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WHAT ARE EATING DISORDERS?

Eating disorders are serious brain-based disorders with significant medical and psychiatric morbidity and mortality.
Elevated rates of life-threatening medical and psychiatric morbidity are common regardless of an individual’s eating disorder diagnosis or weight.
Individuals of all body shapes and sizes may have an eating disorder. The vast majority of those with eating disorders are not visibly emaciated.
Eating disorders affect people of all ages, genders, races, abilities, and socioeconomic statuses.
Eating disorders are treatable and full recovery is always possible.
All healthcare providers should work to mitigate the risk of missing an eating disorder when a patient presents who does not conform to an imagined stereotype of someone with an eating disorder.

Although there are formal guidelines that healthcare professionals use to diagnose eating disorders (DSM-5, APA), unhealthy eating behaviors exist on a continuum. Even if a person does not meet the formal criteria for an eating disorder, they may be experiencing unhealthy eating behaviors that cause substantial distress and may be damaging to both physical and psychological health.

The most common Eating Disorders based on the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5), include the following:

Anorexia Nervosa (AN)

A reversible, biologically based disorder characterized by restriction of energy intake leading to a significantly low body weight in the context of age, sex, developmental trajectory, and health status and associated with a disturbance of body image, intense fear of gaining weight, lack of recognition of the seriousness of the illness and/or behaviors that interfere with weight gain. Two subtypes are distinguished: restricting type and binge eating/purging type.

Bulimia Nervosa (BN)

Binge eating (eating a large amount of food in a relatively short period of time associated with a sense of loss of control overeating) followed by purging or other compensatory behavior (e.g., self-induced vomiting, laxative or diuretic abuse, insulin misuse, excessive exercise, fasting, diet pills) once a week or more, on average, for at least three months. Self-evaluation is unduly influenced by body shape and weight. For individuals who are underweight, the diagnosis of anorexia nervosa binge eating/purging subtype overrides the diagnosis of bulimia nervosa.

Binge-Eating Disorder (BED)

Binge eating (eating a large amount of food in a relatively short period of time associated with a sense of loss of control overeating), in the absence of compensatory behavior, at least once a week for three months or more. Binge eating episodes are associated with eating rapidly, regardless of hunger, until extreme fullness, and/or associated with depression, shame, or guilt.

Avoidant and Restrictive Food Intake Disorder (ARFID)

Significant weight loss, nutritional deficiency, dependence on nutritional supplement or marked interference with psychosocial functioning due to persistent failure to meet appropriate caloric and/or nutritional needs, but without weight or shape concerns. Individuals with ARFID can have other sensory aversions to food due to food textures, temperatures, colors, or smells. ARFID can include extremely selective eating, disrupted appetite cues, lack of interest in food, sensory processing difficulties, or anxiety regarding the consequences of eating (e.g., illness, vomiting, choking).

Other Specified Feeding and Eating Disorder (OSFED):

An eating disorder that does not meet full criteria for one of the above categories but involves specific disordered eating behaviors such as restricting intake, purging and/or binge eating as key features. Atypical Anorexia Nervosa, for example, is a common type of OSFED characterized by all the features of anorexia nervosa in an individual whose weight remains above a minimum weight for age despite significant weight loss.

Unspecified Feeding or Eating Disorder (USFED):

This is a preliminary diagnosis used when eating disorder behaviors are present, but there is insufficient information to make a firm diagnosis.

Important Facts About Eating Disorders:

All eating disorders are serious disorders with the potential for life-threatening physical and psychological complications.
Diet culture and weight bias can interfere with prompt diagnosis and treatment of eating disorders.
Excessive value placed on weight loss, as well as the conflation of health and weight by providers and society, can delay eating disorder recognition and impede treatment.
Eating disorders do not discriminate. They can affect individuals of all ages, genders, ethnicities, socioeconomic backgrounds, and all body shapes, weights, and sizes. Most individuals with eating disorders are not visibly underweight.
Individuals at any weight may be malnourished and/or engage in unhealthy weight control practices.
Individuals with an eating disorder may not recognize the seriousness of their illness and/or may be ambivalent about changing their eating or weight control behaviors.
All instances of precipitous weight loss or gain in otherwise healthy individuals should be investigated for the possibility of an eating disorder. Rapid weight fluctuations can be a potential marker of an eating disorder, although not all restrictive eating results in weight loss.
In children and adolescents, failure to gain expected weight or height, and/or delayed or interrupted pubertal development, should be investigated for the possibility of an eating disorder.
All eating disorders can be associated with serious medical complications affecting every organ system in the body. It is possible to have completely normal labs and no measurable physiologic dysfunction; individuals with this profile but with a suspected eating disorder still merit prompt, multidisciplinary care with an urgent focus on recovery. Eating disorders can also worsen medical symptoms from other diagnoses such as irritable bowel syndrome, migraines, and dysautonomia.
Individuals with eating disorders, and sometimes their loved ones as well, may be reluctant to acknowledge eating disorder symptoms and/or the deleterious impact of the symptoms. Thus, denial of symptoms should not impede consideration of a possible eating disorder diagnosis.

When Do I Worry?

Malnutrition is a serious medical condition that requires urgent attention. It can occur in any individual engaging in disordered eating behaviors, regardless of weight status. Individuals with continued restrictive eating behaviors, binge eating and/or purging, require a comprehensive assessment and immediate intervention.

For more information on common presenting medical signs and symptoms, as well as a comprehensive approach to the eating disorders medical evaluation, refer to the AED Eating Disorders: A Guide to Medical Care.

How Do I Treat?

Following initial stabilization, ongoing evidence-based treatment delivered by a multidisciplinary team of healthcare professionals with expertise in the care of individuals with eating disorders is essential for full recovery. Optimal care includes medical, psychological, nutritional, and, for some patients, psychopharmacologic services. Family members should be included in eating disorder treatment whenever possible.

Medical stabilization, nutritional rehabilitation to achieve weight restoration and address nutrient deficiencies, management of refeeding and its potential complications, and interruption of purging/compensatory behaviors should be the immediate goals of treatment for all individuals with eating disorders. Additional psychological and other therapeutic goals can be addressed in parallel when appropriate.

Weight restoration alone is not sufficient for full recovery. It is equally important that distorted body image and other eating disorder thoughts and behaviors, psychological and psychiatric comorbidities and any social or functional impairments be addressed during the treatment of individuals with eating disorders.

Goals of Treatment:

Medical treatment
- Management of acute and chronic medical conditions including use of acute medical stabilization when appropriate
- Spontaneous (not hormonally induced) resumption of menses and/or return of normal gonadal hormone levels (testosterone or estrogen)
- Resumption of appropriate growth and/or pubertal progression
Nutritional rehabilitation
- Weight restoration
- Restore meal patterns that promote health and social connections
- Broaden food repertoire and macronutrient balance
Normalization of eating behavior
- Cessation of restrictive, binge eating, and/or purging behaviors
- Elimination of disordered or ritualistic eating behaviors
- Eating without over-concern about foods and elimination of fears around eating
Psychosocial stabilization
- Evaluation and treatment of any comorbid psychological diagnoses
- Re-establishment of appropriate social engagement
- Improvement in psychological symptoms associated with ED
- Improved body image

Additional information on treatment of eating disorders can be found in these AED resources:

AED Guide to Selecting Evidence-based Psychological Therapies for Eating Disorders

What Can I Do?

Timely Intervention is critical for individuals with known or suspected eating disorders. When concerned about someone with a possible eating disorder, remember that:

1. Individuals with eating disorders may not acknowledge that they are ill, and/or they may be ambivalent about accepting treatment. Remember that denial of the seriousness of the disorder is a symptom. Individuals may minimize, rationalize, or hide eating disorder symptoms and/or behaviors. Their persuasive rationality and competence in other areas of life can disguise the severity of their disorder. Outside support and assistance with decision-making will likely be necessary regardless of age.

2. Most often parents/guardians are the frontline help-seekers for children, adolescents, and young adults with eating disorders. Trust their concerns. Even a single consultation about an individual’s eating behavior or weight/shape concerns is a strong predictor of the presence or potential development of an eating disorder.

3. Diffuse blame. Help families understand that they did not cause the illness; neither did the individual with the eating disorder choose to have it. This recognition facilitates acceptance of the diagnosis, referral, treatment, and minimizes undue stigma associated with having the disorder.

4. Monitor physical health. Individuals with eating disorders will need close medical monitoring including vital signs and laboratory tests. Individuals with eating disorders should be regularly monitored for acute and chronic medical complications. At times, acute medical stabilization will be necessary. Assessments should be interpreted in the context of physiological adaptation to malnutrition and purging behavior. Healthcare providers need to remember that physical exam and laboratory tests may be normal even in the presence of a life-threatening eating disorder.

5. Consider psychiatric risk. Always assess for psychiatric risk, including suicidal and self-harm thoughts, plans and/ or intent. Up to half of deaths related to eating disorders are due to suicide. While some degree of anxiety and depressive symptoms are common on presentation, proper diagnosis of other mental health comorbidities over time is also suggested as adequate treatment can improve outcome.

Can One Recover From an Eating Disorder?

Yes. Full recovery is possible from all eating disorders.

Early detection and treatment are associated with a better chance of recovery.

Full resolution of symptoms may take an extended period of treatment. Psychological symptoms may transiently increase with initial treatment and improvement in physical health.

REMEMBER that eating disorders are NOT fads, phases, or lifestyle choices. They are biologically based, heritable disorders.

People do not choose to have eating disorders and they can fully recover from eating disorders.

Where Can I Learn More?

For further references and information about eating disorders visit: www.aedweb.org and https://www.aedweb.org/publications

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Eating Disorder Glossary

AED has linked up with F.E.A.S.T. – Families Empowered and Supporting Treatment of Eating Disorders – to launch the first comprehensive Eating Disorders Glossary:

View Glossary

The online glossary defines and explains more than 400 terms and concepts used in diagnosis, treatment and research on eating disorders and disturbances. The 40,000-word reference is designed to help families understand the complex world of eating disorders, but may also prove useful to non-specialist professionals.

Key to the link-up, AED professionals are invited to suggest additions and modifications to this unique dictionary for the benefit of families worldwide. Send your suggestions to glossary@feast-ed.org.