Toward an Understanding of Girls with Eating Disorders

Issue Brief A Series of Research and Policy Publications of The Schubert Center for Child Studies schubert APRIL 2011 center for child studies

Many girls and women develop harmful eating patterns during adolescence and early adulthood, with most cases of anorexia nervosa developing between ages 15 and 19 and most cases of bulimia nervosa developing between ages 20 and 24.1 Younger girls are also at risk for developing patterns of disordered eating. A recent population-based study of U.S. adolescents found that 0.3% of teens suffer from anorexia nervosa, 0.9% suffer from bulimia nervosa, and 1.6% suffer from binge eating disorder.2 More teens suffer from harmful, or disordered, eating patterns that may not meet the diagnostic criteria for an eating disorder but have negative effects on health and well-being. For example, a 2010 study found that 13.4 percent of girls ages 9 to 14 displayed disordered eating behavior.3 Although males can also develop eating disorders, females account for between 90 and 95 percent of people with eating disorders.4

In the state of Ohio in 2007, 30.1 percent of high school students and 35.7 percent of high school girls thought they were slightly or very overweight, compared to 33.8 percent and 46.2 percent in 1993.5 The same study found that 62.5 percent of Ohio female high school students were trying to lose weight. Results showed that 69.6 percent of girls reported exercising to lose weight or to keep from gaining weight, 57.7 percent reported dieting, 14.2 percent fasted, 6 percent vomited or used laxatives, and 8.1 percent used diet pills.7 On the positive side, all of these numbers have decreased since 1999.7 ISSUE BRIEF | APRIL 2011

Toward an Understanding of Girls with Eating Disorders

DEFINITIONS Causes and Consequences of Peer pressure and conflicting gender roles 10 Eating Disorders can also influence risk for eating disorders. The influence of Western media and shift- Eating Disorders ing social norms following the introduction Eating disorders have been linked to a of Western media has made disordered Disordered eating variety of other health and mental health eating a concern in non-Western contexts.11 The term “disordered eating,” while consequences, including death. Anorexia However, some protective factors such as not an official diagnostic category, is nervosa has the highest mortality rate of acceptance of a wide variety of body types often used in studies about adoles- any psychiatric disorder with up to 20 as beautiful and a high value placed on cent eating patterns to determine percent of patients dying from anorexia or rates of unhealthy eating behaviors. caring for oneself may limit the develop- related complications, although treatment Disordered eating behaviors include, ment of eating disorders among girls in can greatly reduce this number.6 All eating but are not limited to, fasting to lose these contexts and provide directions for weight, using diet products, vomiting disorders have been associated with higher preventative programs elsewhere.12 to lose weight, laxative abuse, food rates of suicidality.2 Electrolyte imbalances restriction and binge eating.8,1 caused by vomiting, depressed heart function caused by caloric restriction, and Anorexia nervosa Best Practices and Treatment cardiac complications associated with re- of Eating Disorders “Anorexia nervosa is an eating disor- feeding are major causes of eating disorder that involves an inability to stay der-related morbidity and mortality.6 Eating at the minimum body weight consid- Despite the discouragingly high levels of ered healthy for the person’s age, disorders also can cause gastrointestinal eating disorders and the severity of the height and gender. Persons with this problems, endocrine disorders, osteoporo- consequences, several effective treatment 6 disorder may have an intense fear of sis, and pulmonary system damage. Eating options for eating disorders do exist. The weight gain, even when they are disorders often occur with other psychiatric family-based treatment (FBT) model (also underweight. They may use extreme conditions such as depression, obsessive- known as the Maudsley method) has dieting, excessive exercise, or other compulsive disorder, and personality disor- methods to lose weight.”1 shown promising success in treatment of 7 ders. Disordered eating also has been found children and adolescents with anorexia Bulimia nervosa to be associated with teen cigarette use, nervosa.3 FBT allows children and teens to “Bulimia is an illness in which a person binge drinking, and marijuana and inhalant remain at home and have their treatment 8 binges on food or has regular episodes use. Unfortunately, research suggests that supervised by their parents using tradition- of significant overeating and feels a only a small minority of the people who meet al behavior modification strategies and loss of control. The affected person the criteria for an eating disorder receive with the support of health care profession- then uses various methods – such 9 any form of mental health treatment. 13 as vomiting or laxative abuse – to als. Although nearly a third of patients prevent weight gain.”1 The exact causes of eating disorders are with anorexia nervosa will relapse unknown, but research has demonstrated sometime after their first treatment, longi- Binge-eating disorder that a variety of biological, sociocultural and tudinal research that followed patients for Binge-eating disorder occurs when a environmental factors can influence the a number of years found that more than person recurrently consumes large development of eating disorders. Premature three-quarters of patients had made a full quantities of food, accompanied by birth and other perinatal complications recovery after 10 years.14 The length of time feelings of loss of control, guilt and 3 needed to achieve recovery varied, depend- shame. Binge-eating is rarely increase the risk of eating disorders. Other accompanied by excessive exercise, studies suggest that genes that regulate ing on the definition of recovery, but took fasting, or purging and as a result, serotonin may play a role in eating disorders.9 an average of about 4-6.5 years. people who suffer from binge- Additionally, the changes during puberty, Cognitive behavioral therapy is widely eating disorder are often overweight such as hormonal fluctuations, brain recognized as the most effective treatment or obese.1 changes, and changes in social affiliation, for bulimia nervosa, although most of this 3 can trigger disordered eating behavior. research has been conducted on adults and

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older adolescents. Antidepressants are Selected Additional young women may be linked to a thin sometimes used by adults with bulimia, Resources Regarding Eating body, increasing desire for thinness. especially when psychological therapy is Finally, the article explores feminist Disorders unavailable, but they may not be recom- theories of disordered eating, including mended for adolescents because of that it may be a result of increasingly The following is a list of suggested increased suicide risk.3 Dialectical restrictive standards of female beauty further reading on eating disorders. behavior therapy (DBT), an approach as women have access to more forms of These articles provide epidemiological, originally designed for use with adults success outside the home. sociocultural and clinical perspectives with borderline personality disorder, has on disordered eating, with an emphasis been successfully applied to the treat- Bacalhau, S. & Moleiro P. (2010) Eating on children and adolescents. ment of eating disorders in adults.15 This disorders in adolescents–what to look for? Acta Médica Portuguesa, 23(5), 777-784. treatment approach focuses on issues Anderson-Fye, E. and Becker, A. 2003. which may be particularly important for “Sociocultural Aspects of Eating A study from Leiria, Portugal of 22 patients with eating disorders, such as Disorders.” The Handbook of Eating adolescents on early detection of eating acceptance, relationship deficits and Disorders and Obesity, Chapter 27, pp. disorders found that doctors should give emotion-regulation. In addition, DBT has 565-589. Wiley Press. importance to symptoms such as been shown to be effective for patients weight loss, inappropriate eating This chapter provides an overview of with multiple problems, which is attitude, dissatisfaction with body various sociocultural factors regarding especially useful given the high rates of image, and psychosomatic complaints, eating pathologies and changing co-morbidity often seen in patients with even when they do not meet the criteria patterns of eating pathologies linked to eating disorders. for anorexia nervosa or bulimia nervosa. processes of modernization and Access to treatment is also a significant Westernization. The authors note Becker, A.E., Fay, K.E., Agnew-Blais, J., issue. Treatments are only effective if different patterns of eating disorders in Kahn, A.N., Striegel-Moore, R.H., & patients and their families are able to non-Western contexts, such as non-fat Gilman, S.E. (2011). Social Network afford them. Although the 2009 Mental phobic anorexia nervosa in East Asia, Media Exposure and Adolescent Eating Health Parity and Addiction Equity Act showing that diagnostic tools developed Pathology in Fiji. The British Journal of requires group health plans that offer in the West may not be effective in other Psychiatry, 198: 43-70. mental health and substance abuse contexts. Within Western nations, treatment to provide that coverage with contrary to the image of disordered Researchers from Harvard Medical no greater cost or treatment limitations eating as occurring primarily among School’s Department of Global Health than medical and surgical care, it does Caucasian females, ethnic minority and Social Medicine found that indirect not require all group health plans to groups usually have similar rates of media exposure, such as having friends offer mental health and substance eating pathologies, although recent who watch a lot of TV, had more influ- 16 abuse coverage. The severe medical immigrants show higher rates of eating ence on eating disorder symptoms than complications and the chronic nature of disorders compared to populations in direct media exposure. The study eating disorders show the importance their home countries. The article also followed adolescent girls from Fiji where of providing comprehensive treatment notes that a cultural valuation of broadcast television only became avail- coverage early in the disorder. In thinness, and the movement of this able in the mid-1990s. The findings addition to access, family support is valuation to new areas through media and suggest that interventions aimed at limit- another major consideration, particular- modernization, is often linked to disor- ing media exposure should be focused at ly as most treatments rely on signifi- dered eating patterns, although indige- the community or peer-based level, cant parent involvement to effectively nous sociocultural preference for larger rather than individuals. Also, parents treat the child. bodies may be protective against eating simply limiting their own children’s disorders. As Western media enters new screen time is not enough to protect contexts, the opportunities portrayed for children from the risk of media exposure.

3 ISSUE BRIEF | TOWARD AN UNDERSTANDING OF GIRLS WITH EATING DISORDERS | APRIL 2011

Research suggests that only a small minority of the people who meet the criteria for an eating disorder receive any form of mental health treatment.

Findlay, S., Pinzon, J., Taddeo, D., & Katzman National Institute of Mental Health. (2010). on the importance of evaluating patients D. (2010). Family-based treatment of Eating Disorders. Retrieved January 25, and managing treatment or referring children and adolescents with anorexia 2011, from http://www.nimh.nih.gov/ patients diagnosed with an eating disorder, nervosa: Guidelines for the community health/publications/eating- given rising incidence and prevalence of physician. Journal of Pediatrics and Child disorders/complete-index.shtml anorexia nervosa and bulimia nervosa. The Health, 15(1), 31-35. article provides the full DSM-IV criteria for The National Institute of Mental Health’s anorexia nervosa, bulimia nervosa, and This article gives an overview of the family- website provides an overview of the defini- eating disorders not otherwise specified, as based treatment (FBT) model, which tion of eating disorders, as well as several well as lists of tests that should be evidence suggests is the most effective different types of eating disorders, includ- performed when an eating disorder is treatment for anorexia nervosa in children ing anorexia nervosa, bulimia nervosa and suspected and possible complications of and teenagers. FBT allows young people eating disorders not otherwise specified eating disorders. The article suggests most suffering from eating disorders to remain at (EDNOS). The website also includes a cases of eating disorders can be managed home and gives parents the responsibility for variety of treatment options and areas of in outpatient care and provides recommen- ensuring adequate nutrition and weight current research regarding eating disorders. dations for nutritional rehabilitation and normalization, through direct supervision of weight gain, in addition to descriptions of all meals and snacks, exercise restriction Rome, E.S., Ammerman S., Rosen D.S., family-based therapy, day-treatment and the use of traditional behavioral modifi- Keller R.J., Lock J., Mammel K.A. et al. (2003). programs, hospital-based therapy and cation strategies. The article emphasizes Children and adolescents with eating disor- pharmacotherapy. The article also notes the value of implementing the FBT ders: the state of the art. Pediatrics, 111(1), the high rate of long-term recovery in adoles- approach through primary care physicians, 98-108. cents, although treatment may be protract- either alone or while waiting for more This article provides a review of current ed, and the low mortality rate among specialized services, if needed. literature on eating disorders in order to adolescents with anorexia nervosa determine the current state of the art, Merikangas, K.R., He, J.P., Burstein, M., compared to adults with anorexia nervosa. including pathogenesis and etiology, Swendsen, J., Avenevoli, S., Case, B., et al. prevention and screening, risk factors, Wisniewski, L. & Kelly, E. (2003). The (2011). Service utilization for lifetime nutritional issues, and various issues Application of Dialectical Behavior Therapy mental disorders in U.S. adolescents: regarding treatment and care. Of particular to Eating Disorders. Cognitive and results of the National Comorbidity Survey- note are the role of primary care physicians Behavioral Practice, 10(2), 131-138. Adolescent Supplement (NCS-A). Journal of in recognizing early symptoms of eating American Academy of Child and Adolescent Dialectical Behavior Therapy (DBT) is an disorders, a set of clinical guidelines for Psychiatry, 50(1), 32-45. approach that was originally developed to treatment based upon the severity of treat borderline personality disorder. In this The National Comorbidity Survey–Adolescent eating disorder, and the importance of article, the authors build on studies that Supplement was analyzed to study patterns insurance companies for proper eating suggest that DBT may be useful for the and correlates of lifetime mental health disorder care. treatment of eating disorders by proposing service use by severity, type and number of ways in which DBT may be applied to disorders as defined by DSM-IV. The study Rosen D.S. & the Committee on eating disorders treatment. They outline found that only 12.8% of adolescents and Adolescence. (2010). Identification and aspects of DBT which make it suitable for 17% of girls meeting the diagnostic criteria Management of Eating Disorders in patients with eating disorders and make for an eating disorder had ever received Children and Adolescents. Pediatrics, 126, recommendations for ways in which DBT disorder-specific treatment. The study also 1240-1253. can be modified to more specifically target found that sex, race/ethnicity and urban/ This article provides a review of eating some of the key components of an eating rural residence were related to likelihood of disorders for pediatricians, with an emphasis disorder diagnosis. treatment for a variety of disorders.

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Current Research on Eating The Prevention Health Research Center for the effectiveness of DBT for eating disorder Disorders at Case Western Healthy Neighborhoods at CWRU has several treatment in a range of contexts. She programs aimed at improving access to recently conducted research on DBT Reserve University healthy foods, teaching youth about nutrition telephone skills coaching for patients with Case Western Reserve University has a and promoting physical activity to reduce eating disorders, a service which provides number of current faculty members, includ- childhood obesity. Their FreshLink project after-hours support and assistance to ing many Schubert Center Faculty aims to increase access to healthy foods in patients. Findings demonstrated that the Associates, studying both eating disorders urban areas and educate residents about majority of participants called for assis- and promoting healthy eating behavior. nutrition and the benefits of healthy foods. tance with eating disorder related urges, The Prevention Health Research Center nutritional information, and self-imposed Dr. Eileen Anderson-Fye of the Department recently received a $12.5 million grant to accountability.20 Dr. Wisniewski has also of Anthropology studies body image and begin a seven-year project following 450 recently conducted an evaluation of a day mental health among high school girls in overweight and obese Cleveland Metropolitan treatment program for patients with eating Belize and socio-cultural factors contribut- School District students and examining the disorders in Cleveland.21 ing to eating disorders. Her research effectiveness of three different approaches suggests that upward mobility and intro- to reduce childhood obesity and high blood duction of Western influences results in pressure. Dr. Elaine Borawski, Dr. Leona changing body image and eating ideals,17,10 Cuttler, and Dr. Shirley Moore, are the but that cultural notions of multiple forms principal investigators. FOR MORE INFORMATION of beauty and the importance of caring for Dr. Marilyn Lotas of the Department of oneself may prevent girls from developing The Cleveland Center for Eating disordered eating patterns.12 Nursing studies obesity and hypertension Disorders provides treatment for among children in Cleveland Metropolitan eating disorders, support groups and Dr. Elaine Borawski of the Department of School District. Her study of 2000 CMSD other resources. Epidemiology and Biostatistics and the students in 4th and 7th grade found that http://www.eatingdisorderscleve- Center for Health Promotion Research has 16 percent of students were overweight, land.org studied how observed physical attractive- 26.8 percent were obese and 15.7 percent A nonprofit advocacy organization, ness influences weight preoccupation. Her were hypertensive.19 Her findings suggest The National Eating Disorders that local initiatives should focus on recent study of healthy weight girls in Association seeks to support individ- grades 8 to 12 found that Caucasian girls making healthy food cheaper and more uals and families with eating disor- who were rated by researchers as very accessible to busy parents, improving ders through advocacy, programming attractive were more likely to be trying to school lunches, and providing safe areas for and resources including a toll-free lose weight or to keep from gaining weight physical activity. A policy brief on Dr. helpline. http://www.nationaleatingdisor- than those considered least attractive.18 Lotas’s work in Cleveland schools can be ders.org However, researcher observed attractive- found on the Schubert Center website. ness was not related to preoccupation with Families Empowered and Supporting Dr. Lucene Wisniewski, Adjunct Assistant weight reduction or weight control for Treatment of Eating Disorders Professor with the Department of African-American or Hispanic girls, perhaps (F.E.A.S.T.) is an international organi- due to less narrowly defined body ideals Psychology and Co-Director of the zation of and for families and other and cultural importance of self-acceptance Cleveland Center for Eating Disorders, has caregivers supporting people living and nurturance among these communities.23 been one of the leaders in applying with eating disorders. Dialectical Behavior Therapy (DBT) to eating http://www.feast-ed.org disorders. Her current research evaluates

5 ISSUE BRIEF | APRIL 2011 | SCHUBERT CENTER FOR CHILDHOOD STUDIES

Toward an Understanding of Girls with Eating Disorders

1 Calderon R., Stoep A. V., Collett B., Garrison M. M., and Toth K. (2007). Inpatients with eating disorders: demographic, diagnostic, and service characteristics from a nationwide pediatric sample. International Journal of Eating Disorders, 40: 622-628. 2 Swanson, S., Crow, S.J., Le Grange, D., Swendsen, J., and Merikangas, K.R. (2011). Prevalence and correlates of eating disorders in adolescents. Archives of General Psychiatry, Published online first. Retrieved March 20, 2011, from http://archpsyc.ama-assn.org/cgi/reprint/ archgenpsychiatry.2011.22v1 3 Treasure J., Claudino A. M., and Zucker N. (2010). Eating disorders. Lancet, 375: 583-93. 4 Rosen D.S. & the Committee on Adolescence. (2010). Identification and management of eating disorders in children and adolescents. Pediatrics, 126: 1240-1253. 5 Ohio Department of Public Health. (2007) Ohio Youth Risk Behavior Survey. Retrieved February 22, 2011, from http://www.odh.ohio.gov/odhprograms/chss/ad_hlth/youthrsk/youthrsk1.aspx 6 Pomeroy, C. (2004). Assessment of medical status and physical factors. In Handbook of Eating Disorders and Obesity, Chapter 5, pp. 81- 111. Wiley Press. 7 Thompson, K. J. (2004). Preface. In Handbook of Eating Disorders and Obesity. pp. xii-xix. Wiley Press. 8 Pisetsky, E. M., Chao, Y. M., Dierker, L.C., May, A. M., and Striegel-Moore, R.H. (2008) Disordered eating and substance use in high-school students: Results from the Youth Risk Behavior Surveillance System. International Journal of Eating Disorders, 41: 464-470. 9 Hoek H. W. and van Hoeken D. (2003). Review of the prevalence and incidence of eating disorders. International Journal of Eating Disorders, 34: 383-396. 10 Becker, A., Keel, P., Anderson-Fye, E., and Thomas, J. (2004). “Genes (and/) or jeans?: Genetic and socio-cultural contributions to risk for eating disorders. Journal of Addictive Diseases, 23: 81-104. 11 Becker A. (2004). “Television, disordered eating, and young women in Fiji: negotiating body image and identity during rapid social change.” Culture, Medicine, and Psychiatry, 28: 533-559. 12 Anderson-Fye, E. (2004). “A Coca-Cola shape: cultural change, body image, and eating disorders in San Andrés, Belize.” Culture, Medicine, and Psychiatry, 28: 561-595. 13 Findlay, S., Pinzon, J., Taddeo, D., and Katzman, D. (2010). Family-based treatment of children and adolescents with anorexia nervosa: Guidelines for the community physician. Journal of Pediatrics and Child Health, 15: 31-35. 14 Strober, M., Freeman, R., and Morell, W. (1997). The long-term course of severe anorexia nervosa in adolescents: Survival analysis of recovery, relapse, and outcome predictors over 10-15 years in a prospective study. International Journal of Eating Disorders, 22: 339-360. 15 Wisniewski, L., and Kelly, E. (2003). The application of dialectical behavioral therapy to the treatment of eating disorders. Cognitive and Behavioral Practice, 10:131-138. 16 Mental Health Parity Watch. (2010). Understanding the Law. Retrieved February 24, 2011 from http://www.mentalhealthparitywatch.org/Understanding%20the%20Law/Pages/UnderstandingtheLaw.aspx 17 Anderson-Fye, E. and Lin, J. (2009). “Belief and behavior aspects of the EAT-26: The case of schoolgirls in Belize.” Culture, Medicine, and Psychiatry, 33: 623-638. 18 Colabianchi, N, Ievers-Landis, C., and Borawski, E. (2006). Weight preoccupation as a function of observed physical attractiveness: Ethnic differences among normal-weight adolescent females. Journal of Pediatric Psychology, 31: 803-812. 19 The Schubert Center for Child Studies. (2010). Obesity and Hypertension in Elementary-Age Children. Cleveland: The Schubert Center for Child Studies. Available at http://schubertcenter.case.edu/en-US/SYN/9558/Templates/DocumentDownloadTemplate.aspx 20 Limbrunner, H.M., Ben-Porath, D.D. and Wisniewski, L. (2011). DBT Telephone Skills Coaching with eating disordered clients: Who calls, for what reasons, and for how long? Cognitive and Behavioral Practice, 18: 186-195. 21 Ben-Porath, D.D., Wisniewski, L. and Warren, M. (2010). Outcomes of a day treatment program for eating disorders using clinical and statistical significance. Journal of Contemporary Psychotherapy, 40: 115-123.

The SCHUBERT CENTER FOR CHILD STUDIES in the College of Arts and Sciences at Case Western Reserve University bridges research, practice, policy and education for the well- being of children and adolescents. Our focus is on children from infancy through adolescence in local, national, international and global settings.

Jill E. Korbin, Ph.D. DIRECTOR | Elizabeth Short, Ph.D. ASSOCIATE DIRECTOR | Gabriella Celeste, J.D. CHILD POLICY DIRECTOR | Jessica McRitchie ASSISTANT DIRECTOR Donald Freedheim, Ph.D. FOUNDING DIRECTOR | Nadia El-Shaarawi GRADUATE ASSISTANT | Sarah Miller GRADUATE ASSISTANT | Michelle McTygue GRAPHIC DESIGNER

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