BEHAVIOR
November 1, 2000

A Body to Die For: The ABC's of Eating Disorders

Kathryn J. Zerbe, M.D.
Recovering bulimics should protect their teeth by NOT brushing vigorously.
Dr. Zerbe is the Jack Aron Professor of Psychiatric Education and Women's Mental Health and Director of the Eating Disorders Program at the Menninger Clinic, Topeka, Kansas. She is the author of the landmark book for patients and families,"The Body Betrayed: Women, Eating Disorders, and Treatment."

I had gone to a lot of trouble to land myself in the hospital. At 15, I had embarked on a diet and had shed 50 pounds in six months. My body had started out slightly padded, clad in baggy painter's pants to conceal my thighs. As I shrank, I wore tighter pants to flaunt my success, until those too began to hang on my diminishing frame.


- from Evelyn Strauss's, "Facing the Plate" (Salon 9/13/00), a personal account of the author's experience with an eating disorder.


This is a horrifying but typical picture of a young woman suffering from an eating disorder — something that, according to the National Institute of Mental Health, affects more than five million Americans today. Aside from cases where depression or other mental illness leads to suicide, it is hard to think of a psychological problem that poses a greater threat to a person's physical health. Those afflicted with eating disorders try to lose weight by dieting, purging or other means until they make themselves sick. Though some get treatment and recover, others literally starve themselves to death.

As Ms. Strauss's story illustrates, a particularly troublesome aspect of this illness is that while its victims may appear not to understand that they are making themselves sick, most of the time they know exactly what they are doing to their bodies. In cases like these, friends and family members can beg, plead and try all they want to convince victims that they are too thin or that they are ruining their health but they continue to do it anyway.

What can you do if you or someone you care about is suffering from an eating disorder? The good news is that there are treatments. The first step, however, is to become informed about what eating disorders are, the different kinds and how they affect the body.

There are two main types of eating disorders. Their technical names are anorexia nervosa and bulimia nervosa. The table below shows the main ways in which they differ.

Eating disorders are a uniquely dangerous form of mental illness.

Table 1.
Eating Disorders

(Based on the American Psychiatric Association's Diagnostic and Statistic Manual, IV)
Anorexia Nervosa
  1. Refusal to maintain body weight at or above a minimally normal weight for age
  2. 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
  3. In postmenarcheal females, amenorrhea, i.e., for at least three consecutive menstrual cycles.
Restricting Type:
person not regularly engaged in binge-eating or purging behaviors
Binge-Eating/Purging Type:
In addition to symptoms of anorexia nervosa, the person regularly engages in binge-eating or purging behaviors.
Bulimia Nervosa
  1. Recurrent episodes of binge eating characterized by 1) eating in a discrete amount of time a large amount of food and 2) a sense of lack of control over eating during the episode
  2. Recurrent inappropriate compensatory behaviors in order to prevent weight gain, such as self-induced vomiting, misuse of laxatives, diuretics, enemas, and other medications; fasting or excessive exercise
  3. The binge-eating and inappropriate compensatory behaviors both occur, on average, at least twice a week for three months
  4. Self-evaluation is unduly influenced by body shape and weight
  5. The disturbance does not occur exclusively during episodes of anorexia nervosa.
Purging Type:
During episodes of bulimia nervosa, the person regularly engages in self-induced vomiting, misuse of laxatives, diuretics, or enemas.

Nonpurging Type:
During the episodes of bulimia nervosa, the person has used other inappropriate compensatory behavior such as fasting or excessive exercise but has not regularly engaged in the purgative methods listed above.
What Are the Warning Signs?
Some of the common early warning signs of bulimia are extreme weight fluctuations, preoccupation with diet and really bad breath. Typically, a victim's family or doctor might notice that the victim's weight is going up and down over a period of months or years. The victim may begin to abuse diuretic drugs or laxatives, begin to exercise obsessively or make themselves vomit after meals. Repeated self-induced vomiting leads in the short term to bad breath and in the long run to dental and other physical problems. When confronted, however, the typical bulimic will deny everything.

When asked to explain their behavior, both anorexia and bulimia victims will insist, no matter how objectively thin they may be, that they "feel fat." These feelings can be so extreme and unreasonable that doctors often conclude that victims are mentally ill and have lost contact with reality.3 Deep down, however, this is not the case. In fact, those with eating disorders understand how they really look and what they are doing to themselves. The problem is not that they are irrational or out of contact with reality, but rather that they cannot control their behavior.

Another warning sign of an eating disorder is excessive concern with a particular part of the body. Victims may turn to plastic surgery or liposuction to fix a supposed physical flaw or just to "stay thin."

Certain psychiatric problems often accompany eating disorders. These include depression, anxiety disorders (especially obsessive-compulsive disorder), borderline personality disorder and substance abuse.

Who Are the Victims?
Traditionally, most victims of eating disorders have been thought to be White, economically well-off girls or young women. This remains largely true, although the picture does seems to be changing. Recent studies have shown that growing numbers of African-Americans and other minorities are becoming afflicted with eating disorders, especially bulimia.

Boys and men are also at increasing risk for eating disorder. Although studies show that nine out of ten victims are female, males who participate in certain sports (e.g., wrestling, gymnastics, running), are homosexual, or who suffer from addiction or personal disorders are at greater risk of developing an eating disorder. Anorexic males can be just as preoccupied with body image as females, but tend to want to have a slender waist and muscular, athletic shoulders and chest. This is sometimes called "reverse anorexia".

Eating disorders are appearing among all socioeconomic groups. They are crossing age barriers, showing up in younger and younger children. More and more preschool and grade schoolers are developing eating problems, showing preoccupation with weight and size, and going on diets.

What Is the Cause?
No one has found an exact cause of eating disorders. There are, however, circumstances and influences that make some people more vulnerable. Among preschool children, studies have found a strong association between eating problems and extreme parental attitudes about food and weight, particularly for children of a mother with an eating disorder. Ironically, being overweight is also a contributing factor. And childhood obesity is definitely on the rise.

Today, as many as 50% of grade school children are overweight. This has caused an increase in diseases in children that were once seen almost exclusively in adults, such as Type 2 diabetes. Studies indicate that youngsters who are teased or feel ashamed about their weight are much more likely to develop an eating disorder when they are older. (Parents should be aware that in some cases, children who show symptoms of anorexia may in fact have a pediatric autoimmune neuropsychiatric disorder (known as PANDAS) that is associated with streptococcus infection. This can be cured with antibiotics.

Some people also seem to carry a gene that makes them more likely to develop anorexia nervosa or bulimia nervosa.

Finally, a startlingly high percentage — in the range of 30% to 60% — of those with eating disorders are victims of past childhood physical or sexual abuse, or of a more recent adult trauma such as rape. This could explain why post-traumatic stress disorder is more common in those with eating disorders.
How Eating Disorders Damage the Body

Problems of the Heart and Blood
Most of the health problems caused by eating disorders are side effects of malnutrition. Malnutrition plays havoc with the chemistry of the blood. This, in turn, can lead to low white and red blood cell counts, greater susceptibility to infection, and deficiencies in blood sugar, electrolytes, potassium and other substances that the body needs to function properly.

Decreased estrogen levels, loss of calcium and other effects of malnutrition can also cause osteoporosis (loss of bone density). Frighteningly, this kind of bone loss can become irreversible. In other words, if the eating disorder is severe enough and lasts long enough, the problem may continue even in those who have recovered and begun to eat normally. This makes it urgent to get medical help for a malnourished person as soon as possible.

The semi-starvation caused by eating disorders and the various methods of purging used by bulimics can also do terrible damage to the heart, including causing cardiac arrhythmia. Cardiac arrhythmia means that the heart beats irregularly; this can cause a heart attack and other heart problems.18 Furthermore, recovery from severe malnutrition poses its own risks for the heart. In the "refeeding syndrome," for example, raising body weight too quickly can cause actually congestive heart failure.

"Refeeding syndrome" was discovered during World War II, in experiments aimed at determining the medical and psychiatric effects of starvation. Along with extreme weight loss, the volunteers who participated in these studies experienced a decrease in blood pressure and in the size of their heart. While these effects could be reversed gradually, the studies showed that too rapid refeeding and sudden increase in body size could strain the heart to the point of causing heart failure. In order to avoid the dangers of refeeding syndrome, recovering eating disorder victims should attempt to bring their weight back up only under the strict supervision of a doctor.

Other symptoms of malnutrition-related heart problems include lethargy, lightheadedness, chest pain, leg pain and shallow or labored breathing. Although most of these symptoms go away when the victim regains a normal weight, full recovery can take six months or longer after that point.

The purging practiced by bulimics carries its own set of negative health effects. Bulimia victims who abuse syrup of ipecac (a medicine which induces vomiting) have been known to die from ingesting toxic levels of this substance. Other methods of purging (e.g., self-induced vomiting, abuse of enemas, abuse of laxatives, abuse of diuretics) reduce the amount of many vital chemicals in the body to dangerous levels. Low potassium levels can cause cardiac arrhythmia. Some victims' magnesium and phosphate levels fall so low that they need to be hospitalized for emergency treatment.

Mouth and Dental Problems
Anyone suspected of suffering from bulimia should be thoroughly examined by a dentist. Repeated vomiting causes mouth problems such as severe chapped lips, loss of enamel from the surface of the teeth, cavities, sore throat, gum disease and salivary gland inflammation, which is called sialadenosis, and other problems. Sialadenosis produces so-called "chipmunk face," a common sign of bulimia.

Gastrointestinal Problems
Other than stomach or esophagus rupture, which is rare, the gastrointestinal problems suffered by anorexia and bulimia nervosa victims tend not to be life threatening. The most common is gastroparesis, a condition in which the stomach lining loses some or all of its ability to absorb nutrients from food. Gastroparesis often follows sudden and significant weight loss. Its main symptoms are bloating, nausea, loss of appetite and vomiting. Gastroparesis can also interfere with eating disorder victims' recovery by making them feel pain or discomfort as they begin to eat normally and put on weight.

Eating disorder victims often suffer from reflux, irritable bowel syndrome, and constipation. Constipation is often caused by the abuse of laxatives, which many eating disorder victims mistakenly believe to cause weight loss. Not only is this an ineffective method of weight control, but it can cause abdominal pain, dangerously low potassium levels in the blood,and lasting damage to the large intestine.
Complex Treatment for a Complex Disease
Anorexia and bulimia are not simple illnesses and they have no simple cure. The most effective treatment currently available combines nutritional management and counseling; antidepressants or other psychotropic medications; and individual, group and family psychotherapy and education.26 This approach requires a primary care doctor who can coordinate the different treatments and closely monitor the patient's physical health. Furthermore, because the success of these treatments depends so much on honesty, communication and cooperation, the primary care doctor must maintain a trusting relationship with the recovering eating disorder victim.

Physical and nutritional stabilization is the first step of recovery. The goal should be to bring the victim to at least 90% of their normal body weight. When this goal is reached, many of the psychological effects of starvation, including lethargy, poor concentration, irritability and depression, will lift and most women will begin once more having their periods.

Experts recommend a slow refeeding process, with an average weight gain of two to three pounds per week. Some recovering eating disorder victims will not begin to gain weight until they are taking in as many as 3,000 - 3,600 calories per day. For someone who is used to taking in only 500 - 750 calories per day, the thought of eating a normal, varied diet can be terrifying. For this reason, it is essential for a skilled nutritionist to be involved in the initial phase of "refeeding," to provide counseling and education about maintaining a healthy diet. Refeeding should begin with a 1,000 calorie per day diet, divided into three to five meals, with a gradual increase in calories over a period of days. These meals should be supervised by experienced medical staff in an inpatient, residential or intensive day hospital setting. Here, medical complications that occur during the refeeding process can be monitored.

Most of the heart and blood-related problems that are caused by eating disorders will begin to go away as the victim's weight is gradually and safely brought up to normal. The next step is outpatient treatment, including psychotherapy, aimed at changing their behavior. Sometimes, an initial three-week residential program stay or inpatient hospitalization is necessary to break a long-standing binge/purge cycle. These programs use strict behavioral methods, including locked bathrooms; supervised meetings at high risk times, such as immediately after meals; and carefully controlled access to food to help victims regain control of their behavior.

As for the mouth, dental, and digestive problems brought on by bulimia, the first step in management is obvious: to stop the self-induced vomiting. Unfortunately, this can take weeks or months of therapy. In the meantime, a good short-term treatment is to convince the victim to rinse their mouth with water or with a water/baking soda mixture after each purging episode in order to neutralize acid residue. Recovering bulimics should avoid aggressive brushing weakened teeth with a fluoride toothpaste and may be helped by vitamin supplements, particularly B2 and B6.

After taking care of their nutritional and physical needs, the next step for those on the way back from an eating disorder is psychotherapy, including psychotropic drugs. These can be used safely once their weight has returned to 85% of normal.

Conclusion
Because they combine a variety of physical and psychological problems, eating disorders are uniquely difficult to deal with. Significant number of eating disorder victims refuse or do not respond to treatment. Still, there are plenty of success stories as well. If you see some of the signs of an eating disorder in yourself or in someone you care about, the best answer is to recognize its seriousness and immediately seek out an experienced program, institution or medical team that will put in the time and effort needed to treat these dangerous and insidious diseases.
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