treatment must account for diverse population
Try to picture someone with an eating disorder and you're likely to think of an undernourished young woman, probably around college age. But while young women still account for the majority of people with eating disorders, the number of men affected is increasing. Anorexia nervosa is affecting children 10 and younger, but even seniors are susceptible to the disorder. Some people with eating disorders are extremely thin; others, such as those with binge eating disorder, may be severely overweight.
Given the scope of people affected and the range of symptoms, mental health and medical professionals need to have a broad perspective. We also need to adjust our methods of diagnosing and treating eating disorders, based on the expanding demographics of the affected population.
A mental health or medical professional with a narrow view of eating disorders can easily fail to diagnose a patient. If left untreated, eating disorders can damage the brain, liver, kidneys, heart, GI tract, bones, teeth, skin and hair. They can also lead to death. The National Institute of Mental Health (NIMH) found that females ages 15 to 24 who are diagnosed with anorexia are 12 times more likely to die than are those without anorexia.
Criteria for determining eating disorders are problematic. Weight loss remains an obvious symptom, but weight criteria are sometimes inaccurate and may lead to missed diagnoses.
Young people and men
Why are eating disorders becoming more common in young people and men? Eating diseases have always been a problem for these groups, but if we didn't suspect, we didn't diagnose. We need to have a higher index of suspicion.
Culture is a likely factor, too. We are all exposed to perfect-looking actors and models; some people become obsessed with trying to look that way. Women and girls try to emulate the advertised ideal of beauty, while men and boys seek to be muscular and perceive fat as unmanly.
Children are especially susceptible to cultural influences. They see overweight classmates being ridiculed and become convinced that they need to be thin to be popular. They also see their parents constantly dieting--so why shouldn't they?
A 10-year study by the National Association of Anorexia Nervosa and Associated Disorders (ANAD) found that 86 percent of people who develop eating disorders do so by age 20. Even more alarming, the study shows that one-third of people with eating disorders begin having them between ages 11 and 15, while 10 percent begin at 10 or younger.
The sooner treatment begins after the onset of the disease, the greater the likelihood it will succeed. So why isn't more attention being paid to eating disorders in young people? One reason is that children and young teens need to be treated differently from adults.
For adults, a group setting is useful, because patients can support one another. But if children are grouped with adults, the adults become role models and mentors; the younger patients learn tricks from the older patients to disguise their eating disorders more effectively. It also is inappropriate and potentially harmful for young patients to be exposed to adults who are discussing topics such as sexual abuse.
In addition, developmental differences and psychological maturity must be considered. Many children and young teens have difficulty understanding or expressing their feelings, so group therapy may be beyond their grasp. Individual therapy, combined creatively with play, may be more beneficial.
Finally, parents usually are heavily involved in the treatment of children and young teens. The treatment facility must have an environment where parents are comfortable participating.
Most facilities are not equipped to treat young people, which is a shame, because in some ways they are easier to treat than adults are. If patients 18 or older want to end treatment, they can. And they often do, since patients with long-term eating disorders usually are ambivalent about giving them up (the eating disorder may have become part of the person's sense of identity). By law, parents cannot interfere unless patients are incapable of making decisions for themselves and a court grants guardianship.
Conversely, if children refuse to eat, medical staff can hook them up to a feeding tube, if parents approve. Children typically have not been living with eating disorders for years, so aggressive treatment is more likely to lead to recovery.
While there has not been extensive study of eating disorders in males, ANAD estimates that 1 million men in the United States have them, compared with 7 million women. Men are less likely to seek treatment, according to a study published in the April 2001 American Journal of Psychiatry. They may regard eating disorders as diseases that only women have.
The other problem men face is that they have few options for inpatient care. Most facilities that provide inpatient care treat only women. While treatment needs are similar for men and women, it would be problematic to have a man staying on a unit where all of the other patients are women. In addition, men may seem threatening for women suffering from trauma. Inappropriate contact could create potential social or even liability issues, and could be distracting enough to endanger treatment of other patients.
Redefining weight criteria
How we define weight criteria is another key issue, not only because it affects diagnosis, but because it may have an impact on whether insurance carriers cover treatment, particularly in those who are in the early stages of a disorder.
In some parts of the country, ideal body weight (IBW) is used to determine whether a patient has an eating disorder. Several IBW formulas exist, including the Devine formula, which was developed by B.J. Devine, M.D., in 1974 for use in prescribing dosages.
The Devine formula is commonly used as a weight calculator on Internet sites, even though it skews too low in determining an appropriate weight for short women. Using the Devine formula, an IBW for a woman who is five feet tall would be just 100 pounds. Given that 75 percent of IBW is a common criterion for diagnosing eating disorders, a woman who is five feet tall and weighs 80 pounds might not be considered as having an eating disorder under the Devine formula.
A revised formula developed by J.D. Robinson, M.D., in 1983 is more accurate for women, but tends to be problematic for tall men. Many experts recommend using the Robinson formula for women and the Devine formula for men.
Better still, more medical providers are relying on body mass index (BMI), which measures weight adjusted for height. To calculate BMI, divide a person's weight by height in inches squared and then multiply by 703. A person with a BMI of 18.5 is considered underweight and a person with a BMI of 30 and above is considered obese, regardless of height or gender. A BMI between 19 and 24 is within the accepted range for optimal health.
The BMI can identify discrepancies in IBW formulas. For example, when a woman is at 75 percent of IBW using the Devine formula, the individual may have a BMI ranging from 14.68 to 16.31.
When BMI is used for admission criteria, patients are admitted when their BMI is less than 16. When it is restored to 16 or 17, patients can advance to a day or outpatient program. When the BMI exceeds 18, patients may be able to resume aerobic activities, if they can maintain progress toward their food goal.
Insurance carriers tend to be open to paying for treatment of individuals who have eating disorders based on BMI, even when the individuals might fail to qualify based on IBW. Flexibility is in everyone's best interest, because if treatment is delayed, it becomes more difficult and more expensive to treat the patient. When patients fail to meet the guidelines, they have a perverse incentive to lose weight or become medically unstable so that they can qualify for treatment.
Adjusting the way we view eating disorders is no small matter. It can help us prevent millions of Americans from either eating or starving themselves to death.
By Olivia H. Beckman, M.D.