November 2006

Eating Disorders and Adolescents

by Richard E. Kreipe, MD
An Internet search of “eating disorders” yields 15,000,000 these categories and are said to have an eating disorder, not
websites and almost 20,000 images. Stories about eating otherwise specified (ED-NOS), popularly called “disordered
disorders among popular performers also regularly appear eating”. For a more detailed description of the conditions
in the press (see People magazine October 27, 2006 cover beyond the scope of this article, please visit the Academy for
story), and TV (HBO’s documentary Thin airs later this Eating Disorders (AED, www.aedweb.org, for professionals,
month, beginning November 14th). As is often true, when but highly informative for everyone) and the National Eating
there is a large amount of easily accessed information there Disorders Association (NEDA, www.edap.org, for
is also a large amount of mis-information. The purpose of consumers, but also highly informative with a number of
this article is to inform readers about the facts and recent downloadable fact sheets).
and emerging research findings about eating disorders. First,
the what (definitions), how (behaviors related to eating How Do Adolescents with Eating Disorders Behave?
disorders), who (affected individuals), when (developmental The best way to understand how adolescents with an eating
stages), and why (causes and risk-factors) will be discussed. disorder might behave is to put one’s self in their shoes.
Then, some key points about prevention and treatment will Imagine believing that losing weight is the only way that you
be reviewed. Next, recent and can achieve a sense of mastery in
emerging research findings will be your life. Things are happening all
described. Finally, an innovative around and within your own life that
system of care being developed in seem out of your control. Also
New York State under the imagine that you have always been
leadership of the Department of a perfectionist, but have never really
Health will be shared. felt very good about yourself -
regardless of praise that you get from
What are Eating Disorders? others. Finally, you are surrounded
In restrictive anorexia nervosa by “you can never be too thin”
(AN), a person severely restricts messages from a variety of sources.
caloric intake, and often exercises This might be the situation for a
excessively because of an person with AN. What do you do?
overwhelming desire to lose weight. In bulimia nervosa You might: stop eating breakfast, schedule a class during lunch,
(BN), a person is afraid of gaining weight, but ingests large eliminate snacks, exercise every way possible, and keep busy.
amounts in a brief period (binges), then tries to rid the body However, when these behaviors become extreme or numerous
of the effects of these extra calories by fasting, vomiting, and affect every organ system, including your brain, you end
exercising, or using laxatives immediately afterward. Most up feeling worse, not better, and assume that you just need to
people with an eating disorder do not fit neatly into either of lose more weight to feel better about yourself.

Continued on page 2
Likewise, imagine that you have an intense fear of obesity, chronologic age, so they can occur in childhood through
but lack the “will power” to limit calories on a consistent adulthood. That is, issues related to puberty (see research
basis, the motivation to exercise regularly, and the ability findings), autonomy, identity and relationships often seem
to control impulses or sad moods. You also find comfort to trigger the illness. Sheila MacLeod (MacLeod, 1987)
eating large amounts of high-calorie foods, but doing so noted that an eating disorder is actually “a last ditch effort”
only makes you feel worse. So, you do things to rid your to gain control over feelings of low self-esteem and
body of calories. Although harmful, these things are less ineffectiveness that precede dieting by months to years.
frightening than gaining weight, and may even make you
feel less guilty or sad. This might be the situation for a Why Do Eating Disorders Develop?
person with BN. You might end up not eating breakfast or The AED and NEDA websites have information on the
lunch because you want to lose weight, but then come causes of eating disorders beyond the scope of this article.
home from school, feeling lonely or sad and eat a donut. Simply put, there is no single cause for an eating disorder.
You start feeling better eating donuts and before you know They are complex illnesses with multiple causes that require
it, you’ve eaten the whole box. This makes you feel guilty treatment across a number of domains. Eating disorders
and ashamed, and the only thing you can think of is to are better considered as “developmental” rather than
vomit before anyone else gets home. Your brother arrives “mental” problems. This acknowledges the depth and
home a few minutes later, goes to the pantry and starts breadth of systems that are affected, and minimizes the
yelling at you because all the donuts are gone. stigma still associated with psychological disorders. As
Embarrassment, sadness and anger cause you to vow to NEDA notes “Eating Disorders Are Illnesses, Not Choices”.
never binge and vomit again, but you know deep in your Dr. Jean Kilbourne, author of Can’t Buy My Love: How
heart that you will, because you are trapped in an addictive Advertising Changes the Way We Think and Feel (2000)
cycle, and don’t see any way out of the pattern. addresses the powerful influence of advertising, but notes
that media and marketing are not the sole causes of eating
Who are Affected by Eating Disorders? disorders.
The AED reports that among late adolescent and young
adult females, at least 10% have symptoms of eating How to Prevent and Treat Eating Disorders?
disorders and those with BN outnumber those with AN by The AED and NEDA websites provide more detailed
at least 2-to-1. Although the stereotype for eating disorders information on this important topic. The basic principles of
is a white adolescent or young adult female living in the prevention cited by NEDA include: 1) eating disorders are
suburbs, males get eating disorders, as do older women serious and complex problems that should not be simplified
(who often have a chronic form starting in adolescence), as “anorexia is just a plea for attention,” or “bulimia is just
and people of color. Some individuals seem to be particularly an addiction to food”. Eating disorders arise from a variety
at-risk, however, including models, those with a family of physical, emotional, social, and familial issues, all of which
member who has/had an eating disorder (see research need to be addressed for effective prevention and
findings), or anyone who places an undue emphasis on treatment; 2) eating disorders should not be framed as a
thinness or avoiding obesity, such as athletes who follow “woman’s problem” or “something for the girls”; 3)
diet, appearance, size or weight requirements for their prevention efforts will fail, or encourage disordered eating,
sport. For example, NEDA cites a study of college athletes, if they concentrate solely on warning the public about the
in which more than 1/3 of females reported attitudes and signs, symptoms, and dangers of eating disorders. Efforts
symptoms placing them at risk for AN. The “female athlete should address: a) our cultural obsession with slenderness
triad” (low weight, loss of menstrual periods and weakened as a physical, psychological, and moral issue, b) stereotypic
bones (osteoporosis) even has its own website for gender roles, and c) developing self-esteem and self-respect
professionals (www.femaleathletetriad.org). Although in a variety of areas (school, work, community service,
eating disorders occur in an individual, it is essential to hobbies) that transcend physical appearance. In her book,
recognize that the illness affects the family, school, I’m Like, SO Fat!, Dr. Dianne Neumark-Sztainer (2004)
workplace and community in which the person lives. notes that prevention messages should be directed not only
at eating disorders, or the more common concern of obesity.
When Do Eating Disorders Appear? She argues for a positive approach emphasizing the benefits
Eating disorders typically are first diagnosed between 10 of healthy eating and physical activity
to 20 years of age, with AN generally occurring appearing
13 to 17, and BN tending to emerge 15 to 19. However, Once an eating disorder occurs, holistic treatment is
developmental issues are probably more important than necessary by professionals addressing the medical,

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nutritional, and psychosocial needs of the adolescent and the (Klump et al 2006), and hypothesize that the female brain
family. Therefore, a team approach is generally used. Newer begins to respond to hormones at puberty and that estrogen
evidence refutes previously held beliefs about parents being activates the genes contributing to disordered eating in
the cause of eating disorders and research now shows that vulnerable girls. Finally, this hypothesis is based on recent
parents have an essential role in helping their teenager restore findings that genes, though fixed at birth, vary in their
weight, as the first step toward recovery. Two books for expression, depending on complex environmental factors
consumers about the positive role of parents in treatment (Bulik 2005). Thus, both the why and when of eating
are the internationally acclaimed Help Your Teenager Beat disorders appear to be linked as biological factors which
An Eating Disorder (Lock & leGrange, 2004) and A Stranger interact with environmental influences, in a classic
At The Table (Haltom, C 2004) written by a practicing ecological dynamic. This exciting line of research will
psychologist in Ithaca, NY. For professionals, a recently undoubtedly continue to enlighten our approach to eating
published (www.psych.org/psych_pract/treatg/pg/ disorders.
EatingDisorders3ePG_04-
28-06.pdf) guideline for Closely related to these
eating disorders details recent studies is
treatment principles. emerging research
Medications like Prozac® focused on imaging brain
can be helpful to treat the function for patients with
binge eating and vomiting eating disorders. The
associated with BN, but the most promising technique
most important “medicine” is in this regard is
healthy eating balanced with functional magnetic
enjoyable exercise. resonance imaging
Treatment may need to (fMRI), which localizes
continue for two years or brain activity in
more. anatomically distinct
areas of the brain,
Recent and Emerging including activity
Research associated with specific
Recent studies have increased our understanding of why and neurotransmitters, such as serotonin (Kaye et al 2005).
when eating disorders tend to emerge as they do. First, Studies using fMRI to detail brain activity associated with
international, multi-center studies suggest that genetic factors specific behaviors and symptoms are underway, and in
play a role in the development of AN more than BN (Bulik, combination with genetic studies, will help improve the
et al 2005, Bacanu et al 2005). However, genes do not simply treatment of these conditions.
cause eating disorders. Instead, the increased risk appears
to be related to a vulnerability to depression and/or anxiety, Comprehensive Care Centers for Eating
for which genetic factors are widely accepted (Kaye et al Disorders (CCCED)
2004). This should not be interpreted as parents who have a Based on legislation spearheaded by New York State
personal or family history of depression or anxiety “giving” (NYS), Senator Joseph Bruno, and funding from the NYS
their child an eating disorder, nor as the inevitability of Department of Health, three CCCEDs have been
developing an eating disorder if a person is depressed or established to develop an integrated system of care that
anxious. Genetic studies are extremely complex and require will assure access to consistent, evidence-based treatment
large numbers of subjects. We are recruiting study subjects through a network of professionals. In addition this
for an international genetic study of patients with eating legislation will fund community outreach, education of
disorders with a blood-relative (other than an identical twin consumers and professionals, and multi-center research
or parent) who has, or has had, an eating disorder. Persons to determine the effectiveness of various treatments for
who might be interested in this study can contact Dr. Kreipe eating disorders.
by telephone at 585-275-7844; or by email at
[email protected]) for further information.
For more information visit:
Second, Dr. Kelly Klump’s group has found evidence that
genes are expressed differently in girls who are early in www.health.state.ny.us/diseases/chronic/
puberty compared to those who are more physically mature eating_disorders.htm

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References

Bacanu SA. Bulik CM. Klump KL. Fichter MM. Halmi Kaye WH. Frank GK. Bailer UF. Henry SE. Meltzer
KA. Keel P. Kaplan AS. Mitchell JE. Rotondo A. Strober CC. Price JC. Mathis CA. Wagner A. Serotonin
M. Treasure J. Woodside DB. Sonpar VA. Xie W. Bergen alterations in anorexia and bulimia nervosa: new insights
AW. Berrettini WH. Kaye WH. Devlin B. Linkage analysis from imaging studies. Physiology & Behavior. 85(1):73-
of anorexia and bulimia nervosa cohorts using selected 81, 2005.
behavioral phenotypes as quantitative traits or covariates. Kilbourne, J. Can’t Buy My Love: How Advertising
American Journal of Medical Genetics. Part B, Changes the Way We Think and Feel. Simon & Schuster,
Neuropsychiatric Genetics: the Official Publication of the Inc. 2000.
International Society of Psychiatric Genetics. 139(1):61-8,
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Bulik CM. Bacanu SA. Klump KL. Fichter MM. Halmi Klump KL. Gobrogge KL. Perkins PS. Thorne D. Sisk
KA. Keel P. Kaplan AS. Mitchell JE. Rotondo A. Strober CL. Marc Breedlove S. Preliminary evidence that
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eating-disorder phenotypes for linkage analysis. American
Journal of Medical Genetics. Part B, Neuropsychiatric
Genetics: the Official Publication of the International Lock, J. leGrange D. Help Your Teenager Beat an Eating
Society of Psychiatric Genetics. 139(1):81-7, 2005. Disorder. Guilford Press, 2004.
Bulik CM. Exploring the gene-environment nexus in eating
disorders. Journal of Psychiatry & Neuroscience.
30(5):335-9, 2005. MacLeod, S. Art of Starvation. Random House, 1987

Haltom, CA. Stranger at the Table: Dealing with Your Newmark-Sztainer, D. I’m, Like, SO Fat!: Helping Your
Child’s Eating Disorder” Ronjon Publishing: Denton, TX.. Teen Make Healthy Choices About Eating and Exercise
2004 in a Weight-Obsessed World. New York, NY, The
Guilford Press, 2005.
Kaye WH. Bulik CM. Thornton L. Barbarich N. Masters
K. Comorbidity of anxiety disorders with anorexia and
bulimia nervosa. American Journal of Psychiatry.
161(12):2215-21, 2004 Dec.

The Center of Excellence invites you to visit the ACT for Youth website where additional
copies of this newsletter and many other youth development resources are available.

www.actforyouth.net

Cornell University
Family Life Development Center
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Ithaca, NY 14853
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