Anorexia Nervosa & Other Eating Disorders

Anorexia nervosa is an eating disorder characterized by weight loss (or lack of appropriate weight gain in growing children); difficulties maintaining an appropriate body weight for height, age, and stature; and, in many individuals, distorted body image. People with anorexia generally restrict the number of calories and the types of food they eat. Some people with the disorder also exercise compulsively, purge via vomiting and laxatives, and/or binge eat.

Anorexia can affect people of all ages, genders, sexual orientations, races, and ethnicities. Historians and psychologists have found evidence of people displaying symptoms of anorexia for hundreds or thousands of years.

Although the disorder most frequently begins during adolescence, an increasing number of children and older adults are also being diagnosed with anorexia. You cannot tell if a person is struggling with anorexia by looking at them. A person does not need to be emaciated or underweight to be struggling. Studies have found that larger-bodied individuals can also have anorexia, although they may be less likely to be diagnosed due to cultural prejudice against fat and obesity.

DIAGNOSTIC CRITERIA

To be diagnosed with anorexia nervosa according to the DSM-5, the following criteria must be met:

Restriction of energy intake relative to requirements leading to a significantly low body weight in the context of age, sex, developmental trajectory, and physical health.
Intense fear of gaining weight or becoming fat, even though underweight.
Disturbance in the way in which one's body weight or shape is experienced, undue influence of body weight or shape on self-evaluation, or denial of the seriousness of the current low body weight.

Even if all the DSM-5 criteria for anorexia are not met, a serious eating disorder can still be present. Atypical anorexia includes those individuals who meet the criteria for anorexia but who are not underweight despite significant weight loss. Research studies have not found a difference in the medical and psychological impacts of anorexia and atypical anorexia.

WARNING SIGNS & SYMPTOMS OF ANOREXIA NERVOSA

Emotional and behavioral

Dramatic weight loss
Dresses in layers to hide weight loss or stay warm
Is preoccupied with weight, food, calories, fat grams, and dieting
Refuses to eat certain foods, progressing to restrictions against whole categories of food (e.g., no carbohydrates, etc.)
Makes frequent comments about feeling “fat” or overweight despite weight loss
Complains of constipation, abdominal pain, cold intolerance, lethargy, and/or excess energy
Denies feeling hungry
Develops food rituals (e.g., eating foods in certain orders, excessive chewing, rearranging food on a plate)
Cooks meals for others without eating
Consistently makes excuses to avoid mealtimes or situations involving food
Expresses a need to “burn off” calories taken in
Maintains an excessive, rigid exercise regimen – despite weather, fatigue, illness, or injury
Withdraws from usual friends and activities and becomes more isolated, withdrawn, and secretive
Seems concerned about eating in public
Has limited social spontaneity
Resists or is unable to maintain a body weight appropriate for their age, height, and build
Has intense fear of weight gain or being “fat,” even though underweight
Has disturbed experience of body weight or shape, undue influence of weight or shape on self-evaluation, or denial of the seriousness of low body weight
Postpuberty female loses menstrual period
Feels ineffective
Has strong need for control
Shows inflexible thinking
Has overly restrained initiative and emotional expression

Physical

Stomach cramps, other non-specific gastrointestinal complaints (constipation, acid reflux, etc.)
Difficulties concentrating
Abnormal laboratory findings (anemia, low thyroid and hormone levels, low potassium, low blood cell counts, slow heart rate)
Dizziness
Fainting/syncope
Feeling cold all the time
Sleep problems
Menstrual irregularities—amenorrhea, irregular periods or only having a period while on hormonal contraceptives (this is not considered a “true” period)
Cuts and calluses across the top of finger joints (a result of inducing vomiting)
Dental problems, such as enamel erosion, cavities, and tooth sensitivity
Dry skin
Dry and brittle nails
Swelling around area of salivary glands
Fine hair on body (lanugo)
Thinning of hair on head, dry and brittle hair
Cavities, or discoloration of teeth, from vomiting
Muscle weakness
Yellow skin (in context of eating large amounts of carrots)
Cold, mottled hands and feet or swelling of feet
Poor wound healing
Impaired immune functioning

HEALTH CONSEQUENCES OF ANOREXIA NERVOSA

In anorexia nervosa’s cycle of self-starvation, the body is denied the essential nutrients it needs to function normally. Thus, the body is forced to slow down all of its processes to conserve energy, resulting in serious medical consequences.

The body is generally resilient at coping with the stress of eating disordered behaviors, and laboratory tests can generally appear perfect even as someone is at high risk of death. Electrolyte imbalances can kill without warning; so can cardiac arrest. Therefore, it’s incredibly important to understand the many ways that eating disorders affect the body.

Eating disorders are serious, potentially life-threatening conditions that affect a person’s emotional and physical health. They are not just a “fad” or a “phase.” People do not just “catch” an eating disorder for a period of time. They are real, complex, and devastating conditions that can have serious consequences for health, productivity, and relationships.

Eating disorders can affect every organ system in the body, and people struggling with an eating disorder need to seek professional help. The earlier a person with an eating disorder seeks treatment, the greater the likelihood of physical and emotional recovery.

COMMON HEALTH CONSEQUENCES OF EATING DISORDERS

CARDIOVASCULAR SYSTEM

Consuming fewer calories than you need means that the body breaks down its own tissue to use for fuel. Muscles are some of the first organs broken down, and the most important muscle in the body is the heart. Pulse and blood pressure begin to drop as the heart has less fuel to pump blood and fewer cells to pump with. The risk for heart failure rises as the heart rate and blood pressure levels sink lower and lower.
- Some physicians confuse the slow pulse of an athlete (which is due to a strong, healthy heart) with the slow pulse of an eating disorder (which is due to a malnourished heart). If there is concern about an eating disorder, consider low heart rate to be a symptom.
Purging by vomiting or laxatives depletes your body of important chemicals called electrolytes. The electrolyte potassium plays an important role in helping the heart beat and muscles contract, but is often depleted by purging. Other electrolytes, such as sodium and chloride, can also become imbalanced by purging or by drinking excessive amounts of water. Electrolyte imbalances can lead to irregular heartbeats and possibly heart failure and death.
Reduced resting metabolic rate, a result of the body’s attempts to conserve energy.

GASTROINTESTINAL SYSTEM

Slowed digestion known as gastroparesis. Food restriction and/or purging by vomiting interferes with normal stomach emptying and the digestion of nutrients, which can lead to:
- Stomach pain and bloating
- Nausea and vomiting
- Blood sugar fluctuations
- Blocked intestines from solid masses of undigested food
- Bacterial infections
- Feeling full after eating only small amounts of food
Constipation, which can have several causes:
- Inadequate nutritional intake, which means there’s not enough in the intestines for the body to try and eliminate
- Long-term inadequate nutrition can weaken the muscles of the intestines and leave them without the strength to propel digested food out of the body
- Laxative abuse can damage nerve endings and leave the body dependent on them to have a bowel movement
Binge eating can cause the stomach to rupture, creating a life-threatening emergency.
Vomiting can wear down the esophagus and cause it to rupture, creating a life-threatening emergency.
- Frequent vomiting can also cause sore throats and a hoarse voice.
When someone makes themselves vomit over a long period of time, their salivary (parotid) glands under the jaw and in front of the ears can get swollen. This can also happen when a person stops vomiting.
Both malnutrition and purging can cause pancreatitis, an inflammation of the pancreas. Symptoms include pain, nausea, and vomiting.
Intestinal obstruction, perforation, or infections, such as:
- Mechanical bowel problems, like physical obstruction of the intestine, caused by ingested items.
- Intestinal obstruction or a blockage that prevents food and water from passing through the intestines.
- Bezoar, a mass of indigestible material found trapped in the gastrointestinal tract (esophagus, stomach, or intestines).
- Intestinal perforation, caused by the ingestion of a nonfood item that creates a hole in the wall of the stomach, intestines or bowels.
- Infections such as toxoplasmosis and toxocariasis may occur because of ingesting feces or dirt.
- Poisoning, such as heavy metal poisoning caused by the ingestion of lead-based paint.

NEUROLOGICAL

Although the brain weighs only three pounds, it consumes up to one-fifth of the body’s calories. Dieting, fasting, self-starvation, and/or erratic eating means the brain isn’t getting the energy it needs, which can lead to obsessing about food and difficulties concentrating.
Extreme hunger or fullness at bedtime can create difficulties falling or staying asleep.
The body’s neurons require an insulating, protective layer of lipids to be able to conduct electricity. Inadequate fat intake can damage this protective layer, causing numbness and tingling in hands, feet, and other extremities.
Neurons use electrolytes (potassium, sodium, chloride, and calcium) to send electrical and chemical signals in the brain and body. Severe dehydration and electrolyte imbalances can lead to seizures and muscle cramps.
If the brain and blood vessels can’t push enough blood to the brain, it can cause fainting or dizziness, especially upon standing.
Individuals of higher body weights are at increased risk of sleep apnea, a disorder in which a person regularly stops breathing while asleep.

ENDOCRINE

The body makes many of its needed hormones with the fat and cholesterol we eat. Without enough fat and calories in the diet, levels of hormones can fall, including:
- Sex hormones estrogen and testosterone
- Thyroid hormones
Lowered sex hormones can cause menstruation to fail to begin, to become irregular, or to stop completely.
Lowered sex hormones can significantly increase bone loss (known as osteopenia and osteoporosis) and the risk of broken bones and fractures.
Reduced resting metabolic rate, a result of the body’s attempts to conserve energy.
Over time, binge eating can potentially increase the chances that a person’s body will become resistant to insulin, a hormone that lets the body get energy from carbohydrates. This can lead to Type 2 Diabetes.
Without enough energy to fuel its metabolic fire, core body temperature will drop and hypothermia may develop.
Starvation can cause high cholesterol levels, although this is NOT an indication to restrict dietary fats, lipids, and/or cholesterol.

OTHER Health Consequences

Low caloric and fat consumption can cause dry skin, and hair to become brittle and fall out.
To conserve warmth during periods of starvation, the body will grow fine, downy hair called lanugo.
Severe, prolonged dehydration can lead to kidney failure.
Inadequate nutrition can decrease the number of certain types of blood cells.
Anemia develops when there are too few red blood cells or too little iron in the diet. Symptoms include fatigue, weakness, and shortness of breath.
Malnutrition can also decrease infection-fighting white blood cells.

Mortality and Eating Disorders

While it is well known that anorexia nervosa is a deadly disorder, the death rate varies considerably between studies. This variation may be due to length of follow-up, or ability to find people years later, or other reasons. In addition, it has not been certain whether other subtypes of eating disorders also have high mortality. Several recent papers have shed new light on these questions by using large samples followed up over many years. Most importantly, they get around the problem of tracking people over time by using national registries which report when people die. A paper by Papadopoulos studied more than 6000 individuals with AN over 30 years using Swedish registries. Overall people with anorexia nervosa had a six fold increase in mortality compared to the general population. Reasons for death include starvation, substance abuse, and suicide. Importantly the authors also found an increase rate of death from ‘natural’ causes, such as cancer.

It has not been certain whether mortality rates are high for other eating disorders, such as bulimia nervosa and eating disorder not otherwise specified, the latter of which is the most common eating disorder diagnosis. Crow and colleagues studied 1,885 individuals with anorexia nervosa (N=177), bulimia nervosa (N=906), or eating disorder not otherwise specified (N=802) over 8 to 25 years. The investigators used computerized record linkage to the National Death Index, which provides vital status information for the entire United States, including cause of death extracted from death certificates. Crow and colleagues found that crude mortality rates were 4.0% for anorexia nervosa, 3.9% for bulimia nervosa, and 5.2% for eating disorder not otherwise specified. They also found a high suicide rate in bulimia nervosa. The elevated mortality risks for bulimia nervosa and eating disorder not otherwise specified were similar to those for anorexia nervosa.

In summary, these findings underscore the severity and public health significance of all types of eating disorders.

Special thank you to Walter Kaye, MD, Professor of Psychiatry, Director, UCSD Eating Disorder Research and Treatment Program, University of California, San Diego

ANOREXIA

At any given point in time between 0.3-0.4% of young women and 0.1% of young men will suffer from anorexia nervosa

Several more recent studies in the US have used broader definitions of eating disorders that more accurately reflect the range of disorders that occur, resulting in a higher prevalence of eating disorders.
A 2007 study asked 9,282 English-speaking Americans about a variety of mental health conditions, including eating disorders. The results, published in Biological Psychiatry, found that 0.9% of women and 0.3% of men had anorexia during their life.

Keski-Rahkonen A, Hoek HW, Susser ES, Linna MS, Sihvola E, Raevuori A, …, and Rissanen A. (2007). Epidemiology and course of anorexia nervosa in the community. American Journal of Psychiatry, 164(8):1259-65. doi: 10.1176/appi. ajp.2007.06081388.

When researchers followed a group of 496 adolescent girls for 8 years, until they were 20, they found:
- 5.2% of the girls met criteria for DSM5 anorexia, bulimia, or binge eating disorder.
- When the researchers included nonspecific eating disorder symptoms, a total of 13.2% of the girls had suffered from a DSM-5 eating disorder by age 20.

Stice E, Marti CN, Shaw H, and Jaconis M. (2010). An 8-year longitudinal study of the natural history of threshold, subthreshold, and partial eating disorders from a community sample of adolescents. Journal of Abnormal Psychology, 118(3):587-97. doi: 10.1037/a0016481.

Combining information from several sources, Eric Stice and Cara Bohon (2012) found that
- Between 0.9% and 2.0% of females and 0.1% to 0.3% of males will develop anorexia
- Subthreshold anorexia occurs in 1.1% to 3.0% of adolescent females

Stice E & Bohon C. (2012). Eating Disorders. In Child and Adolescent Psychopathology, 2nd Edition, Theodore Beauchaine & Stephen Linshaw, eds. New York: Wiley.

Young people between the ages of 15 and 24 with anorexia have 10 times the risk of dying compared to their same-aged peers.

Smink, F. E., van Hoeken, D., & Hoek, H. W. (2012). Epidemiology of eating disorders: Incidence, prevalence and mortality rates. Current Psychiatry Reports, 14(4), 406-414.

Fichter, M. M., & Quadflieg, N. (2016). Mortality in eating disorders – Results of a large prospective clinical longitudinal study. International Journal of Eating Disorders, Epub ahead of print.

Males represent 25% of individuals with anorexia nervosa, and they are at a higher risk of dying, in part because they are often diagnosed later since many people assume males don’t have eating disorders.

Mond, J.M., Mitchison, D., & Hay, P. (2014) “Prevalence and implications of eating disordered behavior in men” in Cohn, L., Lemberg, R. (2014) Current Findings on Males with Eating Disorders. Philadelphia, PA: Routledge.

Subclinical eating disordered behaviors (including binge eating, purging, laxative abuse, and fasting for weight loss) are nearly as common among males as they are among females.

An ongoing study in Minnesota has found incidence of anorexia increasing over the last 50 years only in females aged 15 to 24. Incidence remained stable in other age groups and in males.

Lai, K. Y. (2000). Anorexia nervosa in Chinese adolescents—does culture make a Lucas AR, Crowson CS, O’Fallon WM, Melton LJ 3rd. (1999). The ups and downs of anorexia nervosa. International Journal of Eating Disorders, 26(4):397-405. DOI: 10.1002/(SICI)1098108X(199912)26:4<397::AID-EAT5>3.0.CO;2-0.difference?. Journal of Adolescence, 23(5), 561-568.

ARFID

In a group of adolescents with eating disorders receiving treatment at a specialist clinic, 14% met criteria for ARFID. Those with ARFID were more likely to be
- Younger, and
- Male
Many children with ARFID reported the following symptoms:
- food avoidance
- decreased appetite
- abdominal pain
- emetophobia (fear of vomiting)
Nearly half of children with ARFID report fear of vomiting or choking, and one-fifth say they avoid certain foods because of sensory issues.
- The same study found that one-third of children with ARFID have a mood disorder, three-quarters have an anxiety disorder, and nearly 20 percent have an autism spectrum condition

Fisher, M. M., Rosen, D. S., Ornstein, R. M., Mammel, K. A., Katzman, D. K., Rome, E. S., ... & Walsh, B. T. (2014). Characteristics of avoidant/restrictive food intake disorder in children and adolescents: a “new disorder” in DSM-5. Journal of Adolescent Health, 55(1), 49-52.

Nicely, T. A., Lane-Loney, S., Masciulli, E., Hollenbeak, C. S., & Ornstein, R. M. (2014). Prevalence and characteristics of avoidant/restrictive food intake disorder in a cohort of young patients in day treatment for eating disorders. Journal of eating disorders, 2(1), 1.

ATHLETES

In a study of Division 1 NCAA athletes, over one-third of female athletes reported attitudes and symptoms placing them at risk for anorexia nervosa.

Johnson, C. Powers, P.S., and Dick, R. Athletes and Eating Disorders: The National Collegiate Athletic Association Study, Int J Eat Disord 1999; 6:179.

Though most athletes with eating disorders are female, male athletes are also at risk—especially those competing in sports that tend to emphasize diet, appearance, size and weight. In weight-class sports (wrestling, rowing, horseracing) and aesthetic sports (bodybuilding, gymnastics, swimming, diving) about 33% of male athletes are affected. In female athletes in weight class and aesthetic sports, disordered eating occurs at estimates of up to 62%.

Sport Nutrition for Coaches by Leslie Bonci, MPH, RD, CSSD, 2009, Human Kinetics. Byrne et al. 2001; Sundot - Borgen & Torstviet 2004

Among female high school athletes in aesthetic sports, 41.5% reported disordered eating. They were eight times more likely to incur an injury than athletes in aesthetic sports who did not report disordered eating.

Jankowski, C. (2012). Associations Between Disordered Eating, Menstrual Dysfunction, and Musculoskeletal Injury Among High School Athletes. Yearbook of Sports Medicine, 2012, 394-395. doi:10.1016/j.yspm.2011.08.003

One study found that 35% of female and 10% of male college athletes were at risk for anorexia nervosa and 58% of female and 38% of male college athletes were at risk for bulimia nervosa.

The National Center on Addiction and Substance Abuse (CASA) at Columbia University. Food for Thought: Substance Abuse and Eating Disorders. The National Center on Addiction and Substance Abuse (CASA) Columbia University; New York: 2003.

The prevalence of eating disorders in college athletes is higher among dancers and the most elite college athletes, particularly those involved with sports that emphasize a lean physique or weight restriction (e.g., figure skating, wrestling, rowing).

Among female college athletes surveyed, 25.5% had subclinical eating disorder symptoms.

Greenleaf, C., Petrie, T. A., Carter, J., & Reel, J. J. (2009). Female Collegiate Athletes: Prevalence of Eating Disorders and Disordered Eating Behaviors. Journal of American College Health, 57(5), 489-496. doi:10.3200/jach.57.5.489-496

In a survey of athletic trainers working with female collegiate athletes, only 27% felt confident identifying an athlete with an eating disorder. Despite this, 91% of athletic trainers reported dealing with an athlete with an eating disorder. 93% of trainers felt that increased attention needs to be paid to preventing eating disorders among collegiate female athletes. 25% worked at an institution without a policy on managing eating disorders.

A study of female Division II college athletes found that 25% had disordered eating, 26% reported menstrual dysfunction, 10% had low bone mineral density, and 2.6% had all three symptoms.

Beals KA, Hill AK. The prevalence of disordered eating, menstrual dysfunction, and low bone mineral density among US collegiate

Female high school athletes reporting disordered eating were twice as likely to incur a musculoskeletal injury as athletes who did not report disordered eating.

BINGE EATING DISORDER

NEDA has gathered data on the prevalence of eating disorders from the US, UK, and Europe to get a better idea of exactly how common eating disorders are. Although BED is not a new disorder, its new formal recognition in the research community has left far more gaps in the data on the incidence and prevalence of BED than for anorexia and bulimia.

A 2007 study asked 9,282 English-speaking Americans about a variety of mental health conditions, including eating disorders. The results, published in Biological Psychiatry, found that 3.5% of women and 2.0% of men had binge eating disorder during their life
- o This makes BED more than three times more common than anorexia and bulimia combined.
- o BED is also more common than breast cancer, HIV, and schizophrenia.

Hudson JI, Hiripi E, Pope HG Jr, and Kessler RC. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3):348-58. doi:10.1016/j.biopsych.2006.03.040.

When researchers followed a group of 496 adolescent girls for 8 years until they were 20, they found:
- o 5.2% of the girls met criteria for DSM5 anorexia, bulimia, or binge eating disorder.
- o When the researchers included nonspecific eating disorder symptoms, a total of 13.2% of the girls had suffered from a DSM-5 eating disorder by age 20.

Combining information from several sources, Eric Stice and Cara Bohon found that
- o Between 0.2% and 3.5% of females and 0.9% and 2.0% of males will develop binge eating disorder
- o Subthreshold binge eating disorder occurs in 1.6% of adolescent females

Stice E & Bohon C. (2012). Eating Disorders. In Child and Adolescent Psychopathology, 2nd Edition, Theodore Beauchaine & Stephen Linshaw, eds. New York: Wiley.

Research estimates that
- o 28.4% of people with current BED are receiving treatment for their disorder
- o 43.6% of people with BED at some point in their lives will receive treatment
BED often begins in the late teens or early 20s, although it has been reported in both young children and older adults.
Approximately 40% of those with binge eating disorder are male.
Three out of ten individuals looking for weight loss treatments show signs of BED.

For further reading:

Westerberg, D. P., & Waitz, M. (2013). Binge-eating disorder. Osteopathic Family Physician, 5(6), 230-233.

BULIMIA

NEDA has gathered data on the prevalence of eating disorders from the US, UK, and Europe to get a better idea of exactly how common eating disorders are. Older data from other countries that use more strict definitions of anorexia and bulimia give lower prevalence estimates. Several more recent studies in the US have used broader definitions of eating disorders that more accurately reflect the range of disorders that occur, resulting in a higher prevalence of eating disorders:

At any given point in time, 1.0% of young women and 0.1% of young men will meet diagnostic criteria for bulimia nervosa.
A 2007 study asked 9,282 English-speaking Americans about a variety of mental health conditions, including eating disorders. The results, published in Biological Psychiatry, found that 1.5% of women and 0.5% of men had bulimia during their life
When researchers followed a group of 496 adolescent girls for 8 years until they were 20, they found:
- o 5.2% of the girls met criteria for DSM5 anorexia, bulimia, or binge eating disorder.
- o When the researchers included nonspecific eating disorder symptoms, a total of 13.2% of the girls had suffered from a DSM-5 eating disorder by age 20.
Combining information from several sources, Eric Stice and Cara Bohon found that
- o Between 1.1% and 4.6% of females and 0.1% to 0.5% of males will develop bulimia
- o Subthreshold bulimia occurs in 2.0% to 5.4% of adolescent females

Have these numbers changed over time? The answer isn’t clear. It does appear that, at least for the last two decades, the rates of new diagnoses of anorexia and bulimia have remained relatively stable.

A Dutch study published in the International Journal of Eating Disorders found that new diagnoses of anorexia and bulimia remained relatively steady in the Netherlands from 1985-1989 to 1995-1999.
Rates of bulimia increased during the 1980s and early 1990s, and they have since remained the same or decreased slightly
A British study also found stability in new anorexia and bulimia diagnoses in both males and females, although rates of EDNOS diagnoses increased in both groups. (Please note that in the new DSM-5, EDNOS is no longer recognized and a new term of OSFED has been added, meaning Other Specified Feeding or Eating Disorder).
Eating disorder symptoms are beginning earlier in both males and females, which agrees with both formal research and clinical reports.

Favaro A, Caregaro L, Tenconi E, Bosello R, and Santonastaso P. (2009). Time trends in age at onset of anorexia nervosa and bulimia nervosa. Journal of Clinical Psychiatry, 70(12):1715-21. doi: 10.4088/JCP.09m05176blu.

Hoek HW and van Hoeken D. (2003). Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders, 34(4):383-96. doi: 10.1002/eat.10222.

Micali N, Hagberg KW, Petersen I, and Treasure JL. (2013). The incidence of eating disorders in the UK in 2000–2009: findings from the General Practice Research Database. BMJ Open, 3(5): e002646. doi: 10.1136/bmjopen-2013-002646.

Smink FR, van Hoeken D, and Hoek HW. (2012). Epidemiology of eating disorders: incidence, prevalence and mortality rates. Current Psychiatry Reports, 14(4):406-14. doi: 10.1007/ s11920-012-0282-y.

Stice E & Bohon C. (2012). Eating Disorders. In Child and Adolescent Psychopathology, 2nd Edition, Theodore Beauchaine & Stephen Linshaw, eds. New York: Wiley.

van Son GE, van Hoeken D, Bartelds AI, van Furth EF, and Hoek HW. (2012). Time trends in the incidence of eating disorders: a primary care study in the Netherlands. International Journal of Eating Disorders, 39(7):565-9. doi: 10.1002/eat.20316.

BULLYING/WEIGHT SHAMING

The best-known environmental contributor to the development of eating disorders is the sociocultural idealization of thinness.

Culbert, K. M., Racine, S. E., & Klump, K. L. (2015). Research Review: What we have learned about the causes of eating disorders - a synthesis of sociocultural, psychological, and biological research. J Child Psychol Psychiatry, 56(11), 1141-1164.

By age 6, girls especially start to express concerns about their own weight or shape. 40-60% of elementary school girls (ages 6-12) are concerned about their weight or about becoming too fat. This concern endures through life.

Smolak, L. (2011). Body image development in childhood. In T. Cash & L. Smolak (Eds.), Body Image: A Handbook of Science, Practice, and Prevention (2nd ed.).New York: Guilford.

79% of weight-loss program participants reported coping with weight stigma by eating more food.

Andreyeva, T., Puhl, R. M. and Brownell, K. D. (2008), Changes in Perceived Weight Discrimination Among Americans, 1995–1996 Through 2004–2006. Obesity, 16: 1129–1134. doi:10.1038/oby.2008.35

Of American elementary school girls who read magazines, 69% say that the pictures influence their concept of the ideal body shape. 47% say the pictures make them want to lose weight.

Martin, J. B. (2010). The Development of Ideal Body Image Perceptions in the United States.Nutrition Today, 45(3), 98-100. Retrieved from nursingcenter.com/pdf.asp?AID=1023485

Up to 40% of overweight girls and 37% of overweight boys are teased about their weight by peers or family members. Weight teasing predicts weight gain, binge eating, and extreme weight control measures.

Golden, N. H., Schneider, M., & Wood, C. (2016). Preventing Obesity and Eating Disorders in Adolescents. Pediatrics, 138(3). doi:10.1542/peds.2016-1649

Weight-based victimization among overweight youths has been linked to lower levels of physical activity, negative attitudes about sports, and lower participation in physical activity among overweight students. Among overweight and obese adults, those who experience weight-based stigmatization engage in more frequent binge eating, are at increased risk for eating disorder symptoms, and are more likely to have a diagnosis of binge eating disorder.

Andreyeva, T., Puhl, R. M. and Brownell, K. D. (2008), Changes in Perceived Weight Discrimination Among Americans, 1995–1996 Through 2004–2006. Obesity, 16: 1129–1134. doi:10.1038/oby.2008.35

Children of mothers who are overly concerned about their weight are at increased risk for modeling their unhealthy attitudes and behaviors.

Andreyeva, T., Puhl, R. M. and Brownell, K. D. (2008), Changes in Perceived Weight Discrimination Among Americans, 1995–1996 Through 2004–2006. Obesity, 16: 1129–1134. doi:10.1038/oby.2008.35

Weight stigma poses a significant threat to psychological and physical health. It has been documented as a significant risk factor for depression, low self-esteem, and body dissatisfaction.

Andreyeva, T., Puhl, R. M. and Brownell, K. D. (2008), Changes in Perceived Weight Discrimination Among Americans, 1995–1996 Through 2004–2006. Obesity, 16: 1129–1134. doi:10.1038/oby.2008.35

Low self-esteem is a common characteristic of individuals who have eating disorders.

Perceived weight discrimination is significantly associated with a current diagnosis of mood and anxiety disorders and mental health services use.

Hatzenbuehler ML, Keyes KM, Hasin DS. Associations between perceived weight discrimination and the prevalence of psychiatric disorders in the general population. Obesity 2009;17(11)2033–2039

CO-OCCURRING DISORDERS

Two-thirds of people with anorexia also showed signs of an anxiety disorder several years before the start of their eating disorder.
Childhood obsessive-compulsive traits, such as perfectionism, having to follow the rules, and concern about mistakes, were much more common in women who developed eating disorders than women who didn’t.
A study of more than 2400 individuals hospitalized for an eating disorder found that 97% had one or more co-occurring conditions, including:
- 94% had co-occurring mood disorders, mostly major depression
- 56% were diagnosed with anxiety disorders
  - 20% had obsessive-compulsive disorder
  - 22% had post-traumatic stress disorder
  - 22% had an alcohol or substance use disorder
Approximately one in four people with an eating disorder has symptoms of post-traumatic stress disorder (PTSD).

Tagay, S., Schlottbohm, E., Reyes-Rodriguez, M. L., Repic, N., & Senf, W. (2014). Eating disorders, trauma, PTSD, and psychosocial resources. Eating disorders, 22(1), 33-49.

In women hospitalized for an eating disorder, 36.8% regularly self-harmed
A 2009 study in the International Journal of Eating Disorders found that one in five women seeking treatment for an eating disorder had six or more signs of attention-deficit hyperactivity disorder (ADHD).
Personality disorders also commonly occur in individuals with eating disorders.
Among those with anorexia,
- Restricting type: 20% had obsessive-compulsive personality disorder, 10% had borderline personality disorder
- Binge-purge type:12% had obsessive-compulsive personality disorder, 25% had borderline personality disorder
- Among those with bulimia:11% had obsessive-compulsive personality disorder, 28% had borderline personality disorder
A 2014 study found that combined and analyzed data from 20 previous studies found signs of personality disorders in
- 38% of people with EDNOS/OSFED
  - 11% had obsessive-compulsive personality disorder
  - 12% had borderline personality disorder
- 30% of people with binge eating disorder
  - 10% had obsessive-compulsive personality disorder
  - 10% had borderline personality disorder
Depression and other mood disorders co-occur with eating disorders quite frequently.

Mangweth, B., Hudson, J. I., Pope, H. G. Jr., Hausmagn, A., DeCol, C., Laird, N. M., …Tsuang, M.T. (2003). Family study of the aggregation of eating disorders and mood disorders.Psychological Medicine, 33, 1319-1323.

McElroy, S. L. O., Kotwal, R., & Keck, P. E. Jr. (2006). Comorbidity of eating disorders with bipolar disorder and treatment implications. Bipolar Disorders, 8, 686-695.

There is a markedly elevated risk for obsessive-compulsive disorder among those with eating disorders.

Altman, S. E., & Shankman, S. A. (2009). What is the association between obsessive-compulsive disorder and eating disorders? Clinical Psychology Review, 29, 638-646.

One study found that 73.8% of patients with binge eating disorder had at least one additional lifetime psychiatric disorder, and 43.1% had at least one current psychiatric disorder. Among lifetime disorders, mood, anxiety, and substance use disorders were most common. Among current comorbidities, mood and anxiety were most common.

Grilo, C. M., White, M. A. and Masheb, R. M. (2009), DSM-IV psychiatric disorder comorbidity and its correlates in binge eating disorder. Int. J. Eat. Disord., 42: 228–234. doi:10.1002/eat.20599

Up to 69% of patients with anorexia nervosa and 33% of patients with bulimia nervosa have a coexisting diagnosis of OCD.

Binge eating disorder patients with a co-occurring psychiatric disorder also had significantly higher levels of current eating disorder psychopathology, negative affect, and lower self-esteem than did patients with binge eating disorder without a co-occurring condition.

Grilo, C. M., White, M. A. and Masheb, R. M. (2009), DSM-IV psychiatric disorder comorbidity and its correlates in binge eating disorder. Int. J. Eat. Disord., 42: 228–234. doi:10.1002/eat.20599

Certain psychiatric disorders, particularly obsessive-compulsive disorder, mood disorders and personality disorders, frequently are found among those with eating disorders, with estimates ranging from 42-75%.

In a nationally representative survey, 95% of respondents with bulimia nervosa, 79% with binge eating disorder, and 56% with anorexia nervosa met criteria for at least one other psychiatric disorder. 64% of those with bulimia nervosa met criteria for three or more co-occurring psychiatric disorders.

Hudson JI, Hiripi E, Pope HG Jr, and Kessler RC. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3):348-58.

In a study of women with eating disorders, 94% of the participants had a co-occurring mood disorder. 92% of those in the sample were struggling with a depressive disorder.

Blinder, B. J., Cumella, E. J., & Sanathara, V. A. (2006). Psychiatric Comorbidities of Female Inpatients With Eating Disorders. Psychosomatic Medicine, 68(3), 454-462. doi:10.1097/01.psy.0000221254.77675.f5

32-39% of people with anorexia nervosa, 36-50% of people with bulimia nervosa, and 33% of people with binge eating disorder are also diagnosed with major depressive disorder.

Hudson JI, Hiripi E, Pope HG Jr, and Kessler RC. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3):348-58.

"NIH Categorical Spending -NIH Research Portfolio Online Reporting Tools (RePORT)." U.S National Library of Medicine. U.S. National Library of Medicine, 3 Jul. 2017. Web. 11 Jan. 2018.

Milos, G., Spindler, A., Buddeberg, C., & Crameri, A. (2003). Axes I and II comorbidity and treatment experiences in eating disorder subjects. Psychother and Psychosom, 72(5), 276-285.

48-51% of people with anorexia nervosa, 54-81% of people with bulimia nervosa, and 55-65% of people with binge eating disorder are also diagnosed with anxiety disorder.

Hudson JI, Hiripi E, Pope HG Jr, and Kessler RC. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3):348-58.

NIH Categorical Spending -NIH Research Portfolio Online Reporting Tools (RePORT)." U.S National Library of Medicine. U.S. National Library of Medicine, 3 Jul. 2017. Web. 11 Jan. 2018.

Ulfvebrand, S., Birgegard, A., Norring, C., Hogdahl, L., & von Hausswolff-Juhlin, Y. (2015). Psychiatric comorbidity in women and men with eating disorders results from a large clinical database. Psychiatry Res, 230(2), 294-299.

For further reading:

Anderluh, M. B., Tchanturia, K., Rabe-Hesketh, S., & Treasure, J. (2003). Childhood obsessive-compulsive personality traits in adult women with eating disorders: defining a broader eating disorder phenotype. American Journal of Psychiatry, 160(2), 242-247.

Eddy, K. T., Dorer, D. J., Franko, D. L., Tahilani, K., Thompson-Brenner, H., & Herzog, D. B. (2008). Diagnostic crossover in anorexia nervosa and bulimia nervosa: implications for DSM-V. American Journal of Psychiatry, 165(2), 245-250.

Friborg, O., Martinussen, M., Kaiser, S., Øvergård, K. T., Martinsen, E. W., Schmierer, P., & Rosenvinge, J. H. (2014). Personality disorders in eating disorder not otherwise specified and binge eating disorder: a meta-analysis of comorbidity studies. The Journal of nervous and mental disease, 202(2), 119-125.

Kaye, W. H., Bulik, C. M., Thornton, L., Barbarich, N., & Masters, K. (2004). Comorbidity of anxiety disorders with anorexia and bulimia nervosa. American Journal of Psychiatry, 161(12), 2215-2221.

Kostro, K., Lerman, J. B., & Attia, E. (2014). The current status of suicide and self-injury in eating disorders: a narrative review. Journal of eating disorders, 2(1), 1.

Sansone, R. A., Levitt, J. L., & Sansone, L. A. (2004). The prevalence of personality disorders among those with eating disorders. Eating Disorders, 13(1), 7-21.

COMPULSIVE EXERCISE

An estimated 90-95% of college students diagnosed with an eating disorder also belong to a fitness facility.
An estimated 3% of gym-goers have a destructive relationship with exercise. Some studies have found that number may be even higher, including a 2008 Paris study that found that up to 42% of gym-goers have a destructive relationship with exercise.
A study involving fitness professionals revealed that 100% of the participants believed that they would benefit from further education and guidelines for identifying and addressing eating disorders.
There is a strong link between exercise compulsion and various forms of eating disorders.
Between 40% and 80% of anorexia nervosa patients are prone to excessive exercise in their efforts to avoid putting on weight.

Jodi Rubin, ACSW, LCSW, CEDS, Destructively Fit®, Private Practice

Berczik, K., Szabo, A., Griffiths, M., Kurimay, T., Kun, B., Urban R., & Demetrovics, Z. (2012). Exercise Addiction: Symptoms, Diagnosis, Epidemiology, and Etiology. Substance Use & Misuse, 47, 403-417.

Holtkamp, K., Hebebrand, J., Herpetz-Dahlmann, B. (2004). The Contribution of Anxiety and Food Restriction on Physical Activity Levels in Acute Anorexia Nervosa. The International Journal of Eating Disorders, 36(2):163-71.1

Lejoyeux, M., Avril, M., Richoux, C., Embouazza, H. & Nivoli, F. (2008). Prevalence of exercise dependence and other behavioral addictions among clients of a Parisian fitness room. Comprehensive Psychiatry, 49, 353-358.

Manley, R. O’Brien, K. & Samuels, S. (2008) Fitness instructors’ recognition of eating disorders and attendant ethical/liability issues. Eating Disorders: The Journal of Treatment & Prevention, 16(2), 103-116.

McLean Hospital: http://www.nutrition411.com/wp-content/uploads/2013/11/fitnessmanage0704.

Thompson, R. A., & Sherman, R. T. (2010). Eating disorders in sport. New York: Rutledge.

DIABULIMIA

A review of studies published over the last 25 years on the prevalence of eating disorders and insulin restriction among people with diabetes shows that 30%-35% of women restrict insulin in order to lose weight at some point in their life. This number has remained relatively constant over the decades.
A study of adolescents in 2000 across three Canadian cities found that young women with type 1 diabetes were 2.4 times more likely to have a diagnosable eating disorder and 1.9 times more likely to have sub-threshold eating disorder.
In a more recent study, 1/3 of female patients and 1/6 of male patients with Type 1 diabetes reported disordered eating and frequent insulin restriction.
People with diabetes often experience uncontrolled eating when they experience a low blood sugar. In Duke University’s study of 276 individuals with type 1 diabetes the frequency of uninhibited eating contributed to 31.3% of insulin omission for weight management.
A study of adolescents from Norway revealed that in addition to age, negative attitude toward diabetes and negative beliefs about insulin had the highest association with insulin restriction and eating disorder behavior.
People with diabetes also have a higher risk for emotional states often associated with eating disorders. For example, an analysis of 42 studies found that diabetes doubles the likelihood of having clinical depression (1.7 – 2.9 times greater).
While the majority of studies have been conducted within the type 1 diabetes population, there is case study and anecdotal evidence that the same prevalence and risk exists in any person with insulin dependence whether type 1 diabetes, type 2 diabetes or LADA (latent autoimmune diabetes of adults).

Polonsky WH, et al. Insulin omission in women with IDDM. Diabetes Care. 1994;(17):1178–1185.

Affenito SG, et al. Subclinical and Clinical Eating Disorders in IDDM Negatively Affect Metabolic Control. Diabetes Care. 1997; 20(2):182-184.

Goebel-Fabbri AE FJ, et al. Insulin restriction and associated morbidity and mortality in women with type 1 diabetes. Diabetes Care. 2008;31:415–419.

Jones JM, et al. Eating disorders in adolescent females with and without type 1 diabetes: cross sectional study. BMJ. 2000;2000(320):1563–1566.

Doyle EA, et al. Disordered Eating Behaviors in Emerging Adults with Type 1 Diabetes: A Common Problem for both Men and Women. J Pediatric Health Care. 2017;31(3):327-333.

Custal, Nuria, et al. Treatment Outcome of Patients with Comorbid Type 1 Diabetes and Eating Disorders. BMC Psychiatry. 2014;14:140.

Lee-Akers, Dawn. Biological and Psychological Risk Factors for Eating Disorders in Type 1 Diabetes. Poster presented at: Annual Conference of American Association of Diabetes Educators; 2017 Aug 4-7; Indianapolis, IN.

Merwin RM, et al. Disinhibited eating and weight-related insulin mismanagement among individuals with T1D. Appetite. 2014;81:123-130.

Wisting, Line, et al. Adolescents with T1D – The impact of gender, age, and health-related functioning on eating disorder psychopathology. PLoS ONE. 2015;10(11):e0141386.

Anderson RJ, et. al. The Prevalence of Comorbid Depression in Adults with Diabetes. Diabetes Care. 2001;24(6):1069-1078.

Bächle C, Stahl-Pehe A, Rosenbauer J. Disordered eating and insulin restriction in youths receiving intensified insulin treatment: Results from a nationwide population-based study. Int J Eat Disord. 2016 Feb;49(2):191-6

Bermudez, Ovidio, et al. Inpatient Management of Eating Disorders in Type 1 Diabetes. Diabetes Spectrum. 2009;22(3):153-158.

DIETING/”CLEAN EATING”

In a large study of 14– and 15-year-olds, dieting was the most important predictor of a developing eating disorder. Those who dieted moderately were 5x more likely to develop an eating disorder, and those who practiced extreme restriction were 18x more likely to develop an eating disorder than those who did not diet.

Golden, N. H., Schneider, M., & Wood, C. (2016). Preventing Obesity and Eating Disorders in Adolescents. Pediatrics, 138(3). doi:10.1542/peds.2016-1649

62.3% of teenage girls and 28.8% of teenage boys report trying to lose weight. 58.6% of girls and 28.2% of boys are actively dieting. 68.4% of girls and 51% of boys exercise with the goal of losing weight or to avoid gaining weight.

Over one-half of teenage girls and nearly one-third of teenage boys use unhealthy weight control behaviors such as skipping meals, fasting, smoking cigarettes, vomiting, and taking laxatives.

Neumark-Sztainer, D. (2005). I’m, Like, SO Fat!.New York: Guilford.

35-57% of adolescent girls engage in crash dieting, fasting, self-induced vomiting, diet pills, or laxatives. Overweight girls are more likely than normal weight girls to engage in such extreme dieting.

Boutelle, K., Neumark-Sztainer, D.,Story, M., &Resnick, M. (2002).Weight control behaviors among obese, overweight, and nonoverweight adolescents. Journal of Pediatric Psychology,27, 531-540.

Neumark-Sztainer, D., &Hannan, P. (2001). Weight-related behaviors among adolescent girls and boys: A national survey. Archives of Pediatric and Adolescent Medicine, 154, 569-577.

Wertheim, E., Paxton, S., &Blaney, S. (2009).Body image in girls.In L. Smolak & J. K. Thompson (Eds.), Body image, eating disorders, and obesity in youth: Assessment, prevention, and treatment (2nd ed.) (pp. 47-76). Washington, D.C.: American Psychological Association.

Girls who diet frequently are 12 times as likely to binge as girls who don’t diet.

Neumark-Sztainer, D. (2005). I’m, Like, SO Fat!.New York: Guilford.

Even among clearly non-overweight girls, over 1/3 report dieting.

95% of all dieters will regain their lost weight in 1-5 years.

Grodstein, F., Levine, R., Spencer, T., Colditz, G. A., &Stampfer, M. J. (1996). Three-year follow-up of participants in a commercial weight loss program: Can you keep it off? Archives of Internal Medicine 156(12), 1302.

Neumark-Sztainer D., Haines, J., Wall, M., & Eisenberg, M. ( 2007). Why does dieting predict weight gain in adolescents? Findings from project EAT-II: a 5-year longitudinal study. Journal of the American Dietetic Associatio, 107(3), 448-55

19.1% of teenage girls and 7.6% of teenage boys fast for 24 hours or more, 12.6% of girls and 5.5% of boys use diet pills, powders or liquids, and 7.8% of girls and 2.9% of boys vomit or take laxatives to lose weight or to avoid gaining weight.

12.6% of female high school students took diet pills, powders or liquids to control their weight without a doctor’s advice.

Multiple studies have found that dieting was associated with greater weight gain and increased rates of binge eating in both boys and girls.

Golden, N. H., Schneider, M., & Wood, C. (2016). Preventing Obesity and Eating Disorders in Adolescents. Pediatrics, 138(3). doi:10.1542/peds.2016-1649

In elementary school fewer than 25% of girls diet regularly. Yet those who do know what dieting involves and can talk about calorie restriction and food choices for weight loss fairly effectively.

Smolak, L. (2011). Body image development in childhood. In T. Cash & L. Smolak (Eds.), Body Image: A Handbook of Science, Practice, and Prevention (2nd ed.).New York: Guilford.

Middle school girls who dieted more than once a week were nearly four times as likely to become smokers, compared to non-dieters.

A content analysis of weight-loss advertising in 2001 found that more than half of all advertising for weight-loss product made use of false, unsubstantiated claims.

Americans spend over $60 billion on dieting and diet products each year.

Hobbs, R., Broder, S., Pope, H., & Rowe, J. (2006). “How adolescent girls interpret weight-loss advertising.” Health Education Research, 21(5) 719-730.

INSURANCE/LEGAL ISSUES

Eating disorders are associated with some of the highest levels of medical and social disability of any psychiatric disorder.

Klump KL, Bulik CK, Kaye W, Treasure J, Tyson E. Academy for Eating Disorders Position Paper: Eating Disorders are Serious Mental Illnesses. Int J Eat Disord. 2009 Mar;42(2):97-103. doi: 10.1002/eat.20589.

APA Practice Guidelines (2000 & 1993) reports these medical findings:
- Physical consequences of eating disorders include all serious disorders caused by malnutrition, especially cardiovascular compromise.
- Prepubertal patients may have arrested sexual maturity and growth failure.
- Even those who “look and feel deceptively well,” with normal EKGs may have cardiac irregularities, variations with pulse and blood pressure, and are at risk for sudden death.
- Prolonged amenorrhea (>6 months) may result in irreversible osteopenia and a high rate of fractures.
- Abnormal CT scans of the brain are found in >50% of patients with anorexia nervosa.
In 1996, Congress passed the Mental Health Parity Act, a law that requires plans to provide the same annual and lifetime overall limits for mental health benefits as for other health conditions. Eating disorders ought to receive health care coverage and research funding that is equal to that of medical disorders as well as psychiatric conditions categorized as serious forms of mental illness.

JEWISH COMMUNITY

In one study of ultra-Orthodox and Syrian Jewish communities in Brooklyn, 1 out of 19 girls was diagnosed with an eating disorder, which is a rate about 50 percent higher than the general U.S. population (Sacker, 1996).

LGBTQ+ COMMUNITY

Transgender individuals experience eating disorders at rates significantly higher than cisgender individuals.
Research is limited and conflicting on eating disorders among lesbian and bisexual women.
While research indicates that lesbian women experience less body dissatisfaction overall, research shows that beginning as early as 12, gay, lesbian, and bisexual teens may be at higher risk of binge-eating and purging than heterosexual peers.
In one study, gay and bisexual boys reported being significantly more likely to have fasted, vomited, or taken laxatives or diet pills to control their weight in the last 30 days. Gay males were 7 times more likely to report binging and 12 times more likely to report purging than heterosexual males.
Females identified as lesbian, bisexual, or mostly heterosexual were about twice as likely to report binge-eating at least once per month in the last year.
Elevated rates of binge-eating and purging by vomiting or laxative abuse was found for both males and females who identified as gay, lesbian, bisexual, or “mostly heterosexual” in comparison to their heterosexual peers.
Compared to other populations, gay men are disproportionately found to have body image disturbances and eating disordered behavior. Gay men are thought to only represent 5% of the total male population but among men who have eating disorders, 42% identify as gay.
In a 2007 study of Lesbian, Gay and Bisexual (LGB)-identified participants, which was the first to assess DSM diagnostic categories, rather than use measures that may be indicative of eating disorders (e.g., eating disorder symptoms), in community-based (versus those recruited from clinical or academic settings) ethnically/racially diverse populations. Researchers found:
Compared with heterosexual men, gay and bisexual men had a significantly higher prevalence of lifetime full syndrome bulimia, subclinical bulimia, and any subclinical eating disorder.
There were no significant differences between heterosexual women and lesbians and bisexual women in the prevalence of any of the eating disorders.
Respondents aged 18–29 were significantly more likely than those aged 30–59 to have subclinical bulimia.
Black and Latino LGBs have at least as high a prevalence of eating disorders as white LGBs
A sense of connectedness to the gay community was related to fewer current eating disorders, which suggests that feeling connected to the gay community may have a protective effect against eating disorders

Austin, S. Bryn, Sc.D.. 2004. Sexual Orientation, Weight Concerns, and Eating- Disordered Behaviors in Adolescent Girls and Boys. Journal of the American Academy of Child & Adolescent Psychiatry, V43.

Carlat, D.J., Camargo, CA, & Herzog, DB, 1991. Eating disorders in males: a report of 135 patients. American Journal of Psychiatry, 148, 1991.

Center for Disease Control and Massachusetts Department of Education. 1999. Massachusetts State Youth Risk Behavior Survey. National Gay and Lesbian Task Force (with National Coalition for the Homeless)

Ray, Nicholas. 2007. Gay, Lesbian, Bisexual and Transgender Youth: An Epidemic of Homelessness. National Gay and Lesbian Task Force and National Coalition for the Homeless.

Waldron, Jennifer J., Semerjian, Tamar Z., Kauer, Kerrie. 2009. Doing ‘Drag’: Applying Queer- Feminist Theory to the Body Image and Eating Disorders across Sexual Orientation and Gender Identity. In The Hidden Faces of Eating Disorders, Edited by Justine J. Reel & Katherine A. Beals, (63-81).

MARGINALIZED VOICES

Despite similar rates of eating disorders among non-Hispanic Whites, Hispanics, African-Americans, and Asians in the United States, people of color are significantly less likely to receive help for their eating issues.

Marques, L., Alegria, M., Becker, A. E., Chen, C., Fang, A., Chosak, A., & Diniz, J. B. (2011). Comparative Prevalence, Correlates of Impairment, and Service Utilization for Eating Disorders across U.S. Ethnic Groups: Implications for Reducing Ethnic Disparities in Health Care Access for Eating Disorders. The International Journal of Eating Disorders, 44(5), 412–420. http://doi.org/10.1002/eat.20787

Becker, A. E., Franko, D. L., Speck, A., & Herzog, D. B. (2003). Ethnicity and differential access to care for eating disorder symptoms. International Journal of Eating Disorders, 33(2), 205-212. doi:10.1002/eat.10129

Wade, T. D., Keski-Rahkonen A., & Hudson J. (2011).Epidemiology of eating disorders. In M. Tsuang and M. Tohen (Eds.), Textbook in Psychiatric Epidemiology (3rd ed.) (pp. 343-360). New York: Wiley.

Although eating disorders affect a higher proportion of males who identify as gay or bisexual than females, the majority of males with eating disorders are heterosexual.

Strother, E., Lemberg, R., Stanford, S. C., & Turberville, D. (2012). Eating Disorders in Men: Underdiagnosed, Undertreated, and Misunderstood. Eating Disorders, 20(5), 346-355. doi:10.1080/10640266.2012.715512

15% of gay and bisexual men and 4.6% of heterosexual men had a full or subthreshold eating disorder at some point in their lives.

Feldman, M. B. and Meyer, I. H. (2007), Eating disorders in diverse lesbian, gay, and bisexual populations. Int. J. Eat. Disord., 40: 218–226.

Black teenagers are 50% more likely than white teenagers to exhibit bulimic behavior, such as binging and purging.

Goeree, Michelle Sovinsky, Ham, John C., & Iorio, Daniela. (2011). Race, Social Class, and Bulimia Nervosa. IZA Discussion Paper No. 5823. Retrieved from http://ftp.iza.org/dp5823.pdf.

In a study of adolescents, researchers found that Hispanics were significantly more likely to suffer from bulimia nervosa than their non-Hispanic peers. The researchers also reported a trend towards a higher prevalence of binge eating disorder in all minority groups.

Swanson SA, Crow SJ, Le Grange D, Swendsen J, and Merikangas KR. (2011). Prevalence and correlates of eating disorders in adolescents. Results from the national comorbidity survey replication adolescent supplement. Archives of General Psychiatry, 68(7):714-23.

From 1999 to 2009, hospitalizations involving eating disorders increased for all age groups, but hospitalizations for patients aged 45-65 increased the most, by 88 percent. In 2009, people over the age of 45 accounted for 25% of eating disorder-related hospitalizations.

Zhao, Y., Encinosa, W. Update on Hospitalizations for Eating Disorders, 1999 to 2009. HCUP Statistical Brief #120. September, 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb120.pdf

Teenage girls from low-income families are 153% more likely to be bulimic than girls from wealthy families.

Goeree, Michelle Sovinsky, Ham, John C., & Iorio, Daniela. (2011). Race, Social Class, and Bulimia Nervosa. IZA Discussion Paper No. 5823. Retrieved from http://ftp.iza.org/dp5823.pdf.

From 1999 to 2009, the number of men hospitalized for an eating disorder-related cause increased by 53%.

A 2014 study found that rates of disordered eating have increased across all demographic sectors, but at a faster rate in male, lower socioeconomic, and older participants.

Mitchison, D., Hay, P., Slewa-Younan, S., & Mond, J. (2014). The changing demographic profile of eating disorder behaviors in the community. BMC Public Health, 14(1). doi:10.1186/1471-2458-14-943

In a survey of college students, transgender students were significantly more likely than members of any other group to report an eating disorder diagnosis in the past year.

Diemer, E. W., Grant, J. D., Munn-Chernoff, M. A., Patterson, D. A., & Duncan, A. E. (2015). Gender Identity, Sexual Orientation, and Eating-Related Pathology in a National Sample of College Students. Journal of Adolescent Health, 57(2), 144-149. doi:10.1016/j.jadohealth.2015.03.003

A study of 2,822 students on a large university campus found that 3.6% of males had positive screens for eating disorders. The female-to-male ratio was 3-to-1.

Eisenberg, D., Nicklett, E. J., Roeder, K., & Kirz, N. E. (2011). Eating Disorder Symptoms Among College Students: Prevalence, Persistence, Correlates, and Treatment-Seeking. Journal of American College Health, 59(8), 700-707. doi:10.1080/07448481.2010.546461

Subclinical eating disordered behaviors are nearly as common among males as they are among females.

There were no significant differences between heterosexual women and lesbians and bisexual women in the prevalence of any of the eating disorders.

Ray, Nicholas. 2007. Gay, Lesbian, Bisexual and Transgender Youth: An Epidemic of Homelessness. National Gay and Lesbian Task Force and National Coalition for the Homeless.

When presented with identical case studies demonstrating disordered eating symptoms in white, Hispanic and African-American women, clinicians were asked to identify if the woman’s eating behavior was problematic. 44% identified the white woman’s behavior as problematic; 41% identified the Hispanic woman’s behavior as problematic, and only 17% identified the black woman’s behavior as problematic. The clinicians were also less likely to recommend that the African-American woman should receive professional help.

Gordon, K. H., Brattole, M. M., Wingate, L. R., & Joiner, T. E. (2006). The Impact of Client Race on Clinician Detection of Eating Disorders. Behavior Therapy, 37(4), 319-325. doi:10.1016/j.beth.2005.12.002.

MEDIA

According to The Nielsen Company, a U.S.-based global marketing and research firm that tracks media habits and trends worldwide, the average American spends more than 11 hours a day using media—that is more than the average time spent sleeping or working each day.
Among American youth ages 8-18, media are an ever-increasingly large part of their daily routines, fueled by the growing availability of internet-enabled mobile devices, which accounts for almost half of all their screen time. Teens ages 13-18 spend an average of 9 hours a day and tweens ages 8-12 average 6 hours a day using entertainment media. These amounts vary by race, income, and gender, and do not include using media in school or doing homework (Common Sense Media Inc., 2015).
Teens and tweens use media for a variety of activities and have different favorites depending on their gender – boys like to play video games, and girls prefer using social media.
According to the Dove Global Beauty and Confidence Report, 10,500 women and girls in 13 countries and found that beauty and appearance anxiety continue to be critical global issues and media are a key factor driving their concerns.
- Approximately 7 in 10 women and girls report a decline in body confidence and increase in beauty and appearance anxiety, which they say is driven by the pressure for perfection from media and advertising’s unrealistic standard of beauty.
- Almost 8 in 10 girls (79%) and even more women (85%) admit to opting out of important events in their lives when they don’t feel they look their best.
- Nine out of 10 women say they will actually not eat and risk putting their health at stake when they feel bad about their body image. And 7 in 10 girls said they're more likely to be less assertive in their decisions when they're feeling insecure.
- To counteract these unreal messages, a majority of women and girls around the globe are challenging media to portray more diverse physical appearances, age, race, body shapes, and sizes.
In a study on social media, nearly all girls (95%) say they see the onslaught of negative beauty critiques on social media posts, comments, photos, and videos, and a majority see them at least once a week (72%) and wish social media were a space that empowered body positivity (62%).
According to Common Sense Media, 41% of teen girls say the use social media to “make themselves look cooler.” Teens feel pressure to look good and cool online, but also feel social media helps their friendships and

Eating Disorders Explained

Source: NEDIC

ARFID

Avoidant/Restrictive Food Intake Disorder

Avoidant/Restrictive Food Intake Disorder (ARFID), also known as “extreme picky eating,” is an eating disorder characterized by highly selective eating habits, disturbed feeding patterns or both. It often results in significant nutrition and energy deficiencies, and for children, failure to gain weight.

Common eating and feeding challenges for an individual with ARFID include difficulty digesting food; avoidance of specific types of food textures, colors and smells; eating at an abnormally slow pace, or having a general lack of appetite.

ARFID is most common in infants and children, with some cases persisting into adulthood. Preliminary study shows that it may affect up to 5% of children, with boys being at greater risk for developing ARFID, according to Neuropsychiatric Disease and Treatment. Overall, an estimated 3.2% of the general population suffers from ARFID, including 14% to 22.5% of children in pediatric treatment programs for any type of eating disorder (Neuropsychiatric Disease and Treatment).

Diagnostic criteria for ARFID, according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), include:

The individual demonstrates a disturbed eating experience that is associated with one or more of the following:
- Nutritional deficiency as a result of inadequate intake of food
- Weight loss (adults) or failure to gain weight (children)
- Decline in psychosocial function
- Dependence on supplements to maintain nutritional health
The disturbed eating is not due to an explainable external factor, such as food being unavailable or in short supply.
The person does not have a distorted body image.
The feeding disturbance or food restriction is not a result of some other physical or mental illness. For example, a person who loses weight because of the flu or food poisoning does not have an eating disorder, so a diagnosis of ARFID would not be relevant.

Unlike cases of anorexia and bulimia, ARFID does not typically involve poor body image, a drive to be thin or a displeasure with external appearance. However, inadequate nutrition and caloric intake, especially among children, can seriously delay growth or prevent normal weight gain.

ARFID frequently occurs with other conditions, such as autism spectrum disorder (ASD), attention-deficit/hyperactivity disorder (ADHD) and obsessive-compulsive disorders (OCD).

Symptoms of ARFID

Extreme pickiness in choosing food
Anxiety when presented with “fear” foods
For adults, weight loss; for children, failure to gain weight
Dependence on nutritional supplements, a feeding tube or both

ARFID Warning Signs

Avoidance of particular foods, based on texture, color, taste, smell, food groups, etc.
Frequent vomiting or gagging after exposure to certain foods
Difficulty chewing food
Lack of appetite
Trouble digesting specific types of foods
Consumption of extremely small portions
Dependence on external feeding tubes or nutritional supplements
Social isolation

Risk Factors for ARFID

Malnutrition
Weight Loss
Developmental delays
Co-occurring anxiety disorders

Health Risks of ARFID

Malnutrition
Failure to gain weight (children)
Gastrointestinal complications

ARFID Treatment

Because of ARFID’s unique nature – and prevalence among young people – an intensive and specialized treatment approach is needed in most cases.

Walden Behavioral Care offers personalized treatment for individuals and families affected by ARFID. Treatment includes special pediatric and adolescent programming, both involving family-based therapy, which has been proven to minimize disordered behavior, lead to a more balanced diet and improve long-term recovery rates.

Our ARFID-specific treatment includes:

Cognitive Behavioral Therapy (CBT)
Dialectical Behavior Therapy (DBT)
Meal Coaching
Food Exposure Therapy
Family-Based Education
Individual and Group Counseling
Nutritional Counseling

A Full System of Care

Walden offers a full system of care, with treatment and programming at all levels, for all genders. No matter what your background or individual needs may be, and regardless of the complexity of your disorder, Walden will provide the personalized care and support you require, as close to home as possible.

Our continuum of care includes treatment at all levels:

Inpatient Hospitalization
Residential
Partial Hospitalization
Intensive Outpatient
Outpatient

ARFID Treatment Insurance

Walden is proud to be “in network” with most insurance providers and managed care companies. This children, adolescents and adults with ARFID can have the flexible and cost-efficient access to treatment they need. Click here for a list of organizations with which Walden has contractual relationships.

Regain Your Life. Walden Can Help.

If you are concerned that you – or a loved one – may have an eating disorder, we are here to help. Please call 888-791-0004 to speak with a Walden eating disorders intake specialist, or complete the form on the right, to start on the road to recovery.

Getting Started: Intake Assessment

Help for ARFID is always a quick and confidential phone call away.

We will conduct a brief (10 to 15 minute) intake assessment by telephone, during which we will review your concerns and gather basic information about your background, medical history and insurance coverage. Based on the assessment, we will determine whether a more detailed, in-person clinical evaluation is required at the Walden location closest to you.

The evaluation will be conducted by a member of Walden’s clinical staff and will include a psychiatric assessment, an in-depth review of clinical information and a recommendation for the proper level of care. Primary care referrals are not required and we will work with your insurance provider or providers for approval of ARFID treatment.

The entire assessment is confidential, and we will make it as easy and comfortable for you as possible.

Bulimia nervosa

Bulimia nervosa is a life-threatening mental illness characterised by periods of food restriction followed by binge eating, with recurrent compensating behaviours such as purging or restriction.

While the causes of bulimia nervosa are not completely understood, most medical and psychological professionals, acknowledge that an array of biological, social, genetic, and psychological factors play a role in increasing the risk of its onset.

Warning signs

Weight change, including weight loss or weight gain
Tooth pain, or discoloured teeth
Swelling in the cheeks or jaw
Calluses or cuts on the hands and knuckles from purging
Bloating
Dehydration
Purging, or evidence of purging behaviours like frequent trips to the washroom after meals
Restricting food intake
Guilt and anxiety surrounding food or eating
Anxiety, especially social anxiety
Concern with body weight or shape

Common Co-occurring Illnesses

The individual may also be affected by other mental illnesses, including:

Depression or depressed mood
Anxiety (including generalized or social anxiety)
Obsessive-compulsive disorder
History of trauma or post-traumatic stress disorder

Bulimia nervosa may also be linked with self-harm and suicidality.

Diagnosis

Bulimia nervosa is a life threatening mental illness characterized by:

Recurring episodes of food restriction followed by binge eating. A binge-eating episode is characterized by:
a. The consumption of an unusually large amount of food within a relatively short period of time.
b. Feeling out of control over what and how much is eaten.
Recurring behaviours that follow bingeing in order to compensate for the food intake and prevent weight gain. These behaviours can include excessive exercise, fasting or severe restriction, self-induced vomiting, and misuse of laxatives, diuretics, or enemas.
The person tends to negatively evaluate their weight and shape and feels these matter more than most anything else about them; and
The restricting, bingeing, and purging cycle occurs at least once a week for three months.

Individuals with bulimia nervosa often experience shame or embarrassment and may go to extreme lengths to hide these behaviours. They often fall within a “normal” weight range, though there may be frequent fluctuations, making it difficult for loved ones to recognize the eating disorder.

Note: Vomiting can cause severe dehydration and damage to the esophagus and mouth. Dehydration can also be caused by the misuse of laxatives and diuretics and excessive exercise. These types of purging can lead to imbalances in essential body minerals and salts, which can cause cardiac arrest and/or stroke.

Binge Eating Disorder

Binge-eating disorder is characterized by recurring episodes of binge eating. It is important to note that overeating and binge-eating are not the same. Overeating can be described as consuming more food than your body needs at a given time. Most people overeat on occasion. Binge-eating is less common and is marked by psychological distress.

Warning Signs

Changes in body weight
Dresses in layers or clothing that disguises one’s body shape even when not appropriate for the weather
Evidence of binge eating, such as disappearance of food or hoarding of food in secret
Guilt and anxiety surrounding eating or food

Diagnosis

A binge-eating episode is characterized by:

The consumption of an unusually large amount of food during a relatively short period of time.
Feeling out of control over what and how much is eaten and when to stop

A binge-eating episode also includes three or more of the following:
1. Eating very quickly
2. Eating regardless of hunger cues, even if one is already full
3. Eating until uncomfortably or painfully full
4. Eating alone due to embarrassment about the type and quantity of food ingested
5. Feelings of self-disgust, guilt, and depression

The binge-eating episodes are not followed by compensating behaviours (such as excessive exercise, self-induced vomiting, or the misuse of laxatives or diuretics) as in bulimia nervosa.

Binge eating is seen as a disorder when the bingeing episodes occur at least once a week for three months or more.

Other Specified Feeding or Eating Disorders

The eating disorders in this category are related to anorexia nervosa, bulimia nervosa, and binge-eating disorder but differ in that not all of the same conditions apply.

Examples include:

Anorexia nervosa type: all of the same characteristics as anorexia nervosa, however, there is the appearance of being at a normal weight because significant weight loss started at a higher than average weight.
Binge-eating disorder type: all of the same characteristics as for binge-eating disorder; however the binge-eating episodes occur less frequently than once per week and/or for fewer than three months.
Bulimia nervosa type: all of the same characteristics as for bulimia nervosa, however the cycle of bingeing and purging occurs less frequently than once per week and/or for fewer than three months.
Night eating syndrome: The excessive consumption of food following an evening meal or after waking from sleep in the night, which causes extreme psychological distress and interferes with daily functioning.
Purging disorder: Persistent purging behaviours without the presence of binge-eating episodes.

Unspecified Feeding and Eating Disorders

Unspecified feeding or eating disorders cause clinically significant distress or impairment and do not match the criteria for any of the specified eating disorders.

Pica:

Pica is characterized by the persistent consumption of non-food items over a period of at least a month. As a normal part of learning and development, children between 18 months and two years of age may eat non-nutritive, non-food substances. If this behaviour occurs later in life, it should be addressed as quickly as possible. Non-food substances may include paper, soap, cloth, hair, string, wool, soil, chalk, talcum powder, paint, gum, metal, pebbles, charcoal or coal, ash, clay, starch, or ice.

Rumination Disorder:

Rumination refers to consistent regurgitation of chewed and/or partially digested food over a period of at least a month. Previously swallowed food is brought up into the mouth effortlessly, with no sign of gagging or nausea. Similar behaviours can be observed in infants; however, they should outgrow it quickly. When children do not outgrow it, parents should ask for help. Rumination can also be a symptom of anorexia or bulimia.

Unspecified Feeding or Eating Disorder:

This category is used to describe symptoms of a feeding or eating disorder which causes distress and impairment in functioning but does not meet the criteria for anorexia nervosa, bulimia nervosa, binge-eating disorder, OSFED, or ARFID.

Statistics

According to a 2002 survey, 1.5% of Canadian women aged 15–24 years had an eating disorder.
Government of Canada. (2006). The Human Face of Mental Health and Mental Illness in Canada 2006.
The prevalence of anorexia and bulimia is estimated to be 0.3% and 1.0% among adolescent and young women respectively. Prevalence rates of anorexia and bulimia appear to increase during the transition from adolescence to young adulthood.
Hoek, H. W. (2007). Incidence, prevalence and mortality of anorexia and other eating disorders. Current Opinion in Psychiatry, 19(4), 389-394.

Lifetime prevalence rates for AN, BN, and BED tend to be higher among women than in men.
- Lifetime prevalence of AN = 0.9% in women and 0.3% in men
- Lifetime prevalence of BN = 1.5% in women and 0.5% in men
- Lifetime prevalence of BED found to be 3.5% in women and 2.0% in men
The average lifetime duration of BN is found to be approximately 8.3 years.
Hudson, J. I., Hiripi, E., Pope, H. G. & Kessler, R. C. (2007). The Prevalence and Correlates of Eating Disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3), 348-358.

AN has the highest mortality rate of any psychiatric illness – it is estimated that 10% of individuals with AN will die within 10 years of the onset of the disorder.
Sullivan, P. (2002). Course and outcome of anorexia nervosa and bulimia nervosa. In Fairburn, C. G. & Brownell, K. D. (Eds.). Eating Disorders and Obesity (pp. 226-232). New York, New York: Guilford.

Children learn (unhealthy) mainstream attitudes towards food and weight at a very young age. In a study of five-year-old girls, a significant proportion of girls associated a diet with food restriction, weight-loss and thinness.
Abramovitz, B. A. & Birch, L. L. (2000). Five-year-old girls’ ideas about dieting are predicted by their mothers’ dieting. Journal of the American Dietetic Association, 100 (10), 1157-1163.
According to a 2002 survey, 28% of girls in grade nine and 29% in grade ten engaged in weight-loss behaviours.
Boyce, W. F. (2004). Young people in Canada: their health and well-being. Ottawa, Ontario: Health Canada

Thirty-seven percent of girls in grade nine and 40% in grade ten perceived themselves as too fat. Even among students of normal-weight (based on BMI), 19% believed that they were too fat, and 12% of students reported attempting to lose weight.
Boyce, W. F., King, M. A. & Roche, J. (2008). Healthy Living and Healthy Weight. In Healthy Settings for Young People in Canada. Retrieved from http://www.phac-aspc.gc.ca/dca-dea/yjc/pdf/youth-jeunes-eng.pdf.

In a survey of adolescents in grades 7–12, 30% of girls and 25% of boys reported teasing by peers about their weight. Such teasing has been found to persist in the home as well – 29% of girls and 16% of boys reported having been teased by a family member about their weight.
Eisenberg, M. E. & Neumark-Sztainer, D. (2003). Associations of Weight-Based Teasing and Emotional Well-Being Among Adolescents. Archives of Pediatrics & Adolescent Medicine, 157(6), 733-738.

Body-based teasing can have a serious impact on girls’ attitudes and behaviours. According to one study, girls who reported teasing by family members were 1.5 times more likely to engage in binge-eating and extreme weight control behaviours five years later.
Neumark-Sztainer, D. R., Wall, M. M., Haines, J. I., Story, M. T., Sherwood, N. E., van den Berg, P. A. (2007). Shared Risk and Protective Factors for Overweight and Disordered Eating in Adolescents. American Journal of Preventative Medicine, 33(5), 359-369.

Overweight and obese children are more likely to be bullied than their normal-weight peers. For example:
- In a survey of 11–16 year-olds, 10% of normal-weight children reported being bullied, compared to 15% of overweight and 23% of obese children
- Obese girls were 2.7 times more likely than normal weight girls to be verbally bullied on a regular basis and 3.4 times more likely to be excluded from group activities
Janssen, I., Craig, W. M., Boyce, W. F. & Pickett, W. (2004). Associations Between Overweight and Obesity With Bullying Behaviours in School-Age Children. Pediatrics, 113(5), 1187-1194.

In a study of 14–15 year old adolescents, girls who engaged in strict dieting practices:
- Were 18 times more likely to develop an ED within six months than non-dieters
- Had almost a 20% chance of developing an ED within one year
Girls who dieted moderately were five times more likely to develop an ED within 6 months than non-dieters.
Patton, G. C., Selzer, R., Coffey, C., Carlin, J. B. & Wolfe, R. (1999). Onset of adolescent eating disorders: population based cohort study over 3 years. British Medical Journal, 318, 765-768.

In childhood (5–12 years), the ratio of girls to boys diagnosed with AN or BN is 5:1, whereas in adolescents and adults, the ratio is much larger – 10 females to every male.
Public Health Agency of Canada. Canadian Paediatric Surveillance Program, 2003 Results.
Retrieved from http://www.phac-aspc.gc.ca/publicat/cpsp-pcsp03/page6-eng.php.

Four percent of boys in grades nine and ten reported anabolic steroid use in a 2002 study, showing that body preoccupation and attempts to alter one’s body are issues affecting both men and women.
Boyce, W. F. (2004). Young people in Canada: their health and well-being. Ottawa, Ontario: Health Canada.
The fashion industry has long dictated that female models be tall and waif-like; however, male models are now facing increasing pressure to slim down and appear more androgynous, in order to book top fashion jobs.
Trebay, G. (2008, February 7). The Vanishing Point. The New York Times. Retrieved from http://www.nytimes.com/2008/02/07/fashion/shows/07DIARY.html?pagewanted=1.

According to a Norwegian study, elite athletes demonstrate significantly higher rates of EDs compared to population controls. In one study, 20% of elite female athletes met the criteria for having an ED, compared to 9% of female controls. In men, 8% of elite male athletes met the criteria for having an ED, compared to 0.5% of male controls.
Female athletes competing in aesthetic sports (e.g. dance, gymnastics and figure skating) were found to be at the highest risk for EDs. Athletes competing in weight-class and endurance sports were also at elevated risk for EDs.
Sungot-Borgen, J. & Torstveit, M.K. (2004). Prevalence of Eating Disorders in Elite Athletes is Higher Than in the General Population. Clinical Journal of Sport Medicine, 14(1), 25-32.

There are many different kinds of food and weight preoccupations, including eating disorders. This section aims at de-mystifying issues relating to dieting, food, weight concerns, shape concerns, self-esteem and body image. To do so, we will be looking at those influences that most contribute to how we feel about our selves and our bodies, and that ultimately can help us make healthier choices for more enjoyable lives.

Prevalence of Eating Disorders • 905.9 KB

Child and Adolescents • 139.3 KB

Eating Disorders in Males • 732 KB

Dieting and the Diet Industry • 150.4 KB