Eating disorders are a type of illness characterized by a severe disturbance in eating behaviors and thoughts and emotions related to food and eating. People with eating disorders typically become pre-occupied with food and their body weight. They also tend to experience distortions in body image.
Eating disorders affect people of all ages, social and cultural backgrounds. It is estimated that about 20 million women and 10 million men in the U.S. alone will develop an eating disorder at some point in their lives.1 In a 2018 study based on a nationally-representative sample of 36,309 adults – the largest national sample of US adults ever studied – it was found that 0.80 percent of adults will be affected by anorexia nervosa in their lifetime, 0.28 percent will be affected by bulimia nervosa, and 0.85 percent will be affected by binge eating disorder.2
Although we see eating disorders in virtually every population, the types and presentation of eating disorder will vary. How an eating disorder presents in childhood is markedly different than how it may present in a geriatric client.
Eating Disorders in Childhood
When we think of eating disorders, we often think first of teenage girls. Disordered eating is seen in younger children as well and the rate is increasing. While we don’t know exactly what causes an eating disorder, we do know that eating disorders are heritable. If a first degree relative has an eating disorder, the child is 7-12 times more likely to develop disordered eating than a child who does not.Children with chronic illnesses ormental health issues are also at increased risk.
Eating disorders seen in childhood include:
Pica – Persistent ingestion of non-food or non-nutritional substances.
Avoidant/Restrictive Food Intake Disorder – Lack of interest in food or a sensory aversion to certain foods. This avoidance or restriction may lead to significant weight loss.
Rumination – Both voluntary or involuntary regurgitation and rechewing of partially digested food that may be re-swallowed or spat out. Anorexia Nervosa – In children, this disorder may manifest as a preoccupation with food and weight, restricting food, hoarding or hiding food. Younger children are less likely to use compensatory behaviors such as purging, laxative use or exercising excessively.
Bulimia and binge-eating behaviors are less common among younger children.
An eating disorder may not be immediately identifiable in children. Lack of growth is often an early sign that further assessment is warranted.
Eating Disorders in Teens
Eating disorders most often begin to emerge in the pre-teen or teen years. Teens, especially teen girls, are the group most often associated with eating disorders. In fact, research has found that teen girls are more likely to develop a clinical eating disorder than boys. However, when comparing sub-clinical disordered behavior such as binge eating, laxative abuse and fasting for weight loss, the behaviors are nearly as common among boys as they are among girls.6
The most common types of eating disorders among teens are:
Anorexia Nervosa – A disorder characterized by significant weight loss and difficulty maintaining a body weight appropriate for height and age resulting from restriction of food or use of compensatory behaviors such as excessive exercise, purging or laxative abuse.
Bulimia Nervosa – A potentially life-threatening eating disorder characterized by cycles of bingeing and purging in an effort to compensate for the effects of excessive or binge-eating.
Binge-Eating Disorder (BED) – A severe, life-threatening eating disorder characterized by recurrent episodes of eating large amounts of food (quickly and to the point of discomfort. BED is the most common eating disorder in the United States.
Teens are at the greatest risk due to the pressures that they face as they mature. Some contributing factors include:
- Societal pressures – Society places a great deal of emphasis on thinness and unrealistic, “ideal” body images. The pressure to conform is intense and can contribute to a sense of not being thin enough or not measuring up. Pressure also comes from peers and the pressure to fit in with whatever trend happens to be in favor.
- Preferred teen activities – Certain activities appealing to teens can be associated with disordered eating. Modeling, performing and athletics place an emphasis on being lean and fit. For some teens, this can lead to feeling the need to control their weight through unhealthy means or struggle with body image.
- Genetics – Eating disorders are thought to be heritable. If a teen has a first degree relative with an eating disorder, they are at increased risk for disordered eating as well.
- Personality – There is some evidence to suggest that personality traits such as perfectionism, anxiety or rigidity might contribute to the development of disordered eating.
Early signs to be aware of include skipping meals, making excuses for not eating or eating in secret, preoccupation with food or with weight, regularly going to the bathroom right after eating or persistent worry or complaining about being “fat”.
Eating Disorders in Adults
Most eating disorders have their roots in adolescence but there is increasing evidence to suggest that eating disorders can develop in adulthood. In surveys conducted by Australian researchers in 1995 and again in 2005, they found that while younger women reported eating disorder behaviors more often than older women did, the rate of these disorders in older women increased dramatically between the two surveys, while it remained stable for young women. In the same surveys, reports of strict dieting, fasting and purging behaviors also increased dramatically in women ages 45 to 64.
A study of Canadian women found that women ages 45 to 64 were more likely to binge eat, experience guilt about eating, and be preoccupied with food compared with younger women.
A study conducted by a large eating disorders program found that 13% of women over 50 exhibited symptoms of an eating disorder.
Treatment centers are seeing this phenomenon as well as they are treating more and more adult patients, both men and women. While it is unclear as to exactly why these disorders emerge in adulthood, there is some evidence to suggest that social and physical changes that occur in adulthood and mid-life may play a role.
- Aging – With the body undergoing so many physical changes, people may become preoccupied with masking the signs of aging, weight and body image.
- Grief and Loss – Midlife is a time when loss of loved ones becomes more frequent. Grieving a loss can diminish appetite. Restricting, bingeing or purging may be a way to deal with uncomfortable feelings.
- Medical Issues – An illness that results in weight loss may have the effect of reinforcing the weight loss via compliments about one’s slender appearance. The person may continue to restrict to avoid regaining the weight.
- Risk – The person may have had a long-standing eating disorder that went untreated. With age, the ability to deal with the physical and emotional symptoms may prompt the person to seek out medical care.
Older individuals can present with the same types of eating disorders as teens and younger adults. However, it has been noted that the symptoms of older women may not meet the strict standards set forth by the DSM-V. It is also important to rule out medical issues that may mimic an eating disorder or result in marked weight loss.
Special Concerns with Eating Disorders in Elderly Adults
An eating disorder can develop at any age but in the elderly population, it can be easily overlooked. Fearing that they have a “teenager’s” issue, they may be embarrassed to be forthcoming with information. They may not realize the extent of their symptoms and risks. There may be medical issues masking the eating issues and their presentation may not fit the standard profile of a client with an eating disorder.
Whether it is a newly-emerged eating disorder or one that went undiagnosed, an eating disorder with an older adult carries significant risk for co-morbidity and mortality. A thorough mental health assessment is critical and must include medical assessment to rule out or identify any co-occurring medical or other issues that could impact treatment.
The most commonly diagnosed eating disorders in the elderly are anorexia nervosa and bulimia nervosa. A 2010 study of elderly patients diagnosed with an eating disorder found that late onset eating disorders were more common than early onset. Comorbid psychiatric conditions (mostly depression) existed in 60% of the participants. Mortality secondary to the eating disorder was high for this group.
The greatest concern for elderly adults with eating disorders is the toll it can take on the systems of the body. Anorexia and bulimia place a tremendous strain on the body and can result in cardiac issues, electrolyte imbalances, GI distress, or dental problems. This is of particular concern for the bulimic elderly client. The force of repeated purging can have significant detrimental effects on the cardiac and GI systems. Because of the medical fragility that comes with age, management of any eating disorder in this population should be multidisciplinary and include both medical and psychiatric care.
Eating disorders are among the most complicated conditions to treat. Successful treatment begins with a thorough assessment. Understanding the nuances among different groups and knowing what to look for means a more accurate assessment and ultimately better client-centered care.