Enhancing the Understanding of Eating Disorders, Treatment Options

February 21, 2023 - The National Association of Anorexia Nervosa and Associated Disorders (ANAD) estimates that 9% of the global population is affected by an eating disorder, amounting to 28.8 million people in the United States. Although eating disorders have been deemed one of the deadliest mental illnesses, there are still gaps in understanding eating disorders, risks, diagnoses, and treatment options. With the knowledge gaps in mind, many researchers have developed clinical trials to enhance understanding of eating disorders.

General Information on Eating Disorders

Eating disorders are most likely to develop in women from their teenage years to their early twenties; however, many men also suffer from eating disorders. After opioid use, resulting in opioid overdose, eating disorders are the deadliest mental illness, contributing to over 10,000 deaths each year. Many people with an eating disorder have concurrent mental health issues leading to a suicide attempt rate of 26%.

Risk Factors

According to the Mayo Clinic, multiple factors may contribute to or cause an eating disorder, including genetics, chemical imbalances, and psychological or emotional health problems.

A family history of eating disorders is linked to a higher risk of having an eating disorder; however, the exact genetic link is not understood. While data varies on the genetic associations of eating disorders, ANAD estimates that up to 78% of eating disorders can be hereditary. However, the organization notes that the link could be as low as 28%, indicating that additional research must be done to determine if there is a genetic link and how strong it is.

Additional risk factors include another concurrent mental health issue, such as anxiety, depression, or obsessive–compulsive disorder, a history of dieting or starvation, and high-stress levels.

Beyond those risk factors, race, sexuality, and gender identity may alter the probability of having an eating disorder. For example, compared to heterosexual men, gay men are 12 times as likely to report purging. Additionally, they are seven times as likely to report binging. Furthermore, among transgender youth, body dysphoria can trigger eating disorders, with over 30% stating that they use their eating disorder to modify their body in place of hormones.

Minimizing Risk

The Mayo Clinic notes that there is no way to prevent an eating disorder; however, parents and providers can help children develop healthy eating behaviors to minimize their risk. Avoiding dieting around children, creating an open dialogue about healthy eating habits, reinforcing healthy body image, and maintaining a relationship with a child’s pediatrician can help parents minimize the risk of eating disorders and manage them early if they do develop.

Diagnosis

Diagnosing an eating disorder can be difficult, as many patients do their best to hide behaviors from medical professionals and loved ones; however, physical exams, psychological evaluations, and testing for related complications can help identify an eating disorder. The gold standard uses criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Guidelines by the American Psychiatric Association (APA) suggest that a comprehensive patient assessment should include the following:

• reviewing a patient’s height and weight information
• reviewing eating and exercise patterns
• discussing weight control behaviors
• analysis of any prior eating disorder treatment
• discussing the amount of time a patient is preoccupied with thoughts about food, weight, and body shape
• addressing other psychosocial factors that contribute to or are secondary to eating disorders

Treatment

Treating eating disorders is equally complex, requiring a multidisciplinary approach in most cases. Often the care team comprises primary care providers, mental health professionals, and dieticians. One of the most extensive parts of eating disorder treatment is nutrition education, which can help patients understand and develop healthy eating habits.

Across the board, the APA recommends that “patients with an eating disorder have a documented, comprehensive, culturally appropriate, and person-centered treatment plan that incorporates medical, psychiatric, psychological, and nutritional expertise, commonly via a coordinated multidisciplinary team.”

Additional treatment includes family-based therapy and cognitive behavioral therapy. Finally, medications, while not curative, can help patients manage impulses and address other mental health issues contributing to an eating disorder.

The Mayo Clinic is currently conducting a study across its family and pediatric medicine department to gather data on how primary care-based intervention impacts adolescent eating disorders. The study hopes to identify gaps in the assessment and treatment of eating disorders and develop guidelines for treating adolescent restrictive eating disorders in the primary care setting.

Anorexia Nervosa

While there are many types of eating disorders, anorexia nervosa, bulimia nervosa, and binge-eating disorder are the most common and well-understood. The National Institute of Mental Health (NIMH) defines anorexia nervosa — commonly called anorexia — as an eating disorder associated with severe food restriction. People with anorexia nervosa often view themselves as overweight regardless of their actual weight.

The two types of anorexia are restrictive and binge–purge anorexia. Restrictive anorexia is the severe restriction of the quantity and type of food consumed, while binge–purge is characterized by restriction and periods of eating large amounts of food and then purging through vomiting, laxatives, and diuretics.

Symptoms

Many symptoms are associated with anorexia nervosa, including behavioral and physical symptoms. Behavioral symptoms include restrictive eating, emaciation, fear of weight gain, distorted body image, and an unwavering need to be thin. While many people may experience these symptoms, those with anorexia nervosa have extreme manifestations of these behaviors.

Over time, restrictive eating and binge–purge behaviors cause physiological changes as the body is not getting enough nutrients to thrive. These symptoms include osteopenia or osteoporosis, anemia, brittle nails, yellowing skin, lanugo, constipation, low blood pressure, heart damage, brain damage, lethargy, and multiorgan failure.

Treatment

The recommendations by the APA for treating anorexia nervosa include nutritional rehabilitation and weight restoration for patients who require it. Providers are urged to set weight gain goals and a target weight weekly, depending on the patient and their progress. Additional recommendations include eating disorder-focused psychotherapy and educating a caregiver when appropriate.

Current Research

Many current studies are looking to explore additional treatments for anorexia nervosa. One trial, beginning in January 2022, analyzes the use of cannabidiol in anorexia treatment for female patients between 18 and 40. The study is based on the understanding that cannabis may reduce anxiety and increase hunger in many individuals. Although this trial is still early in phase 1 and may be controversial to some, if successful, it could provide an additional tool for treating anorexia.

Another trial is focused on recruiting patients with anorexia between 18 and 45 for transcranial magnetic stimulation (TMS). Based on recent data implicating brain circuitry in anorexia, researchers hope to assess whether TMS can alter neurocircuitry and manage or alleviate disordered behaviors.

Bulimia Nervosa

Bulimia nervosa — called bulimia — is an eating disorder similar to the binge–purge subtype of anorexia, with patients eating large amounts of food and then compensating for eating through vomiting, laxatives, excessive exercise, or more.

Symptoms

Bulimia symptoms are primarily a result of forced vomiting. They include inflammation of the throat, swollen salivary glands, sensitive or decaying teeth, acid reflux disorder, dehydration, gastrointestinal pain or issues, and electrolyte imbalance.

Treatment

Bulimia treatment should also include eating disorder-focused psychotherapy and caregiver education; however, if there is little to no responsiveness to psychotherapy within six weeks of treatment, a provider may prescribe a serotonin reuptake inhibitor such as fluoxetine to adults.

Current Research

Current studies analyze incentive processing and learning in patients with bulimia using functional magnetic resonance imaging (fMRI). The goal is to assess neural differences in instrumental learning, ‘liking,’ and ‘wanting’ between patients with eating disorders and healthy controls.

Binge-Eating Disorder

Binge-eating disorder, the most common eating disorder in the US, is eating substantial amounts of food without purging or other habits associated with bulimia nervosa. These patients often consume large quantities of food in a short period, eat when they are not hungry, eat alone, or eat fast — often, binging leads to weight gain, potentially causing obesity.

Binge-eating disorder recommendations include individual or group psychotherapy. Adults may also be treated with an antidepressant or lisdexamfetamine.

Current Research

A recent study focused on analyzing the efficacy of behavioral weight loss therapy (BWL) and naltrexone bupropion (NB) for treating binge-eating disorders in obese patients. The study had four experimental groups: a placebo group, a group receiving NB, a placebo and BWL group, and a BWL and NB group. While the study has not been published yet, preliminary results reported to clinicaltrials.gov reveal that the frequency of binge eating episodes was the lowest in the group receiving BWL and NB. Data also showed that even in the absence of BWL, NB reduced binge eating episodes.

Looking Forward

The APA has identified various research needs despite the available tools for diagnosing and treating eating disorders. Among the many research avenues required for an advanced understanding of eating disorders, diagnosis, and treatment, the APA identifies the following research areas:

• developing population-based preventative interventions
• optimizing short- and long-term patient outcomes
• identifying biomarkers
• analyzing the efficacy of psychotherapy
• determining the effectiveness of medications