Eating disorders

  • Eating disorders are serious mental illnesses characterised by an unhealthy preoccupation with eating, exercise and body weight or shape. Eating disorders can lead to physical, emotional and social consequences. Eating disorders have the highest mortality (death) rate of all psychiatric illnesses.

    Eating disorders are thought to affect up to nine per cent of the population, affecting both males and females and people from all cultural backgrounds.

    It is not known why someone gets an eating disorder. There is no single cause, but many factors may contribute such as genes and the environment that the young person grows up in.

    While many young people worry about body image and will often try dieting and/or exercise to lose weight, these behaviours by themselves are very different from eating disorders.

    Types of eating disorders

    Anorexia nervosa

    Anorexia nervosa (AN) is distinguished by an obsessive drive to lose weight through food restriction and/or excessive exercise, despite the person being at a low body weight. This is due to a distorted body image where the young person thinks they are fat or overweight when they are not. This leads to intense fear about gaining weight. AN beliefs are so strong that they will make eating a healthy amount of food very difficult for the young person, leading to chronic starvation. This starvation can have serious medical consequences. 

    Atypical anorexia nervosa

    A young person with atypical anorexia nervosa has lost a significant amount of weight and has all the features of anorexia nervosa. However, they have a normal body weight or are overweight. The medical and psychological consequences of atypical anorexia nervosa are as serious as anorexia nervosa itself.

    Bulimia nervosa

    Bulimia nervosa (BN) is recognised  by recurrent episodes of binge eating (eating an abnormally large amount of food quickly) associated with a feeling of loss of control around the eating. This is then followed by behaviours to avoid gaining weight, such as vomiting (purging), laxative misuse or over-exercising. Young people with BN are also very critical of their body shape, size and weight. 

    Avoidant restrictive food intake disorder (ARFID)

    ARFID is characterised by an avoidance of eating foods. This could be due to a number of different reasons, such as:

    • concerns about the appearance/ taste /smell/ texture of the food
    • uncomfortable sensations resulting from eating
    • a past negative experience with the food
    • simply being disinterested in food.

    This avoidance may lead to a failure to gain weight, nutritional deficiencies, or significant impairment in the young person’s life. For example, they may be unable to socialise with others if food is involved.

    Signs and symptoms of eating disorders

    There are some physical and behavioural signs that someone may have an eating disorder.

    Physical signs

    • significant weight loss or rapid weight changes
    • in females, the loss or disturbance of menstrual periods
    • sensitivity to the cold – feeling cold most of the time, even in warm environments
    • lethargy, tiredness
    • dizziness, fainting
    • reduction in ability to concentrate.

    Behavioural signs

    • consistently reducing fat, calorie counting, skipping meals, fasting and avoiding certain food groups (e.g. dairy, meat or carbohydrates)
    • making excuses to avoid eating meals
    • excessive and/or compulsive exercise
    • greater preoccupation with body shape, weight and appearance than an average person
    • intense fear of gaining weight
    • distorted body image (e.g. complaining of feeling or looking fat when they are actually a healthy weight or underweight)
    • distress and/or anger at meal times
    • bathroom visits and/or showers after meals (where they will cause themselves to vomit)
    • frequent weighing of self
    • unusual eating behaviours (e.g. cutting food into tiny pieces)
    • avoiding social situations involving food 
    • obsessive interest in food and cooking but then not eating anything they cook
    • moodiness/irritability
    • social withdrawal and wanting to be alone more. 

    Treatment for eating disorders

    Eating disorders have very serious medical and psychological consequences and need both psychological and medical treatments.

    Psychological treatment

    Family based treatment (Maudsley approach)

    Family based treatment (FBT) is the treatment with the best evidence for helping a young person who has AN and atypical anorexia nervosa. There is also some evidence that FBT also works for ARFID.

    FBT is an intensive outpatient (not staying in hospital) treatment that empowers parents and encourages them to be proactive and take charge of their child's eating and behaviour. The focus is mainly on returning the young person to their healthy weight and previous physical health.

    The family works with a trained therapist and a specialist team to present a united front in their fight against the eating disorder. The young person is also medically monitored by doctors and nurses throughout FBT to ensure that they are safe to continue their treatment as an outpatient.

    Individual psychological treatment

    Cognitive behavioural therapy (CBT) is a psychological treatment that has been found to be effective for BN. CBT focuses on identifying and challenging the abnormal thoughts about food and body image that are associated with bingeing and vomiting behaviours.

    It often involves the young person monitoring their own behaviour and using strategies to reduce the amount of bingeing and purging they do. This type of treatment is generally provided in a one-on-one setting.

    Medical treatment

    Starvation can lead to problems with heart rate, blood pressure, low bone density, puberty and growth. A young person diagnosed with an eating disorder will need to attend regular medical appointments with their GP, paediatrician or clinical nurse consultant. The frequency of these appointments will vary depending on how unwell the child is.

    It is important any hospital or specialist service knows who your GP is, so the GP can be sent copies of any blood tests or treatment plans.

    Nutritional consultation by your treatment team

    The team treating your child consults with a dietitian when needed. The dietitian gives the team nutritional advice that will help them support parents/guardians to provide a healthy and balanced diet for their child.

    Hospital admissions

    Eating disorders can be so harmful to a young person's health that it is not safe for the young person to be at home. This is often referred to as being medically unstable.

    A young person is medically unstable when there are significant changes in their heart rate, blood pressure, hydration or electrolytes (salts that are essential for the normal functioning of the cells in the body). If a young person with an eating disorder is medically unstable they will be admitted to hospital until the treatment team considers them to be medically safe and there is an appropriate treatment plan in place.

    Key points to remember

    • Eating disorders are serious mental illnesses, with the highest mortality rate out of all psychiatric illnesses.
    • They include anorexia nervosa (AN), atypical anorexia nervosa, bulimia nervosa (BN) and avoidant restrictive food intake disorder (ARFID).
    • Eating disorders involve a serious and unhealthy preoccupation with eating, exercise and body weight.
    • Eating disorders require psychological treatment as a family or individual, and in severe cases hospitalisation is needed.

    For more information

    Common questions our doctors are asked

    My child has been a very picky eater since she was young. How is this different form ARFID?

    Many children and young people have preferences for foods and many will have aversions to some foods. It can sometimes be difficult to distinguish normal picky eating from ARFID. Despite their pickiness, most children are able to maintain their nutritional requirements. Individuals with ARFID do not eat enough to meet their energy and nutritional needs and their food avoidance has a significant impact on their daily lives.

    How common are eating disorders in males?

    It is thought that up to 25 per cent of eating disorders occur in males. A lack of recognition of the disorder in males may mean that this could be an underestimate. Over-exercising and the extreme pursuit of muscle growth can be a sign of the disorder.

    Can people recover from eating disorders?

    Yes, recovery is possible and early intervention is key to a successful recovery.

    Developed by The Royal Children's Hospital Centre for Adolescent Health. We acknowledge the input of RCH consumers and carers.

    Reviewed May 2021.

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