All My Children

While eating and body image are sources of concern or exasperation for millions of people, for some they become the focus of extreme and potentially dangerous behavior. According to the American Psychiatric Association, at any given time roughly a half million people in the United States are affected with an eating disorder. Of these, 95 percent are young women between the ages of twelve and twenty-five, most from middle- or upper-income families. (These conditions are rarely seen in developing countries.) Athletes, models, dancers, and others in the entertainment industry are at particular risk, usually because of intense concern over maintaining a particular, often unrealistic, appearance or level of performance.

The two most common eating disorders, other than obesity, are anorexia nervosa and bulimia nervosa.

Anorexia nervosa

Anorexia nervosa is a condition of self-imposed starvation that eventually leads to a body weight at least 15 percent below the expected level for an individual’s age and height. It is characterized by an extreme fear of gaining weight and a striking disturbance of body image; the anorexic who appears grossly emaciated will look in the mirror and see herself as overweight. This distorted perception typically is stubbornly resistant to feedback from families, friends, and health professionals, even in the face of serious physical and medical consequences.

As more weight is lost, the fear of gaining weight intensifies rather than diminishes, leading to nonstop preoccupation with eating and weight. Behaviors that are called obsessive-compulsive often attend this disorder. What little food is eaten will usually be derived only from “safe” low-calorie sources, often measured out in precise quantities and then consumed in an exacting, almost ritualistic manner. Food might be cut into tiny pieces and then arranged and rearranged on the plate to give the impression that some of it has been eaten. Anorexics may obsess over the number of calories they consume from medication or even from licking a postage stamp. Often they carefully monitor body measurements such as upper arm circumference. The fervor with which calories e restricted is frequently applied to burning them as well, and an anorexic individual might exercise vigorously for hours every day. Other efforts to rid the body of calories may include “purging” behaviors, such as self-induced vomiting, which are seen more commonly in bulimia nervosa (see below).

It should come as no surprise that medical consequences, most arising from body’s attempt to conserve energy, become more serious as starvation and weight loss continue. With loss of fat and circulating estrogen, the intricate hormonal interplay of a woman’s monthly cycle shuts down. (The absence of three consecutive menstrual periods is one of the diagnostic criteria for anorexia nervosa.) This, combined with an ongoing inadequate intake of nutrients and calcium, leads to loss of bone density, which can cause stress fractures, especially in the presence of intense exercise.

Starvation leads to reduced capacity of the stomach, delays in its emptying of food, and constipation, all of which may be falsely interpreted by the anorexic as gaining weight. Dry skin, thinning of the scalp hair, and development of a fine hair growth on the body called lanugo typically occur. Loss of fat stores and metabolic energy conservation lead to a lower body temperature, often causing the anorexic individual to wear more layers of clothing to keep warm. More serious complications arise from the heart, which typically slows its contraction rate and decreases in size in response to efforts to conserve energy. Heart rhythm might become irregular, sometimes to a degree that is life-threatening, especially in the presence of purging behavior, which depletes the body of potassium.

For all these reasons, anorexia nervosa should be considered a very serious condition with lethal risks. Between 5 and 20 percent of anorexics die from starvation, cardiac arrest, or suicide. (The higher death rates are observed among those with a long duration of anorexia, more severe weight loss, poor family support, and multiple relapses despite treatment.)

Bulimia nervosa

Bulimia nervosa is characterized by behavior known as hinging and purging, which may continue for decades. During a binge, an individual quickly consumes an enormous amount of food containing many thousands of calories, often without even chewing or tasting it. The resulting physical and emotional discomfort will then provoke a purge, usually involving self-induced vomiting. Bulimics often use laxatives and diuretics (so-called water pills, medications that increase urine output)—sometimes in dangerous quantities—in a misguided belief that the medications will somehow help rid the body of the food that isn’t lost through vomiting. The binging and purging cycles may occur a few times a week or, in severe cases, several times daily.

Bulimia is much more common than anorexia, but it frequently goes undetected because most episodes take place in secret and typically do not lead to significant weight loss. (However, some individuals with anorexia may engage in binge-and-purge behaviors.) Nevertheless, bulimia can have many serious medical consequences. The repeated exposure of teeth to stomach acid (during vomiting) can erode enamel, cause a yellowish discoloration, and lead to decay. The throat and esophagus might become chronically inflamed, and the salivary glands—especially the parotid glands that lie directly in front of the ears—can become enlarged in response to continuing episodes of vomiting. Repeated use of laxatives can lead to severe constipation, while heavy diuretic use may have an adverse effect on kidney function.

Potentially dangerous disturbances in heart rhythm can arise from the repeated loss of potassium from vomiting, as well as from excessive ingestion of diuretics and laxatives. Other equally serious (but fortunately uncommon) events include bleeding and even rupture of the esophagus or stomach from frequent vomiting. Food aspirated into the airway during vomiting can cause choking or pneumonia.

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