By Ariella Soffer, Ph.D., Clinical Psychologist, Soffer & Associates Comprehensive Psychological Services
There is no question that our society has a preoccupation with body shape and size, weight, diet and exercise. Estimates have suggested that nearly half of the population (of all genders/gender identities) demonstrate disordered or problematic relationships with food, body or exercise in some form or another. Base rates of clinically diagnosed eating disorders, however, are estimated to be between 1-3% of the general population. So where’s the disconnect?
Let’s consider the defined Eating Disorders in the Diagnostic and Statistical Manual (V) and then provide differentiation between clinically significant eating disorders and the continuum of Disordered Eating Behavior. There are four diagnosable Eating Disorders as outlined in the manual: Anorexia Nervosa, Bulimia Nervosa, Binge Eating Disorder, and Eating Disorder Not Otherwise Specified. Each of these have certain diagnosable criteria, with particular recommended treatments and associated prognoses, each defined below along with who is at risk. But let’s also shed light on the 48-49% of those with Disordered Eating Behaviors, since those behaviors may still lead to both physical and emotional health problems.
Characterized primarily by self-starvation and excessive weight loss.
- Inadequate food intake leading to significant weight loss
- Intense fear of weight gain, obsession with size and persistent behavior to prevent weight gain
- Disturbance in self-image
- Denial of the seriousness of low body weight
Health consequences include:
- Heart failure, osteoporosis, muscle loss, and growth of lanugo (hair all over the body)
Characterized primarily by a cycle of binge eating followed by compensatory behaviors, such as self-induced vomiting, in an attempt to counteract the effects of binge eating.
- Regular intake of large amounts of food accompanied by a sense of loss of control over eating behavior
- Use of inappropriate compensatory behaviors such as vomiting, laxative or diuretic abuse, fasting and/or obsessive or compulsive exercise
- Extreme concern with body weight and shape
Health consequences include:
- Heart failure, gastric rupture, tooth decay, rupture of the esophagus, and pancreatitis
Binge Eating Disorder
Characterized primarily by recurrent binge eating without the frequent use of compensatory measures. Dieting/restriction is a regular part of the disorder for most people.
- Eating a larger amount of food than normal during a short time frame (example: any two- hour period) or feeling distress around eating smaller amounts of food (subjective binges) at times
- Lack of control over eating during the binge episode (feeling you can’t stop eating or control what or how much you are eating)
- Bingeing in isolation and feeling disgust, shame, or guilt after the episode
Health consequences include:
- Metabolic issues including PCOS (polycystic ovary syndrome), joint and muscle pain, gastrointestinal problems, depression, anxiety, and substance abuse
Eating Disorder(s) Not Otherwise Specified (can include the following)
Avoidant Restrictive Food Intake Disorder (ARFID)
Characterized primarily by limitations in the amount and/or types of food consumed, but does not involve any distress about body shape or size, or fears of fatness.
- An eating or feeding disturbance (e.g., apparent lack of interest in eating or food; avoidance based on the sensory characteristics of food; concern about aversive consequences of eating) as manifested by persistent failure to meet appropriate nutritional and/or energy needs
Other Specified Feeding or Eating Disorder (OSFED)
A feeding or eating disorder that causes significant distress or impairment but does not meet the criteria for another feeding or eating disorder.
Examples of OSFED include:
- Atypical anorexia nervosa (weight is not low)
- Bulimia nervosa (with less frequent behaviors)
- Binge eating disorder (with less frequent occurrences)
- Purging disorder (purging without binge eating)
- Night eating syndrome (excessive nighttime food consumption)
Eating disorders come in many different forms and OSFED is equally as severe as other eating disorder diagnoses.
Who is at Risk?
Anyone can develop an eating disorder regardless of gender, age, race, ethnicity, culture, size, socioeconomic status, or sexual orientation. Eating disorders also impact the family, friends, and loved ones of someone struggling.
Eating disorders do not discriminate based on race, ethnicity, gender or sex. Historically, they were considered to be a largely female problem, where in reality, males represent ⅓ of the eating disordered population. In one study, transgender students were the group most likely to be diagnosed with an eating disorder (Diemer, 2015). Sadly, eating disorders tend to re-emerge at any stage of life and often recur, making this class of mental health concerns one of the most challenging to treat.
Eating disorders are not a behavior of choice by those afflicted. A combination of genetics, biological, environmental and social elements in a person’s life all lead to the development of pathology. Most often another mental health concern like depression, anxiety or trauma presents comorbidly with Eating Disorders, and both must be treated in tandem for best results.
Eating disorders have the highest mortality rate of any psychiatric illness. This bears repeating because it can be difficult for people to integrate this. Eating disorders have the highest mortality rate of any psychiatric illness. Although they aren’t the most common psychiatric problem they are the most lethal. The numbers indicate that nearly half of the population has sub-clinical symptoms of disordered eating behavior (i.e. exhibits some symptoms of the disorders listed above without developing a full blown eating disorder). Therefore, it is very important to consider and pay attention to when these symptoms become a more preoccupying or significant problem for you or someone you love, as this is a slippery slope.
In addition to medical complications from binge eating, purging, starvation, and over-exercise, suicide is also common among individuals with eating disorders. Potential health consequences include heart attack, kidney failure, osteoporosis, and electrolyte imbalance. People who struggle with eating disorders also have intense emotional distress and a severely impacted quality of life.
What is Disordered Eating Behavior? (NOT an Eating Disorder)
Symptoms of disordered eating might include some of the exact same behaviors, though presented in a less severe or debilitating manner, than those in an Eating Disorder:
- Food restriction
- Binge eating
- Excessive exercise
- Use of diet pills or laxatives
Symptoms may also include
- Self-worth based highly, or even exclusively, on body shape and weight
- Disturbance in the way one experiences their body, i.e., a person who falls in a healthy weight range but continues to feel that they are overweight
- Rigid exercise routine
- Obsessive calorie counting
- Anxiety about certain foods or food groups
- Rigid approach to eating, such as only eating certain foods, inflexible meal times, refusal to eat in restaurants or outside of one’s own home
The differentiation hinges on degree of symptom expression: is it to a less frequency or lower level of severity than someone with a clinically diagnosed eating disorder.
The baseline questions I ask people to consider when he or she presents for treatment are:
- How much is thinking about food/diet/exercise/body image interfering in your daily life? In your social relationships?
- How much does it control your life?
- Do you find that food and exercise control your life?
- How much anxiety do thoughts of food and exercise, or lack thereof, generate?
How do you Know if Someone has an Eating Disorder?
Here are some of the subtle behaviors you might notice in yourself, a friend or a loved one so you can try and help them.
- Mood changes, skipping social events, isolation.
Routine changes are a big red flag. Given how often Depression, Anxiety and Social Anxiety in particular are found coupled with Eating Disorders, you might notice someone opting out of social plans, finding that they prefer to be alone more often than usual.
- Adding lots of condiments to food.
Someone with an eating disorder may add a lot of condiments to their food—more specifically, condiments that have the most flavor for the least calories. This may include vinegar, lemon juice, hot sauce, salsa, and pepper. Obviously loving salsa doesn’t automatically signal an eating disorder, but this can be a small sign that, when combined with other eating disorder symptoms, may signal a bigger problem.
- Obsession with fitness trackers or apps.
It’s tough in this day and age to separate “healthy habit” from “obsession.” Again, keep in mind we are talking about instances where this tends to control someone’s day, causing them to opt out of other activities as a result of a desire to “close their circles” on the Apple Watch.
- Refusing small food items, or counting every single one of their calories.
Most of us probably don’t think about the calories in gum, breath mints, or even bite-sized food items, but someone with a restrictive eating disorder likely would. They might inquire about the calories or check the labels on even the smallest items—or they might flat-out refuse that stick of gum in an effort to avoid the calories.
- Extremely regimented eating habits.
Take note if a friend or family member suddenly becomes unusually meticulous about her eating routine. Watch for someone who may only eat at particular times, with only certain utensils, and only food one makes him or herself. Some may tend to play with food in lieu of eating it when in public so it takes attention away from how much has been eaten.
- Pulling on skin to check for fat.
Generally placing an obsession on fat, both the amount on one’s body and the types of fats and amounts consumed.
- New diets or food obsessions.
Be aware of someone who shows other symptoms of anorexia or orthorexia after beginning a fad diet. Claiming to be vegan or gluten-free can be a smoke screen for disordered eating habits. In addition, a newfound obsession with cooking shows or preparing food may also be concerning. You wouldn’t imagine someone with an eating disorder would want to watch food shows, but they can take up cooking and Food Network as a new hobby. Sometimes the person wants to cook or bake for everyone, but never enjoys their own handiwork. In the case of binge eating, sometimes they will make a whole batch of extra food to consume privately.
The brain chemistry changes in men and women with restrictive eating disorders. There is a tendency for someone to not be able to sit still, which is part of the pathology.
- Suddenly gaining weight.
The most prevalent eating disorder in the United States is binge eating disorder, which can lead to weight gain instead of loss that even doctors can miss. People with binge eating disorder consume unusually large amounts of food at one time, and feel like they have little control once they start eating. In addition, they may eat until they’re uncomfortable, feel guilt or shame after a binge, or hide their binges from others.
- Buying large quantities of food, but glossing it over.
Binge eaters may also be found with lots of decadent foods on hand in mass quantities.
Here’s how you can help a friend or loved one who might have an eating disorder:
If you think your loved one may be suffering from an eating disorder, learn more about eating disorders by visiting the NEDA or ERC Web sites. Approach your friend privately first, and focus on the behavioral changes that concern you; avoid discussing weight.
Ariella Soffer, Ph.D., is a Licensed Clinical Psychologist who owns a group practice in Manhattan. Dr. Soffer’s practice specializes in parenting consultation, sports psychology, perinatal mental health and in addition to general mental health concerns. Soffer & Associates Comprehensive Psychological Services website can be found here: DrAriellaSoffer.com