An estimated 0.51 to 1 percent of young women in Western societies suffer from the full syndrome of anorexia nervosa, while to 2 to 4 percent of American college women meet the criteria for bulimia nervosa and up to 5 percent of young Westernized women of college age suffer from atypical or partial syndromes.

Six times as many women as men are affected, but while men have been less severely afflicted by the drive for thinness, they have been increasingly preoccupied with changing their body shape.

A much larger percentage of Americans (more than 50 percent) are restrained eaters (interrupting eating behavior before normal comfortable satiety terminates a meal) in other words, the foot is always on the brake.

The disorder generally takes root after months or years of self-critical scrutiny of body size and shape. Some begin dieting because their friends or family members are dieting or are making comments about their appearance.

The peak of onset of primary anorexia nervosa is the early and late teens—14 to18 years of age—but can happen as early as age seven and as late as the 70's.

Young women with sensitive, self-critical and sometimes compulsive aspects to their personality who:

• Have a history of depressive disorder
  
• Live an enmeshed life—living in each other's pockets; no freedom to grow separately; and excessive reactivity to each others moods and behaviors
  
• Participate in sports, ballet, modeling, wrestling, and other activities that promote thinness, accentuating the drive to lose weight
  

are more vulnerable to the development of an eating disorder.

The first clues to anorexia or bulimia nervosa may be subtle. For example, women may have amenorrhea caused by weight loss, with fractures from estrogen deficiency-related osteoporosis, or the loss of tooth enamel from repeated vomiting. Usually, it’s the concern of family, friends, teachers, and sometimes coaches who raise the issue of anorexia rather than because the patients are worried.

The diagnostic criteria for anorexia nervosa are:

• Self-induced starvation to a weight at least 15 percent below normal
  
• An intense, irrational fear of becoming fat
  
• Amenorrhea, in women missing three consecutive menstrual periods, and in men by a decrease in sexual function and interest
  

In more than 95 percent of patients, anorexia nervosa begins with a conscious wish to lose weight through dieting, often combined with:

• Excessive exercise
  
• Self-induced vomiting
  
• Abuse of laxatives, diuretics, or diet pills
  

Two major classes of patients with anorexia nervosa have been identified as those who:

• Solely restrict their food intake (restricting subtype)
  
• Binge while at low weight, and then induce vomiting or abuse laxatives or diuretics (binge/purge subtype)
  

Patients with both subtypes organize their behaviors, social lives, thinking, and ultimately their identity around promoting and maintaining weight loss and resisting weight gain. Families are distressed by the eating disorder, making families feel helpless, angry or defeated and this occasionally provokes abuse.

The final, chronic stage of the disorder has two features:

• The illness becomes autonomous, resisting change, and the patient develops an identity based on the anorexia nervosa, a "sick role" that derails normal social and psychological development
  
• The chronically low weight may also be sustained by the effects of malnutrition, such as slowed gastric emptying and severe abdominal distress
  

Patients' emaciated state has characteristic signs, including:

• Hypotension
  
• Bradycardia
  
• Decreased core temperature
  
• Loss of both intra-abdominal and subcutaneous body fat
  
• Decreased muscle mass
  
• Osteoporosis
  
• Brain shrinking
  
• Vary degrees of anemia and endocrine dysfunction
  Low gonadotropins and sex steroid concentrations
  
• High circulating cortisol and growth hormone concentrations
  

Management of Anorexia Nervosa

Most patients meeting the criteria for anorexia nervosa should be treated as inpatients for several weeks to months so patients can be stabilized medically, and then started on nutritional rehabilitation.

The best rehabilitation approach is to persuade patients to accept a prescription of healthy amounts of food with the promise they will not be allowed to become fat. Education and support help patients understand their illness and need for treatment.

Nutritional rehabilitation is the first step to management. The central challenge is to persuade patients to:

• Think differently about their body size and nutritional needs
  
• Understand the role that their illness has come to serve in their life
  

Successful management also includes:

• Identifying and treating coexisting moods
  
• Anxiety
  
• Personality disorders
  
• Alcohol or other substance abuse
  

After a patient's weight returns to a healthy range, intensive practice in patterns of healthy daily living consolidates the treatment gains. Aftercare usually requires two to three years, and may involve individual, group, or family treatment.

About Eating Disorders

Anorexia Nervosa

Bulimia Nervosa

Atypical Eating Disorders

Nutritional Assessment

Awareness and Prevention

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