Eating Disorders - Risk Factors

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• Have an inability to soothe oneself
• Have an inability to empathize with others
• Have a need for admiration
• Be hypersensitive to criticism or defeat

Accompanying Emotional Disorders

Between 40 - 96% of all eating-disordered patients experience depression and anxiety disorders. Depression, anxiety, or both is also common in families of patients with eating disorders. It is not clear if emotional disorders, particularly obsessive-compulsive disorder (OCD), cause the eating disorders, increase susceptibility to them, or share common biologic cause.

Obsessive-Compulsive Disorder (OCD). Obsessive-compulsive disorder is an anxiety disorder that occurs in up to 69% of patients with anorexia and up to 33% of patients with bulimia. In fact, some experts believe that eating disorders are variants of OCD. Obsessions are recurrent or persistent mental images, thoughts, or ideas, which may result in compulsive behaviors (repetitive, rigid, and self-prescribed routines) that are intended to prevent the manifestation of the obsession. Women with anorexia and OCD may become obsessed with exercise, dieting, and food. They often develop compulsive rituals (weighing every bit of food, cutting it into tiny pieces, or putting it into tiny containers). The presence of OCD with either anorexia or bulimia does not, however, appear to have any influence on whether a patient improves or not.

Other Anxiety Disorders. A number of other anxiety disorders have been associated with both bulimia and anorexia, including:

• Phobias. Phobias often precede the onset of the eating disorder. Social phobias, in which a person is fearful about being humiliated in public, are common in both types of eating disorders.
• Panic Disorder. Panic disorder often follows the onset of an eating disorder. It is characterized by periodic attacks of anxiety or terror (panic attacks).
• Post-Traumatic Stress Disorder. One study of 294 women with serious eating disorders reported that 74% of them recalled a traumatic event, and more than half exhibited symptoms of post-traumatic stress disorder (PTSD) -- an anxiety disorder that occurs in response to life-threatening circumstances.

Depression. Depression is common in people with eating disorders, particularly anorexia. Depression and eating disorders are also linked to a similar seasonal pattern, as indicated by the following observations:

• For many people, depression is more severe in darker winter months. Similarly, a subgroup of bulimic patients suffers from a specific form of bulimia that worsens in winter and fall. Such patients are more apt to have started bingeing at an earlier age and binge more frequently than those whose bulimia is more consistent year round.
• Onset of anorexia appears to peak in May, which is also the peak month for suicide.

Major depression is unlikely to be a cause of eating disorders, however, because treating and relieving depression rarely cures an eating disorder. The severity of the eating disorder is also not correlated with the severity of any existing depression. In addition, depression often improves after anorexic patients begin to gain weight.

Being Overweight

A 2002 study reported that among American teenagers 18% of overweight girls and 6% of overweight boys reported extreme eating disorder behaviors, including use of diet pills, laxatives, diuretics, and vomiting. Researchers are working on strategies for preventing the development of eating disorders among overweight adolescents. A 2006 study that targeted overweight college-age women reported success with an Internet-based cognitive behavioral therapy program that helped these women become more comfortable with their body weight and shape. The program also included information on the risks of eating disorders, and education on healthy eating and weight maintenance.

Body Image Disorders

Body Dysmorphic Disorder. Body dysmorphic disorder (BDD) involves a distorted view of one’s body that is caused by social, psychologic, or possibly biologic factors. It is often associated with anorexia or bulimia, but it can also occur without any eating disorder. People with this disorder commonly suffer from emotional disorders, including obsessive-compulsive disorder and depression. As part of obsessive thinking, some people with BDD may obsess about a perceived deformity in one area of their body, and may repeatedly seek cosmetic surgery to “correct” it. People with BDD are also at higher risk for suicidal thinking and attempts. Some evidence suggests that treatment with fluoxetine (Prozac), a common antidepressant known as an SSRI helps reduce this problem, even in people without an eating disorder.

Muscle Dysmorphia. Experts are also increasingly reporting a disorder in which people have distorted body images involving their muscles. It tends to occur in men who perceive themselves as being "puny,” which results in excessive body building, preoccupation with diet, and social problems. Such individuals are prone to eating disorders and other unhealthy behaviors, including the use of anabolic steroids.

Excessive Physical Activity

Highly competitive athletes are often perfectionists, a trait common among people with eating disorders.

Female Athletes and Dancers. Women in "appearance" sports, including gymnastics and figure skating, and in endurance sports, such as track and cross-country, are at particular risk for anorexia. Success in ballet also depends on the development of a wiry and extremely slim body. Estimates for episodes of eating disorders among such athletes and performers range from 15 - 60%.

Male Athletes. Male wrestlers and lightweight rowers are also at risk for excessive dieting. One-third of high school wrestlers use a method called weight-cutting for rapid weight loss. This process involves food restriction and fluid depletion by using steam rooms, saunas, laxatives, and diuretics. Although male athletes are more apt to resume normal eating patterns once competition ends, studies show that the body fat levels of many wrestlers are still well below their peers during off-season and are often as low as 3% during wrestling season. Of concern is a recently recognized body-image disorder, referred to as muscle dysmorphia, which occurs mostly in men who are preoccupied with weight lifting and who perceive themselves as puny.

Men and Women in the Military. Studies also show a higher-than-average risk for eating disorders in men and women in the military. A study of eating behavior on one Army base reported that 8% of the women had an eating disorder, compared to 1 - 3% in the civilian female population.

Vegetarianism

In general, vegetarianism, with careful planning, is a healthy practice for both adults and adolescents. Studies report, however, that vegetarianism in adolescence may be a risk factor for eating disorders in both males and females. In one study, while vegetarian teens ate more fruits and vegetables, they were also twice as likely to diet frequently, four times as likely to intensively diet, and eight times as likely to use laxatives as their non-vegetarian peers. Another study indicated that college-aged vegetarian women were significantly more likely to have eating disorder-like attitudes and behaviors than women who were not vegetarians.

These studies do not mean that being a vegetarian equates with having an eating disorder. They do suggest, however, that parents with children who suddenly become vegetarians should be sure that their children are eating a balanced meal with sufficient protein, calories, and important minerals, such as calcium. Parents also might suspect anorexic behavior in their child under certain conditions:

• If the child has stopped eating meat only to avoid fat rather than from other motives, such as love of animals or to improve health.
• If the vegetarian diet coincides with rapid weight loss.
• If the child avoids important vegetable products because of calories (such as whole grains) or because of fats and oils (such as tofu, nuts, and dairy products).

Diabetes or Other Chronic Diseases

According to one survey, 10.3% of teenage girls and 6.9% of boys with chronic illness, such as diabetes or asthma, had an eating disorder. Some recent research suggests an endocrinological link between obesity, diabetes, and eating disorders.

Diabetes. Eating disorders are particularly serious problems for people with either type 1 or type 2 diabetes.

• Binge eating (without purging) is most common in type 2 diabetes and, in fact, the obesity it causes may even trigger this diabetes in some people.
• Both bulimia and anorexia are common in type 1 diabetes. A 2005 study indicated that as many as 25% of young women with type 1 diabetes may develop abnormal eating habits, and that the combination of diabetes and an eating disorder can have serious health consequences in the women’s future. Diabetic women often omit or underuse insulin in order to control weight. If such patients develop anorexia, their extremely low weight may appear to control the diabetes for a while. Eventually, however, if they fail to take insulin and continue to lose weight, these patients develop life-threatening complications.

Click the icon to see an image of type I diabetes.

Early Puberty

There is a greater risk for eating disorders and other emotional problems for girls who undergo early puberty, when the pressures experienced by all adolescents are intensified by experiencing, possibly alone, these early physical changes, including normal increased body fat. One interesting study reported that:

• Before puberty, girls ate quantities of food appropriate to their body weight, were satisfied with their bodies, and noted their depression increased with lower food intake.
• After puberty, girls ate about three-quarters of the recommended calorie intake, had a worse body self-image, and noted their depression increased with higher food intake.

This study reported on girls without eating disorders, but it certainly suggests patterns that can lead to eating problems, particularly in girls who go through puberty early. Other studies also indicate that girls who start menstruating at a younger age are more likely to develop eating disorders.

Review Date: 12/13/2006
Reviewed By: Harvey Simon, MD, Associate Professor of Medicine, Harvard Medical School; Physician, Massachusetts General Hospital.

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