Eating disorder
Specialty	Psychiatry, clinical psychology
Symptoms	Abnormal eating habits that negatively affect physical or mental health[1]
Complications	Anxiety disorders, depression, substance abuse,[2] arrhythmia, heart failure and other heart problems, acid reflux (gastroesophageal reflux disease or GERD), gastrointestinal problems, low blood pressure (hypotension), organ failure and brain damage, osteoporosis and tooth damage, severe dehydration and constipation, stopped menstrual cycles (amenorrhea), infertility, stroke[3]
Types	Binge eating disorder, anorexia nervosa, bulimia nervosa, pica, rumination disorder, avoidant/restrictive food intake disorder, night eating syndrome[1]
Causes	Unclear[4]
Risk factors	Gastrointestinal disorders, history of sexual abuse, being a dancer or gymnast[5][6][7][8]
Treatment	Counseling, proper diet, normal amount of exercise, medications[2]

An eating disorder is a mental disorder defined by abnormal eating behaviors that adversely affect a person's physical or mental health.^[1] Types of eating disorders include binge eating disorder, where the patient eats a large amount in a short period of time; anorexia nervosa, where the person has an intense fear of gaining weight and restricts food or overexercises to manage this fear; bulimia nervosa, where individuals eat a large quantity (binging) then try to rid themselves of the food (purging); pica, where the patient eats non-food items; rumination syndrome, where the patient regurgitates undigested or minimally digested food; avoidant/restrictive food intake disorder (ARFID), where people have a reduced or selective food intake due to some psychological reasons; and a group of other specified feeding or eating disorders.^[1] Anxiety disorders, depression and substance abuse are common among people with eating disorders.^[2] These disorders do not include obesity.^[1] People often experience comorbidity between an eating disorder and OCD. It is estimated 20–60% of patients with an ED have a history of OCD.^[9]

The causes of eating disorders are not clear, although both biological and environmental factors appear to play a role.^[2][4] Cultural idealization of thinness is believed to contribute to some eating disorders.^[4] Individuals who have experienced sexual abuse are also more likely to develop eating disorders.^[7] Some disorders such as pica and rumination disorder occur more often in people with intellectual disabilities.^[1]

Treatment can be effective for many eating disorders.^[2] Treatment varies by disorder and may involve counseling, dietary advice, reducing excessive exercise, and the reduction of efforts to eliminate food.^[2] Medications may be used to help with some of the associated symptoms.^[2] Hospitalization may be needed in more serious cases.^[2] About 70% of people with anorexia and 50% of people with bulimia recover within five years.^[10] Only 10% of people with eating disorders receive treatment, and of those, approximately 80% do not receive the proper care. Many are sent home weeks earlier than the recommended stay and are not provided with the necessary treatment.^[11] Recovery from binge eating disorder is less clear and estimated at 20% to 60%.^[10] Both anorexia and bulimia increase the risk of death.^[10] When people experience comorbidity with an eating disorder and OCD, certain aspects of treatment can be negatively impacted. OCD can make it harder to recover from obsession over weight and shape, body dissatisfaction, and body checking.^[12] This is in part because ED cognitions serve a similar purpose to OCD obsessions and compulsions (e.g., safety behaviors as temporary relief from anxiety).^[13] Research shows OCD does not have an impact on the BMI of patients during treatment.^[12]

Estimates of the prevalence of eating disorders vary widely, reflecting differences in gender, age, and culture as well as methods used for diagnosis and measurement.^[14][15][16] In the developed world, anorexia affects about 0.4% and bulimia affects about 1.3% of young women in a given year.^[1] Binge eating disorder affects about 1.6% of women and 0.8% of men in a given year.^[1] According to one analysis, the percent of women who will have anorexia at some point in their lives may be up to 4%, or up to 2% for bulimia and binge eating disorders.^[10] Rates of eating disorders appear to be lower in less developed countries.^[17] Anorexia and bulimia occur nearly ten times more often in females than males.^[1] The typical onset of eating disorders is in late childhood to early adulthood.^[2] Rates of other eating disorders are not clear.^[1]

Classification

ICD and DSM diagnoses

These eating disorders are specified as mental disorders in standard medical manuals, including the ICD-10 and the DSM-5.

• Anorexia nervosa (AN) is the restriction of energy intake relative to requirements, leading to significantly low body weight in the context of age, sex, developmental trajectory, and physical health. It is accompanied by an intense fear of gaining weight or becoming fat, as well as a disturbance in the way one experiences and appraises their body weight or shape. There are two subtypes of AN: the restricting type, and the binge-eating/purging type. The restricting type describes presentations in which weight loss is attained through dieting, fasting, and/or excessive exercise, with an absence of binge/purge behaviors. The binge-eating/purging type describes presentations in which the individual with the condition has engaged in recurrent episodes of binge-eating and purging behavior, such as self-induced vomiting, misuse of laxatives, and diuretics.

Pubertal and post-pubertal females with anorexia often experience amenorrhea, that is the loss of menstrual periods, due to the extreme weight loss these individuals face. Although amenorrhea was a required criterion for a diagnosis of anorexia in the DSM-IV, it was dropped in the DSM-5 due to its exclusive nature, as male, post-menopause women, or individuals who do not menstruate for other reasons would fail to meet this criterion.^[18] Females with bulimia may also experience amenorrhea, although the cause is not clear.^[19]

• Bulimia nervosa (BN) is characterized by recurrent binge eating followed by compensatory behaviors such as purging (self-induced vomiting, eating to the point of vomiting, excessive use of laxatives/diuretics, or excessive exercise). Fasting may also be used as a method of purging following a binge. However, unlike anorexia nervosa, body weight is maintained at or above a minimally normal level. Severity of BN is determined by the number of episodes of inappropriate compensatory behaviors per week.
• Binge eating disorder (BED) is characterized by recurrent episodes of binge eating without use of inappropriate compensatory behaviors that are present in BN and AN binge-eating/purging subtype. Binge eating episodes are associated with eating much more rapidly than normal, eating until feeling uncomfortably full, eating large amounts of food when not feeling physically hungry, eating alone because of feeling embarrassed by how much one is eating, and/or feeling disgusted with oneself, depressed or very guilty after eating. For a BED diagnosis to be given, marked distress regarding binge eating must be present, and the binge eating must occur an average of once a week for 3 months. Severity of BED is determined by the number of binge eating episodes per week.^[1]
• Pica is the persistent eating of nonnutritive, nonfood substances in a way that is not developmentally appropriate or culturally supported. Although substances consumed vary with age and availability, paper, soap, hair, chalk, paint, and clay are among the most commonly consumed in those with a pica diagnosis. There are multiple causes for the onset of pica, including iron-deficiency anemia, malnutrition, and pregnancy, and pica often occurs in tandem with other mental health disorders associated with impaired function, such as intellectual disability, autism spectrum disorder, and schizophrenia. In order for a diagnosis of pica to be warranted, behaviors must last for at least one month.
• Rumination disorder encompasses the repeated regurgitation of food, which may be re-chewed, re-swallowed, or spit out. For this diagnosis to be warranted, behaviors must persist for at least one month, and regurgitation of food cannot be attributed to another medical condition. Additionally, rumination disorder is distinct from AN, BN, BED, and ARFID, and thus cannot occur during the course of one of these illnesses.
• Avoidant/restrictive food intake disorder (ARFID) is a feeding or eating disturbance, such as a lack of interest in eating food, avoidance based on sensory characteristics of food, or concern about aversive consequences of eating, that prevents one from meeting nutritional energy needs. It is frequently associated with weight loss, nutritional deficiency, or failure to meet growth trajectories. Notably, ARFID is distinguishable from AN and BN in that there is no evidence of a disturbance in the way in which one's body weight or shape is experienced. The disorder is not better explained by lack of available food, cultural practices, a concurrent medical condition, or another mental disorder.^[20]
• Other Specified Feeding or Eating Disorder (OSFED) is an eating or feeding disorder that does not meet full DSM-5 criteria for AN, BN, or BED. Examples of otherwise-specified eating disorders include individuals with atypical anorexia nervosa, who meet all criteria for AN except being underweight despite substantial weight loss; atypical bulimia nervosa, who meet all criteria for BN except that bulimic behaviors are less frequent or have not been ongoing for long enough; purging disorder; and night eating syndrome.^[1]
• Unspecified Feeding or Eating Disorder (USFED) describes feeding or eating disturbances that cause marked distress and impairment in important areas of functioning but that do not meet the full criteria for any of the other diagnoses. The specific reason the presentation does not meet criteria for a specified disorder is not given. For example, an USFED diagnosis may be given when there is insufficient information to make a more specific diagnosis, such as in an emergency room setting.

Other

• Compulsive overeating, which may include habitual "grazing" of food or episodes of binge eating without feelings of guilt.^[21]
• Diabulimia, which is characterized by the deliberate manipulation of insulin levels by diabetics in an effort to control their weight.
• Drunkorexia, which is commonly characterized by purposely restricting food intake in order to reserve food calories for alcoholic calories, exercising excessively in order to burn calories from drinking, and over-drinking alcohol in order to purge previously consumed food.^[22]
• Food maintenance, which is characterized by a set of aberrant eating behaviors of children in foster care.^[23]
• Night eating syndrome, which is characterized by nocturnal hyperphagia (consumption of 25% or more of the total daily calories after the evening meal) with nocturnal ingestions, insomnia, loss of morning appetite and depression.
• Nocturnal sleep-related eating disorder, which is a parasomnia characterized by eating, habitually out-of-control, while in a state of NREM sleep, with no memory of this the next morning.
• Gourmand syndrome, a rare condition occurring after damage to the frontal lobe. Individuals develop an obsessive focus on fine foods.^[24]
• Orthorexia nervosa, a term used by Steven Bratman to describe an obsession with a "pure" diet, in which a person develops an obsession with avoiding unhealthy foods to the point where it interferes with the person's life.^[25]
• Klüver-Bucy syndrome, caused by bilateral lesions of the medial temporal lobe, includes compulsive eating, hypersexuality, hyperorality, visual agnosia, and docility.
• Prader-Willi syndrome, a genetic disorder associated with insatiable appetite and morbid obesity.
• Pregorexia, which is characterized by extreme dieting and over-exercising in order to control pregnancy weight gain. Prenatal undernutrition is associated with low birth weight, coronary heart disease, type 2 diabetes, stroke, hypertension, cardiovascular disease risk, and depression.^[26]
• Muscle dysmorphia is characterized by appearance preoccupation that one's own body is too small, too skinny, insufficiently muscular, or insufficiently lean. Muscle dysmorphia affects mostly males.
• Purging disorder. Recurrent purging behavior to influence weight or shape in the absence of binge eating.^[1] It is more properly a disorder of elimination rather than eating disorder.

Symptoms and long-term effects

Symptoms and complications vary according to the nature and severity of the eating disorder:^[27]

Possible complications

acne	xerosis	amenorrhoea	tooth loss, cavities
constipation	diarrhea	water retention and/or edema	lanugo
telogen effluvium	cardiac arrest	hypokalemia	death
osteoporosis[28]	electrolyte imbalance	hyponatremia	brain atrophy[29][30]
pellagra[31]	scurvy	kidney failure	suicide[32][33][34]

Associated physical symptoms of eating disorders include weakness, fatigue, sensitivity to cold, reduced beard growth in men, reduction in waking erections, reduced libido, weight loss and growth failure.^[35]

Frequent vomiting, which may cause acid reflux or entry of acidic gastric material into the laryngoesophageal tract, can lead to unexplained hoarseness. As such, individuals who induce vomiting as part of their eating disorder, such as those with anorexia nervosa, binge eating-purging type or those with purging-type bulimia nervosa, are at risk for acid reflux.^[36]

Polycystic ovary syndrome (PCOS) is the most common endocrine disorder to affect women. Though often associated with obesity it can occur in normal weight individuals. PCOS has been associated with binge eating and bulimic behavior.^{[37][38][39][40][41][42][excessive citations]}

Other possible manifestations are dry lips,^[43] burning tongue,^[43] parotid gland swelling,^[43] and temporomandibular disorders.^[43]

Psychopathology

The psychopathology of eating disorders centers around body image disturbance,^[44] such as concerns with weight and shape; self-worth being too dependent on weight and shape; fear of gaining weight even when underweight; denial of how severe the symptoms are and a distortion in the way the body is experienced.^[35]

The main psychopathological features of anorexia were outlined in 1982 as problems in body perception, emotion processing and interpersonal relationships.^[45][46] Women with eating disorders have greater body dissatisfaction.^[47] This impairment of body perception involves vision, proprioception, interoception and tactile perception.^[48] There is an alteration in integration of signals in which body parts are experienced as dissociated from the body as a whole.^[48] Bruch once theorized that difficult early relationships were related to the cause of anorexia and how primary caregivers can contribute to the onset of the illness.^[45]

A prominent feature of bulimia is dissatisfaction with body shape.^[49] However, dissatisfaction with body shape is not of diagnostic significance as it is sometimes present in individuals with no eating disorder.^[49] This highly labile feature can fluctuate depending on changes in shape and weight, the degree of control over eating and mood.^[49] In contrast, a necessary diagnostic feature for anorexia nervosa and bulimia nervosa is having overvalued ideas about shape and weight are relatively stable and partially related to the patients' low self-esteem.^[49]

Pro-ana subculture

Pro-ana refers to the promotion of behaviors related to the eating disorder anorexia nervosa. Several websites promote eating disorders, and can provide a means for individuals to communicate in order to maintain eating disorders. Members of these websites typically feel that their eating disorder is the only aspect of a chaotic life that they can control.^[50] These websites are often interactive and have discussion boards where individuals can share strategies, ideas, and experiences, such as diet and exercise plans that achieve extremely low weights.^[51] A study comparing the personal web-blogs that were pro-eating disorder with those focused on recovery found that the pro-eating disorder blogs contained language reflecting lower cognitive processing, used a more closed-minded writing style, contained less emotional expression and fewer social references, and focused more on eating-related contents than did the recovery blogs.^[52]

Causes

There is no single cause of eating disorders.^[53]

Many people with eating disorders also have body image disturbance and a comorbid body dysmorphic disorder (BDD), leading them to an altered perception of their body.^[54][55] Studies have found that a high proportion of individuals diagnosed with body dysmorphic disorder also had some type of eating disorder, with 15% of individuals having either anorexia nervosa or bulimia nervosa.^[54] This link between body dysmorphic disorder and anorexia stems from the fact that both BDD and anorexia nervosa are characterized by a preoccupation with physical appearance and a distortion of body image.^[55]

There are also many other possibilities such as environmental, social and interpersonal issues that could promote and sustain these illnesses.^[56] Also, the media are oftentimes blamed for the rise in the incidence of eating disorders due to the fact that media images of idealized slim physical shape of people such as models and celebrities motivate or even force people to attempt to achieve slimness themselves.^[57] The media are accused of distorting reality, in the sense that people portrayed in the media are either naturally thin and thus unrepresentative of normality or unnaturally thin by forcing their bodies to look like the ideal image by putting excessive pressure on themselves to look a certain way. While past findings have described eating disorders as primarily psychological, environmental, and sociocultural, further studies have uncovered evidence that there is a genetic component.^[58]

Genetics

Numerous studies show a genetic predisposition toward eating disorders.^[59][60] Twin studies have found a slight instances of genetic variance when considering the different criterion of both anorexia nervosa and bulimia nervosa as endophenotypes contributing to the disorders as a whole.^[56] A genetic link has been found on chromosome 1 in multiple family members of an individual with anorexia nervosa.^[58] An individual who is a first degree relative of someone who has had or currently has an eating disorder is seven to twelve times more likely to have an eating disorder themselves.^[61] Twin studies also show that at least a portion of the vulnerability to develop eating disorders can be inherited, and there is evidence to show that there is a genetic locus that shows susceptibility for developing anorexia nervosa.^[61] About 50% of eating disorder cases are attributable to genetics.^[62] Other cases are due to external reasons or developmental problems.^[63] There are also other neurobiological factors at play tied to emotional reactivity and impulsivity that could lead to binging and purging behaviors.^[64]

Epigenetics mechanisms are means by which environmental effects alter gene expression via methods such as DNA methylation; these are independent of and do not alter the underlying DNA sequence. They are heritable, but also may occur throughout the lifespan, and are potentially reversible. Dysregulation of dopaminergic neurotransmission due to epigenetic mechanisms has been implicated in various eating disorders.^[65] Other candidate genes for epigenetic studies in eating disorders include leptin, pro-opiomelanocortin (POMC) and brain-derived neurotrophic factor (BDNF).^[66]

There has found to be a genetic correlation between anorexia nervosa and OCD, suggesting a strong etiology.^[13][67][68] First and second relatives of probands with OCD have a greater chance of developing anorexia nervosa as genetic relatedness increases.^[68]

Psychological

Eating disorders are classified as Axis I^[69] disorders in the Diagnostic and Statistical Manual of Mental Health Disorders (DSM-IV) published by the American Psychiatric Association. There are various other psychological issues that may factor into eating disorders, some fulfill the criteria for a separate Axis I diagnosis or a personality disorder which is coded Axis II and thus are considered comorbid to the diagnosed eating disorder. Axis II disorders are subtyped into 3 "clusters": A, B and C. The causality between personality disorders and eating disorders has yet to be fully established.^[70] Some people have a previous disorder which may increase their vulnerability to developing an eating disorder.^[71][72][73] Some develop them afterwards.^[74] The severity and type of eating disorder symptoms have been shown to affect comorbidity.^[75] There has been controversy over various editions of the DSM diagnostic criteria including the latest edition, DSM-V, published in 2013.^{[76][77][78][79][80]}

Comorbid Disorders

Axis I	Axis II
depression[81]	obsessive–compulsive personality disorder[82]
substance abuse, alcoholism[83]	borderline personality disorder[84]
anxiety disorders[85]	narcissistic personality disorder[86]
obsessive–compulsive disorder[87][88]	histrionic personality disorder[89]
Attention-deficit hyperactivity disorder[90][91][92][93]	avoidant personality disorder[94]

Cognitive attentional bias

Attentional bias may have an effect on eating disorders. Attentional bias is the preferential attention toward certain types of information in the environment while simultaneously ignoring others. Individuals with eating disorders can be thought to have schemas, knowledge structures, which are dysfunctional as they may bias judgement, thought, behaviour in a manner that is self-destructive or maladaptive.^[95] They may have developed a disordered schema which focuses on body size and eating. Thus, this information is given the highest level of importance and overvalued among other cognitive structures. Researchers have found that people who have eating disorders tend to pay more attention to stimuli related to food. For people struggling to recover from an eating disorder or addiction, this tendency to pay attention to certain signals while discounting others can make recovery that much more difficult.^[95]

Studies have utilized the Stroop task to assess the probable effect of attentional bias on eating disorders. This may involve separating food and eating words from body shape and weight words. Such studies have found that anorexic subjects were slower to colour name food related words than control subjects.^[96] Other studies have noted that individuals with eating disorders have significant attentional biases associated with eating and weight stimuli.^[97]

Personality traits

There are various childhood personality traits associated with the development of eating disorders, such as perfectionism and neuroticism.^[67][68][98] These personality traits are found to link eating disorders and OCD.^[67][68][98] During adolescence these traits may become intensified due to a variety of physiological and cultural influences such as the hormonal changes associated with puberty, stress related to the approaching demands of maturity and socio-cultural influences and perceived expectations, especially in areas that concern body image. Eating disorders have been associated with a fragile sense of self and with disordered mentalization.^[99] Many personality traits have a genetic component and are highly heritable. Maladaptive levels of certain traits may be acquired as a result of anoxic or traumatic brain injury, neurodegenerative diseases such as Parkinson's disease, neurotoxicity such as lead exposure, bacterial infection such as Lyme disease or parasitic infection such as Toxoplasma gondii as well as hormonal influences. While studies are still continuing via the use of various imaging techniques such as fMRI; these traits have been shown to originate in various regions of the brain^[100] such as the amygdala^[101][102] and the prefrontal cortex.^[103] Disorders in the prefrontal cortex and the executive functioning system have been shown to affect eating behavior.^[104][105]

Celiac disease

People with gastrointestinal disorders may be more risk of developing disordered eating practices than the general population, principally restrictive eating disturbances.^[6] An association of anorexia nervosa with celiac disease has been found.^[106] The role that gastrointestinal symptoms play in the development of eating disorders seems rather complex. Some authors report that unresolved symptoms prior to gastrointestinal disease diagnosis may create a food aversion in these persons, causing alterations to their eating patterns. Other authors report that greater symptoms throughout their diagnosis led to greater risk. It has been documented that some people with celiac disease, irritable bowel syndrome or inflammatory bowel disease who are not conscious about the importance of strictly following their diet, choose to consume their trigger foods to promote weight loss. On the other hand, individuals with good dietary management may develop anxiety, food aversion and eating disorders because of concerns around cross contamination of their foods.^[6] Some authors suggest that medical professionals should evaluate the presence of an unrecognized celiac disease in all people with eating disorder, especially if they present any gastrointestinal symptom (such as decreased appetite, abdominal pain, bloating, distension, vomiting, diarrhea or constipation), weight loss, or growth failure; and also routinely ask celiac patients about weight or body shape concerns, dieting or vomiting for weight control, to evaluate the possible presence of eating disorders,^[106] specially in women.^[107]

Environmental influences

Child maltreatment

Child abuse which encompasses physical, psychological, and sexual abuse, as well as neglect, has been shown to approximately triple the risk of an eating disorder.^[108] Sexual abuse appears to be about double the risk of bulimia; however, the association is less clear for anorexia. The risk for individuals developing eating disorders increases if the individual grew up in an invalidating environment where displays of emotions were often punished. Abuse that has also occurred in childhood produces intolerable difficult emotions that cannot be expressed in a healthy manner. Eating disorders come in as an escape coping mechanism, as a means to control and avoid overwhelming negative emotions and feelings. Those who report physical or sexual maltreatment as a child are at an increased risk of developing an eating disorder.^[108]

Social isolation

Social isolation has been shown to have a deleterious effect on an individual's physical and emotional well-being. Those that are socially isolated have a higher mortality rate in general as compared to individuals that have established social relationships. This effect on mortality is markedly increased in those with pre-existing medical or psychiatric conditions, and has been especially noted in cases of coronary heart disease. "The magnitude of risk associated with social isolation is comparable with that of cigarette smoking and other major biomedical and psychosocial risk factors." (Brummett et al.)

Social isolation can be inherently stressful, depressing and anxiety-provoking. In an attempt to ameliorate these distressful feelings an individual may engage in emotional eating in which food serves as a source of comfort. The loneliness of social isolation and the inherent stressors thus associated have been implicated as triggering factors in binge eating as well.^{[109][110][111][112]}

Waller, Kennerley and Ohanian (2007) argued that both bingeing–vomiting and restriction are emotion suppression strategies, but they are just utilized at different times. For example, restriction is used to pre-empt any emotion activation, while bingeing–vomiting is used after an emotion has been activated.^[113]

Parental influence

Parental influence has been shown to be an intrinsic component in the development of eating behaviors of children.^[114] This influence is manifested and shaped by a variety of diverse factors such as familial genetic predisposition, dietary choices as dictated by cultural or ethnic preferences, the parents' own body shape and eating patterns, the degree of involvement and expectations of their children's eating behavior as well as the interpersonal relationship of parent and child.^[114] It is also influenced by the general psychosocial climate of the home and whether a nurturing stable environment is present. It has been shown that maladaptive parental behavior has an important role in the development of eating disorders. As to the more subtle aspects of parental influence, it has been shown that eating patterns are established in early childhood and that children should be allowed to decide when their appetite is satisfied as early as the age of two. A direct link has been shown between obesity and parental pressure to eat more.^[115]

Coercive tactics in regard to diet have not been proven to be efficacious in controlling a child's eating behavior. Affection and attention have been shown to affect the degree of a child's finickiness and their acceptance of a more varied diet.^{[116][117][118][119][120][121]}

Adams and Crane (1980), have shown that parents are influenced by stereotypes that influence their perception of their child's body. The conveyance of these negative stereotypes also affects the child's own body image and satisfaction.^[122] Hilde Bruch, a pioneer in the field of studying eating disorders, asserts that anorexia nervosa often occurs in girls who are high achievers, obedient, and always trying to please their parents. Their parents have a tendency to be over-controlling and fail to encourage the expression of emotions, inhibiting daughters from accepting their own feelings and desires. Adolescent females in these overbearing families lack the ability to be independent from their families, yet realize the need to, often resulting in rebellion. Controlling their food intake may make them feel better, as it provides them with a sense of control.^[123]

Peer pressure

In various studies such as one conducted by The McKnight Investigators, peer pressure was shown to be a significant contributor to body image concerns and attitudes toward eating among subjects in their teens and early twenties.^[124]

Eleanor Mackey and co-author, Annette M. La Greca of the University of Miami, studied 236 teen girls from public high schools in southeast Florida. "Teen girls' concerns about their own weight, about how they appear to others and their perceptions that their peers want them to be thin are significantly related to weight-control behavior", says psychologist Eleanor Mackey of the Children's National Medical Center in Washington and lead author of the study. "Those are really important."^[125]

According to one study, 40% of 9- and 10-year-old girls are already trying to lose weight.^[126] Such dieting is reported to be influenced by peer behavior, with many of those individuals on a diet reporting that their friends also were dieting. The number of friends dieting and the number of friends who pressured them to diet also played a significant role in their own choices.^{[127][128][129][130]}

Elite athletes have a significantly higher rate in eating disorders. Female athletes in sports such as gymnastics, ballet, diving, etc. are found to be at the highest risk among all athletes. Women are more likely than men to acquire an eating disorder between the ages of 13 and 25. About 0–15% of those with bulimia and anorexia are men.^[131]

Other psychological problems that could possibly create an eating disorder such as Anorexia Nervosa are depression, and low self-esteem. Depression is a state of mind where emotions are unstable causing a person's eating habits to change due to sadness and no interest of doing anything. According to PSYCOM "Studies show that a high percentage of people with an eating disorder will experience depression."^[132] Depression is a state of mind where people seem to refuge without being able to get out of it. A big factor of this can affect people with their eating and this can mostly affect teenagers. Teenagers are big candidates for Anorexia for the reason that during the teenage years, many things start changing and they start to think certain ways. According to Life Works an article about eating disorders "People of any age can be affected by pressure from their peers, the media and even their families but it is worse when you're a teenager at school."^[133] Teenagers can develop eating disorder such as Anorexia due to peer pressure which can lead to Depression. Many teens start off this journey by feeling pressure for wanting to look a certain way of feeling pressure for being different. This brings them to finding the result in eating less and soon leading to Anorexia which can bring big harms to the physical state.^{[citation needed]}

Cultural pressure

Western perspective

There is a cultural emphasis on thinness which is especially pervasive in western society. A child's perception of external pressure to achieve the ideal body that is represented by the media predicts the child's body image dissatisfaction, body dysmorphic disorder and an eating disorder.^[134] "The cultural pressure on men and women to be 'perfect' is an important predisposing factor for the development of eating disorders".^[135][136] Further, when women of all races base their evaluation of their self upon what is considered the culturally ideal body, the incidence of eating disorders increases.^[137]

Socioeconomic status (SES) has been viewed as a risk factor for eating disorders, presuming that possessing more resources allows for an individual to actively choose to diet and reduce body weight.^[138] Some studies have also shown a relationship between increasing body dissatisfaction with increasing SES.^[139] However, once high socioeconomic status has been achieved, this relationship weakens and, in some cases, no longer exists.^[140]

The media plays a major role in the way in which people view themselves. Countless magazine ads and commercials depict thin celebrities. Society has taught people that being accepted by others is necessary at all costs.^[141] This has led to the belief that in order to fit in one must look a certain way. Televised beauty competitions such as the Miss America Competition contribute to the idea of what it means to be beautiful because competitors are evaluated on the basis of their opinion.^[142]

In addition to socioeconomic status being considered a cultural risk factor so is the world of sports. Athletes and eating disorders tend to go hand in hand, especially the sports where weight is a competitive factor. Gymnastics, horse back riding, wrestling, body building, and dancing are just a few that fall into this category of weight dependent sports. Eating disorders among individuals that participate in competitive activities, especially women, often lead to having physical and biological changes related to their weight that often mimic prepubescent stages. Oftentimes as women's bodies change they lose their competitive edge which leads them to taking extreme measures to maintain their younger body shape. Men often struggle with binge eating followed by excessive exercise while focusing on building muscle rather than losing fat, but this goal of gaining muscle is just as much an eating disorder as obsessing over thinness. The following statistics taken from Susan Nolen-Hoeksema's book, (ab)normal psychology, show the estimated percentage of athletes that struggle with eating disorders based on the category of sport.

• Aesthetic sports (dance, figure skating, gymnastics) – 35%
• Weight dependent sports (judo, wrestling) – 29%
• Endurance sports (cycling, swimming, running) – 20%
• Technical sports (golf, high jumping) – 14%
• Ball game sports (volleyball, soccer) – 12%

Although most of these athletes develop eating disorders to keep their competitive edge, others use exercise as a way to maintain their weight and figure. This is just as serious as regulating food intake for competition. Even though there is mixed evidence showing at what point athletes are challenged with eating disorders, studies show that regardless of competition level all athletes are at higher risk for developing eating disorders that non-athletes, especially those that participate in sports where thinness is a factor.^[143]

Pressure from society is also seen within the homosexual community. Gay men are at greater risk of eating disorder symptoms than heterosexual men.^[144] Within the gay culture, muscularity gives the advantages of both social and sexual desirability and also power.^[145] These pressures and ideas that another homosexual male may desire a mate who is thinner or muscular can possibly lead to eating disorders. The higher eating disorder symptom score reported, the more concern about how others perceive them and the more frequent and excessive exercise sessions occur.^[145] High levels of body dissatisfaction are also linked to external motivation to working out and old age; however, having a thin and muscular body occurs within younger homosexual males than older.^[144][145]

Most of the cross-cultural studies use definitions from the DSM-IV-TR, which has been criticized as reflecting a Western cultural bias. Thus, assessments and questionnaires may not be constructed to detect some of the cultural differences associated with different disorders. Also, when looking at individuals in areas potentially influenced by Western culture, few studies have attempted to measure how much an individual has adopted the mainstream culture or retained the traditional cultural values of the area. Lastly, the majority of the cross-cultural studies on eating disorders and body image disturbances occurred in Western nations and not in the countries or regions being examined.^[19]

While there are many influences to how an individual processes their body image, the media does play a major role. Along with the media, parental influence, peer influence, and self-efficacy beliefs also play a large role in an individual's view of themselves. The way the media presents images can have a lasting effect on an individual's perception of their body image. Eating disorders are a worldwide issue and while women are more likely to be affected by an eating disorder it still affects both genders (Schwitzer 2012). The media influences eating disorders whether shown in a positive or negative light, it then has a responsibility to use caution when promoting images that projects an ideal that many turn to eating disorders to attain.^[146]

To try to address unhealthy body image in the fashion world, in 2015, France passed a law requiring models to be declared healthy by a doctor to participate in fashion shows. It also requires re-touched images to be marked as such in magazines.^[147]

There is a relationship between "thin ideal" social media content and body dissatisfaction and eating disorders among young adult women, especially in the Western hemisphere.^[148] New research points to an "internalization" of distorted images online, as well as negative comparisons among young adult women.^[149] Most studies have been based in the U.S., the U.K, and Australia, these are places where the thin ideal is strong among women, as well as the strive for the "perfect" body.^[149]

In addition to mere media exposure, there is an online "pro-eating disorder" community. Through personal blogs and Twitter, this community promotes eating disorders as a "lifestyle", and continuously posts pictures of emaciated bodies, and tips on how to stay thin. The hashtag "#proana" (pro-anorexia), is a product of this community,^[150] as well as images promoting weight loss, tagged with the term "thinspiration". According to social comparison theory, young women have a tendency to compare their appearance to others, which can result in a negative view of their own bodies and altering of eating behaviors, that in turn can develop disordered eating behaviors.^[151]

When body parts are isolated and displayed in the media as objects to be looked at, it is called objectification, and women are affected most by this phenomenon. Objectification increases self-objectification, where women judge their own body parts as a mean of praise and pleasure for others. There is a significant link between self-objectification, body dissatisfaction, and disordered eating, as the beauty ideal is altered through social media.^[148]

Although eating disorders are typically under diagnosed in people of color, they still experience eating disorders in great numbers. It is thought that the stress that those of color face in the United States from being multiply marginalized may contribute to their rates of eating disorders. Eating disorders, for these women, may be a response to environmental stressors such as racism, abuse and poverty.^[152]

African perspective

In the majority of many African communities, thinness is generally not seen as an ideal body type and most pressure to attain a slim figure may stem from influence or exposure to Western culture and ideology. Traditional African cultural ideals are reflected in the practice of some health professionals; in Ghana, pharmacists sell appetite stimulants to women who desire to, as Ghanaians stated, "grow fat".^[153] Girls are told that if they wish to find a partner and birth children they must gain weight. On the contrary, there are certain taboos surrounding a slim body image, specifically in West Africa. Lack of body fat is linked to poverty and HIV/AIDS.^[154]

However, the emergence of Western and European influence, specifically with the introduction of such fashion and modelling shows and competitions, is changing certain views among body acceptance, and the prevalence of eating disorders has consequently increased.^[154] This acculturation is also related to how South Africa is concurrently undergoing rapid, intense urbanization. Such modern development is leading to cultural changes, and professionals cite rates of eating disorders in this region will increase with urbanization, specifically with changes in identity, body image, and cultural issues.^[155] Further, exposure to Western values through private Caucasian schools or caretakers is another possible factor related to acculturation which may be associated with the onset of eating disorders.^[156]

Other factors which are cited to be related to the increasing prevalence of eating disorders in African communities can be related to sexual conflicts, such as psychosexual guilt, first sexual intercourse, and pregnancy. Traumatic events which are related to both family (i.e. parental separation) and eating related issues are also cited as possible effectors.^[156] Religious fasting, particularly around times of stress, and feelings of self-control are also cited as determinants in the onset of eating disorders.^[157]

Asian perspective

The West plays a role in Asia's economic development via foreign investments, advanced technologies joining financial markets, and the arrival of American and European companies in Asia, especially through outsourcing manufacturing operations.^[158] This exposure to Western culture, especially the media, imparts Western body ideals to Asian society, termed Westernization.^[158] In part, Westernization fosters eating disorders among Asian populations.^[158] However, there are also country-specific influences on the occurrence of eating disorders in Asia.^[158]

China

In China as well as other Asian countries, Westernization, migration from rural to urban areas, after-effects of sociocultural events, and disruptions of social and emotional support are implicated in the emergence of eating disorders.^[158] In particular, risk factors for eating disorders include higher socioeconomic status, preference for a thin body ideal, history of child abuse, high anxiety levels, hostile parental relationships, jealousy towards media idols, and above-average scores on the body dissatisfaction and interoceptive awareness sections of the Eating Disorder Inventory.^[159] Similarly to the West, researchers have identified the media as a primary source of pressures relating to physical appearance, which may even predict body change behaviors in males and females.^[158]

Fiji

While colonised by the British in 1874, Fiji kept a large degree of linguistic and cultural diversity which characterised the ethnic Fijian population. Though gaining independence in 1970, Fiji has rejected Western, capitalist values which challenged its mutual trusts, bonds, kinships and identity as a nation.^[160] Similar to studies conducted on Polynesian groups, ethnic Fijian traditional aesthetic ideals reflected a preference for a robust body shape; thus, the prevailing 'pressure to be slim,' thought to be associated with diet and disordered eating in many Western societies was absent in traditional Fiji.^[161] Additionally, traditional Fijian values would encourage a robust appetite and a widespread vigilance for and social response to weight loss. Individual efforts to reshape the body by dieting or exercise, thus traditionally was discouraged.^[162]

However, studies conducted in 1995 and 1998 both demonstrated a link between the introduction of television in the country, and the emergence of eating disorders in young adolescent ethnic Fijian girls.^[163] Through the quantitative data collected in these studies there was found to be a significant increase in the prevalence of two key indicators of disordered eating: self-induced vomiting and high Eating Attitudes Test- 26.^[164] These results were recorded following prolonged television exposure in the community, and an associated increase in the percentage of households owning television sets. Additionally, qualitative data linked changing attitudes about dieting, weight loss and aesthetic ideas in the peer environment to Western media images. The impact of television was especially profound given the longstanding social and cultural traditions that had previously rejected the notions of dieting, purging and body dissatisfaction in Fiji.^[164] Additional studies in 2011 found that social network media exposure, independent of direct media and other cultural exposures, was also associated with eating pathology.^[165]

Hong Kongedit

From the early- to-mid- 1990s, a variant form of anorexia nervosa was identified in Hong Kong.^[166] This variant form did not share features of anorexia in the West, notably "fat-phobia" and distorted body image.^[166] Patients attributed their restrictive food intake to somatic complaints, such as epigastric bloating, abdominal or stomach pain, or a lack of hunger or appetite.^[158] Compared to Western patients, individuals with this variant anorexia demonstrated bulimic symptoms less frequently and tended to have lower pre-morbid body mass index.^[158] This form disapproves the assumption that a "fear of fatness or weight gain" is the defining characteristic of individuals with anorexia nervosa.^[166]

Indiaedit

In the past, the available evidence did not suggest that unhealthy weight loss methods and eating disordered behaviors are common in India as proven by stagnant rates of clinically diagnosed eating disorders.^[167] However, it appears that rates of eating disorders in urban areas of India are increasing based on surveys from psychiatrists who were asked whether they perceived eating disorders to be a "serious clinical issue" in India.^[158] One notable Indian psychiatrist and eating disorder specialist Dr Udipi Gauthamadas is on record saying, "Disturbed eating attitudes and behaviours affect about 25 to 40 percent of adolescent girls and around 20 percent of adolescent boys.^[168] While on one hand there is increasing recognition of eating disorders in the country, there is also a persisting belief that this illness is alien to India. This prevents many sufferers from seeking professional help.^[169]"

23.5% of respondents believed that rates of eating disorders were rising in Bangalore, 26.5% claimed that rates were stagnant, and 42%, the largest percentage, expressed uncertainty. It has been suggested that urbanization and socioeconomic status are associated with increased risk for body weight dissatisfaction.^[158] However, due to the physical size of and diversity within India, trends may vary throughout the country.^[158]

Zdroj:https://en.wikipedia.org?pojem=Eating_Disorder
Text je dostupný za podmienok Creative Commons Attribution/Share-Alike License 3.0 Unported; prípadne za ďalších podmienok. Podrobnejšie informácie nájdete na stránke Podmienky použitia.

---