Eating Disorder Awareness Week: Feb 1-7, 2021
Eating Disorders: An Overview
Eating disorders (EDs) are serious psychiatric conditions that are characterized by significant disturbances in the behaviours and attitudes that surround eating, body weight, and body shape (American Psychiatric Association, 2013). Described as a persistent disruption in eating or eating-related behaviours, EDs result in a “distorted consumption or absorption of food that significantly impairs physical health or psychosocial functioning” (American Psychiatric Association, 2013, p. 329). EDs are the product of a complex interaction between genetic, biological, psychological, and environmental factors, and affect people of all ages, genders, ethnicities, body shapes and weights, and socioeconomic statuses (Mental Health Commission of Canada (MHCC), 2017; Eating Disorders Foundation of Canada, 2014).
EDs have been found to decrease quality of life for both the individuals struggling with them (Ágh et al., 2015; DeJong et al., 2013) and their families or caregivers (Zabala, Macdonald, & Treasure, 2009; de la Rie, van Furth, de Koning, Noordenbos, & Donker, 2005).
The debilitating symptoms of EDs result in significant consequences in many areas of life: not only are mental and physical health compromised, but personal relationships, current and future education and employment opportunities, and financial security are often jeopardized as well (Eating Disorders Foundation of Canada, 2014).
Since the majority of affected individuals develop the disorder at a young age, there is a high risk of the condition becoming chronic, and thus the potential for a large number of productive life years to be lost (Lindenberg, Moessner, Harney, McLaughlin, & Bauer, 2011). This suffering is further enhanced by the fact that EDs can lead to life-threatening medical complications and frequently co-occur with other debilitating mental illnesses such as bipolar, depressive, and anxiety disorders (Aardoom, Dingemans, & van Furth, 2016; American Psychiatric Association, 2013).
Overall, EDs are characterized by chronicity, relapse, suffering, functional impairment, and risk for depression and anxiety disorders, future obesity, substance abuse, suicide attempts, and mortality (Agras & Robinson, 2018).
Types of Eating Disorders
Three of the most prevalent and widely studied types of EDs are anorexia nervosa, bulimia nervosa, and binge-eating disorder.
Anorexia Nervosa The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) states that anorexia nervosa can be diagnosed when an individual restricts caloric energy intake to the extent that they are unable to maintain a healthy body weight; demonstrates an intense fear of weight gain or becoming fat even though they are at a significantly low weight; and has distorted perceptions related to shape or weight, places excessive influence of body weight or shape on self-evaluation or mood, or demonstrates a persistent lack of recognition of the seriousness of the situation (American Psychiatric Association, 2013). Anorexia nervosa is one of the most widely known EDs and while it represents a high proportion of individuals struggling with EDs in an inpatient setting, it is likely less common than other EDs such as bulimia nervosa and binge-eating disorder in the general population (Dalle Grave & Calugi, 2007). The DSM-5 states the 12-month prevalence of anorexia nervosa to be 0.4% in females and 0.04% in males with the age of onset typically being early to late adolescence (American Psychiatric Association, 2013). Numerous articles have found that the incidence of anorexia nervosa has been steadily increasing over time—especially for the high-risk demographic of females aged 15–19 years old (Agras & Robinson, 2018). The course and outcome associated with anorexia nervosa is highly variable (American Psychiatric Association, 2013). It has been observed that of the individuals struggling with anorexia nervosa that seek treatment, only a minority achieve remission within one year and sustain recovery, whereas many individuals battle with their diagnosis for greater than a decade (Agras & Robinson, 2018). Individuals diagnosed with anorexia nervosa at an older age and those who experience greater delays between onset of illness symptoms and treatment initiation have been found to have worse prognoses than their counterparts (Steinhausen, 2002).
Bulimia Nervosa The diagnostic criteria for bulimia nervosa according to the DSM-5 includes regular (i.e. at least once per week on average for a period of three months) episodes of binge eating and recurrent, inappropriate compensatory behaviours in order to prevent weight gain such as self-induced vomiting, misuse of laxatives/diuretics/other medications, fasting, or excessive exercise (American Psychiatric Association, 2013). An episode of binge eating is defined by “eating, in a discrete period of time, an amount of food that is definitely larger than what most individuals would eat in a similar period of time under similar circumstances, and a sense of lack of control over eating during the episode” (American Psychiatric Association, 2013, p. 345). The DSM-5 describes the 12-month prevalence of bulimia nervosa to be between 1% and 1.5% in adolescent females (American Psychiatric Association, 2013). When looking at samples consisting of treatment-seeking individuals, it has been observed that similar to anorexia nervosa, the gender ratio for bulimia nervosa is approximately 10 females for every 1 male affected (American Psychiatric Association, 2013). Within the general population, where the majority of individuals do not seek treatment for their ED, the gender ratio seems to be closer to 3 females for every 1 male (Agras & Robinson, 2018). Typically, the onset of bulimia nervosa occurs in late adolescence to young adulthood (American Psychiatric Association, 2013). In comparison to anorexia nervosa, the course and outcome accompanying bulimia nervosa is more favourable (American Psychiatric Association, 2013). When examining individuals receiving treatment for bulimia nervosa five years after diagnosis, it has been found that approximately 70% recover, 20% show signs of improvement but continue to experience symptoms, and 10% remain chronically ill (Agras & Robinson, 2018).
Binge-Eating Disorder Binge-eating disorder is diagnosed when an individual experiences recurrent episode of binge eating—on average, a minimum of once per week for three months (American Psychiatric Association, 2013). The binge eating episodes must be coupled with three or more of the following characteristics: “eating much more rapidly than normal; eating until feeling uncomfortably full; eating large amounts of food when not feeling physically hungry; eating alone because of feeling embarrassed by how much one is eating; or feeling disgusted with oneself, depressed, or very guilty afterwards” (American Psychiatric Association, 2013, p. 350). Furthermore, a diagnosis of binge-eating disorder includes the presence of significant distress regarding binge eating and the absence of recurrent use of inappropriate compensatory behaviour as in bulimia nervosa (American Psychiatric Association, 2013). Without any data on the global prevalence of binge-eating disorder, the DSM-5 relies on the United States National Comorbidity Survey which indicates that the lifetime prevalence is 3.5% for females and 2.0% for males (Hudson, Hiripi, Pope Jr., & Kessler, 2007). Hudson and colleagues (2007) report the mean age at onset of binge-eating disorder to be 25.4 years, thereby proposing a marginally older age of inception when compared to anorexia nervosa and bulimia nervosa. Since binge-eating disorder was introduced in the Diagnostic and Statistical Manual of Mental Disorders (4th ed.) as a provisional disorder in 1994 and was only granted an official ED diagnosis in the DSM-5 in 2013, there is currently an absence of research adequately describing the long-term effects, incidence, and course of the disorder (Agras & Robinson, 2018).
Eating Disorders and Mortality
In addition to causing a tremendous amount of disability and suffering, EDs can be fatal. Considered the deadliest of all mental illnesses, EDs are 12 times more likely to lead to death than their counterparts (MHCC, 2017). Most notably, anorexia nervosa has the highest mortality rate of any psychiatric disorder with a value between 10% and 15% (Arcelus, Mitchell, Wales, & Nielsen, 2011; Eating Disorders Foundation of Canada, 2014). Bulimia nervosa is estimated to have a mortality rate of approximately 5% (Eating Disorders Foundation of Canada, 2014). When taken together, anorexia nervosa and bulimia nervosa account for the deaths of approximately 1,000–1,500 Canadians annually—a number which is likely to be higher in reality as many individuals succumb to associated health complications or death by suicide (Eating Disorders Foundation of Canada, 2014; MHCC, 2017).
Burden of Disease
The Global Burden of Disease Study 2010 found that anorexia nervosa and bulimia nervosa account for 1.9 million disability-adjusted life years (DALYs) and are the 12th leading cause of DALYs in females aged 15–19 in high-income countries (Erskine et al., 2016). While the greatest burden falls on this demographic, there is a growing prevalence of EDs in low- and middle-income countries (Erskine et al., 2016). Due to methodological challenges and lack of epidemiological data, quantification is difficult, and therefore it is likely that the global burden of EDs is underrepresented (Erskine et al., 2016).
Current data describing the incidence and prevalence of EDs within Canada is lacking. This is especially true for certain Canadian populations including children and youth, ethnic and visible minorities, Indigenous people, and sexual and gender minorities (Canadian House of Commons Standing Committee on the Status of Women, 2014). Based on information from Statistics Canada, it is estimated that at any one time between 725,800 and 1,088,700 Canadians meet the diagnostic criteria for an ED (National Initiative for Eating Disorders, 2017).
For more information about eating disorders and Eating Disorder Awareness Week visit the National Eating Disorder Information Centre at www.nedic.ca
Aardoom, J. J., Dingemans, A. E., & van Furth, E. F. (2016). E-health interventions for eating disorders: Emerging findings, issues, and opportunities. Current Psychiatry Reports, 18(42).
Ágh, T., Kovács, G., Pawaskar, M., Supina, D., Inotai, A., & Volkó, Z. (2015). Epidemiology, health-related quality of life and economic burden of binge eating disorder: A systematic review. Eating and Weight Disorders – Studies on Anorexia, Bulimia and Obesity, 20(1), 1-12.
Agras, W. S., & Robinson, A. (Eds.). (2018). The Oxford handbook of eating disorders. New York, NY: Oxford University Press.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: American Psychiatric Publishing.
Arcelus, J., Mitchell, A. J., Wales, J., & Nielsen, S. (2011). Mortality rates in patients with anorexia nervosa and other eating disorders: A meta-analysis of 36 studies. Archives of General Psychiatry, 68(7), 724-731.
Canadian House of Commons Standing Committee on the Status of Women. (2014). Eating disorders among women and girls in Canada. Retrieved from: https://www.ourcommons.ca/Content/Committee/412/FEWO/Reports/RP6772133/fewor p04/feworp04-e.pdf
Dalle Grave, R., & Calugi, S. (2007). Eating disorder not otherwise specified in an inpatient unit: The impact of altering the DSM-IV criteria for anorexia and bulimia nervosa. European Eating Disorder Review, 15(5), 340-349.
de la Rie, S. M., van Furth, E. F., de Koning, A., Noordenbos, G., & Donker, M. C. (2005). The quality of life of family caregivers of eating disorder patients. Journal of Eating Disorders, 13(4), 345-351.
DeJong, H., Oldershaw, A., Sternheim, L., Samarawickrema, N., Kenyon, M. D., Broadbent, H., ... Schmidt, U. (2013). Quality of life in anorexia nervosa, bulimia nervosa, and eating disorder not-otherwise-specified. Journal of Eating Disorders, 1(43).
Eating Disorders Foundation of Canada. (2014). About eating disorders. Retrieved from https://www.edfc.ca/about-eating-disorders/
Erskine, H. E., Whiteford, H. A., & Pike, K. M. (2016). The global burden of eating disorders. Current Opinion in Psychiatry, 29(6), 346-353.
Hudson, J. I., Hiripi, E., Pope Jr., H. G., & Kessler, R. C. (2007). The prevalence and correlates of eating disorders in the National Comorbidity Survey Replication. Biological Psychiatry, 61(3), 348-358.
Lindenberg, K., Moessner, M., Harney, J., McLaughlin, O., & Bauer, S. (2011). E-health for individualized prevention of eating disorders. Clinical Practice & Epidemiology in Mental Health, 7, 74-83.
Mental Health Commission of Canada. (2017). Catalyst – March 2017 – Crucial conversations needed about eating disorders: NIED advocates for awareness, funding to fight eating disorders. Retrieved from https://www.mentalhealthcommission.ca/English/catalyst- march-2017-crucial-conversations-needed-about-eating-disorders
National Initiative for Eating Disorders. (2017). Canadian research on eating disorders. Retrieved from http://nedic.ca/sites/default/files//Canadian%20Research%20on%20Eating%20Disorders%20-%20Formatted.pdf
Steinhausen, H. C. (2002). The outcome of anorexia nervosa in the 20th century. International Journal of Eating Disorders, 159(8), 1284-1293.
Zabala, M. J., Macdonald, P., & Treasure, J. (2009). Appraisal of caregiving burden, expressed emotion and psychological distress in families of people with eating disorders: A systematic review. European Eating Disorders Review, 17(5), 338-349.