In the United States, as many as 10 million females and 1 million males are fighting a life-and-death battle with an eating disorder such as anorexia or bulimia. Millions more are struggling with binge-eating disorder. The true number is difficult to know because many people manage to hide their eating problems even from those closest to them. Once thought to be restricted to middle- and upper-income families, eating disorders are increasingly found at every social and economic level.
Eating disorders most commonly start in girls between ages 14 and 17 years but are also seen in adolescent boys and younger children. Overall, girls with eating disorders outnumber boys by about 10 to 1. The roots of the problem appear to be complex. Outside influences are one contributor to eating disorders; for example, magazines, movies, and television promote thinness. Most young people can deal with the message, but those who develop an eating disorder are more susceptible and cannot keep the media images in perspective. Young people are rarely aware of the extent to which images are altered to make models or actresses appear perfect, and they aspire to what they perceive as perfect beauty. However, there are invariably more complex and deep-seated psychological issues and genetic vulnerabilities that influence who is susceptible, including low self-esteem.
No age group is immune. Eating disorders in children younger than 14 years are described as childhood onset. Some women secretly persist in eating disorders from their teens into their 20s, 30s, and beyond. Others develop abnormal eating and exercise behaviors in response to stress long after adolescence is over. This type of eating and overconcern with body shape and image is an occupational hazard for those whose jobs or activities rely on appearance, such as fashion models, dancers and other performers, and competitive athletes like gymnasts.
Types of Eating Disorders
The principal eating disorders are anorexia nervosa, or self-starvation, and bulimia nervosa, or binge eating followed by purging through induced vomiting or laxative abuse to prevent weight gain. Another less “formal” but common eating disorder is bulimorexia—starvation alternating with gorging and induced purging. Whatever the specific behavior and diagnosis, those with eating disorders share a preoccupation with their food, weight, and shape; have a severely erratic or inadequate food intake; and can’t regulate their eating and related emotions. They often have other symptoms of anxiety, depression, and obsessive-compulsive thoughts and symptoms. Some develop substance use problems over time. Girls who start menstruating earlier than their peers tend to have more problems with body image and a somewhat higher risk of eating disorders. Children from families with eating disorders and obsessive-compulsive disorders are also more vulnerable.
Eating Disorder Risk Factors*
Family history of eating disorder or obesity
Affective illness or alcoholism in first-degree relatives
Ballet, gymnastics, modeling, “visual sports”
Personality traits (eg, perfectionism)
Parental eating behavior and weight
Physical or sexual abuse
History of excessive dieting, frequently skipped meals, compulsive exercise
*Source: Rome ES, Ammerman S, Rosen DS, et al. Children and adolescents with eating disorders: the state of the art. Pediatrics. 2003;111:e98–e108
Risks for Adolescent Athletes
High school and college athletes are particularly susceptible to eating disorders. For example, some coaches encourage wrestlers to develop strength by training above their weight limits but competing at a lower weight, just under the limit. Wrestlers may be pressured to lose several pounds in the few days before a competition. Adolescent athletes are often urged to follow drastic and unbalanced weight-loss regimens (eg, eating only bananas or oranges for days). In the past, several college wrestlers died when trying to make a weight class by going without food and water and working out while wearing special clothing to promote sweating. These practices are unsafe.
The American College of Sports Medicine and some states have released guidelines for weight control and monitoring high school and collegiate wrestlers (www.acsm.org). Coaches should be responsible for encouraging healthful eating and exercise. Parents who suspect that their children are subjected to dangerous or abusive practices should stop their children’s involvement and bring their concerns to the attention of school or college authorities.
Common Forerunners for Eating Disorders
Be on the lookout for diet fads, especially with adolescent girls. Some, such as high-protein, very low-carbohydrate regimens, require medical supervision when used in adolescents. They’ve been around for decades and resurface periodically under new names. The more extreme diet routines are never intended for long-term adoption. Prescription and nonprescription over-the-counter and over-the-Internet preparations and supplements are poorly regulated and have contributed to serious and deadly problems.
Ephedra-containing over-the-counter diet aids illustrate the hazards of these products. In 2004, after compounds containing ephedra or the related compound ephedrine were found to be associated with a number of deaths, they were banned by the Food and Drug Administration. Fenphen combination prescription diet pills led to fatal heart complications in some users in the 1990s. Ipecac abuse by people with eating disorders caused permanent damage to hearts.