused. "That's not central to the diagnosis, but when it's finally acknowledged, it becomes extremely important to the treatment," he says. "For some with anorexia, restricting food seems to be an attempt to obliterate their sexuality."

Health Effects
Anorexic women tend to experience signs of premature aging. "Their menstrual periods stop, their breasts become shriveled - both ways of obliterating sexuality," Dr. Jacobson notes. They also may experience osteoporosis and cardiovascular problems, among others. Patients with bulimia may experience dental problems, a result of the regurgitated stomach acids.

If left untreated, eating disorders can be fatal. Patients are at risk for serious heart conditions and kidney failure, which may lead to death. The National Institute of Mental Health estimates the mortality rate among people with anorexia at 0.56% per year, and approximately 5.6% per decade, or about 12 times higher than the annual death rate due to all causes of death among females 15 through 24 in the general population. NIMH estimates 0.5 to 3.7% of females suffer from anorexia nervosa in their lifetimes, and 1.1% to 4.2% of females have bulimia nervosa in their lifetimes.

Treatment May Take Time
One of the goals of treating patients with eating disorders is to help them achieve "a healthy dose of self-acceptance," Dr. Jacobson says. But that can take many sessions of therapy. One of the obstacles - and one of the diagnostic criteria - is that people with eating disorders cannot perceive themselves realistically. Regardless of how thin they've become and how much weight they've lost, they persist in seeing themselves as too fat. "They're acutely aware of people who are thinner than they are," he adds. Patients with eating disorders often suffer from depression, Dr. Jacobson says.

Initially, however, patients must restore their weight to normal, healthy levels. Dr. Jacobson often insists that patients be evaluated by a physician and work with a dietitian to learn good eating habits. In severe cases, patients may be hospitalized until their malnutrition is reversed and they begin to gain weight. Ultimately, the goal is achieving long-term remission and rehabilitation, or full recovery.

People with eating disorders often do not recognize or admit that they are ill. As a result, they may strongly resist getting and staying in treatment. Family members or other trusted individuals could be helpful in ensuring that the person with an eating disorder receives needed care and rehabilitation. Some people may recover after a single episode. For others, treatment may be long-term.

Parents and family members need to look for "obvious strange eating patterns or inappropriate weight loss," Dr. Jacobson says. "They should be alert if adolescents suddenly refuse to eat or appear to be eating less than normal." The earlier an eating disorder can be detected, the sooner treatment can begin, he says.

Barbara Abel
HealthLink Contributing Writer

MCW Health News presents up-to-date information on patient care and medical research by the physicians of the Medical College of Wisconsin.