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The Scary Rise In Adult Eating Disorders
Susan was 43
Usually she just had a cup or two of plain pasta. Sometimes, as a treat, a diet soda. But whatever she ate or drank, Susan* kept it to around 500 calories a day. A year passed, and anytime she tried to eat more, her stomach would clench until she vomited. Her skin turned blotchy, her eyes became sunken, her hair started falling out. Yet, she felt numb.
Susan had overcome a turbulent upbringing, married a great guy, and set up house in a small, idyllic Pacific Northwest town. Life was good, until two years ago, when her out-of-control, alcoholic father ended up in the hospital. Once again, his crises cast a dark shadow on her life, and Susan's old emotional demons returned. Her insides twisted every time the phone rang, would it be the doctor? the police?, and little by little, the constant drama of dealing with her dad squelched her normally healthy appetite.
By June 2011, the 5'4" Susan had lost over 40 pounds and weighed in at less than 100.
She found excuses not to join her family at the dinner table, focusing instead on privately planning out every morsel that went into her mouth. Her husband grew frantic until, finally, Susan went to a doctor, who was at a loss. He ruled out a series of gastrointestinal conditions, then said, "And you're too old for anorexia.".
Eating disorders leaped into the national conscience in the 1970s and '80s, when the number of diagnosed cases exploded. The patients were adolescent girls, many of whom became anorexic or bulimic as a means of controlling their bodies, and, by extension, their lives, as they made their way through puberty. So many girls fell victim that eating disorders were branded a teenage disease. (And experts continue to see a troubling number of cases among teen girls, says Ovidio Bermudez, M.D., board member of the National Eating Disorders Association.)
Yet lately doctors have noticed a disturbing spike among a different group: women in their late twenties, thirties, and forties. At the Renfrew Center's 11 treatment locations, the number of patients over age 35 has skyrocketed 42 percent in the past decade. Likewise, a couple of years ago at the Eating Recovery Center in Denver, an estimated 10 percent of patients were over age 25; today, a whopping 46 percent are over 30. And when it opened in 2003, the University of North Carolina's Eating Disorders Program was designed for adolescents, now half of its patients are over 30 years old.
Just like their younger counterparts, adult eating disorders deliver a mind-body punch that kills more people than any other mental illness. Patients of all ages can suffer impaired brain function, infertility, dental decay, or even kidney failure or cardiac arrest. But while the teen and adult diseases share physical symptoms, and both can be tied to deep psychological roots, their catalysts are quite different, says psychotherapist Jessica LeRoy, of the Center for the Psychology of Women in Los Angeles. "As women get older and their lives evolve, so do their stressors and triggers," she says. These can nudge the door open for an eating disorder. But research on the adult-onset versions is lacking, and without sufficient tools and awareness, women like Susan are being misdiagnosed.
When her physician failed to pinpoint a cause, Susan and her husband sought several more opinions about her ever-shrinking size. The other doctors also ignored the possibility of an eating disorder, though one did suggest she seek psychiatric care. Susan went back home, where she lived in fear and confusion, her health rapidly deteriorating. Finally, a friend whose teenage daughter was anorexic recognized her symptoms and urged the family to consult an eating disorder specialist. After two years of starving herself, Susan checked into a clinic, where she needed to be hooked up to a feeding tube to survive.
On any given day, nearly 40 percent of American women are on a diet. The weight-worry gun is loaded early: By the time they reach age 10, 8o percent of girls fret that they're fat. Their main "thinspiration," according to experts: the ultra-slim starlets glorified in popular culture.
It seems unlikely, though, that women who make it into adulthood with healthy eating habits would suddenly become swayed by such images. "Grown women used to be allowed to have curves," says LeRoy. "As they got older, their bodies were supposed to change, especially after having kids." But times have changed. The emergence of the MILF meme has spawned a novel form of pressure for an older age-group. And though LeRoy point outs that appearing svelte post-pregnancy isn't a bad thing, "the problem is when mothers try to turn back the clock and look like they're 18 by starving themselves."
Of course, celeb scapegoats are not the only cultural influence at play. Ironically, a growing national impetus on super-healthy living might be fueling some adult eating disorders, says Emmett Bishop, M.D., director of adult services at the Eating Recovery Center in Denver. While the message itself (smart food choices, reduced portion sizes, ample exercise) is justified, and necessary in fighting America's obesity epidemic, "some women who are prone to eating disorders might take that message and run too far with it," says Bishop, using it to validate food restriction or as an excuse not to eat at all.
Particularly at risk are women with extreme personalities (i.e., those who lean toward all-or-nothing behavior), says eating disorder nutritionist Sondra Kronberg, R.D., director of the Eating Disorder Treatment Collaborative in New York. "When a woman like this hears that red meat has a higher fat content, she might really hear 'All meat is bad and loaded with fat; I can't eat it,'" she explains. And cutting out entire food groups can snowball into a full-fledged disorder.
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Contributing to these catalysts is the growing fervor over food sensitivities and allergies, says Kronberg. What starts out as necessary restriction, say, nixing wheat due to a gluten allergy, could ignite larger restrictive-eating behavior, leading to a seriously dialed-down diet that excludes critical nutrients.
But experts also note that adult eating disorders aren't all driven by the need to look young or eat extra healthfully. Restriction or purging can also be outward manifestations of much deeper emotional turmoil, says Cheryl Kerrigan, a recovered adult anorexic and author of Telling ED No! "For some women, it's not about the food," she says. "It's about the feelings."
Katy was 26 the first time she stuck a finger down her throat. A Detroit native, she'd grown up happy and with healthy eating habits. But as she climbed the proverbial ladder at her public relations firm, her stress level also rose (frustratingly, her salary stayed on the bottom rung). One day, after dinner with her husband, Katy slipped into the bathroom. "It was like I had pressure inside me that I needed to release," she says. "Afterward, I felt much better." She flushed the toilet and went downstairs to watch TV.
Before long, Katy was purging up to eight times a day. At work, she'd vomit, wash up, and return to her desk without anyone noticing. "I was like a closet smoker," she says. Unlike many bulimia patients, Katy wasn't trying to erase calories or shed dress sizes; she rarely ever binged and throughout her sickness she remained a size 14. Rather, she came to feel that throwing up was evidence that she ran her own life.
The desire for control is common among adult eating disorder patients, says Kronberg. Women are loaded with more responsibilities, such as paying the mortgage or caring for aging parents. They're also navigating big life transitions, career changes, marriage, pregnancies, divorce, that can leave even a steady person feeling off-kilter.
"As early as age 30, many women hit a point at which they feel there are certain things they should have accomplished," says Kronberg. "They evaluate their lives, and if they see a void, they look for something that will make them feel good." In essence, a perceived lack of success can morph into a feeling of failure and become an eating disorder catalyst. But emerging research shows that yet another factor could turn an innocent desire for self-improvement into an unstoppable compulsion.
If two women with the same background have similar careers and diets, why might just one develop an eating disorder? Scientists now believe that some people carry an inherited vulnerability and that the illness can run in families.
The developing picture is complex: One specific gene does not spawn the disease. Inherited eating issues are likely due to a combination of genetic factors, ones that may skip a generation, lie dormant for decades, or never become active at all, says Sari Shepphird, Ph.D., author of 100 Questions and Answers About Anorexia Nervosa.
What experts do know is that "something has to come in from the outside to turn the eating disorder on," says psychologist and genetic researcher Craig Johnson, Ph.D., former president of the National Eating Disorders Association. Dieting and exercise are often the initial switches. Whenever any woman does either, she's actually changing her brain's neurochemistry. (For most people, this is necessary to create new healthy habits.) To wit, studies show that women with anorexia or bulimia have abnormal levels of several neurotransmitters, chemicals that affect anxiety and appetite. It's possible that something deep in their DNA was triggered to mess with the stuff.
Currently, there's no genetic test for an eating disorder, but just because your mom or sister struggles with food doesn't mean you're doomed to follow suit. Instead, women with a family history should be cautious about throwing themselves into hard-core diets or workout regimens, especially if they also have anorexia-related behavioral traits such as perfectionism or anxiety, or bulimia-related traits like impulsivity and restlessness.
The encouraging news is that adult women with late-onset eating disorders often have an easier time healing than adolescents do. About 50 percent of patients will fully recover, says Shepphird, likely because many women over 30 have the maturity needed to recognize that they need help. Most seek treatment because they want to get better, as opposed to teens, who are usually pushed into therapy by their parents or doctors, says Johnson. (Take Katy's case: She knew that purging was dangerous. After tearfully confessing to her husband, she entered counseling.)
In the past, however, older women have felt out of place in treatment programs geared toward teenagers, says Laurie Glass, a recovered adult anorexic and the author of Journey to Freedom from Eating Disorders. Glass fell ill in 2003 when she was 32 but resisted entering a recovery center because of her age. "The guilt and the shame were overwhelming. I thought, I'm an adult, I should know better," she says. Instead, she sought out a dietitian for counseling.
Of course, had she become sick in 2012, Glass would likely have found plenty of patients her age at eating disorder treatment centers all around the country. As the larger medical community slowly becomes aware that eating issues don't disappear with adolescence, grown women have a better chance of being properly diagnosed. Still, says Johnson, if you suspect you have a problem, seek out an eating disorder clinic.
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Anorexia and bulimia aren't the only dangerous eating behaviors
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Eating disorders affect both the mind and the body. Although deviant eating patterns have been reported throughout history, eating disorders were first identified as medical conditions by the British physician William Gull in 1873. The incidence of eating disorders increased substantially throughout the twentieth century, and in 1980 the American Psychiatric Association formally classified these conditions as mental illnesses.
Individuals with eating disorders are obsessed with food, body image, and weight loss. They may have severely limited food choices, employ bizarre eating rituals, excessively drink fluids and chew gum, and avoid eating with others. Depending on the severity and duration of their illness, they may display physical symptoms such as weight loss; amenorrhea; loss of interest in sex; low blood pressure; depressed body temperature; chronic, unexplained vomiting; and the growth of soft, fine hair on the body and face.
Clinically, anorexia nervosa is diagnosed as intentional weight loss of 15 percent or more of normal body weight. The anorexic displays an inordinate fear of weight gain or becoming fat, even though he or she may be extremely thin. Food intake is strictly limited, often to the point of life-threatening starvation. Sufferers may be unaware of or in denial of their weight loss, and may therefore resist treatment.
Bulimia nervosa is characterized by repeated episodes of bingeing followed by compensatory behaviors to prevent weight gain. Compensatory behaviors include vomiting, diuretic and laxative abuse, fasting, or excessive exercise. Like the anorexic, the typical bulimic has an unusual concern about body weight and weight loss. Unlike the anorexic, he or she is acutely aware of this condition and has a greater sense of guilt and loss of self control.
Binge eating disorder.
Binge eating disorder is characterized by eating binges that are not followed by compensatory methods. This condition, which frequently appears in late adolescence or the early twenties, affects between 15 and 50 percent of individuals participating in diet programs and often develops after substantial diet-related weight loss. Of those affected, 50 percent are male.
Eating disorder not otherwise specified.
The category eating disorder not otherwise specified (EDNOS) is used to diagnose individuals whose eating disorders are equally as serious as anorexia nervosa, bulimia nervosa, or binge eating disorder, but do not meet all of the diagnostic criteria for these illnesses. An example of EDNOS might be a female who fulfills all of the criteria for anorexia but is still having regular menstrual periods, or an individual with all of the signs of bulimia who binges and purges less than twice a week.
Originally considered to be a disease targeting affluent white women and adolescents, eating disorders are now prevalent among both males and females, affecting people of all ages and from many ethnic and cultural groups. As many as 70 million people worldwide are estimated to suffer from these conditions, with one in five women displaying pathological eating patterns.
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Environmental, social, biological, and psychological factors all contribute to eating-disorder risk. Early childhood environment and parenting may have a substantial impact. Many sufferers report dysfunctional family histories, with parents who were either emotionally absent or overly involved in their upbringing. As a result, these children may not tolerate stress well, they may have low self-esteem, and they may have difficulty in interpersonal relationships. Children who have been abused either physically, sexually, or psychologically are also highly vulnerable to eating disorders, particularly bulimia. Those raised by eating-disordered parents may be at heightened risk due to repeated exposure to maladaptive food-related behaviors.
Societal influences also contribute to this illness. Increasingly, Westernized culture portrays thinness as a coveted physical ideal associated with happiness, vitality, and well-being, while obesity is perceived as unhealthy and unattractive. This has encouraged a growing sentiment of body dissatisfaction, particularly among young women. Endless images of unrealistically thin models and actors in all forms of media further promote body dissatisfaction—one of the strongest risk factors for the development of disordered eating.
Treatment is based on a combination of psychotherapy, medication, and nutritional counseling. Goals include restoration of healthy body weight, correction of medical complications, adoption of healthful eating habits and treatment of maladaptive food-related thought processes, treatment of coexisting psychiatric conditions, and prevention of relapse. Depending on the severity of the illness, therapy may be conducted on an outpatient, day treatment, or inpatient basis.
DiagnosisAnorexia nervosa.Bulimia nervosa.Binge eating disorder.Eating disorder not otherwise specified.PrevalenceRisk FactorsCausesTreatment ModalitiesOutpatient therapy.Day treatment programs.Inpatient hospitalization.Medication.OutcomesBibliographyInternet Resources
Outpatient therapy provided by practitioners specializing in eating disorders is appropriate for highly motivated patients within 20 percent of their normal body weight and whose illness is mild or just developing. Treatment consists of cognitive-behavioral therapy, intensive nutritional counseling, support-group referrals, and medical monitoring. At the outset of treatment, a contract is established, outlining an anticipated rate of weight gain (usually between 0.5 and 2 pounds per week), target goal weight, and consequences if weight gain is not achieved. Vitamin and mineral supplementation and the use of liquid supplements to facilitate weight gain may also be indicated.
Day treatment programs.
Day treatment programs are being used with increasing frequency in place of inpatient hospitalization. This form of therapy provides an intermediate level of care for patients who require frequent monitoring but do not require treatment twenty-four hours a day. It may be used for patients who are not responding to outpatient therapy or who are stepping down from inpatient hospitalization. Treatment, which may take place four or five days per week from morning until evening, is similar in structure to outpatient therapy, but is provided on a more intensive level.
Inpatient hospitalization is indicated for patients whose eating disorder has reached life-threatening status. Criteria for admission to such programs are weight loss of 25 percent or more of ideal body weight or the presence of an eating disorder in a child or adolescent. It may also be necessary for individuals who are medically unstable. Usually, participants in inpatient programs are anorexic, although hospitalization for bulimia may be necessary if there is serious deterioration of vital signs, uncontrollable vomiting, or concurrent psychiatric illness.
Medication is increasingly becoming a routine part of treatment for eating disorders. Antidepressants, particularly the selective serotonin reuptake inhibitors (SSRIs), are the most effective and most commonly used medication in treating this spectrum of illnesses. They are found to be of greatest benefit when used in combination with therapy, and are of little value if offered on their own. In the case of anorexia, these medications are most effective if employed after successful weight restoration is achieved, at which time they can be useful for relapse prevention and the treatment of coexisting psychiatric conditions. SSRIs are also used in preventing binge relapses among bulimics, although their effectiveness ceases once the medication is discontinued. Although antidepressants have also been employed in the treatment of binge eating disorder, outcomes have not been sufficiently positive to warrant recommendations for their use.
Individuals are usually considered to be ready to terminate therapy once they have achieved a healthy body weight and can eat all foods free of guilt or anxiety. For a complete recovery, extensive treatment may be required from six months to two years, and for as long as three to five years in cases where other psychiatric conditions are present. For some, eating disorders will be a lifelong struggle, with stressful or traumatic events triggering relapses that may require occasional check-in therapy to restore healthful eating patterns.
Eating Disorders throughout History