chapter 47 Weight problems and eating disorders
INTRODUCTION AND OVERVIEW
BACKGROUND
Anorexia nervosa was first described by Sir William Withey Gull in 1873, although he mistakenly assumed that the emaciated woman he discussed had no appetite. Binge eating among anorexia nervosa patients was described in 1979 and the first diagnostic criteria for bulimia nervosa was proposed in 1979. The prevalence of eating disorders is not increasing but the awareness of these problems by lay people and healthcare professionals has risen exponentially in the past 40 years. The presentation of patients can be slightly different in different cultures and appears to be changing. The emphasis on body image, with adolescent women wanting to be like skinny models and film stars, is declining. Currently the governments and public health professionals in most developed countries are attempting to educate people to try to combat the increasing incidence of obesity in all age groups of people. As a result, more adolescents presenting with eating disorders are aiming to ‘eat healthily and exercise more’, in contrast to ‘lose weight for a perfect body image’.
PREVALENCE
Current information suggests that the figures in Box 47.1 give a reasonable estimate of the prevalence of the eating disorders in women aged 13–30 years. Not all these people have sought treatment for their eating disorder and the majority are not assessed and treated by eating disorder specialists.
BOX 47.1 Prevalence of eating disorders by age 30
Anorexia nervosa: 1% (range 0.5–2%)
Bulimia nervosa: 2% (range 1–3%)
(EDNOS: eating disorder not otherwise specified; includes binge-eating disorder.)
The estimated prevalence of anorexia-nervosa-like problems is probably 3–4% and bulimia-nervosa-like 6–8%. These women are included in the EDNOS prevalence in Box 47.1. The prevalence of binge-eating disorder is thought to be 1–4%, with one in three being male, but this may not include older men and women, and may include adolescent sufferers of any or all of the other eating disorders.
AETIOLOGY
There is no consensus on why eating disorders occur. There are many explanations and these include genetic, physiological, social and psychological perspectives (Fig 47.1) and involve theories relating to childhood and adolescent development. Weight loss precedes the onset of the eating disorder. The initial weight loss may be intentional and in response to post-pubertal weight gain in women, or it may occur for other reasons such as illness or change in exercise routine.
PERPETUATING FACTORS
Factors associated with the beginnings of the eating disorder may not be those that cause it to continue for more than a brief period and possibly to become chronic (Fig 47.2). Simple examples are receiving attention from people, achieving what others cannot, being able to eat anything and not put on weight, or being a scapegoat for family problems.
All the behaviours are associated with temporary decreases in anxiety and dysphoric moods.