Category: Eating Disorders

University of Minnesota Project Eating Among Teens (EAT) researchers have identified factors that may increase overweight adolescents' risk of engaging in extreme weight control behaviors such as self-induced vomiting, the use of diet pills, laxatives, and diuretics, as well as binge eating. Overweight youth with certain socio-environmental, psychological, and behavioral tendencies, such as reading magazine articles about dieting, reporting a lack of family connectedness, placing a high importance on weight, and reporting having participated in unhealthy weight control behaviors, are more likely to suffer from eating disorders.

Dianne Neumark-Sztainer, Ph.D., M.P.H., R.D., School of Public Health, and colleagues used data from Project EAT, an ongoing study that assessed eating and weight-related behaviors in 4,746 adolescents from 31 urban Minneapolis-St. Paul schools during the 1998-99 academic year. Youth were surveyed at two time points; the first occurring when participants were in middle school and high school, and the second occurring five years later.

Researchers found that disordered eating habits among overweight youth are linked to specific tendencies for both males and females, but a number of specific differences between genders were noticed. For example, increased hours of moderate to extreme physical activity and lower self-esteem predicted higher risk for disordered eating among females. For males, depressive symptoms, poor eating patterns, including high fast food and sweetened beverage intake, increased their risk of disordered eating. These findings link different patterns of behaviors and different potential motivators for overweight male and female adolescents to developing eating disorders.

"Further exploration of these gender differences may be important in understanding who is at highest risk for developing disordered eating behaviors and whether different intervention strategies may be needed to prevent disordered eating among males and females," said Nancy Sherwood, Ph.D., assistant professor at the University of Minnesota School of Public Health and a co-author of the study.

Findings from this study also suggest the importance of strong family relationships for overweight adolescents. These youth face pressures above and beyond those faced by their non-overweight peers due to strong social pressures to be thin. Lack of family connectedness, including not eating family meals together, was found to increase the risk of disordered eating behaviors in both young males and females.

While an important public health priority is to prevent obesity, it is also important to prevent the use of disordered eating behaviors among overweight adolescents. Findings from this study indicate the importance of working with overweight youth to prevent an unhealthy preoccupation with weight, promote a positive psychological well-being, avoid unhealthy weight control behaviors, and encourage family connectedness.

This study was supported by the Maternal and Child Health Bureau, Health Resources and Service Administration, and the U.S. Department of Health and Human Services.

Research to be presented at the Annual Meeting of the Society for the Study of Ingestive Behavior (SSIB) shows that exposing rats to a context associated with eating chocolate activates a part of the brain’s reward system known as the orexin system. This finding helps explain why eating can be triggered by environmental cues even in the absence of hunger. The results have implications for the development of new drug treatments for overeating.  

The rate of obesity continues to rise within the United States and abroad, and over-consumption of tasty food is an obvious culprit. Little is known regarding how palatable foods affect the brain, but it seems that especially tasty foods elicit brain responses similar to those elicited by drugs of abuse such as cocaine and nicotine, pointing to a general involvement of the brain’s “reward” system.

A common factor may be activation of orexin neurons in the brain, which are recruited during of rewards such as a tasty food or a dose of cocaine.  “Our research program is focused on identifying brain systems that are activated by palatable food intake. The hypothalamic orexin system is known to promote wakefulness and arousal; however, it is now clear that this system also participates in the regulation of reward-related behaviors, including overconsumption of palatable foods,” says Derrick Choi, lead author. Because reward anticipation is a contributing factor to relapse to drug use, Choi hypothesizes that orexin is an ideal candidate system that may underlie the rewarding aspects of eating highly palatable foods, which clearly can lead to obesity.

In their current study, the researchers trained rats to expect a piece of Hershey’s milk chocolate in a unique environment. After training, rats were placed into the same environment, where no chocolate was present. The researchers found that the expectation of chocolate alone activated brain orexin systems.  The results could explain why individuals tend to overeat in contexts associated with prior experiences of eating good food. “It entirely possible that future treatments for obesity will involve a combination of lifestyle changes as well as pharmacological therapies aimed at orexin and other brain systems, to regulate food reward-related behaviors,” said Choi.

This research was supported by USARMY W81XWH-06-2-0019 and P01 DK056863-09.

The lead author was Derrick Choi, Department of Psychiatry, University of Cincinnati, Cincinnati, OH, USA. Co-authors were JF DAVIS, ME FITZGERALD, SC BENOIT. Department of Psychiatry, University of Cincinnati, Cincinnati, OH, USA.

New imaging technology provides insight into abnormalities in the brain circuitry of patients with anorexia nervosa (commonly known as anorexia) that may contribute to the puzzling symptoms found in people with the eating disorder. In a review paper published online in Nature Reviews Neuroscience, Walter Kaye, MD, professor of psychiatry and director of the Eating Disorders Program at the University of California, San Diego, and colleagues describe dysfunction in certain neural circuits of the brain which may help explain why people develop anorexia in the first place, and behaviors such as the relentless pursuit of dieting and weight loss.

"Currently, we don't have very effective means of treating people with anorexia," said Kaye. "Consequently, many patients with the disorder remain ill for years or eventually die from the disease, which has the highest death rate of any psychiatric disorder."

A better understanding of the underlying neurobiology – how behavior is coded in the brain and contributes to anorexia —is likely to result in more effective treatments, according to the researchers.

Childhood personality and temperament may increase an individual's vulnerability to developing anorexia. Predisposing factors, some suspected to be inherited, such as perfectionism, anxiety, or obsessive-compulsive tendencies may precede the onset of an eating disorders. These traits become intensified during adolescence as a consequence of many factors such as hormonal changes, stress and culture.

"Adolescence is a time of transition, when individuals must learn to balance immediate and long-term needs and goals in order to achieve independence," said Kaye. "For such individuals, learning to cope with mixed societal messages and pressures may be overwhelming, exacerbating underlying traits of anxiety and a desire to perfectly achieve."

Once a patient develops anorexia, starvation and malnutrition cause profound effects on the brain and other organ systems. Such changes include neuro-chemical imbalances, which may, in turn, exaggerate the preexisting traits and accelerate the disease process.

"Individuals with anorexia tend to report that dieting reduces anxiety, while eating increases it," said Kaye. "This is very different from most individuals, who experience hunger as unpleasant." The powerful drive to avoid being anxious drives actually weight loss in anorexia nervosa, triggering the out-of-control spiral that results in severe emaciation and malnutrition.

In addition, people with anorexia nervosa tend to not experience pleasure or live "in the moment." They often have exaggerated and obsessive worry about the consequences of their behaviors, looking for rules when there are none, and are overly concerned about making mistakes. Co-author Julie L. Fudge of the Department of Psychiatry & Neurobiology and Anatomy at the University of Rochester Medical Center, notes that imaging studies suggest that individuals with anorexia have an imbalance between circuits in the brain that regulate reward and emotion (the ventral or limbic circuit) and circuits that are associated with consequences and planning ahead (the dorsal or cognitive circuit.)

"Brain-imaging studies also show that individuals with anorexia have alterations in those parts of the brain involved with bodily sensations, such as sensing the rewarding aspects of pleasurable foods," said co-author Martin Paulus, UC San Diego professor of psychiatry, who heads UC San Diego's Laboratory of Biological Dynamics and Theoretical Medicine. "Anorexics may literally not recognize when they are hungry."

One such brain region is the anterior insula, which is critically important for interoception, or the self-awareness of internal body signals. In addition to a failure to respond appropriately to signals of hunger, symptoms of anorexia – such as distorted body image and diminished motivation to change – could be related to disturbed interoceptive awareness.

"Anorexia is very complicated, and there needs to be a paradigm shift in understanding its underlying cause," said Kaye. "We're just beginning to understand how the brain is working in people with this disorder."

Kaye noted that the temperament and personality traits that may create a vulnerability to develop anorexia may also have a positive aspect. These traits include attention to detail, concern about consequences, and a drive to accomplish and succeed. "It's my clinical experience that many individuals who recover from anorexia do well in life," he said.

Anorixia Nervosa Symptoms

Symptoms of the disease anorexia nervosa, more commonly known as anorexia, include the patient's refusal to maintain body weight at or above a minimally normal weight for age and height; and intense fear of gaining weight or becoming fat, even when the individual is underweight. Although anorexia is characterized as an eating disorder, it remains unknown whether there is primarily a disturbance of appetite, or whether change in appetite is secondary to other issues such as anxiety or obsessional preoccupation with weight gain. When malnourished and emaciated, individuals with the disease have widespread and severe alterations of the brain and other organs. As it is unclear whether these changes are the cause of consequence of severe weight loss, individuals who have recovered from anorexia have been studied. While approximately 50% to 70% of affected individuals eventually recover, a significant proportion of patients develop a chronic illness or die, making anorexia the number one cause of death among psychiatric diseases.

 Eating disorders are frequently seen as psychological or societal diseases, but do they have an underlying biological cause? A new study shows that the levels of a brain protein differ between healthy and anorexic women.

Anorexia is a serious and occasionally fatal eating disorder most commonly affecting women. Scientists do not yet understand the physical causes of anorexia, though some studies suggest a link to low levels of a brain protein called BDNF. Now, a study recommended by Cynthia Bulik, a member of Faculty of 1000 Medicine and leading expert in the field of psychiatry and eating disorders, shows that BDNF levels are higher in women who have recovered from anorexia. This suggests that low BDNF levels may be reversible.

Researchers at Chiba University in Japan found that anorexic women had lower levels of BDNF in their blood than healthy women or those who had recovered from anorexia. Women with low BDNF also had the lowest self-image, suffered from anxiety and depression, and performed poorly on certain tests of cognitive ability.

Further study is needed to determine what role BDNF plays in anorexia, and if it can be used to predict the risk of developing it, but Bulik forecasts that "…BDNF may emerge as a useful biomarker of [anorexia] and of recovery from [anorexia]."

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Journal Reference:

1. Nakazato M, Tchanturia K, Schmidt U, Campbell IC, Treasure J, Collier DA, Hashimoto K, Iyo M. Brain-derived neurotrophic factor (BDNF) and set-shifting in currently ill and recovered anorexia nervosa (AN) patients. Psychol Med, 2009 Jun 39(6):1029-35

 In everyday life, someone who takes a perfectionist’s approach to activities might be admired or even rewarded with a pat on the back.

These attitudes are tied to a commonly held, but mistaken, belief that perfectionism will ultimately produce achievement and social success. But a psychologist warns that perfectionism is not a healthy, or even effective, approach to life’s challenges.

“Perfectionism is a double-edged personality trait,” says Simon Sherry, assistant professor of psychology.

A newly-published study shows why individuals with a high degree of perfectionism are often setting themselves up for a host of physical, emotional and mental problems– particularly related to binge eating. Although less well recognized than anorexia or bulimia, binge eating is a serious disorder. Binge eating occurs when a person feels out of control and rapidly consumes a large amount of food in a short period of time. Binge eating elevates the risk of developing depression, obesity, diabetes and other problems.

Dr. Sherry, of Dalhousie University in Halifax Nova Scotia, has published “The Perfectionism Model of Binge Eating” in the Journal of Personality and Social Psychology, along with co-author Peter Hall of the University of Waterloo. By closely following the daily activities of a large group of undergraduates, the researchers believe that they’re the first to identify why perfectionism results in binge eating.

They have also honed in on the type of perfectionist who is most at risk–someone who believes that others are evaluating their performance critically (as opposed to someone who is self-critical). This kind of perfectionist concludes that a parent, a friend or a boss is being harshly judgmental of their performance and pressuring them to be perfect.

“It seems that as perfectionists go about their day-to-day lives, they generate a lot of friction,” says Dr. Sherry. “Because of their inflexibility and unrealistic expectations they also create problems in their relationships.”

Let’s imagine how a perfectionist might begin their day.

Today’s Goals

• Run faster than yesterday’s personal best.
• Drink coffee instead of having breakfast.
• Earn the highest grade in the class on that mid-term.
• Meet for group project at 3 p.m. sharp to fix presentation.
• Find the most original gift for friend’s birthday.

What happens when the day ends up looking more like this instead?

Today’s Failures

• Running time misses personal best altogether.
• Earned 89 on the midterm, so six others are ahead of me now.
• Manage to limit lunch to a salad.
• Group is late for meeting, so presentation is still boring.
• Friend is disappointed with birthday gift.

Chances are the next sequence of events will involve self-harm.

Today’s Secret

• Late in the day, lose control and binge eat.
• Feel a horrible ‘pit in the stomach.’
• Hide the evidence to keep the secret.
• Criticize and loathe myself.
• Dwell on being alone and isolated.

Binge eating becomes an effort to escape from being overwhelmed with feelings of loneliness, failure and sadness. To temporarily escape from a discouraging reality, it’s necessary to do away with higher order thought. The experience of eating–smelling, chewing, tasting–is immediate and visceral.

“Think about it–when was the last time that you were rapidly eating a pizza and pondering a major life decision at exactly the same time?” asks Dr. Sherry.

While binge eating banishes troubles and difficulties in the short term, it also generates powerful negative emotions of guilt and shame that are longer lasting.

“We want to improve the lives of perfectionists with patterns of disordered eating,” he says.

The intent is that this research will translate directly into better care, through improved assessment and treatment opportunities. Society does demand achievement, but perfectionism is often maladaptive–a conscientious and adaptable person who can modify goals and expectations is better able to excel.

Perfectionists are often not self aware and are reluctant to seek help, posing a conundrum: They don’t want to admit they’re imperfect.

“I’m hopeful that students will read about this and realize that there are effective interventions for binge eating, including some help for perfectionism–change is possible.”

Getting your teenager to drink a chocolate milkshake isn't something most parents need to worry about. But this is just the approach used in one treatment for anorexia nervosa. Known as Behavioral Family Therapy, or the Maudsley Approach, parents are called up on to supervise the eating habits of their anorexic child, feeding them high-calorie meals like milkshakes and macaroni and cheese until they regain a healthy weight.

For the first time, the Maudsley Approach is being compared with a more established treatment known as Family Systems Therapy as part of an ongoing National Institutes of Health (NIH)-funded treatment study at NewYork-Presbyterian Hospital/Westchester Division and five other centers nationally. Both are outpatient therapies for adolescents, aged 12 to 18.

"Anorexia is a life-threatening condition. Treating it early is very important since it is during the teenage years that this disorder usually takes hold," says Dr. Katherine Halmi, founder of the Eating Disorders Program at NewYork-Presbyterian Hospital/Westchester Division and professor of psychiatry at Weill Cornell Medical College. "Traditionally, patients with anorexia have been treated in a hospital setting or through one-on-one outpatient therapy. While inpatient treatment is still appropriate in acute cases, we have increasingly seen the value of family-oriented outpatient therapy for adolescents."

The current study is designed to compare two different therapeutic approaches that involve the family — one is a behavioral therapy initially focused on weight gain, and the other examines various underlying issues in the family dynamic.

In the Maudsley Approach, named after the hospital in London where it was developed in the 1980s, the anorexic teenager attends therapy sessions together with their parents and siblings. Parents work with the Maudsley therapist to develop ways in which they can monitor their child's intake, choosing the amounts and types of foods necessary for them to regain to a healthy weight. Siblings are encouraged to act as a support system for their sister or brother. Once patients achieve a healthy weight, they graduate toward taking more responsibility for their intake. At this point, family and developmental issues relevant to the patient maintaining a healthy weight are addressed.

In Family Systems Therapy, families also attend regular therapy sessions, but discussions do not necessarily focus on eating. Instead, family members are free to broadly explore and challenge any problematic communication patterns or stressors within the family unit.

"In Maudsley, food is medicine that restores the body and mind. When the body is starving, the mind also weakens, becoming more susceptible to anorexia's rigid, often obsessive logic. Supervised feeding helps to break this vicious cycle. With the anorexia in charge, the adolescent really cannot regain the weight on his or her own. Nutritional rehabilitation gives the brain the nutrition it needs to re-establish healthy eating habits," says Dr. Dara Bellace, a clinical psychologist at NewYork-Presbyterian Hospital/Westchester Division and an instructor of psychology in psychiatry at Weill Cornell Medical College.

"This approach does not blame parents, but rather calls on their ability to nurse their child back to health. It requires a strong commitment to be with them for every meal — something that can mean rearranging schedules and taking a tag-team approach to sharing the responsibility," adds Dr. Bellace. "The adolescent must also dedicate themselves to the therapy, understanding that, until they regain the weight, their parents will be feeding them much as they did when they were younger, deciding what and how much they eat and making sure they finish."

Previous research has shown the Maudsley Approach successfully prevented hospitalization and helped adolescents recover their normal weights, with at least 75 percent of patients maintaining their recovery after five years.

A total of 240 adolescents aged 12 to 18 are being recruited for the study at six centers: NewYork-Presbyterian/Westchester; Stanford University in Palo Alto, Calif.; Sheppard Pratt in Baltimore, Md.; University of California at San Diego; University of Toronto; and Washington University in St. Louis. Those eligible must be medically stable individuals ages 12 to 18 with a body weight between 75 percent and 87 percent of its healthy range. Families are randomized to receive either the Maudsley Approach or Family Systems Therapy. In each family treatment, they attend 16 one-hour sessions over the course of nine months. Sessions are held weekly for the first seven to eight weeks, bimonthly for the next six sessions, and monthly for the remaining sessions.

Anorexia nervosa is an eating disorder characterized by extreme low body weight and body image distortion with an obsessive fear of gaining weight. The condition largely affects adolescent females, who make up more than 40 percent of all cases. As much as 3 percent of American girls and women are anorexic. Contributing causes may include genetics, personality type, hormones, stress and societal pressures.

Anorexia carries the highest mortality rate of any psychiatric condition. Previous research by Dr. Halmi found that 7 percent of affected women died within 10 years. In a Swedish study that followed patients for 30 years, 18 percent to 20 percent of the women died. Even when anorexia is not fatal, it can cause long-term complications, including damage to the heart and bones.

 The study was initiated in 1985. A total of 51 teenagers with anorexia nervosa were studied, together with an equally large control group of healthy persons. The groups have been investigated and compared several times as the years have passed.

"This study is unique in an international perspective. It is the only study in the world that reflects the natural course of anorexia nervosa in the population", says Elisabet Wentz, Associate Professor in Child and Adolescent Psychiatry at the Sahlgrenska Academy.

The research group has published new results from the study in two scientific journals: the British Journal of Psychiatry and the International Journal of Eating Disorders.

Three women have still not recovered from anorexia, 18 years after the start of the study. Thirteen people, or around 25%, are on disability benefit or have been signed off sick for more than six months due to an eating disorder or other psychiatric disorder.. Thirty-nine percent have at least one other psychiatric disorder, in addition to the eating disorder. The most common of these is obsessive compulsive disorder.

But the results also contain some positive surprises.

"Previous studies have shown that anorexia is a diagnosis with a very poor prognosis, with as many as one in five patients dying as a result of the disease. In contrast, we have not had a single death among the subjects of our study", says Elisabet Wentz.

Other studies have also shown that infertility is a common complication for adult women who have had anorexia, as are increased risks of giving birth prematurely and of post-natal depression. The women in the two groups in this study have had essentially the same number of children, but the women who have had anorexia were younger when they had their first child. Such children had a lower birth weight than children of women in the control group.

"None of the women who had had children still suffered from an eating disorder, but it is still more common that they worry about whether their babies are putting on weight", says Elisabet Wentz.

Brief Facts: Anorexia Nervosa

Anorexia nervosa is one of the most common psychiatric disorders among young women, and 1% of all teenage girls suffer from the condition. The figure for boys is 0.1%. The most common age range for being diagnosed with anorexia is 14-17 years, and the condition can continue for a very long time.

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Journal References:

1. Wentz E, Gillberg IC, Anckarsäter H, Gillberg C, Råstam M. Adolescent-onset anorexia nervosa: 18-year outcome. The British Journal of Psychiatry, 2009; 194 (2): 168 DOI: 10.1192/bjp.bp.107.048686
2. Wentz et al. Reproduction and offspring status 18 years after teenage-onset anorexia nervosa-A controlled community-based study. International Journal of Eating Disorders, 2009; DOI: 10.1002/eat.20664

A PhD thesis at the University of the Basque Country (UPV/EHU) has analysed the role played by a number of emotional variables, such as the way in which negative emotions are controlled or attitudes to emotional expression, and to use these variables as tools to predict the possibility of suffering an eating disorder.

The author of the thesis, Ms. Aitziber Pascual Jimeno, presented her work under the title, Emotions and emotional control in eating disorders: predictor role and emotional profiles.*

This work focused on two objectives: to find out if certain emotional variables play an significant role in the development of these disorders; and to know in more detail the emotional profiles, both of women at risk of contracting an eating disorder as well as of those already suffering from one.

To this end, the following emotional variables have been specified: those relative to emotional experience —the frequency of positive and negative emotions, anxiety, low self-esteem and the influence of diet, weight and the body shape on the emotional state—; negative perception of emotions, negative attitude to emotional expression, alexithymia —the inability to identify own emotions and to express them verbally— and the manner of controlling negative emotions.

Moreover, another variable has also been taken into account: the need for control. This variable is not strictly emotional, but has a clear emotional component, given that people with a high need for control, experience anxiety and unwellness when perceiving lack of control.

Study of women

In order to undertake the study, 433 women took part; 143 of these suffered from some kind of eating disorder and 145 in risk of contracting one. The results of the study show that, in general, the majority of the variables put forward can be used as predictive of suffering an eating disorder. The variables which, above all, alert to greater risk of developing an eating disorder are when the emotional state of the person is excessively influenced by diet, weight and body shape, when self-esteem is low, and when, in anxiety situations, emotions are not expressed and the person tends to act in an impulsive manner.

These results have important implications, above all when drawing up prevention programmes for eating disorders. With the data obtained, it can be said that many of the emotional variables dealt with in Ms Pascual’s work should be taken into account when drawing up these prevention programmes.

Serious illnesses

Eating disorders are very serious illnesses that have dire consequences for the sufferer, both physically as well as psychologically and socially, and there are disorders that are evermore widespread. Much research has been undertaken in order to find out the factors involved in their development, but the role played by the various emotional variables at the onset of these disorders has hardly been investigated. This thesis presented at the UPV/EHU focused on this matter more deeply.

* Ms Pascual is a graduate in Psychology and carried out her thesis under Ms Itziar Etxebarria Bilbao and Ms María Soledad Cruz Sáez, from the Department of Basic Psychological Processes and their Development at the Faculty of Psychology of the UPV/EHU. She is currently working as a lecturer at the University.