Children's Hospital Colorado
Eating Disorders

Eating Disorders (Anorexia and Bulimia Nervosa)

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What is an eating disorder?

An eating disorder arises when a person develops a distorted relationship with food and weight, but it involves much more than simple dieting, exercise or feeling too full. Eating disorders take several forms, including anorexia nervosa, bulimia nervosa, avoidant restrictive food intake disorder or an atypical eating disorder (also known as "other specified feeding or eating disorder," or OSFED).

  • Anorexia nervosa: "Anorexia nervosa" literally means loss of appetite due to nervousness, but the name is misleading. Except in advanced phases of the illness, a person with anorexia nervosa is always hungry. A person with anorexia exercises enormous control to restrict their eating, even in the face of severe physical hunger. 
  • Bulimia nervosa: Bulimia nervosa is a disorder that involves eating large amounts of food and then getting rid of it by vomiting or using laxatives, diuretics or diet pills. Some people with bulimia also purge after a binge by fasting for days or by exercising for hours. 
  • Avoidant restrictive food intake disorder: Children can have different reasons (aside from anorexia and bulimia) for weight loss or failure to gain weight as expected. Some kids have an extreme fear of vomiting or choking, and may restrict their intake because of this. Other kids may have been chronic picky eaters with feeding problems since birth who are falling of their growth curves. Our Eating Disorders Program also treats school-age children and adolescents with these problems by using a combination of cognitive behavioral therapy, parent-supported nutrition and family-based treatment.

Who gets eating disorders?

Although anyone can suffer from an eating disorder, there are some trends in gender and age. Both anorexia and bulimia are about eight times more common in females than in males. Between 1 to 13% of American high school and college-age women are estimated to have anorexia nervosa, bulimia nervosa or OSFED. Young people often work hard to keep their struggles with food secret, so it's hard to know just how many people suffer from eating disorders.

Anorexia

Anorexia nervosa can develop at any age, but it most often begins during the teenage years. The risk of developing an eating disorder often starts when a teenager decides to "get healthier" or "more fit" and follows a diet, but then goes beyond initial weight loss goals and severely limits intake. Often, the teenager is at a normal weight when they begin to diet. Anorexia nervosa begins to set in when the teen reaches the chosen goal, but still feels they are not thin enough. Even though the teen may now be extremely thin, he or she feels fat. So the teen resolves to restrict intake further and may also increase exercise in an effort to increase the rate of weight loss.

Anorexia nervosa affects girls more often than boys, but there has been an increase in the number of males suffering from anorexia nervosa. Males face similar societal pressures to be strong and "buff," and they also have trouble with self-esteem issues that contribute to the development of eating disorders.

Family members may not realize what's happening until the person with anorexia nervosa becomes dangerously underweight. By this time, they have severely limited what they will eat and have restricted their fat intake. Exercise may continue relentlessly for hours each day as they adhere to a rigorous schedule that burns up even more unwanted calories. No matter what friends and family might say, a person with anorexia usually denies there is a problem and refuses to give up his or her extreme diet. Without professional intervention, the person will continue to get thinner until their health and life are in serious danger.

The typical person with anorexia nervosa is a perfectionist and an overachiever, excelling in school and involved with lots of activities. Sometimes, the preoccupation with weight starts in response to a stressful event, such as a loss of friends or problems in the family. It may begin as a way to deal with general pressures such as growing up, fitting in socially, doing well in school or keeping everyone happy in the family.

Bulimia

Like anorexia, bulimia often begins with a diet. But the dieter soon feels deprived and panicky and experiences intense hunger urges, and the cycle of restricting and binge eating sets in. The binge is followed by feelings of guilt about their loss of control and fear of getting fat. Bingeing is usually followed by desperate attempts to get rid of the food just eaten, but purging leaves the teen with bulimia still hungry. The vicious binge/purge cycle begins again.

This becomes a routine that is difficult to interrupt. People with bulimia nervosa, afraid that others will think their habit disgusting, become secretive and fearful of discovery. They may spend more and more time alone, sometimes going through the binge/purge cycle several times a day.

People with bulimia aren't always physically hungry; they have learned to use food to cope with stress and emotional difficulties. Erratic eating patterns develop in response to using food as a coping tool, which leads to the inability to respond to hunger and satiety in an appropriate manner. People with bulimia usually maintain close to normal weights. They often go through their binges and purges in private, so the condition may be hard to detect.

The typical person with bulimia nervosa is especially concerned with how others see them; they may be emotionally insecure and lack confidence. The individual feels that they live behind a façade: competent and attractive on the outside, but inept and disgusting underneath. Dieting initially begins as a way to feel better about oneself and to win approval from others. Bulimia tends to begin in the teen years and often continues into adulthood.

Avoidant restrictive food intake disorder (ARFID)

Avoidant restrictive food intake disorder (ARFID) is an eating disorder in which an individual limits the amount or type of food they consume, resulting in significant weight loss, lower than expected weight gain or faltering growth. Teens or children with ARFID may be underweight, experience significant nutritional deficiency or depend on liquid nutrition supplements or tube (NG or G-tube) feeding.

ARFID is different from anorexia, as people experiencing ARFID don't have a drive for thinness or fear of weight gain and don't feel disturbed by their body weight or shape.

The malnutrition created by ARFID can contribute to medical instability, loss of growth potential, osteoporosis and infertility.

Symptoms and factors that can contribute to developing ARFID include:

  • Avoidance of food due to narrow preferences based on taste, texture, smell or appearance
  • Concern about the consequences of eating (stomach pain, fullness, vomiting or choking phobias)
  • Lack of interest in food or persistent low appetite that isn't caused by depression or anorexia 

Children and adolescents with ARFID are often described as “picky eaters” and may have tantrums or show other behaviors to avoid food. They are often “below the growth curve,” due to inadequate nutrition for their weight and height, sometimes for many years.

The Family Based Therapy approach is helpful for children and adolescents with ARFID. Through this therapy, caregivers learn how to provide adequate nutrition for growth and development while helping kids learn how to complete meals and expand their diet. Parents and caregivers also learn strategies for managing food avoidance, anxiety and emotional distress. Children and adolescents often benefit from exposure therapy and general psychotherapy to help with distress and any co-existing mental health problems.  

What causes eating disorders?

Despite more than 50 years of research, the cause of eating disorders remains largely unknown. We do know that living in a culture that values thinness and promotes dieting increases the risk of kids developing an eating disorder like anorexia or bulimia. In fact, research shows that by the age of 7, many children have already decided that it isn't okay to be fat.

Genetic factors, family history and certain personality traits, such as perfectionism, harm avoidance and anxiety also contribute to the likelihood of developing an eating disorder. The pressure to be slender is especially intense for girls and young women in their teens. Two-thirds of girls between the ages of 10 and 15 have tried dieting. Cultural messages about thinness are directed almost entirely toward women, and puberty is a time when young people are confronted with a rapidly changing body.

An understanding of issues that may have contributed to the onset of dieting and exercise leading to the eating disorder is important, but normalizing eating behavior and weight remains the most important intervention. It is often difficult for the person with an eating disorder to admit that they need help. That's why it may be up to friends, family members, coaches or teachers to guide the young person to the help they need.

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