The desire to eat is basic for most of us. That’s why it is often difficult, if not impossible, for parents and family members to understand why it is so hard for those with eating disorders to eat normally.

If patients with eating disorders could simply eat in a normal, healthy manner, they would not have eating disorders. Parents, friends, family members, and even our patients themselves often need to be reminded of this simple fact.

This does not mean that the eating problems can’t be changed -- that is what treatment is all about. It also does not excuse patients from taking responsibility to change their behaviors, sometimes with our help.

Dr. Terrill Bravender, director of adolescent medicine and associate professor of pediatrics Duke University Medical Center and medical director of the Duke Eating Disorders Program, discusses eating disorders and the treatment for them below.

Terrill Bravender, MD, MPH

Although we usually think of eating disorders as referring to anorexia nervosa and bulimia, other behaviors may also be considered eating disorders, such as binge eating, chronic dieting, over-exercising, and other food-related problems.

Adolescent girls are at the greatest risk, and are 10 times as likely as boys to develop eating disorders.

It has been estimated that at any given time 1 out of 200 teenage girls have anorexia, and 1 out of 50 teenage girls have bulimia. These numbers probably underestimate the extent of eating disorder behaviors, since they represent only those with the most severe problems.

For example, about two out of every three high school girls say they are on a diet to lose weight, and 40 percent of nine- and 10-year-old girls report being on a diet to lose weight.

Diagnosing Eating Disorders

Doctors use strict guidelines to diagnose eating disorders, and these criteria may be somewhat limiting.

Anorexia nervosa has all of the following characteristics:

• Weight loss to less than 15 percent below minimum normal for height and age
• Intense fear of gaining weight or becoming fat
• Distorted body image
• Cessation of menstrual periods

Diagnosis of bulimia has all of the following characteristics:

• Binge eating episodes, at least twice per week for three months
• Recurrent purging behaviors such as self-induced vomiting, laxative use, prolonged fasting
• Over-concern with body image and weight

Even when an individual does not fit all of the criteria for anorexia or bulimia, she may still have a problem requiring treatment. Deciding the difference between normal adolescent body concerns, and the development of very intense fears of becoming overweight can be difficult for parents and doctors alike.

Risk Factors

The causes of eating disorders are complex, and involve genetic, biological, psychological, social, and cultural issues, and each patient has her own personal reasons for the eating disorder.

Certain risk factors, other than being female, may make teens more vulnerable to eating disorders. For instance, if someone has a family member with a history of an eating disorder, or is a perfectionist, eager to please others, has difficulty resolving conflicts, or has low self esteem, she may have an increased risk for the development of an eating disorder.

Eating disorders are also more likely in young women who participate in certain activities such as gymnastics, figure skating, distance running, and ballet.

Medical Complications

There are a variety of potential medical complications that may be very serious, and parents should be alert to certain signs that may signal an eating disorder.

Teens with anorexia may feel cold easily, develop constipation, fatigue, irritability, or difficulty concentrating, and may even develop hair loss, dry skin, a low heart rate and low blood pressure. Despite these multiple health issues, they may deny that there is a problem.

Teens with bulimia may develop stomach pain or bloating, constipation, swollen cheeks, or swollen feet and ankles; they may also feel dizzy when they stand up, and may develop dental cavities.

Treatment

The best treatment for eating disorders involves a team approach. This team should include a medical doctor, a mental health provider (such as a psychologist or clinical social worker), a nutritionist and of course, the family.

Many patients will also benefit from seeing a psychiatrist, participating in group therapy, or involving a school counselor or nurse.

The Duke Eating Disorders Program particularly emphasizes the role that parents and other family members can play in our patients’ recovery process. To this end, we have developed a parent-training program to help parents learn more about eating disorders, learn to understand their children’s illnesses better, and to help them become key members of the eating disorder treatment team.

With proper treatment, most teenagers with eating disorders are able to fully recover. Recovery is not fast, though. Most patients have outpatient appointments on a weekly basis for months, and then are seen at less frequent intervals for about one year.

Prevention

The best thing that parents can do to prevent eating disorders in their children is to examine their own personal eating attitudes and behaviors.

Children are great imitators, and when young children say they are on diets to lose weight, they are usually repeating what they have heard their parents say.

Parents should try to model good eating; this includes eating a well-balanced diet, not rewarding themselves (or their children) with food, and eating meals together as a family.

More information about the Duke Eating Disorders Program and more detailed information about eating disorders is available on the program’s web site: http://eatingdisorders.mc.duke.edu/

-- Terrill Bravender, MD, MPH, is the director of adolescent medicine and associate professor of pediatrics Duke University Medical Center, and is medical director of the Duke Eating Disorders Program.

-- Dennis Clements, MD, PhD, MPH, is the chief of primary care pediatrics at Duke Children's Hospital.