Disordered Eating: Anorexia Nervosa, Bulimia, and Pica

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E S U DisorderedM O O G Eating:R N S I S N AnorexiaA R L A C Nervosa, E R L O E Bulimia, and E G L A A Pica G S N E R O C F F T O O Y N T ± R E Y P L Nutrition OScoreboardN O R TRUE FALSE 1 The United StatesP has one of the world’s highest rates of anorexia nervosa.W 2 Eating disorders resultE from psychological, and not biological, causes. I V 3 People in manyE different cultures may consume clay, dirt, and other nonfood substances. R R O on next page Answers F Brown_U11_1-16.qxd 5/21/04 10:43 AM Page 2

E S U Answers to Nutrition Scoreboard [ KEY CONCEPTS AND FACTS ] M TRUE FALSE 1 Anorexia nervosa is most common in the UnitedO ✔ • Anorexia nervosa, bulimia to the value placed on States and other Westernized countries. ItO is rarely nervosa (bulimia), binge- thinness by that society. observed in developing, non-Westernized nations.1 eating disorder, and pica are • An important route to the G R four specific eating disor- prevention of anorexia 2 The cause (or causes) of eating disordersS is not yet ✔ ders. They may seriously N nervosa and bulimia is to known. Both psychologicalI and biologicalS factors threaten health. change a society’s cultural may play a role. N A • Eating disorders are much ideal of thinness and to more common in females eliminate biases against 3 Although not recommendedR L for health reasons, peo- ✔ than males. people (especially women) ple in many Adifferent culturesC practice pica—the who are not thin. regular ingestion of nonfood items such as clay • The incidence of eating dis- and dirt. E R orders in a society is related L O E E G L A A The EatingG Disorders S N R Three square mealsE a day, an occasional snack or missed meal, and caloric intakes that average outC to matchO the body’s need for calories—this set of practices is con- sidered “orderly” eating. F Self-imposed semi-starvation, feast and famine cycles, purging binge eating,F purging, and the regular consumption of nonfood substances such as T The use of self-induced vomit- paint chipsO and clay—these behaviors are symptoms of disordered eating. ing, laxatives, or diuretics Four specificO types of disordered eating patterns are officially recognized as eat- (water pills) to prevent ing disorders and have been assigned diagnostic criteria. They are (1) anorexia ner- Y N 2 weight gain. vosa,T (2) bulimia nervosa, (3) binge-eating disorder, and (4) pica. Other forms of disordered ±eating such as compulsive overeating, restrained eating, and food preoc- Rcupation have been observed, but too little research exists to establish criteria for Ediagnosis.Y P L O AnorexiaN Nervosa R O It’s about 9:30 on a Tuesday night. You’re at the grocery store picking up sandwich fixings and some milk. Although your grocery list contains only P four items, you arrive at the checkout line with a half-filled cart. The woman W in front of you has only five items: a bag with about 10 green beans, an E apple, a bagel, a green pepper, and a 4-ounce carton of nonfat yogurt. As she I carefully places each item into her shopping bag, you notice that she is V dreadfully thin. E The woman is Alison. She has just spent half an hour selecting the food R she will eat tomorrow. Alison knows a lot about the caloric value of foods and makes only low-calorie choices. Otherwise, she will never get rid of her R excess fat. To Alison, weight is everything—she cannot see the skeleton-like appearance others see when they look at her. O As a child, Alison enjoyed little independence. Decisions about her life F were made for her, a situation that contributed to her low self-esteem. Dur- ing her teen years, Alison was overweight and clearly remembers the painful Brown_U11_1-16.qxd 5/21/04 10:43 AM Page 3

E S Illustration 11.1 U A day’s diet? For a person with anorexia nervosa, it was. The

Richard Anderson foods shown Mprovide approxi- mately 562O calories. O G R N S I S N A R L A C E R L anorexia nervosa O An eating disorder character- E ized by extreme weight loss, E poor body image, and irra- teasing and ridicule she had to endure. Now Alison isG on her own, away L tional fears of weight gain and from home and in control in an out-of-control way. A obesity. You didn’t know this about Alison when you saw her. ThereA is much more to anorexia nervosa than meets the eye. G S N R Individuals with anorexia nervosa starve themselvesE (Illustra- tion 11.1). They can never be too thin—no matter howO emaci- ated they may be. As shown in Illustration C11.2, peopleF with anorexia nervosa look extraordinarily Fthin from the neck

down. The face and the rest of the head usuallyT look normal PhotoEdit, Felicia Martinez O because the head is the last part of the body toO be affected by starvation. Y Instead of the normal amount of body N fat (20–25% of body weight), people with anorexiaT nervosa± have little fat (7–13% of body weight).3 TheyR become cold easily and have unusually low heart rates Eand sometimesY an irregular heart- beat, dry skin, low blood pressure,L absent or irregular men- strual cycles, infertility, Pand poor pregnancy outcomes (Table 11.1).4 ApproximatelyO 9 in 10 Nwomen with anorexia nervosa have significant bone loss, andO 38% have osteoporosis. The extent of bone lossR correlates strongly with undernutrition: the lower the body weight,P the lower the bone density. Improving calcium and vitamin D Wintakes and use of bone-density drugs have limited effectivenessE in rebuilding bones in females with current or past anorexiaI nervosa.5 V The Female AthleteE Triad] Pediatricians, nutritionists, and coaches are beginning to be on the lookout for eating disor- ders, menstrual R cycle dysfunction, and decreased bone mineral density Rin young, female athletes. Low caloric intakes and underweight related to eating disorders can lower estrogen lev- els andO disrupt menstrual cycles. The lack of estrogen Illustration 11.2 decreasesF calcium deposition in bones and reduces bone den- Eating disorders occur in males as well as females, but sity at a time when peak bone mass is accumulating. females make up approximately 95% of all cases. Brown_U11_1-16.qxd 5/21/04 10:43 AM Page 4

E TABLE 11.1 S FEATURES OF ANOREXIA NERVOSA. U Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edi- tion, Text Revision. Copyright 2000 American Psychiatric Association. M A. Essential Features O 1. Refusal to maintain body weight at or above 85% of normal weight for age and height. O 2. Intense fear of gaining weight or becoming fat, despiteG being underweight.R 3. Disturbance in the way in which body weight or Nshape is experS ienced, undue influ- ence of body weight or shape on self-evaluation,I or denialS of the seriousness of cur- rent low body weight. The average size of female N A 4. Lack of menstrual periods in teenage females and women (missing at least three con- gymnasts on the U.S. secutive periods). R L Olympic team shrank from Restricting type: Person does not regularly engage in binge-eating or purging behavior. 5 feet 3 inches tall and 105 A C pounds in 1976 to 4 feet 9 Binge-eating type: Person regularly engagesE in binge-eating or purging behavior (self-induced vomiting; laxative, diuretic, or enemaR use). inches tall and 88 pounds L O in 1992. B. Common Features in FemalesE ON THE SIDE 1. Low-calorie diet, extensive exercise,E low body fat 2. Soft, thick facial hair, Gthinning scalp hair

Photo Disc L 3. Loss of heart muscle,A irregular,A slow heartbeat 4. Low blood pressureG S 5. Increased susceptibility to infection 6. Anemia N E R 7. Constipation O 8. Low bodyC temperatureF (hypothermia) 9. DryF skin 10. Depression T 11.O History of physical or sexual abuse O Y12. Low estrogen levels 13. Low Nbone density T 14. Infertility,± poor pregnancy outcome R E C. CommonY Features in Males L1. Most of the common features in females P 2. Substance abuse O N 3. Mood and other mental disorders R O P W Irregular or absent menstrual cycles used to be thought of as “no big deal.” E That attitude has changed, however, due to research results indicating that abnor- I mal cycles in young females are related to delayed healing of bone and connective V tissue injuries, and to bone fractures and osteoporosis later in life.6 E Motivations Underlying Anorexia Nervosa] The overwhelming desire to R become and remain thin drives people with anorexia nervosa to refuse to eat, even R when ravenously hungry, and to exercise intensely. Half of the people with anorexia binge eating turn to binge eating and purging—features of bulimia nervosa—in their efforts to The consumptionO of a large lose weight.7 Preoccupied with food, people with anorexia may prepare wonderful amountF of food in a small meals for others, but eat very little of the food themselves. Family members and amount of time. friends, distressed by their failure to persuade the person with anorexia to eat, Brown_U11_1-16.qxd 5/21/04 10:43 AM Page 5

E S Illustration 11.3 U There is a need for a more

Richard Anderson realisticM body shape on televisionO and in fashion magazines. —VivienneO Nathanson, British G R physician, 2000 N S I S N A R L A C E R L O E E G L A A G S report high levels of anxiety. Although adults oftenN describeR people with anorexia as “model students” or “ideal children,” their Epersonal lives are usually marred by low self-esteem, social isolation, and unhappiness.C 8 O TABLE 11.2 F RISK GROUPS FOR What Causes Anorexia Nervosa?] TheF cause of anorexia nervosa isn’t yet clear. ANOREXIA NERVOSA.13 It is likely that many different conditions, both Tpsychological and biological, pre- O 9 dispose an individual to become totally dedicatedO to extreme thinness. The value • Dieters that Western societies place on femaleY thinness,N the need to conform to society’s • Ballet dancers expectations of acceptable bodyT weight and shape, low self-esteem, and a need to • Competitive athletes control some aspect of one’s life completely ± are commonly offered as potential (gymnasts, figure causes for this disorder (IllustrationR 11.3).10 skaters) E Y • Fitness instructors How Common Is AnorexiaP Nervosa?]L It is estimated that 1% of adolescent and young women in the Western world and less than 0.1% of young males have • Dietetics majors anorexia nervosa. TheO disorderN has been reported in girls as young as 5 and in • People with type 1 women through theirR forties; O11 however, it usually begins during adolescence. It is (insulin dependent) estimated that oneP in ten females between the ages of 16 and 25 has “subclinical” diabetes anorexia nervosa, or exhibitsW some of the symptoms of the disorder.12 Certain groups ofE people are at higher risk of developing anorexia nervosa than others (Table 11.2). IPeople at risk come from all segments of society, but tend to be overly concerned about their weight and food, and have attempted weight loss from an early age.14 V E Treatment]R There is no “magic bullet” treatment that cures anorexia nervosa quickly and completely. In all but the least severe cases, the disorder generally takes a good dealR of time and professional help to correct. Treating the disorder is often difficult because few people with anorexia believe their weight needs to be increased.O 15 FTreatment programs for anorexia nervosa generally focus on restoring nutri- tional health and body weight, psychological counseling to improve self-esteem and Brown_U11_1-16.qxd 5/21/04 10:43 AM Page 6

E S attitudes about body weight and shape, antidepressant or other medications,U family therapy, and normalizing eating and exercise behaviors. These programs are suc- cessful in 50% of people, and partially successful in most other cases.16 One-third of people with full recovery from anorexia nervosa will relapse withinM 7 years or less. By 8 years after diagnosis, 3% of people with anorexia nervosaO will have died from the disorder, and it claims the lives of 18% 33 years later. Results of treatment are often excellent when the disorder is treated early.17 Unfortunately,O many people with the condition deny that problems exist and postponeG treatmR ent for years. Ini- tiation of treatment is often prompted by a relative,N coach,S or friend.18 I S Bulimia Nervosa N A Finally home alone, Lisa heads to the Rpantry andL then to the freezer. She has carefully controlled her eating for theA last day C and a half and is ready to eat everything in sight. E It’s a bittersweet time for her. Lisa knowsR the eating binge she is preparing L will be pleasurable, but that she’ll hateO herself afterward. Her stomach will ache from the volume of foodE she’ll consume, she’ll feel enormous guilt from losing control, and she’ll be horrifiedE that she may gain weight and will have to starve herself all overG again. LisaL is so preoccupied with her weight and body shape that she doesn’tA see the connection between her severe dieting and her bouts of uncontrolledA eating. To get rid of all the food she is about to eat, she will do Gwhat she S has done several times a week for the last year. Lisa avoids the Nhorrible Rfeelings that come after a binge by “tossing” every- thing she ate Eas soon as she can. In just 10C minutes,O Lisa devours 10 peanut butter cups (the regular size), a 12-ounce bag of chocolateF chip cookies, and a quart of mint chocolate chip ice cream.F Before 5 more minutes have passed Lisa will have emptied her stomach, takenT a few deep breaths, thrown on her shorts, and started the O 5-mile routeO she jogs most days. As she jogs, she obsesses about getting her 138-pound,Y 5-foot 5-inch frame down to 115 pounds. She will fast tomor- row and seeN what news the bathroom scale brings. T ± bulimia nervosa RLisa is not alone. Bulimia nervosa occurs in 1 to 3% of young women and in about An eating disorder character- E0.5% ofY young males in the United States.19 The disorder is characterized by regu- ized by recurrent episodes of lar episodesL of dieting, binge eating, and attempts to prevent weight gain by purg- rapid, uncontrolled eating of P ing; use of laxatives, diuretics, or enemas; dieting; and sometimes exercise. In most large amounts of food in aO cases,N bulimia nervosa starts with voluntary dieting to lose weight. At some point, short period of time. EpisodesR Ovoluntary control over dieting is lost, and people feel compelled to engage in binge of binge eating are often fol- eating and vomiting.20 The behaviors become cyclic: food binges are followed by lowed by purging. P guilt, purging, and dieting. Dieting leads to a feeling of deprivation and intense W hunger, which leads to binge eating, and so on. Once a food binge starts, it is hard E to stop. I Table 11.3 lists the features of bulimia nervosa. Approximately 86% of people V with this condition vomit to prevent weight gain and avoid postbinge anguish. A E smaller proportion of people use laxatives, diuretics (water pills), or enemas alone R or in combination with vomiting.22 Laxatives, enemas, and diuretics do not prevent weight gain, however, and their regular use can be harmful. The habitual use of lax- R atives and enemas causes “laxative dependency”—these products become necessary for bowel movements. Diuretics can cause illnesses by depleting the body of water O and certain minerals and disturbing its fluid balance.23 F The lives of people with bulimia nervosa are usually dominated by conflicts about eating and weight. Some affected individuals are so preoccupied with food Brown_U11_1-16.qxd 5/21/04 10:43 AM Page 7

E TABLE 11.3 S U FEATURES OF BULIMIA NERVOSA.21 Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edi- tion, Text Revision. Copyright 2000 American Psychiatric Association. M A. Essential Features O 1. Recurrent episodes of binge eating. An episode of binge eating is characterized by both of the following: O a. Eating an amount of food within a two-hour period of time that is definitely G R larger than most people would eat in a similar amount of time and under similarN S circumstances. I S b. A sense of lack of control over eating during the episode; a feeling that one can- not stop eating or control what or how much one is eating. N A 2. Recurrent inappropriate compensatory behavior in order to prevent weightR gain, such L as self-induced vomiting; misuse of laxatives, diuretics, enemas, or otherA medications; C fasting; or excessive exercise. E 3. The binge eating and inappropriate compensatory behaviors both occur, on average,R L at least twice a week for 3 months. O 4. Self-evaluation is unduly influenced by body weight and shapeE. 5. The disturbance does not occur exclusively during episodes of anorexia Enervosa. Purging type: The person regularly engages in self-induced vomitingG orL the misuse of laxatives, diuretics, or enemas. A A Nonpurging type: The person regularly engages in fastingG or excessive exercise but does not regularly engage in self-induced vomiting or the misuse Sof laxatives, diuretics, or enemas. N E R B. Common Features C O 1. Weakness, irritability F 2. Abdominal pain, constipation, bloatingF T 3. Dental decay, tooth erosion O 4. Swollen cheeks and neck O 5. Binge on high-calorie foods Y N 6. Eat in secret T ± 7. Normal weight or overweightR 8. Guilt and depression Y 9. Substance abuse E 10. Dehydration P L 11. Impaired fertilityO N 12. History of Rsexual abuse O P W that they spend days Esecuring food, bingeing, and purging. Others experience only occasional episodes Iof binge eating, purging, and fasting.24 Unlike those Vwith anorexia nervosa, people with bulimia usually are not under- weight or emaciated.E They tend to be normal weight or overweight.25 Like anorexia nervosa, bulimia nervosa is more common among athletes (including gymnasts, weight lifters, R wrestlers, jockeys, figure skaters, physical trainers, and distance run- ners) andR ballet dancers than in other groups.26 Bulimia nervosa leads to major changes in metabolism. The body must con- stantlyO adjust to feast and famine cycles and mineral and fluid losses. Salivary glands becomeF enlarged, and teeth may erode due to frequent vomiting of highly acidic foods from the stomach.27 Brown_U11_1-16.qxd 5/21/04 10:43 AM Page 8

E S Is the Cause of Bulimia Nervosa Known?] U “Do you follow a special diet?” asks the dietitian at the eating disorder clinic. M “Yes,” answers the client with bulimia. “Feast or famine.” O The cause of bulimia nervosa is not known with certainty, but the scientific finger is pointing at depression, abnormal mechanisms for regulatingO food intake, and restrained eating feast-and-famine cycles as possible causes.28 FastsG and restrainedR eating may The purposeful restriction of prompt feelings of deprivation and hunger that mayN trigger Sbinge eating.29 The ideal food intake below desired thinness may become more and more difficult Ito achieveS as the feast-and-famine amounts in order to control cycles continue. N body weight. A Treatment] The cornerstone of bulimia RtreatmentL is nutrition and psychological binge-eating disorder counseling to break the feast-and-famine cycles. Replacing the disordered pattern of An eating disorder character- A C eating with regular meals and snacks often reduces the urge to binge and the need ized by periodic binge eating, to purge. Psychological counseling aimedE at improving self-esteem and attitudes which normally is not followed R toward body weight and shape goesL hand in hand with nutrition counseling. In by vomiting or the use of laxa- many cases, antidepressants are a useful componentO of treatment.30 The full recov- tives. People must experience ery of women with bulimia nervosaE is higher than that for anorexia nervosa. Nearly eating binges twice a week on E all women with bulimia achieve partial recovery, but one-third will relapse into average over a period of 6 G bingeing and purging within 7 years.L31 Bulimia nervosa usually improves substan- months to qualify for the A tially during pregnancy; about 70%A of women with the condition will improve their diagnosis. eating habits for the sakeG of their S unborn baby.32 N Binge-EatingE DisorderR O Psychiatrists now C recognizeF an eating disorder called binge-eating disorder (Table 11.4). PeopleF with this condition tend to be overweight or obese, and one-third are male.34 Like individualsT with bulimia nervosa, people with binge-eating disorder eat several thousandO calories’ worth of food within a short period of time during a soli- tary binge, feel aO lack of control over the binges, and experience distress or depres- Y sion after the Nbinges occur. People must experience eating binges twice a week on averageT over a period of 6 months to qualify for the diagnosis. Unlike individuals with ± bulimia nervosa, however, people with binge-eating disorder don’t R vomit, use laxatives, fast, or exercise excessively in an attempt to control TABLE 11.4 E Y 35 L weight gain. FEATURES OF BINGE-EATINGP DISORDER.33 It is estimated that 9 to 30% of people in weight-control pro- N grams and 30 to 90% of obese people have binge-eating disor- 1. Rapid consumption ofO extremely large 36 amounts of food (several thousand calories) der. The condition is far less common (2 to 5%) in the general R O 37 in a short period of time population. Stress, depression, anger, anxiety, and other nega- P tive emotions appear to prompt binge-eating episodes. Prelimi- 2. Two or more such episodes of binge eating W nary evidence indicates that binge-eating disorder may be related per week over a period of 6 months E to a genetic mutation that impairs control of normal eating 3. Binge eating by oneselfI behavior.38 4. Lack of control Vover eating or an inability to stop eating during a binge E The Treatment Approach to Binge-Eating Disorder] The 5. Postbinge-eatingR feelings of self-hatred, treatment of binge-eating disorder focuses on both the disor- guilt, and depression or disgust dered eating and the underlying psychological issues.39 Persons 6. Purging,R fasting, excessive exercise, or other with this condition will often be asked to record their food compensation for high-calorie intakes not intake, indicate bingeing episodes, and note feelings, circum- presentO stances, and thoughts related to each eating event (Illustration F 11.4). This information is used to identify circumstances that prompt binge eating and practical alternative behaviors that may Brown_U11_1-16.qxd 5/21/04 10:43 AM Page 9

E S REALITY CHECK U Portion Distortion

Close to home M Photo Disc Although she hides it, you are sure your O sister has bulimia nervosa and that she is O not getting help. You are deeply con- cerned for her health and well-being, but G R don’t know what to do about it. N S Here’s what Heather and Crystal say theyI S would do: Heather: N A Crystal: I’d talk with her about Who do you think has theR L I’d spend more time with getting help. A C her to let her know better idea I love her. E R L O E ? E G L AnswersA on next pageA G S N E R prevent it. Individuals being treated for binge-eatingO disorder are usually given information about it, attend individual and C groupF therapy sessions, and receive Illustration 11.4 nutrition counseling on normal eating, Fhunger cues, and meal planning. Antide- Example of a food diary of a pressants may be part of the treatment. TreatmentT is successful in 85% of women person with binge-eating 40 O disorder. treated for binge-eating disorder. O Y Resources for Eating N T ± Disorders R Daily Food Record Information and services Erelated toY eating Date disorders are available from a variety of P L Type and amount Meal, Snack, Eating triggers sources. Services are best delivered by health Time of food and beverage Binge? (feelings, situation) care teams specializingO and experiencedN in the treatment of eatingR disorders. O Contact 7:30 am coffee, 2 cups M Hunger! with a primary Pcare physician, dietitian, or sugar 2 tsp nurse practitioner is oftenW a good start to the cornflakes, 2 cups process of identifyingE qualified health care skim milk, 1 cup teams. Reliable sourcesI of information about eating disorders, support groups, 11:30 am tuna sandwich M Bored, hungry nearby treatmentV centers, and hot lines can ice tea, 2 cups be found on Ethe Internet. (See “WWW Links” at theR end of the unit.) 7:30 pm 3 hamburgers B Stressed out, One of the most important resources for 2 large fries angry at my coach people withR an eating disorder may be a 24 oreos trusted friend or relative. This unit’s “Real- 1/2 gallon ice cream ity Check”O explores this resource in a very personalF way—by putting you in the shoes of a person whose sister has bulimia. Brown_U11_1-16.qxd 5/21/04 10:43 AM Page 10

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ANSWERS TO REALITY CHECK S U Photo Disc Close to home M Both ideas are admirable and deserve a thumbs-up. Heather’s idea is aimed directly at O helping her sister consider treatment and may O be the appropriate action to take sometimes. There is a way to talk to a relative or friend G R about your concerns for them that may help N S Heather both of you. Learn more about it from the I S Crystal information presented in Table 11.5. N A R L A C E R L Undieting: The Clash O E between Culture andE Biology G There is a saying that women underreportL their weight and men overreport their A height.A Clearly there are cultural norms at work here. —L. Cohen, 200142 G S The pressure to conformN to society’s standard of beauty and acceptability is thought to be a primary forceE underlyingR the development of eating disorders.43 Children acquire prevailing culturalO values of beauty before adolescence. As early as age 5, American children C learnF to associate negative characteristics with people who are overweight Fand positive characteristics with those who are thin.44 Standards of beauty defined by modelsT and movie and television stars often include thinness, but O O TABLEY 11.5N T HELPING A± FAMILY MEMBER OR FRIEND WITH AN EATING DISORDER. R Whether at work, home, or play, many of us experience anxiety and a sense of helplessness E whenY someone we love is living with an eating disorder. We may feel compelled to take P actionL to help, but aren’t sure what to do or how to do it. Here are some tips on how to Nexpress your concerns to a friend or relative with an eating disorder. O 1. Gather information about services for people with eating disorders to share with your R O friend or relative. P 2. Talk with your friend or relative privately when there is enough time to fully discuss the W issue. Tell them you are worried and that they may need to seek help. E 3. Encourage your friend or relative to express his or her feelings, and then listen intently. I Be accepting about the feelings that are expressed. Be ready to talk to them more about V it in the future. E 4. Do not argue with your friend or relative about whether she or he has an eating disor- der. Let your friend or relative know you heard what was said, but that you are con- R cerned that he or she may not get better without treatment. R 5. Seek emergency medical help in life-threatening situations. Only individuals with an eating disorder can make the decision to get help. Knowledge that O people who love them will be around to support them and their decision to seek treatment F may help encourage the person with an eating disorder to take action.41 Brown_U11_1-16.qxd 5/21/04 10:43 AM Page 11

E S Photo Disc U M O O G R N S I S N A R L IllustrationA 11.5 C The trend toward size acceptance. Acceptance of a realisticE standardR of body weight and shape—one that correspondsL to health and physical fitness—and respect for O Epeople of all body sizes may be the most effective measures that canE be taken to prevent anorexia nervosa, bulimia G nervosa,L and binge-eating disorder. A A G S N R the body shape portrayed as best is often unhealthfullyE thin and unattainable by many. The disparity between this ideal and Cwhat peopleO normally weigh has led to widespread discontent. Approximately 50% of normal-weightF adult women are dis- satisfied with their weight; and many diet,F binge, and purge occasionally or fast in an attempt to reach the standard of beauty set forT them.45 O A movement toward acceptance of body Osize, fashionable attire for larger peo- ple, full-size models, and a moreY realistic view of individual differences in body shapes is emerging slowly in America (Illustration N 11.5). Acceptance of a realistic standard of body weight and shape—oneT ± that corresponds to health and physical fitness—and respect for peopleR of all body sizes may be the most effective measures that can be taken to preventE anorexiaY nervosa, bulimia nervosa, and binge-eating disorder. P L O N Pica R O P When did I start eatingW clay? I know it might sound strange to you, but I started craving clayE in the summer of ’58. It was a beautiful spring morn- ing—it had just Irained. I smelled something really sweet in the breeze com- ing in my bedroom window. I went outside and knew instantly where the sweet smell wasV coming from. It was the wet clay that lies all around my house. I scoopedE some up and tasted it. That’s when and how I started my craving Rfor that sweet-smelling clay. I keep some in the fridge now because it tastes even better cold. R A most intriguing type of eating disorder, pica has been observed in chimpanzees pica (pike-eh) and inO humans in many different cultures since ancient times.46 The history and per- The regular consumption of sistenceF of pica might suggest that the practice has its rewards. Nevertheless, impor- nonfood substances such as tant health risks are associated with eating many types of nonfood substances. clay or laundry starch. Brown_U11_1-16.qxd 5/21/04 10:43 AM Page 12

E TABLE 11.6 S U CHARACTERISTICS OF PICA. A. Essential features: Regular ingestion of nonfood substances such as clay, paintM chips, laundry starch, paste, plaster, dirt, or hair. B. Other common features: Occurs primarily in young children and pregnantO women in the southern United States. O G R The characteristics of pica are summarized inN Table 11.6.S Young children and pregnant women are most likely to engage in theI practice;S for unknown reasons, it geophagia (ge-oh-phag-ah) rarely occurs in men.47 It most commonly takesN the formA of geophagia (clay or dirt Clay or dirt eating. eating), pagophagia (ice eating), amylophagiaR (laundryL starch and cornstarch eat- pagophagia (pa-go-phag-ah) ing), or plumbism (lead eating). A potpourriA of nonfoodC substances, listed in Table Ice eating. 11.7, may be consumed. Pica has a forceful calling card: E amylophagia (am-e-low- R L 48 phag-ah) Pica permits the mind no rest until it is satisfied. O Laundry starch or cornstarch It is not clear why pica exists, althoughE several theories have been proposed. eating. E G plumbism Geophagia L Lead (primarily from old paint A A flakes) eating. Some people very muchG like to eatS certain types of clay or dirt. Those who do often report that the clay or dirt tastes or smells good, quells a craving, or helps relieve nausea or an upset stomach.N The belief that certain types of clay provide relief from E R C O TABLE 11.7 F F A PARTIAL LIST OF NONFOODT SUBSTANCES REPORTED TO BE CONSUMED BY INDIVIDUALS WITH PICA.O O AnimalY droppings Coffee grounds Leaves Plaster N TBaking soda± Cornstarch Mothballs Sand R Burnt matches Crayons Nylon stockings String E CigaretteY butts Dirt Paint chips Wool P ClayL Foam rubber Paper O NCloth Hair Paste Coal Laundry starch Pebbles R O P W E I V E R R O F Photo Disc Brown_U11_1-16.qxd 5/21/04 10:43 AM Page 13

E S stomach upsets may have some validity: a component of some clays is used in nau- U sea and diarrhea medicines. There is no evidence that geophagia is motivated by a Photo Disc need for minerals found in clay or dirt, however.49 Although the reasons given for clay and dirt ingestion make the practice under- M standable, the consequences to health outweigh the benefits. Clay and dirt con- O sumption can block the intestinal tract and cause parasitic and bacterial O infections.50 The practice is also associated with iron-deficiency and sickle-cell ane- mia in some individuals.51 G R N S Pagophagia I S N A Have you ever known somebody who constantly crunches on ice? That person may have a 9-in-10 chance of being iron deficient. Regular ice eating, to the extentR of oneL or more trays of ice cubes a day, is closely associated with an iron-deficientA state.C Ice 52 eating usually stops completely when the iron deficiency is treated.E R Ice eating may be common during pregnancy. In one study ofL women from low- income households in Texas, 54% of pregnant women reported eatiOng large amounts of ice regularly. Ice eaters had poorer iron statusE than other pregnant women who did not eat ice.53 E G L Amylophagia A A G The sweet taste and crunchy texture of flaked laundry starch arSe attractive to a small number of women, especially during pregnancy. IfN the laundryR starch preferred is not available, cornstarch may be used in its place.E Laundry starch is made from unre- fined cornstarch. The taste for starch almostC always disappearsO after pregnancy.54 Laundry starch and cornstarch have the same numberF of calories per gram as do other carbohydrates (4 calories per gram).F Consequently, starch eating provides calories and may reduce the intake of nutrient-denseT foods. In addition, starch may O PhotoEdit contain contaminants because it is not intendedO for consumption. Starch eaters’ diets are generally inferior to the diets of pregnant women who don’t consume Y N 55 starch, and their infants are moreT likely to be born in poor health. ± Plumbism R E Y The consumption of lead-containingP L paint chips poses a major threat to the health of children in the United States and many other countries (Illustration 11.6). Many older homes and buildings,O especiallyN those found in substandard housing areas, are covered with lead-basedR paint O and its dried-up flakes. Children may develop lead poisoning if theyP eat the sweet-tasting paint flakes or inhale lead from contaminated dust and soil near the buildings. An estimated 1 million young children in the United W 56 States have elevated bloodE lead levels. High levels of Iexposure to lead can cause profound mental retardation and death in young children. Low levels of exposure can lead to hearing problems, growth retardation,V reduced intelligence, and poor classroom performance. Chil- dren with lead Epoisoning are more likely to fail or drop out of school than children not exposedR to lead in their environment.57 Eating disorders affect the health and well-being of over a million people in the Illustration 11.6 United States.R Although there are treatment strategies, such as counseling and the The regular consumption of removal of lead-based paints from old houses and apartments, the solution to eat- lead-based paint chips from ing disordersO lies in their prevention. With the exception of certain types of pica dis- old houses is a major cause cussedF here, the most effective way to prevent eating disorders may be to adjust our of lead poisoning in young expectations and cultural norms to reflect reality. children. Brown_U11_1-16.qxd 5/21/04 10:43 AM Page 14

E S Nutrition UP CLOSE U Eating Attitudes Test M O FOCAL POINT: Discover if your eating attitudes and behaviors are within a normal range. O G R N S Date Age Gender I S Height Present weight How long at present weight? N A Highest past weight How long ago? R L Lowest past weight How long ago? Answer the following questions using these responses: A C A = always S = sometimes U = usually R = rarelyE R O = often N = never L 1. I am terrified of being overweight. O 2. I avoid eating when I am hungry. E 3. I find myself preoccupied with food. E G 4. I have gone on eating binges where I feel that I may not be ablLe to stop. 5. I cut my food into very small pieces. A A 6. I am aware of the calorie content of the foodsG I eat. S 7. I particularly avoid foods with a high-carbohydrateN R content. 8. I feel that others would prefer that I ateE more. 9. I vomit after I have eaten. C O 10. I feel extremely guilty after eating. F F 11. I am preoccupied with a desire to be thinner.T 12. I think about burning up calories O when I exercise. 13. Other people think I am too thin. O Y N 14. I am preoccupied withT the thought of having fat on my body. 15. I take longer than other people ± to eat my meals. 16. I avoid foods withR sugar in them. 17. I eat diet foods.E Y 18. I feel that foodP controlsL my life. 19. I displayO self-controlN around food. 20. I feelR that others O pressure me to eat. 21. I giveP too much time and thought to food. 22. I feel uncomfortableW after eating sweets. 23. I engageE in dieting behavior. 24. I like myI stomach to be empty. 25. I enjoyV trying new rich foods. 26. IE have the impulse to vomit after meals. Feedback (includingR scoring) can be found at the end of Unit 11. Source: McSherry JA. Progress in the diagnosis of anorexia nervosa. Journal of the Royal Society of Health 1986;106:8–9. (Eating Attitudes Test developed by Dr. PaulR Garfinkel.) O F Brown_U11_1-16.qxd 5/21/04 10:43 AM Page 15

E Key Terms S amylophagia, page 11-12 bulimia nervosa, page 11-6 plumbism, page 11-12 U anorexia nervosa, page 11-3 geophagia, page 11-12 purging, page 11-2 M binge eating, page 11-4 pagophagia, page 11-12 restrained eating, page 11-8 binge-eating disorder, page 11-8 pica, page 11-11 O O G R www links N S www.anad.org ing treatment” to learn about components Iwww.mirror-mirror.org/eatdis.htmS This site, from the National Association of of treatment of eating disorders and loca- Subject categories allow you to select top- Anorexia Nervosa and Associated Disorders, tion of nearby care providers. N ics suchA as myths and realities of eating provides free hot line counseling, a www.edreferral.com R disorders,L where to get help, recovery, and national network of support groups, and This site includes basic information Aon eat- Clinks to other Web sites. health care referrals. ing disorders along with specific Einforma- www.hedc.org www.nedic.ca tion on treatment and recovery for men, R Harvard’s Eating Disorders Center’s site L The National Eating Disorder Info Center in pregnant women, and others with eatingO provides facts about eating disorders, Toronto provides information and resources disorders. E answers to FAQs (frequently asked ques- on eating disorders and weight preoccupa- www.naafa.org E tions), advice on how to help a friend, tion, and a telephone support line, infor- From the National AssociationG to Advance child, or self with an eating disorder, and mation on support groups, and listings of L where to find help. Fat Acceptance, Inc.,A this site is dedicated Canada-wide treatment resources. to improving the quality of lifeA for fat www.nationaleatingdisorders.org people. It takesG on policies S and practices Declare independence from a weight- related to sizeN discrimination and promotes obsessed world on this site. Click on “seek- size acceptanceE by individualsR and society. O Notes C F F 1. Lake AJ et al. Effect of Western culture tion counseling.T J Am Diet Assoc 1988; & Thera 2000;14:367–77; and Patel et on women’s attitudes to eating and per- O 88:49–51. al., eating disorders. ceptions of body shape. Int J Eat Disord 9. TamburrinoO MB, McGinnis RA. 17. Herzog DB et al., Recovery and relapse 2000;27:83–9. Y AnorexiaN nervosa: a review. Panminerva in anorexia and bulimia nervosa: a 7.5 2. American Psychiatric Association. Diag-T Med 2002;44:301–11. year follow-up study, J Am Acad Child nostic and statistical manual of mental 10.± Eating disorders (www. nimh.nih.gov); & Adol Psychiatr 1999;38:829–37; Her- disorders: DMS-IV, 4th ed., Text Revi- zog DB et al, Mortality in eating disor- R and Patel DR et al., Eating disorders, sion. Washington, DC: 2000. Y Indian J Pediatr 1998;65:487–94. ders: a descriptive study, Int J Eat E Disord 2000;28:20–6; and Tamburrino 3. Mazess RB, Barden HS, Ohlrich ES. 11. Eating disorders (www. nimh.nih.gov); Skeletal and body-compositionP effects Lof and McGinnis, Anorexia nervosa: a and Feldman W, Feldman E, Goodman review. anorexia nervosa. Am OJ Clin Nutr N1990; JT, Culture versus biology: children’s 52:438–41. attitudes toward thinness and fatness, 18. Treating eating disorders, Harvard O Women’s Health Watch 1996 May:4–5; 4. Eating disorders. FactsR about eating dis- Pediatrics 1988;81:190–4. orders and the search for solutions. and When eating goes awry: an update P 12. Grinspoon, Prevalence and predictive on eating disorders, Food Insight 1997 National Institute of MentalW Health, factors for regional osteopenia. Bethesda, MD, 2001. www.nimh.nih.gov. Jan/Feb:35. E 13. Grinspoon, Prevalence and predictive 19. Eating disorders (www. nimh.nih.gov). 5. Grinspoon S et al. PrevalenceI and pre- factors for regional osteopenia; and dictive factors for regional osteopenia in Worobey J, Schoenfeld D, Eating disor- 20. Faris PL et al. Effect of decreasing affer- women with anorexiaV nervosa. Ann dered behavior in dietetics students and ent vagal activity with ondansetron on Intern Med 2000;133:790–4.E students in other majors, J Am Diet symptoms of bulimia nervosa: a ran- 6. Beals KA, Manore MM. Disorders of Assoc 1999;99:1100–2. domized, double-blind trial. Lancet R 2000;355:792–70. the female athlete triad among collegiate 14. Grinspoon, Prevalence and predictive athletes. Int J Sports Nutr Exer Metab factors for regional osteopenia. 21. APA, DMS-IV. 2002;12:281–93.R 15. APA, DMS-IV. 22. APA, DMS-IV. 7. APA, DMS-IV. O 16. Robinson PH, Recognition and treat- 23. Robinson, Recognition and treatment of 8.F Omizo SA, Oda EA. Anorexia nervosa: ment of eating disorders in primary and eating disorders. psychological considerations for nutri- secondary care, Alimentary Pharmacol 24. APA, DMS-IV. Brown_U11_1-16.qxd 5/21/04 10:43 AM Page 16

E S 25. APA, DMS-IV. 37. Hohlstein, Eating disorders program; 48. Craign FW. Observations onU cachexia 26. Edell D, Beware of personal trainers and Basdevant A et al. Prevalence of Africana or dirt-eating. Am J Med Sci with their looks, IDEA Health and Fit- binge eating disorder in different popu- 1935;17:365. ness Source. www.healthcentral.com/ lations of French women. Int J Eat Dis- 49. Johns T, Duquette M. MDetoxification drdean/ DeanFullTextTopics.cfm?ID= ord 1999;18:309–15. and mineral supplementation as func- 41044&src=n2, accessed 9/2000; and 38. Eating disorders III, disease definition; tions of geophagy. OAm J Clin Nutr When eating goes awry: an update on and Branson et al., Binge eating. 1991;53: 448–56.O eating disorders. 39. Hay PJ, Bacaltchuk J. Psychotherapy 50. APA,G DMS-IV.R 27. APA, DMS-IV. for bulimia nervosa and bingeing 51. Korman SH, Pica as a presenting symp- 28 Faris et al., Effect of decreasing affer- (Cochrane Review). In: The Cochrane Ntom in childhoodS celiac disease, Am J ent vagal activity; and Tolstoi LG. The Library, Issue 2, 2003. I Clin NutrS 1990;51:139; and Hack- role of pharmacotherapy in anorexia 40. Fairburn et al., Distinctions between N worthA SR, Williams LL. Pica for foam nervosa and bulimia. J Am Diet Assoc binge eating disorder and bulimia rubber in patients with sickle-cell dis- 1989;89:1640–6. nervosa. R ease.L South Med J 2003; 96:81–3. 29. Herzog DB, Copeland PM. Bulimia 41. Eating Disorder Referral and Informa-A 52.C Reynolds RD, Binder HJ, Miller MB, nervosa—psyche and satiety (editorial). tion Center, www.edreferral.comE and Chang WWY, Horan S, Pagophagia N Engl J Med 1988;319:716–8. Harvard’s Eating Disorders Center, R and iron deficiency anemia, Ann Intern 30. Robinson, Recognition and treatment www.hedc.org, accessed 6/03. L Med 1968;69:435–40; and Coltman of eating disorders; and Eating disor- 42. Cohen, LA, Nutrition and cancer pre- O CA Jr., Pagophagia and iron lack, E JAMA 1969;207:513–16. ders III, Disease definition, epidemiol- vention. Nutr Today 2001;36:78–9.E ogy, and natural history, www. 43. Lake et al., Effect ofG Western culture 53. Rainville AJ. Pica practices of pregnant mentalhealth.com, accessed 12/2000. on women’s attitudes. L women are associated with lower A maternal hemoglobin level at delivery. J 31. Herzog et al., Recovery and relapse in 44. Feldman et al., Culture vs. biology. anorexia and bulimia nervosa. A Am Diet Assoc 1998;98:293–6. 45. Branson et al.,G Binge eatingS as a major 32. Hohlstein LA. Eating disorders pro- 54. Edwards et al., Clay- and cornstarch- phenotype;N and Zuckerman DM, Colby eating women. gram. American Dietetic Association A, Ware NC, LayersonR JS. The preva- annual meeting, Boston, 1997 Oct 27. lence ofE bulimia among college students. 55. Edwards et al., Clay- and cornstarch- 33. APA, DMS-IV. AmC J Public HealthO 1986;76:1135–7. eating women. 34. Eating disorders (www.nimh.nih.gov). 46. Cooper M. Pica:F a survey of the histor- 56. Child health USA. Washington, DC: ical literature as well as reports from Maternal and Child Health Bureau, 35. Fairburn CG et al. Distinctions F U.S. PHS;2000. between binge eating disorder and the fields Tof veterinary medicine and O anthropology. Springfield (IL): Charles 57. Child health USA. bulimia nervosa. Arch Gen Psychiatry O 2000;57:659–65. C. Thomas; 1957. Y 47. EdwardsN CH, McDonald S, Mitchell 36. Branson R et al. Binge eating as a major phenotype of melanocortin 4 T ±JR, et al. Clay- and cornstarch-eating receptor gene mutations. N Engl J Med women. J Am Diet Assoc 1959;35: R 810–15. 2003;348:1096–103. E Y P L N NutritionO R OUP CLOSE PEating Attitudes Test W FeedbackE for Unit 11 I Never = 3 V Rarely = 2 E Sometimes = 1 R Always, usually, and often = 0 A total score under 20 points may indicate abnormal eating behavior. If you think you have an eating disor- R der, it is best to find out for sure. Careful evaluation by a qualified health professional is necessary to exclude any possible underlying medical reasons for your symptoms. Contacting a physician, nurse practi- O tioner, dietitian, or the student health center is an important first step. You may wish to show your Eating F Attitudes Test to the health professional.