Eating Disorders

What is anorexia nervosa?

Anorexia nervosa is a complicated eating disorder with medical, behavioral, and psychological components. People with anorexia nervosa limit how much and what they eat. Patients with anorexia nervosa are below their body’s ideal weight, typically after significant weight loss. They have a distorted body image, over-preoccupation with food and their body, and an intense fear of gaining weight.

Individuals most commonly develop anorexia nervosa during adolescence. Youth of any gender, race/ethnicity, or socioeconomic background can develop anorexia nervosa. However, many groups, particularly boys, are less likely to be recognized as potentially having any eating disorder.

Anorexia nervosa can be life threatening. Malnutrition experienced as a result of anorexia nervosa places the body in danger. Early diagnosis and treatment are therefore extremely important.

Types of anorexia nervosa

There are two types of anorexia nervosa.

• Restricting type: An individual severely limits how much and what types of foods they eat.
• Binge/purge type: An individual restricts their food intake but sometimes will eat an excessive amount and then make themselves throw up or otherwise get rid of the calories.

What are the signs of anorexia nervosa?

If your child is struggling with anorexia nervosa, you may notice them to be more socially withdrawn, irritable, moody, or depressed. Some of the other signs of anorexia nervosa include:

• intense fear of gaining weight, even while losing weight
• distorted view of their body, weight, size, or shape; for instance, sees self as overweight despite being severely underweight
• refusal to maintain a healthy body weight
• excessive physical activity
• insistence that they don’t feel hungry
• preoccupation with food preparation but reluctance or refusal to eat what is prepared

Physical symptoms of anorexia may include:

• significant weight loss
• body weight below a healthy range
• missed or irregular menstrual periods
• dry skin
• abdominal pain or bloating after eating
• constipation
• fatigue
• problems maintaining normal body temperature, feeling cold when others are hot
• development of fine, downy body hair
• stress fractures

Anorexia nervosa complications

Anorexia is a serious disease. It can affect many systems of your child’s body:

• Heart: Anorexia nervosa can lead to heart complications such as mitral valve prolapse (a floppy valve in the heart), arrhythmias (a fast, slow or irregular heartbeat), bradycardia (slow heartbeat), hypotension (low blood pressure), and heart failure.
• Blood: About one-third of teens with anorexia have mild anemia (low red blood cell count). Up to 50 percent of anorexic adolescents develop leukopenia (low white blood cell count).
• Stomach and intestines: Normal movement in the intestinal tract often slows down with very restricted eating and severe weight loss. Gaining weight, and taking certain medications, can help to restore your child’s normal intestinal function.
• Kidneys: Individuals with anorexia nervosa may limit their fluid intake leading to dehydration which can result in highly concentrated urine. Polyuria (increased production of urine) may also develop when the kidneys start to lose their ability to concentrate urine. These changes usually return to normal when your child gets back to a normal weight.
• Hormones: One of the most telling symptoms of anorexia is amenorrhea, or when a girl or woman misses her menstrual cycle for three or more months in a row. Teens with anorexia may also have lower levels of growth hormone, which may explain their failure to grow normally. Normal nutrition usually restores normal growth.
• Bones: If your child has anorexia, they are at an increased risk for low bone density. If anorexic behavior starts before the bones are fully formed (usually mid to late teens), there is a greater risk of osteopenia (decreased bone tissue) or osteoporosis (bone loss) or fractures.

What is a binge eating disorder (BED)?

Binge eating disorder affects millions of Americans. The condition is marked by frequent episodes of eating an abnormally large amount of food in a short amount of time while experiencing a loss of control.

Children and teens with binge eating disorder may:

• eat large amounts of food even when they don’t feel hungry
• eat alone out of embarrassment at the quantity of food they are eating
• feel disgusted, depressed, and guilty after overeating

Binge eating disorder often goes hand in hand with anxiety or depression.

This disorder is different from bulimia nervosa (also known as binge-purge syndrome) because people with binge eating disorder usually don’t purge afterward by vomiting or using laxatives.

Binge eating disorder can have serious health consequences. Early diagnosis and treatment are therefore extremely important.

What are signs of a binge eating disorder?

If your child has a binge eating disorder, signs and symptoms may include:

• recurring episodes of binge eating
• feeling helpless to stop eating
• eating a lot even when not hungry
• dissatisfaction with themselves and their body appearance
• preoccupation with food, weight, and body shape
• weight fluctuations
• food disappearing from the kitchen, hidden food wrappers

Binge-eating complications

Complications of a binge eating disorder may include:

• obesity
• suicidal thoughts
• type 2 diabetes
• high blood pressure
• heart disease
• heartburn
• depression

What is bulimia nervosa?

Bulimia nervosa is defined as uncontrolled episodes of overeating (bingeing), followed by a means of purging such as:

• self-induced vomiting
• misuse of laxatives, enemas, or diuretics (medications that cause increased production of urine)
• fasting
• excessive exercise

Bingeing is defined as eating extremely large amounts of food in a short period of time (usually less than two hours). This is accompanied by a sense of loss of control while eating and is usually followed by profound feelings of guilt or shame.

It’s estimated that 1 to 5 percent of adolescents have bulimia nervosa. The condition is more common in girls and women than in boys and men.

Bulimia nervosa can have serious medical consequences. Early intervention and treatment are therefore extremely important.

What are the signs of bulimia nervosa?

If your child has bulimia nervosa, their symptoms may include:

• feelings of dissatisfaction with themselves and their body’s appearance
• preoccupation with food, weight, and body shape
• episodes of eating excessive amounts of food in a relatively short period of time, often in secret
• fear of not being able to stop eating during bingeing episodes
• self-induced vomiting, usually in secret
• excessive exercise or fasting after eating
• inappropriate use of laxatives, diuretics, or other cathartics
• irregular or missed menstrual periods

Physical signs of bulimia nervosa include:

• swollen face
• sore throat
• dry, flaky skin
• constant upset stomach
• heartburn
• constipation
• scarring on the back of the fingers from self-induced vomiting
• weight fluctuations

Bulimia complications

Bulimia nervosa is a serious disease. Complications a young adult with bulimia may include:

• serious electrolyte problems, possibly leading to serious heart problems
• irregular menstrual periods
• loss of bone density
• dehydration
• tooth decay
• constipation
• anxiety
• depression

How are eating disorders diagnosed?

Parents, teachers, coaches, or instructors may identify signs of a possible eating disorder, but the diagnosis is usually made by experienced clinicians. Early treatment can often prevent future problems. Therefore, if you notice symptoms of an eating disorder in your child, it’s a good idea to seek evaluation and treatment.

To diagnose an eating disorder, your child’s doctor will assess changes in your child’s weight. They will also ask your child about:

• their eating habits
• their feelings about their body shape and size
• their use of laxatives or diet pills to lose weight
• their exercise habits

They will also ask your child if they have had any symptoms such as:

• abdominal pain
• bloating
• constipation
• hair loss or change in hair texture
• cold intolerance
• fatigue
• weakness
• fainting
• substance use
• depression

Your child’s doctor will likely also conduct the following studies:

• a social history, a review of risk factors at home, school, and outside activities
• a family history to assess conditions such as eating disorders, obesity, alcoholism, depression, or other mental illness in the family
• a physical exam, including pulse, temperature, weight and height, skin and hair changes, heart function, and abdomen

How are eating disorders treated?

Complete recovery from an eating disorder is possible. The goal of eating disorder treatment is to treat any immediate medical concerns, work on eliminating disordered behaviors, and treat co-occurring issues like depression and anxiety.

Over time, treatment can help your child replace distorted thinking patterns and develop a positive sense of self so they can return to their appropriate phase of adolescent development.

Eating disorders are usually treated with a combination of therapies:

• individual therapy (usually including both cognitive and behavioral techniques)
• family therapy
• medical care and monitoring
• nutritional counseling
• behavior modification
• medications

While medication, such as antidepressants or mood stabilizers, may be helpful, family members play a vital role in supporting your child’s recovery.

Many patients with eating disorders receive treatment while living at home. However, if your child’s heart rate, breathing, or pulse become irregular, or if they show other signs of serious medical illness, they may be admitted to the hospital. In the hospital, clinicians will work to stabilize their health and may place them on a special meal plan with customized weight-gain goals. They will continue to meet with therapists in the hospital if their physical health is stable.

How we care for eating disorders

Boston Children's Hospital’s Eating Disorders Program takes a multidisciplinary approach to treating patients with eating disorders. We are committed to helping our patients and their families at every step of the treatment process, and we provide recommendations with their specific needs and circumstances in mind.

We provide both inpatient medical and outpatient care. If your child is an outpatient, they will be seen by a physician or nurse practitioner from our Division of Adolescent/Young Adult Medicine as well as a dietitian. Your child may also see a psychologist or social worker.

If your child’s vital signs become unstable, they will be admitted to the hospital and treated with guidance from our inpatient clinical pathway. They will meet with medical doctors, behavioral medicine clinicians, and dietitians while participating in a special meal plan with customized goals for gaining weight.