Feeding and Eating Disorders

1. 14 Feeding and Eating Disorders

2. Overview • What is peculiar about eating disorders is that they are linked to Western culture, where food is plentiful and physical appearance is highly valued • In Western society, eating disorders are the third most common illness in adolescent females

3. How Eating Patterns Develop • Normal development • Problematic eating habits and picky eating are common in early childhood • Societal norms and expectations affect girls more than boys • Beginning around age 9, girls are more anxious than boys about losing weight • Most important impact on fundamental biological processes is early parent-child relationship • Entering school comes with pressure to conform to perceptions of desirable body type

4. Developmental Risk Factors • Early eating habits, attitudes, and behaviors • Western sociocultural values and preoccupation with weight and dieting • May be internalized and expressed in children as young as age 7-10 • A constellation of physical and psychological factors are linked to early eating problems and distorted beliefs

5. Developmental Continuum of Eating Habits and Disorders

6. Transition into Adolescence • Anorexia and bulimia typically occur during adolescence • Girls place greater emphasis on self-perceptions of their physical appearance more than boys

7. Transition into Adolescence (cont’d.) • Contradictory social messages imply that women must be successful in traditional feminine and masculine roles • Changes encourage smoking and other substance use to prevent impulse to binge eat and consequences of weight gain

8. Dieting and Weight Concerns • Restrictive dieting is common in North America, even among elementary school children • Chronic dieting is associated with gender and developmental factors

9. Dieting and Weight Concerns (cont’d.) • Dieting may lead to a vicious cycle of weight loss and weight gain, overeating, and the “false hope syndrome,” as well as binge eating and subsequent purging • Many young people diet, but only a small minority develop eating disorders

10. The Binge-Purge Cycle

11. Biological Regulators • Metabolic rate • Body weight • Growth • Major hormonal determinants of physical growth rate during childhood are the growth hormone (GH) and thyroid hormone • Additional gonadal steroids kick in during adolescence to produce a further growth spurt and skeletal maturation

12. Obesity • Approximately one in six children and adolescents (aged 2-19) in North America are obese • Childhood obesity is a chronic medical condition • Is severely stigmatized in North American society and carries many social and health hazards • Significantly affects children’s psychological and physical development

13. Calculation of a Child’s BMI

14. Prevalence and Development • In U.S. and Canada, obesity rate nearly tripled for boys age 7-13 and more than doubled for girls between the early 1980s to mid-2000s • Worldwide, prevalence of childhood overweight and obesity has increased from 4.2% in 1990 to 6.7% in 2010

15. Risks • Risks include cardiovascular problems, diabetes, and elevated cholesterol and triglycerides • Obesity is a major factor in reducing life expectancy in North America • Preadolescent obesity is a risk factor in the later emergence of eating disorders

16. Prevalence of Obese Children in the U.S.

17. Culture and Socioeconomic Status • Among U.S. children and adolescents • Hispanic boys are significantly more likely to be obese than non-Hispanic White boys • Non-Hispanic black girls are significantly more likely to be obese than non-Hispanic White girls • U.S. has the highest percentage of overweight children in data comparing 15 industrialized countries

18. Culture and Socioeconomic Status (cont’d.) • Problems for low-income populations • Low cost and availability of fast food and junk food • Diminished physical activities due to living in unsafe neighborhoods

19. Causes • Heritability accounts for a substantial portion of the variance in obesity • Leptin hormone carries instructions to the brain to regulate energy and appetite • Parents determine food availability, and they model an approach to exercise and diet • Family disorganization plays a role • Poor communication, lack of perceived family support, and sexual and physical abuse

20. Treatment • Prevention or intervention of childhood obesity involves the individual’s health and family resources • Restricting diets are not usually recommended • Treatment should: • Address the parents’ knowledge of nutrition • Increase the child’s physical activity • Should instill active, less sedentary routines for both parents and child

21. Feeding and Eating Disorders • Feeding and eating disorders that occur during infancy or early childhood constitute a general diagnostic category • Avoidant/restrictive food intake disorder • Pica

22. Avoidant/Restrictive Food Intake Disorder • Characterized by a sudden or marked deceleration of weight gain and a slowing or disruption of emotional and social development prior to age 6 • Prevalence and development • Affects up to one-third of young children • Equally common among boys and girls • Many factors lead to the initial problem • There is no typical developmental outcome

23. Causes and Treatment • Many interacting risk factors influence a child’s adaptation to a certain level of caloric intake • Failure to thrive (FTT) may result from deprivation of maternal stimulation and love

24. Causes and Treatment (cont’d.) • Avoidant/restrictive food intake disorder is associated with: • Family disadvantage, poverty, unemployment, social isolation, parental mental illness, and maternal eating disorders (specific risk factor) • Treatment involves detailed assessment of feeding behavior and parent-child interactions, while allowing parents to play a role in the infant’s recovery

25. Pica • Ingestion of inedible, nonnutritive substances (e.g., hair, insects, and paint) for a period of at least one month • Affects mostly very young children and those with intellectual disability • May be life-threatening if it continues into adolescence

26. Prevalence and Development • Pica is more prevalent among institutionalized children and adults • Especially those with severe impairments and mental retardation • Affects 0.3-14.4% of children and adults with intellectual disabilities • 9-25% of those in institutions

27. Causes and Treatment • Specific causes have not been isolated • Vitamin or mineral deficiency • No evidence of genetic factors • Can be a serious and substantial problem • Risk of lead poisoning or intestinal obstruction • Treatments are based on operant conditioning procedures and teaching caregivers to keep the child’s environment tidy and removing dangerous substances

28. Eating Disorders of Adolescence • Two important periods of adolescence for eating disorders • Early passage into adolescence • Transition from later adolescence to young adulthood • Childhood risk factors (eating problems, dieting patterns, and negative body image) • May cause teens to exert excessive control over their eating as a way to manage stress and physical changes

29. Anorexia Nervosa • Characterized by refusal to maintain minimally normal body weight; intense fear of gaining weight; and significant disturbance in perception and experiences of body size • DSM-5 subtypes • Restricting type - individual loses weight through diet, fasting, or excessive exercise • Binge-eating/purging type

30. Diagnostic Criteria for Anorexia Nervosa

31. Bulimia Nervosa • Much more common than anorexia • Primary feature is recurrent binge eating • Binges are followed by compensatory behaviors (intended to prevent weight gain) in the form of two subtypes: • Purging • Non-purging

32. Diagnostic Criteria for Bulimia Nervosa

33. Diagnostic Criteria for Bulimia Nervosa (cont’d.)

34. Bulimia Nervosa (cont’d.) • Thinking is rigid and absolutistic (all or nothing attitude) • The individual either feels completely in control or completely out of control • Medical consequences are severe, but not as severe as consequences resulting from anorexia

35. Binge Eating Disorder • Similar to bulimia without the compensatory behaviors • Involves periods of eating more than other people would, accompanied by feeling of loss of control • Affects 1.5%-3% of adolescents • Has negative health correlates

36. Diagnostic Criteria for Binge Eating Disorder

37. Prevalence and Development • Prevalence of anorexia nervosa and bulimia among adolescents is 0.3% and 0.9%, respectively • Persons with anorexia are 15% or more below normal weight and engage in binge eating only occasionally • Those with bulimia are within 10% of normal weight and binge frequently; then purge to control their weight

38. Prevalence and Development (cont'd.) • Eating disorders among boys • More common than originally believed • Young men place emphasis being muscular • Sexual orientation and eating disorders • Gay men are at greater risk for behavioral symptoms of eating disorders compared to heterosexual men

39. Ethnic and Cross-Cultural Considerations • Anorexia occurs around the world, although it may manifest differently • Bulimia is a culture-bound syndrome • Arising predominately in Western regions of the world • Higher SES for women was considered a risk factor in the past • Upon reaching a certain level of affluence, the association between high SES and eating disorders may no longer exist

40. Developmental Course • Onset of anorexia is usually between ages 14 and 18 • Often begins with dieting - gradually leads to life-threatening starvation (5% mortality rate) • Fewer than one-half show full recovery; one-third show fair improvement, and one-fifth continue on a chronic course • Worse outcomes are correlated with: • Longer illness duration; bingeing and purging; and comorbid affective or anxiety disorders

41. Developmental Course (cont’d.) • Onset of bulimia is in late adolescence and young adulthood • Binge eating often develops during or after a period of restrictive dieting • May follow a chronic course or occur intermittently

42. Developmental Course (cont’d.) • Between 50-75% of patients with bulimia show full recovery over several years • Disordered eating tends to decline in early adulthood • Body dissatisfaction remains an issue for many young adults

43. Causes • Single best predictor or risk for developing an eating disorder is being an adolescent female • Biological and environmental variables are inextricably linked • Biological dimension - may contribute to the maintenance of the disorder • Genetic and constitutional factors • Eating disorders run in families

44. Causes (cont’d.) • Neurobiological factors • Imbalances of serotonin, which regulates hunger and appetite, may be implicated • Biochemical similarities have been found between people with eating disorders and those with OCD • Social dimension • Features of contemporary Western culture may be implicated in eating disorders

45. Causes (cont’d.) • Sociocultural factors • Western culture self-worth, happiness, and success are determined primarily by physical appearance • Teenage girls - weight loss and being skinny are more important than sexual issues, alcohol and drug abuse, mental health, disease, and environmental issues • Mass media influences perceptions of body dissatisfaction

46. Causes (cont’d.) • Family influences • Teen’s eating disorder may be functional • Directing attention away from basic family conflicts • Family processes may contribute to an overemphasis on weight and dietary control • Child sexual abuse may be a risk factor for eating disorders, especially bulimia • General risk factor for psychopathology, rather than specific risk factor for eating disorders

47. Causes (cont’d.) • Psychological dimension • Hilda Bruch stated that eating disorders are related to struggle for autonomy, competence, control, and self-respect • Arthur Crisp considers anorexia to be a type of phobic avoidance disorder, in which the phobic objects are normal adult body weight and shape • Mood disorder is often comorbid with anorexia

48. Psychological Dimension (cont'd.) • Bulimia is associated with: • Mood swings, poor impulse control, obsessive-compulsive behaviors, major depression, anxiety disorders, and substance abuse • Almost 90% of persons with eating disorders have other Axis I disorders • Usually depression, anxiety, or OCD

49. Psychological Dimension (cont'd.) • Discrepancy between one’s actual self and one’s ideal self increases the likelihood of eating problems, especially among women • The adolescent with bulimia or anorexia feels: • Efforts to restrict diet and lose weight are ways of gaining control over her life and of becoming a better person

50. A Dynamic Perspective on the Determinants of Eating Disorders