Eating Disorders

Aside from substance use disorders (SUDs), eating disorders comprise the highest mortality rates of all psychiatric disorders, directly causing over 10,200 deaths each year.1 2 8 9 Even though treatments for eating disorders have advanced over the years, those who received inpatient treatment for anorexia nervosa still have a “more than five times” increased risk of death — giving the disorder an estimated mortality rate of about 5%. Up to 4% of females and 0.3% of males suffer from anorexia nervosa during their lifetime.3 9 10 11

Eating disorders can affect people of any age, sex, gender, race, size, sexual orientation, or family medical history.2 The prevalence of eating disorders is generally higher in women than in men, with data also showing increases in eating disorders among BIPOC, LGBTQ+, and other minority populations, including female veterans and those with disabilities.2 12 Causes for the high rates of mortality with eating disorders are complicated but can include:

• Cardiovascular complications (increased risk for heart disease, high cholesterol, and high blood pressure)13 14 15
• Malnutrition16 17
• Suicide18

This guide examines the causes, symptoms, and available treatments for individuals struggling with eating disorders and disordered eating behaviors.

Here is a handy chart breaking down important details about anorexia nervosa, bulimia nervosa, and binge eating disorder.19 20

Eating disorders are mental illnesses characterized by severe and persistent disturbance in eating behaviors with associated distressing emotions and thoughts related to eating. The most common symptoms of eating disorders are:20

• Binge eating
• Purging
• Severe calorie restriction

The obsessive nature of eating disorders concerning food, weight, and body image often leads to significant psychological distress. Eating disorders are also commonly comorbid with other issues, including depression, anxiety, and substance abuse. Eating disorders may develop during childhood or early adolescence. More rarely, they manifest in adults.

Eating disorders can have many causes and are often a complex interaction of genetic, psychological, and social factors. Social and psychological factors appear to be the leading causes. Many eating disorders relate to feelings of poor body image and low self-esteem.20

Poor body image and low self-esteem often manifest from societal pressure about appearances. Certain personality traits have been linked to eating disorders, such as:21

• Anorexia nervosa and perfectionist traits
• Bulimia nervosa and impulsive personality traits

However, determining the exact cause of an eating disorder is not simple, and a wide variety of things may trigger them. Research is ongoing in determining the causes of disordered eating behaviors.

Anorexia and bulimia are the most common eating disorders, followed by binge eating disorder. Other Specified Feeding or Eating Disorders (OSFED) comprise the fourth category for individuals who do not align with the first three disorders.

Disordered eating or diets evolve into eating disorders by degrees. The degree to which a person controls their eating and the motivation behind the behavior can turn a diet into an eating disorder. A diet is an intentional regulation of food intake to modify the body (losing weight, etc.) with a finite objective — losing 10 pounds or adding 15 pounds of muscle, for instance. But strict dieting is rarely necessary and can often become disordered.

Disordered eating refers to abnormal eating behaviors that don’t meet the criteria for an eating disorder. For example, someone who occasionally binges and purges but does not engage in these activities often or in as extreme a fashion may be diagnosed with disordered eating behaviors and not fit the complete diagnosis of bulimia.

Eating disorders take dieting and disordered eating to the extreme. Individuals with eating disorders often find it impossible to let go of their behaviors even after they have met a set goal. Once they complete an objective, a new one replaces it. Eating habits become a compulsion.

Eating disorders have both long-term and short-term impacts. In the short term, eating disorders can evoke physical consequences:6 19 20

• Tooth erosion
• Abnormal blood pressure
• Low heart rate
• Muscle atrophy
• Hair loss
• Electrolyte imbalances
• High cholesterol
• Inflamed esophagus
• Peptic ulcers
• Constipation
• Fatigue

The emotional and psychological impacts of eating disorders can be equally devastating to the sufferer and include issues like depression, anxiety, low self-esteem, social isolation, and more.

In the long-term, eating disorders carry an increased risk for:6 19 20

• Diabetes
• Anemia
• Osteoporosis
• Kidney failure
• A drop in internal body temperature
• Infertility
• Organ failure
• Severe constipation
• Brittle hair and nails
• Dry skin
• Heart disease
• Brain damage

The long-term consequences of eating disorders can severely raise a patient’s mortality rate. Individuals suffering from anorexia have the highest mortality rate for psychological illnesses other than opioid addiction.2

Consider your behaviors and emotions when evaluating your own behavior to determine whether you have an eating disorder. The following are signs of some form of disordered eating:6 19 20

• Feeling guilty after meals
• Using diet pills
• Defining your self-worth by the food choices you make
• Excessive exercising to compensate for calories consumed
• Having trouble in social situations
• Feeling nervous, anxious, or tense when faced with unplanned eating
• Frequent weight fluctuations
• Weight cycling (Yo-yo dieting)
• Very rigid eating or exercising schedules
• Feelings of guilt when eating
• Preoccupation with weight gain
• Emotionally driven eating
• Occasional purging or binge eating
• Feeling possessive of food
• Categorizing foods as “good” or “bad”
• Drinking a lot of fluids to feel full faster when eating
• Skipping meals
• Restrictive dieting
• Irregular eating patterns

When identifying the signs of eating disorders in friends and family, it’s essential to remember that these signs can often be challenging to spot, particularly in the earliest stages. Eating disorders are about shame, and hiding them is often a priority for the sufferer.

However, keeping the disorder hidden as time passes becomes more challenging, especially if the individual begins to lose or gain weight quickly. The following are common physical or emotional signs that may indicate someone you know suffers from an eating disorder:6 19 20

• Tooth decay or erosion
• Dehydration
• Constant sore throat
• Purging behaviors, such as frequent bathroom visits after meals or the unusual use of laxatives
• Secretive food behaviors
• Extreme and rapid weight loss
• Refusing to eat normal quantities of food
• Avoiding food altogether
• Worry over weight gain
• Withdrawal from friends and activities
• Dry or yellowing skin
• Emaciation
• Unusual fatigue and lethargy
• Ulcers

As with many subjects, it’s often a challenge to identify factual information about eating disorders in the sea of misinformation. Here we’ll separate reality from myth.2 26

The following statistics give a sense of the magnitude and severity of these disorders.

• Eating disorders affect at least 9% of the global population, including 28.8 million Americans in their lifetime.2
• Less than 6% of individuals with eating disorders are medically diagnosed as underweight, meaning most fall into average or healthy weight ranges.2
• Between 28% to 74% of the risk for eating disorders is genetic.2
• Eating disorders are the deadliest mental illnesses, behind substance use disorders.2
• Approximately 26% of people with eating disorders attempt suicide.2
• The economic cost of eating disorders is $64.7 billion annually.2
• Gay men are seven times more likely to report binge eating and 12 times more likely to report purging than their heterosexual counterparts.2
• Transgender college students report experiencing disordered eating at four times the rate of cisgender students.2
• 20%-30% of adults with eating disorders also have autism.2
• Up to 4% of females in the U.S. will have bulimia during their lifetime, and 3.9% of those afflicted will die from the condition.7
• 5.2% of individuals with EDNOS will die from health complications.7
• 25% of college-aged women engage in binging and purging to control weight.7
• Over 50% of teenage girls and 33% of adolescent boys use restrictive measures to lose weight.7

Anorexia nervosa has the highest mortality rate of all mental illnesses, except for opiate addiction.2 6 This disorder is characterized by periods of self-starvation resulting in low body weight. Psychologically, patients with anorexia are motivated by an intense fear of gaining weight or becoming “fat.”

There are two subtypes of anorexia nervosa:22

1. Restricting type. This disorder manifests when individuals limit calories primarily by dieting, fasting, or excessively exercising.
2. Binge eating/purging type. This subtype involves intermittent binge eating and purging behaviors.

Signs of disorder

Signs of anorexia nervosa develop over time as the condition worsens and may include:6 22

• Cold intolerance
• Muscle weakness and atrophy
• Heartburn and reflux
• Cessation of menstrual periods
• Dizziness or fainting from dehydration
• Brittle hair and nails
• Stress fractures from compulsive exercise
• Severe constipation, bloating, and fullness after meals
• Bone loss resulting in osteopenia or osteoporosis
• Depression, irritability, anxiety
• Poor concentration and fatigue

The impacts of anorexia nervosa are tragic and deadly, as individuals with the disorder have an over 18 times higher risk of dying from suicide than the general population.27

Treatment

Treatment for anorexia nervosa consists of several elements, depending upon the individual and the severity of their problem. Getting help early on is preferable and often more successful, as with other conditions.

Your doctor will need to address any imminent medical problems first. This may mean getting treatment for related heart issues, osteoporosis, anemia, and malnutrition. Medical evaluations and psychiatric assessments are essential components to help patients normalize their eating and weight control behaviors. They may also refer you to a dietitian.

A dietitian will help you develop a nutritional plan that counters anxieties about eating and gives you practice with consuming a wide variety of foods across regularly spaced meals. You will also be counseled to address body dissatisfaction issues, although these usually take longer to correct than eating behaviors.

In cases of severe anorexia, inpatient treatment or a residential behavioral program may be the best option. Forms of therapy in treating anorexia include cognitive behavioral therapy (CBT), psychotherapy, and medications to assist with comorbid anxiety or depression.28 29

Understanding that you have a problem with eating is the first step to getting help. If you or someone you know suffers from an eating disorder, look at the resources below for treatment information and advice.

Once you’ve acknowledged the problem, seeing your primary care physician is the best next step. They can help you access mental health resources to begin your path to recovery.

Resources for help

• National Association of Anorexia Nervosa and Associated Disorders
• Eating Disorder Hope
• Mayo Clinic: Anorexia Nervosa
• National Eating Disorders Association: Help & Support
• Office on Women’s Health: Anorexia Nervosa

Bulimia is another serious mental health condition with consequences for the digestive system. People who have bulimia and use vomiting as a means of purging can cause long-term physical damage to the esophagus, mouth, and teeth. Those who use laxatives to purge can incur long-term problems with bowel movements.30

Some comorbid physical conditions related to bulimia include:23 30 31

• Metabolic syndrome
• Electrolyte imbalances
• Sialadenitis (swollen salivary gland)
• Pancreatic abnormalities
• Arrhythmias (irregular heartbeat)
• Oligomenorrhea or amenorrhea (irregular or absent menstrual cycle)

Signs of disorder

Signs of bulimia nervosa develop over time as the condition worsens and may include:6 23

• Misuse of diuretics, laxatives, or diet pills
• Dehydration as a result of excessive purging
• Frequent trips to the bathroom after meals
• Chronic sore throat
• Fad dieting
• Fear of eating in public or around others
• Dental decay and erosion of tooth enamel
• Heartburn and gastroesophageal reflux
• Steals or hoards food
• Developing food rituals

Treatment

If you are struggling with bulimia or know someone who is, seeking treatment is imperative for long-term health and wellness. Seeing a medical doctor or mental health professional should be your first step. For more resources on treatment options, see the resources below.

Resources for help

• Binge Code
• Eating Disorder Hope: Bulimia
• Mayo Clinic: Bulimia Nervosa
• National Eating Disorders Association: Bulimia
• WithAll

Binge eating is more than simply overindulging on occasion. It becomes a severe disorder driven by uncontrollable urges that disrupt a person’s life. Binge eating can lead to:24 30 31

• Social isolation
• Depression
• Type 2 diabetes
• Heart disease
• Obesity
• High blood pressure

Signs of disorder

A diagnosis of binge eating disorder requires frequent binges associated with feelings of a lack of control. It must also include three or more of the following behaviors:6 24

• Eating food more rapidly than usual
• Eating large amounts of food when not hungry
• Eating until uncomfortably full
• Eating alone to avoid judgment about the quantity one is eating
• Feeling shame, guilt, and depression after eating binges

Treatment

The most effective treatment for binge eating disorder is cognitive behavioral therapy. Interpersonal therapy may also be effective; your doctor may prescribe antidepressant medications during and after treatment.32 33

If a patient has incurred physical health issues due to binge eating, they must also be addressed by their doctor or treatment professional.

Resources for help

• National Eating Disorders Association: Binge Eating
• Food Addicts in Recovery Anonymous
• Mayo Clinic: Binge Eating Disorder

Other Specified Feeding or Eating Disorders (OSFED) comprise many lesser-known eating disorders, such as:

Over a quarter of college-aged women report binging and purging behaviors, and other eating disorders appear at much higher rates among college students.7 There are several theories for this common problem, which are listed below.

• Academic pressure and stress often lead to eating disorders. This stress can bleed into everyday life and behaviors, such as eating.
• Social stresses in college lead to many students’ attempts to fit in and feel accepted. Body image is a significant component of self-esteem, and many students seek unhealthy beauty standards to gain popularity.
• Many college students do not seek treatment for their eating disorders due to shame and social stigma.
• Eating disorders among female college students are much higher than among males. This may be due to more significant social pressure to fit in, academic stress, and a lack of structure around food in their family home.
• An increase in alcohol use in college brings added calories and weight gain. Many students may engage in risky eating behaviors to drop the “freshman 15” or reduce weight from drinking.
• All-you-can-eat meal plans may contribute to eating disorders because they provide unlimited food choices that may increase weight, followed by immediate crash dieting. Repeated crash dieting can evolve into an eating disorder.
• College athletes are at a higher risk of developing an eating disorder based on athletic pressure, desires for improved physical performance, and holding onto college scholarships based on athletics.

How to address disordered eating in college

One of the first steps you can take if you believe you or someone you know is suffering from disordered eating or an eating disorder is to contact your school’s medical health center for counseling with a professional. Colleges today recognize the problem of eating disorders among college students and will have resources to help them seek treatment on-campus or off.

Browse the following list for valuable resources we can recommend.

• About Face is an organization dedicated to arming girls and women with the knowledge to stand tall in a culture that diminishes them.
• Academy for Eating Disorders provides resources for professionals, students, and experts.
• ANAD (National Association of Anorexia Nervosa and Associated Disorders) is the leading non-profit in the U.S. providing free support services to those with eating disorders, disordered eating, and impaired body image.
• ANRED (Anorexia Nervosa and Related Eating Disorders) is a non-profit organization that ceased operation in 2009. However, the organization still provides comprehensive information about eating disorders.
• The American Psychiatric Association provides resources and comprehensive information about many eating disorders and disordered eating.
• The American Psychological Association provides information and resources for those suffering from eating disorders or those worried about a friend or family member.
• Bulimia.com provides resources for individuals with bulimia and co-occurring eating disorders.
• The Center: A Place of Hope is a Top Ten Facility for treating depression, eating disorders, and other mental health issues.
• Center for Eating Disorders provides outpatient treatment, education, support, and referral services for individuals struggling with eating disorders and related issues. It currently includes telehealth treatment instead of in-person therapy.
• Eating Disorders Online offers educational information, scientific research, and resources on eating disorders.
• Calmerry provides a mental health digest and online resources for patients and professionals treating eating disorders. Read our full review of Calmerry.
• Eating Recovery Center is a nationwide leader in eating disorder recovery, with 35 centers nationwide and virtual treatment options.
• EDReferral.com provides referrals for those with eating disorders seeking treatment.
• F.E.A.S.T. is a global organization providing resources, information, and support for families dealing with eating disorders.
• The Multi-Service Eating Disorder Association is a non-profit organization dedicated to education and awareness of eating disorders and their early detection.
• MedlinePlus is the National Institute of Health’s online library of eating disorder information and resources.
• Mindfulness is an outpatient clinic providing individual and family therapy for eating disorders.
• Mirror-Mirror: Eating Disorders provides information and support for those struggling with eating disorders and their loved ones.
• The National Institute of Health offers information and resources regarding eating disorders.
• NEDA includes screening tools, eating disorder hotlines, comprehensive information, and additional resources for those seeking help.